Public Health in the
Era of Health Reform
MEND Conference
June 13, 2013
Jonathan E. Fielding, MD, MPH, MBA
Director and Health Officer
Los Angeles County Department of Public Health
Distinguished Professor of Health Services and Pediatrics
Schools of Public Health and Medicine, UCLA
The Affordable Care Act presents unique
opportunities for prevention
No-cost preventive
medical services
Expanded Access to
Coverage
Photo Credit: Doug Mills/The New York Times
March 2010
Public Health &
Prevention Fund
National Prevention
Strategy
2
DPH’s Immediate
Role
• Enrolling uninsured
children and families at
DPH and partner agencies
(Children’s Health
Outreach Initiatives)
• Ensuring that full
complement of needs are
met
• HIV, substance abuse,
children with special health
care needs
3
Potential Challenges Post Health Reform
As more individuals access care:
─ Professional capacity may not be adequate to meet
demand
─ “Residually” uninsured may have less access
─ Improvements in consumer health literacy and provider
cultural competencies will be critical
As new players enter the healthcare marketplace:
─ Consumer protection will be critical
4
Prevention & Public Health Fund
• The nation’s first mandatory
funding stream dedicated to
improving public health
• Originally funded at $15 billion
for FY 2010 – 2019 and
$2 billion every year thereafter
5
• In February 2012, legislation reduced the
fund by $5 billion over 10 years.
• The fund is under constant threat of elimination.
6
Prevention & Public Health Fund:
Community Transformation Grant
• $9.8 million per year in LA County supports:
1.
2.
3.
4.
5.
Tobacco free living
Active living and healthy eating
High impact clinical preventive services
Social and emotional wellness
Healthy and safe physical environments
Percent of Adults Who Are Current Smokers,
by FPL, LA County, 2011
16
14.6
14.5
14
11.9
12
11.8
10
8
6
4
2
0
0-99% FPL
100-199% FPL
200-299% FPL
Los Angeles County Health Survey, 2011
Los Angeles County, Department of Public Health, Office of Health Assessment and Epidemiology
300% or above FPL
8
Rethink Your Drink Campaign
• Sugar sweetened beverages (SSB) are
the largest single source of added
sugar and calories in the American
diet.
• On average, nearly 39% of adults in
LA County drink at least one SSB per
day.
• > 43% of children 17 or younger
consume at least one SSB on an
average day.
– A child’s risk for obesity increases an
average of 60% with every additional
daily serving of soda.
Portion Control Campaign
• "Choose Less, Weigh Less"
• With bigger food portions come
more calories.
• Consuming extra calories can lead
to obesity, diabetes, heart disease
and some cancers.
Videos of portion size PSAs can be found at:
http://www.youtube.com/playlist?list=UUJLnJaiTK2jnRhYWyCp865g&feature=plcp
Underlying Determinants of Health
“Conditions in the social, physical,
and economic environment in
which people are born, live, work,
and age. They consist of policies,
programs, and institutions and
other aspects of the social
structure, including the government
and private sectors, as well as
community factors.”
Healthy People 2020: An Opportunity to Address Societal Determinants of Health in the U.S.,
Objectives for 2020, July 11, 2010. Top photo credit: New York Times, Beatrice de Gea, Oct 19, 2008.
Mortality (50%)
Health
Outcomes
Morbidity (50%)
Tobacco use
Health behaviors
(30%)
Diet & exercise
Alcohol use
Unsafe sex
Clinical care
(20%)
Health Factors
Access to care
Quality of care
Education
Employment
Social & economic
factors (40%)
Income
Family & social support
Community safety
Programs and
Policies
County Health Rankings model © 2010 UWPHI
Physical environment
(10%)
Environmental quality
Built environment
12
Poverty is a poison
without adequate
antidotes…
but, there are ways to
mitigate the effects.
13
Partial Antidote: A Healthy Community
1. Meets basic needs of all
2. Provides quality and sustainable
environment
3. Maintains adequate levels of
economic and social development
4. Promotes health
5. Fosters social relationships that
are supportive and respectful
Adapted from Health in All Policies Task Force Report to the CA Strategic Growth Council, Dec 3 2010
and presentations by CDPH, Linda Rudolph, MD, MPH.
Adverse Health Impacts From Poor Community
Design
 traffic safety
 water quality & quantity
 social capital
 elder health & mobility
 mental health
 physical activity

air pollution
 crime & violence
 health disparities
 obesity & chronic disease
Cities/Communities with Lowest and Highest
Childhood Obesity Prevalence, 2008
Bottom 10*
Top 10*
Obesity
Prevalence
(%)
Rank of
Economic
Hardship
(1 - 128)
West Athens
30.6
94
South Gate
30.7
Florence-Graham
Obesity
Prevalence
(%)
Rank of
Economic
Hardship
(1 - 128)
Manhattan Beach
3.4
2
110
Calabasas
5.0
8
31.0
128
Hermosa Beach
5.1
1
West Whittier-Los Nietos
31.1
81
Agoura Hills
5.3
10
West Carson
31.4
56
Beverly Hills
5.4
19
Vincent
32.2
69
Malibu
5.9
4
East Los Angeles
32.9
117
Palos Verdes Estates
7.3
5
Hawaiian Gardens
33.4
107
San Marino
7.8
15
South El Monte
34.5
111
Rolling Hills Estate
8.4
9
Walnut Park
38.7
113
La Canada Flintridge
8.5
18
City/Community Name
Average 10 highest
32.7%
Ave Median Household Income
City/Community
Name
Average 10 lowest
$37,747
6.2%
Ave Median Household Income
$99,555
16
*Table excludes cities/communities where number of students with BMI data < 500.
Source: CA Physical Fitness Testing Program, CA Department of Education. Includes 5th, 7th, and 9th graders enrolled in LAC public schools; 2000 Census
DPH Efforts toward Healthy Communities
Key strategies:
 Provide grants to cities & non-profits to create safe routes to
school plans, bicycle/pedestrian master plans, complete streets etc.
 Influence regional transportation policies to support PH goals
 Facilitate development of “joint use agreements” between
schools and cities
 Expand access to healthy foods via community market
conversions, promotion of farmers markets
 Support recreational programming and health education at
regional parks in high-crime communities (“Parks After Dark”)
Health Influences Over the Lifetime
Relative
magnitude
of influence
5
10
15
20
30
40
50
60
70
80
Age (years)
Adapted from Nordio S. 1978. Needs in Child and Maternal Care. Rational utilization and Social Medical resources.
Riviests Italiana de Pediatria 4:3-20. As cited in Halfton, N., M Hochstein. 2000. The Health Development Organization:
An Organizational Approach to Achieving Child Health Development, The Milbank Quarterly 78(3):447-497.
18
Partial Antidote:
Healthy Early Childhood and Before
Right photo credit: Cade Martin, CDC
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Prevention Before Day One
• Preconception
– Maintain healthy weight
– Folic acid supplementation
• Prenatal
– Early care
– Healthy weight gain
– Disease screening (e.g. Diabetes)
• Maternal obesity in early
pregnancy more than doubles risk
of obesity in child 2-4 years old¹
1. Whitaker, R.C. Predicting Preschooler Obesity at Birth: The Role of Maternal Obesity in Early Pregnancy.
Pediatrics 2004. 114:e29-e36.
20
Breastfeeding = Optimal Infant Nutrition
Best health outcomes are associated with:
• exclusive breastfeeding
• sustained breastfeeding
21
Breastfeeding – Prevention for Babies
Risk Differences for Various Diseases
Acute
0%
Chronic
-10%
-20%
-30%
-19%
-23%
-24%
-40%
-40%
-42%
-39%
-50%
-60%
-70%
-64%
Ip S, Breastfeeding and maternal and infant health outcomes in developed countries. Rockville, MD: U.S. Dept. of
Health and Human Services, Public Health Service, Agency for Healthcare Research and Quality; 2007.
-36%
Early Childhood Education
• Head Start enrollment
has been linked with a
reduction in childhood
obesity and decreased
smoking prevalence
later in life1
• Preschool leads to long-term gains in cognitive
ability and socialization2-6
• First 5 LA working as an equalizer across LAC
1) Ludwig J, Phillips DA. The benefits and costs of Head Start. Cambridge MA: National Bureau of Economic Research, 2007;
2) Barnett WS. Long-term effects of early childhood programs on cognitive and school outcomes. The future of children. 1995:25-50.
3) Bowman BT, et al. Eager to learn: Educating our preschoolers: National Academy Press; 2001.;
4) Yoshikawa H. Long-term effects of early childhood programs on social outcomes and delinquency. The future of children. 1995:51-75;
5) Gomby DS, et al. Long-term outcomes of early childhood programs: Analysis and recommendations. The future of children. 1995:6-24;
6) Henry GT, et al. Georgia pre-k longitudinal study: Final report 1996-2001. Atlanta, GA: Georgia State University, Andrew Young School of Policy Studies. 2003.
23
Partial Antidote: Improving Educational
Outcomes
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Education Matters:
More Formal Education = Longer Life Expectancy
Life expectancy at age 25
70
60
47.9
50.6 52.2
54.7
57.4 58.5
56.4
53.4
50
Years of School
Completed
0-11 yrs
40
12 years
13-15 years
30
16 or more years
20
10
0
Men
Women
Robert Wood Johnson Foundation. Overcoming Obstacles to Health: Report from the Robert
Wood Johnson Foundation to the Commission to Build a Healthier America. February 2008.
25
And It Matters to the Next Generation:
Mother’s Education Related to Infant Mortality
Infant Mortality Rates (per 1,000 live births)
9
8
7
8.1
7.6
Years of School
Completed by
Mother, All Ages
6.2
6
5
0-11 years
4.2
4
12 years
12-15 years
16 or more years
3
2
1
0
Robert Wood Johnson Foundation. Overcoming Obstacles to Health: Report from the Robert
Wood Johnson Foundation to the Commission to Build a Healthier America. February 2008.
26
Percent of Adults with Less than a High School
Diploma, by Race/Ethnicity, LA County
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
46%
14%
16%
13%
7%
White, Non-Hispanic
Hispanic
Black
Asian
Pacific Islander
Note: African American, Asian, Pacific Islander, and American Indian Alaska Native categories include persons reporting both
Hispanic and non-Hispanic Origin, therefore categories are not mutually exclusive
U.S. Census Bureau, 2005-2009. 5-Year American Community Survey, Table B15002 &C15002
27
Additional Partial Antidotes:
 Vocational training
 Job placement services
 Literacy programs
 English as Second
Language (ESL) Courses
 Child care supports
 Elderly/disabled care supports
 Affordable housing supports
 Unemployment coverage
 Access to legal services
Photo credit: Ruby Washington, New York Times
28
Challenge with Partial Antidotes for Poverty
• Scale
• Sustainability
• Interconnectedness
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Reversing the Poison
Sustainable solutions require many sectors together
to strategically create healthy communities
and improve social environments
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Policies as Levers of Change
Agriculture: Direct agricultural subsidies toward more nutritious
food (corn/corn syrup fresh fruits and vegetables)
Transportation: Increase development and utilization of mass
transit (less driving more walking  better air & weight loss)
Advocate for complete streets initiatives with bike lanes, marked
crosswalks
Environment: Support environmental policies to improve air
quality (e.g. cleaner energy sources, land use regulations)
Tax: Use tax policy to reduce percentage in poverty
- Increase proportion of eligible residents claiming EITC
- Use tax as an incentive/disincentive (e.g. tobacco tax)
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More Work to Be Done
• Health reform has kick-started important changes
and more work is needed to improve our local
physical and social environments
• Health and well-being are dependent on an
interplay of factors
• Public Health has to engage partners about shortand long-term health implications of decisions
and policies (i.e. Health in All Policies)
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