Dennis P. Andrulis, PhD, MPHSenior Research Scientist

Texas Health Institute&

Associate ProfessorUniversity of Texas School of Public Health

Advancing Equity through Health Care Reform: A State-Federal Discussion of Promising State PoliciesNational Association of State Health Policy (NASHP)

May 31, 2012 | Washington, D.C.

ACA’s Vision, Promise and Background Monitoring and Tracking Design Status of Diversity & Equity Provisions

▪ Health Insurance Exchanges▪ Safety Net▪ Workforce Diversity▪ Public Health & Prevention▪ Research, Data and Quality

Where do we go from here?

Working to eliminate health disparities and advance health equity is central to the Affordable Care Act (ACA) of 2010.

Over three dozen provisions that directly address disparities, diversity and cultural/linguistic competence.

Dozens of other provisions with major implications for racial/ethnic disparities and equity.

Tracking will continue into 2013.

Good Moderate Poor

Health InsuranceProvisions well on their way in

implementation – e.g., final rules

issued, research, service or

demonstration grants awarded

Provisions in starting phases

of implementation–

e.g., interim rules issued, RFPs/RFAs

announced, planning grants

awarded

Provisions not yet

implemented due to timeline,

without appropriations, and/or being

contested in the Supreme Court

Safety Net

Workforce

Quality & Research

Public Health & Prev.

Overall Level of Progress

Tracking 62 provisions specific to race, ethnicity, language and diversity as well as

general provisions with major implications for racially and ethnically diverse populations.

For each of the 62 provisions, we are conducting:▪ Extensive analysis of legislative language in ACA▪ Analysis of federal registry, policy reports, peer-review

literature▪ Review of related national, state, local models & best-

practices▪ Review of early successes and lessons learned▪ Opportunities and challenges

To fill gaps, we are conducting interviews with:▪ National experts and advocates▪ Representatives from federal and state government▪ Representatives from racial/ethnic organizations▪ Health plans, hospitals, health centers and other grantees

GoodModera

te Poor

Non-discrimination in Federal Programs

√

Use of Plain Language in Health Plans

√

State Exchanges

- C/L Summary of Benefits √

- C/L Info. & Navigators in Exchanges

√

- C/L Claims Appeals Process √

Remove cost-sharing for AI/AN √

Market Incentives for Reducing Disparities

√

Overall Level of Progress

Note: Other broader provisions not listed here but that we are tracking to understand their implications for diverse communities include: Medicaid expansion; large and small employer provisions; high risk pools; individual mandate and CHIP reauthorization.

TX

FL

NMGA

AZ

CA

WY

NV

AK

OK

MSLA

MT

TN

Adapted from: National Conference of State Legislatures, Federal Health Reform: State Legislative Tracking Database. http://www.ncsl.org/default.aspx?TabId=22122; Politico.com; Commonwealth Fund Analysis.

WA

ORID

SD

ND

MNWI

MI

IA

AR

IL

OH

WVVA

AL

PA

NY

ME

MA

NHVT

HI

Legislation signed into law post-passage of ACA

UTCO

KS

NEIA

MO

ILIN

KY

WVVA

NC

SC

DCMD

DE

NJ

CTRI

State exchange in existence prior to passage of ACA

13 States & DC with Legislation to Establish Exchanges, as of May 2012

C/L Summary of Benefits & Uniform Glossary Final Rules & Guidance:

▪ C/L summaries when >10% of population in county literate in same non-English language

▪ Existing template & glossary in English, Spanish, Tagalog, Chinese and Navajo

Models: ▪ Kaiser Permanente and its Virtual Translation Center; ▪ NY’s Medicaid Managed Care Plan provides translated documents if >5% of county’s

population speak the same foreign language.

C/L Internal & External Claims Appeals Processes Interim Final Rules:

▪ 10% threshold for C/L; ▪ Oral interpretation requirement for assistance in filing claims and appeals.

Models: ▪ LA Care which has an online repository of translated claims & appeals documents.

continued…

C/L Information, Outreach and Navigators Final Rules:

▪ Application, forms , notices, outreach & education must meet plain language standards;

▪ Must also indicate availability of language services in translated taglines; ▪ C/L competence of navigators in enrollment, providing referrals, handling

complaints, conducting outreach and other functions.

Forthcoming Rules: ▪ Standards for C/L competency of navigators.

Models:▪ California State Exchange is planning outreach campaigns targeting

Latinos, African Americans and other racial/ethnic minorities along with a statewide C/L competent Consumer Assistance Program

GoodModera

te Poor

Community Health Center √Other Health Centers Support* √Non-Profit Community Benefit √Primary Care Extension Program

√

Community Health Teams √

Overall Level of Progress

* Comprised of Nursed-Managed Centers, School-Based Health Centers, Teaching Health CentersNote: We are also tracking Reductions to Medicare/Medicaid DSH Program and its Implications for Diverse Patient Populations.

IRS Guidelines: Specifies that the assessment represent broad interests of the

community including input from “leaders, representatives, or members of medically underserved, low income, and minority populations, and populations with chronic disease needs, in the community served by the hospital facility.”

Opportunities: Involve community to identify & prioritize unmet needs Encourage collaboration in health care community

Models (California’s Tulare Regional Medical Center): Qualitative data from five focus groups was compiled into 6 key areas

for action, which included Culturally and Linguistically Appropriate Services.

“Specific attention needs to be paid to improving healthcare experiences and promoting better adherence to medical recommendations for the Valley’s culturally diverse residents.”

$18 billion reduction phased in 2014-202010 in Medicaid disproportionate share hospital program—which finances 22% of unreimbursed care at public hospitals

State/local safety-net financing possibly in jeopardy due to antipathy toward undocumented and myth that “uninsured problem is solved”

Financial pressures on safety-net in caring for 52 million uninsured between now and 2014, given growth in uncompensated care, low profit margins, and location of many in high-poverty areas

Risks to safety net’s ability to compete for newly insured patients and participate in systems innovation

GoodModerat

e Poor

Increasing Diversity Among Providers 1 √

Health Professions Training for Diversity √

Redistribute Graduate Medical Education Slots √

Community Workforce Infrastructure Investments 2

√

Collect & Publicly Report Data on Workforce Diversity

√

Cultural Competence Training in Health Professions3

√

Model Cultural Competence Curricula √

Community Health Workers √

Overall Level of Progress

1. Includes support for: primary care physicians; long term care providers; dentists; mental health providers; and nursing professions.

2. Includes: National Health Services Corps; loan repayment; & investments in AHECS & HBCUs.

3. Includes: cultural competence training for home care aides & pain care providers & other professions.

To date, $1.25 Billion of Prevention Fund dollars have been used to fund a variety of health-related programs with workforce and community-based health care interventions

▪ $1 Billion for 2012 in question

In all States, the federal government spent $198 M last year to create new residency positions for primary care doctors and ramp up training capacity for physicians

Trust for America’s Future

California, Texas, New York, Illinois, Florida Total ACA Funds Used - $1.26 Billion $32.6 M for health professions workforce demonstration

projects, which will help low income individuals receive training and enter health care professions that face shortages.

$7.2 M for the expansion of the Physician Assistant Training Program, a five-year initiative to increase the number of physician assistants in the primary care workforce.

$2.55 M to support teaching health centers, creating new residency slots in community health centers.

$1.4 M to support the National Health Service Corps, by assisting in repaying educational loans of health care professionals in return for their practice in health professional shortage areas.

Healthcare.gov – 3/15/2012

GoodModera

te Poor

Data by Race, Ethnicity & Language √

Patient-Centered Outcomes Research Institute

√

NIMHHD & OMHs in HHS Agencies √

Hospital Value-Based Incentive Program √

National Quality Strategy & Interagency Group

√

Centers of Excellence √

Health Impact Assessments √

Develop, Improve & Evaluate Quality Measures

√

Disparities Research in Post-Partum Depression

√

Cultural Competency Research √

Overall Level of Progress

Health Disparities is 1 of 5 PCORI Priorities – Draft Research Agenda includes a focus on comparative effective research to: Reduce disparities in health outcomes Assess benefits/risks of treatment Identify strategies to overcome barriers such as culture and

language Identify best practices for racial/ethnic sub-populations.

Release of PCORI Funding Announcement (PFA) related to Disparities (Deadline: July 21, 2012) Anticipate to fund 14 contracts totaling $12 million Awards for “studies that will inform the choice of strategies to

eliminate disparities” See: http://www.pcori.org/assets/PFA-Addressing-Disparities-05222012.pdf

GoodModera

te Poor

Community Transformation Grants √

Maternal & Child Home Visiting √

Personal Responsibility Education √

Reauthorization of Indian Health Care Improv. Act

√

National Prevention Strategy & Fund √

Obesity, Diabetes, Cancer Programs √

National Oral Health Campaign √

Culturally Appropriate Decision Aids √

Overall Level of Progress

61 Awards to 36 States

35 Implementation Grantees: All intend to address low-income populations > 50% intend to target African Americans & Hispanics/Latinos 1 in 3 will address health issues of American Indians/Alaska

Natives Nearly all target children & 1 in 5 will address older adults

26 Capacity-Building Grantees: Establish or strengthen community coalitions Conduct community health assessments, including diverse

populations Develop community-based solutions that also address disparities

??? Supreme Court Decision ???

For many health equity objectives in ACA, the seeds have been sown. It is the opportunities that need to be seized.

Dennis P. Andrulis, PhD, MPHSenior Research Scientist, Texas Health Institute

Associate Professor, University of Texas School of Public Health

Nadia J. Siddiqui, MPHSenior Health Policy Analyst, Texas Health Institute

Maria Rascati Cooper, MAHealth Policy Analyst, Texas Health Institute

Lauren Jahnke, MPAffConsultant, LRJ Research & Consulting

Ebbin Dotson, PhDExecutive Director, Adjunct Professor

University of Texas School of Public Health

For inquiries, please contact Dr. Andrulis (dpandrulis@gmail.com) or Nadia Siddiqui

(nsiddiqui@texashealthinstitute.org).