Improving Population Health

Community Benefit in the Population Health Literature

By David A. Kindig, MD, PhD

We try to keep this blog accessible and policy relevant, and therefore carefully avoid being overly academic. However, we also regularly follow the literature, which is a challenge given the breadth of multidisciplinary scholarship underpinning the field. So periodically I will point to particularly recent and relevant articles that may be of interest to readers. The list of 11 journals we regularly scan is listed at the bottom of this post. I welcome your flagging for me other journals and articles you suggest we follow. I’m going to start this series by focusing on an article from the December 2011 issue of the American Journal of Public Health.

The Impact of the Individual Mandate and Internal Revenue Service Form 990 Schedule H on Community Benefits from Nonprofit Hospitals by Principe K, Adams EK, Maynard J, and Becker ER.

Is There Synergy in Community Development Financing and Population Health?

By David A. Kindig, MD, PhD

It’s been more than a year since I first blogged – with some incredulity – on the first Federal Reserve Healthy Communities Conference.

The Healthy Communities Initiative was created by the Federal Reserve System and the Robert Wood Johnson Foundation to encourage stronger linkages between community development and health. That first meeting, in July 2010, was devoted to building bridges and understanding between two fields with potential for synergy in goals and resources but very little else in common (including language).

This week I attended a follow-up meeting called Healthy Communities: Building Systems to Integrate Community Development and Health. Sponsored by the Federal Reserve Bank of San Francisco, the Robert Wood Johnson Foundation, and the Pew Charitable Trusts, the meeting brought together about 120 leaders from academia, foundations, banking and finance, and the federal government (including the White House, HUD, DOE, DHHS, and EPA).

The ACA’s Essential Health Benefits: Start Simply, Learn over Time, Make it Better

By John R. Ball, MD, JD

On October 6, the Institute of Medicine released the report Essential Health Benefits: Balancing Coverage and Cost. The report was in response to a request from the Department of Health and Human Services to recommend “criteria and policy foundations” for the Secretary’s determination of the essential health benefits (EHB) required to be offered by qualified health plans participating in the new state health insurance exchanges established by the Patient Protection and Affordable Care Act (ACA).

Early press coverage, which is often the public’s only impression of such reports, pretty much got it right: the report called for a balancing of the comprehensiveness of coverage with the affordability of the benefit package. If cost were not taken into account in constructing benefits, the resulting package would rapidly become unaffordable, frustrating the central intent of the ACA, which was to make health insurance more available to more people. 

Ignoring Evidence and Economics at Our Peril

By David A. Kindig, MD, PhD

Two recent New York Times articles jumped off the page at me. The first, on the recommendation by the U.S. Preventive Services Task Force to forego routine screening for prostate cancer with the PSA test, received wide media coverage. The second, on an Institute of Medicine (IOM) panel recommendation that costs should explicitly be considered in deciding what benefits must be provided by insurance plans, received less attention. Both deserve attention from population health advocates and policy makers.

Will the Jobs Bill Impact Population Health?

By David A. Kindig, MD, PhD

The last week has seen much attention devoted to the issue of jobs and unemployment in our country. Presidential elections often hinge on the state of the economy and the persistence of high unemployment rates will likely play a greater role in 2012 than in previous periods. While a growing literature shows that displaced workers (defined as individuals who lose their jobs as part of plant closings, mass layoffs, and other firm-level employment reductions) tend to experience significant long-term earnings losses as well as decreased job stability, lower employment rates, earlier retirement, lower personal spending, and decreased health insurance coverage.

In addition to these primarily economic effects, there are likely to be health effects as well. Unemployment (measured as the percent of the population age 16 and over that is unemployed but seeking work) is one of seven key measures in the County Health Rankings’ Social and Economic Factors, but is only briefly mentioned in Healthy People 2020’s new section on the Social Determinants of Health.

CMS Turns an Ear to Population Health

By David A. Kindig, MD, PhD

Last month I was privileged to be part of a group invited to the federal Center for Medicare and Medicaid Innovation (“Innovation Center”) to discuss population health models and opportunities. Why would the federal agency with the overwhelming job of controlling health care costs and implementing health reform be concerned about this?

The reason is that the Centers for Medicare and Medicaid Services (CMS) is viewing its approach to health improvement through the lens of the Triple Aim, with its Innovation Center being a new engine for revitalizing and sustaining Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP) and ultimately, for improving the health care system for all Americans.

IRS Invites Comments Regarding Community Health Needs Assessments

We recognize the importance of IRS Community Benefit policy as a potential population health improvement tool and so want  to call readers’ attention to the new call for comments on this issue.

From the notice:

This notice addresses the community health needs assessment (“CHNA”) requirements described in section 501(r)(3) of the Internal Revenue Code (“Code”) and related excise tax and reporting obligations, applicable to hospital organizations that are (or seek to be) recognized as described in section 501(c)(3) of the Code…

…Although the CHNA requirements are not effective until taxable years beginning after March 23, 2012, Treasury and the IRS are publishing this notice regarding the CHNA requirements now because they understand that some hospital organizations may choose to start the process of conducting CHNAs and developing implementation strategies in advance of the effective date.

Comments are due September 23, 2011.

The IOM Weighs in on Multisector Health Policy

By David A. Kindig, MD, PhD

A few weeks ago I wrote about the first report in the Institute of Medicine For the Public’s Health series on The Role of Measurement in Action and Accountability. The second report, Revitalizing  Law and Policy to Meet New Challenges was released last week. Its overall purpose is to review how statutes and regulations “prevent injury and disease, save lives, and improve the health of populations.” This post will focus on the third chapter, “Intersectoral Action for Health.”

There is growing consensus around the idea that multisectoral solutions are needed to address broad population health challenges.  Various conceptual approaches have been suggested, such as Health Outcome Trusts, Accountable Health Communities (by Sanne Magnan, former Minnesota Commissioner of Health), and my own “Super Integrator” concept. The opportunity for the federal government to coordinate across all departments is also the charge and the promise of the new National Prevention Council. The IOM chapter on intersectoral action provides an excellent and concise summary of the evidence and arguments for such an approach, and includes three important recommendations (the report has nine recommendations altogether):

David Brooks: Pop Health Columnist?

David A. Kindig, MD, PhD

For me, reading David Brooks’ twice weekly New York Times column is a must. Dubbed “the liberals favorite conservative,” Brooks writes from a moderate and evidence based perspective that is almost always illuminating and refreshing.

In his June 13 column titled Pundit Under Protest, he complained about having to cover the upcoming Presidential campaign because “the two parties contesting this election are unusually pathetic. Their programs are unusually unimaginative. Their policies are unusually incommensurate to the problem at hand.”

Brooks said that what the country needs is a political party that “would be offering a multifaceted reinvigoration agenda. It would grab growth ideas from all spots on the political spectrum and blend them together. Its program would be based on the essential political logic: If you want to get anything passed, you have to offer an intertwined package that smashes the Big Government vs. Small Government orthodoxies and gives everybody something they want.”

National Prevention Strategy Released

Last week the Surgeon General and the National Prevention Council released the first National Prevention Strategy report. They are to be congratulated for this since it is a major milestone in the effort to improve population health, and should be required reading for all who share this goal. As this effort unfolds over the coming years, enhancements such as those suggested in this blog will still be required. But for now, let’s read and appreciate the effort to date.

Hospital Community Benefit: An Update on Opportunities and Challenges

By David A. Kindig, MD, PhD

Last summer, I called attention to the IRS request for comments on reporting requirements for non-profit hospitals, which must justify their tax exempt status by providing “community benefit” to the communities they serve. This is a big deal, since having this status amounts to a collective tax savings for these nonprofit hospitals of about $13 billion annually (a 2007 IRS estimate). Stories such as this one in Modern HealthCare highlight the controversial nature of this issue. Last week I attended a conference sponsored by St. Louis University and the Hilltop Institute to review current policy and research perspectives with regard to community benefit.

Dialogue on ACO Draft Rules

Dan Fox's recent post on the new draft rules for Accountable Care Organizations (ACOs) caught the attention of Charles Fahey, who observed that "multiple agencies each with its own agenda and funding streams as well as overlapping general purposes....leaves the health of the population as a whole as no one's responsibility." Fahey's comment has relevance to today's post on the accountability framework proposed by the IOM and also brings to mind a couple of pieces in the archives (see Obstacles to Population Health Policy: Is Anyone Accountable? and Do We Need a Population Health Super-Integrator?)

This policy and funding integration question remains one of the largest challenges for our field, since improvement requires action from multiple determinant sectors such as health care, public health, health behaviors, and those influencing the social and physical environments.

Academy Health Pre-Conference on Community Benefit (June 11)

Readers may recall last summer's post calling for population health advocates to send comments into the IRS regarding the Community Benefit provisions of the tax code. While no IRS revisions have yet been announced, there is great potential for this stream of funding to enhance population health investments as the uninsured gain coverage.

 

To explore these issues more fully, St Louis University and the Hilltop Institute are sponsoring a one day Academy Health pre-conference on Community Benefit June 11 in Seattle. Information can be found here. I'll be moderating an afternoon panel and would love to see many of you there.

ACOs and Population Health: Strong Goals, Weak Requirements

By Daniel M. Fox, PhD and David A. Kindig, MD, PhD

The Accountable Care Organizations (ACOs) described in the draft rules for the Medicare Shared Savings Program, published in the Federal Register on April 7, 2011, have a “three part aim”: achieving “better care for individuals…better health for populations…and lower growth in expenditures.” For the first time a federal program that finances health care has set improving population health as a prominent goal.

There is, however, a contradiction in how the draft rules address population health. The rules recognize that health has multiple determinants, but they make stronger demands for engaging in clinical prevention than for addressing these multiple determinants. This post gives examples of this contradiction and suggests ways to address it. We invite readers to comment and add their suggestions; and to note that the Centers for Medicare and Medicaid Services has established a deadline of June 6th for submitting comments.

The National Prevention Strategy Framework: Applause and Critique

By David A. Kindig, MD, PhD

Last week the Advisory Group on Prevention, Health Promotion, and Integrative and Public Health Council met for the first time and discussed its draft National Prevention Strategy Framework.

This Council and Strategy represent an unprecedented opportunity. By emphasizing integration across federal departments, the Council creates the possibility for a Health-in-All possibilities approach to health improvement that embraces a robust population health framework. The Advisory Group is ably chaired by Jeff Levi, CEO of the Trust for America’s Health (TFAH). He and TFAH have been critically important in the efforts to promote prevention and public health in health reform and other federal budget efforts.

Medicare Cost-Cutting Controversy

By David A. Kindig, MD, PhD

A front page article in today’s New York Times discusses the controversy over the yet to be appointed Medicare Payment Board. Readers may recall that I have previously and strongly advocated for eliminating Medicare (and non Medicare) expenditures that are wasteful and ineffective (see Controlling Healthcare Expenditures and Can Rationing Be Rational?). Yesterday, New York Times columnist David Leonhardt was awarded a 2011 Pulitzer Prize for work that included his deficit reduction interactive puzzle. Of 39 choices provided by the puzzle, a cap to Medicare spending (tied to 1% over GDP per capita) yielded the greatest projected cost savings and eliminated over 40% of the deficit. This option was an overwhelming favorite among those who preferred spending cuts over tax increases.

Most serious commentators have indicated that Medicare cost savings of some kind are necessary. Population health advocates see the potential for using these savings in part to rebalance our health investments and expand resources for prevention and the social determinants of health. Those opposing regulatory intervention when and where market forces are inadequate have a responsibility to show how other approaches will produce the needed results.

 

Did You Find Population Health in the State of the Union?

By David A. Kindig, MD, PhD

I listened carefully, but I don’t think I heard the words population health, public health, or prevention anywhere in the speech. But I think Obama is a closet population health advocate like Sam Brownback and Peter Orszag.

There was no mention of health outcomes, disparities, or even national health performance goals --  where we have much work to do, especially in relation to other countries. However, the domestic part of the speech dealt primarily with two major drivers of health -- education and jobs (fully 40% of the health factors score in our County Health Rankings is made up of social and economic indicators such as these).

Effective education policies have the dual benefit of improving both educational attainment and health status across the lifespan, from the earliest intrauterine life stages through formal schooling and beyond. And, in an evening when bipartisan dating was a major sub-theme, this should appeal to liberals and conservatives alike since it expands opportunity without the government directly reallocating resources.

In my experience, much of the population health research and advocacy in the areas of income and employment has focused on more liberal-leaning public governmental policies such as tax reform, income enhancement programs like earned income tax credits (EITC), and public job creation. These are important, but job creation is primarily in the private sector, and policies improving economic competitiveness need to be supported as well. I don’t know what the right balance between these is, but it should be made on evidence rather than ideology from either side of the dating game. The President also emphasized our expanding opportunities to create jobs in the clean energy sector; weaning off coal and oil has secondary unmentioned health benefits as well.

We did hear the word health, but of course only in the context of health insurance reform. Even though the County Health Rankings model only ascribes 20% of health outcomes to healthcare, it is critically important that all Americans have access to it. So I applaud the President for standing firm on this. Acknowledging that the Patient Protection Act is not perfect, he expressed hope for bipartisan enhancements. Though the President did not directly address the specifics of healthcare cost containment, it must remain a high, common ground priority on the health reform agenda. I believe we could and should eliminate or rationally ration high cost treatment options that offer little or no benefit, for both deficit reduction and redirecting savings towards prevention.

So population health improvement and disparity reduction did not rise to the level of an explicit State of the Union “Winning the Future” theme. But many of the featured components are so important in their own right that the combined secondary effect could represent a bipartisan stealth attack on this critical challenge.

David A. Kindig, MD, PhD, is Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences at the University of Wisconsin School of Medicine and Public Health.

Help Shape the National Prevention Strategy

By David A. Kindig, MD, PhD

Last Friday, a draft framework of the National Prevention Strategy was posted on healthcare.gov. The draft strategy, required by the Patient Protection and Affordable Care Act, has been developed through the National Prevention, Health Promotion, and Public Health Council, in conjunction with the Department of Health and Human Services, the Centers for Disease Control and Prevention, and other federal departments. Surgeon General Dr. Regina Benjamin chairs the council and on October 1st she hosted a conference call to overview the draft strategy and invite questions and comments from stakeholders.

The draft framework has the following vision, goals, and strategic directions, excerpted below from the full document:

Draft Vision: Working together to improve the health and quality of life for individuals, families, and communities by moving the nation from a focus on sickness and disease to one based on wellness and prevention.

Draft Goals: In order to achieve the vision for the National Prevention Strategy, efforts will be targeted toward the following goals. Each goal can be applicable to every member of the Council and to many public and private partners.

1. Create community environments that make the healthy choice the easy and affordable choice
2. Implement effective preventive practices

Draft Strategic Directions: The intent is to use the Strategic Directions a) to frame specific actionable proposals to meet the goals and achieve the vision for the Strategy, and b) as a lens through which to view federal and non‐federal activities in order to identify how they can best promote wellness and effective prevention. In large part, the Strategic Directions are designed to address ways to prevent significant causes of death and disability by focusing action on the factors that underlie these causes.

The Draft Strategic Directions are:

• Active Lifestyles
• Address Specific Populations’ Needs to Eliminate Health Disparities
• Counter Alcohol/Substance Misuse
• Healthy Eating
• Healthy Physical and Social Environment
• High Impact, Quality Clinical Preventive Services
• Injury‐Free Living
• Mental and Emotional Wellbeing
• Strong Public Health Infrastructure
• Tobacco‐Free Living

The development of this National Prevention Strategy is a welcome opportunity to ensure that health reform is not limited to health insurance reform, as important as that goal is. Population health advocates have a responsibility to help shape this effort, ensuring that it reflects the broad population health perspective which underpins this blog and the County Health Rankings. For example, as important as lifestyle and individual behavior changes are, we know that these are significantly influenced by upstream determinants in the social and physical environments. Their status as the first Strategic Goal is therefore appropriate and appreciated. Care will have to be taken that they are not lost as only one factor in the longer list of Strategic Directions. This is particularly  important given  the membership on the Council of many Cabinet Secretaries such as Education, Housing, Labor, Transportation and Energy -- a “health in all” policies perspective will be important for this work.

In addition, the draft doesn’t specifically mention early childhood and prenatal environments, but given their long term health impacts, these deserve significant attention. Finally, health care cost containment should be viewed as a community prevention opportunity strategy, as these growing expenditures necessarily limit broad population health investment opportunities.
 
During last Friday’s call, Surgeon General Benjamin responded to a very wide range of concerns, and invited additional stakeholder comments on the draft strategy. She should be commended for taking on this critical and challenging task. It is our responsibility to help her and her colleagues by submitting comments on this strategy (send to prevention.council@hhs.gov). I invite you to share your comments on the blog as well.

David A. Kindig, MD, PhD is Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences at the University of Wisconsin School of Medicine and Public Health.

How to Spend $15 Billion to Make America Healthier

By David A. Kindig, MD, PhD

Last week, the U.S. Senate defeated the Johanns amendment to the Small Business Jobs and Credit Act of 2010. In doing so, legislators spared (for now, at least) the 10-year, $15 billion Prevention and Public Health Fund established by the Patient Protection and Affordable Care Act (PPACA). The purpose of the fund is “to provide for expanded and sustained national investment in prevention and public health programs to improve health and help restrain the rate of growth in private and public sector health care costs.” (For more information about PPACA’s prevention-oriented provisions, see the recent New England Journal of Medicine perspective coauthored by Assistant Secretary for Health Howard Koh and Secretary of Health and Human Services Kathleen Sebelius.)

The landmark Prevention and Public Health fund represents a tremendous victory for health advocates throughout the country, and many have offered suggestions on what to do with the money.

Secretary Sebelius announced in June how the fund’s FY 2010 $500 million would be allocated. Those of us who celebrate the fund’s creation share a desire for the dollars to actually make a difference and the 2010 allocation provides a good starting point for improving population health. But we must seek out continued opportunities for advocacy as the allocation grows over time to an annual $2 billion in 2015-2020.

I’ve tracked the dialogue and debates surrounding the fund over the last year and have some thoughts on how a population health perspective might guide our next steps.

First, keep in mind that the fund is quite small relative to ambitious goals established by the PPACA. On an annual basis, the amount is less than 0.01% of that spent on health care services. We must be both realistic in our expectations and strategic in our spending.

Second, funding should be related to the determinants of health model. While research does not yet allow the precise identification of the investment balance across determinants, we know a balance is required. The County Health Rankings assigns weights of 20% to health care, 10% to the physical environment, 30% to health behaviors, and 40% to the socioeconomic environment.

I’d suggest that the Prevention and Public Health fund take a similarly broad Community Prevention approach. The relatively small amount of money will likely have the largest impact if efforts emphasize creating policies and programs that create healthy environments, as has been emphasized by Dr. Jeffrey Levi’s Congressional testimony. The Convergence Partnership has urged for a similar approach, noting that “while clinical prevention is important…we must focus on changing the policies and systems that shape neighborhoods so that they foster health.” Additional recommendations are likely to emerge from the new National Prevention, Health Promotion, and Public Health Council, which is mandated by the PPACA to “develop and make public a national prevention, health promotion, and public health strategy” by March 23, 2011.

Third, priority should be given to communities who have the lowest health outcomes and are improving less rapidly or even losing ground. A recent letter from prominent population health leaders to Secretary Sebelius emphasizes the importance of focusing assistance on places where health outcomes are poor and health disparities are high. Communities with comparatively healthy populations should be applauded, recognized for their achievements, and serve as examples to others – but they should receive fewer new resources. If this is rationing, so be it. With limited resources, a population health perspective requires investments that produce the most health improvement and disparity reduction per dollar invested.

What we’ve got is a relatively short period of time and relatively few dollars. But ten years from now, when we assess what we’ve accomplished through the Prevention and Public Health Fund, we should be proud of the choices we make now.

David A. Kindig, MD, PhD, is Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences at the University of Wisconsin School of Medicine and Public Health.

Will the Prevention and Public Health Fund’s $15 Billion Be Spared on September 14th?

By David A. Kindig, MD, PhD

On September 14, 2010, the U.S. Senate will vote on two opposing amendments to the Small Business Jobs and Credit Act of 2010. The outcome could save or eliminate the $15 billion that has been set aside through the Prevention and Public Health Fund to support national, state, and local programs to promote health and reduce health disparities.

At issue is a small tax reporting provision within the Patient Protection and Affordable Care Act (PPACA). Specifically, the provision mandates that businesses, charities, and state and local governments file one form 1099 for each business providing in excess of $600 in property, goods and services (the current requirement is for services only and has been associated with significant underreporting).

There is bipartisan consensus that the new provision (scheduled to go into effect in 2012) excessively burdens small businesses with paperwork, but differences in the two proposed solutions are dramatic.

On one side is Senator Mike Johanns (R-NE), who is calling for a full repeal of the tax reporting requirement. He proposes to make up the lost revenue by completely eliminating the $15 billion Prevention and Public Health Fund and by lowering the individual mandate from 8% to 5% of income.

Senator Bill Nelson (D-FL) has offered a competing amendment that keeps the Prevention Fund intact. Nelson’s amendment scales back the reporting requirements: businesses with fewer than 25 employees would be exempted from the reporting, and the reporting threshold would be increased from $600 to $5,000 per vendor or service provider. Senator Nelson’s amendment proposes to make up lost revenue by repealing tax cuts for the five largest oil companies.

The Senate will vote on both amendments on September 14. Each will require 60 votes to pass, and the voting is likely to be close.

Please contact your senators to express your concerns and let them know how you’d like them to vote next week.

David A. Kindig, MD, PhD, is Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences at the University of Wisconsin School of Medicine and Public Health.

Population Health and the Federal Reserve...Are You Kidding?

By David A. Kindig, MD, PhD

I’ve mentioned before that a “convergence of scholarship, policy, and practice initiatives seems poised to bring an overdue population health perspective to thinking about and acting on health and health improvement.” One of the purposes of this blog is to keep track of all that is bubbling up in likely—and often unlikely—places.

This convergence was exemplified by a meeting I attended last week at the Federal Reserve in Washington, DC. The event was co-sponsored by the Federal Reserve Bank of San Francisco and the Robert Wood Johnson Foundation and was titled “Healthy Communities: Exploring the Intersection of Community Development and Health.”

The meeting brought together public and private sector experts in policy, community development, and finance to explore what the fields of health and community development can learn from each other (for background reading, check out this issue of Community Development and Investment Review).

Here are some initial impressions:

• I learned that the “other” CDC is the Community Development Financial Institutions or Corporations, which promote affordable housing and business development to keep individuals and families out of poverty. (See articles by Richter and Andrews in Community Development and Investment Review issue linked to above.)
• I was pleased that the multiple and social determinants of health took center stage, with significant discussion on the damaging biological stress pathways associated with lower socioeconomic status.
• The fields of health and community development share many priorities, including early childhood investments, fresh food infrastructure, and efficient and innovative healthcare delivery.
• We must aggressively advocate for health in all policies, from nonprofit hospital Community Benefit regulations to the Community Reinvestment Act.
• Both the White House and the OMB seem fully supportive of multisectoral and place-based strategies as well as redirecting financial streams in innovative and more cost-effective directions.
• There may be a major opportunity for collaboration between federal Community Health Centers (CHCs) and community development organizations as CHCs are set to greatly expand to cover 40 Million low income persons under health care reform.

As we continue to call for broad and inclusive approaches for improving population health, we need to continue to identify common ground and build alliances with partners in unlikely places.

Have any to add to the list?

David A. Kindig, MD, PhD, is Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences at the University of Wisconsin School of Medicine and Public Health.

Why Should People Who Care About Our Country's Health Contact the IRS Before July 22nd?

By David A. Kindig, MD, PhD

There is a looming deadline that those of us who care about health should know about.

For more than 55 years, nonprofit hospitals have had to justify their tax exempt status by providing benefits to the communities they serve. This is a big deal, since having this status amounts to a collective tax savings for the nonprofit hospitals of about $20 billion annually.

Until recently, nonprofit hospitals have mostly contributed this “community benefit” by providing care to people who can’t afford it and by offering screenings, health education, and other outreach activities. Hospitals were neither required to engage in certain activities nor document or evaluate their efforts.

Over the past couple of years, however, reporting requirements have increased.

One of the newer reporting requirements is IRS Form 990 Schedule H, where nonprofit hospitals report their community benefit activities. Unfortunately, Schedule H doesn’t give credit where credit is due.

The form does give credit for contributions made in the areas of charity care, health professions education, research, health education, and some types of community outreach. But it gives no credit for contributions beyond health care in areas such as housing, the environment, economic development, community coalition building, advocacy, and community workforce development. Of course, these are exactly the kind of investments we need more of to improve health outcomes and reduce disparities.

Although the IRS has not yet specified community benefit financial requirements (such as a fixed dollar amount or a revenue percentage), some are advocating that this happen sooner rather than later. Experts believe that charity care currently makes up a large part of community benefit spending, but the need for that should change with fewer uninsured as health care reform gets underway. Dollars currently used to provide healthcare for the uninsured could and should become available for other activities.

In addition, the new Patient Protection and Affordable Care Act (PPACA, PL 111-148) requires hospitals to conduct community health assessments every three years. What has not yet been decided is whether hospitals will be required to conduct these assessments independently or whether they will be allowed to collaborate with other community agencies.

The IRS is currently seeking public comment on how to best align Schedule H with the PPACA.

I urge you to submit your opinions by the July 22 deadline. Here are the points I’ll be including in my own message:

• Hospitals should carry out the required community health assessments in partnership with local public agencies and other community organizations and not be forced to conduct a separate, independent needs assessment.
  
• The new rules should explicitly allow public health and community health improvement activities to count as community benefit
  
• The IRS should call for more research to recommend whether an overall dollar or revenue percentage should be required--and if so, how funds should be allocated among charity care, public health programs, and other activities.
  

Let’s help create a permanent mechanism for making community health expenditures count—and keep coming—for population health improvement.

...............................................................................................................

I appreciate the assistance of Connie Evashwick, ScD at St Louis University and Pamela Russo, MD, MPH at the Robert Wood Johnson Foundation in providing background on this issue.

David A. Kindig, MD, PhD, is Emeritus Professor of Population Health Sciences and Emeritus Vice-Chancellor for Health Sciences at the University of Wisconsin School of Medicine and Public Health.

Reform vs. Transform

By Jonathan Fielding, MD, MPH, MA, MBA

Health insurance reform has been passed. Those of us who feel health care is a right can now see the path to get 95% of the population covered. The evidence is clear: health insurance reform can save lives. But what was missing in the rancorous debate over “health reform” was a sense of context. How important is health care compared with other factors that influence individual and collective health? Are we making investment decisions that flow from the answers to this question? The truth is that health care coverage expansion, albeit overdue and an essential social good, will have a relatively small effect on our relative position of 37th among the nations of the world in life expectancy.

If we want longer, healthier lives, lives with more years of independence and high functioning, we need to complement health insurance reform with more fundamental reform—a transformation of the health enterprise. Transformation requires answering the fundamental question: “What determines our individual and collective health?”

The studies provide a clear but surprising answer. The conditions in which we live, work, and play are the most important health influences. A high school graduate lives on average seven fewer years less than a college graduate. Smoking, other drug use, obesity, inadequate physical activity, and a diet too rich in processed foods are major contributors to our health and functioning—on balance, more important than whether we see a doctor for a routine physical. Medical care is important, and can be life prolonging—but it is only part of the opportunity to minimize most health problems.

This is not fresh news. But there is an almost total disconnect between the fight over “health reform” and what investment would provide the highest value in terms of quality and years of life along with reducing the gaping health disparities among different groups, defined by ethnicity, race, culture, and geography. What we need is a  nation that thinks differently about how we get to be healthy. We must view and act as if health is a necessary characteristic of populations, not just individuals. If we did, we would invest more heavily in evidence-based prevention—both for patients and communities. 

Thinking differently about what determines our health can be transformative. We will ask better questions of ourselves and of those who make policy, both public and private. Thinking differently could cause us to encourage our elected representatives to consider how policies in agriculture, transportation, housing, and social services can support health.

Does subsidization for growing corn, the source of the inexpensive high fructose corn syrup ubiquitously present in foods, improve our health? Does it make sense to have schools with the best local playgrounds declare them off limits to neighbors in their communities? Should almost all our investment in transportation be for roads and highways rather than mass transit and more bikeable, walkable communities? Why should medical care be tax advantaged while we pay after tax for fruits and vegetables or fitness clubs or smoking cessation classes?

The passage of health insurance reform has helped answer the nagging question of access to medical care. Now we have the opportunity—and the imperative—to ask the larger questions about how to improve our health. Shouldn’t the first question be, “If we want to invest cost-effectively to improve health for everyone in our country, what would we do differently—as a nation, as communities, and as individuals?”

Commissioner Jonathan Fielding, MD, MPH, MA, MBA serves as Director of Public Health and Health Officer for Los Angeles County, where he is responsible for the full range of public health activities for 10 million county residents.