The ability to receive health care when needed, more formally referred to as access to care, has long been the Achilles' heel of the American system. We have enjoyed the somewhat dubious recognition of providing the most expensive care in the world, not always meeting the highest standards of quality and certainly not available to every citizen. It is this lack of access to care that most critics have emphasized when evaluating the American health care delivery system. We were, until the passage of the Patient Protection and Affordable Care Act (ACA) in 2010, the only industrialized nation in the world lacking a national plan for universal access to health services. While the controversy that surrounds the ACA has in many ways caused diversion from its core purpose, it is that purpose-a pathway to universal access to health care-that brings into sharp focus the intersection of public health as a discipline and the ACA.
Public health is population health-a concept that ideally, when implemented, should result in optimizing resources such that everyone receives the most appropriate mix of health services across the continuum of needed care. While the ACA is still years away from the goal of universal health care, its tenets provide the foundation for programs that emphasize population health. At the systems level of care, policy and funding target issues that affect all or targeted groups of citizens. An individual's high blood pressure is a personal concern, but millions of hypertensive citizens are a public health concern because the outcome (aggregate cost of illness, lost productivity) has the potential for national and often international impact. We are now aware that with almost 10 million previously uninsured Americans covered by the ACA, the need for providers who are trained to provide that most appropriate mix of health services may prove to be the most formidable challenge to expanding access.
There are those rare occasions when events, such as the ACA, provide the opportunity to evaluate what researchers and policy analysts refer to as a natural experiment. No previous legislation has mandated universal coverage for American citizens. Medicare is an entitlement program for older adults and persons with a disability, and Medicaid is a means tested approach to the provision of care for the historically underserved and vulnerable. Thus, the passage of the ACA should be treated as that line in the sand that demarcates the point at which we began the journey toward universal coverage.
Public policy's role in determining access to care gained national attention in the 1960s with the introduction of Medicare and Medicaid. The classic article of Aday and Andersen,1 "A Framework for the Study of Access to Medical Care," published in 1974, provided a methodology for evaluating the determinants of access. In their article, the authors present indicators such as the financing of care and the funding of resources that should be evaluated to determine the success of access driven policy. Henrik Blum,2 a pioneer in health planning, reinforced Aday and Andersen's initial premise in his classic Force Fields of Health model when he pointed to the social, economic, and policy environment as the most critical aggregation of variables determining how, when, and if individuals received care and what sort of care they received, as well as if and when access was achieved. Our social, economic, and policy environment is such that National Health Service systems such as those in the United Kingdom and Sweden would neither be endorsed nor acceptable. Rather, the ACA, uses the foundation of our free enterprise economy to achieve access to care through the creation of a venue that would permit private insurers to offer a variety of health coverage options to the uninsured. This venue is the health insurance marketplace. Similarly, the need to provide primary care services on a yet untested scale identified public health as the logical existing component of our health delivery system capable of building the programs and supplying the workforce because of the historical emphasis on population health.
The 2 articles comprising the public policy, funding, and finance section speak to the vital role Aday and Andersen's access indicators and Blum's social, economic, and policy environment play in this acknowledged intersection of the ACA and public health in very different but equally important ways. In "Strategies for Policy Evaluation of Health Insurance Marketplaces," Bias et al3 propose a policy evaluation process suitable for comparative analyses within and among all health insurance marketplaces-state, federal, and partnership. The authors provide a thorough description of the process used to develop the evaluation with emphasis on a large number of variables, all of which evolve from the literature and have been shown to have an impact on access to care. Montes and Webb,4 recognize that public health faces a unique challenge because the lack of standardized nomenclature for public health workers prohibits effective planning for workforce development and training. In their article, "The Affordable Care Act's Implications for a Public Health Workforce Agenda: Taxonomy, Enumeration, and the Standard Occupational Classification System,"4 they present a compelling argument for a standardized enumeration process that is inclusive and through inclusiveness strengthens the planning process for public health workers and by inference identifies the resources needed to provide services.
Health insurance marketplaces are the pivotal tool designed to make universal coverage available, and the tool designed to make the concept of universal coverage acceptable and survive as a single payer system could not have survived. The marketplaces were conceived using the very basic economic principle of the competitive model. When consumers are presented with variations of a single product or service, they will choose that product or service that provides them with the most satisfaction at the best price. The marketplaces operationalize the frequently quoted economic principle of the "biggest bang for your buck." Consistent with the literature on access to care over a 50-year time period, the authors identify 3 basic components of a comprehensive evaluation plan, economic outcomes, health outcomes and consumers' processes and perceptions.4(p3)
In this case, however, we are looking at more than 1 stakeholder. The government, the uninsured, and the insurance companies are interested in the economic aspects of the marketplace-is the cost right for the consumer, are insurance companies placing themselves at risk, and, finally, is the government making a wise investment that will result in reducing the health expenditure burden overall? Health outcomes again are the topic of concern for the stakeholders in the marketplace. Government is contending that early preventive care will result in improved health outcomes that will over time reduce health expenditures. Insurance companies are interested in gathering a diverse pool of insured individuals to achieve a cost-effective balance of the well with the chronically and acutely ill. Individuals presenting for care may not be able to precisely identify the health outcome they are seeking. However, they can identify their level of satisfaction with both the process and the outcome for a given episode of care or service encounter. The authors correctly observe that consumer processes and perceptions are absolutely critical to the success of the marketplace and that, indeed, as we know from the basic competitive model, consumer demand is based on a number of variables that the authors measure using the assessment tools AIDA, SERVQUAL, and WebQual.4(p12). Accurate measurement of consumer processes and perceptions cannot be underestimated when one considers the initial failure of the Web site and the consequent lack of consumer interest and desire to participate.
Montes and Webb correctly point out that the public health workforce should be viewed as an investment, but a lack of knowledge about the number of workers and what they do is a source of concern for the discipline. One might add that this lack of knowledge should also be a source of concern for all stakeholders-government, insurers, and consumers-because public health has the potential to become the most influential discipline in the health services sector.
The utilization literature is replete with data acknowledging the relationship between cost, quality, and outcome and what is needed to ensure affordable care that is available and acceptable to a diverse population. The best outcomes are achieved when satisfied consumers respond to cues leading them to preventive care, thereby eliminating the need for most costly and preventable acute and/or urgent care. In other words, the sort of care that is the domain of public health workers. However, a lack of consensus as to who should do what, when, and how is the major challenge facing the discipline. Another issue is what classification system should be used to identify and define the workforce comprising the public health discipline. Montes and Webb point out that the Bureau of Labor Statistics' Occupational Classification System presents the best possible solution because it is the "nation's accepted system for classifying, collecting and analyzing employment data."4(p12) The Occupational Classification System also has name and place recognition and has been in existence for some time, thereby eliminating the need to build an entirely new system. The authors' review of the literature is a valuable contribution to the discussion, comprehensive, and serves to frame their presentation of 2 options for the identification and definition of public health occupations using the SOC (Figure 1).
As an academic administrator, I can certainly attest to the confusion that leads to inappropriate resource allocation when a proposal reached my office to educate registered nurses as health coaches. Public health nurses are in great demand, but the shortage is so acute that it will take years to fill all of the openings. In contrast, there are well-thought through 12-month programs that end in certification as a health coach. In addition, we know that the best outcomes are achieved when we have culturally sensitive and acceptable workers in the more direct consumer contact occupations such as health coach and patient navigator who can assist the newly enrolled but frequently unfamiliar with the complexities and the lack of continuity of the US health care system. More importantly, nurses, health coaches, and patient navigators are all defined as public health workers, albeit the nurse is certainly prepared to offer care at a very different level. This example illustrates the need to refine the classification system and the need to have agreement if we are to achieve the most cost-effective and satisfactory approach to care that is acceptable to consumers.
These 2 articles bring informed, thoughtful contributions to the importance of the intersection between the ACA and public health. Most important, both articles arrive at similar conclusions. If we lack a comprehensive, implemented model of the health insurance marketplace, and if we fail to meet the challenge of a standardized and trained public health workforce, the ACA will fail to meet its primary goal: affordable, quality, and accessible care for all.
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