What's the point of having public-health programs for people without health insurance if everybody has health insurance?
Public-health advocates have spent the past three years living in fear of that question: With the Affordable Care Act theoretically ensuring that everyone is covered, lawmakers might figure it's safe to gut long-standing public-health programs.
For a while, those fears seemed well-founded.
"Even within months of the initial passage of the ACA, I had lobbyists for other "˜good-guy' causes calling and saying, "˜OK, when can we start thinking of these programs as offsets or pay-fors for other activities we'd like to put forward in the appropriations bill or as new authorizations?' " says Tim Westmoreland, a visiting professor at Georgetown Law who helped craft the Ryan White Care Act of 1990, which serves low-income HIV patients. "And I said, "˜Whoa, whoa, whoa, whoa, whoa.' "
But now many in the public-health community say those worries have passed — or at least have been overtaken by a different concern: that lawmakers will see the need to continue the programs but slash their funding anyway because of the nation's larger budget concerns.
"It's going to be more a matter of degree, the argument going forward," says Dan Hawkins, the head of policy at the National Association of Community Health Centers. "There will be an argument about scale and size."
That debate has already begun. And what Washington has given with one hand, it has sometimes taken away with the other. Community health centers got an $11 billion grant over five years through the 2010 ACA, $9.5 billion of which was earmarked for expanding operations — only to see their regular funding cut by $600 million in fiscal 2011, which would erase approximately one-third of that budget over five years. Title X appropriations for family planning fell 7 percent in fiscal 2010 to $294 million in 2012. Sequestration is likely to exacerbate funding problems in the future.
Meanwhile, community health centers are bracing for more demand than ever. The nonpartisan Congressional Budget Office predicts that, despite Obamacare, 31 million non-elderly Americans will remain uninsured in 2023. Those people will continue to look to community centers to meet their health needs. And some of the millions of people who do become insured under Obamacare will likely turn there, too. Those centers say they will struggle to meet that double-barreled expansion in demand if lawmakers are giving them less money, even if Medicaid and private insurance contributions rise.
Public-health officials point to work that's been done in Massachusetts as a preview of what's likely to happen to public-health programs after the ACA is fully implemented. A 2012 study funded by the American Cancer Society looked at use of services through the breast and cervical cancer program following the state's passage of health care reform in 2006. The researchers, using Census Bureau data, concluded that even as the ACA increases health coverage and the levels of cancer screening among women, "if future numbers of women served by [the National Breast and Cervical Cancer Early Detection Program] are comparable to recent numbers, the program will still only be able to meet the needs of one-fifth to one-third of those eligible." But Congress approved only $185 million for the early-detection program in fiscal 2011 and $184 million in 2012 — just 73 percent and 67 percent, respectively, of the funding set out in the law's 2007 reauthorization.
And, officials say, health insurance alone isn't enough to make up the difference. The Centers for Disease Control and Prevention, which runs the early-detection program, states on its website, "Even with adequate health insurance, many women will still face substantial barriers to obtaining breast- and cervical-cancer screening, such as geographic isolation, limited health literacy or self-efficacy, lack of provider recommendation, inconvenient times to access services, and language barriers."
Public-health providers also note the so-called added benefits of their programs, such as counseling and other support services, that aren't included in Medicaid or many private insurance plans.
Another big question for public-health programs is what will happen with state Medicaid expansions. In 2012, the Supreme Court ruled that states had the choice to expand their Medicaid programs with federal funding or to opt out. States that take the latter route — so far, 21 have done so, and five are still debating it — are likely to have larger populations that rely on public-health programs. Right now, the funding mechanisms for the Ryan White law aren't based on how many people have coverage in a particular state, but those variations are soon to be much more dramatic, complicating questions of how to allocate the money Congress appropriates.
Congress may want to wait and see how the ACA plays out before making any longer-term decisions on programs such as Ryan White, which is up for reauthorization at the end of September. Sticky battles loom ahead, but officials are relieved that at least they won't be over their programs' life or death. That's a fight they now feel they have won.