Reduction in US Health Care Spending Required to Meet the Institute of Medicine's 2030 Target

Objectives. To quantify changes in US health care spending required to reach parity with high-resource nations by 2030 or 2040 and identify historical precedents for these changes.Methods. We analyzed multiple sources of historical and projected spending from 1970 through 2040. Parity was defined as the Organisation for Economic Co-operation and Development (OECD) median or 90th percentile for per capita health care spending.Results. Sustained annual declines of 7.0% and 3.3% would be required to reach the median of other high-resource nations by 2030 and 2040, respectively (3.2% and 1.3% to reach the 90th percentile). Such declines do not have historical precedent among US states or OECD nations.Conclusions. Traditional approaches to reducing health care spending will not enable the United States to achieve parity with high-resource nations; strategies to eliminate waste and reduce the demand for health care are essential.Public Health Implications. Excess spending reduces the ability of the United States to meet critical public health needs and affects the country's economic competitiveness. Rising health care spending has been identified as a threat to the nation's health. Public health can add voices, leadership, and expertise for reversing this course.

Excess Medical Care Spending: The Categories, Magnitude, and Opportunity Costs of Wasteful Spending in the United States

Landmark reports from reputable sources have concluded that the United States wastes hundreds of billions of dollars every year on medical care that does not improve health outcomes. While there is widespread agreement over how wasteful medical care spending is defined, there is no consensus on its magnitude or categories. A shared understanding of the magnitude and components of the issue may aid in systematically reducing wasteful spending and creating opportunities for these funds to improve public health.To this end, we performed a review and crosswalk analysis of the literature to retrieve comprehensive estimates of wasteful medical care spending. We abstracted each source's definitions, categories of waste, and associated dollar amounts. We synthesized and reclassified waste into 6 categories: clinical inefficiencies, missed prevention opportunities, overuse, administrative waste, excessive prices, and fraud and abuse.Aggregate estimates of waste varied from $600 billion to more than $1.9 trillion per year, or roughly $1800 to $5700 per person per year. Wider recognition by public health stakeholders of the human and economic costs of medical waste has the potential to catalyze health system transformation.

Expanded In-School Instructional Time and the Advancement of Health Equity: A Community Guide Systematic Review

Expanded in-school instructional time (EISIT) may reduce racial/ethnic educational achievement gaps, leading to improved employment, and decreased social and health risks. When targeted to low-income and racial/ethnic minority populations, EISIT may thus promote health equity. Community Guide systematic review methods were used to search for qualified studies (through February 2015, 11 included studies) and summarize evidence of the effectiveness of EISIT on educational outcomes. Compared with schools with no time change, schools with expanded days improved students' test scores by a median of 0.05 standard deviation units (range, 0.0-0.25). Two studies found that schools with expanded day and year improved students' standardized test scores (0.04 and 0.15 standard deviation units). Remaining studies were inconclusive. Given the small effect sizes and a lack of information about the use of added time, there is insufficient evidence to determine the effectiveness of EISIT on academic achievement and thus health equity.

Making Strides Toward Health Equity: The Experiences of Public Health Departments

OBJECTIVES

We explored the definition of health equity being used by public health departments and the extent of engagement of public health departments in activities to improve health equity, as well as facilitators and barriers to this work.

DESIGN

We conducted 25 semistructured qualitative interviews with lead public health officials (n = 20) and their designees (n = 5). All interviews were transcribed and thematically analyzed.

SETTING

We conducted interviews with respondents from local public health departments in the United States (April 2017-June 2017).

PARTICIPANTS

Respondents were from local or state public health departments that were members of the Big Cities Health Coalition, accredited or both.

RESULTS

Many departments were using a definition of health equity that emphasized an equal opportunity to improve health for all, with a special emphasis on socially disadvantaged populations. Improving health equity was a high priority for most departments and targeting the social determinants of health was viewed as the optimal approach for improving health equity. Having the capacity to frame issues of health equity in ways that resonated with sectors outside of public health was seen as a particularly valuable skill for facilitating cross-sector collaborations and promoting work to improve health equity. Barriers to engaging in work to improve health equity included lack of flexible and sustainable funding sources as well as limited training and guidance on how to conduct this type of work.

CONCLUSIONS

Work to improve health equity among public health departments can be fostered and strengthened by building capacity among them to do more targeted framing of health equity issues and by providing more flexible and sustained funding sources. In addition, supporting peer networks that will allow for the exchange of resources, ideas, and best practices will likely build capacity among public health departments to effectively do this work.

Quantifying the Value of Prevention: A Survey of Public Health Departments' Quantitative and Economic Modeling Capacity

OBJECTIVE

To improve the understanding of local health departments' (LHDs') capacity for and perceived barriers to using quantitative/economic modeling information to inform policy and program decisions.

DESIGN

We developed, tested, and deployed a novel survey to examine this topic.

SETTING

The study's sample frame included the 200 largest LHDs in terms of size of population served plus all other accredited LHDs (n = 67). The survey was e-mailed to 267 LHDs; respondents completed the survey online using SurveyMonkey.

PARTICIPANTS

Survey instructions requested that the survey be completed from the perspective of the entire health department by LHD's top executive or designate. A total of 63 unique LHDs responded (response rate: 39%).

MAIN OUTCOME MEASURE(S)

Capacity for quantitative and economic modeling was measured in 5 categories (routinely use information from models we create ourselves; routinely use information from models created by others; sometimes use information from models we create ourselves; sometimes use information from models created by others; never use information from modeling). Experience with modeling was measured in 4 categories (very, somewhat, not so, not at all).

RESULTS

Few (9.5%) respondents reported routinely using information from models, and most who did used information from models created by others. By contrast, respondents reported high levels of interest in using models and in gaining training in their use and the communication of model results. The most commonly reported barriers to modeling were funding and technical skills. Nearly all types of training topics listed were of interest.

CONCLUSIONS

Across a sample of large and/or accredited LHDs, we found modest levels of use of modeling coupled with strong interest in capacity for modeling and therefore highlight an opportunity for LHD growth and support. Both funding constraints and a lack of knowledge of how to develop and/or use modeling are barriers to desired progress around modeling. Educational or funding opportunities to promote capacity for and use of quantitative and economic modeling may catalyze use of modeling by public health practitioners.

Building Capacity for Evidence-Based Public Health: Reconciling the Pulls of Practice and the Push of Research

Timely implementation of principles of evidence-based public health (EBPH) is critical for bridging the gap between discovery of new knowledge and its application. Public health organizations need sufficient capacity (the availability of resources, structures, and workforce to plan, deliver, and evaluate the preventive dose of an evidence-based intervention) to move science to practice. We review principles of EBPH, the importance of capacity building to advance evidence-based approaches, promising approaches for capacity building, and future areas for research and practice. Although there is general agreement among practitioners and scientists on the importance of EBPH, there is less clarity on the definition of evidence, how to find it, and how, when, and where to use it. Capacity for EBPH is needed among both individuals and organizations. Capacity can be strengthened via training, use of tools, technical assistance, assessment and feedback, peer networking, and incentives. Modest investments in EBPH capacity building will foster more effective public health practice.

The Debate About Electronic Cigarettes: Harm Minimization or the Precautionary Principle

Two contrasting reviews (authored by Abrams et al. and Glantz & Bareham) in this volume have reached opposing conclusions on the effects of electronic cigarettes in a debate that is dividing the scientific and professional communities that have devoted careers to controlling the manufacture, advertising, sale, and use of combustible cigarettes. The research on the types, degree, and extent of harm from e-cigarettes is far from complete and, together with trends in teenage smoking and vaping, has raised new questions and prospects about the potential benefits that the new electronic products offer smokers of combustible cigarettes in quitting or at least cutting back on the known risks associated with the traditional forms of smoking. The rapidly morphing forms, constituents, promotions, and uses of the electronic varieties of the new nicotine delivery products (in this case electronic cigarettes) make research on their biological and behavioral effects moving targets. The two sides of this argument have produced a global divide on policy strategies.

The Debate About Electronic Cigarettes: Harm Minimization or the Precautionary Principle

Two contrasting reviews (authored by Abrams et al. and Glantz & Bareham) in this volume have reached opposing conclusions on the effects of electronic cigarettes in a debate that is dividing the scientific and professional communities that have devoted careers to controlling the manufacture, advertising, sale, and use of combustible cigarettes. The research on the types, degree, and extent of harm from e-cigarettes is far from complete and, together with trends in teenage smoking and vaping, has raised new questions and prospects about the potential benefits that the new electronic products offer smokers of combustible cigarettes in quitting or at least cutting back on the known risks associated with the traditional forms of smoking. The rapidly morphing forms, constituents, promotions, and uses of the electronic varieties of the new nicotine delivery products (in this case electronic cigarettes) make research on their biological and behavioral effects moving targets. The two sides of this argument have produced a global divide on policy strategies.

Public health and the economy could be served by reallocating medical expenditures to social programs

As much as 30% of US health care spending in the United States does not improve individual or population health. To a large extent this excess spending results from prices that are too high and from administrative waste. In the public sector, and particularly at the state level, where budget constraints are severe and reluctance to raise taxes high, this spending crowds out social, educational, and public-health investments. Over time, as spending on medical care increases, spending on improvements to the social determinants of health are starved. In California the fraction of General Fund expenditures spent on public health and social programs fell from 34.8% in fiscal year 1990 to 21.4% in fiscal year 2014, while health care increased from 14.1% to 21.3%. In spending more on healthcare and less on other efforts to improve health and health determinants, the state is missing important opportunities for health-promoting interventions with a strong financial return. Reallocating ineffective medical expenditures to proven and cost-effective public health and social programs would not be easy, but recognizing its potential for improving the public's health while saving taxpayers billions of dollars might provide political cover to those willing to engage in genuine reform. National estimates of the percent of medical spending that does not improve health suggest that approximately $5 billion of California's public budget for medical spending has no positive effect on health. Up to 10,500 premature deaths could be prevented annually by reallocating this portion of medical spending to public health. Alternatively, the same expenditure could help an additional 418,000 high school students to graduate.

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Medical spending in California rose in 25 years from 14% to 21% of the State budget.

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In this period spending on public health fell by a similar percentage.

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California spends $6 billion annually on healthcare that does not improve health.

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Redirecting this money to tobacco prevention would prevent 12,300 deaths annually.

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Redirecting it to education would help an additional 418,000 students graduate.

School-Based Health Centers to Advance Health Equity: A Community Guide Systematic Review

CONTEXT

Children from low-income and racial or ethnic minority populations in the U.S. are less likely to have a conventional source of medical care and more likely to develop chronic health problems than are more-affluent and non-Hispanic white children. They are more often chronically stressed, tired, and hungry, and more likely to have impaired vision and hearing-obstacles to lifetime educational achievement and predictors of adult morbidity and premature mortality. If school-based health centers (SBHCs) can overcome educational obstacles and increase receipt of needed medical services in disadvantaged populations, they can advance health equity.

EVIDENCE ACQUISITION

A systematic literature search was conducted for papers published through July 2014. Using Community Guide systematic review methods, reviewers identified, abstracted, and summarized available evidence of the effectiveness of SBHCs on educational and health-related outcomes. Analyses were conducted in 2014-2015.

EVIDENCE SYNTHESIS

Most of the 46 studies included in the review evaluated onsite clinics serving urban, low-income, and racial or ethnic minority high school students. The presence and use of SBHCs were associated with improved educational (i.e., grade point average, grade promotion, suspension, and non-completion rates) and health-related outcomes (i.e., vaccination and other preventive services, asthma morbidity, emergency department use and hospital admissions, contraceptive use among females, prenatal care, birth weight, illegal substance use, and alcohol consumption). More services and more hours of availability were associated with greater reductions in emergency department overuse.

CONCLUSIONS

Because SBHCs improve educational and health-related outcomes in disadvantaged students, they can be effective in advancing health equity.

Out-of-School-Time Academic Programs to Improve School Achievement: A Community Guide Health Equity Systematic Review

CONTEXT

Low-income and minority status in the United States are associated with poor educational outcomes, which, in turn, reduce the long-term health benefits of education.

OBJECTIVE

This systematic review assessed the extent to which out-of-school-time academic (OSTA) programs for at-risk students, most of whom are from low-income and racial/ethnic minority families, can improve academic achievement. Because most OSTA programs serve low-income and ethnic/racial minority students, programs may improve health equity.

DESIGN

Methods of the Guide to Community Preventive Services were used. An existing systematic review assessing the effects of OSTA programs on academic outcomes (Lauer et al 2006; search period 1985-2003) was supplemented with a Community Guide update (search period 2003-2011).

MAIN OUTCOME MEASURE

Standardized mean difference.

RESULTS

Thirty-two studies from the existing review and 25 studies from the update were combined and stratified by program focus (ie, reading-focused, math-focused, general academic programs, and programs with minimal academic focus). Focused programs were more effective than general or minimal academic programs. Reading-focused programs were effective only for students in grades K-3. There was insufficient evidence to determine effectiveness on behavioral outcomes and longer-term academic outcomes.

CONCLUSIONS

OSTA programs, particularly focused programs, are effective in increasing academic achievement for at-risk students. Ongoing school and social environments that support learning and development may be essential to ensure the longer-term benefits of OSTA programs.

Economic Impact of Tobacco Price Increases Through Taxation: A Community Guide Systematic Review

CONTEXT

Tobacco use is a leading cause of preventable death in the U.S. and around the world. Increasing tobacco price through higher taxes is an effective intervention both to reduce tobacco use in the population and generate government revenues. The goal of this paper is to review evidence on the economic impact of tobacco price increases through taxation with a focus on the likely healthcare cost savings and improvements in employee productivity.

EVIDENCE ACQUISITION

The search covered studies published in English from January 2000 to July 2012 and included evaluations of national, state, and local policies to increase the price of any type of tobacco product by raising taxes in high-income countries. Economic review methods developed for The Guide to Community Preventive Services were used to screen and abstract included studies. Economic impact estimates were standardized to summarize the available evidence. Analyses were conducted in 2012.

EVIDENCE SYNTHESIS

The review included eight modeling studies, with seven providing estimates of the impact on healthcare costs and three providing estimates of the value of productivity gains. Only one study provided an estimate of intervention costs. The economic merit of tobacco product price increases through taxation was determined from the overall body of evidence on per capita annual cost savings from a conservative 20% price increase.

CONCLUSIONS

The evidence indicates that interventions that raise the unit price of tobacco products through taxes generate substantial healthcare cost savings and can generate additional gains from improved productivity in the workplace.

The Interaction Between an Individual's Acculturation and Community Factors on Physical Inactivity and Obesity: A Multilevel Analysis

OBJECTIVES

We examined whether the interactions between primarily speaking English at home and community-level measures (median household income and immigrant composition) are associated with physical inactivity and obesity.

METHODS

We pooled the 2005 and 2007 Los Angeles County Health Survey data to construct a multilevel data set, with community-level median household income and immigrant density as predictors at the community level. After controlling for individual-level demographic variables, we included the respondent's perceived community safety as a covariate to test the hypothesis that perceived public safety mediates the association between acculturation and health outcomes.

RESULTS

The interaction between community median household income and primarily speaking English at home was associated with lower likelihoods of physical inactivity (odds ratio [OR] = 0.644; 95% confidence interval [CI] = 0.502, 0.825) and obesity (OR = 0.674; 95% CI = 0.514, 0.882). These odds remained significant after we controlled for perceived community safety.

CONCLUSIONS

Resources in higher-income areas may be beneficial only to residents fully integrated into the community. Future research could focus on understanding how linguistic isolation affects community-level social learning and access to resources and whether this differs by family-level acculturation.

Programs to increase high school completion: a community guide systematic health equity review

CONTEXT

High school completion (HSC) is an established predictor of long-term morbidity and mortality. U.S. rates of HSC are substantially lower among students from low-income families and most racial/ethnic minority populations than students from high-income families and the non-Hispanic white population. This systematic review assesses the effectiveness of programs to increase HSC and the potential of these programs to improve lifelong health among at-risk students.

EVIDENCE ACQUISITION

A search located a meta-analysis (search period 1985-2010/2011) on the effects of programs to increase HSC or General Educational Development (GED) diploma receipt; the meta-analysis was concordant with Community Guide definitions and methodologic standards. Programs were assessed separately for the general student population (152 studies) and students who were parents or pregnant (15 studies). A search for studies published between 2010 and August 2012 located ten more recent studies, which were assessed for consistency with the meta-analysis. Analyses were conducted in 2013.

EVIDENCE SYNTHESIS

The review focused on the meta-analysis. Program effectiveness was measured as the increased rate of HSC (or GED receipt) by the intervention group compared with controls. All assessed program types were effective in increasing HSC in the general student population: vocational training, alternative schooling, social-emotional skills training, college-oriented programming, mentoring and counseling, supplemental academic services, school and class restructuring, multiservice packages, attendance monitoring and contingencies, community service, and case management. For students who had children or were pregnant, attendance monitoring and multiservice packages were effective. Ten studies published after the search period for the meta-analysis were consistent with its findings.

CONCLUSIONS

There is strong evidence that a variety of HSC programs can improve high school or GED completion rates. Because many programs are targeted to high-risk students and communities, they are likely to advance health equity.

Health education 2.0: the next generation of health education practice

Social, physical, and economic environments are the greatest determinants of our individual and collective health. Inadequate or substandard environments of all types present barriers to health. Addressing these broader determinants will be the quintessential core in the next era of public health practice. The framework for health improvement is shifting to a robust and comprehensive ecological model, wherein the broader constructs of health determinants will be central issues in population health improvement practice requiring expanded partnerships, increased application of scientific evidence, and healthy policy development within and outside of the traditional health sector. Health educators are uniquely positioned to effectively engage essential partners, shape information for policy makers, leverage the evidence base to implement effective interventions and maximize beneficial health outcomes, and add to the evidence base with thorough and systematic evaluation and reporting.

Restaurant owners' perspectives on a voluntary program to recognize restaurants for offering reduced-size portions, Los Angeles County, 2012

Introduction

Reducing the portion size of food and beverages served at restaurants has emerged as a strategy for addressing the obesity epidemic; however, barriers and facilitators to achieving this goal are not well characterized.

Methods

In fall 2012, the Los Angeles County Department of Public Health conducted semistructured interviews with restaurant owners to better understand contextual factors that may impede or facilitate participation in a voluntary program to recognize restaurants for offering reduced-size portions.

Results

Interviews were completed with 18 restaurant owners (representing nearly 350 restaurants). Analyses of qualitative data revealed 6 themes related to portion size: 1) perceived customer demand is central to menu planning; 2) multiple portion sizes are already being offered for at least some food items; 3) numerous logistical barriers exist for offering reduced-size portions; 4) restaurant owners have concerns about potential revenue losses from offering reduced-size portions; 5) healthful eating is the responsibility of the customer; and 6) a few owners want to be socially responsible industry leaders.

Conclusion

A program to recognize restaurants for offering reduced-size portions may be a feasible approach in Los Angeles County. These findings may have applications for jurisdictions interested in engaging restaurants as partners in reducing the obesity epidemic.

Declines in sugar-sweetened beverage consumption among children in Los Angeles County, 2007 and 2011

This study assessed changes in consumption of sugar-sweetened beverages (SSBs) among children (aged ≤17 years) in Los Angeles County. We analyzed children’s data from the 2007 (n = 5,595) and 2011 (n = 5,934) Los Angeles County Health Survey. The percentage of children who consumed 1 or more SSB per day decreased from 43.3% in 2007 to 38.3% in 2011 (P < .001); this decrease was seen across most sociodemographic subgroups. Despite measurable progress in reducing SSB consumption among children in Los Angeles County, consumption remains high, highlighting the need for additional policy and programmatic interventions.

Building community disaster resilience: perspectives from a large urban county department of public health

An emerging approach to public health emergency preparedness and response, community resilience encompasses individual preparedness as well as establishing a supportive social context in communities to withstand and recover from disasters. We examine why building community resilience has become a key component of national policy across multiple federal agencies and discuss the core principles embodied in community resilience theory-specifically, the focus on incorporating equity and social justice considerations in preparedness planning and response. We also examine the challenges of integrating community resilience with traditional public health practices and the importance of developing metrics for evaluation and strategic planning purposes. Using the example of the Los Angeles County Community Disaster Resilience Project, we discuss our experience and perspective from a large urban county to better understand how to implement a community resilience framework in public health practice.

Estimating benefits of past, current, and future reductions in smoking rates using a comprehensive model with competing causes of death

Introduction

Despite years of declining smoking prevalence, tobacco use is still the leading preventable contributor to illness and death in the United States, and the effect of past tobacco-use control efforts has not fully translated into improvements in health outcomes. The objective of this study was to use a life course model with multiple competing causes of death to elucidate the ongoing benefits of tobacco-use control efforts on US death rates.

Methods

We used a continuous-time life course simulation model for the US population. We modeled smoking initiation and cessation and 20 leading causes of death as competing risks over the life span, with the risk of death for each cause dependent on past and current smoking status. Risk parameters were estimated using data from the National Health Interview Survey that were linked to follow-up mortality data.

Results

Up to 14% (9% for men, 14% for women) of the total gain in life expectancy since 1960 was due to tobacco-use control efforts. Past efforts are expected to further increase life expectancy by 0.9 years for women and 1.3 years for men. Additional reduction in smoking prevalence may eventually yield an average 3.4-year increase in life expectancy in the United States. Coronary heart disease is expected to increase as a share of total deaths.

Conclusions

A dynamic individual-level model with multiple causes of death supports assessment of the delayed benefits of improved tobacco-use control efforts. We show that past smoking reduction efforts will translate into further increases in life expectancy in the coming years. Smoking will remain a major contributor to preventable illness and death, worthy of continued interventions.

Healthy people: a 2020 vision for the social determinants approach

For the past three decades, the Healthy People initiative has represented an ambitious yet achievable health promotion and disease prevention agenda for the nation. The recently released fourth version-Healthy People 2020-builds on the foundations of prior iterations while newly embracing and elevating a comprehensive "social determinants" perspective. By clearly articulating a new overarching goal to "create social and physical environments that promote good health for all" and a new topic area dedicated to defining the social determinants of health approach, it breaks new ground. Specifically, the 2020 plan emphasizes the need to consider factors such as poverty, education, and numerous aspects of the social structure that not only influence the health of populations but also limit the ability of many to achieve health equity. Improving health is too multifaceted to be left to those working in the health sector alone. Using a social determinants approach can reframe the way the public, policy makers, and the private sector think about achieving and sustaining health. This article describes why such a social determinants approach can enhance our collective efforts to improve population health. This is achieved by defining the context for this new perspective, the process by which the Healthy People 2020 goals and objectives were developed, and the challenges and opportunities ahead. Adding this broad, social determinants perspective and vision for shared societal responsibility for change leaves Healthy People 2020 poised to promote a stronger legacy for a healthier nation and reaffirm a unity of purpose for the future.

A framework for mobilizing communities to advance local tobacco control policy: the Los Angeles County experience

The Los Angeles County Tobacco Control and Prevention Program was significantly restructured in 2004 to improve capacity for local policy adoption. Restructuring included creating a fully staffed and trained policy unit; partnering with state-funded tobacco control organizations to provide high-quality, continuous technical assistance and training; implementing a highly structured policy adoption approach; expanding community capacity building; and establishing local coalitions to mobilize communities. Over the ensuing 6 years (2004-2010), 97 tobacco control policies were enacted in the county's 88 cities and unincorporated area, including 79 that were attributable to the program. By comparison, only 15 policies were enacted from 1998 to 2003. Expanding policy adoption capacity through program restructuring may be achievable in other local jurisdictions.

Moderate influenza vaccine effectiveness in Victoria, Australia, 2011

We used a sentinel general practitioner (GP) network to conduct surveillance for laboratory-confirmed influenza amongst patients presenting with influenza-like illness (ILI) in Victoria, Australia in 2011. The test negative variation of the case control study design was used to estimate effectiveness for seasonal trivalent influenza vaccine. Cases and controls were ILI patients that tested positive and negative for influenza, respectively. Vaccination status was recorded by GPs and vaccine effectiveness (VE) was calculated as (1-adjusted odds ratio)x100%. There were 529 patients included in the study, of which 29% were influenza positive. Twelve percent of study participants were reported as vaccinated, 6% of cases and 15% of controls. Adjusted VE against all influenza was 56%, but not statistically significant. There was generally little variation in VE estimates when stratified by virus type and subtype, which is consistent with good matches between circulating strains and the vaccine strains. The VE was higher among adults of working age than among children.

Moderate influenza vaccine effectiveness in Victoria, Australia, 2011

We used a sentinel general practitioner (GP) network to conduct surveillance for laboratory-confirmed influenza amongst patients presenting with influenza-like illness (ILI) in Victoria, Australia in 2011. The test-negative variation of the case control study design was used to estimate effectiveness for seasonal trivalent influenza vaccine. Cases and controls were ILI patients that tested positive and negative for influenza, respectively. Vaccination status was recorded by GPs and vaccine effectiveness (VE) was calculated as (1-adjusted odds ratio)x100%. There were 529 patients included in the study, of which 29% were influenza-positive. Twelve percent of study participants were reported as vaccinated, 6% of cases and 15% of controls. Adjusted VE against all influenza was 56%, but not statistically significant. There was generally little variation in VE estimates when stratified by virus type and subtype, which is consistent with good matches between circulating strains and the vaccine strains. The VE was higher among adults of working age than among children.

Health reform and Healthy People initiative

The passage of the Affordable Care Act builds on and strengthens the foundation for prevention and wellness that Healthy People--the nation's health promotion and disease prevention aspirations for a healthier nation--established. The Affordable Care Act reaffirms the themes of Healthy People by promoting population-based prevention and sets the stage for Healthy People 2020. The heart of Healthy People 2010 lies in its leading health indicators, reflecting high-priority health issues for the nation. National progress requires broad application of the ecological health model. We reviewed the status of each Healthy People 2010 indicator and noted how the Affordable Care Act drives future positive health outcomes using the ecological model of health as a prism for viewing health improvement.