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3
Policy
INTRODUCTION
In the previous chapters, the committee framed the numerous chal-
lenges and opportunities for defining and measuring the determinants of
living well with chronic illness. This chapter describes the associated chal-
lenges of designing and implementing effective public policies aimed at
living well with chronic illnesses.
First, the chapter defines health policy, which is aimed at improving the
delivery of health care (clinical medicine) and public health, and describes
the need for better integration between the two fields. It includes a brief
description about the barriers to developing effective health policy, includ-
ing budgetary challenges, and the lack of systematic evidence-based policy
assessment, evaluation, and surveillance.
Next, the chapter identifies the range of public policies that have an
impact on living well with chronic illness. Using Frieden’s pyramid of Fac-
tors that Impact Health (Frieden, 2010) as a framework, the chapter sum-
marizes a continuum of policies ranging from structural (or distal) policies,
which have the largest impact on the broad population of those who are
chronically ill, to individual-level (or proximal) policy interventions, which
have a more targeted impact on a smaller number of people.
Beginning with the base of Frieden’s pyramid (Frieden, 2010), the chap-
ter highlights numerous public policies that have an impact on the ability of
high-risk populations with chronic illnesses to live well. Numerous social
policies have proven critical in maintaining function and independence for
chronically ill populations who are most disadvantaged in terms of income
119
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120 LIVING WELL WITH CHRONIC ILLNESS
and/or disability. The recent Institute of Medicine (IOM) report For the
Public’s Health: Revitalizing Law and Policy to Meet New Challenges
(2011) describes these policies and makes detailed recommendations about
the need to review and revise various public health policies and laws in
order to improve population health. Many of these policies and laws are
designed to prevent illness in the general population and to help prevent
further morbidity in those already chronically ill—for example, clean in-
door air laws and smoking cessation interventions.
Extending through the tip of Frieden’s pyramid, the chapter concludes
with policies that impact health care delivery and self-care, also important
in supporting those with chronic illness to live well. Recently passed fed-
eral health reform, the Affordable Care Act (ACA), represents the most
significant changes to health care policy since the passage of Medicare and
Medicaid in 1965. Given the numerous provisions targeted to improving
health care delivery and population health, the chapter describes aspects
of the ACA that are particularly relevant to the well-being of those with
chronic illness.
Finally, in order to promote synergistic improvements in public poli-
cies that have the potential to impact health, the chapter describes a broad
Health in All Policies (HIAP) strategy that seeks to assess the health impli-
cations from both health and nonhealth public- and private-sector policies.
Defining Health Care (Clinical Medicine) and Public Health Policy
In general, public policy refers to the “authoritative decisions made
in the legislative, executive, or judicial branches of government that are
intended to direct or influence the actions, behaviors, or decisions of oth-
ers” (Longest and Huber, 2010). Health policy is the subset of public poli-
cies that impacts health care delivery (clinical medicine) and public health
(population health).
Most health policy in the United States is health care (clinical medicine)
policy, aimed at regulating or funding the loosely coordinated mechanisms
for the financing, insurance, and delivery of individual-level health care ser-
vices (Hardcastle et al., 2011; IOM, 2011; Shi and Singh, 2010). Whereas
public health focuses on the health status of broad populations across gen-
erations, clinical care focuses on individuals. The committee discussed the
need to expand beyond this fairly simplistic view of health and in Chapter 1
provides a framework (Figure 1-1) for considering the relationship among
determinants of health, the spectrum of health, and policies and other in-
terventions that help those with chronic illness to “live well.”
To the extent that Americans often think in terms of their individual
health status rather than in terms of population health, it may be under-
standable why policy makers focus on allocating resources and regulating
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policy in health care services. However, the health and well-being of the
individual and the health of the population are interrelated and interde-
pendent. Choucair (2011) suggests that “maintaining two disciplinary silos
(public health and clinical medicine) is not the answer. Bridging the gap
is critical if we are serious about improving the quality of life of our resi-
dents. . . . [W]e will not be successful unless we translate what we learn in
research all the way into public policy.” Many public policies that improve
health, especially for those with chronic illness, could be provided more
effectively and efficiently in a more integrated, better aligned health system
(Hardcastle et al., 2011). The committee discusses the need for a more inte-
grated health system in detail in Chapter 6 and provides several examples of
partnerships among clinical care, public health, and community organiza-
tions that promote health for those with chronic illness.
Barriers to Effective Health Policy
As expressed in the recent IOM report (2011), “now is a critical time to
examine the role and usefulness of the law and public policy more broadly,
both in and outside the health sector, in efforts to improve population
health.” The report noted the need for improvements in public policy as a
result of several factors, including but not limited to developments in the
science of public health; the current economic crisis and severe budget cuts
faced by local, state, and federal government; the lack of coordination of
health policies and regulations; recent passage of federal health reform (the
ACA); and increasing rates of obesity in the U.S. population.
Defining the appropriate role of government, however, is at the heart of
public policy making in the United States. Although Americans value their
health, many also value their ability to make individual choices about their
health care, health behavior, and quality of life. Accordingly, many policy
makers place high priority on individual liberties and, concomitantly, a lim-
ited role for government. Policy makers balance multiple competing public
policy interests, made more challenging in the current economic climate
in which competition for resources is high. For this reason, it is critical to
integrate health care policy with public health policy and reframe them both
to be consistent with other societal values, such as prosperity, economic
development, long-term investment, and overall well-being. Reminding
policy makers in all sectors of government that “businesses can rise and
fall on the strength of their employees’ physical and mental health, which
influence[s] levels of productivity and, ultimately, the economic outlook of
employers” (IOM, 2011) will help to emphasize the economic implications
of population health. Given that two-thirds of U.S. health care spending
is consumed by just 28 percent of people who have two or more chronic
illnesses (Anderson, 2010), the country can avoid unnecessary costs and
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122 LIVING WELL WITH CHRONIC ILLNESS
poor health by addressing the underlying cause of illness (Hardcastle et
al., 2011).
The data and analytic methodology for assessing effective public policy
is often lacking, and demonstrating causality between policy interventions
and their intended outcome is difficult, especially for interventions that
require longitudinal follow-up and assessment. The IOM report For the
Public’s Health: Revitalizing Law and Policy to Meet New Challenges
(2011) outlined several important large-scale policy initiatives targeting
childhood disadvantage to prevent poor health in adulthood. Examples
include “home health visiting programs, early stimulation in child care
programs, and preschool settings (i.e., Early Head Start and Head Start)”
(IOM, 2011). Yet questions about the long-term efficacy of many of these
types of interventions remain (The Brookings Center on Children and Fami-
lies and National Institute for Early Education Research, 2010). Chapter 4
provides a detailed description of a number of community-based initiatives
aimed at improving the health and well-being of those with chronic illness.
An added challenge to developing effective health policy, which is in
itself an iterative cyclical process, is the fact that tracking and evaluating
policy implementation and efficacy are not done in a systematic fashion
at the state or federal level. Instead, surveillance of various public policies
occurs across government, foundations, the private sector, and various
nonprofit organizations. The Kaiser Family Foundation, the Robert Wood
Johnson Foundation, the National Association for State Health Policy,
and the Commonwealth Fund provide an abundance of information about
current federal and state laws as they relate to chronic illness. In addition,
such organizations as the Trust for America’s Health and the County Health
Rankings help to inform local, state, and national policy across the deter-
minants of multiple chronic conditions (MCCs). Yet, generally speaking,
these organizations do not systematically assess how well specific state and
federal laws are being implemented or how well they are working to achieve
their stated goals. Alternatively, organizations focused on specific illnesses,
such as the Arthritis Foundation, can effectively advocate for state and fed-
eral policies that impact their constituencies. What is missing is widespread
collaboration between these two extremes, as well as a focus on policies
that pertain directly to well-being and quality of life. Many organizations
are only beginning to work in a collective fashion to achieve similar policy
goals, such as living well with chronic illness.
Other nonprofit organizations, such as the National Council for State
Legislatures (NCSL), track state policies that pertain to such chronic ill-
nesses as diabetes. NCSL provides information about diabetes minimum
coverage requirements for state-regulated health insurance policies, state
Medicaid diabetes coverage terms and conditions, and an overview of fed-
eral funding from the Centers for Disease Control and Prevention (CDC) to
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state-sponsored diabetes prevention and control programs (NCSL, 2011).
In addition, NCSL, the National Governors Association, the National
Academy for State Health Policy, and other groups also track other state-
level health policy issues, such as state implementation of federal health
reform. According to NCSL, at least 32 states have enacted and signed laws
specific to ACA health insurance implementation as of July 2011. These
laws cover a wide variety of issues in at least 15 categories.
In addition to the need for better surveillance of public policy, research
on the relationship between law and legal practices and population health
and well-being is still developing (Burris et al., 2010). Moreover, questions
about the cost-effectiveness of various health policies are paramount. Policy
makers require evidence about effectiveness, projected outcomes, and value
in order to judge the merits of proposed policies. However, concerns about
using science to measure cost-effectiveness in health care delivery have led
some policy makers to raise concerns about the rationing of health care
services by the government (California Healthline, 2010). For the Public’s
Health: Revitalizing Law and Policy to Meet New Challenges (IOM, 2011)
extensively evaluated how research could be used to improve public policy
surveillance. The committee suggested that “research on the comparative
effectiveness and health impact of public health laws and policies could be
conducted by documenting geographic variation and temporal change in
population exposure to specific policy and legal interventions.” The com-
mittee recommended that an interdisciplinary team of experts be given ap-
propriate resources to evaluate evidence for outcome assessments of policies
and regulations and derive new guidelines for setting evidence-based policy.
Chapter 5 provides a detailed description and framework for chronic dis-
ease surveillance that will be required to adequately evaluate policies aimed
at helping those with chronic illness to live well.
American Values in Public Policy
Even as new research establishes that social and environmental factors
significantly influence health status, Americans often question this world-
view (IOM, 2011). For the Public’s Health: Revitalizing Law and Policy to
Meet New Challenges (IOM, 2011) describes four “imperatives”—rescue,
technology, visibility, and individualism—that influence American policy
making. These imperatives tend to focus policy makers’ attention on crises
or novel events that have a compelling narrative, and away from concepts
more commonplace, such as “living well”:
1. Rescue imperative: people are more likely to feel emotionally con-
nected to individual misfortune and circumstances, but less inclined
to react to negative information conveyed in statistical terms.
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124 LIVING WELL WITH CHRONIC ILLNESS
2. Technology imperative: people find more appeal in cutting-edge
biomedical technologies than in population-based interventions.
3. Visibility imperative: people take for granted public health activi-
ties that occur “behind the scenes” unless a crisis arises, such as
influenza.
4. Individualism imperative: Americans generally value individualism,
favoring personal rights over public goods.
CONTEXTUALIZING HEALTH POLICY
INTERVENTIONS: FRIEDEN’S PYRAMID
Although most interventions aimed to help people with chronic ill-
ness live well focus on the individual, the Health Impact Pyramid (Figure
3-1) illustrates why interventions focused more on public health may be
beneficial as well (Frieden, 2010). The base of Frieden’s pyramid includes
health-related socioeconomic factors, with interventions aimed at reducing
poverty and increasing educational levels. The next level of the pyramid
Increasing Increasing Individual
Population Impact Effort Needed
Counseling
and Education
Clinical
Interventions
Long-Lasting Protective
Interventions
Changing the Context
to Make Individuals’ Default Decisions
Healthy
Socioeconomic Factors
FIGURE 3-1 Health Impact Pyramid.
SOURCE: Frieden, T.R. 2010. A framework for public health action: The health
impact pyramid. American Journal of Public Health 100(4):590–595. The Sheriden
Press.
3-1.eps
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recommends changing the environmental context to prevent illness, using
such interventions as water fluoridation and environmental changes to en-
courage physical activity. The third level involves one-time, or infrequent,
protective interventions, such as vaccines to prevent infectious disease.
The fourth and fifth levels of the pyramid include clinical interventions
and counseling/educational interventions. The intervention levels differ
in both the individual effort needed for the intervention to be successful
and their potential impact. Moving down the pyramid, there is an inverse
relationship: individual effort required decreases as the population impact
increases. Although more individual approaches may be appropriate for
helping those with chronic illness manage illness-specific aspects of their
health (e.g., counseling and reminder systems to encourage diabetic patients
to adhere to medication regimens), interventions further down will be of
benefit as well (e.g., increasing access to facilities for physical activity can
help those with arthritis be more physically active and improve their physi-
cal functioning). Each of these interventions can, and often does, have an
impact on an individual’s overall well-being.
Policies Aimed at Socioeconomic Factors
Frieden’s pyramid (Figure 3-1) begins with a focus on socioeconomic
factors. Persons with chronic illnesses need protection of their rights to ac-
cessibility of services, programs, public facilities, transportation, housing,
and other necessities for independent living and having a high quality of life
in addition to their public health and health care needs. Federal policies,
such as the Ticket to Work and Self-Sufficiency program within the Medic-
aid system (Stapleton et al., 2008), or paid medical leave for employees and
caregivers (Earle and Heymann, 2011) have proven instrumental in helping
those with chronic illness live well.
These policies range from providing income support to low-income
and disabled individuals—such as the Social Security Amendments of 1956,
which created the Social Security Disability Insurance (SSDI) program—to
transportation policies that require all new American mass transit vehicles
to come equipped with wheelchair lifts (for example, the Urban Mass
Transportation Act, 1970), to tax policies that preclude fringe benefits,
such as health insurance, from being counted as taxable income, to com-
munity supports such as those provided through the Older Americans Act,
such as nutrition assistance, home- and community-based services, as well
as caregiver supports. The context of public law generally creates this en-
vironment. Although many of these broad social policies are expensive to
implement and increasingly difficult to expand when resources are scarce,
research suggests that there are associated cost savings as well as increased
quality of life. Full description of the numerous policies that impact quality
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126 LIVING WELL WITH CHRONIC ILLNESS
BOX 3-1
Additional Examples of Public Policies That Impact Living Well
with Chronic Illness
Independent living support policy
• 965—The (American) Vocational Rehabilitation Amendment authorizes
1
federal funds for construction of rehabilitation centers, expansion of existing
vocational rehabilitation programs, and creation of the National Commis-
sion on Architectural Barriers to Rehabilitation of the Handicapped.
• 965—The Older Americans Act provides funding based primarily on the
1
percentage of an area’s population 60 and older for nutrition and supportive
home- and community-based services, disease prevention/health promo-
tion services, elder rights programs, the National Family Caregiver Support
Program, and the Native American Caregiver Support Program.
• 978—Title VII of the Rehabilitation Act Amendments established the first
1
federal funding for consumer-controlled independent living centers and
the National Council of the Handicapped under the U.S. Department of
Education.
• 990—The Ryan White Comprehensive AIDS Resource Emergency Act
1
was meant to help communities cope with the HIV/AIDS epidemic.
Transportation policies
• 970—The Urban Mass Transportation Act requires all new American mass
1
transit vehicles to come equipped with wheelchair lifts. Although the Ameri-
can Public Transportation Association delayed implementation, regulations
were issued in 1990.
of life is beyond the scope of this report. However, a number of significant
policies that are critical to helping those with chronic illness and disability
are provided (see Box 3-1).
The Americans with Disabilities Act (ADA) of 1990 and the ADA
Amendments Act of 2008 were considered national civil rights bills for
people with disabilities. The scope of these laws includes the public sector
(federal, state, and local governments) and the private sector (businesses
with 15 or more employees), mandating “reasonable accommodations” for
workers with disabilities. The ADA contains four mandate areas: employ-
ment protection; public service, including transportation and accessibility;
nondiscrimination in public accommodations and services offered by most
private entities; and telecommunication services. Given the committee’s
definition of “living well” as a self-perceived level of comfort, function,
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Privacy policies
• 996—The Health Insurance Portability and Accountability Act provided the
1
first federal protections against genetic discrimination in health insurance.
The act prohibited health insurers from excluding individuals from group
coverage because of past or current medical problems, including genetic
predisposition to certain diseases.
• 008—The Genetic Information Nondiscrimination Act was designed to
2
prohibit the improper use of genetic information in health insurance and
employment. The act prohibits group health plans and health insurers from
denying coverage to a healthy individual or charging that person higher
premiums based solely on a genetic predisposition to developing a disease
in the future. The legislation also bars employers from using individuals’
genetic information when making hiring, firing, job placement, or promotion
decisions.
Access to health care policies
• 965—Medicare and Medicaid, established through passage of the Social
1
Security Amendments of 1965, provides federally subsidized health care
to disabled and elderly Americans covered by the Social Security program.
These amendments changed the definition of disability under the Social
Security Disability Insurance program from “of long continued and indefinite
duration” to “expected to last for not less than 12 months.”
and contentment with life, the role that the ADA has played in the lives of
those with disability is immeasurable.
Although the ADA has proven essential for those with chronic illness,
its implementation has significant disparities by condition. More specifi-
cally, analyses suggest that provisions of the ADA disproportionately under-
protect people with psychiatric disabilities (Campbell, 1994). Research also
has found that people with visual impairments rate the ADA lower than
do people with hearing and mobility impairments (Hinton, 2003; Tucker,
1997). Furthermore, the “doubly disadvantaged,” those with poor educa-
tion and job skills plus a disability, do not appear to benefit in the long
term from the ADA (Daly, 1997). Overall, the ADA has narrowed the gaps
among those with and without disabilities in the areas of education and
political participation. However, the similar gap in employment has not
narrowed. The employment rate for those of working age with a disability
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128 LIVING WELL WITH CHRONIC ILLNESS
is 75 percent of those with a nonsevere disability and 31 percent of those
with a severe disability. For those without a disability, the employment rate
is 84 percent (U.S. Census Bureau, 2010).
Other major concerns that impact the ability of those with chronic ill-
ness to live well are income and housing: 27.9 percent of those of working
age with disabilities live below the poverty level compared with 12.5 per-
cent of the general population (U.S. Census Bureau, 2011). SSDI is avail-
able to those who have worked long enough to pay taxes and are deemed
disabled, and Social Security Income (SSI) is available for those deemed dis-
abled and poor. Both programs require that (1) the recipient be deemed
unable to complete work done previously or able to adjust to other work
and (2) the disability persists for at least one year in duration. In 2008, the
average SSDI payment was $12,048 per year, or 116 percent of the federal
poverty level (FPL) for one person. Recent data suggest that for those on
SSI income, housing costs consume somewhere between 60 and 140 percent
of income (NAMI, 2010). Many with disabilities struggle to find affordable
and accessible housing, despite the existence of disability-specific housing
legislation and other U.S. Housing and Urban Development programs to
provide affordable housing.
Caregivers of those with chronic illness often struggle with maintaining
their own health and well-being as they care for their loved one. The Family
and Medical Leave Act entitles eligible covered employees up to 12 weeks
of job-protected, unpaid leave during any 12-month period in order to care
for family members with a serious health illness or their own serious health
illness; the employee maintains group health benefits during this leave. Even
for those with the ability to maintain a job, recent data suggest that one
of the largest causes of home foreclosures is a medical crisis. Specifically,
a study of those going through home foreclosure in four states found that
medical crises contributed to half of all home foreclosure filings (Robertson
et al., 2008).
Public policies that address the next level of Frieden’s pyramid, chang-
ing the context in order to make individuals’ default decisions healthy,
include state and local clean indoor air and smoke-free laws and ordi-
nances as well as state tobacco taxes. Although the role of government in
U.S. health care delivery has long been a contentious one (Starr, 1982), the
case of tobacco control illustrates that a chronic disease risk factor can be
amenable to U.S. public policy intervention. Data from the CDC celebrate
“the 58.2 percent decrease in the prevalence of smoking among adults
since 1964 [which] ranks among the 10 great public health achievements
of the 20th century” (IOM, 2011). As described in For the Public’s Health:
Revitalizing Law and Policy to Meet New Challenges (IOM, 2011), “the
tobacco story also provides a rich example of a suite of public health inter-
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ventions (including the power to tax and spend, indirect regulation through
litigation, and intervening on the information environment), several of
them public policies, to improve population health, specifically by reducing
mortality and morbidity due to its use.” As outlined in the 2000 Surgeon
General’s Reducing Tobacco Use report (HHS, 2000), beginning in 1950,
“the series of Surgeon General’s reports began meticulous documentation
of the biologic, epidemiologic, behavioral, pharmacologic, and cultural
aspects of tobacco use. . . . The past several years have witnessed major
initiatives in the legislative, regulatory, and legal arenas, with a complex set
of results still not entirely resolved.” The strides made in tobacco control
have a direct impact on improving the well-being of those both with and
without chronic illness.
Indeed, despite significant political obstacles, public health advocates
have successfully developed and implemented public policy to prevent
tobacco use at multiple levels of government. Halpin et al. (2010) outline
a broad set of policies aimed at reducing demand for/restricting the supply
of tobacco products that range from individual level interventions to broad
societal interventions. Although the public health effort to lower tobacco
use continues, the public policy lessons are generalizable to other areas in
which policy action is needed in order to improve health outcomes. Specific
policies include raising excise taxes on tobacco; lowering the cost of treat-
ments for tobacco addiction; regulating exposure to environmental tobacco
smoke; regulating the contents of tobacco products; regulating packaging
and labeling; banning tobacco advertising, promotion, and sponsorship;
prohibiting tobacco sales to minors; regulating physical access to tobacco
products; and eliminating illicit tobacco trade (Halpin et al., 2010).
Public policies that address the third level of Frieden’s pyramid and
target long-lasting protective interventions include insurance mandates that
require coverage of preventive services, like colonoscopies and immuniza-
tions. Those with functional impairment or disability are particularly sus-
ceptible to poor health behaviors given their mental, social, and economic
burden as well as their family and caregiver stress. Growing evidence
indicates that a comprehensive approach to prevention can save long-term
health care costs, mitigate needless suffering, and improve overall well-
being, but more evidence is needed to understand how these policies impact
people with MCCs.
Examples of public policies that prevent chronic disease in the general
population and reduce morbidity in those already living with a chronic
illness are highlighted in Box 3-2. Chapter 4 on community-based inter-
vention provides additional details on policies and interventions that affect
lifestyle behaviors, screening and vaccination, and other inventions such as
self-help and disease management.
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140 LIVING WELL WITH CHRONIC ILLNESS
plans, and projects in diverse economic sectors using quantitative, qualita-
tive and participatory techniques” (WHO, [a]). In addition, HHS recom-
mends HIAs as a planning resource for implementing Healthy People 2020,
recognizing that HIAs can provide recommendations to increase positive
health outcomes and minimize adverse health outcomes (CDC, [a]).
As the definition suggests, an HIA can be applied to many different
types of policy decisions. Doing an HIA of a policy may mean assessing
the likely impacts of a federal, state, or local law; a regulation issued by an
administrative agency at any of these levels; or the manner in which a law
or regulation is implemented. An HIA of a plan could refer to any public-
or private-sector plan, and an HIA of a project can refer to a wide range of
construction, economic, or other projects.
In general, an HIA is performed before the policy, plan, or project is
implemented. The goal is to identify any potential impact on health before
it is too late to change course. Although the emphasis of an HIA is often
on preventing or mitigating any potential negative consequences, an HIA
can also be used to optimize health benefits or to identify potential missed
opportunities to improve health.
A challenging but promising element of HIAs is the need to collaborate
across sectors and disciplines. For example, an assessment of the potential
health impact of a new highway project may require involvement of health,
environmental, and transportation experts. The health experts alone may
need to include epidemiologists, community health experts, and physicians.
In addition, these experts must interact extensively with policy makers and
community members in order to meaningfully assess potential impacts.
This kind of interdisciplinary approach can lead to better decision making
with regard to the current project. Furthermore, it can inform public health
experts about a broad range of other policy areas, positioning them to bet-
ter identify opportunities for health improvement in the future (Rajotte et
al., 2011).
CONCLUSION
The challenge of living well with chronic illness is shared by individuals
and families, communities, health care providers, workplaces, organiza-
tions, and communities. Numerous public policies are critical to maintain-
ing function and independence for chronically ill populations who are
most disadvantaged in terms of income and/or disability for living well
with chronic illness. These include important social policies and programs
like SSI, SSDI, and the ADA, as well as numerous other public policies that
create healthy environments in which to live.
There are also a number of health care policies that directly impact
those with chronic illness through better coordination of health care deliv-
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ery, many of which were included in recently passed federal health reform,
the ACA. However, a system of coordinated policies and supports to assist
those with chronic illness to live well is rare and not broadly considered
by many policy makers. Better integration of health care policy and public
health policy and assessing which policies are most effective at improving
the function and well-being of those with chronic illness can ultimately lead
to better health and economic outcomes.
In order to assist those with chronic illness to live well, the model
adopted by the committee for this report and outlined in Chapter 1
(Figure 1-1) highlights the need to understand the complicated relationship
among myriad determinants of health, health policies and other interven-
tions, and the spectrum of health status. Adopting a HIAP strategy provides
an opportunity to apply this model. Given its interdisciplinary approach to
policy making, the HIAP framework creates synergistic improvements in
overall health status via the assessment of the health implications from both
health and nonhealth public- and private-sector policies. As such, HIAP can
help to integrate health care and public health policy and better coordinate
with various social supports and programs that are critical in helping those
with chronic illness to function independently and live well.
RECOMMENDATIONS 7–8
The statement of task question asks what policy priorities could ad-
vance efforts to improve life impacts of chronic disease. In response, the
committee makes two recommendations, derived from the discussion above.
Recommendation 7
The committee recommends that CDC routinely examine and adjust
relevant policies to ensure that its public health chronic disease man-
agement and control programs reflect the concepts and priorities em-
bodied in the current health and insurance reform legislation that are
aimed at improving the lives of individuals living with chronic illness.
Recommendation 8
The committee recommends that the secretary of HHS and CDC ex-
plore and test a HIAP approach with HIAs as a promising practice on
a select set of major federal legislation, regulations, and policies, and
evaluate its impact on health related quality of life, functional status,
and relevant efficiencies over time.
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ANNEX 3-1 The Affordable Care Act: Provisions Impacting Chronic
Illness
Provision Description
Title I
Extension of Dependent Mandates all group health plans and health insurance
Coverage issuers offering group or individual health insurance that
Sec. 1001 also offers dependent coverage to allow dependents to
remain on their parent’s health insurance until they turns
26 years of age.
Appeals Process Group health plans and health insurance issuers
Sec. 1001 offering group or individual health insurance coverage
must implement an effective internal appeals process
for coverage determinations and claims, including
appropriate notice of the process and the availability
of any consumer assistance to help enrollees navigate
their appeals. The plan must allow enrollees to review
their files, present evidence and testimony as part of the
appeals process, and receive continued coverage pending
the outcome of the appeal.
Health Insurance Consumer Grants to states or Health Benefit Exchanges to establish,
Information expand, or offer support for offices of health-consumer
Sec. 1002 assistance or health insurance ombudsmen programs.
National Diabetes Prevention Authorizes a national program focused on reducing
Program preventable diabetes in at-risk, adult populations.
Sec. 1050
Immediate Access to Insurance Temporary high-risk health insurance pools have
for Uninsured Individuals with been established for individuals who have preexisting
a Pre-existing Condition conditions and have been uninsured for at least 6 months.
Sec. 1101 Pools provide health insurance coverage to eligible
individuals; cover at least 65 percent of the costs of
benefits; ensure that the out-of-pocket expense limit is
no greater than the limit for high-deductible plans; vary
premiums only by family structure, geography, actuarial
value of the benefit, age, and tobacco use; and include an
appeals process to enable individuals to appeal decisions
under this section.
Closing the Medicare Medicare beneficiaries who reached the Medicare
Prescription Drug “Doughnut prescription drug coverage gap or “doughnut hole” in
Hole” 2010 received a $250 rebate. To close the “doughnut
Sec. 1101 hole,” coinsurance for generic drugs in the coverage gap
will be reduced beginning in 2011, and a reduction in
coinsurance for brand-name drugs in the gap begins in
2013.
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143
POLICY
ANNEX 3-1 Continued
Provision Description
Affordable Choices of Health Each state must establish an American Health Benefit
Benefit Plans (Exchanges) Exchange and a Small Business Health Options Program
Sec. 1311 (SHOP) Exchange to facilitate the purchase of qualified
health plans.
Title II
Medicaid Expansion: New eligibility for Medicaid beginning on January 1,
Coverage for the Lowest 2014, for individuals under age 65 earning an income
Income Populations that does not exceed 133 percent of the federal poverty
Sec. 2001 level.
Community First Choice An optional Medicaid benefit through which states could
Option offer home- and community-based attendant services
Sec. 2401 and supports to Medicaid beneficiaries with disabilities
and whose income does not exceed 150 percent of the
federal poverty line for activities of daily living beginning
October 1, 2011.
Removing Barriers to Home- This provision gives states the option to provide more
and Community-Based types of services through a state plan amendment (rather
Services than a Medicaid waiver) for qualified disabled Medicaid
Sec. 2402 individuals. They can provide targeted services to
specific populations and extend full Medicaid benefits
to individuals receiving home- and community-based
services, but they may not limit the number of individuals
eligible for home- and community-based services.
Money Follows the Person Extends the “Money Follows the Person Rebalancing
Rebalancing Demonstration Demonstration” through September 30, 2016, and
Program (MFP) adjusts the time period of required institutional residence
Sec. 2403 (individuals must reside in an inpatient facility for no less
than 90 consecutive days).
Providing Federal Coverage The Federal Coordinated Care Office, housed in CMS,
and Payment Coordination for will bring together officials of the Medicare and Medicaid
Dual Eligible Beneficiaries programs to more effectively integrate benefits under
Sec. 2602 these programs and to improve coordination between
federal and state governments for individuals eligible
for benefits under both Medicare and Medicaid (dual
eligibles).
State Option to Provide States have the option to amend their Medicaid benefits
Health Homes for Enrollees to enroll Medicaid beneficiaries with chronic illnesses
with Chronic Conditions into a health home selected by the beneficiary (including
Sec. 2703 services that are provided by a designated provider, a
team of health care professionals, or a health team).
continued
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144 LIVING WELL WITH CHRONIC ILLNESS
ANNEX 3-1 Continued
Provision Description
Title III
Hospital Value-Based Establishes a value-based purchasing (VBP) program for
Purchasing Program hospitals participating in Medicare starting in fiscal year
Sec. 3001 2013. Under this program, a percentage of the hospital
payment is tied to hospital performance on quality
measures related to common and high-cost conditions.
The National Strategy for A national strategy to improve the delivery of health care
Quality Improvement in services, patient health outcomes, and population health,
Health Care (“National including a comprehensive strategic plan to achieve
Quality Strategy”) priorities identified by the HHS secretary.
Sec. 3011
Center for Medicare & This new center will test various innovative payment
Medicaid Innovation and service delivery models to determine how these
Sec. 3021 models reduce program expenditures while preserving
or enhancing the quality of care provided to individuals
enrolled in Medicare, Medicaid, and the Children’s
Health Insurance Program.
Medicare Shared Savings A program that incentivizes groups of providers and
Program suppliers to work together through accountable care
Sec. 3022 organizations (ACOs) with the goal of promoting
accountability, and thus better care coordination, for
Medicare fee-for-service patient populations.
National Pilot Program on A national pilot program encouraging hospitals, doctors,
Payment Bundling and postacute care providers to improve patient care
Sec. 3023 and achieve savings for the Medicare program through
bundled payment models.
Extension for Specialized Extends the Medicare Advantage Special Needs Plan
Medicare Advantage Plans for (SNP) program through 2013.
Special Needs Individuals
Sec. 3205
Establishing Community Grants to states, state-designated entities, and Indian
Health Teams to Support the tribes to establish community health teams. The health
Patient-Centered Medical teams will make it possible for local primary care
Home providers to better address disease prevention and chronic
Sec. 3502 illness management by facilitating collaboration between
these providers and existing community-based health
resources.
Medication Management A grant program for medication management services
Services in Treatment of provided through the Patient Safety Research Center
Chronic Disease (Section 3501) to aid pharmacists in implementing
Sec. 3503 medication management services for the treatment of
chronic illnesses.
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145
POLICY
ANNEX 3-1 Continued
Provision Description
Patient Navigator System “Patient navigators” will coordinate health care services
Sec. 3510 needed for the diagnosis and treatment of chronic
illnesses. Patient navigators will also facilitate the
involvement of community organizations in assisting
individuals who are at risk for or who have chronic
illnesses to receive better access to high-quality health
care services.
Title IV
National Prevention Council The National Prevention, Health Promotion and Public
Sec. 4001 Health Council’s main responsibilities will include
coordination and leadership at the federal level and
among all federal departments and agencies with respect
to prevention, wellness, and health promotion practices,
the public health system, and integrative health care in
the United States; development of a national prevention
strategy; and recommendations to the president and
Congress concerning the nation’s most pressing health
issues.
Prevention and Public Health Establishes a Prevention and Public Health Fund in
Fund HHS. The fund will provide for an expanded national
Sec. 4002 investment in prevention and public health programs to
improve health and help contain health care costs.
Medicare Personalized Medicare must cover annual wellness visits and
Prevention Plan personalized prevention plan services with the creation of
Demonstration Project an individual plan that includes completion of a health
Concerning Individualized risk assessment (HRA) and takes into account the results
Wellness Plan of the HRA.
Sec. 4103
Removal of Barriers to Medicare will pay 100 percent (waiving beneficiary
Preventive Services in coinsurance and deductibles) for covered preventive
Medicare services if the services are recommended with a grade of
Sec. 4104 A or B by the U.S. Preventive Services Task Force.
Improving Access to Medicaid diagnostic, screening, preventive, and
Preventive Services for Eligible rehabilitation services are expanded to include approved
Adults in Medicaid clinical preventive services, recommended adult
Sec. 4106 vaccinations, and any medical and remedial services
recommended by a physician for the maximum reduction
of physical or mental disability and restoration of an
individual to the best possible functional level.
continued
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146 LIVING WELL WITH CHRONIC ILLNESS
ANNEX 3-1 Continued
Provision Description
Incentives for Prevention of A program to award grants to states to provide incentives
Chronic Disease in Medicaid for Medicaid beneficiaries who participate in programs
Sec. 4108 and demonstrate changes in health risk and outcomes by
meeting specific targets.
Community Transformation Grants awarded to finance the policy, environmental,
Grants programmatic, and infrastructure changes needed to
Sec. 4201 promote healthy living and reduce disparities in the
community.
Healthy Aging, Living Well; Grants awarded to state or local health departments
Evaluation of Community- for a 5-year pilot program to provide public health
Based Prevention and Wellness and community interventions, community preventive
Programs for Medicare screenings, clinical referrals for individuals with chronic
Beneficiaries illness risk factors, and other preventive services to
Sec. 4202 individuals who are between ages 55 and 64.
Employer wellness programs Programs to expand use of evidence-based prevention and
Sec. 4303 health promotion approaches in the workplace.
Title V
State Health Care Workforce A competitive health care workforce development
Development Grants grant program to enable state partnerships to complete
Sec. 5102 comprehensive planning and to carry out activities leading
to coherent and comprehensive health care workforce
development strategies at the state and local levels.
First, for planning grants to help states plan for current
and future health care workforce needs and, second,
for implementation grants to help state partnerships
implement activities that will result in a coherent
and comprehensive plan for health care workforce
development, addressing current and projected workforce
demands in the state.
Training Opportunities for A grant program to fund eligible entities to provide new
Direct Care Workers training opportunities for direct care workers who are
Sec. 5302 employed in long-term care settings and agree to work
in the field of geriatrics, disability services, long-term
services and supports, or chronic care management
for a minimum of 2 years following completion of the
assistance period.
Grants to Promote the A grant program to support community health workers
Community Health Workforce and to promote positive health behaviors and outcomes
Sec. 5313 for populations in medically underserved communities.
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POLICY
ANNEX 3-1 Continued
Provision Description
Co-Locating Primary and Grants for coordinated and integrated services through
Specialty Care in Community- the colocation of primary and specialty care in
Based Mental Health Settings community-based mental and behavioral health settings.
Sec. 5604
Title VI
Patient Centered Outcomes A private, nonprofit institute to advance research on the
Research Institute comparative clinical effectiveness of health care services
Sec. 6301(a) and procedures to prevent, diagnose, treat, monitor, and
manage certain diseases, disorders, and health conditions.
This research will assist patients, clinicians, purchasers,
and policy makers in making informed health decisions.
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148 LIVING WELL WITH CHRONIC ILLNESS
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