Research Objective: The Affordable Care Act established new resources and incentives for hospitals, insurers, public health agencies, and others to contribute to disease prevention and health promotion activities, potentially changing the structure of public health delivery systems and expanding the implementation of strategies that improve population health. This study uses data from the 1998-2014 National Longitudinal Survey of Public Health Systems to examine: (1) the degree and nature of change in multi-sectoral contributions to public health activities; and (2) the extent to which these system changes are attributable to key ACA provisions including coverage expansions, Prevention and Public Health funding, and adoption of public health accreditation standards.
Study Design: Our retrospective cohort design follows more than 350 U.S. metropolitan communities over time using survey data collected initially in 1998 and again in 2006, 2012, and 2014 (2016 data pending). Local public health officials report on the availability of 20 recommended public health activities in the community, and the organizations that contribute to performing each activity including hospitals, primary care providers, insurers, employers, schools, and community-based organizations. We classify communities into one of seven categories of multi-sector system capital based on a cluster analysis of the scope of activities contributed by each type of organization, along with network-analytic measures of inter-organizational connectedness in performing activities (density, degree and betweenness centrality). We link survey data with secondary data sources containing measures of ACA implementation, including health insurance coverage expansion through Medicaid and exchanges, federal funding received from ACA’s Prevention and Public Health Fund, and compliance with national public health accreditation standards promoted through ACA’s National Public Health Improvement Initiative (NPHII). Fixed-effects models with instrumental-variables are used to estimate changes in multi-sector system capital that are attributable to ACA implementation components, while controlling for both observable and unmeasured confounders.
Population Studied: A total of 354 metropolitan communities, representing more than 70% of the total U.S. population. Samples of nonmetropolitan communities were included in 2006 and 2014 as robustness tests.
Principal Findings: Communities with the highest levels of system capital based on scope of activity and multi-sector contributions increased from 24% of the sample in 1998 to 37% in 2006, but fell to 31% in 2012 and recovered modestly to 33% in 2014. Within sectors, hospitals increased their contributions to public health activities by nearly 20% between 2012 and 2014, while insurers, employers, and nonprofit community-based organizations showed smaller but significant increases in contributions (p<0.05). ACA-related coverage gains by themselves had no discernable effects on multi-sector contributions to public health, but ACA prevention funding and public health accreditation standards had strong positive effects on these contributions (p<0.01). The largest gains in multi-sector contributions were observed among communities that achieved both accreditation standards and sizable coverage gains.
Conclusions: ACA implementation has strengthened multi-sector contributions to public health activities, particularly through enhanced prevention funding and adoption of public health accreditation standards.
Implications for Policy or Practice: Maintaining the ACA's public health and prevention components is likely to be essential for realizing the law's intended effects on system change and population health.