Closing session: 'Let's evolve and let's do it together'

The last time this blogger felt such hair-raising excitement at an APHA meeting, civil rights philosopher Cornel West had whipped attendees into such a social justice tizzy that I thought 13,000 public health practitioners were going to spill into the Denver streets and start building healthier communities right there on the spot. But here in Charlotte at the smaller Midyear Meeting, I'd say the excitement (and sheer relief) were even bigger, more powerful and entirely motivating.

As many of the more than 400 folks at this year's Midyear Meeting came into the ballroom of the Westin Hotel for the closing session, the scroll from scotusblog.com was being projected onto a giant screen in the front of the room. It was pretty tense before the ruling came down; folks were standing around in groups, staring at the screen with the worried looks of parents whose daughter just left for the prom. Let's just say it was nerve-wracking.

Then the blog scroll popped up: "The individual mandate survives as a tax." And the crowd goes wild. And I mean wild. Even our very own Dr. Benjamin was seen wiping tears of joy from his face. It was a very good day for public health.

So, as you could imagine, it was a little hard to herd hundreds of jubilant public health practitioners to their seats to begin the closing session, but Dr. Benjamin managed to do it. Lisa Simpson, president and CEO of AcademyHealth, then came to the lectern to begin moderating a discussion on the "Path to the New Public Health."

First up was Lydia Ogden, director of the Health Reform Strategy, Policy and Coordination Office at the Centers for Disease Control and Prevention. She began by noting that the forces that drive change in the health care system aren't going away. Such forces are synergistic, she said, with the first being demographic changes. For example, between 8,000 and 10,000 people turn 65 years old everyday in the United States and that will happen every day for the next 18 years — "that's a profound change," Ogden said.

Another force of change will be the growing federal deficit, she said, noting that the feds borrow 41 cents of every dollar they spend. In turn, Ogden said this is one of the most fundamental questions we need to ask ourselves: Is what we're about to do worth borrowing 41 cents plus interest?

Looking ahead she said it's critical that public health and clinical practitioners not only partner, but take the time to better understand each other's work and challenges. To illustrate her point, she told a little story. Imagine public health came to you and said it wanted to marry health care. But because the two were pretty ignorant of each other, you'd have some qualms as to the longevity of the partnership. The moral: "If you want to be understood seek first to understand," Ogden said.

"One size won't fit all but if we keep focusing on our differences, we won't be able to learn as efficiently as we need to," she said. "Let's evolve and let's do it together."

Arkansas Surgeon General Joseph Thompson, director of the Arkansas Center for Health Improvement, began his time at the lectern with a Supreme Court-induced "WHOOP!" Then he asked the audience to join in with their own "WHOOPS" and they happily obliged.

Thompson said he never uses the term "public health" outside a room of fellow public health practitioners. For those outside the field, the term can come with too many preconceived notions. People, he said, may simply tune you out. But that doesn't mean people don't want to get in on the public health game, even if that's not what they call it.

"We have new players who are thinking about denominator medicine," Thompson said. "We don't need to argue about whether it's public health."

Lastly, Thompson called on those in health departments that provide direct clinical services to start learning how to bill for those services. He said it'll be next to impossible to maintain such services just with state funds — to have a viable financial future, we need to figure out how to bill.

Session speaker Cara McNulty, senior group manager at Target Corporation, said the company has a direct interest in the health and well-being of its more than 350,000 employees. In fact, McNulty said Target brought her onboard specifically to take on that issue. Her role, she said, is to look beyond health care and insurance plans to how to engage employees in staying healthy and happy. Like Thompson, she doesn't use the term "public health" when working with employers because they simply don't know what it means, she said. Instead, she keeps the conversation focused on improving the health of employees, which also improves the bottom line for employers.

"When working with employers, we need you to talk with them about policy, systems and environmental change," McNulty said. "Health isn't our primary business and we need your partnership."

Unfortunately, McNulty said she's never had someone from the local health department approach her about partnering, which she called on session attendees to start doing — "there's a huge opportunity to work with employers...if we're not all working collectively then we will never achieve population health."

"Be very clear in your language," she said. "Help us understand what you're trying to achieve because, believe me, as employers we want to improve health."

Then it was back to the news of the day, the 5-4 Supreme Court decision upholding the Affordable Care Act. (Though the court did rule that states can't be forced to participate in the law's Medicaid expansion and that Congress does not have the power to punish states that don't participate by withholding existing Medicaid funds. The court did, however, rule that the Medicaid expansion is constitutional.) Gene Matthews, with the Network for Public Health Law, called it a "breathtaking day." Still, many attendees as well as APHA's Dr. Benjamin cautioned against sitting on our laurels.

"We can take a victory leap but the fight and battle continue," said one attendee.

To see what others in the public health and health care arenas are saying about the ruling, visit APHA's Public Health Newswire.

And don't forget to register today for APHA's 140th Annual Meeting from Oct. 27–31 in San Francisco. This year's Annual Meeting theme is "Prevention and Wellness Across the Life Span."

See you next time in the City by the Bay!

A little birdie told me so: Tweet of the day

On this last and very exciting day of APHA's Midyear Meeting, the Tweet of the Day goes out to Twitterer @shannonmace, who reminds us that parts of the Supreme Court decision still need to be carefully examined:

"Piece that needs to be carefully parsed out is that states option not to participate in Medicaid expansion w/o penalty" #APHAmid12

'A victory for us all'

The live feed from scotusblog.com was up in the Midyear Meeting's closing session room.
This update was received with thunderous applause.

If we had bottles of champagne here in Charlotte, the corks would still be popping and the celebratory bubbly flowing. This blogger can't imagine a better place to be right now than surrounded by fellow folks who believe that health care should be a human right and not a privilege. Here are just a few quotes from some very happy APHA members.

"I think this is fantastic. It's surprising...but I'm very proud of the court. Now we can go forward. It's a fantastic decision for the health of the American public." — Past APHA President Deborah Klein Walker

"It's a victory for us all." — Cheryl Johnson Benjamin, South Carolina's United Way of the Midlands

"I'm amazed that logic has won out. It's so amazing to celebrate with all these public health people." — Kerry Burch, North Carolina's Mecklenburg County Health Department

"It's why I went to public health school. It's about time." — Adele Amodeo, executive director, California Public Health Association-North

"The Prevention Fund is constitutional and Congress ought to leave it alone." — Georges Benjamin, executive director, APHA

Read APHA's news release for a full statement from Benjamin on the Supreme Court's ruling.

Upheld!!!

The scene here is absolutely ecstatic. This quote says it all from attendee Mona Sarfaty, a former staffer for U.S. Sen Ted Kennedy and a professor at Thomas Jefferson University in Philadelphia:

"Forty years of work. I'm laughing and crying at the same time."

Above, photos of the Midyear Meeting attendees reacting to the Supreme Court ruling upholding nearly all of the Patient Protection and Affordable Care Act.

Countdown for health reform

Alright folks, just about an hour until we know the fate of the Affordable Care Act. Stay tuned to the APHA Meetings Blog for reactions from the Midyear Meeting here in Charlotte. Talk about nervous energy...

Community prevention: Where the rubber meets the road

We’re all waiting with baited breath for the Supreme Court to hand down its ruling on the Affordable Care Act on Thursday morning, but essentially we’ve been implementing it for the past two years. And a huge component of the law is all about prevention.

In a Wednesday afternoon session, “Innovations in Community Prevention,” panelists shared just how they’ve been putting prevention to work. As we’ve heard throughout this meeting, assuring the future health of the next generation relies on innovation and building community partnerships. So, let’s hear how the experts are doing just that.

“Local relationships are where it’s at,” presenter Jeffrey Engel reminded attendees.

According to Engel, the policy director of North Carolina’s state health department, the Tarheel state has received the fourth largest Community Transformation Grant award in the nation. It’s been using the money to develop policy addressing tobacco-free spaces, active living by design, healthy eating and clinical preventive services.

In 2006, one out of 60 of the state’s community colleges was tobacco-free. Ironically, Engel pointed out, that campus happened to be located in the tobacco-rich Raleigh-Durham area. Now, thanks in no small part to the state’s prevention grants, virtually all are tobacco-free.

But Mary Balluff was quick to point out that some states and cities don’t have such a grand cache.

Balluff, of the Douglas County Health Department, shared how they’ve applied their grant dollars in Omaha, Neb., a city that at one point was ranked 142 out of 183 largest cities in terms of health risks. Balluff saw this as room for improvement.

Through the work of its Communities Putting Prevention to Work Grant — most appropriately branded “Douglas County Putting Prevention to Work” — the county recruited 19 partners across nine initiatives, from a traffic safety campaign to a healthy corner store initiative.

Balluff touted the steps she and her colleagues employed for community engagement: a common agenda, shared measurement, mutually reinforced activities and continuous engagement.

Next up was Terrence Roach, who spells prevention: “Y-M-C-A.”

“The table had been set, but we weren’t there,” said Roach, senior director of organization and community change of YMCA of the USA, referring to the important role the “Y” could play in community prevention.

“The Y's strength has historically been in the primary prevention stage. But, with the rise of chronic disease, we needed to move the Y’s focus further down,” he said. (Think more secondary and tertiary levels of disease prevention.)

So through its Healthy Communities Initiatives, which Roche said served as a basis for Community Transformation Grants, the Y developed diabetes and childhood obesity prevention programs. 

“If you weren’t overweight or didn’t have risk factors, you weren’t eligible to be a part of that program,” he told attendees.

The Y now boasts a robust policy program and lobbying arm. Through its work, it has helped create hundreds of healthy corner stores, more than 1,000 safe routes to school and community parks, and more than 2,000 tobacco-free buildings in communities across the country.

“When we first started, the table was set and we weren’t there,” he said. “Now over a decade later, we’ve set the table and are asking others to join us.”

Getting ready to face the future

Judith Monroe kicked off today's afternoon session with jellyfish. Not actual jellyfish (though that would've been one seriously memorable session). A story about jellyfish.

Monroe, who's deputy director of the Centers for Disease Control and Prevention, told the story of Jellyfish Lake, which is located in the Rock Islands of Palau. Millions of years ago, Jellyfish Lake formed as a landlocked saltwater lake, and the jellyfish got trapped, never to go to the ocean again. So they began to adapt. Their new environment didn't have the same old predators, so the jellyfish lost their stingers. They freely swim to the top of the lake to get sunlight and to the bottom to get rich nitrogen. The jellyfish have the lake to themselves — as Monroe said, they have a pretty good life.

Of course, this isn't a story entirely about jellyfish. Monroe was using it as a metaphor for the kind of adaptation and transformation that public health must undergo as well. During the Wednesday afternoon session on "Visions of the Future: A Leadership Challenge," Monroe, who moderated the session, said public health has to contemplate three things: What should we continue doing, what should we start doing and what should we stop doing.

Massachusetts Health Commissioner John Auerbach told attendees how his state has been transforming and adapting. Six years after the state adopted its own health reform law, 98 percent of Massachusetts residents, including 100 percent of children, are insured. But there's still work to be done, Auerbach said. He said there are five new challenges and skills that public health needs to work on.

First, zero in on the social and economic conditions that affect people's health and employ effective policy to shape those conditions. Second, hone new skills, enhance analytical skills and learn about health information technology. Third, clarify who the payers are and what the responsibilities of public health are. Fourth, be better at demonstrating the value of public health work, particularly prevention (ideally, he said public health should be able to show insurers the return on investment within 18 months). And fifth, link population health and clinical care, and provide input on what quality care entails.

Lillian Shirley, president of the National Association of County and City Health Officials, noted that each jurisdiction will have to struggle according to its own circumstances to make progress. Then Shirley made a well-received shout-out to her fellow nurses, calling on attendees not to overlook the contributions of the nursing workforce. (For example, she said folks in her state of Oregon are "hysterical" over a Medicaid expansion because they say there's not enough doctors; to which Shirley says: what about the role of nurses? Cue more applause.)

"How are we going to knit together all these really great things that are going on...and make it a system transformation," she said. "We have to put our shoulder to the wheel on that one."

Nancy Terwood, East Great Lakes regional director of the National Association of Local Boards of Health, called on attendees to "look at your board of health member as an untapped resource." She noted that board of health members "really are the voice of local public health...we can be your legs, your voices, your arms." Unfortunately, she said that a recent association survey found that boards of health members desperately need training in a variety of areas, including how to do self-assessments and how to advocate for public health. Boards of health members, she said, "want to learn about helping you."

When it comes to the health of American Indian communities, Paul Allis, director of public health programs at the National Indian Health Board, said there's been a lot of progress on partnerships between federal health officials and tribal ones. He noted that the movement toward accreditation is helping to elevate public health within tribal communities. Though he did say that tribal leaders want to interact with state, local or federal leaders, "from nation to nation."

Public health, Shirley said, attracts people to it because of its mission, vision and values. We're attractive to people who want to change the world, she said, so let's "capture that excitement."

A little birdie told me so: Tweet of the day

Today's Tweet of the Day goes to Twitterer @Sarahwk, who said:

Learning about tribal health issues at #APHAmid12. Wow — a lot of needs and not an area you hear about a lot. Would like to hear more.

No problem! Check out these fantastic resources from the Indian Health Service, the National Library of Medicine and the National Indian Health Board.

Working lunch

Midyear meeting attendees participated in roundtable sessions on a variety of topics during Wednesday's lunch hour.

Public health gets with tech

Steve Cline started with a disclaimer: "I'm not an IT geek." Still, the coordinator for health information technology at the North Carolina Department of Health and Human Services, says he has a lot of appreciation for what technology has done — and most definitely will do — for the public's health.

"I really believe health (information technology) is a new frontier for public health that we really need to embrace," he told attendees at a Wednesday morning session on "Technological Strategies to Advance Public Health."

Next Cline asked attendees an interesting question: Why do we tolerate such poor information technology in health? We wouldn't accept it in many other aspects of our lives. (Seriously, how many times have we all stopped what we were doing to curse our slow telephone, computer, insert any electronic gizmo here.) But when it comes to health, barely an audible peep. The technology for medical interventions has made enormous leaps and bounds, but in terms of the overall operation of the health system, we have a long way to go, Cline said.

Fortunately, North Carolina is helping to lead the way toward a more tech-savvy health system. The goals of the state's health information technology efforts, which has more than $1 billion invested in its development, are: improved quality, better health, controlled costs and better engagement with health care consumers.

"North Carolina is really living out the concept that public health must be more integrated with clinical care and medical providers if we're to be relevant and sustainable," Cline said.

A couple examples of North Carolina's successes: Community Care of North Carolina, which is comprised of 14 networks of providers committed to caring for Medicaid, Medicare and uninsured patients, is busy investing in an informatics center that will create a systems-wide approach to patient care and foster new, innovative models of delivery. Also, the North Carolina Community Health Information Portal, which is still under development, is taking "huge amounts of data and turning that into compelling stories" to help us do the work of public health, Cline said.

Information technology reform is health care reform, he told attendees.

Daniel Jensen, associate director of public health at Olmsted County Public Health Services in southeast Minnesota, was described during his introduction as an evangelist for public health information exchange. Jensen told attendees about the impressive amount of work that public health has done to bring communities of care together via improved information technology.

For example, the public health agency is working to coordinate better asthma care between parents, providers, public health and schools. Today, just through improving the "paper sharing" process, there's 2,500 asthma action plans now on file with school nurses. When the effort began, less than 400 such plans were on file despite the more than 5,000 students who had serious asthma problems. Now, the focus has turned to building an online portal for school nurses so no matter which school they're working at, they'll know which kids have asthma and how to be prepared in case of an asthma attack.

"We can build better systems," Jensen said.

Public health + medicine = healthy people

The Institute of Medicine's J. Michael McGinnis presents during Wednesday
morning's session on public health and clinical care.

Medicine cannot exist without public health. Public health cannot exist without medicine. That’s the case made by physician and long-time health leader J. Michael McGinnis, MD, MPP, during this morning’s Midyear Meeting plenary session on integrating public health and clinical care.

“The relationship between medicine and public health … is in my view the central health policy issue of our time,” said McGinnis, a senior scholar at the Institute of Medicine.

He described the continuum of care: “At one end are those prevention efforts that are exclusively targeted to an entire population to the other end where treatment is targeted exclusively to one individual or patient. The other [interventions] lie scattered like a bell-shaped curve in the middle.”

He founded his case on three points:

1.    Medicine cannot provide effective and informed treatment to the patient without public health.
2.    Public health cannot advance the health of the population without medicine.
3.    The nation’s health and economic security will be at a disadvantage as long as financial incentives work in the middle.

McGinnis, a long-time member of APHA, argued that the 10 greatest public health achievements of the last century as outlined by the Centers for Disease Control and Prevention, such as vaccinations, healthy work places, motor vehicle safety and control of infectious disease, “are all a result of close collaboration between medicine and public health.”

So what happened to cause a split between the two communities?

“Throughout the 1960s, it was the success of this partnership that ironically frayed the ties,” according to McGinnis. The extension of the lifespan brought an increasing prevalence of chronic conditions and a more medically needy population around which developed a vast network of highly technical interventions and diminished attention to public health. And that was compounded by a dramatic change in financing with the creation of Medicare and Medicaid.

“Health expenditures going to prevention fell to below 5 percent, which is where it sits today,” he said. “What’s really changed are the economic incentives.”

He pressed his case for increased collaboration, asking the full room of meeting attendees to consider CDC Director Tom Frieden’s winnable battles, including food safety, immunizations, health care-associated infections, mother-to-child infection of HIV, motor vehicle injuries and tobacco use.

“How many of these battles can only be won by public health? How many can only be won by medicine?” he asked. “Virtually none.”

But, as he sees it, collaboration is trending. McGinnis pointed to a long list of items that are forging the relationship between medicine and public health, including an aging population, the potential for bioterrorism, information technology and new and emerging infectious diseases.

“It’s very clear that vigilance (on communicable disease) cannot be practiced effectively without very tight seamless communications between those treating them and those watching the habits of those individuals,” he said.

And regarding the impact of rising health care costs, “we already see that $2.7 trillion [in annual health care spending] is driving a stronger focus on prevention and public health. It’s a good thing, but it’s coming at a very high price.”

And with the Supreme Court opinion on the Affordable Care Act pending, “we hope tomorrow that those (prevention) elements will be retained,” as those are among the most important provisions, he said.

Despite the formidable challenges of the future, “I’m optimistic because I know the public health community. And I believe we’re seeing a ‘greening’ of the medical community,” McGinnis said.

By that, he meant in four ways: (1) the environmental sense — taking medical care outside the doors of the clinic and into the community; (2) the enlightened sense —health is shaped by so much more than medical care — even for those who are ill; (3) the restorative sense — the caring dimension is a vital contributor to the healing process; and (4) the fiscal sense — recognition of improving payments and payment structures for prevention and population health.

“Fee-for-service really doesn’t work,” according to McGinnis. The medical community itself if ready to abandon it and it drives a wedge between medicine and public health, he said.

Regardless of the Supreme Court opinion, McGinnis is hopeful: “Even if the Affordable Care Act is overturned, the spirit is there.”

The Supreme Court: Will they or won't they?

We're just about 24 hours away from knowing the fate of the Affordable Care Act and the predictions are in full swing. Will they or won't they? Will they strike the whole thing down or just parts? Will the individual mandate pass muster? What does it all mean for the enormous amount of work that's already been done to implement the law and create the state-based health insurance exchanges? Will the Prevention and Public Health Fund still be around by the end of the week? Will the Medicaid expansion stand? (Does anyone else feel like a 10-year-old in the back seat of your parent's car on a summer road trip — Are we there yet? Are we there yet?)

During yesterday evening's special session on the insanely anticipated Supreme Court decision, panelists took us through the possible decisions and consequences. The running theme on what exactly it all means for the future of our broken health care system? It's too soon to tell. But let's do a quick run-down anyway.

Sarah Somers, managing attorney at the National Health Law Program, said the case before the Supreme Court is actually three separate cases wrapped into one. The four issues before the court are: is the individual insurance mandate constitutional, is the Medicaid expansion constitutional, can the individual mandate be severed from the rest of the law, and can this case even be heard right now. (That last issue is related to a federal statute that says a tax can't be challenged until it has first been assessed.)

When it comes to the mandate, the question is what authority does Congress have to regulate interstate commerce? And while there's no question that health care is interstate commerce, Somers said here's the twist: Congress regulates activity, so is deciding to not buy health insurance an activity or an inactivity? We'll find out tomorrow in what Somers said could be a "dramatic statement about what Congress has the power to do."

On the heels of the mandate is severability. The plaintiffs say that none of the law is severable — if one provision goes, they all go. The feds say different. They say the mandate is severable from everything except some of the law's insurance-related provisions, among them the ban on discriminating against people with pre-existing conditions. (What a misfortunate step backward that would be.)

Next up the law's Medicaid expansion, which would require states to cover people with yearly incomes up to 138 percent of the federal poverty level. According to the Congressional Budget Office, the feds would cover 93 percent of the Medicaid expansion over its first nine years. Still, the plaintiffs claim the expansion is unduly coercive — in other words, the deal is so sweet that the states can't turn it down. Somers said this particular ruling could be huge, as it has big implications for whether the federal government can attach requirements to federal funds.

Lastly, the court could kick the decision down the road until 2014, but observers say it's not likely.

APHA Executive Director Georges Benjamin, who was a panelist during last night's session, noted that the fate of the state-based health insurances exchanges is one of the wild cards. He said he believes the exchanges, which are meant to be competitive marketplaces where residents can buy affordable insurance, can indeed work without the individual mandate. He also commented on how pleased he would be if the landmark Prevention and Public Health Fund is found constitutional. Still, he said that those who think we'll just be going back to the status quo if the law is struck down are wrong. It won't be the status quo, he said, it'll be worse, as implementation of the health reform law is a significant economic driver and job creator.

During the session's Q&A period, a number of attendees called for better messaging around the law, noting how little people actually know about the facts. In response, Somers said to check out the Network for Public Health Law, which has a wealth of information available to all. Also, visit APHA's Supreme Court Case page for even more info.

What are your hopes for tomorrow? Let us know in the comments section below!

Supper time

Midyear Meeting attendees were treated to a tasty dinner spread last night at the Westin Hotel before a special session on the coming Supreme Court decision.

Top photo, APHA President-elect Adewale Troutman, left, talks with a fellow meeting attendee. Middle and bottom photos, meeting attendees grab a bite and catch up.

Addressing health inequities means doing things differently

Parks are great but not if they aren’t located in neighborhoods that face high obesity and diabetes rates. Bike paths are awesome, but they won’t have much of an impact in the community if they aren’t well distributed across the city. And just because we’ve done something a certain way for 20 years isn’t a good reason to keep doing it – particularly when it comes to improving health.

Once again, public health leaders at APHA’s Midyear Meeting are talking about how they are doing things differently to tackle the problem.

A Tuesday session, “Achieving Health Equity: Solutions from the Field,” highlighted local initiatives to underscore health as an issue of justice.



“When we look at what is causing inequities in health, we come to accept it based on evidence. That really, social determinants of health play an enormous role in determining health outcomes,” said Barbara Ferrer, executive director of the Boston Public Health Commission.

Ferrer says the heart and soul of Boston are people of color.

“In those neighborhoods, you will see much worse outcomes. Be it foreclosures, elevated blood levels, higher hospitalization rates."

She and her colleagues have developed a health equity agenda to rid the city of these prevailing health equities that center on reducing low birth weights, tacking obesity, lowering chlamydia rates and building community capacity.



“We’ve really entered into areas where we’ve traditionally not been active,” Ferrer said.

And those efforts are starting to see results.

In 1999, the city was home to 90 dumpster storage lots. Today, there are only 12. Two hundred community garden plots are now in its place. The city has done more work around gun laws, paid sick leave and tobacco control.

“Policies that are good for health aren’t always health policy.”

APHA President-elect Adewale Troutman underscored this notion for the audience. He stressed the need to recognize structural factors that improve health conditions – be it land space, jobs, transportation, air quality.

“You have to ask yourself, can you do this work or do you need to change it and find another mechanism to make it work? Are we willing to take a risk changing society and structure?”

Opening session: 'The biggest risk of American health care today is that it will fail the moral test'

Uncertainty. It's a theme that many public health practitioners are all too familiar with these days. So much is changing so fast. And yet it's vital that public health keep up, adapt, transform, move forward — make itself into a lean, mean disease-fighting machine. It's a lot for a public health plate that's not only already overflowing, but being asked to hold more and more food with tinier and tinier plates. (Excuse the food metaphor; this blogger skipped lunch.)

Luckily, North Carolina — our generous host for the Midyear Meeting — has had some success tackling the problem. Its answer: Focus on continuous quality improvement; really zero in. According to opening session speaker Laura Gerald, North Carolina's state health officer, the state has fully embraced the concept of quality improvement. A few examples: The state was the first to mandate all local health departments achieve accreditation; strategic public-private partnerships, such as the North Carolina Center for Public Health Quality, are rapidly driving momentum toward quality improvement across the state; and work to coordinate healthy living efforts and build capacity in under-served communities is creating new opportunities for better health all the time.

Gerald said cost-containment measures and budget cuts are driving the need to find quality improvement strategies that increase efficiency while preserving and enhancing health outcomes. But even with quality improvement, budget cuts present a huge challenge, she said. For example, she said this year the state shifted its master settlement agreement monies that used to go toward tobacco education and prevention back to North Carolina's general fund. That means tobacco funds have gone from $18 million to $2.7 million. It also means that Gerald doesn't know how the state is going to sustain the hard-fought declines it has accomplished in youth tobacco use.

"'It appears I wasted my time studying medicine and public health when I should have been studying magic...(now that I'm being expected to) pull stuff out of thin air," she said to a roomful of knowing laughs.

Opening session speaker E. Winters Mabry, health director with the Mecklenburg County Health Department, noted that if you've seen one North Carolina Health Department, you've seen one North Carolina Health Department. However, accreditation has become the common bond that brings the state's health departments together, he said.

He told attendees about the department's largest effort — its school health program. Mabry said the department has worked hard to build close relationships with local school systems and now has a school health staff of 150 and a budget of $10 million. With more than 10 percent of students coming to school with serious chronic illnesses, such as asthma and diabetes, the school nurses provide case management and track specific indicators, such as grades, behavior and health outcomes. Last year, Mabry said, nurses managed thousands of children and had positive outcomes in the 95 percent. This is "special work," said Mabry, who ended his time at the opening session mic with a quote from Frederick Douglass: "It is easier to build strong children than to repair broken men."

Next up came keynote speaker Donald Berwick. A man who APHA Executive Director Georges Benjamin introduced with this quote: "When the dust settles...people will clearly see that the steps and programs that he initiated...will transform the way medicine is practiced in this country and many people will live longer because of that."

Berwick, former administrator of the Centers for Medicare and Medicaid Services, started off by noting that while he has great affection for the public health community and readily accepted APHA's invitation to speak, he didn't actually know what to say. He had writer's block (a common and not always preventable affliction among bloggers too.) The question he was asked to speak on — how public health can thrive in a changing health care landscape — was a hard one; one that doesn't submit itself well to easy soundbites, he said. Nevertheless, it's a problem with a solution, Berwick told attendees.  

First, he spoke about the Affordable Care Act — a law that he said holds great promise. Berwick said the law does two things: it tries to make health care a human right as well as make health care sustainable through improvement measures. Improvement, he said, was his compass when he was working in Washington, D.C. And you need a compass, "so you don't lose your mind," he joked. Improvement was the "how" to improve the system; the "what" was defining what improvement meant. That "what" question is what brought Berwick and CMS to pursue its now-famous triple aim: population health, experience of care and cost per capita. At the end of the day, Berwick said the system must embrace improvement strategies to sustain itself and serve the people.

"The biggest risk of American health care today is that it will fail the moral test," he said.

So, what does it all mean for public health? Berwick said the honest answer is that, well, he doesn't know. He discussed some of the classic problems that public health still faces: Like how do we tell the story of a disease we prevented from happening in the first place? How do we effectively make the case in an era of economic restraint that prevention has value that goes beyond saving money? That even though prevention doesn't always save money, it's still worth doing. And, finally, how does public health communicate its story?

Here was his prescription for public health: reduce costs in public health where you can; cooperate — don't work in silos; partner with nontraditional entities, such as employers and health systems; help reduce health care costs and waste; and focus and mobilize.

"Public health needs mobilization too," he said. "If there isn't political force behind the public health endeavor, it will remain frail."

To hear more from Berwick, check out this video (which is also at the top of this post) on APHA's YouTube Channel.

A little birdie told me so: Tweet of the day

As is now tradition during APHA meetings, we'll be posting a Tweet of the Day from Twitterers using the official meeting hashtag, which this year is #APHAMid12. Today's Tweet of the Day comes from past APHA President Deborah Klein Walker, known as @DKWpublichealth, who tweeted in response to opening session speaker and North Carolina State Health Officer Laura Gerald:

NC Health Officer Gerald states prevention efforts funded by tobacco tax has been drastically cut #APHAmid12 @APHAAnnualMtg What next?

This blogger imagines similar sentiment can heard within the halls of budget-strapped health departments around the country. Let's just hope that what's next isn't an uptick in tobacco use.

So many reasons, too little time

People come to APHA meetings for all kinds of reasons. Networking, learning, presenting, celebrating. North Carolina resident Paul Jung, a member of the U.S. Public Health Service, needed to get his APHA fix. He said he came to this year's Midyear Meeting to get a "boost to hold me through until the APHA Annual Meeting in the fall…and since it's in my backyard, it made it even easier."

Jung says he's most interested in the meeting's public health workforce track. He's hoping to discover some innovative ways that the U.S. Public Health Service can effectively work with local public health folks. And, he said he's looking forward to catching up with fellow service members from around the country.

Joy Reed, a fellow North Carolina resident attending from Raleigh, is at the Midyear Meeting for a couple reasons. First, she's come to promote the first enumeration study of public health nurses since the 1950s. Reed, who's the public health nursing director for the North Carolina Department of Health and Human Services, said the study will gather data on numbers, demographics as well as job descriptions for the country's public health nurses.

If you want more info on the Robert Wood Johnson Foundation-funded study, which is just beginning to roll out, introduce yourself to Reed. She's easy to spot — she's the one wearing a pin that says "Public Health Nurse. Count Me In."

"The networking is the biggest benefit for me," she said.

Of course, Reed said it'll be nice to be with fellow public healthers when the Supreme Court's health reform decision comes down on Thursday.

Michael Meit, co-director of the NORC Walsh Center for Rural Health Analysis, flew into Charlotte to present during a session on health equity. But he said he's also excited about coming together with fellow public health practitioners to "think strategically" about public health's future. Meit will be presenting on the issues and struggles confronting America's rural communities, where he said public health is often nonexistent or underdeveloped.

Meit said that while "I love public health — it's what I do," he does believe the field needs to make more of an effort to connect with rural communities. In fact, he said that public health overlooks rural communities to its own detriment, as rural residents tend to be very active in politics and have a stronger voice with their representatives. We need to start a different dialogue, Meit said.

"We need to change the dialogue from government and taxes to clean water, safe food, healthy children and healthy families," he said.

Health department accreditation is what's piquing Noble Maseru's interest here in Charlotte. The health commissioner for the city of Cincinnati, Maseru said he's also hoping to learn about new approaches to prevention as well as new ways to partner with the clinical sector. He's hoping Thursday's Supreme Court decision will be a time of "jubilation."

Catherine Bolek, director of sponsored research at the University of Maryland-Eastern Shore, traveled to Charlotte to search for new grant opportunities — or as she called it, "I'm chasing the dollar."

Why did you decide to come to Charlotte? Let us know in the comments section below!

Hello Charlotte!

Greetings from Charlotte and the start of APHA's 2012 Midyear Meeting! It's gonna be an exciting three days filled with anticipation for Thursday's Supreme Court decision on health reform. But until then, it's time to get to work. Or as they say in the South, let's go hog wild for public health!  

Above, a few snapshots from the literary-themed park known as The Green, which is just a couple blocks from Midyear Meeting headquarters at the Westin Hotel in downtown Charlotte.

A welcome letter from APHA's Dr. Benjamin

Dr. Georges Benjamin

Greetings public health colleagues,

As you all know, these are uncertain times for public health. Budgets are on the decline, staff and services are being cut, and hard-fought gains in community health and public health capacity hang in the balance. In addition, new and celebrated sources of public health support, such as those within the landmark Prevention and Public Health Fund, are under near constant threat of elimination. And with the fate of the Affordable Care Act now in the hands of the Supreme Court, the future seems even murkier than before.

That's the bad news. The good news is that public health is no stranger to uncertain times. We know how to overcome seemingly insurmountable obstacles to improving our communities' health — we've done it before and we'll do it again...and again and again. It's what we do. Still, continuing our work toward long-held public health goals means quickly adapting to new constraints, taking advantage of new opportunities and technologies, prioritizing efficiency and effectiveness, and learning how to communicate our successes in compelling and relatable ways.

These are not easy tasks, which is why coming together to share promising practices, discuss pressing problems and solutions, and learn from each other's experiences is vital. It's why I hope you'll join me and your fellow public health practitioners from all over the nation at APHA's 2012 Midyear Meeting in Charlotte, N.C., from June 26 to 28. With a theme of "The New Public Health: Rewiring for the Future," the Midyear Meeting will offer a variety of insightful sessions and presentations from local, state and federal public health leaders.

Just a few of the meeting's many highlights include: A special evening session on the Supreme Court's health reform decision (cross your fingers!); sessions covering the latest in successful public health advocacy and social media use with tools and info you can bring home with you; and more than one opportunity to network with new and old public health friends. Click here for a complete schedule of sessions and speakers.

Of course, no matter where you are June 26-28, you can keep up with all the happenings via APHA's social media and news offerings, including the APHA Meetings Blog, our Public Health Twitter (don't forget to use the hashtag#APHAMid12) and our Public Health Newswire.

I hope to see you soon in Charlotte. Together, I know we can make a difference.

Best (and healthy) wishes,
Dr. Georges Benjamin

Celebration or frustration?: Charlotte & the Supreme Court health reform decision

Are you as nervous as I am? Cause I'm pretty nervous. In fact, just thinking about the upcoming Supreme Court decision on the fate of the Affordable Care Act makes me feel like I've had one too many cups of much-too-strong coffee. My fingers are so crossed right now that I'm not sure if I'll ever be able to straighten them out again.

What does make me feel better is knowing that around the same time the Supreme Court decision is released I'll be surrounded by fellow public health admirers and practitioners who also believe that health care should be a right and not a privilege. That's because this blogger will be at APHA's 2012 Midyear Meeting in Charlotte, N.C., which takes place June 26–28, and I hope you'll be there too.

Of course, whichever way the decision comes down, it's sure to be THE topic of conversation at the Charlotte gathering. That means not only will attendees have the chance to mull over the (good or bad) news with colleagues from across the country, we'll also get to hear perspectives from some of the nation's top public health leaders.

And whether the court comes down for or against the historic health reform law, either decision means public health has some major work to do, which is what the Midyear Meeting is all about — getting public health ready to survive and thrive into the future. (Already on the meeting schedule for the evening of Tuesday, June 26, is a special session called "29 States, Nine Justices, Two Lawsuits: What does it all mean for the nation's health?")

To learn more about what exactly was argued before the Supreme Court, check out this article from APHA's The Nation's Health newspaper. And for perspectives from public health advocates on what they thought of the health reform arguments before the Supreme Court, check out this article from the public health blog The Pump Handle. (Disclosure: This article was also written by yours truly.)

APHA also commissioned a new analysis by the National Health Law Program of the major issues at stake and potential rulings.

Here's to hoping that Charlotte will be a time for celebration! Keep those fingers crossed!

A sneak peek at keynote speaker Donald Berwick

Berwick

As most of you already know, APHA meetings are packed with inspirational speakers and noted public health leaders. (Anyone remember the 2010 APHA Annual Meeting with opening session speaker Cornel West? Well, if you saw it, you wouldn't forget it. And if you didn't, then here you go. Get ready for some serious social justice with this video.)

This year's Midyear Meeting in Charlotte, N.C., will again offer an impressive roster of movers and shakers in public health. So, we thought we'd offer a little sneak peek at the Midyear Meeting's opening session speaker, Donald Berwick, who took the helm of the Centers for Medicare and Medicaid Services shortly after the signing of the Affordable Care Act in 2010. During his tenure at CMS, Berwick oversaw significant changes, including the expansion of evidence-based preventive services for Medicare enrollees. Today, Berwick is a senior fellow at the Center for American Progress.

Read more about Berwick's thoughts on the challenges facing public health in this Q&A with APHA's newspaper, The Nation's Health. And to learn more about the speakers you'll see in Charlotte (in just a few weeks!) take a look at this year's Midyear Meeting schedule.