I remember very well the evening of March 21, 2010. There was a possibility that Congress would pass that night what has come to be known as the Affordable Care Act (ACA). I told my family, "I am going to bed, and when I wake up in the morning, my work may be tripled for the next 10 years." The ACA,1 the most sweeping piece of health legislation since the 1960s, was passed that evening and was signed into law 2 days later.
In the 4 years since the ACA was passed, the US health system has begun a process of transformative change. The health care and public health systems are working to understand what it means to focus together on the Triple Aim of better health, better care, and lower cost,2 and the Centers for Disease Control and Prevention (CDC) has adopted as one of its 3 strategic priorities building a stronger link between public health and health care. This is hard work.
I know firsthand how challenging it is to think about how public health can contribute to a transforming health system in my role as Director of the Georgia Health Policy Center (GHPC) at Georgia State University. The GHPC has been engaged nationally in this space since before the ACA was passed:
* In 2006, the GHPC studied the business of public health in Georgia.3 The study revealed that people trust public health and look to it to lead to healthier communities.
* Two years prior to the passage of the ACA, the GHPC was asked by the CDC to create a framework for how potential health reform legislation might include a focus on public health. A comprehensive, nationwide study culminated in a "Health in All Policies" framework and a report titled, "Finding the Voice of Public Health in the National Health Reform Dialogue: An Integrative Model for Health System Transformation."4 In fact, one passage of the ACA contains language from this report.
* In 2009, the GHPC assembled a multidisciplinary health reform team to study and translate the law as it evolved. The objective was not to judge the law but rather to understand it and to help others comprehend and adapt to it.
* Subsequent to the passage of the ACA, the health reform team developed case studies on the impact of health reform for 15 stakeholder groups and published, "Health Reform: From Insights to Strategies, A Variety of Perspectives."5
* The team also developed a series of policy briefs, provided consultation to other states, produced the 50-State Health Reform Calculator for Small Businesses, and developed presentation materials on the ACA for a wide range of stakeholder groups. These stakeholder analyses provided the opportunity for the GHPC to not only gain in-depth learning regarding many facets of the legislation but also help these groups better understand the ACA and its potential impact on their organizations.
Recognizing how challenging it was for state and local public health leaders to think about how the ACA might affect their roles in a transforming system, the CDC once again partnered with the GHPC and the National Network of Public Health Institutes in 2012 to develop a planning tool to help local, state, and national public health professionals lead through health system change with an adaptive leadership mind-set, using policy opportunities included in the ACA to advance population health. Adaptive leadership, among other things, is about getting up on the balcony and viewing patterns instead of being caught up in the field of action.6
"Leading Through Health System Change: A Public Health Opportunity Planning Tool"7 was developed with insights of the CDC, the GHPC health reform team, 20 national public health leaders, and the Association of State and Territorial Health Officers senior deputies and was piloted with the California Department of Public Health and Virginia's District Health Directors.
The planning tool is divided into 3 sections: Health Reform 101; Adaptive Leadership; and guided practices. The guided practices include questions related to public health's role in the provision of clinical services, surveillance and monitoring of health status, and community health planning. The intent of the tool, beyond its aid in planning, is to give public health leaders practice using adaptive leadership skills. Each guided practice question is transformed from a technical to an adaptive question. By working through the guided practices, public health leaders are better able to apply adaptive thinking to system change opportunities as they emerge.
The tool was officially launched on July 1, 2013. It has been widely disseminated, including being featured in the Morbidity and Mortality Weekly Report8 and by the American Public Health Association during National Public Health Week and in The Nation's Health.9 Currently, there are more than 1250 registered users from all 50 states. Through active dissemination, technical assistance, and continued refinement, the planning tool is supporting public health leaders in adapting to a changing health environment.
As I reflect on the transformation our health system has begun, I look forward to the near future in which public health leaders are prepared to leverage the ACA, and other policy opportunities, to improve population health. Four categories that the GHPC team identified for involving public health professionals were as follows: (1) public insurance coverage including Medicaid, Medicare, and children's health insurance; (2) private insurance including health insurance companies, managed care, health insurance exchanges, and the private insurance market; (3) quality and measurement including the Centers for Medicare & Medicaid Services, the Agency for Healthcare Research and Quality, and Healthcare Effectiveness Data and Information Set; and (4) provider education including physicians, advanced practice nurses, physicians assistants, behavioral health providers, and other health professionals. To leverage these opportunities, public health leaders need to be in the right place at the right time. This will require them to be armed with the tools, knowledge, and skills to inform the future of public health; able to address technical and adaptive challenges; and able to build bridges and embed public health into all aspects of the health care system. They will need to be knowledgeable about how public health principles can be promoted and integrated into public and private health care financing and reimbursement, and they will need to be tireless.
The articles in this issue provide insight and guidance to public health leaders who want to apply adaptive leadership skills to challenging issues. Two address subjects related to the provision of clinical services (the tool's first guided practice). One explores how the implementation of Patient Centered Medical Homes encourages integration of public health,10 whereas the other explores the potential for community health workers to expand their capacity to perform enrollment tasks and service delivery.11 Another article focuses quality and measurement (the tool's second guided practice), providing a roadmap for evaluation of insurance exchange functions.12
Three articles focus on community health needs assessments13,14,15 (the tool's third guided practice). The articles examine the relationships between collaborative community assessment and population size, governance types, and local health department and coalition-led efforts; the range of per capita community benefit spending that is allocated for community health improvement activities; and how the ACA, coupled with meaningful use requirements, led to increased collaboration and shared priorities among stakeholders in a rural community.
There are other examples of high leverage, adaptive public health leadership all around us. The California Department of Public Health, after using the public health planning tool, has positioned itself to be in the right place at the right time by hiring a health reform lead with a background in Medicaid and by assigning a staff person to be present in meetings related to the health insurance marketplace. The CDC has teamed up with the Centers for Medicare & Medicaid Services to share in the evaluation of Centers for Medicare and Medicaid Innovation awards. Public health is leading or actively participating in the development of accountable care communities.
Sometimes people tell me they fear they have missed the boat when it comes to impacting the implementation of the ACA. I do not see it this way. We are only 4 years into the implementation of the most sweeping health policy of our generation. To me, there are endless opportunities that will result in improved population health. My instinct on that evening of March 21, 2010, was correct. Our potential workload for the next decade has probably tripled. We need to work together to prepare as many public health practitioners as possible to lead the country through this period of health system transformation.
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