Public health's role in health care reform—Lessons from Massachusetts

How will full implementation of the Affordable Care Act (ACA) affect the work and goals of state and local public health departments—and how can public health personnel contribute to the success of health care reform? The experience in Massachusetts has some important lessons, according to an article published online by the Journal of Public Health Management and Practice.

Just as Massachusetts was implementing its ground-breaking legislation, John Auerbach was appointed state Commissioner of . In a special 'Management Moment' article, he addresses some lessons learned—"our victories as well as our mistakes"—regarding the public health's role in the era of reform.

'Five Important Lessons' from the Massachusetts Experience

With the ongoing nationwide rollout of the ACA, public health activists and employees at the local, state, and national levels are asking what health care reform will mean for the work they do. In his article, Auerbach—now Distinguished Professor of Practice and Director of the Institute on Urban Health Research and Practice at Northeastern University, Boston—summarizes five important lessons learned from the Massachusetts experience.

Getting a Seat at the Table—Auerbach "learned the hard way" that public health personnel had to fight for a decision-making role in implementing health care reform. They needed a crash course in the basics of insurance, while building an appreciation for the "values, priorities, and incentives" of insurers. They also came to understand the need for hard data to demonstrate some of the "core assumptions" of public health—for example, that programs would produce short-term reductions in health costs.

Taking a Critical Look at Public Health Work—Rather than a "circle the wagons" mentality, Auerbach and colleagues learned they needed to make a "balanced, analytical assessment" of how health care reform would affect public health initiatives. Instead of reacting to program cuts, Auerbach now thinks his department would have been better off performing a comprehensive review of the likely impacts on various programs. "[C]hange was inevitable," he writes. "We were either going to be guiding change or reacting to it."

Defending Traditional Public Health, When Appropriate—In some cases, public health officials needed to make a stand in defense of traditional public health services. Auerbach cites the key example of childhood vaccination programs—planned cuts in state funding would have dealt a major setback to statewide success. It took months of negotiations with the legislature and insurers to come up with a "creative alternative" to across-the-board cuts.

Watching for Chances to Contribute—By "trial and error," Auerbach and colleagues identified a few important opportunities for public health to contribute to the success of health care reform. These included efforts to help reduce health care costs while documenting improved health outcomes. In hindsight, Auerbach believes this should have been a higher priority—perhaps coordinated by national public health organizations.

Envisioning a Better Model—Over time, the emphasis of health care reform in Massachusetts shifted from expanding access to controlling costs and improving the quality of health care. As they gained familiarity with the insurance industry, the public health community became "better prepared to conceptualize new models for linking population health with reimbursable clinical care." Auerbach outlines some programs included in the state's updated global payment model, developed with public health input.

While there's still a "very steep learning curve," Auerbach writes, "Health care reform is working in our state [with] continual involvement of public health officials and practitioners in the process." He hopes the lessons learned in Massachusetts will be of value as the ACA becomes implemented nationwide—particularly in ensuring that the essential public health mission continues to survive and thrive in a changing health care environment.

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