By Edward McField, PhD, Associate Professor in the Center of Leadership in Health Systems
Fast Facts: El Sol Neighborhood Educational Center
- Began in 1991
- Trains Community Health Works in a partnership with LLU SPH
- Impacts more than 250,000 people through various outreach and educational programs
- Has programs in nutrition, mental health, domestic violence, and other areas
Fast Facts: African American Health Coalition
- Formed in 2006 as a key advisor to the County of San Bernardino
- Is a group of health care and mental health medical advocates
- Collaborates with El Sol Neighborhood Educational Center
- Advocates for positive changes by eliminating barriers to care and promote culturally relevant activities and research
Number of people in millions who were previously uninsured, now covered by insurance because of the ACA.
...one of the intangible results of the ACA is that it opened up a space for much needed discussion on strategies to improve access and quality, while reducing costs.
The Rear-view Mirror: Where Were We?
It seems like it was only yesterday that the nation was engaged in what could be appropriately described as a never-ending cycle of rhetorical and philosophical debates about the best strategies to increase access and improve quality, while stemming the exponential increase in costs of health care. By now, we all know and are able to effectively articulate the difference between the Patient Protection and Affordable Care Act (ACA) and “ObamaCare.” Answer: There is no difference. But what are the implications and opportunities for public health?
Perhaps many family gatherings were ended prematurely because of the debate on the subject of health care reform, a debate often heavily politicized. However, even political allegiances were not enough to identify supporters from detractors. On one hand, some thought the law did not go far enough to ensure universal access. Others soon recanted and abandoned some of the very key provisions that they had initially conceived, proposed, and championed, such as the requirement that everyone assume personal responsibility for their health insurance or pay a fine.
Proponents of reform argued that too many people lacked health coverage and care; the system focused on treatment instead of prevention; there was a lack of attention to social determinants of health and health disparities; an inefficient delivery and payment system; US health care spending unsustainable; and that despite expenditures, the US system ranked low in terms of health outcomes. President Obama himself articulated many of these arguments in an Op-Ed that appeared in The New York Times. Not surprisingly, the argument was that health care reform should then include the goal of promoting equity in access to care, support for primary care, enhanced health information technology, new payment models, a national quality strategy informed by research, and federal requirements for health care disparity monitoring.
The ACA was approved and then signed into law on March 23, 2010, with some of the key provisions taking effect on January 1, 2014. Although the debate of its virtues still rages in some congressional circles, the public seems to have accepted that the ACA is here to stay. But has the ACA lived up to its promise or is this a case of severely over-promising and extremely under-performing? Or is the truth somewhere in the middle?
Where Are We?
The ACA includes provisions that seem to have a polarizing effect. One of these is the “individual mandate,” the requirement that all individuals have health insurance or pay a penalty, later technically defined as a tax by the US Supreme Court as it upheld the constitutionality of the law. Conversely, a much beloved feature is the elimination of “pre-existing conditions” which came into effect this year. I had a first-hand experience with this a few years back when I found myself shopping for health insurance for my family. As my wife filled out the necessary forms, she responded honestly and in the affirmative to some of the questions in the application. It was not a surprise (but disappointing) that a few weeks later we received a letter from the insurance company rejecting our application. Fortunately, it was not a life-threatening situation and we had the fall-back option of employer-sponsored insurance but the experience certainly increased my empathy for the millions of individuals who did not have health insurance due to the pre-existing condition loophole.
Today, this barrier to health care no longer exists. Reports show that the ACA has reduced the number of uninsured. The Centers for Disease Control and Prevention (CDC) reports that forty-one million or 13.1 percent of U.S. residents were uninsured during the quarter when benefits started to take effect for people who signed up for coverage into private insurance or Medicaid via the health exchanges or elsewhere. That’s the lowest number and percentage of uninsured people since the CDC started conducting its survey in 1997. It’s also down 3.8 million people and 1.3 percentage points from 14.4 percent at the end of 2013.
Similarly, the RAND Corporation, a nonpartisan and nonprofit national research organization that develops solutions to public policy challenges, estimates a net gain of 9.3 million in the number of American adults with health insurance coverage from September 2013 to mid-March 2014. The 9.3 million-person increase in insurance is driven not only by enrollment in marketplace plans but also by gains in employer-sponsored insurance (ESI) and Medicaid. The report concluded that for most people the ACA has not changed their health insurance coverage and that among adults, 80 percent still had the same form of coverage in March 2014 as in September 2013. This is significant, as the concern that there would be massive cancellation of employer-sponsored policies as a result of the ACA, has not materialized.
Notwithstanding, it would be a mistake to describe the gains resulting from the ACA solely in quantitative terms, such as the number of individuals covered or the opportunity costs, but an argument can be made that equally important are the qualitative benefits. For example, one of the intangible results of the ACA is that it opened up a space for much needed discussion on strategies to improve access and quality, while reducing costs. Many public health professionals fittingly celebrated the passage of the law, a crowning achievement of decades of public advocacy to focus on prevention.
Where Are We Going?
Since the passage of the ACA, policymakers, insurance companies, and health providers are all anxious to determine what factors contribute to increased enrollment and subsequent appropriate use of coverage. Although increasing access to care is a worthy goal, it is important to recognize that improved access to care is not analogous to improved utilization of health care services. In other words, obtaining insurance does not guarantee appropriate and timely use of services. My research among Latinos, African American, and Asian-Pacific Islanders, found that access is often determined by structural or systems factors that impact availability, whereas utilization is generally predicted by cultural or attitudinal factors. The structural and individual-level factors often interact with one another and successful interventions to improve health and access to health care should focus on both.
The ACA does not only represent opportunities for health care providers but also for Loma Linda University School of Public Health. The school (LLU SPH) has garnered increased attention, stemming from a variety of endeavors, including but not limited to cutting edge research on consumption of walnuts, in the Adventist Health Study, and efforts in tobacco cessation, to name a few. While Loma Linda University has always embraced a moral imperative to focus on prevention and wellness, if anything, the ACA now provides the legal framework and justification for promoting some of the long-standing health values and focusing on community-level interventions to improve health and healthy living. Researchers at LLU School of Public Health also continue to explore additional questions, including but not limited to:
What are some of the culturally-relevant, cost effective quality improvement strategies for organizing and delivering care?
What organizational characteristics are needed to support effective work site wellness policies and programs?
How to effectively assess health in all policies and the impact on social determinants of health?
LLU health and social entrepreneurs, including clinicians focused on finding new ways to organize and deliver health care, to entrepreneurs capitalizing on the newfound emphasis on prevention and wellness, are maximizing opportunities afforded by the ACA. Consistent with this vision, the LLU School of Public Health continues to build on its commitment to the surrounding community, particularly in the city of San Bernardino.
One does not have to go too far to identify non-clinical community-based organizations that are embracing the promise of the ACA. One of those organizations is El Sol Neighborhood Educational Center (El Sol), which is currently developing training for Community Health Workers to become integral to the health delivery system throughout the Inland Empire.
Community health workers are community members who serve as connectors between health care consumers and providers to promote health among groups that have traditionally lacked access to adequate health care. This approach is consistent with Community-based Care Transition Teams that are referenced in the ACA. Alexander Fajardo, Director of El Sol, said, “clearly there is a need for clinicians and health centers to better interface with the community they serve. This is the goal of the Clinical Community Health Worker initiative, which builds on a longstanding tradition and proven strategy of using paraprofessionals and community residents to achieve sustainable change in attitudes, behaviors, and skills not only to manage disease but to prevent them.” LLU Institute for Community Partnerships and the LLU School of Public support El Sol in developing its capacity to prepare community health workers, a fitting example of opportunities for workforce development enshrined in the ACA.
Another LLU non-clinical partner that is embracing the ACA to improve health is the African American Health Coalition (AAHC), which is working not only to increase knowledge and change attitudes towards the health system among marginalized communities but also to connect individuals and assist with navigating the complex health system. All state Marketplaces resulting from health reform are required to have Navigators and other similar Assister Programs to help consumers understand their coverage options, apply for assistance, and enroll. As Linda Hart, Director of the AAHC affirms, “our community has capacity but our goal is to reduce stigma of using community health services or general stigma attached to illness, particularly mental health”. The School of Public Health is providing support to the African American Health Coalition through technical assistance with training, and program development and evaluation, as it works to improve access and appropriate use of health services.
The cases of El Sol Neighborhood Educational Center and the African American Mental Health Coalition are only two of several examples in which the LLU School of Public Health is actively engaged in improving health and strengthening the safety net, a system of health care providers that primarily serve patients who otherwise cannot afford or gain access to care. However, improving the delivery of services is not enough. This only addresses one part of the “downstream” versus “upstream” equation. One emphasizes treatment and care, whereas the other emphasizes prevention and addresses the social and environmental factors that impact health (also known as social determinants). To achieve improved health and a reduction of aggregate health care costs, we must embrace the ACA’s focus on prevention, a hallmark of Loma Linda University’s tradition and its value of whole-person care. At LLU School of Public Health we have an opportunity to impact social determinants of health and where needed, intentionally engage in advocating for systems changes and policies that promote health equity and improve and sustain healthy lifestyles.
Remember the 45,000? That is the number of individuals who died every year because of lack of health insurance prior to the passage of the ACA. The ACA, as any other law, is not perfect and there are always opportunities for change. Although it represents an important step forward it should be contextually recognized as merely the continuation of efforts to improve our nation’s health. LLU’s emphasis on prevention and wholeness is timeless and transcends ideology. Herein is the opportunity for the School of Public Health, to design strategies that impact individual health, build community capacity to foster healthy environments, as we promote interventions that improve health systems. This is an open invitation to join these efforts.
Ed McField, PhD, is Associate Professor and Program Director, DrPH in Health Policy and Leadership at Loma Linda University School of Public Health. He is affiliated with the Center for Leadership in Health Systems where he focuses on health equity, access to health care, and strengthening the safety net.