Defining Integration.

Hardcastle et al. are critical of the dichotomy between health care delivery and public health, arguing that they should be conceptualized as two interconnected parts of a single health system.^{Reference Gostin, Jacobson, Hyman and Studdert24} In their view, “a fully integrated health system requires that all government policies reflect the ultimate goal of improving the health of the population.”²⁵ Hence, public health and personal clinical care are interdependent fields that can, and should be, merged into one health system. We call this “full integration.”

At the moment, full integration remains elusive. However, as described below, many initiatives exhibiting some degree of integration already exist. This suggests that it makes sense to view integration as a continuum, from incidental to total.

What's lacking is an overall assessment of how existing initiatives differ, which strategies are most effective, and whether any of them are sustainable. As discussed below, recent evaluations of new health care delivery models that move toward integration, along with community-based programs and multi-sector partnerships, have shown limited improvements in population health.²⁶ These initiatives, however, do not exemplify full integration. Moreover, it remains unclear what full integration would entail and how it could be implemented. At a minimum, moves toward full integration would require close cooperation between health departments and provider organizations to identify and measure population health outcomes^{Reference Parrish27} as well as connections to community organizations.

Drivers of Integration.

As noted above, there is a growing awareness that poor health status indicators, rates of disease and injury in the community, and the high cost of medical care cannot be addressed through clinical care changes alone. This is especially true regarding chronic diseases, such as cancer or diabetes. In particular, people with multiple chronic diseases incur very high medical costs that can best be reduced through community interventions and general prevention efforts that reduce disease rates over time.²⁸ As a result, federal and state governments, and private foundations are investing in programs to reduce the SDOH that substantially contribute to systematic health care deficiencies.

Another push for integration comes from the continuing decline in the public health system's ability to achieve sustained community health improvements due to declining public investment, persistent attacks from opponents (including affected industries and antigovernment political groups), limited political power, and competitors encroaching on its responsibilities. From 2008 to 2010, the local health department (LHD) workforce declined by approximately 19%.²⁹ In Washtenaw County (Michigan), a relatively wealthy community, the health department's budget is equivalent to 1992 dollars, despite a growing population and many new demands.³⁰ (The opioid crisis is not the only unfunded responsibility straining health department budgets.)

A third factor driving integration is pressure from payers and policymakers for health systems to take responsibility for population health improvements. The current health policy mantra of moving from volume to value requires caring for patients (especially chronic care patients) in the community rather than through long inpatient stays. Thus, reimbursement incentives and pressure to justify tax-exempt status are likely to support community-based care in the future.

The ACA's Population Health Initiatives

The ACA included several provisions designed to move the health care system closer to public health. These can be roughly divided into three categories: 1) provisions that aimed to increase access to clinical services; 2) payment reforms that incentivized providers to focus more on population health; and 3) reforms that enhanced community-based initiatives and broader public health efforts. Although space precludes a thorough assessment of each, and important research continues, it is clear that some gains toward integration have occurred. Nevertheless, true integration remains far off.

a) Collaborations and Partnerships.

Even apart from the ACA, many LHDs, hospitals, and other stake-holders have entered into collaborations to improve community health. These efforts include some initiatives similar to those discussed above as well as efforts that are narrower in scope and scale than the ACA-related programs.

In some cases, clinical care organizations have undertaken innovative activities to address SDOH. These may or may not currently involve the LHD, but serve as examples of potential strategies for greater integration. One example is a Henry Ford Health System initiative to fund a light rail project in Detroit).⁶⁵ Another is a Rutland Regional Medical Center (VT) project with NeighborWorks of Western Vermont, a community development financial institution (CDFI) that provides loans, financial education, and renovations to homebuyers and owners.⁶⁶ The hospital gave $75,000 toward grants and loans for home repairs, and sends nurses on home visits to determine how to prevent falls or asthma attacks with those repairs.⁶⁷

Some of these initiatives focus on improving access to healthy food. For instance, Mount Carmel Health System (Trinity Health) funds the Healthy Food for Ohio program, which offers grants and loans to businesses providing healthy foods in designated food deserts across the state.⁶⁸ Other initiatives offer a broader range of services. For example, Hennepin Health-PMAP is a Medicaid plan in the Minneapolis area that covers health care and also dental services, transportation, housing, and employment services for high-risk, low-income patients.⁶⁹ Providers partnered with social service and public health leaders to create a “tightly integrated medical and social service system.”⁷⁰ From 2012 to 2013, ED visits fell 55% among clients placed in supportive housing through the program.⁷¹

So far, success for these collaborations has been mixed. For example, Mattessich and Rausch found that about 45% of community health collaborations have been successful.^{Reference Mettessich and Rausch72} In contrast, some have achieved impressive successes.⁷³ A 2014 report from the Commonwealth Center for Governance Studies concluded that such partnerships can be “important vehicles for identifying and addressing community health needs.”⁷⁴ The report also emphasized the importance of hospitals working with public health departments as well as broad sections of the community.⁷⁵

Although new collaborations continue to develop, and research continues, the future of such efforts and their ability to promote integration remain questionable. The CHNA regulations do not require hospitals to fund community partnerships; and hospitals' incentives and capacity to do so may decline if insurance rates fall, leading to more uncompensated care.⁷⁶ In any event, long-term sustainable funding models for AHCs remain uncertain.

Equally important, collaborations often emphasize short-term clinically-based metrics that can be expected to reduce health care costs. In effect, they adopt what Tanenbaum calls an “instrumental” view of population health, seeing it in service to cost-savings in the health care sector.⁷⁷ Given current measurement techniques, population health gains cannot be easily translated into short-term savings. Moreover, AHCs and similar collaborations lack the capacity to engage in a wide-range of public health functions, including investigating disease outbreaks, abating nuisances, or promulgating regulations. In effect, these collaborations lack both legal authority and public accountability. These key points will be discussed further below.

b) Health in All Policies/Health Equity.

One important development is the proliferation of Health in All Policies (HiAP) initiatives, which have been promoted in recent decades by major public health organizations, academic researchers, and nonprofit organizations. As Rudolph et al. explain, “Health in all policies is an approach to improving the health of all people by incorporating health considerations into collaborative decision-making across sectors and policy areas.”^{Reference Rudolph78} The term does not refer to a specific set of policies, rather an approach to developing and implementing governmental policies that address the SDOH.^{Reference de Leeuw, Gase, Pennotti, Smith, Wernhamand and Teutsch79} HiAPs' defining feature is cross-sectoral collaboration, and its core insight is that health is largely determined outside of the health care sector. Nonetheless, these initiatives usually occur within the government, with only sporadic private sector involvement, primarily through foundation grants.

HiAP initiatives are closely related to health equity programs. Hall and Jacobson found that HiAP programs are gradually transitioning to focus on health equity.^{Reference Hall and Jacobson80} They conclude that HiAP is useful as an organizing principle in providing a framework around which multiple stakeholders can operate, but data demonstrating how these initiatives have improved health equity or reduced health disparities are limited.⁸¹

c) The Triple Aim.

Several new initiatives have also emerged from private foundations and not-for-profit organizations. For example, the Institute for Healthcare Improvement's has championed the triple aim strategy, which as discussed above, focuses on redesigning primary care and linking it to population health and disease management.⁸² Specifically, the triple aim comprises three critical objectives: improving population health; enhancing the patient experience of care (including quality, access, and reliability); and reducing, or controlling the costs of care.⁸³ So far, there is no systematic empirical evidence that the approach has in fact integrated population health factors into clinical settings, probably because it relies on the payment mechanisms that have limited ability to offer providers incentives to address SDOH.⁸⁴

Current Political Challenges

Since the onset of the Trump Administration, the integration project has faced an uncertain future. Although Republican efforts to “repeal and replace” the ACA failed several times in 2017,^{Reference Roubein85} and litigation over the ACA's fate continues,^{Reference Goldstein86} a series of less dramatic legislative and regulatory actions have already taken place, which threaten the modest steps that have been taken to date.

The Prevention and Public Health Fund has faced particular threats. Each of the failed Congressional efforts to repeal and replace the ACA would have slashed support for that program. Since then, the Tax Cuts and Jobs Act cut $750 million from the Fund to pay for the Children's Health Insurance Program, and the Bipartisan Budget Act of 2018 cut the fund by another $1.35 billion over 10 years so that only $840,600 remains available, further reducing its potential effectiveness.⁸⁷ These cuts to the fund which helps support many local public health agencies, indicates the low priority the current leadership in Washington holds for prevention, never mind the integration project.

Access to preventive services may also decline if the numbers of the uninsured rise due to the repeal of the individual mandate,^{Reference Pear88} and other less heralded, steps that the Administration has taken to reduce access to the ACA exchanges.^{Reference Pear89} Equally significant, are new regulations designed to ease the way for association and short-term, limit-duration insurance plans.⁹⁰ Both types of plans may lead healthy people away from the exchanges and to less-comprehensive coverage. Likewise, the President has required federal agencies to encourage the expanded use of Health Reimbursement Accounts,⁹¹ which may also move people into less comprehensive plans that do not cover essential benefits. In addition, women with ACA-compliant employer-sponsored plans may lose access to contraceptive coverage as the result of the Administration's decision to allow any employer to opt out on grounds of conscience.^{Reference Pear, Ruiz and Goodstein92}

Moving somewhat in the other direction was the recent passage of the CHRONIC Care Act, which will allow Medicare Advantage Plans to provide more flexible supplemental benefits for individuals with chronic care, including environmental modifications and transportation services.^{Reference Willink and DuGoff93} The Act also attempts to enhance ACOs in a variety means, including by requiring CMS to allow all ACOs to prospectively assign beneficiaries, and by permitting ACOs to give beneficiaries cash incentives to seek primary care.^{Reference Shah94} Those enhancements might not matter if new changes proposed by the Administration go into effect. The changes would require all ACOs to accept risk of loss, not just bonuses, after two years instead of the six-year window now allowed; this would likely result in fewer ACOs remaining in the program.⁹⁵

Although at times the Administration and Republican leaders have looked favorably on ACOs, they have shown less enthusiasm for payment reform initiatives that move away from the fee-for-service model.^{Reference Cunningham96} Moreover, their perspective seems contrary to the integration project. Under their vision, health insurance and health care are individual matters, and each person should have to pay only for the care that he or she wants. So, for example, Republican Congressman John Shimkus explained his support for repealing the ACA's essential benefits requirement by asking, “What about men having to purchase prenatal care?”^{Reference Manchester97} To Shimkus, prenatal care was simply an individual service that should only be financed by those who use it.

That vision is antithetical to public health's population perspective, and the integration project. If health is purely personal, and individuals should pay only for their own needs, ACOs, AHCs, and any initiative that seeks to align provider incentives with the population goals are destined to remain limited in their reach and impact.⁹⁸ As a consequence, efforts to align health care with broader community health metrics will remain marginal, except perhaps in communities with high concentrations of Medicaid beneficiaries. If integration exists only for underserved and vulnerable communities, it will inevitably remain the exception, rather than the rule.

Current Implementation Challenges

Assuming that improving the community's health is a shared goal for health departments and health-care providers, implementing the integration project might alleviate some of the reciprocal challenges both face in addressing SDOH. That is, health departments have the capacity but not the resources to address SDOH; health care providers have the resources but not the capacity.

Underfunded and often claimed to be in disarray, state and LHDs continue to have primary responsibility for securing public health, in part through promulgating and enforcing health codes.^{Reference Salinsky99} Their efforts have led to significant improvements in sanitation, declines in vaccine-preventable diseases,¹⁰⁰ development of laboratory capacity,¹⁰¹ and control of infectious diseases such as tuberculosis, and have helped improve the public's health during the last 150 years.¹⁰² In recent decades, LHDs have also been at the forefront of tobacco-control efforts, as well as new interventions aimed at reducing consumption of unhealthy foods.¹⁰³ Many, but not all of these achievements, rely on departments' legal authority.

One reason why integration is essential for addressing the community's health is that few health care administrators have the skills and capacities to work across the current clinical-community divide. Public health leadership for implementing integration would include training on ways to establish community-based connections and navigate patient care across clinical and non-clinical settings. And public health practitioners can work with clinicians to detect social needs and develop strategies for addressing them in the community. For example, an important aspect of the AHC Model is that it relies on a still untested screening tool to detect social needs in clinical settings.^{Reference Billioux104} Public health input can contribute to successful SDOH screening and implementation strategies.

Most health care providers remain in the private sector. Although they have far more resources than LHDs, they lack legal powers, as well as the constitutional restraints and political oversight to which LDHs are subject.¹⁰⁵ This raises the question: what happens to health departments as they move toward implementing integration with their larger, better-resources health care partners?

One possibility is that health care providers (and insurers) will assume greater responsibility (and provide more resources) for population-focused initiatives that do not require the exercise of legal authority. For example, provider-led collaborations, or even fully-integrated entities, may support healthy eating campaigns, vaccine clinics, and social services to assist patients with housing or public benefits.¹⁰⁶ If these initiatives are identified and planned in collaboration with LHDs, they may free-up department resources,¹⁰⁷ allowing officials to focus more fully on efforts that require legal authority (for example, code enforcement) that only they can undertake. Under this scenario, integration would result in a complementary and supportive division of efforts aimed at improving the health of a community.

But there are less rosy scenarios. One is that public health departments will increasingly adopt the perspectives of their more influential (and wealthy) provider-partners. Of course, this would not be a totally new development. Already, LHDs offer individual, clinical health services, especially to under-served populations, and public health has long viewed health problems through an individualistic lens. This perspective became especially influential during the late twentieth century as non-communicable diseases were associated with individual behavior choices.^{Reference Parmet108}

Despite embracing a broader population perspective that emphasizes SDOH and the need for health equity,¹⁰⁹ it is possible that as health departments join forces with health care providers, they may begin to adopt health care's narrower definition of population and more individualistic focus. (This seems especially likely if public health entities rely on funds from the health care sector to support their activities.) This could potentially lead departments to emphasize interventions that operate relatively downstream. For example, one can imagine enhanced screening programs or healthy eating workshops. While such efforts already exist, the question is whether LHDs' increased reliance on and collaboration with providers will lead to an over-emphasis of such efforts in lieu of more upstream efforts that are designed to address the economic and social roots of health inequities.^{Reference Jacobson and Gollust110}

A second possibility, which may co-exist with the first, is that integration will leave LHDs with fewer, not more resources. According to Leider and colleagues, many leaders of large urban health departments are worried about just such a possibility. One stated, “The main thing that we've talked about is that the ACA does medicalize some public health issues and at the same time pull some discrete funding away from public health agencies.”^{Reference Leider111} The continuous threats to the Prevention and Public Health Fund suggest that such concerns are very real. As health care providers undertake more community health efforts (with or without collaboration from health departments), support for LHDs may erode even further.

In response to budgetary restraints, LHDs may pull back and focus on core functions, such as infectious disease control.^{Reference Balaban112} This would be problematic because, as suggested above, health departments' mission, perspective, and toolkits are distinct from those of health care providers. No matter how robust the public input and collaboration, ACOs, AHCs, and like collaborations cannot inspect nursing homes, abate nuisances, declare and respond to public health emergencies, or promulgate new regulations in response to new problems. Nor are these new entities, no matter how innovative, subject to the same legal and democratic oversight as are LHDs. They do not have to respect constitutional rights, and their priorities are not subject to rejection at the ballot box. In addition, because large hospitals and provider groups play a major role in these organizations, AHCs and ACOs would face numerous potential conflicts of interest. In particular, they remain subject to perverse incentives that may discourage them from tackling some population health problems.^{Reference Hancock113} The extent and impact of these conflicts merits future research as integration proceeds.

The Future of Public Health

The integration project contributes to the wide-ranging debate among public health advocates, practitioners, and policymakers as to how the public health system can best be organized to meet expected population health challenges. Our analysis thus has important implications for the future of public health. The parlous state of the governmental public health system is one reason for considering integration as a long-term survival strategy, especially at the local level. Within state health and human services departments, it would be appropriate to consider how public health can be integrated fully into the health care and human services responsibilities. From that perspective, the public health system will either change from within or have change imposed upon it. Integration is one possible option.

Even if integration were to develop further, health departments would almost certainly retain primary responsibility for infectious disease surveillance and response. This might allow health departments to focus on the IOM's three core public health services — policy development, assessment, and assurance.¹¹⁴ As part of its policy development responsibilities, health departments would also retain their legal and regulatory authority.

Our concern is that the current discussion about the governmental public health system's future is based on nostalgia rather than pragmatic and realistic expectations of future possibilities. The fact that health systems might seriously begin to absorb the population health role reinforces the need to expeditiously develop a sustainable future role for the public health system. In short, although the integration project holds much promise for providing new support and collaboration for health departments, the danger remains that public health agencies will find themselves eclipsed, rather than enhanced. If so, population health will suffer.