Background
Promoting public health helps governments, communities, and individuals cope with and address health challenges. Public policies can actively promote healthy habits, create supportive environments, and strengthen community action and personal skills.
Preventive Health Services
From a public health perspective, prevention is always preferable to treatment. Yet not all individuals have access to preventive health services. As such, a key dimension of public health is equitably expanding access and use of these services. One way is to address cost barriers to preventive and screening services. This could lead to cost savings by early identification or prevention of health conditions that, if discovered later, could require expensive treatments.
Older adults underuse preventive services, such as screenings. Among the services they are less likely to seek is screening for HIV and other sexually transmitted diseases. In addition, there are significant racial and ethnic disparities in their use. These disparities persist regardless of income and health insurance status.
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. Millions of Americans remain uninsured. And despite near-universal coverage by Medicare for those at or above age 65, 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. 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. Medicare beneficiaries can also 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 requires the federal implementation of a broad range of public health activities. These especially include prevention programs such as education campaigns, tools to prevent and manage chronic diseases, support for healthy behaviors. The ACA also increased investment in state and local public health infrastructure.
Annual wellness visits for Medicare beneficiaries that include personalized prevention plans were also implemented as part of the health reform law.
Additional Public Health Concerns
Smoking remains one of the leading causes of preventable death in the U.S. The health dangers to secondhand smokers—those who live and work in proximity to smokers—are also well established. States regulate tobacco sales and use with the aim of reducing known adverse health outcomes for the general public and smokers. In the U.S., 28 states, Washington DC, Puerto Rico, and the U.S. Virgin Islands, plus hundreds of cities and counties have enacted comprehensive smoke-free laws. These cover workplaces, restaurants, bars, public transit, and other enclosed, nonresidential spaces. The states are Arizona, California, Colorado, Connecticut, Delaware, Hawaii, Illinois, Iowa, Kansas, Maine, Maryland, Massachusetts, Michigan, Minnesota, Montana, Nebraska, New Jersey, New Mexico, New York, North Dakota, Ohio, Oregon, Rhode Island, South Dakota, Utah, Vermont, Washington, and Wisconsin.
Climate change has led to more extreme-weather days, increased the number and intensity of natural disasters, and changes in infectious disease patterns. Older adults, people with disabilities, people of color, people with low incomes, and people with chronic illnesses bear the greatest burden of disease and death related to climate change. Extremely hot and cold days, which are increasing because of climate change, can be life-threatening for older adults. Older adults and people with disabilities also face greater challenges in evacuating safely during a natural disaster (see also Disasters and Extreme Weather).
PUBLIC HEALTH PROMOTION: Policy
PUBLIC HEALTH PROMOTION: Policy
Eliminating disparities in the use of preventive and screening services
Disparities in the use of prevention and screening services in public and private health insurance programs should be identified. Strategies to eliminate these disparities should be developed and implemented.
Medicaid cost-sharing for preventive services and screenings
State Medicaid programs should 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 being charged for preventive and screening services that are supposed to be free.
The practice of recoding a routine screen when an abnormality is found as diagnostic—for which cost-sharing then applies—should be eliminated.
Providers should be required to alert beneficiaries of any cost-sharing obligations they might incur for screenings given A or B grades by the U.S. Preventive Services Task Force. That information should be provided before the screening.
Smoking bans
Federal and state governments should enact legislation banning smoking in nonresidential public buildings, public transportation, bars, and restaurants.
Disbursement of settlement funds
Preference for allocating government or private revenues from settlements related to public health (e.g., tobacco, opioids) should be given to programs designed to improve public health, including Medicaid and Medicare, recovery and prevention programs, and efforts to expand access to long-term care and other health care services. The funds should be allocated with a focus on improving equity. 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 settlement funds should be spent. Those expenditures should be disclosed annually. 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 using settlement funds to balance state budgets.
Pollution control
Public agencies should take specific and effective steps to control all forms of pollution (including biological and chemical agents) that threaten health, safety, and quality of life.
Public health effects of climate change and extreme-weather conditions
Policymakers should mitigate the immediate effects of climate change events on the health of older adults and other vulnerable populations. This includes ensuring affordable access to heating and cooling, particularly during extreme temperature days (see also Energy).
During extreme-weather or climate-related events, policymakers should:
- provide immediate assistance to vulnerable populations, particularly those with chronic health conditions that are exacerbated by the effects of climate change; and
- address the needs of people with disabilities, who may have greater difficulty evacuating or otherwise getting assistance during an emergency.
Policymakers should devise plans for the environmental, socioeconomic, and infrastructural impacts of climate change on the health of older adults and other vulnerable populations. Those plans should include ways to prevent and mitigate adverse impacts.
Federal, state, and local governments should work to mitigate the effects of climate change and extreme-weather conditions by:
- expanding (and simplifying) eligibility and increasing funding for weatherization programs and affordable energy programs, including but not limited to the Low Income Home 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 for 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 Energy Affordability for details on Low Income Home 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; 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.