Randy Gutzke, a longtime IV drug user who says he struggles daily to stay sober, recently was offered a quick-results test for hepatitis C at a West Side community health center in Chicago.
A case manager also reviewed the behaviors that put him at risk for contracting a hepatitis C infection, such as getting tattoos from unregulated shops and sharing razors, needles and "cookers."
"It wouldn't be shocking, just due to my lifestyle," said Gutzke, 44. But 20 minutes later, he learned he had tested negative.
More than 1,500 people have been screened for hepatitis C since February 2013 at public health "field stations" run through the University of Illinois at Chicago's Community Outreach Intervention Projects, thanks to a $150,000 grant funded through the Affordable Care Act. While the sweeping federal law is best known for expanding insurance coverage, its authors also hoped to improve health and cut costs by investing upfront in prevention, wellness and public health initiatives.
At the COIP centers, that means giving away a $20 test in hopes of detecting infections that can lead to liver failure and expensive organ transplants if not treated. More than a third of the people tested have come up positive, according to Basmattee Boodram, a research assistant professor in epidemiology at UIC. The money also funds counseling services and assistance with signing up for health insurance.
"The goal is to really shift from treating sick people to keeping our population healthy," said Rachel Abramson, executive director of HealthConnect One, which has used ACA money to promote breast-feeding and evaluate community-based doula programs.
This year, nearly $1 billion is to be distributed through the law's Prevention and Public Health Fund to local health departments and organizations that deal with smoking, obesity, diabetes, heart disease and stroke, immunization, suicide prevention, early cancer detection and other issues. By comparison, the law's insurance provisions are expected to cost $36 billion this year, according to the Congressional Budget Office and the Joint Committee on Taxation.
The initiative's proponents see preventive care as a way to keep health care costs from spiraling out of control. Americans spend $2.7 trillion a year on medical care, according to the Centers for Disease Control and Prevention, with more than 75 percent going toward chronic, often avoidable, diseases such as Type 2 diabetes and lung cancer.
"We have an expensive system that isn't necessarily getting the outcomes you'd expect," said Susan Swider, a professor in the college of nursing at Rush University Medical Center who serves on the ACA's 22-member Advisory Group on Prevention, Health Promotion, and Integrative and Public Health. "We certainly do well at the high-tech medical aspect. It's this more nuanced prevention — this health where people live, work and play — that we struggle with."
The new fund remains controversial, with critics complaining that money is being spent on silly things without enough accountability or congressional oversight. Republican U.S. Sen. Mike Enzi of Wyoming called it a "slush fund … to build sidewalks, jungle gyms and swingsets."
Supporters acknowledge that it can be difficult to prove the effectiveness of prevention programs, as some benefits may not emerge until years later. Only 15.7 percent of high school students currently smoke, a record low, but "there's really a long lag period" before we can expect a corresponding decline in lung cancer rates, said Ursula Bauer, director of the CDC's National Center for Chronic Disease Prevention and Health Promotion.
But with two-thirds of Americans overweight or obese — and nearly a fifth still smoking — health officials say concerted action is needed to prevent an onslaught of related diseases. Smoking remains the leading cause of preventable death in the country, killing more than 480,000 Americans a year.
"We as a nation cannot afford to treat chronic disease in the next generation unless we can meaningfully decrease the number of people with chronic disease in the next generation," said Joel Africk, executive director of the Respiratory Health Association, which has used ACA funding to work with the Chicago Public Schools on anti-tobacco programs.
In Chicago, the number of students in grades 9-12 who smoke dropped from 13.6 percent in 2011 to 10.7 percent in 2013, new CDC data show. Advocacy groups say that shift will save hundreds of millions of dollars in future health expenses.
Since the ACA passed in 2010, the federal government has given programs in Illinois about $56.3 million from the Prevention and Public Health Fund, according to the CDC.
At the local level, it can be tricky to tease out which spending results directly from the new fund, as many programs also draw on regular federal appropriations. The American Recovery and Reinvestment Act of 2009, often called the stimulus act, provided money not only for shovel-ready construction projects, but also for physical fitness programs, immunizations, tobacco control and other health initiatives.
Health advocates say the ACA fund has provided seed money for new programs and given ongoing efforts a much-needed financial boost.
"Often, past prevention funding was a one-and-done deal," said Erica Salem, a former deputy commissioner in the Chicago Department of Public Health, which has received $11.7 million from the Prevention and Public Health Fund since 2010. "This funding is helping us create the systems changes that will remain in place long after the money is gone."
Last year, for example, $484,000 in ACA funding went toward helping open a health clinic next to Davis Elementary School, in a low-income, medically underserved Latino neighborhood on the Southwest Side. The location is designed to help kids stay in school and their parents stay at work by keeping everyone healthy.
"It's a longer-term view of health," said Cynthia Barnes-Boyd, who oversees the clinic as UIC's senior director of community engagement and neighborhood health partnerships. "If people really understood that prevention would improve expenditures on health care, there wouldn't be such opposition. We're so illness-focused."
Veronica Perez, 19, can walk to the clinic from her home across the street. Before, she had to travel nearly an hour for health care, she said, causing her to miss work at a Chipotle restaurant. While visiting for a recent checkup, she also got a preventive health lesson from a nurse practitioner. Perez also has learned to drink more water to avoid headaches.
"I would want to cry because my head hurt so much," she said.
Blanca Rivera, 42, a single mother of five, came to figure out why she had gained 50 pounds in five years. Lisa Radville, a family nurse practitioner, checked on her thyroid, but also spoke with Rivera about managing stress and eating more fruits and vegetables. "We're trained in wellness," Radville said. "I find that more exciting than prescribing insulin."
North of the city, Evanston Township High School got $75,000 in ACA money to renovate its health space by removing asbestos and adding hands-free faucets, fresh paint and new flooring, furniture, refrigerators and medical equipment.
"You feel like you're in a professional medical office, which is what we are," said Kathryn Swartwout, who directs the center. "We want kids to be learning how to use medical care. … School-based health centers are a really fabulous way to reach teenagers. Adolescents are hard to reach."
The ACA also puts dollars behind long-standing public health efforts such as health screenings and vaccinations.
"The purpose of the national prevention strategy is to get us to think about how we're delivering preventive services as simple as a flu shot to all people," said Barbara Otto, another member of the ACA advisory group on prevention. She's chief executive officer of Health & Disability Advocates, a national policy group that focuses on access to health care and job services for people with disabilities and the working poor.
Erie Family Health Center drew on ACA prevention funds to use its electronic record system to help provide 785 cervical cancer screenings last year.
"That, in the long run, saves money," said Dr. Lee Francis, president and CEO of Erie. "We identify women who are due for Pap tests, we track them, we call them up, we get them to come in for tests and we track their results."
The federal health law is about far more than insurance, Francis said. "It's also about bringing preventive services to all Americans, to make it easier and more affordable."
Those who offer hepatitis C testing and counseling to at-risk Chicagoans like Gutzke say the effort helps change clients' behavior and improves their quality of life. Whether the test results are positive or negative, "they make some changes," said case manager Estella Rivers, a recovering drug addict who is hepatitis C and HIV positive. "People will act when they get information."