By LaMar Hasbrouck, MD, MPH, Executive Director, NACCHO

This month marks the sixth anniversary of the passage of the Patient Protection and Affordable Care Act (ACA). The law has brought about significant change to the healthcare and public health landscape, fundamentally shifting how we as a nation think about the meaning and value of health.

The Department of Health and Human Services estimates that an impressive 17 million uninsured people have gained health insurance under the law. In addition to expanding access to care, the ACA encourages a more holistic approach to care by rewarding clinical care providers for value instead of volume. As a result, we’re seeing a greater focus on quality and outcomes in the clinical setting.

The law has also facilitated a closer link between public health and clinical healthcare providers. The ACA offers new mechanisms for paying for prevention and incentivizes hospitals to engage in activities beyond their walls to improve the health of their communities. It has also brought about new payment structures that are modifying previous ways of doing business. In the face of these changes, local health departments (LHDs) have been grappling with how to define their unique value and role in a changing system.

The Public Health Transformation Sentinel Network
In the fall of 2014, NACCHO created the Public Health Transformation Sentinel Network to collect information about how LHDs are responding to health system transformation at the local level. The network includes 39 members in 28 states. NACCHO surveyed the network three times in 2015. The findings, summarized in a recent report, show that LHDs are pursuing a number of different strategies to adapt to health system transformation.

The survey found that the majority of LHDs have changed the way they operate because of the ACA. Some LHDs have limited their role as clinical care providers, instead taking a more population-focused approach. Many are serving as health system navigators to connect people to care. Network members also reported involvement in activities related to expanding Medicaid eligibility; some noted that members of their staff have become Certified Application Counselors to better serve as health system navigators.

Other LHDs have expanded clinical services, exploring mechanisms for billing and reimbursement that better align with the new system. Those LHDs are engaged in evaluating the need for their clinical services and assessing the financial viability of providing such offerings. LHDs that have successfully implemented such billing and reimbursement models have found the revenue from such services offers a reliable and sustainable funding stream. Others have concluded that it no longer makes fiscal sense to continue offering clinical services.

LHDs are also engaging with clinical care providers in unprecedented ways. For example, survey results show that 42% of respondents were aware of LHDs in their state that were exploring involvement in the Accountable Care Organization (ACO) model. LHDs are also serving as conveners in their communities by facilitating community health assessment and improvement planning in coordination with hospitals and other community partners. This renewed need for collaboration is requiring LHDs to work with a growing number of local stakeholders.

New Opportunities, New Challenges
While health system transformation has created multiple opportunities for LHDs to improve population health, it has also presented a number of challenges. Funding for LHDs has declined significantly over the last decade, leaving many LHDs underprepared to meet the demands of a new era.

Survey respondents noted that LHDs lack the capacity, infrastructure, and workforce needed to fully engage in public health transformation. LHDs need employees who are able to work across sectors, identify and address health inequities, make data-driven decisions, and think strategically about how to meet the needs of their communities.

Small and rural health departments face particularly challenging issues. Many of these health departments remain safety-net clinical care providers in their medically underserved communities, and yet may be simultaneously encouraged to move away from a clinical care model to a population-based approach. Indeed each LHD will have to analyze the unique factors in their community to determine the best way to serve their residents moving forward.

Looking Ahead
LHDs will likely be contending with these changes to our public health system and their role within it for several years to come. LHDs are undeniably facing a complex set of issues; no one solution is right for every health department. NACCHO strongly encourages all LHDs to develop a clear vision for their communities; remain nimble, adaptive, and willing to move in new directions; and communicate clearly and repeatedly the value of their work to their constituents and partners. The ACA is a catalyst that is ultimately changing the culture, consciousness, and purpose of public health. NACCHO remains committed to helping LHDs navigate this uncharted territory by sharing innovative models and practices, facilitating peer-sharing, developing helpful tools and resources, and asserting the value of LHDs on Capitol Hill. Together, we’re shaping the future of public health.

Resources

• Public Health Transformation Sentinel Network Report
• Public health transformation video
• NACCHO Exchange: Public Health Transformation
• Charting a New Path: Helping Local Health Departments Navigate Emerging Issues in Public Health, Journal of Public Health Management and Practice, March/April 2016
• 2015 Forces of Change Survey
• Stories from the Field: A Community-Wide Effort to Expand Access to Health Insurance