the patient protection & affordable care act (pp aca)

The Patient Protection &

Affordable Care Act(PP ACA)

The Patient Protection &

Affordable Care Act(PP ACA)Will it Help

Public Health?Will it Help

Public Health?

American Association of American Association of Public Health PhysiciansPublic Health Physicians

San Francisco, CA, October 28, 2012San Francisco, CA, October 28, 2012

Jonathan Weisbuch, MD, MPHJonathan Weisbuch, MD, MPH

[email protected]@mac.com

Information Information ResourcesResources

Information Information ResourcesResources

• www.healthcare.govwww.healthcare.gov• www.healthcare.govwww.healthcare.gov

• www.aarp/getthefactswww.aarp/getthefacts• www.aarp/getthefactswww.aarp/getthefacts

• http://healthreform.kff.ohttp://healthreform.kff.orgrg

• http://healthreform.kff.ohttp://healthreform.kff.orgrg

• HR 3590: The Patient HR 3590: The Patient Protection and Protection and Affordable Care ActAffordable Care Act

• HR 3590: The Patient HR 3590: The Patient Protection and Protection and Affordable Care ActAffordable Care Act

• http://www.apha.org/NR/rdonlyres/http://www.apha.org/NR/rdonlyres/

• [email protected]@apha.org• [email protected]@apha.org

AgendaAgenda

History behind ACA Problems in the PH System PP ACA Benefits to Public Health

The Future: The Election of 2012

Will we Keep What We Have, Will we Keep What We Have, Regress, Regress,

Or Expand PH & Medicare for ALL?Or Expand PH & Medicare for ALL?

History behind ACA Problems in the PH System PP ACA Benefits to Public Health

The Future: The Election of 2012

Will we Keep What We Have, Will we Keep What We Have, Regress, Regress,

Or Expand PH & Medicare for ALL?Or Expand PH & Medicare for ALL?

Egypt & China John Adams: Merchant Seaman Act, 1798 Dorothea Dix & Franklin Pierce, 1854

Theodore Roosevelt: Bull Moose Party

Lyndon Johnson: Medicare & Medicaid Barack Obama: Affordable Care Act, 2010

Egypt & China John Adams: Merchant Seaman Act, 1798 Dorothea Dix & Franklin Pierce, 1854

Theodore Roosevelt: Bull Moose Party

Lyndon Johnson: Medicare & Medicaid Barack Obama: Affordable Care Act, 2010

History

Problems in American Problems in American MedicineMedicine

Problems in American Problems in American MedicineMedicine

Cost: $2.6 trillion in 2010 Access: 50 million uninsured Quality: US is #37 in World Profits outrank Service “Let the Market Decide” “No Socialized Medicine” “Repeal ‘ObamaCare’! ”

Cost: $2.6 trillion in 2010 Access: 50 million uninsured Quality: US is #37 in World Profits outrank Service “Let the Market Decide” “No Socialized Medicine” “Repeal ‘ObamaCare’! ”

Again, You have heard it all; so let’s go on!Again, You have heard it all; so let’s go on!

Federal Agencies: USDA, EPA, OSHA, FEMA, DEd, DEnerg, etc., and

DHHS: PHS (CDC, Prison Hlth, Niosh), FDA, INH, HRSA, etc.

Congress: Do they have a Clue? States: 55 Health Depts. Counties and Cities: 3000 Assns: ASTHO, NACCHO, APHA, AAPHP, etc.

Federal Agencies: USDA, EPA, OSHA, FEMA, DEd, DEnerg, etc., and

DHHS: PHS (CDC, Prison Hlth, Niosh), FDA, INH, HRSA, etc.

Congress: Do they have a Clue? States: 55 Health Depts. Counties and Cities: 3000 Assns: ASTHO, NACCHO, APHA, AAPHP, etc.

Problems in American PProblems in American Public Health Systemublic Health System

Problems in American PProblems in American Public Health Systemublic Health System

LEADERSHIP??LEADERSHIP??

Needs in American Public Needs in American Public Health SystemHealth System

Needs in American Public Needs in American Public Health SystemHealth System

PhysicalPhysical

Socio-Cultural-Socio-Cultural-EconomicEconomic BiologicBiologic

Health System

Health System

Air Pollution Air Pollution ControlControl

Occupational Occupational SafetySafety

Drinking Drinking WaterWater

Transportation Transportation SafetySafety

Health Ed & Health Ed & PromotionPromotion

School School Health Health Prison Prison Health Health

Food Food Safety Safety

Emergency Emergency Mgmt.Mgmt.Epidemic Epidemic ControlControl

Chronic Disease Chronic Disease ControlControl

Vital Vital Records Records

Pub Health Pub Health LabLab

VaccinVaccines es PH PH

ClinicClinics s

Family Family Planning Planning

STDs STDs

Climatic Climatic Hazards Hazards

Where does PH fit into a $2.6 Where does PH fit into a $2.6 trillion Health System?trillion Health System?

COMMUNITY

Public Public HealthHealth

Prim Prim CareCare

Sec Sec CareCare

Tert Tert CareCare

LTC LTC CareCare

Home Home CareCare

Pre- Pre- Hosp Hosp CareCare

Ambulatory

Care

Hospital

Care

$60 B $750 B $900 B $216 B $53 B< $50 B

2010 2010

CosCost:t:

(est)(est)Number:Number: 312million

16 million runs

587 millio

n vsts.

6 Mil Patients

35 Mil Admts.&

166 Mil Bd--Dys

3 Mil Patients

PreventionPrevention

451 million vsts.

The ACA has assigned $650 Million for PH &The ACA has assigned $650 Million for PH &Expanded Prevention Services Expanded Prevention Services

A.A. Community Prevention Community Prevention: $ 298 Mil. State & local: $ 222 Tobacco Prevention: $ 60 Obesity & Fitness: $ 16

B.B. Clinical Prevention Clinical Prevention: $ 182 Wellness & Prevention (vac): $ 112 Behavioral Health & 1O Care: $ 70

A.A. Community Prevention Community Prevention: $ 298 Mil. State & local: $ 222 Tobacco Prevention: $ 60 Obesity & Fitness: $ 16

B.B. Clinical Prevention Clinical Prevention: $ 182 Wellness & Prevention (vac): $ 112 Behavioral Health & 1O Care: $ 70

And More….And More….

How are PH & Prevention Funds Allocated?How are PH & Prevention Funds Allocated?How are PH & Prevention Funds Allocated?How are PH & Prevention Funds Allocated?

C.C. PH Infrastructure & PH Infrastructure & Training: $ 137 MilTraining: $ 137 Mil PH Infrastructure: $ 40 PH Workforce: $ 45 PH Capacity: $ 52

D.D. Research & Tracking: Research & Tracking: $ 133$ 133 Healthcare Surveillance: $ 84 Prevention Research (USTFPS): $ 49

C.C. PH Infrastructure & PH Infrastructure & Training: $ 137 MilTraining: $ 137 Mil PH Infrastructure: $ 40 PH Workforce: $ 45 PH Capacity: $ 52

D.D. Research & Tracking: Research & Tracking: $ 133$ 133 Healthcare Surveillance: $ 84 Prevention Research (USTFPS): $ 49

How are PH & Prevention Funds Allocated?How are PH & Prevention Funds Allocated?How are PH & Prevention Funds Allocated?How are PH & Prevention Funds Allocated?

Total for Prevention: $ 650 MillionTotal for Prevention: $ 650 Million

COMMUNITY

Public Public HealthHealth

Prim Prim CareCare

Sec Sec CareCare

Tert Tert CareCare

LTC LTC CareCare

Home Home CareCare

Pre- Pre- Hosp Hosp CareCare

A.A.Tobacco & Obesity/Fitness Tobacco & Obesity/Fitness ($60 M)($60 M)

B.B. Wellness & Wellness & Behavioral Health Behavioral Health

($182)($182)

State & local State & local ($ ($ 222 M)222 M)

C.C.PH Training & PH Training & Infrastructure Infrastructure

($137)($137)

D.D. Health Care Surveillance & Prevention Health Care Surveillance & Prevention Research Research ($133)($133)

Are These Enough? NO!! But they are a START!Are These Enough? NO!! But they are a START!Are These Enough? NO!! But they are a START!Are These Enough? NO!! But they are a START!

Which Elements of the System will Benefit Which Elements of the System will Benefit from $650 Million from the ACA? from $650 Million from the ACA?

But First, let us Consider Who But First, let us Consider Who Gets Care & Who Generates CostsGets Care & Who Generates CostsBut First, let us Consider Who But First, let us Consider Who Gets Care & Who Generates CostsGets Care & Who Generates Costs

Healthy Insured

58%

14%14%

14%14%

16%16%

1.6%1.6%Population Distribution Health Expenditure %

$1.3 trillion$1.3 trillion 58% 58%

15%15%

$335 billion

19%$450 billion 4%

InsuredInsured (Healthy): 165 million165 million

InsuredInsured (Unhealthy):(Unhealthy): 42 million42 million

Medicare, Elderly: 42 million42 million

Medicare, SSI: 4.8 million4.8 million

Uninsured: Uninsured: 48 million48 million

30% of Population: 30% of Population: the Elderly & Unhealthy Insured

uses 81% of Resourcesuses 81% of Resources

25% of Insured (25% of Insured (50 million50 million) ) are on Medicaidare on Medicaid

Now Let us ask: “Where Do We In Public Health go from

Here?

Ancients: Egypt/ China

Ancients: Egypt/ China

2013

?2013

?Merchant Seaman

1798

Merchant Seaman

1798

Medicare/ Medicaid

1965

Medicare/ Medicaid

1965

Affordable Care Act

2010

Affordable Care Act

2010

QuickTime™ and a decompressor

are needed to see this picture.

The SCOTUS Ruling on the The SCOTUS Ruling on the ACA May HelpACA May Help

The SCOTUS Ruling on the The SCOTUS Ruling on the ACA May HelpACA May Help

What About TAXES?What About TAXES?What About TAXES?What About TAXES?

Congress may use a Tax to Achieve its OBJECTIVE

IMPLICATION for Pub Hlth A Tax can be used for PH goals

A Tax can Influence Behavior Tax is triggered by a Situation

Invites Targetted Taxes

Congress may use a Tax to Achieve its OBJECTIVE

IMPLICATION for Pub Hlth A Tax can be used for PH goals

A Tax can Influence Behavior Tax is triggered by a Situation

Invites Targetted Taxes

Some ExamplesSome ExamplesSome ExamplesSome Examples Tax on Tanning Salons Tax on Pollution Taxes on Tobacco & Alcohol Or a TAX on PEOPLE who SMOKE A Tax on Body Mass, Or a Tax Credit for Weight LOSS

Or a Credit for Vaccinating Children

And More….

Tax on Tanning Salons Tax on Pollution Taxes on Tobacco & Alcohol Or a TAX on PEOPLE who SMOKE A Tax on Body Mass, Or a Tax Credit for Weight LOSS

Or a Credit for Vaccinating Children

And More….Ref: Mello, MM, & Cohen, IG, NEJM.org, Oct 17, 2012

But Caveats ExistBut Caveats ExistBut Caveats ExistBut Caveats Exist

Taxes can be used for PH Goals

But they can be Blocked as Well

Legislatures do not always Agree

Nor do the VOTERS who may Balk

Taxes can be used for PH Goals

But they can be Blocked as Well

Legislatures do not always Agree

Nor do the VOTERS who may Balk

BUT the Supreme Court Decision BUT the Supreme Court Decision

Will Not Determine the FUTUREWill Not Determine the FUTURE

The 2012 Election The 2012 Election

will Determine the will Determine the

FutureFuture

The 2012 Election The 2012 Election

will Determine the will Determine the

FutureFuture

Four Options ExistFour Options Exist

Option #1 Option #1 (similar to 111th (similar to 111th Congress)Congress)

Option #1 Option #1 (similar to 111th (similar to 111th Congress)Congress)

US House: US House: RepublicanRepublican

Rep: 256Rep: 256Dem: 178Dem: 178

US Senate: US Senate: DemocraticDemocratic

Rep: 46Rep: 46Dem: 52Dem: 52

Ind: 2Ind: 2

Presidency: Obama, Democrat

Option #2 Option #2 (House & Senate go (House & Senate go RED)RED)

Option #2 Option #2 (House & Senate go (House & Senate go RED)RED)

US House stays US House stays RepublicanRepublican

Rep: 256Rep: 256Dem: 178Dem: 178

US Senate goes US Senate goes RepublicanRepublican


Ind: 2Ind: 2

Presidency: Obama is Re-elected

Option #3Option #3Option #3Option #3

US House: US House: RepublicanRepublican

Rep: 256Rep: 256Dem: 178Dem: 178

US Senate: US Senate: RepublicanRepublican


Ind: 1Ind: 1

President: Romney & VP:

Ryan

Option #4Option #4Option #4Option #4

US HouseUS House

Dem: 225 Dem: 225 Rep: 205Rep: 205

US SenateUS SenateDem: 55 Dem: 55 Rep: 44Rep: 44Ind: 1Ind: 1

President O O b a m ab a m a

Is Re-Is Re-electedelected


are needed to see this picture.

Given Four Options, Given Four Options, What is the FUTURE What is the FUTURE for Public Health & Health Care after for Public Health & Health Care after

2012?2012?

Given Four Options, Given Four Options, What is the FUTURE What is the FUTURE for Public Health & Health Care after for Public Health & Health Care after

2012?2012?

RepublicansRepublicans will Repeal will Repeal ACAACA; ;

Privatize Privatize

MedicareMedicare and and Eliminate Eliminate

MedicaidMedicaid

Affordable Care Affordable Care Act will be Solid; Act will be Solid;

Medicare Medicare for Allfor All; ; might might

be Considered.be Considered.

MedicaidMedicaid, WHO , WHO KNOWS?? KNOWS??

Option 1 or 2: Who Knows? More Gridlock?Option 1 or 2: Who Knows? More Gridlock?

Option 3: Option 4:

PUBLIC HEALTH. PUBLIC HEALTH. Could ProsperCould Prosper

If Public Health is to If Public Health is to Prosper, We Must Achieve Prosper, We Must Achieve

Option #4Option #4

If Public Health is to If Public Health is to Prosper, We Must Achieve Prosper, We Must Achieve

Option #4Option #4 We must then work with Congress; through AMA, AMA, APHA, NACCHO, ASTHO, APHA, NACCHO, ASTHO, APPHPAPPHP

We must continue to work our local POLITICALPOLITICAL Game,

If Obama loses, we will be in entrenchment mode.

We must then work with Congress; through AMA, AMA, APHA, NACCHO, ASTHO, APHA, NACCHO, ASTHO, APPHPAPPHP

We must continue to work our local POLITICALPOLITICAL Game,

If Obama loses, we will be in entrenchment mode.

We Must Work to Improve the We Must Work to Improve the ACA. Work to Prevent RepealACA. Work to Prevent Repeal

Regardless of the Regardless of the ElectionElection

Regardless of the Regardless of the ElectionElection

BUT WE WILL SURVIVEBUT WE WILL SURVIVE

Questions?Questions?

& Discussion& Discussion

HistoryEgypt: ~2500 BCE; Health Insurance (?)Egypt: ~2500 BCE; Health Insurance (?)

And China: ~1600 BCE; HMOs (?)

US HistoryUS History

Signed into Law, the Merchant Seaman’s Act of Merchant Seaman’s Act of 17981798, which Required all Seaman to buybuy Insurance

giving the US the resources to create a Federal Health System in all US Seaports, serving Seamen and other Federally qualified groups,

President John Adams, 1798

It became the basis for the It became the basis for the Public Health Service; and Public Health Service; and the VA Hospital System.the VA Hospital System.

Early 20th Century Early 20th Century HistoryHistory

TR, Franklin & HarryTR, Franklin & Harry

All failed to pass Universal Health CareAll failed to pass Universal Health Care

1912 1937 1949

More History

LBJ: In 1964 the Election Mattered

LBJ: In 1964 the Election Mattered

And LBJ signed Medicare & Medicaid And LBJ signed Medicare & Medicaid in Independence, MO, July 30, 1965in Independence, MO, July 30, 1965

Painful History

ClintonClinton: 1993-94


are needed to see this picture. The Failure of Clinton’s The Failure of Clinton’s Health Reform Legislation, Health Reform Legislation, opened the Flood Gates to opened the Flood Gates to

an Expanded Private an Expanded Private Health Insurance IndustryHealth Insurance Industry

And Yesterday’s History

President Obama, in 2010,

with a Democratic Majority in the House and Senate

Signed the Patient Patient

Protection Protection Affordable Care Affordable Care

Act, ACAAct, ACA

March 23, 2010

Fundamental Issues in Health Fundamental Issues in Health Care that ACA will try to SolveCare that ACA will try to SolveFundamental Issues in Health Fundamental Issues in Health

Care that ACA will try to SolveCare that ACA will try to Solve

CostCost

AccessAccess

QualityQuality

40 to 50 million Americans

are UninsuredUninsured

Docs, Pts, Hosps, are

all FrustratedFrustrated

17% of GNP 17% of GNP and rising and rising

Below 37 other Below 37 other nationsnations Too much Service, not enough BenefitToo much Service, not enough Benefit

150,000 unnecessary deaths a year150,000 unnecessary deaths a year Infant Mortality: High, especially in MinoritiesInfant Mortality: High, especially in Minorities Life Expectancy: Below Japan, Europe, CanadaLife Expectancy: Below Japan, Europe, Canada

AccessAccess for 310 million CostCost Reduction QualityQuality Improvement:

Longer Life, Lower Infant Mortality, Lower Chronic Disease by Age

Expanded Primary Care More Preventive Services

AccessAccess for 310 million CostCost Reduction QualityQuality Improvement:

Longer Life, Lower Infant Mortality, Lower Chronic Disease by Age

Expanded Primary Care More Preventive Services

WHERE Do WE Want to BE?WHERE Do WE Want to BE?(Goals)(Goals)

WHERE Do WE Want to BE?WHERE Do WE Want to BE?(Goals)(Goals)

2012:2012: Elect Progressives in November Elect Progressives in November 2013:2013: Federalize Medicaid early Federalize Medicaid early

Cover Cover ALLALL Pregnant Women & Infants Pregnant Women & Infants Expand Medicare Coverage to Expand Medicare Coverage to LTC & NHsLTC & NHs Increase Payroll Deduction to 4.0% and Increase Payroll Deduction to 4.0% and

Eliminate FICA Cap of $106,000Eliminate FICA Cap of $106,000 --> --> $320± B$320± B Enact a Financial Activity Transfer Tax: Enact a Financial Activity Transfer Tax: $0.50/shr --> ~ $550 billion/ $0.50/shr --> ~ $550 billion/ year from NYSEyear from NYSE

Total Input to Medicare Trust Fund: ~ $900 BTotal Input to Medicare Trust Fund: ~ $900 B

2012:2012: Elect Progressives in November Elect Progressives in November 2013:2013: Federalize Medicaid early Federalize Medicaid early

Cover Cover ALLALL Pregnant Women & Infants Pregnant Women & Infants Expand Medicare Coverage to Expand Medicare Coverage to LTC & NHsLTC & NHs Increase Payroll Deduction to 4.0% and Increase Payroll Deduction to 4.0% and

Eliminate FICA Cap of $106,000Eliminate FICA Cap of $106,000 --> --> $320± B$320± B Enact a Financial Activity Transfer Tax: Enact a Financial Activity Transfer Tax: $0.50/shr --> ~ $550 billion/ $0.50/shr --> ~ $550 billion/ year from NYSEyear from NYSE

Total Input to Medicare Trust Fund: ~ $900 BTotal Input to Medicare Trust Fund: ~ $900 B

HOW Do WE Get THERE?HOW Do WE Get THERE?(Phase I)(Phase I)

HOW Do WE Get THERE?HOW Do WE Get THERE?(Phase I)(Phase I)

20142014: Expand : Expand MedicareMedicare Age Eligibility: Age Eligibility: Add 50 to 65 age group;Add 50 to 65 age group; Add 1 to 20 year olds to eligible groupAdd 1 to 20 year olds to eligible group Increase FICA to 7% of Payroll --> $560 B ± Increase FICA to 7% of Payroll --> $560 B ±

20152015: Make 35 to 50 : Make 35 to 50 MedicareMedicare Eligible Eligible Increase Payroll Deduction to 8.5% (+ $120 B)Increase Payroll Deduction to 8.5% (+ $120 B)

20162016: Add 20 to 35 to : Add 20 to 35 to MedicareMedicare Eligibility Eligibility Increase Payroll Deduction to 11% --> ~ $1,100 BIncrease Payroll Deduction to 11% --> ~ $1,100 B Total Annual Input to MTF: $900 + $550 + $350* =Total Annual Input to MTF: $900 + $550 + $350* =

$2,000 Billion$2,000 Billion* General Fund for Medicaid Costs* General Fund for Medicaid Costs

20142014: Expand : Expand MedicareMedicare Age Eligibility: Age Eligibility: Add 50 to 65 age group;Add 50 to 65 age group; Add 1 to 20 year olds to eligible groupAdd 1 to 20 year olds to eligible group Increase FICA to 7% of Payroll --> $560 B ± Increase FICA to 7% of Payroll --> $560 B ±

20152015: Make 35 to 50 : Make 35 to 50 MedicareMedicare Eligible Eligible Increase Payroll Deduction to 8.5% (+ $120 B)Increase Payroll Deduction to 8.5% (+ $120 B)

20162016: Add 20 to 35 to : Add 20 to 35 to MedicareMedicare Eligibility Eligibility Increase Payroll Deduction to 11% --> ~ $1,100 BIncrease Payroll Deduction to 11% --> ~ $1,100 B Total Annual Input to MTF: $900 + $550 + $350* =Total Annual Input to MTF: $900 + $550 + $350* =

$2,000 Billion$2,000 Billion* General Fund for Medicaid Costs* General Fund for Medicaid Costs

Getting THERE: Getting THERE: (Phase II(Phase II ) )

Getting THERE: Getting THERE: (Phase II(Phase II ) )

2011 is Where We Begin2011 is Where We Begin2011 is Where We Begin2011 is Where We Begin

$450 B

Medical Costs

$100 B$100 B

$350 B

$400 B

$300 B

$20 B$20 B

1,000,0001,000,000

$30 B$30 B

$70 B$70 B

$250 B

$250 B

309,500,000 $2,000 B

Population UninsuredAge Gps 2013

80 - 8575- 80 42,386,118 0% - 70- 7565- 7060- 6555- 60 47,532,368 13% 6,179,208 50- 5545- 5040- 45 70,884,743 18% 12,404,830 35- 4030- 3525- 30 64,176,375 30% 13,512,912 20- 25 -4,100,00015- 20 44,211,683 0% - 10- 155 - 10 42,887,656 0% - 1 - 5

Total Population: 312,078,943 Female Male Total Uninsured 27,996,950

% Uninsured 9.0%

Reduction in Uninsured 21,789,926

Annual Cost

Billions

$450

$120

$ 16

$686Total

2013 to 2014

Total Reduction in Uninsured:

Reduces # of Uninsured Mothers & Children by 13.5 millionReduces # of Uninsured Mothers & Children by 13.5 million

2013-14

If Democrats are ElectedIf Democrats are ElectedIf Democrats are ElectedIf Democrats are Elected

(4,000,000)(4,000,000)

Population UninsuredAge Gps 2014 to 2016

80 - 8575- 80 42,386,118 0% - 70- 7565- 7060- 6555- 60 47,532,368 0% - 50- 5545- 5040- 45 70,884,743 18% 12,404,830 35- 4030- 3525- 30 64,176,375 30% 17,612,912 20- 2515- 20 44,211,683 0% - 10- 155 - 10 42,887,656 0% - 1 - 5


% Uninsured 9.6%


In 2014: Add 50 to 65 year olds

4a.4a.

Annual Cost

Billions

$465

$120

$ 16

$931Total

$330

2015 to 2016

Total Reduction in Uninsured: 19,769,134

Next 2 yrs.


80 - 8575- 80 42,386,118 0% - 70- 7565- 7060- 6555- 60 47,532,368 0% - 50- 5545- 5040- 45 70,884,743 0% - 35- 4030- 3525- 30 64,176,375 30% 17,612,912 20- 2515- 20 44,211,683 0% - 10- 155 - 10 42,887,656 0% - 1 - 5


% Uninsured 5.6%



4b.4b.

Annual Cost

Billions

$490

$120

$ 16

$1,186Total

$332

$355

2017 to 2018


Years 5 & 6


80 - 8575- 80 42,386,118 0% - 70- 7565- 7060- 6555- 60 47,532,368 0% - 50- 5545- 5040- 45 70,884,743 0% - 35- 4030- 3525- 30 64,176,375 0% - 20- 2515- 20 44,211,683 0% - 10- 155 - 10 42,887,656 0% - 1 - 5

Total Population: 312,078,943 Female Male Total Uninsured -

% Uninsured 0.0%



4c.4c.

17,612,912

Annual Cost

Billions

$504+ ($300)

$120

$ 211

Total

$336

$355

Final 2 years

$1,826


the patient protection & affordable care act (pp aca)

Documents

health depts

ph prevention funds

ph medicare

wellness behavioral

tobacco prevention

ph fit

ph workforce

ph capacity