Public Health Community Worries About Money as Obamacare Begins

Several federal provisions assist the neediest Americans. Now that everyone is supposed to have insurance, will they be unnecessary?

Squashed: Will certainhealth care programs be moot?  
National Journal
Catherine Hollander
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Catherine Hollander
Aug. 29, 2013, 10:58 a.m.

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.

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