 I'm very pleased to welcome you to today's talk in the series on health reform and the ACA. Today's talk is cosponsored by the McLean Center along with the Institute of Politics at the University of Chicago. I'm so pleased that Steve Edwards, the Deputy Director of the Institute, is with us today to hear our speaker. Our speaker, as you know, is Commissioner Bechara Shouker. Since 2009, when Dr. Shouker was recruited by Mayor Richard M. Daly, he has served as the Commissioner of the Chicago Department of Public Health. Commissioner Shouker oversees one of the country's largest and most complex health agencies, an agency that serves almost 3 million people. In 2011, Commissioner Shouker and Mayor Emanuel launched Healthy Chicago. This was the city's first comprehensive public health agenda. Commissioner Shouker has worked to secure more than $60 million in new funding for a broad range of programs, including initiatives to prevent obesity, tobacco use, teen pregnancy, and also to conduct comparative effectiveness research. Commissioner Shouker has served as Vice Chair of Community Medicine in the Department of Family and Community Medicine at Northwestern University's Feinberg School of Medicine. In this capacity, he created the Chicago Community Engagement Program, which mentors students who are interested in developing local and global community engagement projects that focus on education and community service. Commissioner Shouker received his MD from American University in Beirut in 1997, completed his family medicine residency at Baylor, and received his master's degree in healthcare management from the University of Texas in 2009. Today, Commissioner Shouker will be speaking on Healthy Chicago, this new initiative, and the Affordable Care Act. Please join me in giving a warm welcome to Commissioner Shouker. Thank you everybody for coming here today. My name is Bishara Shouker, and I figured for the next hour or so, we'll cover a little bit about the implication of the Affordable Care Act on local government. For the video recorder, I'm more of a walker, so I'm going to keep you busy for the next hour. And I just realized that usually when I go to speak, I usually have one microphone, and here I have two. So, note the self next time I'm speaking at the University of Chicago, no slim-fit suits. You just need to wear a good old regular suit. So, you know, back in 2011, when Mayor Emanuel asked me to stay on board with his administration, one of the very first things that we chatted about is how do we make sure that we're transforming the health of a community of almost three million people. And a lot of us, especially folks in the medical field, and I'm, you know, I went to medical school and I, you know, spent a lot of time learning about how do you treat disease and how do you counsel patients. A lot of time we focus a lot on individual behavior, and this is extremely important. But if we're really serious about transforming the health of a community, it's not just about individual behavior. It's more about how do we behave as a community, how do we behave as a city, what type of policy systems and environmental changes we need to implement in our city so we can improve the health of our community. So, when the Mayor and I had this conversation, that's when the idea of bringing together a group of community leaders talked to our community partners and developed a public health agenda for the city. And that's when we released Healthy Chicago. It was one of the achievements that the Mayor wanted to do in the first 100 days of his administration, and I know many of you know about the Mayor and patients, I won't say, is one of the best characteristics there. So, within the first 100 days we developed that agenda. We've worked with so many community partners. We've talked to internal experts, local experts. Many of the folks are sitting here in the room who we counseled with, asked for advice, and we've released a public health agenda. And in that agenda, we identified 12 public health priorities. We've set measurable targets that we'd want to reach for each one of those priorities between, you know, that we'd want to reach by 2016 and 2020. And most importantly, we've identified almost 200 strategies, mostly focusing on policy systems and environmental change to transform the health of our community. So, when it comes to the priorities, there's no surprise to anybody. We're talking about tobacco, we're talking about obesity, we're talking about teen pregnancy or adolescent health. And then we set those targets, we made them very clear for better accountability. We invest almost $200 million every year into the public health system. So, we wanted to make sure that the public is holding us accountable on what outcomes are we getting from those investments, and we made those targets public. And one of those priorities was around access to care. And right around that time, a year earlier, that's when President Obama signed the Affordable Care Act into law. And for us, at first, it was how do we make sure that access to care is improved throughout the city? But very quickly, we've realized that the Affordable Care Act has a lot more than access to insurance. And you probably all followed the debates, followed the coverage, you know, I know Steve covered it extensively on WBEZ at the time, and it was covered all over the news. And most what you've heard about the Affordable Care Act was about insurance reform. And very, very little you've heard about anything else. So, to me, when I think about the Affordable Care Act, I think of it in two buckets. There's one bucket around insurance reforms, but then there's a huge bucket around health system redesign. And to me, this is really where the opportunity is that hasn't gotten enough attention. So, what I'm going to cover for the next hour or so is really how are these two buckets impacting our work as a local health department and how are we trying to maximize the benefits of the Affordable Care Act locally when it comes to these two buckets? So, I'm going to start by talking about insurance reform and really increasing access to coverage. So, when we started thinking about this, we knew that there are around 500,000 people in our city who are uninsured. So, we needed to know more information about these folks. Who are they? Where do they live? What kind of characteristics do we know about them? So, we partnered with an organization that I'm sure many of you are very familiar with called Health and Disabilities Advocates. And we worked with them and we issued a report that we called at the time Enroll Chicago. We issued this report back in the summer that gave us a snapshot of where the 500,000 uninsured people are in our city. And we started asking ourselves more, you know, the questions as to how can we be of help as a local health department to make sure that these folks have access to the right information to enroll in insurance. You know, the Affordable Care Act made very clear, you know, roles and responsibilities for state government, you know, for navigators, community partners that will be hiring navigators and enrolling people. And it says very little about the role of local government on enrolling residents. And we knew that there's a role that we could play. So, we tried to figure out what can we play as a role that's effective in enrolling residents. You know, when we looked at the map, we know there's around 506,000 who are uninsured. We looked at income levels, we know where they live by community and the darker the color, the more likely that community has uninsured folks. And we implemented some of our, you know, the formulas as to who gets subsidy, who gets insurance exchanges, who gets, you know, who gets Medicaid expansion. And if you think about it, today the Affordable Care Act was going to cover more people is through two main buckets. One bucket is through expanding Medicaid and the other bucket is through creating the marketplaces. If you make less than 138% of the federal poverty limit, you'll automatically be in the expanded Medicaid bucket. If you make anywhere between 138% of the federal poverty limit and more, you're going to be in the marketplace, but you will get subsidy all the way, even if you make up to 400% of the federal poverty limit, you'll get some subsidy to purchasing your insurance. So when we looked at those numbers, 506,000 are uninsured, and if we look at the income eligibility, almost half of these folks will be Medicaid eligible and a little bit less than half will get into the marketplace with tax subsidy. So we said, okay, we needed to know more. Who are these uninsured and what do we know about them? So we also know that, you know, out of our uninsured, there's 33,415 folks who are disabled in our city who are uninsured. We know that there are 145,000 SNAP recipients who are uninsured. 7,288 seniors who are uninsured. We even have 40,161 children and youth who are uninsured, knowing very well that in the state of Illinois, you qualify for Medicaid irrespective of your documentation status. So we knew that we have an opportunity here irrespective of the Affordable Care Act, but we also know that there's 108,000 people who are undocumented. So that process helped us narrow down how do we need to focus our resources, how do we work with state government, how do we work with over 40 partner organizations that got funding to hire navigators and enroll folks. So we started also looking at, you know, where are these undocumented live? How can we make sure that we're, you know, how do we make sure that the undocumented really continue to have access to services? And we asked ourselves the questions, if the Affordable Care Act is excluding undocumented, is it really going far enough when it comes to reform? And the answer, I think, you know, the Affordable Care Act is not going enough until there is coverage. There's some type of solution for immigration and there is immigration reform. But what we know from the Affordable Care Act is there is additional funding that is going to the community health centers or federally qualified health centers that are providing a lot of services for those who are undocumented. So we wanted to see where these federally qualified health centers are, and you'll see them here on the maps, and we know that they are providing a lot of services to uninsured but also undocumented. And if you look at the number of people who these federally qualified health centers are serving, almost half a million residents in our city are receiving services through federally qualified health centers. I think there are plenty of those around here, you know, access, Chicago family, Circle family, I know near north is now on the south side, and other places that are providing services for those who are uninsured but also undocumented. So we got back to the question, what can we do as a local government? We don't qualify to getting money for navigators, but we know that as a city government and through a bunch of agencies, there are literally hundreds of thousands of people who interface with their local government on a day-to-day basis. So can we leverage this opportunity to reach out to those who are uninsured and make sure they have the right information to get insured? And that's when Mayor Emanuel asked all of the city agencies to work with us to try to figure out what can we do. So we started talking to all these folks. We know that there's a Chicago Housing Authority where 55,000 residents depend on us for housing. The Chicago family and support services, they have multiple city centers, community centers throughout the city to provide services to seniors and other people who need assistance. We know libraries are all over the city and people interface with our libraries on a regular basis. So that's when we released our Enroll Chicago initiative. And through that initiative, we wanted to literally capitalize on those opportunities where residents are interacting with us as city government. So this is one example. I'm going to start by talking about artists. We know that artists' insurance rates is much higher than the rest of the population. I think from a study from 2013, 43% of artists don't have insurance as compared to the 20% or so of the general population. And when we asked them why they're uninsured, the overwhelming majority say, simply we can't afford it. So knowing that now they have an opportunity to enroll either in expanded Medicaid or in the marketplaces, we've worked with the Department of Cultural Affairs and special events, and we hosted an event specifically targeted to artists. In our very first event, we had over 125 artists who had an enrollment process. Simply they had no idea what the Affordable Care Act is all about. It took me a long time to understand a lot of the details of the Affordable Care Act. So it was great to bring in our partners who have the navigators and place these navigators face-to-face with the artists and make sure that our artists starting to get enrolled in insurance. The other thing that we know is libraries. There are over 108 librarians who we already trained throughout the system to make sure that they have some basic information. So when our residents are interfacing with the librarians, they have the right answers. They can connect them to the right information. And now we've hosted a series of those trainings. And now librarians, if you interface with the library system, will be able to connect residents or uninsured for services that they need. The other story that I'm very excited about is actually our work with taxi drivers. And when you think about it from a study that was done in 2011, we know that 70% of taxi drivers in Chicago are uninsured. 70% compared to the 20% of the general population. We also know there are around 12,000 taxi drivers in the city, so that gives you over 8,000 taxi drivers who would qualify for insurance because they all have some type of documentation status for our US citizens, so they do qualify for the Affordable Care Act. And we also know that every day, over 300 taxi drivers come to the business affairs and consumer protection building at the city to either renew or update their license. 300 every day, and it takes on average an hour and a half to two hours. So we started an initiative where we had navigators placed at that building where they're interfacing with taxi drivers and talking to them about their opportunities. And this, to me, is extremely important for so many different reasons. One over 8,000 taxi drivers would be eligible to apply. They'll have the right information. But the other piece that's more important, taxi drivers in a lot of these communities, many of them are immigrants, are really the gateway to come into these communities that might not necessarily interface the best way with our US-made healthcare system. So by engaging taxi drivers, you're not just engaging them and their families. You're also engaging their friends, their neighbors, community members that we might not be able to reach very easily. This initiative has gotten tons of coverage. It was on the morning edition on NPR yesterday. It got coverage on the Associated Press and others. And we've been very successful in enrolling taxi drivers. We started by saying, oh, we'll probably be there a couple of days a week, see how it goes. And now we've been there five days a week, every day of the week. And we're going to continue to be there all the way until the end of March. You know, the other group that we thought we could make a difference is really the young and the invincible. You know, this is the group that our Affordable Care Act really heavily, heavily depends on to make sure that they are getting enrolled. That's the young and the healthy. And we know that City Colleges is around 120,000 of those students and a large number of them are uninsured. So we partnered with Enroll America and now we have navigators placed at these, every one of these City Colleges to make sure that these students are getting the right information and in many instances actually and a lot of instances we're enrolling students right on site. The other group I want to spend some time talking about are kids. And you know, I mentioned earlier that in Illinois we're one of the lucky states that as a child you will qualify for Medicaid irrespective of your documentation status if your family, you live in a family that makes 300% or lower than the federal poverty limit. But from our report what we've noticed is there are a lot of kids in Chicago, you know, almost 40,000 or over 40,000 who are uninsured. And when we looked at their income level almost 20,000 are making less than, they come from families making less than 138% of the federal poverty limit. These are kids who qualify today, well they qualified years and years ago for Medicaid and they didn't have Medicaid insurance. So can we make a difference there? What can we do there? And keep in mind that another city agency that we work very, very closely with is the Chicago Public Schools. And we know these kids, we know what schools they go to, we know if they have Medicaid or not because we compare our list of students who qualify for free and reduced lunch to the list of kids who have Medicaid and we can literally figure out school by school, by kid, by student, those students who don't have insurance. So we invested some money to actually launch this initiative to identify those kids and work with them to get them enrolled. Most of these kids will qualify for traditional Medicaid but some might qualify for some other options through the Affordable Care Act. And we, you know, through this initiative where the city is investing a bunch of money, we were able to get Atlantic philanthropies to join us in that investment and we put out a request for proposal and we're partnering with LISC as a community partner to identify those communities with the highest rates of lack of insurance for kids and target those interventions for students in their communities, with their families and the opportunities there is not just the kids, it's also their parents now. So when we're talking to get the parents to enroll their kids in Medicaid, it's a great opportunity to enroll their parents in other options that they might have through the Affordable Care Act. So we're really excited about this project. So you might ask yourself, where are we right now? I mean, this has been, you know, a progress for now over a year because if you remember last year, Cook County was able to receive a waiver to start enrolling people in expanded Medicaid as of 2013 instead of waiting to 2014. So in theory, we have an advantage or, you know, in reality, as a city and as a county, we have an advantage over the rest of the country because we started enrolling people in expanded Medicaid or we called it County Care last year as of last year. So you might ask yourself, where are we? And the numbers that I'm going to share with you, they're not official yet, they're not the most updated, but I wanted to share them with you anyway to give you a snapshot of where we are. When you look at Medicaid, we have around 151,000 enrolled statewide, which is a good number. It's not the 200,000 that we think will qualify in Chicago alone, but it's a definitely step in the right direction. We know that through County Care, there's 74,000 applications that's already approved. I know that there are, you know, over 120,000 applications that were submitted, so there's a huge backlog there and I know that the state is working on that, but we know there's 70% of the County Care enrollees are from Chicago and we're really excited about that and we've made an effort last year to make sure that our residents are benefiting from that approach. We also know that 36,000 were enrolled through the SNAP express enrollment because we know that SNAP recipients will qualify anyway and there are 41,000 who apply through the regular traditional process. These are the latest that I have. I don't know how, you know, how there probably are more updated numbers, but as a few weeks ago, we had 88,602 residents throughout the state who enrolled in the marketplaces and if you look at it, the overwhelming majority of those were qualifying for financial assistance and if you look at the different level of coverage that they're getting, there's a lot of those are getting, you know, the silver which is kind of the middle of the pack package that they could see. So we've seen some good progress. I'm excited. I'm hopeful. I think it's going to take us a while to get to the 97%, 98% that we'd like to see. You know, we know from Massachusetts it took them a couple of years to get to where they are and their coverage and it's going to take us a while here as well, but we're really hopeful that even though that the timeline or the deadline for the marketplace ends at the end of March for Medicaid expansion, which is the population that we really are interested in making sure they have access to insurance right now, we have year long to kind of continue to enroll these folks. So the second bucket of the Affordable Care Act I'm going to spend some time on talking about and again, you probably have heard, I looked at the great list of speakers who participated in this coverage and the series of seminars and it looks like you got great presentations on different topics, but I do want to spend a little bit of time talking about the health system redesign aspects of the Affordable Care Act. And I'm going to, you know, there are three areas of focus. I'm going to only focus on the first two. You know, the state does a lot of the work around the workforce and infrastructure. We don't do a lot of that as a city government, but I'm going to be talking about the first top two. There's a clear focus in the Affordable Care Act and actually for one of the very, very first time on public health and prevention. So let's talk a little bit about what the Affordable Care Act included. How many of you have heard of the National Prevention Strategy? Just a few. So this was a significant aspect of the Affordable Care Act that called on the development of a national prevention strategy for our country. And it also to make it, you know, to make the implementation of the strategy easier and actually the development of the strategy, the Affordable Care Act called on the creation of a national prevention council that included cabinet members from across the federal government that was chaired by the Surgeon General. It's still there, it's still up and running to actually develop that strategy and implement that strategy. And that prevention strategy put some guiding principles. That's how that national prevention strategy looks like. So when the mayor and I were talking about Healthy Chicago, the way we looked at Healthy Chicago was really is our local version to implementing the national prevention strategy. And we developed them kind of similarly at the same timeline the prevention strategy was released in I think June of 2011 and we've released our local version or Healthy Chicago in August of 2011. So our Healthy Chicago agenda is the local version of the national prevention strategy. The mayor asked every city agency had, you know, of over 15 or so of the city agencies to create the entire agency council for the implementation of Healthy Chicago and we've set guiding principles for all these agencies to see how they can participate in making our city a healthier city. So when you look more in depth about this public health and prevention focus it has implications for physicians but also it has a lot of implications for the public health system or local government. You know, for physicians that aspect the Affordable Care Act talked a lot about integrated services talked a lot about workforce development whether it's primary care workforce it put a lot of money in the national health service core so we make sure that, you know, our students are ending up going into primary care going back to work and low income community, urban communities rural communities it put a lot of money to expand federally qualified health centers we've mentioned that a little bit earlier for physicians but for people in public health we've seen a significant investment in working around key public health efforts focusing on policy systems and environmental change and this was one of the very first significant investment into the public health system in general in our country where the Affordable Care Act put aside $15 billion for the first 10 years to invest into these policy systems and environmental changes it also put a lot of investment in chronic disease prevention a lot of investment in epidemiology and core public health function and the expansion of the federally qualified health centers who we've seen as really partners in making the health of our communities better so when you look at this is one of my favorite graphs and it shows how the $15 billion are supposed to be spent in the first 10 years between FY10 and FY19 and then after that it goes $2 billion per year but a lot of our friends in congress like to call this fund as a slush fund and they keep cutting it year after year and right now really there's a significant cut to that fund but at least it's still there and what that fund provides provides dollars for is clinical prevention community prevention workforce and infrastructure and research and tracking so I'm going to give you a snapshot of how we're using some of these dollars here in Chicago so out of that bucket Chicago were able to receive over 40 million dollars in funding from this very specific bucket to do different types of prevention and public health activities over the last couple of years there's a lot of systems improvement around immunization especially around HPV immunization the department was just a few months ago we've received significant amount of dollars we were one of 12 awardees in the country to really work with the healthcare system to make sure that providers and physicians have the right decision support tools in the exam rooms to enhance and improve our HPV vaccination records there's a lot of work around lab capacity we've gotten a lot of funding over the last few years prevention, tobacco prevention and then we know that many of our partners here in the system like Erie Family Health Center received a residency teaching grant in partnership with Northwestern University and now they have a family medicine residency training program at Erie Health Center which is a federally qualified health center training physicians to be primary care docs in our community and as I looked through the list of the seminar speakers I saw that my really good friend Romana was a speaker here last week talking about Pikori who she's now one of the leaders at Pikori which is a dedicated fund to really focus on a lot of the clinical interventions a lot of the system redesign interventions and transformative design interventions and she's leading that effort so I won't be spending a lot of time but I'll be mentioning some of the grants that Chicago has gotten from that pool of money so I'm going to talk a little bit about some of the policy changes that we were able to make as a city because of those funds that we've received and most of these funds came around the policy and system change came directly to the health department so I'm going to start by talking about flavored tobacco sales when you think about flavored tobacco specifically mental what we think about very quickly what we know from research is that these flavored tobacco products specifically mental are proven starter products for youth we know that we know that they are proven starter product for youth we know that we know that over 70% of black youth who smoke, smoke, mental cigarettes we know that over 70% of LGBT youth who smoke smoke, mental cigarettes we know that 50% of Hispanic youth who smoke, smoke, mental cigarettes so we know that the tobacco industry or big tobacco has been very clever and identifying targets and really get them addicted to these products and then we also know that 90% of adult smokers started smoking as kids so to me it's a no brainer what do we really need to do to prevent kids from picking up that very very first cigarette and since we know that flavored tobacco products are that proven starter products we needed to do something about that so the mayor asked the Board of Health back this past summer to host community town hall meetings to get input from the community as to what can we do about flavored tobacco and we hosted four of these town hall meetings that culminated in a significant report talking about flavored tobacco specifically about mental cigarettes with over 25 different policy recommendations and this past December Chicago became the first city in the country to restrict the sales of flavored tobacco including mental cigarettes within 500 feet of schools because we know from research that you know the higher the density of retailers that are selling cigarettes around schools the more likely kids in those schools will be experimenting with cigarettes so we're really happy about this this ordinance it'll be in effect starting June but we're really excited about this very groundbreaking policy around flavored tobacco in the city of Chicago the other thing we've leveraged some of these ACA dollars is to create more and more smoke free environments we know that you can't smoke within 15 feet of a main entrance of a building you can't smoke at work but there are a lot more that we can take this to the next level can we talk about smoke free or tobacco free campus policies and we worked with many institutions including the city colleges to make all of their campuses including parking lots including their their little parks and all of that to make them tobacco free and that policy changed with city colleges impacted the lives of 120,000 students who could now learn in a tobacco free environment and also 6,000 staff and faculty so last year we've worked with the University of Illinois that the Chicago campus that became smoke free we've also worked with hospital systems where not smoke free campus or did not have smoke free or tobacco free campus policies to make a difference so we've continued to work with organizations to improve and expand the environments that are smoke free or tobacco free in our city we've also worked with the public housing authority so if you think about it 55,000 residents depend on us for a residency to live for housing so we said those residents we want them to have the ability to make a choice to live in a tobacco free environment and now many of our Chicago housing authorities have the tobacco free or smoking free policies where even inside your apartments you can't smoke because we know that with all the share there we know that with the circulation that if you smoke in one apartment you're really being exposed to secondhand smoke in the next door apartment so a lot of progress these are all the things that we worked with over the last year or so to develop more and more smoke free campus policies and because of a very targeted aggressive advertisement campaigns to encourage people to quit smoking and call the tobacco quit line what we've seen over the last 6 months of 2013 the calls to the tobacco quit line which is a free resource for our residents is more than doubled when you compare it to the last 6 months the reason that's happening is so many different there's so many different reasons but one of them is really our very aggressive tobacco campaign ads that are driving residents or smokers to the tobacco quit line and we know that 73% of the callers are either black or Hispanic so we know we're targeting the population that needs support the most when it comes to ads when it comes to obesity we spent a lot of our time talking about unhealthy and affordable food for the first time also we had a comprehensive food plan for our city it was also funded by one of these grants from the affordable care act where we worked with the department of planning and development as well as the consortium to lower obesity in Chicago's children to develop a food plan for our city that addresses the food access issues and that has a key strategies and all of that we've also worked on healthy vending pulled all the unhealthy items from the vending machines in the parks district we pulled all the sugary drinks vending machines from the Chicago Public Schools but we've also pulled the unhealthy items from every one of our vending machines the snack vending machines and the beverage vending machines and every one of our city buildings and we've challenged the private sectors to follow those same guidelines so that employees and customers have access to healthier food and we decided to use vending machines you know the neighbor cart is probably one of my most favorite projects because it really looks at the interface between economic development and public health and this is in partnership with Treetwise many of you are very familiar with Treetwise where they're identifying residents who are recently out of homelessness or residents who are recently out of jail providing them with the right training and support to become small business owners great economic development project but when you think about that small business it's basically having kiosks selling fresh fruit and vegetables mostly in food desert areas and that's where that intersection between economic development and public health works very well together last year we had 15 of those up and running mostly in low access community this year we're going to have 15 more so we're going to have a total of 30 of those out in the community many of you are also very familiar with our urban farming policies that we've changed a lot of these policies and ordinances to make it easier to do urban farming in our city and I know that the mayor has been personally engaged in making sure that many of the mainstream grocers are coming up to low access communities opening up stores and that will make definitely a significant difference the other key strategy when it comes to obesity is our built environment and how do we make sure that we're creating that's suitable or that's encouraging for physical activity and also as part of the funding from the Affordable Care Act we worked with the Department of Transportation and many partners in the community on a new guidelines or the complete streets guidelines and the key shift in that set of guidelines we're really shifting the priorities for who our streets are designed for I think when we all think about streets we think about our cars but the reality is everybody who's using a street is a pedestrian at one point in their commute and if we're serious about creating an environment where people could be more physically active we have to prioritize pedestrians and that's what those guidelines said said streets top priorities are pedestrian followed by public transit and biking followed by cars and there's a you know something our former transportation commissioner my really good friend Gabe Klein would say his advice to people if you're commute is a mile or less you really should walk that commute if your commute is between one mile and four miles you really should bike to get where you're supposed to go if your commute is between four miles to eight miles you should use public transportation to get to where you're supposed to go if your commute is more than eight miles you should consider using public transportation but if you can't get there using public transportation you should consider using a car and this is really that philosophy is what happened in that complete streets guidelines that we've issued this past year and as a result of that you're seeing a lot of built environment support a lot more protected bike lanes in our city so that residents would feel more comfortable where they're supposed to go the Divi bike has been a tremendous success we had almost 800,000 trips that have been happening already more than 1.7 miles million miles that have been written really great very successful program you know we're going to continue to add more bike lanes I don't know how many of you are on Dearborn very often this is right in the heart of the central business district where we took one lane and the heart of the central business district and transformed this car lane into two-way bike lane and added the right lights and signage for bikers I can't think of any other city that has the courage honestly to take a car lane and the heart of the central business district to make that change so we're really happy with the progress there the other work that we've done is really around baby friendly hospital designation this is also very important when it comes to breastfeeding and when we started this process this is a WHO designation that allows hospitals to implement a set of policies to encourage breastfeeding for moms right after they give birth at the hospitals and I'm really happy to report that 15 of our 19 maternity hospitals right now are in the pathway to becoming a baby friendly hospital and get that designation so we're really excited we're really excited about about that the other thing that we've done is we've worked a lot with the Chicago Public School and we actually just recently received another additional funding to continue our work with CPS and if you think about it, CPS is 404 or so thousand students who go there every day what a great opportunity for public health interventions and we've spent a lot of time building the right infrastructure to be able to make a difference with CPS students we have a chief health officer right now who has dual reporting relationship to the CPS CEO but also to me at the health department so we created the right infrastructure to make a difference we've changed the standards of the 59 million meals that are offered at CPS every year think about that, 59 million meals have now much much better standards on the type of food that's being offered there we've worked with CPS on removing unhealthy snacks, we've worked with them but being called the cupcake Nazi is not something that I'm proud of during my tenure at the health department we've worked on supporting vendors who are coming to CPS schools, make sure they're selling healthier items we've by extending the school days and I know this has been there's been a lot of debate on extending school days and I used to listen to all your coverage on extending the school days one huge win, one of the main reason why I was so supportive of extending school days is the possibility of bringing recess back to school and we did that and just recently the Board of Ed passed a comprehensive PE policy that brings PE back to our students every one of our students, every grade this is really exciting and that really is a result of the dedicated efforts and times that we were able to afford because of the affordable care act so a lot of work around policy changes but we've also done some work around systems changes there are a couple of examples I'm very excited about and you know one of them is our partnerships with federally qualified health centers and how do we customize their electronic health record system so physicians when they're interfacing with our patients have the right decision support tool to do the right thing when it comes to prevention I practice at a federally qualified health centers I ran a federally qualified health centers I ran the implementation of electronic health records at a health health center system and I know how important that is so we're working with so many different partners to make sure that if your patient smokes and you ask them a few questions we should make it so easy for our providers that if that patient is ready to quit smoking that physician or that provider could with a click of a button send the message to the tobacco quit line and the tobacco quit line can initiate the call to that patient who's ready to quit smoking so that we create an incentive for that person to quit smoking we're looking at so many different adoration of those approaches that we're very very excited about we work with many partners to make that happen the other thing around system changes is public health accreditation and I want to take a minute to talk about this because it's critical you know when I moved to the health department when I joined the health department I didn't know honestly much about local health departments I'm curious I'm always like to learn more but I very quickly realized that there's no accreditation process for local health departments and I come from the medical system there's jaco, there is all kind of accreditation that we have to work on and right at the time I was appointed the CDC and the public health accreditation board created an accreditation path for local health departments and I took this very seriously because we want to make sure that what we're doing is the right thing when it comes to the health department and we want to make sure that those hundreds of millions of dollars that we're spending year after year are spent based on some type of standards and I'm happy to report that as of August of this past year in 2013 we became the first big city health department and actually the only big city health department in the country that's accredited and I'm very very proud of that because it really tells us that our efforts and our focus is really in the right direction when it comes to systems improvement the other thing that was key also in the Affordable Care Act was requiring hospitals to do community assessments if they want to maintain their not-for-profit status so we know that this was an opportunity for hospitals to be engaged beyond their emergency department, their medicine floor, their surgical floor so we worked with all these hospitals to try to figure out are there opportunities for partnership there and when we compare all the community health needs assessment and there's a report on that on our website we found that there's a huge opportunity for overlap, there's a huge opportunity for leveraging a lot of the community health hospital assessments to make a difference in population health we know that local hospitals spent 1.4 billion dollars in some type of charity investment over per year in our system, in our city so how can we leverage those dollars to look at areas where we can find better opportunities to really improve the system so that's an area that we've been also focusing on I'm going to spend just a few minutes on innovation because I know Framana was here and Matthew was here a few weeks ago you guys probably have heard a lot about these so I'm going to spend a little bit talking about how the Affordable Care Act is really pushing for innovation and within the Center for Medicare and Medicaid Services there was a creation of an innovation center and that's really dedicated a lot of funds to push for innovation in the health care system at so many different levels throughout we've received some funding there to really look at different opportunities to improve the health care system I think to me this is another area where there is a lot of opportunities for improving health outcomes is that intersection between public health and clinical medicine and the funds that are coming from the Center for Medicaid and Medicaid Services and innovation are really targeted towards that principle so it's a lot of excitements there are different models that are being developed by policy experts there's a lot of push to think about compelling approaches not really funding the status quo but really push the limit, redesign systems really think differently about things there's a lot of talk about accountable care organizations there's a lot of talk about dual illegibles there's a lot of opportunities for bundled payments tons of opportunities when it comes to redesigning our our health care system we also know that there are innovation grants that are right here in Chicago there's actually a couple that are right here at the University of Chicago and we're very excited to work with the lead PIs on both of those innovation at the state level we've been working very closely with the state on the new funding that they've received last year to create this alliance for health to help us rethink what Medicaid pays for what are these services that Medicaid pays for and really help us reimagine what Medicaid would look like and this is a process that we've been heavily engaged in the community's been engaged in there are a lot of round table discussions around that so I encourage you to be part of that process as well on the PCORI side I'm very excited actually about one funding opportunity that we've been integral to that went to the University of Illinois that's looking at residents that are multiple visitors repetitive visitors to the emergency department because of asthma so are there opportunities to do more targeted case management for these folks and then is there a role for a local health department where we have tons of inspectors that do healthy homes visits to be able to go to these families homes inspect the homes and see if there are triggers that are triggering asthma for those kids in their homes and try to mitigate that risk and be happy about it's just got funded recently the other project I'm very excited about is something called the Chicago Health Atlas how many of you have heard of the Chicago Health Atlas okay many of you great so what we've done with the Chicago Health Atlas one of the key strategy that the mayor's been pushing us to do is really data liberation so if we have data sets as government agencies let's just liberate these data we don't really unless there's a reason why we want to be so protective let's liberate them and make sure they're available to researchers community partners so what we've done last year we've opened up tons of data sets and we created the Chicago Health Atlas so that residents and communities could go to these website at thatchicagohalthatlas.org and really learn more about their communities and what we've done we've worked with informatics folks from different institutions and we were able to get a dump of data we identified clinical data from 2006 from five major healthcare institutions and we were able to put those data into one database that allows us access to de-identified but individual clinical data for over 3 million residents from metro Chicago and including almost a million from Chicago as a city so huge opportunity for us to really reimagine what we can do with these data and because of all these partners have been working together on the Chicago Health Atlas recently we were able to apply for one of the PICORI grants and receive over 7 million dollars from PICORI to really take that Chicago Health Atlas and give it a shot of steroids and really take it to the next level so we're really really excited about this so many different partners are involved and if you think about the future of medicine it's all going to be about data predictive analytics is so key if you don't know what predictive analytics is I really encourage you to read about it when I think about it people in the corporate world predict what kind of soup we're going to purchase from the grocery store if we use our loyalty card on a regular basis so there's no reason why we don't use similar methodology to try to predict who's going to need healthcare, who's going to need public health services so this is really exciting so there's a lot of stuff happening on the Affordable Care Act that really is impacting the way we behave as a local health department but it really all boils down to the fact that if we are serious about transforming the health of our population we really need to be thinking a lot more than just individual behavior we really have to think about how do we behave as a city just yesterday we've released our 2013 annual report for Healthy Chicago I know many of you are on Twitter I think it's the McLean seminar hashtag I just tweeted earlier today actually scheduled it to be released right now probably the link to the annual report so I encourage you to take a look at it and it gives you an idea of the type of work that we're doing as a city and there are all these different ways where you can connect with us we love it when people interact with us on social media so please take a moment to follow us on Twitter Facebook and I'm looking forward to the conversation thank you so much you feel that it's a major problem still in Chicago and does your agency have the power to shut down or deny the opening of charter schools to don't have playgrounds athletic fields and gyms because I have taught some of those schools and they should never have been allowed to open so the question around obesity and children is a significant issue in the city but this is an issue that actually I'm very very happy to report that we're turning the corner on if you think about it back in 2003 so short 10 years ago one in four kids entering kindergarten to the Chicago public schools were obese that's one in four and those kids were obese not overweight and obese just obese 10 years later we just issued a report looking at our 2012 data that showed that now one in five kids entering kindergarten are obese so we're making some progress we're definitely turning the corner on pediatric obesity what that means is a thousand kids are entering kindergarten now at a healthier weight so I'm happy with the progress we're making we actually now for the first time in ever we have a data sharing agreement with CPS to actually get the data from CPS from their physical exam forms we've completed our first comprehensive obesity report back in 2012 back in 2011 and we've updated the data with 2012 2013 data last year so that's how we track that right now on a regular basis when it comes to to charter schools who don't have playgrounds my understanding and I might be wrong that these charter schools still have to abide by some of these policies and the PE policy is very very clear physical activity is back at CPS it's back for every grade and it's back to stay so we want to make sure that kids continue to have access to to PE classes I seriously seriously doubt we have the authority to prevent opening of these charter schools if we do I'll look into that you know I've learned you know I've always thought that everything in public health and health is controversial until I started being more involved in following what happens in education it's a lot more controversial there that's for sure I think we have microphones they develop relationships with nothing in their area these are people with serious mental illness others who still live near the ones that remain open have been put on Medicare I mean I'm sorry Medicaid Medicare on my mind put on Medicaid and have been told oh sorry you can't use your Medicaid at these clinics anymore and I you know I'm wondering what kind of responsibility you and the city are going to take for the mental health of these seriously mentally ill patients so the mental health question is a question I get all the time and this is a very very important issue to us so if you think about it you know traditionally we've been known as the department of clinical services really not the department of public health and we've delivered primary care and mental health services for years and years back in 2012 or actually in 2011 when we were preparing for the 2012 budget we've realized that it's really time to challenge the status quo and reform our own mental health system but most importantly enhance the mental health system throughout the city so here's what we've done so the first thing we've done back in 2012 we said we need to improve our own system so we had 12 clinics all poorly staffed not enough staff in each one of these clinics that were delivering services really on a shoe strength so we said let's validate these clinics from 12 to 6 better staff each one of these clinics and make sure that residents would depend on us for services continue to have access to services so that's what we've done we've transitioned the care of 429 insured clients those were insured residents who have insurance we transitioned their care to the community mental health providers we followed up with them a month later we scheduled their appointments we followed up with them a month later and we followed them 60 days later and if they didn't like the new provider we asked them to come back and as a matter of fact out of the 429 residents who are insured we transitioned their care 62 came back to our system but most importantly what we did is we enhanced the overall mental health system throughout the city so we said okay how can we improve access to psychiatric services for people throughout the community we made available half a million dollars for community mental health providers to hire more psychiatrists and as a result of that more than 5,000 psychiatric visits has happened this past year alone actually in the first three months of 2013 we said okay we know that the integration between mental health services and behavioral and substance abuse is not good enough so we invested another million dollars into community mental health providers to enhance that integration between mental health and substance abuse then we said we've never done any services for kids we know kids need behavioral health services so we've partnered with the Illinois Children's Health Care Foundation four million dollar investment into Humboldt Park and Englewood to make sure that kids in those two neighborhoods have access to be integrated primary care and behavioral health services and then we've worked with thresholds and HRDI to reopen two of our former clinics to make them available for our residents so we've enhanced the system dramatically over the last couple of years and for the folks who depended on us for services we made sure we followed them every one of them we tracked every one of them and we made sure that they follow that they continue to receive care now when it comes to today with more and more people having access to insurance you want to keep something very important in mind folks who don't have insurance have very limited options when it comes to mental health services and if we want our mental health clinics as a city agency to start accepting private insurance then those who don't have insurance are not going to have places to go to or enough places to go to so we do want to continue to be the provider of last resort especially for those who are uninsured but keep in mind that if you're our own patient and you have Medicaid and you continue to have Medicaid you're most then welcome to continue to receive services with us if you're our existing patient who is uninsured but now becomes eligible for insurance and you choose to stay with us you're most then welcome to stay with us but if you're a new patient who comes in through our door who has insurance we're going to tell you these are your options there are so many more options for you to be able to receive services but if you still want to come and receive services with us we're still going to take you so I feel like these changes we have to adapt we cannot continue to keep the status quo everything is changing in our system and if we don't change as a government and I know that everybody will tell you oh we love change, we love change the reality is people love the status quo a lot of people economic you know economic interest depends on the status quo we cannot be a status quo department we have to have the courage to change the system and improve the system for our residents there's a question here so the question about the now that more and more people will be insured there's going to be a lot need for more services and the capacity might not be there this is actually a function of the state health department we work very closely with Dr. Hasbrook and his team they just recently issued a new report around workforce and around services that kind of look at that at that balance I'll be happy to share with you that report we don't take the lead as a local health department when it comes to that you might check into the Cook County Detention Center the Chicago schools run the school in there and a lot of those kids about 60% or more have mental health issues so someone brought up the psychiatric services those might be enhanced there but I did have a question on the food carts are those what areas is there a map of those that can be viewed online not now but can people look those up there's going to be 15 more are they just in the food desert areas or are they going to be available to all of Chicago and I saw a show on hydroponics which can be put on roofs they don't use soil so the weight is much less something you could look into thank you for the suggestion when it comes to the food cart I thought I had the map here we do have the map the majority of these food carts are in low access communities the majority of the new carts that are coming up will be in low access communities and I can't tell you how important advocacy is to get these food carts to places I remember Lauren Hughes a medical student at Rush University heard about the food carts and figured that her patients around the UIC campus are not having enough access to fresh food and vegetables they can go out and find all kind of stores that are selling junk there literally she lobbied worked with the hospital administration worked with streetwise and now she has the area there has a food cart so anybody who would be interested to update the connections those have been amazing I spent time talking to these vendors it's an amazing transformation stories for them individually but most importantly to me also is the access to healthy and affordable food but if you can email me I'll be happy to share with you the map we have a question there and I think there's somebody here who would be next Any possibility you could frame the trauma center desert issue as a city of Chicago Department of Public Health issue that you could devote some resources to the trauma center issue is actually beyond our jurisdiction we don't have the capacity or the internal talent to be involved in this I know it's a state issue I know this issue keeps coming up on a regular basis but we'll be happy to be involved peripherally but really it's a state level issue I have a question we look at the health insurance plans the bronze and the silver there is often a significant amount of co-insurance that a person has to pick up or in some cases you can find a list even like Northwestern University of Chicago insurance plans are not even accepted so is there a concern that you'll see things that are positive on paper but in reality actually mean that the person has in theory insurance but it's essentially useless so you bring in a very very important question and when you think about it there are a couple of really good things about just having access to insurance period irrespective of what your deductible is or what your co-pay is the fact that preventive measures have to be covered at no cost to residents to those who are insured so this morning actually right before coming here I was at the Breast Health Summit in Roseland and one of the key challenges for women to getting mammography services even those who are insured was all along to have to pay co-pay to get a mammogram co-pay to get a physician's visit and then have to meet their deductible so this has been a huge barrier for women to getting mammography services so what we know from the Affordable Care Act all these preventive measures have to be covered no cost no co-pay not part of your deductible so that aspect I'm very very excited about but on the flip side is what you mentioned is what happens when now you have to meet a deductible of a thousand bucks or fifteen hundred bucks what happens when you know you have to receive those services but you have to come up with all these out of pocket money and this is a conversation that I'm directly involved in with federally qualified health centers so if you remember also in 2012 we partnered with federally qualified health centers and we transitioned the care of our own clinics to these federally qualified health centers and we support federally qualified health centers to deliver services in those clinics and these CEOs are telling me even when people have insurance they might prefer to pay the sliding scale rather than having to pay the co-pay and then meet their deductible and all of that in reality I don't know what the future is going to look like I think we're going to learn this year we're going to learn more next year but we'll keep an eye on how that the impact would be very very good question taking a little bit on the discussion of HPV the I've been talking to other practitioners and we're not sure if the Gardasil vaccine is with zero co-pays in most situations and then a related one you've probably seen research that suggests in black women the coverage of the current Gardasil for oncogenic HPV strains is less reliable can you address both and also that so there are a couple of things that we're working on on the HPV piece and I think the organization team was very lucky to actually have received this grant I think our focus right now has been mostly on improving systems so there are decision support tools for providers to be able to order and get girls and boys their HPV vaccine we're making some vaccines available for federally qualified health centers so for those who are uninsured and those who are under insured they would be able to have access to HPV vaccines and they should be resolved or at least should be addressed in one way shape or form I'll be happy to follow up with you separately on the access piece on the black women coverage I'm not the right person to chat about this Dr. Julie Morita will be the right person and I'll be happy to connect you with her she's our medical director for immunization but I know this is on her radar she's mentioned that to me but I don't know all the details Is there a co-pay under the Affordable Care Act for receiving the vaccine? I don't think so it's part of the preventative measures but I can double check on that The mentions of breast cancer and obesity brought to mind the significant health disparities that exist within the city of Chicago and surrounding communities I'd like to know what progress is being made to close those disparities and what impact the expansion of health insurance under ACA will really have on the ability of the public health sector to drive those disparities closed those issues is an extremely important issue and what we've this morning for example at the Breast Health Summit when you think about it black women are slightly less likely than white women to getting breast cancer but in Chicago they're one and a half times more likely to die from breast cancer if you look at Roseland and the three communities around it Beverly, Washington Park and Beverly, Washington Heights and Auburn Gresham they have the top four highest rates of premature death from breast cancer so on this issue specifically the reason why we have disparities is really three reasons one, we want to make sure that more and more black women are getting screened we want to make sure that these black women are getting screened with high quality mammograms and not just the analog machines but also digital machines and good appropriate radiologists reading the reports and you want to shrink the time it takes to diagnose a black woman with breast cancer you want to shrink that time between she's diagnosed and she's linked to care so on this specific issue our approach has been how can we resolve these three pieces and can we close the disparities gap by working on this so I had that same exact conversation with the mayor a few months ago and as a result of that we've invested $200,000 with Roseland Community Hospital to expand access to 1500 women to get access to mammography services so the screening piece we know that Roseland Hospital was able to secure a grant to get an upscale digital mammography machine so it's not the good old analog machine and we know that they're working with the metropolitan breast cancer task force to have navigators on site so when they're diagnosed a woman with breast cancer this woman is linked directly into care so for each one of these disparities there's a different approach that we're taking and if you look at healthy Chicago and the strategies that we've developed they were really developed with that lens in mind how do you close disparities gap so that's really the way I look at healthy Chicago is really our most aggressive assault as a city on disparities and we're starting to see some moving the needle on those disparities but it takes a time to move the needle on those disparities and keep in mind you know I think to really make a difference on disparities all these public health interventions are nice and dandy but unless we go to the basic social determinants of health we empower people to get better education we empower people to get out of poverty we empower people to get better jobs until we work on these social determinants of health all of our equity work is not going to be good enough to be able to close disparities gap but those metrics that we track really look directly into disparities issues going back to the produce cards I think that's such an exciting program and I was wondering if you're looking at more ways to further economic and workforce development through public health initiatives. The short answer to this is no unfortunately the you know we work as close as we can with the Department of Planning and Economic Development in the city and this was you know it took a long time to get this project up and running and I don't know about you but this is my first government job and I'm realizing very I've realized very quickly that things don't happen very easily and you have to be you know very patient I'm getting things done I don't I'm not aware of any specific workforce development project that ties in directly into public health I know there are a few state level initiatives I know there's a community health worker bill right now and the and the in Springfield that's kind of making its way that would eventually create a new group of you know legitimize a good really hard-working group of public health workers in our communities but I don't think we're directly involved in anything else at this point so I'll ask you a local question Commissioner so here one of your last slides you had public health and medical care and integration so here at the University of Chicago there's been a lot of talk now about doing population health management so moving ahead what do you see as some of the most promising ways that the Department of Public Health might collaborate with the University of Chicago looking at our catchment area and population actually one of the areas that are most excited about in public health and you know when people ask me why you've been there for four years this is your fifth year why are you still there and I you know my question is there are two areas in public health that are extremely exciting right now it's that intersection between public health and economic development and we're doing a lot of work with LISC and the LISC communities and the new communities programs and others and you know I've had multiple round table discussions with folks at Woodlawn and the intersection is extremely interesting and I think the other part is the intersection between public health and clinical medicine so we're working on different projects right now I know the University of Chicago we work with you very closely on the diabetes translational research project to build the right infrastructure so that we have better surveillance for diabetes that we could be of support to academicians but also to the community with Northwestern we're working on a keep your heart healthy project where we are in two communities North Londale and in Humboldt Park on trying to identify individuals at high risk for cardiovascular disease and link them to care this is funded by the GE foundation and it started as a pilot program very soon we're going to announce a significant expansion to this funding opportunities and expanding to more communities our work with the University of Illinois around asthma repetitive asthma visitors to the emergency department is another example we are now piloting a project with rush around using technology to be able to connect what kids are eating in schools and can we use that as a way to make sure that we're changing behavior so I think there are a lot of opportunities with hospital systems with the community health needs assessments that hospital has to do there are a lot of opportunities there I know healthcare systems have to be part of or will be part of accountable care entities and those entities have to be looking into population health very clearly so there's tons and tons of opportunities the challenge is how do we have the bandwidth to do this type of work so from the department side we built the infrastructure specifically for that so we have now chief innovation and strategy officer who you know Dr. J. Baud who's working specifically on this area to see how we can leverage those relationship Dr. Julian Owinski who joined the department also leading that type of effort Dr. Arlene Hankinson who's joined the department and how those intersections can get better so far to be honest with you we've been very pragmatic when we see opportunities we see funding opportunities we have the right partners we jump in that's why these types of conversations are very helpful to build those type of connections and when opportunities come up we apply for funding your talk was wonderful you talked for an hour with a wealth of information and I didn't count one single thing but thank you very much for a great talk thank you I do run every morning so far I get plenty of breaths running I did five miles this morning so I'm good thank you big hand for Dr. Steer thank you so much for having me