AZPHA has a track record which goes back to decades of advocating for the advancement of public health. When it comes to achieving that goal, many factors come into play. At the cornerstone is the importance of preventing illnesses and injuries - think of the old saying "a stitch in time saves nine".
But prevention (things like vaccines, epidemiology, food safety and security, nutrition, maternal and child health, assurance and licensure, physical activity) isn't enough to improve health outcomes. Folks need access to healthcare too for both preventive checkups and other care that might be associated with acute or chronic medical conditions.
That's one of the reasons that we were so pleased when the Affordable Care Act passed a few years ago. Not only did the law make strides toward providing healthcare to people that didn't have health insurance, but it also implemented interventions and aligned incentives to keep people healthier. An essential core public health value.
I've never been one to believe that there's only one way to improve health outcomes and provide better access to care, but I've always believed that the ACA brought us down the road toward achieving those goals.
When Americans voted in the last election, there were clear differences of opinions amongst candidates for various offices about the effectiveness of the ACA. Now that the election is over, elected officials are in the process of implementing policy decisions related to access to care and public health that could have very real-life consequences.
This week the US House of Representatives leadership unveiled their plan to overhaul the US healthcare system and repeal and replace the ACA. It's called the American Health Care Act. There would be a lot of changes to the US healthcare system if it ultimately passes as-is. It's complicated, but I'll try to hit the high points.
For one thing, the bill would repeal the individual mandate that people get health insurance or face a tax penalty. A main reason that the individual mandate was included in the ACA is to broaden the pool of people buying health insurance- a tool to lower overall costs. It's unclear how premiums will be kept in check without the mandate. The proposal mentions the creation of high-risk pools, something that has been tried before but hasn't been successful.
The bill would offer people "refundable tax credits" to help people buy health insurance rather than the current subsidy system. Current ACA subsidies to buy insurance in the state and federally facilitated ACA marketplaces would end and be replaced by lower advance-able refundable tax credits. I can't intuitively see how making this kind of change makes buying insurance more affordable- but maybe I'm missing something. It would generally keep intact the ACA's requirement that health insurance cover people with pre-existing health conditions- but it would let insurers charge higher amounts to people that let their health insurance lapse.
Perhaps some of the biggest changes in terms of access to care would be in the Medicaid system- our health care system for low income people. Low income has long been linked to worse health outcomes for a host of reasons- so it's no surprise that many of the health disparities in the US are among people that have their health insurance through the Medicaid system.
The American Health Care Act would restructure the Medicaid program so that states get a set amount of money from the US every year, placing a lot more financial risk on the states basically transferring financial risk from the federal government to the states. Down the road, this would likely result in more stringent enrollment criteria, lower payments to providers, and fewer covered services in states- limiting healthcare among those with the largest health disparities.
The plan would also repeal the federal funding that helped finance Medicaid expansion up to 138% of the federal poverty limit. Thirty one states have expanded Medicaid as allowed by the ACA (including AZ of course). It's unclear what the plan would be to get this group (people between 100 - 138% of federal poverty access to healthcare).
The proposal also freezes Medicaid funding to Planned Parenthood for a year. Thus would limit low income women's access to cancer screening, family planning etc. in many parts of Arizona.
Finally, the proposed plan would eliminate the Prevention and Public Health Fund which would have a profound impact on core public health functions at the CDC and in state and county public health programs. The plan eliminates the fund in FFY 2018, substantially reducing CDC investments in states for things like vaccines, programs to reduce chronic diseases, epidemiology and laboratory capacity. This would result in an immediate reduction in about $9.3M/year in public health funding in Arizona.
Perhaps the most damage would be done to the "317" vaccine program, which would be reduced by 50%. The 317 Immunization Program plays a critical role in achieving national immunization coverage targets and reductions in disease. This critical program supports vaccinations from newborns to seniors. Hardly a smart idea, since vaccines are the number one and most cost-effective public health intervention of the last 100 years.
By eliminating these public health investments in evidence-based disease prevention programs states (including Arizona) could also lose critical programs that fight obesity, tobacco, and respond to public health threats like outbreaks of infectious diseases.
The Prevention and Public Health Fund represents 12% of CDC funding - so that kind of loss to the agency would inevitably result in lost public health prevention capacity across the country.
Remember, the proposed American Health Care Act released this week is just that- a proposal. In order to be implemented, it would need to be approved by our federal elected officials- people that work for us- the American people.
To view APHA's stance on the AHCA, please click here.
Let's make sure they're acting in our best interest by asking important questions and adding our public health voice to the debate.