Public Health 2030: Scenarios for the Boston Public Health Commission

1. Public Health 2030: Scenarios for the Boston Public Health Commission

2. The Public Health 2030 Scenario Effort Conducted by the Institute for Alternative Futures. Funded by the Robert Wood Johnson Foundation and the Kresge Foundation to: • Explore key forces shaping public health • Consider the future of public health functions, financing & sustainability • Build expectable, challenging & visionary scenarios that facilitate preparation, imagination & aspiration • Provide & widely distribute the scenarios as a tool for public health agencies, organizations & schools

3. Scenario Zones Visionary/Surprisingly Successful Expectable Challenging

4. Public Health 2030: Scenarios for the Boston Public Health Commission Scenario 1 Smarter Public Health, Missed Opportunities Scenario 2 Under Water Scenario 3 Public Health as Chief Health Strategist Scenario 4 A Renaissance of Civic and Social Responsibility

5. Scenario 1: Smarter Public Health, Missed Opportunities Highlights

6. Scenario 1: Smarter Public Health, Missed Opportunities Boston economy grows in tandem with national economy. • Mild national recessions in 2015 and 2022 • Periodic federal and state cuts and program eliminations

7. Scenario 1: Smarter Public Health, Missed Opportunities Climate change: increased sea-level rise, summer heat waves, and increased storm intensity and/or frequency.

8. Scenario 1: Smarter Public Health, Missed Opportunities 2018 Hurricane • Called Boston's Hurricane Katrina • Evacuations OK but with disparities in recovery

9. Scenario 1: Smarter Public Health, Missed Opportunities In health care, 98% + access to care, and most care is integrated and capitated. • More people are effectively assessed and even treated at home, yielding health care savings • Hospitals deploy community health workers (CHWs)

10. Scenario 1: Smarter Public Health, Missed Opportunities In health care, 98% + access to care, and most care is integrated and capitated. • Large health care provider systems routinely improve neighborhood conditions

11. Scenario 1: Smarter Public Health, Missed Opportunities In health care, 98% + access to care, and most care is integrated and capitated. • Doc Watson, digital health coaches common “Dr. Watson” for Public Health Digital coach (“avatar”)

12. Scenario 1: Smarter Public Health, Missed Opportunities In health care, 98% + access to care, and most care is integrated and capitated. • BPHC retains its hold on homeless, addictions, and emergency medical services (EMS)

13. Scenario 1: Smarter Public Health, Missed Opportunities Surveillance, emergency prep, analyses improve. • City integrates surveillance systems, Internet of Things

14. Scenario 1: Smarter Public Health, Missed Opportunities Surveillance, emergency prep, analyses improve. • BPHC uses games, digital coaches, and simulations to improve health education and emergency preparedness, mitigation, and recovery Personal Health Advocate Avatar V2.1

15. Scenario 1: Smarter Public Health, Missed Opportunities Surveillance, emergency prep, analyses improve. • BPHC more effectively analyzes and targets community conditions shaping health

16. Scenario 1: Smarter Public Health, Missed Opportunities But ACOs create their own epidemiology or population health units, turn to universities and private companies for most advanced analytics.

17. Scenario 1: Smarter Public Health, Missed Opportunities Key Outcomes • Challenging for BPHC to consistently prove its value to HC and get recognized for advisor and convener roles • BPHC achieves 3 overarching goals in obesity, low birth-weight babies, and chlamydia

18. Scenario 1: Smarter Public Health, Missed Opportunities Key Outcomes • Fundamental problems of poverty, social exclusion and homelessness remain • BPHC forced to do more with less funding and fewer staff

19. Scenario 2: Under Water Highlights

20. Scenario 2: Under Water Boston faces serious municipal finance challenges. • City’s economic health & revenue drops • National 2016 recession • 2018 superstormhits Boston • Reduction in resident students; Decline of Boston education sector

21. Scenario 2: Under Water Over time, cuts leave BPHC to focus on: • infectious disease control and prevention • emergency preparedness • emergency medical services • homeless and addiction services.

22. Scenario 2: Under Water Health worsens especially for working poor. • Federal health reform was only partially implemented, partially repealed

23. Scenario 2: Under Water Health worsens especially for working poor. • Addictions funding is integrated into primary care, demand for mental health services increases • But payment reductions and provider shortages disproportionately affect the poor Shortage of primary care providers

24. Scenario 2: Under Water Health worsens especially for working poor. • Digital health coaches and “virtual doctor” services grow but vary in quality

25. Scenario 2: Under Water Climate change and superstorm drain resources, leave significant physical and economic damages. • Hotter summers and related droughts, more intense storms throughout the year, greater potential for infectious diseases and mold

26. Scenario 2: Under Water Climate change and superstorm drain resources, leave significant physical and economic damages. • Full recovery from superstorm takes years

27. Scenario 2: Under Water Climate change and superstorm drain resources, leave significant physical and economic damages. • BPHC improves ability to forecast and warn about, for example, likely asthma attacks by neighborhood. • But this often does not lead to earlier response and prevention because of resource constraints

28. Scenario 2: Under Water BPHC struggles to be effective and heard. • Big Data - Corporations and health care providers hire skilled analysts to do their own big data analytics • Big Data - BPHC has to work with growing volume of data with large blind spots for low-income people and people of color

29. Scenario 2: Under Water BPHC struggles to be effective and heard. • Public health messaging is tuned out among proliferating competition in a variety of channels, ads, and communications

30. Scenario 2: Under Water Key Outcomes • Health gaps between the "haves" and "have-nots" worsens • Little to no community prevention • stymied by challenges in funding • difficulties in recruiting cross-sectoral partners • lack of political will

31. Scenario 3: Public Health as Chief Health Strategist Highlights

32. Scenario 3: Public Health as Chief Health Strategist Boston becomes a beacon for the rest of the nation in successfully improving health equity and racial justice. • Nationally, strong economic recovery; Prevention Fund restored; “Health in all policies” movement takes hold • By 2016, MA passes a living wage law with automatic cost-of-living adjustments • Boston’s citywide long term vision for health

33. Scenario 3: Public Health as Chief Health Strategist Health care integrates equity lens into clinical practice and outcomes, performance assessments and quality improvement activities. • Near-universal coverage in the state, excellent care • Systematic screening for health and SDH factors and needs lead to shared investments and programs in systemic solutions for violence prevention and health

34. Scenario 3: Public Health as Chief Health Strategist Health care integrates equity lens into clinical practice and outcomes, performance assessments and quality improvement activities. • Digital health coaches, social networks, games and simulations guide users toward healthy behaviors • Demand for EMS services declines with improved care, services, and prevention Prevention Digital health agents, gaming, social networking

35. Scenario 3: Public Health as Chief Health Strategist Mapping, games, and simulations facilitate community engagement and planning. • BPHD develops health dashboards for each community to track progress • Virtual simulations and games of Boston’s health allow for exploration and consideration of emergency scenarios and fair access to opportunities for health.

36. Scenario 3: Public Health as Chief Health Strategist BPHC uses its convening powers and connections to identify and accelerate promising opportunities and evidence-based practices, initiatives, and policies. • BPHC functions as health equity and health promotion coach for Boston government. • Enhances and leads effective community health endeavors.

37. Scenario 3: Public Health as Chief Health Strategist Key Outcomes • Health equity and racial justice improve. • Widespread community engagement. • Boston’s government becomes a role model. • BPHC is widely recognized as the City’s chief health strategist.

38. Scenario 4: A Renaissance of Civic and Social Responsibility Highlights

39. Scenario 4: A Renaissance of Civic and Social Responsibility Constraints fuel creativity. • Nationally, unemployment remains high, another major recession in 2017 is followed by slow and uneven recovery

40. Scenario 4: A Renaissance of Civic and Social Responsibility Constraints fuel creativity. • Growing excitement around innovative health-improving technologies and vibrant social movement of “civic hacking” (including development of apps to help people manage their health)

41. Scenario 4: A Renaissance of Civic and Social Responsibility Constraints fuel creativity. • BPHC uses prizes and current funding sources to accelerate innovations and save costs

42. Scenario 4: A Renaissance of Civic and Social Responsibility Publicly available simulations and comprehensive data: • Enhance impact assessments and evaluations • Improve policy design • Facilitate funding streams

43. Scenario 4: A Renaissance of Civic and Social Responsibility Health care often presses beyond clinical needs to improve population health. • Virtually all Bostonians gain access to effective health care • Most care is provided through integrated and capitated ACOs

44. Scenario 4: A Renaissance of Civic and Social Responsibility Triple Aim Health care often presses beyond clinical needs to improve population health. • BPHC joins ACOs and other providers in population and community health endeavors, often as a leader and/or coach • Demand for EMS, homeless, and addiction services declines Community Centered Health Home

45. Scenario 4: A Renaissance of Civic and Social Responsibility Key Outcomes Many BPHC functions are taken on by other institutions and consumers; BPHC increasingly shifted to emphasize its role in capacity-building, mapping, and incentivizing the development of public- and private-sector solutions and consumer tools.

46. Scenario 4: A Renaissance of Civic and Social Responsibility • BPHC's successes inspire other Boston agencies and organizations. • BPHC monitors innovations and assures community representation in the innovation process.

47. Scenario 4: A Renaissance of Civic and Social Responsibility Key Outcomes • Health equity and racial justice improve • Innovation platform provides sophisticated decision-making tool that is inclusive of all Bostonians

48. Scenario 4: A Renaissance of Civic and Social Responsibility Key Outcomes • Many BPHC functions are performed to large extents by other institutions, public- and private-sector solutions, and consumer tools • Widespread community engagement, innovation platform provides sophisticated decision-making tool that is inclusive of all Bostonians

49. See the scenario matrix for a side-by-side comparison of the scenarios across multiple dimensions

50. Rate the Likelihood & Preferability of Each Scenario