The proposed federal budget would significantly cut funding to major public health agencies and programs like the CDC, NIH, Medicaid, and EPA. The CDC budget would be cut by 17% which a former CDC director said would force them to fight epidemics and health threats with both hands tied behind their back while wearing a blindfold. The budget also cuts Medicaid by $800 billion over 10 years which could impact access to care. Several state marketplaces also proposed substantial premium increases for plans purchased under the Affordable Care Act.

1. The Rules May be Changing
but the Game is the Same
Ali S. Khan, MD, MPH
Professor and Dean, College of Public Health, UNMC
Assistant Surgeon General (Ret.), USPHS

2. • Health and Human Services: - $12.7 billion (16.2%)
• Center of Disease Control and Prevention: - $1.2 billion (17%)
• National Institutes of Health: - $ 5.7 billion (17.5%)- among the
hardest-hit research agencies
• Medicaid: - $800 billion over 10 years
• Environmental Protection Agency: - $2.6 billion (31.4%) - among the
hardest-hit public health agencies
• Labor: - $2.5 billion (21%)- includes elimination of some
training grants for occupational safety and health
FY18 President’s Budget for
Major Public Health Agencies
“The proposed budget would force CDC to fight
epidemics and health threats with both hands tied behind
their back while wearing blindfold”
http://files.constantcontact.com/6ce74d4e301/cec81ce7-67da-492f-8b01-903827035f93.pdf
https://www.hhs.gov/sites/default/files/fy2018-budget-in-brief.pdf

3. • Describe: The public and private sectors changes
that are impacting bringing together healthcare and
primary care
• Advocate: Engage academic public health as a core
new partner
• Challenge: Create new multi-sector partnerships
that leverage aligned financial incentives
Learning Objectives

4. The State of
our Health
Academic-private
partnerships
Changing landscape of health
Successful new models
Call to
Action

5. The State of
our Health
Academic-private
partnerships
Changing landscape of health
Successful new models
Call to
Action

6. What do we pay for health care ?
6

7. Healthcare Premium
• Connecticut marketplace,
Anthem, covers 35,000, wants
to raise premiums 33.8%
• Maryland marketplace,
BluChoice, covers 160,000,
wants to raise premiums 53.4%
• Virginia marketplace covers
295,000, on track for an ave.
increase of 30.6%
• Requested rate increases, not
the final numbers
• May change after negotiations
between states and insurers
Source: State Insurance Departments
Credit: Sarah KliffKliff, Sarah (2017) “Insurers want to raise Obamacare rates as much as 53 percent”. Vox.com Retrieved from May 22, 2017

8. • National Health Expenditure Projections for 2015-2025:
o health spending will grow at average rate of 5.8% annually (or 4.8% per capita)
o annual growth 1.3% faster than (GDP) – health share of GDP is expected to rise
from 17.5% 2014 to 20.1% by 2025
o initial impacts of Affordable Care Act’s coverage expansions will fade
o growth in health spending expected to respond to
 changes in economic growth
 faster growth in medical prices
 population aging
o By 2025, Federal, state, and local governments projected to finance 47% of all
national health spending (45% in 2014)
• In 2015, U.S. health care spending
reached $3.2 trillion
o a 5.8% annual increase
o $9,990 per person
o 17.8% of Gross Domestic Product
(GDP)

9. Health care costs now approaching 20% of GDP and still rising
almost as fast as before (slight deceleration for 2014-2015)
Source: McKinsey, “Accounting for the Cost of U.S. Health Care.” (2011). Center for American Progress.
9

10. Size of “bubble” reflects amount of private contribution to total
health care expenditures.
10

11. Percentages Uninsured For Adults Ages 18–64, By
Race And Ethnicity, 2012–14
Stacey McMorrow et al. Health Aff
doi:10.1377/hlthaff.2015.0757
©2015 by Project HOPE - The People-to-People Health Foundation, Inc.
Access to Care

12. © 2016 Arcadia Healthcare Solutions
12

13. Health Disparity, Omaha, NE

14. Zip Code as Predictor of Health
Source: City of Portland, Oregon, Office of Health Equity and Human Rightswww.calendow.org

15. Estimated annual percentage change in all-cause mortality by age
and sex in (A) Canada, (B) England and Wales, (C) the USA, and (D–
H) various racial and ethnic groups in the USA, 1999–2014
Shiels et al(2017) . Trends in premature mortality in the USA by sex, race, and ethnicity from 1999 to 2014: an analysis of death certificate data. http://dx.doi.org/10.1016/ S0140-6736(17)30187-3

17. Source: BMJ Quality & Safety. Health and social services expenditures: associations with health outcomes,
EH Bradley, BR Elkins, J Herrin, B Elbel, March 2011
Ratio of Social to Health Services:
Spending by Country
17

18. Social Determinants of Health
Race/Ethnicity Culture
Education
Social Economic
Status
Neighborhood
Geographic
Location
Occupation Gender Sexual Orientation

20. The State of
our Health
Academic-private
partnerships
Changing landscape of health
Successful new models
Call to
Action

21. 12th
Source: American’s Health Ranking, 2016 http://www.americashealthrankings.org/
America’s Health Rankings 2016

22. Strengths:
• Low rate of drug deaths
• Low prevalence of low birthweight
• Low prevalence of frequent mental distress
Challenges:
• High prevalence of excessive drinking
• High prevalence of obesity
• High incidence of pertussis
Highlights:
• In the past year, immunizations among
children aged 19 to 35 months decreased 8%
from 80.2% to 73.8%
• In the past four years, the percentage of the
population without health insurance
decreased 30% from 12.8% to 9.0%.
• In the past five years, preventable
hospitalizations decreased 29% from 65.7 to
46.9 discharges per 1,000 Medicare
enrollees.
• In the past five years, preventable
hospitalizations decreased 29% from 65.7 to
46.9 discharges per 1,000 Medicare
enrollees.
• In the past year, premature death increased
7% from 6,125 to 6,529 years lost per
100,000 population.
• In the past year, health disparity status
improved (43rd to 32nd).
State Findings: Nebraska, 2016

23. 42nd
TN #1
11.2*
20.4*
* Percentage of adults who self-reported either binge drinking
(consuming more than 4 [women] or more than 5 [men] alcoholic
beverages on a single occasion in the last month) or chronic
drinking (consuming 8 or more [women[ or 15 or more [men[
alcoholic beverages per week) Source: American’s Health Ranking, 2015 http://www.americashealthrankings.org/
Binge Drinking

24.  14% of high school students reported binge drinking during
the past 30 days (2014/2015 Nebraska Youth Risk Behavioral Survey)
 20% of adults (18+) reported binge drinking during the past
30 days (CDC, 2014)
 Nebraska jumped from 8th to 5th worst in terms of its binge
drinking rates among the 50 states and D.C. in 2014 (CDC, 2014)
 Four of Nebraska’s communities (Omaha, Lincoln, Grand
Island, and Norfolk) ranked in the top 15 of nearly 200 cities
indexed for binge drinking rates across the country (CDC, 2012)
Binge Drinking in Nebraska

25. Screening, Brief Intervention, and Referral to Treatment: An
evidence-based practice used to identify, reduce, and prevent
problematic use, abuse, and dependence on alcohol and illicit
drugs.
 Screening – a healthcare professional assesses a patient for
risky substance use behaviors using standardized screening
tools in any health care setting
 Brief Intervention – a healthcare professional engages a patient
showing risky substance use behaviors in a short conversation,
providing feedback and advice
 Referral to Treatment – a healthcare professional provides a
referral to brief therapy or additional treatment to patients who
screen in need of additional services (SAMHSA)
What is SBIRT?

26. Between June 6, 2016-August 31, 2016 screened 536
patients 19 and older were eligible to be screened and
369 were screened
86 of the 369 (23%) scored positive on the AUDIT –C
for some level of risk (4 or higher on AUDIT C) for
their alcohol use.
Next Steps—Improve Brief Intervention Work through
Integrated Care and Roll out to 30+ clinics as we
implement Patient Centered Medical Home. In
addition CRAAFT has been added for adolescents.
SBIRT Pilot- CHI Health Family
Practice Pilot

28. Nebraska ranks 12th overall but…
It ranks 41st in Colorectal Cancer
Screening compared to other states
A Case for CRC Screening
Sources: America’s Health Rankings 2016
Nebraska Department of Health and Human Services (N/A) “Nebraska Colon Cancer Screening Program”.
http://dhhs.ne.gov/PublicHealth/NCP/Pages/Home.aspx

29. Achieving 80% by 2018 in Nebraska
means, fewer people will be
diagnosed with colorectal cancer and
lives will be saved by 2030.
Robinson, Tamara and et al (N/A) “Nebraska 20/20: An Academic-Practice Partnerships Model for Health- A
Community Based Approach to Increasing Colorectal Screening Rates” American Cancer Society
Improving CRC Screening Rates

30. Strategic Planning – Work Groups
WG #1 – Develop Business Case for State Funding and
Private/Donated Services
WG #2 – Identify Data Silos and Establish Data Sharing to
Benchmark
WG #3 - Establish/Recommend Guidelines for Donated
Colonoscopy Services & Streamline Process for Every Woman
Matters (EWM)
WG #4 - Develop a Unified Message and Distribution System for
CRC
WG #5 - Develop NeHII Data Analytics for CRC Data Collection
Strategic Planning- Work Groups

31. Healthy Lincoln CRC Project
27 clinics
Round 1- Early 2016
(between Feb. and May)
Round 2- Summer
(June/July)
Round 3- November 2016

32. Model how population health
can be advanced through
collaborative, multi-
institutional efforts to
improve health and
health systems on a
community
basis.
Accountable Health Community (AHC)
Bridge to Accountable
Health State

33. llll11111D
9 SOCIOECONOMIC
FACTORS
Access to health foods
Access to preventive care
Employment Equality
Connected/Accessible
transportation
Livable median wage
Quality Education
Relationships/support network
Safe/affordable housing
Safe Community
THESE SOCIOECONOMIC FACTORS , HEALTH BEHAVIORS
AND CHRONIC DISEASES IMPACT OUR QUALITY OF LIFE
94,000 OR 1 IN 6
Douglas county residents report having to limit their daily activity due
to emotional, physical or mental health
41% of these residents live in NE and in SE Douglas County
Source: Live Well Omaha
4 HEALTH
BEHAVIORS
Lack of physical activity
Poor diet
Substance use and binge
drinking
Tobacco use
INFLUENCE
4 CHRONIC
DISEASES
Cancer
Heart disease and
stroke
Lung disease
Type 2 diabetes
78% OF EARLY DEATHS
IN DOUGLAS COUNTY
Leading cause of death linked to
chronic diseases
socioeconomic
factors
40%
Clinical Factors
20%
Behavi
oral
Factor
s
30%
Physical
Environment…
THE CASE FOR AN
ACCOUNTABLE
HEALTH COMMUNITY
There are multiple
factors that impact
our health. By working
together to address
them, we can improve
quality of life and
reduce the number of
deaths linked to
chronic disease in our
community
LEAD TO CAUSING

35. The State of
our Health
Academic-private
partnerships
Changing landscape of health
Successful new models
Call to
Action

36. American Health Care Act
(AHCA)

37. Modified Source: PwC Health Research Institute
Source: http://healthyamericans.org/assets/files/TFAH-2017-FundingCrisisRpt-FINAL.pdf
Public Health: $100 billion (3% of $3.36 trillion)
Shift the focus to preventative health protecting
the entire populations through promotion of
healthy lifestyles, research for disease and
injury prevention and detection and control of
infectious diseases

39. Proposed: CMS Accountable Health Communities Core Health-Related
Social Needs Screening Questions
Housing Instability
1. What is your housing situation today?
2. Think about the place you live. Do you have problems with any of the
following? (check all that apply)
Food Insecurity
3. Within the past 12 months, you worried that your food would run out before
you got money to buy more.
4. Within the past 12 months, the food you bought just didn’t last and you
didn’t have money to get more.
Transportation Needs
5. In the past 12 months, has lack of transportation kept you from medical
appointments, meetings, work or from getting things needed for daily living?
(Check all that apply)
Utility Needs
6. In the past 12 months has the electric, gas, oil, or water company
threatened to shut off services in your home?
Interpersonal Safety
7. How often does anyone, including family, physically hurt you?
8. How often does anyone, including family, insult or talk down to you?
9. How often does anyone, including family, threaten you with harm?
10. How often does anyone, including family, scream or curse at you?

40. Precision Prevention Medicine
Geisinger Fresh Food Pharmacy:
• Participants meet one-on-one with a registered
dietitian
• Receive recipes and hands-on instruction on
how to prepare healthy meals
• Go home with different kind of prescription
consisted of five days’ worth of free, fresh food
Aubrey, Allison (2017) “Fresh Food by Prescription: This Health Care Firm is Trimming Costs- And Waistlines”. http://www.npr.org/sections/thesalt/2017/05/08/526952657/fresh-food-by-prescription-
this-health-care-firm-is-trimming-costs-and-waistline?utm_source=facebook.com&utm_medium=social&utm_campaign=npr&utm_term=nprnews&utm_content=20170508

41. AHCos
Moving to Healthcare 3.0
Halfon, Neal et al (2014) “Applying a 3.0 Transformation Framework to Guide a Large-
Scale Health System Reform” Health Affairs
http://content.healthaffairs.org/content/33/11/2003.full

42. PUBLIC HEALTH 3.0
TIMELINE
Public Health 3.0
www.heathypeople.gov/ph3

44. The State of
our Health
Academic-private
partnerships
Changing landscape of health
Successful new models
Call to
Action

45. • Multi-sectoral partnerships
• Backbone organizations
• Data and metric
• Leadership
• Practical evidence-based interventions
Aligned Financial Incentives
Secret Sauce

46. https://www.washingtonpost.com/news/to-your-health/wp/2017/05/08/u-s-life-expectancy-varies-by-more-than-20-years-from-county-to-county/?utm_term=.46c85ccbad7d
Life Expectancy across the U.S

47. Differences in county mortality rates associated with comprehensive population health system
capital, 2014.
Glen P. Mays et al. Health Aff 2016;35:2005-2013
©2016 by Project HOPE - The People-to-People Health Foundation, Inc.

48. All Costs $ All Outcomes
Your Activities Here
Shared Savings

49. YOUR CHALLENGE
CONVINCE THEM TO PROMOTE
FRUITS AND VEGETABLES

50. Acknowledgements
Trang K Hoang, MPH
Matt Bosley, MD, MPH-Candidate
Bob Rauner, MD, MPH