Realizing the Vision of Health Equity in the Affordable Care Act: Assessing Progress & Building Opportunities for the Future

Dennis P. Andrulis, PhD, MPH Senior Research Scientist, Texas Health Institute Associate Professor, UT School of Public Health & Nadia J. Siddiqui, MPH Senior Health Policy Analyst, Texas Health Institute 141 st Annual APHA Meeting, November 4, 2013, Boston, MA Project Support: WK Kellogg Foundation, The California Endowment, & Kaiser Permanente

ACA & Racial and Ethnic Health Equity Series 5 Reports, Nearly 60 Provisions on Advancing Equity Report 1: Health Insurance Marketplace Report 2: Health Care Safety Net Report 3: Health Care Workforce Report 4: Public Health & Prevention Report 5: Research, Quality & Innovation

- Culturally & linguistically appropriate marketing, outreach, and education - Non discrimination - Special provisions for American Indians - Medicaid - CHIP - Health Centers - DSH Payments - Community Health Needs Assessment - Primary Care - Underserved Areas - Workforce Diversity - Cultural Competence - National Healthcare Workforce Commission - Prevention & Public Health Fund - CTGs - Obesity - Cancer - Diabetes - Oral Health - American Indian Health - National Quality Strategy - PCORI - NIH/NIMHD - CMS Innovation - ACOs - Medical Homes - Agency OMHs - Race/Ethnicity Data Standards

ACA’s Overall Progress on Advancing Equity Health Insurance Marketplace Safety Net Workforce Diversity Data, Research, Quality Public Health & Prevention Total More Fully funded or Implemented 7 3 7 4 6 27 (48%) Partially Funded or Implemented Not Funded or Implemented 0 1 3 6 3 4 16 (29%) 1 6 4 1 13 (23%) 8 7 19 11 11 56

ACA Status & Implications for Advancing Health Equity as we Approach 2014

Health Insurance Marketplaces

Projected Enrollees by Race & Ethnicity

42% or over 12 million Non-Whites 25% will speak a language other than English at home 6% 25% 11% 58%

White Black or African American Hispanic or Latino Other Source: KFF.

A Profile of Health Insurance Exchange Enrollees, March 2011.

How Are Marketplaces Addressing Disparities?

Source: Andrulis DP, Jahnke LR, Siddiqui NJ, and Cooper MR. Implementing Cultural and Linguistic Requirements in Health Insurance Exchanges, 2013. Texas Health Institute: Austin, TX. Available at: http://www.texashealthinstitute.org/health care-reform.html

Medicaid Expansion:

Projected Eligible by Race and Ethnicity

• •

6.8 million or 45% of New Medicaid Eligible are Non-White.

* In 29 States Moving toward Expansion, 3.8 million Non-Whites .

**

Percent of Population with Income below 138% FPL who will be Eligible for Medicaid in 2014, by Race and Ethnicity 54,9% 19,4% 18,7%

White Hispanic or Latino African American

7,0%

Other *Source: Kenney, G.M., Zuckerman, S., Dubay, L., Huntress, M., Lynch, V., Haley, J., & Anderson. (2012). Not

Opting in to the Medicaid Expansion under the ACA: Who are the Uninsured Adults Who Could Gain Health Insurance Coverage? Timely Analysis of Immediate Health Policy Issues

. Robert Wood Johnson Foundation and Urban Institute.

**Data extrapolated from Kenney et al., 2012.

ACA Capacity Initiatives to Meet New Demand Minority Health Professions

(HBCUs)

Enhance Capacity in Underserved Areas

(NHSC)

Health Center Support

(FQHCs, NMHC, School & Teaching Health Centers)

Primary Care Workforce Support Enhancing Capacity Payment & Delivery Innovations

(ACOs, PCMHs, 1115 Waivers)

Access to Care in the Safety Net

Challenges to Advancing Health Equity through the ACA

1. Funding & Sustainability

• More than half of the provisions received substantially less than authorized or no funding from the ACA.

• Declining support for minority health and health professions.

– HCOP & COE programs – HHS’ minority health initiatives • Uncertain support for sustaining public health & prevention initiatives.

2. Political Antipathy

Antipathy toward the law may thwart progress to advance equity in many states.

• Antagonism to Marketplace • In states not expanding Medicaid… – 2 million, low-income diverse individuals will fall through cracks – 60% of uninsured African Americans in states not expanding – 44% of uninsured Hispanics in states not expanding • Undocumented immigrants left at margins • Misinformation, and confused & reluctant consumers generally; for some, language barriers.

Billboard on 42

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St. Near Times Square

3. Time

• ACA’s broader provisions are priority, but will equity issues be integrated?

– Health insurance marketplaces – Medicaid expansion • Measurable outcomes in short run (2-3 years) – Patient Centered Outcomes Research Institute – CMS Innovation Center • Cultivating partnerships and collaborations takes time not available under many ACA provisions.

4. Equity is Not a Priority

• Implementing ACA’s insurance provisions takes center stage, likely to limit attention to equity and diversity.

• Many minority health & underrepresented minority health professions provisions with declining support.

• Cultural competence is not a priority – almost no support!

• How to reframe equity in context of mainstream priorities?

2014 & Beyond: Actions and Opportunities for Advancing Equity

1. Monitoring & Adapting Marketplace Implementation to Advance Equity

• “Window of Opportunity” to advance equity given support & attention to marketplaces .

• Equity must be integrated early on & be ongoing: – Leadership & governance – Navigator & assister recruitment & training – Outreach & enrollment – Language services and assistance – Community engagement – Measurement & evaluation

Variation in Marketplaces & Implications for Equity

• Most Progressive , with both Medicaid expansion and state-run Marketplace.

• Somewhat Progressive , with Medicaid expansion and/or state-run or partnership Marketplace, in challenging political environment.

• Least Progressive , opposed to the ACA with federal Marketplace and/or no Medicaid expansion .

2. Addressing Gaps in Access & Capacity to Meet Needs of a Growing Diverse Patient Population

• Assisting in transitioning the safety net – Infrastructure support for delivery & payment reform – Actions to support care for remaining uninsured – Monitoring & reassessing DSH payment reductions – Tracking 1115 waiver innovation and potential models • Supplementing existing workforce support – Supply of providers in underserved & diverse areas – Minority-serving institutions & HBCUs – Health professions programs for under-represented minorities – Cultural competency education & training

3. Building on ACA’s Community-Based Initiatives to Engage and Reach Diverse Communities

• Offers opportunity to break new ground in bringing communities more directly into health and health care programs. • Offers direct role for philanthropy and private sector to leverage and expand, sustain, and evaluate community efforts.

4. Advancing Metrics, Measuring, & Monitoring

• Monitoring ACA programs for impact, outcomes, and effectiveness by race & ethnicity – Marketplace implementation – Enrollment in exchanges & Medicaid – Navigator & assister programs – DSH payment reduction impacts • Texas Health Institute to develop Report Card on Implementation Progress of Marketplace Initiatives for Advancing Racial & Ethnic Equity

5. Education & Advocacy for Advancing Equity

• Community forums to educate audiences on the ACA & opportunities to bridge disparities.

• State and local forums on “how to” effectively integrate diversity and equity into various ACA supported activities.

• Continued advocacy around key disparities priorities: – Oral health disparities – Cultural competency education – Minority health professions programs

Closing Remarks

• Many provisions in place to advance equity.

• BUT time, dollars, launch challenges, misinformation, and active and passive resistance to the law threaten to deflect resources and delay or diminish the law’s equity vision and potential.

• Need for active advocacy and efforts to keep equity high on the health care reform agenda and across priorities reflected in the ACA.

Our Health Care Reform & Equity Team

Dennis P. Andrulis, PhD, MPH

Senior Research Scientist, Texas Health Institute Associate Professor, University of Texas School of Public Health

Nadia J. Siddiqui, MPH

Senior Health Policy Analyst, Texas Health Institute

Maria R. Cooper, MA

Health Policy Analyst, Texas Health Institute

Lauren Jahnke, MPAff

Consultant, LRJ Research & Consulting

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Website: http://www.texashealthinstitute.org/health-care-reform.html