Improving the Population’s Health : The Affordable Care Act and the Importance of Integration

Heath care and public health are typically conceptualized as separate, albeit overlapping, systems. Health care’s goal is the improvement of individual patient outcomes through the provision of medical services. In contrast, public health is devoted to improving health outcomes in the population as a whole through health promotion and disease prevention. Health care services receive the bulk of funding and political support, while public health is chronically starved of resources. In order to reduce morbidity and mortality, policymakers must shift their attention to public health services and to the improved integration of health care and public health. In other words, health care and public health should be treated as two parts of a single integrated health system (which we refer to as the health system throughout this article). Furthermore, in order to maximize improvements in health status, policymakers must consider the impact of all governmental policies on health (a Health in All Policies Approach). The Patient Protection and Affordable Care Act of 2010 (ACA or the Act) reflects the dominance of health care over public health. As its name suggests, the statute’s primary goal is to improve access to health care services through insurance system reforms. In contrast, politicians neglected the goal of improving the population’s health in this monumental overhaul of our health system. Although the ACA does little to mandate health system integration, various opportunities exist within the Act’s implementation for decision makers to improve coordination between health care and public health. In the first part of this article, we argue that the key purpose of health reform should be the improvement of health. Evidence indicates that public health efforts - health promotion and disease prevention - contribute more to reductions in morbidity and mortality than improved access to health care services. We then argue that optimal gains in health status will occur through effective and efficient integration of public health and health care services. In the third part of the article, we explore the ACA’s contribution to the goal of improving the population’s health. Specifically, we critically analyze the extent to which the Act facilitates integration between public health and health care. Drawing from the health policy literature, we discuss strategies for advancing integration, with a view to guiding the Act’s implementation and future health care debates. We conclude by advocating for a broad approach to integration - a Health in All Policies Approach - which would integrate health considerations into all areas of government policy