The Affordable Care Act and Healthcare Reform in the Urban Environment
Submitted by Laura Murphy, RN
April 27, 2015
NUR: 4110 Urban Health Issues
Professor Pearlman, MSN, MA, PMHCNS, BC, RN

Introduction
The Patient Protection and Affordable Care Act of 2010 (ACA) will have profound and far-reaching implications for urban public health in America. Population health and prevention are cornerstones of the federal policy. The elimination of health disparities is also a primary focus of the public health initiatives directed by the legislation (Rosenbaum, 2011). This is an important topic because obesity and other chronic conditions linked to modifiable behaviors have become the leading causes of death in our country (McMorrow, Kenney, & Goin, 2014). This affects the physical and economic health of our country as a whole.
Chronic health conditions disproportionately affect persons of lower economic status and in poorer, urban communities (McMorrow, Kenney, & Goin, 2014). According to Olden, Ramos, and Freudenberg (2009), “Evidence documents profound disparities between affluent and socioeconomically disadvantaged, and white and black Americans” (p. 819). When comparing the African American population to non-Hispanic whites, African Americans are 40% more likely to be obese and 60% more likely to have diabetes. They are 30% more likely to have heart disease and 40% more likely to die from a stroke (FamiliesUSA, 2009). There are inequities across the genders as well. African American women are more likely than their white counterparts to die from breast cancer, cervical cancer, and in childbirth. Children are also negatively affected. Infant mortality and asthma is twice as high in the African American population and they are 70% more likely to be obese than white children (FamiliesUSA, 2009). Since 80% of our country’s population is concentrated in urban areas, these health disparities are most evident in our cities, which house the richest and the poorest Americans (Olden, Ramos, & Freudenberg, 2009).
The Impact of the ACA on Urban Health
The ACA attempts to narrow the gap in health disparities in two broad ways: first, by increasing the number of Americans with health insurance, and second, by integrating public health priorities into the national agenda. Towards this end, the ACA created The National Prevention, Health Promotion, and Public Health Council (The Prevention Council). The Prevention Council, chaired by the U.S. Surgeon General, is tasked with developing a national strategy that includes the goal of promoting health in all policies and all agencies that influence health (Bovbjerg, Ormond, & Waidmann, 2011). To ensure funding for public health initiatives, the ACA appropriated 500 million dollars in 2010 to the newly created Prevention Fund, and funding has increased each year. As of 2016 and each fiscal year thereafter, the fund will receive 2 billion dollars per year as directed by section 4002 of the ACA (The Kaiser Family Foundation (KFF), 2013). Clearly, this is a paradigm shift in our government’s approach and commitment to public health.
The second way in which the ACA promotes public health is by increasing the number of insured with the Individual Mandate and by increasing the eligibility requirements for Medicaid. Studies have shown insured Americans are more likely to have a primary care physician, routine check-ups and earlier detection of health conditions than their uninsured counterparts (Hernández-Cancio, Mahan, & Stoll, 2014). As World Health Organization Director General Margaret Chan said, access to healthcare is the “single most powerful concept that public health has to offer” (Parento, 2014, p. 7). The ACA is expected to increase the number of insured Americans by 32 million people by 2019 (Davis & Somers, 2011). Insurance companies must cover 15 preventive services at no cost to the insured. These services include blood pressure, cholesterol, and diabetes screenings; obesity and nutritional counseling; immunizations, HIV and other sexually transmitted disease screenings; mental health, tobacco and substance abuse counseling (U.S. Department of Health and Human Services, 2015). These built in services are undoubtedly meant to promote population health.
Challenges and Barriers to Tackling These Issues
There are many challenges to improving population health in urban environments. As Steve Whitman, the director of the Sinai Urban Health Institute in Chicago said, “The causes of urban pathology are poverty and racism. There are a million things that are subsumed under those” (Thomson, 2011, p. 7). Employment has traditionally been the method by which most people received health insurance and were able to afford medications and preventative services. Decades of institutionalized racism has left large parts of communities undereducated and underemployed. Poor health behaviors have become part of the larger culture as evidenced by the high obesity and diabetes rates in the urban African American population (Thomson, 2011, p. 7). The ACA attempts to address these issues by providing more equal access to healthcare but clearly it will not eradicate racism and poverty. These are large issues and there is a strong association between poverty and poor health.
In addition, public health policy is trying to change people’s behavior and health practices. It is asking people to change their diet and activity levels—often in neighborhoods where there is no access to better food choices or safe places to exercise. Access to healthcare is thought by some public health officials to account for only 20% of a person’s health, “whereas other factors such as environment, behaviors and socioeconomics—that is public health—account for 80% of a person’s health” (Thomson, 2011, p. 10). To make communities healthier, we need to change the physical environment. People need grocery stores and parks. They need culturally competent education programs about diet and nutrition. This requires a capital investment and coordination among government and community organization to make urban communities healthier. With the current high profile of public health issues and resources provided by the ACA, the time to act is now.
Review of the Literature
McMorrow, Kenney, and Goin (2014) examined the differences in lower versus higher income, non-elderly adults in obtaining preventive health services from 2000 to 2010, before the ACA was implemented. Previous studies had shown that lack of insurance, lower income, and lower education levels, were associated with less use of preventative care. Their results showed that insurance coverage accounted for only 25% to 40% of the disparities in obtaining services. Thus, the additional 60% to 75% was explained by other factors such as age, health status and education (McMorrow, Kenney, & Goin, 2014). The implications from this study suggest that though increasing coverage through the ACA will help increase use of preventative services, other interventions are necessary, such as health education, information campaigns, paying providers for quality performance, and offering incentives to providers for adhering to screening guidelines (McMorrow, Kenney, & Goin, 2014).
Olden, Ramos, and Freudenberg (2009) suggest that since changing personal behavior and cultural practices has been difficult, there are environmental and social interventions that can be implemented through greater regulation. For example, the American Medical Association estimates that lower sodium intake could save over 150,000 lives a year. The researchers state that salt intake is a “risk factor to hypertension and cardiovascular disease, primary causes of death and disparities in the USA” (Olden, Ramos, & Freudenberg, 2009, p. 821). In 1982, the Food and Drug Administration called for a reduction of salt in processed foods, but no regulations have been passed. Additionally, air pollution, and exposure to lead and other toxic wastes are higher in communities with minority residents. This exposure leads to cancers and respiratory diseases, and birth defects. They conclude that advancing policies that address these environmental hazards will help eliminate health disparities (Olden, Ramos, & Freudenberg, 2009).
In another article, researchers interviewed 45 public health officials from the Big Cities Health Coalition departments to assess the impact of the ACA on local health departments (Leider, Castrucci, Russo, & Hearne, 2015). Most leaders agreed the ACA created challenges and opportunities. An unanticipated effect of expanding insurance coverage in the lower income community has been a decrease in demand for services traditionally provided by these departments. As a result, leaders are reexamining the role of local health departments in terms of clinical services they provide. However, they “uniformly acknowledged that realignments in funding prompted by the ACA are changing the role that their offices can play in controlling infectious diseases, providing maternal and child health services, and more generally providing a social safety net” (Leider, Castrucci, Russo, & Hearne, 2015, p. 66). Rosenbaum (2011) suggests that public health departments can aid in the outreach and enrollment process and can work with the Exchanges to monitor health plans. She also states that even after full implementation of the ACA, almost 25 million people will remain without health insurance and there is a still a need to serve this population (Rosenbaum, 2011).
Finally, in a review of the Prevention Council’s 2014 Status Report, Lushniak, Alley, Ulin, and Graffunder (2015) said the report “demonstrates important progress in three areas: federal leadership, incorporation of health into cross-sector federal programs and community implementation” (p. 229). As a leader and employer, the federal government has integrated health promotion into its many domains. For example, the National Park Service now offers Healthy Food Standards and 97% of federally sponsored child care centers have received Let’s Move certifications. The Federal Employee Health Benefit Program also covers comprehensive tobacco cessation counseling and medications and all workplaces are smoke-free. However, the authors acknowledge, to achieve the Prevention Council’s mission, “the government will need to do more than change internal policies” (Lushniak, Alley, Ulin, & Graffunder, 2015, p. 230). In an example of government agencies working together, they mention the Partnership for Sustainable Communities, an initiative to promote “affordable, livable communities through streamlined investment strategies across the Department of Housing and Urban Development, the Department of Transportation, and the Environmental Protection Agency” ( Lushniak, Alley, Ulin, & Graffunder, 2015, p. 230). Since 2009, this partnership has provided over 4.5 billion to over 1000 projects in all 50 states to promote healthier communities.
SCO: Home Visitation Program
SCO Family of Services is a nonprofit organization that has been serving vulnerable populations in New York City and Long Island for over 100 years (sco.org). According to information obtained from the SCO website, SCO operates more than 87 programs at over 111 locations. These programs target four identified areas of impact, which include “getting young children off to a good start, launching youth into adulthood, stabilizing and strengthening families and unlocking potential for children and adults with special needs” (sco.org). They provide a broad range of services including homeless shelters, early childhood intervention, after-school programs, and support services for children and adults with special needs.
Among the many programs SCO utilizes in its mission to improve the lives of children and mothers is the Family-Nurse Partnership (FNP). The FNP serves low-income women pregnant with their first child. These women receive home visits from a registered nurse, from early in pregnancy until the child’s second birthday. This is an evidenced-based program, with proven positive outcomes (familynursepartnership.org).
Founded by David Olds, a doctor of pediatrics and psychiatry, the idea for the program began in the 1970s when he was working at a day care center. He realized to help children in lower income families get a better start in life; they needed earlier intervention in the home and even before they were born. A pilot program began and after several randomized controlled trials, the program was ready for dissemination in 1996. It is now active in 43 states (familynursepartnership.org).
Some of the positive outcomes from the NFP program include a reduction in hypertensive disorders during pregnancy, a reduction in child abuse and neglect, and fewer intellectual and behavioral problems at age six. A long-term 15-year follow up study showed a reduction in childhood arrests (familynursepartnership.org). This has proven to be a cost effective model as well. One analysis noted that “NFP nurse-visited families gained academic and employment skills to become economically self-sufficient” (familynursepartnership.org). Another analysis estimated that every federal dollar spent on the program yielded $5.70 in savings (familynursepartnership.org). These costs are estimated by a reduction in Food Stamp programs and Medicaid costs over 10 years as the women become more financially stable. Clearly, this is a model program for first-time mothers and their children and one which funding from the ACA should support. This targeted program can strengthen communities through preventative services for at-risk, lower income women and children. It has demonstrated positive short-term and long-term outcomes, and cost-effective benefits.
Stakeholders
The ACA is a massive piece of legislation and it affects virtually all areas of our society. The stakeholders include the federal, state, and local governments; hospitals and other healthcare delivery systems; primary care providers and their patients; employers, local health departments and community organizations. The federal government has a made a tremendous financial investment in healthcare reform and must collaborate with states to increase Medicaid funding and eligibility. States must partner with Exchanges and insurance companies to disseminate insurance coverage. Hospitals will have a greater number of patients seeking healthcare and will receive lower reimbursement for some services. Under the Act, non-profit hospitals will be required to perform community assessments every three years and implement strategies to meet those identified needs or face a financial penalty (KFF, 2013). Primary care providers must shift their focus towards preventing disease and will receive incentives for keeping their patients well. A greater number of businesses are now required to cover their employees imposing a financial cost (KFF, 2013). Local health departments have an opportunity to fund more programs and initiatives and collaborate with community organizations to improve the health of the population. Finally, consumers of healthcare are affected as well. The wealthiest Americans will pay more in capital gains, and middle income Americans may pay more for less with higher deductibles and co-pays. Newly Medicaid eligible Americans will have access to affordable care. As the director for the Office of Health and Family Services in Kentucky said, “under the ACA, we are all in this together, and the health of each of us, influences the cost for everyone. And we will be better for it, because for the first time there is no viable option for long-term cost control but to improve health at a population level” (Parento, 2014, p. 7).
Policy Recommendations
Based on my research for this report, I would recommend the FNP program be expanded nationally for all lower income women during their first pregnancy. This model program is exactly the type of preventative, cost-effective service the ACA wants to promote. Other policy recommendations include applying evidenced-based design principles to housing developments currently in use. Since it seems unlikely we are going to tear them down, and knowing the impact environment has on health, we need to make them better. Increased funding to promote safety, green space, supermarkets, and access to health services should be a priority under the new spirit of public health funding and policy. In New York City, there are over 180,000 residents living in 334 housing development projects (nyc.gov). There could be a small clinic in each development to provide some clinical and social services. Additionally, the urban community needs more leaders to talk about health. I was thinking about the Black Lives Matter movement. If the organizers of these protests took to the streets to raise awareness about the health crisis in the African American population, maybe that would help raise awareness in the community. Also, communities need culturally competent care. They need people from their own culture and background to develop a trusting relationship with larger healthcare community. We need more people of color as primary healthcare providers.
Finally, I think a public advertising campaign would be helpful. I see many commercials on television about the risks of smoking. Why not apply this strategy to obesity, diabetes, and heart disease? In addition, I do not think the national conversation about healthcare reform has stressed to consumers that preventative services and screenings are now offered at no cost to the insured. This information could be mentioned in the ad campaigns and insurance companies could send out flyers twice a year to their customers with this information.
Summary
In conclusion, the Affordable Care Act of 2010 has the potential to dramatically improve the overall health of our country by increasing the number of insured and by making public health a priority for all federal agencies. However, it is not a perfect piece of legislation and will not eliminate all disparities. It will not eradicate racism or poverty or fix our education system—many of the factors that contribute to poor health behaviors. I would argue that it does not go far enough towards achieving universal healthcare as 25 million people will be left behind. I would also argue that a single payer system would have been ideal, though probably impossible to achieve. Still, something had to be done to stem the rising tide of healthcare costs and an ever increasingly obese and diseased nation. Our country was at a crossroads and action was necessary. Compromises were made during its passage, but public health and funding for it remained a priority. It is an enormous achievement for our nation and the most monumental legislation of our time. Many challenges remain both from the Republicans in Congress, and in the implementation process of its ambitious agenda. It will be some time before we will feel the full effects and are able to assess outcomes. I am hopeful that the ACA will achieve its goals of greater population health and narrow the gap in health disparities between the rich and poor.
References
Bovbjerg,R., Ormond, B., & Waidmann, T.( 2011). What directions for public health under the affordable care act? The Urban Institute Health Policy Center. www.healthpolicycenter.org. Retrieved April 18, 2015.
Davis, C. S., & Somers, S. (2011). National health care reform and the public’s health. Journal of Law, Medicine & Ethics, 3965-68.
FamiliesUSA. familiesusa.org/product/african-american-health-disparities-compared-to-non-hispanic-whites. Retrieved April 20, 2015.
Family Nurse Partnership. http://www.nursefamilypartnership.org. Retrieved April 26, 2015
Hernández-Cancio, S. , Mahan, D., Stoll, K., (2015). Medicaid expansion and health disparities: African Americans. Issue Brief. Retrieved April 20, 2015 from http://familiesusa.org/product/medicaid-expansion-and-health-disparities-african-americans.
Leider, J., Castrucci, B., Russo, P., & Hearne, S.,(2015). Perceived impacts of healthcare reform on large urban health departments. Journal of Public Health Management Practice,66-75
Lushniak, B. D., Alley, D. E., Ulin, B., & Graffunder, C. (2015). The national prevention strategy: Leveraging multiple sectors to improve population health. American Journal Of Public Health, 105(2), 229-231.
McMorrow, S., Kenney, G., & Goin, D. (2014). Determinants of receipt of recommended services: Implications for the affordable care act. American Journal of Public Health. 104, 2392-2399.
Olden, K., Ramos, R. M., & Freudenberg, N. (2009). To reduce urban disparities in health, strengthen and enforce equitably environmental and consumer laws. Journal of Urban Health, 86(6), 819-824.
Parento, E. W. (2014). The affordable care act and the need for public health leadership. Hastings Center Report, 44(1), 7.
Rosenbaum, S., (2011). Law and the public’s health. Public Health Report. Jan. 130-134
SCO Family of Services. http://sco.org/programs/early-childhood/ Retrieved April 20, 2015
Summary of the Affordable Care Act (2013). The Henry J. Kaiser Family Foundation. www.kff.org
Thomson, S. (2011). Urban health care: Disparities abound. Health Progress, 92(6), 5-11