Background
Public health should promote and protect the health of people and the communities in which they live, learn, work, and play. Strategies to improve the public’s health are multifaceted and involve multiple entities, including federal and state governments, health providers, faith- and community-based organizations, and individuals.
From a public health perspective, prevention is always preferable to treatment and cure. However, not all individuals have access to preventive health services, and not everything is preventable.
The persistence of cost barriers to the use of preventive and screening services may result in more costs to Medicare when preventable conditions later emerge and require expensive treatments. These barriers do not aid in the promotion of public health.
Strategies to protect and promote public health include preventing disease and disability; monitoring and containing communicable disease outbreaks; improving health through sound nutrition, access to nutritious food, exercise, and healthy behaviors; ensuring air and water quality and food safety; preventing injuries and violence; and ensuring access to safe and stable affordable housing.
Older Americans underuse preventive services, such as screenings. In addition, there are significant racial and ethnic disparities in their use, regardless of income and health insurance status. Screening for HIV and sexually transmitted diseases is particularly important among older adults. It is estimated that nearly half of individuals living with HIV are ages 50 and older.
The Affordable Care Act (ACA) eliminated cost-sharing for most private and publicly-funded preventive and screening services. However, some cost barriers to preventive care still exist. These include when services are miscoded or re-classified as diagnostic if and when providers discover a health problem. And despite near-universal coverage by Medicare, Medicare beneficiaries face cost barriers as well.
Medicare beneficiaries who receive certain recommended vaccines through Medicare Part D (the prescription drug program) are exposed to cost-sharing. Medicare beneficiaries can also be exposed to cost-sharing for an exempt screening if the service is reclassified as a diagnostic service when an abnormality is found. For example, under current Medicare law, a routine screening colonoscopy does not require cost-sharing, but if a polyp is found the screening is recharacterized as a diagnostic test and cost-sharing is then required. Finally, Medicare beneficiaries can be required to pay cost-sharing (but not deductibles) for services associated with the receipt of a screening service, such as charges for anesthesia given during a routine screening colonoscopy.
The ACA contains provisions that require certain federal agencies to implement a broad range of public health activities. They include:
- conducting a national public-private campaign aimed at raising awareness of activities that prevent chronic disease and promote health;
- maintaining a website with evidence-based information on health promotion and disease prevention, and with an online tool to help individuals determine their risk for specific diseases and offer them customized advice;
- providing guidance to states and health care providers regarding prevention and obesity-related services available to Medicaid beneficiaries;
- developing a plan promoting healthy lifestyles and self-management of chronic diseases for Medicare beneficiaries, and
- establishing a National Prevention, Health Promotion, and Public Health Council to develop a national prevention and health promotion strategy and to provide recommendations to the president and Congress about pressing health issues.
The ACA requires the Centers for Disease Control and Prevention to:
- establish and implement a science-based national media campaign on health promotion and disease prevention, and
- fund state and local pilot programs to improve the health of people age 55–64 through community-based public health interventions.
The ACA also required the Government Accountability Office to conduct a study on how often Medicare beneficiaries age 65 and older receive recommended vaccines covered under Medicare Part D and to make recommendations for increasing immunization rates among Medicare beneficiaries.
Additional public health provisions of the ACA include:
- mandating investments in state, territorial, and local public-health infrastructure;
- providing grants to implement recommended services;
- eliminating cost-sharing for certain preventive services and health screenings in Medicare and private health insurance;
- providing enhanced federal funding for states that choose to eliminate Medicaid cost-sharing for certain preventive services—including screenings;
- creating Community Transformation Grants to promote individual and community health and reduce disparities;
- establishing a Prevention and Public Health Fund designed to expand and sustain the infrastructure needed to prevent disease, detect it early, and manage conditions before they become severe. The goals are to increase the national investment in prevention and public health, to improve health, and to enhance health care quality;
- creating a demonstration program that will make grants available to state Medicaid programs to test the use of evidence-based incentives for Medicaid beneficiaries to prevent chronic diseases; and
- requiring restaurants, retail food establishments, and vending machine operations with 20 or more locations to post calorie content on menus and menu boards, and to offer accessible nutritional information to customers.
An annual wellness visit for Medicare beneficiaries that includes a personalized prevention plan was also implemented as part of the health reform act.
Climate change and public health—public health challenges resulting from climate change include greater exposure to unsafe temperatures, increases in severe weather events, harm to water supplies, and increased vector-borne disease. Vulnerable populations such as communities of members of historically disadvantaged groups, older adults, individuals with low incomes, and people with chronic illnesses bear the greatest burden of injury, disease, and death related to climate change. Climate change also may adversely impact people with physical and cognitive impairments. A 2010 AARP Public Policy Institute study, Affordable Home Energy and Health: Making the Connections, notes that for many older adults, even moderate temperature changes can lead to adverse health outcomes.
Central air-conditioning and home heating are essential aspects of mitigating the health effects of fluctuations in climate. Therefore, it is critical to ensure that older adults, especially those who are most vulnerable, have continued access to affordable home energy. One federal program that helps individuals with low incomes pay their energy costs is the Low Income Home Energy Assistance Program (LIHEAP).
Policies and programs to address the health threats posed by climate change and high home energy costs can complement existing efforts in health and long-term care to improve patient health status, reduce the economic cost of avoidable health care services, and facilitate independent living.
PROMOTING PUBLIC HEALTH: Policy
Promoting public health
All levels of government should conduct activities designed to promote public health, including:
- funding preventive services and health promotion;
- researching health-promotion behaviors and educating the public about them;
- tracking and educating the public about preventable injuries, including the impact of gun violence and its ramifications on public health;
- supporting outreach and education about the value of engaging in healthy behaviors, with information targeted to consumers, family caregivers, and employers; and
- funding and supporting community-based strategies to address the social determinants of health.
Other activities should include:
- adequately funding preventive health services and health-promotion programs (e.g., nutritional screening and counseling, exercise and weight-control programs, and drug-, alcohol-, and tobacco-addiction treatment programs) and preventive health education programs for people most in need;
- educating individuals about risk factors for prevalent health conditions, behaviors that reduce health risks (e.g., exercise and nutrition), and the importance of preventive care (e.g., mammography, cancer screening, early immunizations for children, and influenza and pneumococcal pneumonia immunizations for older Americans);
- identifying health-promoting behaviors, the ways in which such behaviors are linked to health improvements, and the costs and benefits associated with health-promoting behaviors; andidentifying ways to support the implementation of evidence-based, nondiscriminatory workplace wellness programs by small employers.
Personal responsibility
All levels of government should help people fulfill their personal responsibility to protect their health by taking advantage of health-education opportunities and affordable and appropriate preventive health measures.
Policymakers and others at all levels of government should collaborate to develop, fund, implement, and evaluate strategies to protect and improve the public’s health.
They should support policies and implement programs that promote healthy behaviors.
Governments should call national attention to public health issues, promote the application of scientific knowledge to policymaking, support the collection and analysis of public health data, and strengthen state and local capacity to deliver public health services.
Federal, state and local governments should provide incentives for people to engage in those behaviors and strengthen the physical infrastructure that supports such health-promoting behaviors.
Sound public health strategies for protection and promotion, disease prevention, and intervention should be based on evidence and should have proven efficacy. Costs and benefits should be considered but should not be determinative. In addition to infrastructure development (such as laboratory capacity, provider education, and surveillance capacity), federal, state, and local strategies to improve the public’s health should focus on broad-based community interventions such as promotion of healthy lifestyles, prevention of disease and disability, research and education, epidemiological work, water treatment, and sewage disposal.
Public health workforce
Ensuring adequate funding
The federal government should adequately fund the Prevention and Public Health Fund.
All levels of government should increase funding for public health activities, implementation of public health prevention and promotion, enforcement of environmental and safety standards, research, and for public and professional health education.
All levels of government should:
- direct sufficient financial and technological resources toward solving environmental problems and work cooperatively with the private sector to address environmental concerns;
- direct sufficient financial and technological resources toward the timely development and manufacture of safe, effective vaccines—during vaccine shortages, the federal and state governments should not adopt policies that allocate vaccines solely on the basis of age;
- provide financial support for research into effective strategies to protect the public from biological attacks; and
- provide funding to ensure that key public- and private-sector health care personnel are adequately prepared to respond to public health crises relevant to their areas of practice.
Eliminating disparities in the use of preventive and screening services
Medicaid cost-sharing for preventive services and screenings
State Medicaid programs should elect the option to make certain preventive and screening services available to beneficiaries without any cost-sharing obligations.
Medicare cost-sharing for preventive services and screenings
The federal government should take the lead in addressing medical coding issues that result in individuals wrongfully having to pay a portion of the cost for exempt preventive and screening services.
The federal government should eliminate the requirement that when an abnormality is found on a routine screening (e.g., during a colonoscopy) the test is then considered a diagnostic procedure to which cost-sharing applies.
The federal government should require providers to alert beneficiaries to any cost-sharing obligations they might incur for screenings rated A or B by the U.S. Preventive Services Task Force. This information should be provided before the screening.
Pollution control
Coordinated emergency and crisis planning
All levels of government should collaborate to identify, develop, fund, and implement timely, effective response plans for national, state, and local public health crises.
Governments should develop strategies designed to meet the health care needs of people affected by catastrophic events (e.g., hurricanes, avian influenza, West Nile virus). Such strategies should, at a minimum, finance health care for the uninsured for a reasonable period of time, and should ensure the availability and accessibility of needed services. The federal government should require all states to develop comprehensive disaster plans designed to adequately protect the health and welfare of vulnerable populations such as older adults and people with disabilities during a public health crisis.
Research
Federal and state governments should support research that identifies the effects of health-promoting behaviors on public health (e.g., the impact of exercise on cardiovascular and cognitive health) and should fund cost-benefit research on health-promoting behaviors regarding both the public and private sectors (e.g., the cost to employers of workers’ inactivity).
Communicable diseases
Health care providers and individuals should be educated about behavioral risk factors for contracting and spreading serious communicable diseases. These include diseases such as tuberculosis, hepatitis, and HIV/AIDS. Health providers should recognize the importance of taking sexual histories and discuss HIV/STD prevention with patients age 50 and older. Programs should teach all individuals who know or have reason to believe that they may be infected to protect others from infection, and to advise those whom they know to be at risk to seek testing. The outcome of such tests must be confidential, consistent with public health responsibilities, and subject to the requirements of confidentiality standards.
Smoking bans
Federal and state governments should enact legislation banning smoking in nonresidential public buildings, on public transportation, and in restaurants.
Preference for allocating government revenues from tobacco company settlements should be given to programs designed to improve public health, including Medicaid and Medicare, antismoking and smoking-cessation programs, and efforts to expand access to long-term care and other health care services. Tobacco settlement funds should not replace existing federal or state funding in these areas.
To promote government accountability, states should develop a public process for deciding how tobacco settlement funds should be spent and for disclosing annually how they are spent. The information should be brought to the attention of the general public.
State governments should ensure that their public health infrastructures are adequate, strong, and sustainable over the long term before they use tobacco settlement funds to balance state budgets.
Public health effects of climate change and extreme weather conditions
All levels of government should work to prevent and minimize the effects of climate change, such as expanding eligibility for affordable energy programs like the Low Income Home Energy Assistance Program.
Federal, state and local governments should work to mitigate the effects of climate change by:
- expanding (and simplifying) eligibility and increasing funding for weatherization programs, affordable energy programs including but not limited to the Low Income Energy Assistance Program (LIHEAP);
- prioritizing home weatherization programs that target the medically frail;
- identifying and implementing best practices for educating people about the risks, facilitating weather protection and operating emergency alert systems; and
- identifying and maintaining emergency locations for heating and cooling displaced people in extreme weather.
To prevent and mitigate the potentially adverse health effects of climate change on older people, all levels of government should:
- expand categorical eligibility for LIHEAP, weatherization services, and other affordable energy programs in order to target groups identified as most at risk of adverse health outcomes—possible participants can be identified through eligibility for state Medicaid waiver programs and the Medicare Part D Low-Income Subsidy or other programs (see also Chapter 10, Utilities: Telecommunications, Energy, and Other Services—Low Income Energy Assistance Programs);
- make referrals for LIHEAP, weatherization, and other affordable energy programs;
- support education and outreach efforts to increase awareness about weatherization programs—both within the health care community and among older adults, their families, and caregivers—of resources that can help people maintain access to healthy and comfortable temperatures;
- give priority to in-home repair or modification programs that serve medically frail participants (such as under a state Medicaid waiver) so they can have access to cost-effective energy efficiency measures that protect health and safety, such as special coatings for flat-roofed row houses that lower indoor temperatures in summer (see also Chapter 10, Utilities: Telecommunications, Energy and Other Services—Low-Income Energy Assistance Programs); and
- identify and implement best practices for communicating with the public—especially older adults, their families, and their caregivers—about the risks of heat waves and cold temperatures, links between temperature and health, and the most effective prevention, education, and response efforts.