Obamacare and the Legacy of Population Health Improvement
*LaMar Hasbrouck, MD, MPH
Executive Director, National Association of County and City Health Officials, USA
Submission: February 21, 2017; Published: February 28, 2017
*Corresponding author: LaMar Hasbrouck, Executive Director, National Association of County and City Health Officials, Washington DC, USA.
How to cite this article: Lamar H. MenObamacare and the Legacy of Population Health Improvement. JOJ Pub Health. 2017; 1(2): 555560. DOI:10.19080/JOJPH.2017.01.555560
Commentary
Nowadays, there’s a lot of talk about dismantling Obamacare. Opponents debate the best ways to repeal and replace parts or all the 2010 law. Proponents, on the other hand, lament the potential fate of roughly 24 million Americans that have benefited from the expanded health care coverage. Pundits and prognosticators attempt to predict the fate and timeline of the law, and the required bridge legislation that will be required for a realistic transition from what is to what will be. To say that Obamacare is a political football would be an understatement. Therein lies the problem. The label “Obamacare” stuck, ensuring that it would remain a partisan law synonymous with the administration of former President Barack Obama. That is unfortunate because of the tendency to throw out the baby with the bathwater. No law is perfect. This one is no exception. The law as drafted was cumbersome and unwieldy. Its more than twenty thousand pages, individual mandates, and personal penalties were not popular. There were the communication problems, including messaging about keeping your doctor which was confusing if not misleading. Then there was the website, healthcare.gov, that turned turn the information superhighway into a traffic jam at rush hour.
Seemingly lost in the partisan politics was the original intent of the law. The Patient Protection and Affordable Care Act (PPACA), Obamacare by its original name, is more descriptive of the purpose (and spirit) of the law, namely to provide patient-centered, health protection that won’t break the bank. By expanding federal Medicaid, creating insurance exchanges, implementing payment and insurance reforms, and encouraging innovation, PPACA has effectively broadened the tent of health coverage for millions of Americans. What’s not to love about that? Significantly, the law also recognized the importance population health, or as I like to call it, health beyond the walls of the medical facility. That provision might be one of the most significant, yet underappreciated, parts of the law.
By directly (and indirectly) promoting population health improvement, PPACA represents a major paradigm shift: apurposeful call to action to prioritize the link between health care and population health, and the importance of the enabling ecosystem. There is a growing consensus among health professionals that health is not merely the absence of disease, but rather the state of complete physical, mental, social, and spiritual well-being. Further, there is an appreciation for the harmonious relationship that exists when healthy individuals thrive in resilient communities supported by sustainable systems of health. Yet, despite this more holistic view of health, policy makers tend to equate health with health care. In doing so, they ignore or minimize importance of contextual factors that influence health. The way that we have traditionally measured the health of populations was by calculating rates of death, morbidity, disability, hospitalization, and life expectancy. In other words, we tracked only the metrics for physical health. Increasingly, we are incorporating broader measures that in fact predict those measures: the social determinants of health. These determinants of health are far more contextual in nature and include income, housing, food security, educational attainment, transportation, presence or absence of social service providers, language proficiency, neighborhood stability, and more. The predictive value for health status based on whether someone has a regular health care provider pales by comparison to whether someone lives in lower income neighborhood with all the factors that are inherent in such a neighborhood. For example, zip codes have become the most powerful predictor of life expectancy.
We should be mindful that while context matters, it is possible to overcome some of these influences. Health outcomes are poorer for people living in some zip codes in part because of specific deficits (e.g., jobs with livable wages, quality schools, fresh produce). However, every community, no matter how challenged also has strengths (assets). The key for vulnerable communities is to augment their assets in meaningful ways that result in improved health outcomes for the residents. Population health improvement specialists, including public health experts, can assist in this endeavor, but the community must take the lead. There are several critical questions that must be addressed to improve not only the health, but the health expectancy of communities. I define health expectancy as the reasonable expectation that a person living in given community can expect to achieve and maintain health and wellness. The first question is who will convene community stakeholders, including informal leaders, business partners, health care and public health professionals, and leaders from other important sectors to have a constructive dialogue about the needs? Second, who will act as the master architect (or chief community health strategist) and set the agenda for discovering and investing in solutions for building a culture of health? Third, how will this agenda be articulated and disseminated? And finally, what shifts need to occur to embolden, encourage, incentivize, enable, and support the members in the community to invest in the plan to transform community?
If communities can successfully address these critical questions, they can begin to collectively attack the precursors to poor health outcomes. When this occurs, the gaps in health outcomes have the potential to close, and the expectancy for health will likely increase. Successful strategies will undoubtedly incorporate community organizing, priority setting, and recruitment of resources; they will require access to actionable data and ongoing measurement to track progress to goals; and, they will employ innovative social networking and consumer interactive tools.
Obamacare is far from perfect. But there are some features that have been universally welcomed, such as coverage for dependent children until age 26, preventive care services like immunizations, and guaranteed health coverage even with preexisting conditions. However, there were some design flaws. Regrettably, for some, there have been raising premiums, unaffordable co-pays, and limited physician choices. Whatever becomes of the law, it’s emphasis on population health improvement has forced health care providers to look beyond their examination and waiting room. They must now look out into the communities in which their patients live, work, and play. Hopefully, that genie will not be put back into the bottle.