Transcript Slide 1

Dennis P. Andrulis, PhD, MPH
Senior Research Scientist
Texas Health Institute
&
Associate Professor
University of Texas School of Public Health
Advancing Equity through Health Care Reform:
A State-Federal Discussion of Promising State Policies
National Association of State Health Policy (NASHP)
May 31, 2012 | Washington, D.C.

ACA’s Vision, Promise and Background

Monitoring and Tracking Design
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Status of Diversity & Equity Provisions
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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.
2008
• Series of analyses of House & Senate Health Reform Bills (Joint Center)
2010
• Report entitled, Patient Protection and Affordable Care Act of 2010:
Advancing Health Equity for Racially and Ethnically Diverse Populations
(Joint Center)
2011
• Report on Federal Progress on Cultural & Linguistic Competence Specific
Provisions of ACA (SRA International)
2012
• Tracking Implementation Status and Progress of ACA’s Provisions Specific
to & with Major Implications for Racial/Ethnic Health Equity
(W.K. Kellogg, Kaiser Permanente, The California Endowment)
Tracking will continue into 2013.
Tracking 62 provisions specific to race, ethnicity, language and
diversity as well as general provisions with major implications
for racially and ethnically diverse populations.
Overall Level of Progress
Health Insurance
Safety Net
Workforce
Quality & Research
Public Health & Prev.
Good
Moderate
Poor
Provisions 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

For each of the 62 provisions, we are conducting:
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▪
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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:
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National experts and advocates
Representatives from federal and state government
Representatives from racial/ethnic organizations
Health plans, hospitals, health centers and other grantees
Overall Level of Progress
Good
Non-discrimination in Federal Programs
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Use of Plain Language in Health Plans
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Moderate
Poor
State Exchanges
- C/L Summary of Benefits
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- C/L Info. & Navigators in Exchanges
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- C/L Claims Appeals Process
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Remove cost-sharing for AI/AN
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Market Incentives for Reducing Disparities
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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.
13 States & DC with Legislation to Establish Exchanges, as of May 2012
NH
WA
VT
MT
ND
AK
MN
OR
ID
NY
WI
SD
WY
RI
CT
MI
PA
IA
NE
NV
IL
UT
CO
CA
OH
IN
WV
IA
KS
MO
TN
OK
NM
TX
WV
NC
VA
SC
AR
MS
HI
VA
KY
IL
AZ
ME
AL
GA
LA
FL
State exchange in existence prior to
passage of ACA
Legislation signed into law post-passage of ACA
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.
NJ
DE
MD
DC
MA
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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.
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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…
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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
Overall Level of Progress
Good
Community Health Center
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Other Health Centers Support*
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Non-Profit Community Benefit
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Moderate
Poor
Primary Care Extension Program
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Community Health Teams
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* Comprised of Nursed-Managed Centers, School-Based Health Centers, Teaching Health Centers
Note: We are also tracking Reductions to Medicare/Medicaid DSH Program and its Implications for
Diverse Patient Populations.
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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.”
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Opportunities:
 Involve community to identify & prioritize unmet needs
 Encourage collaboration in health care community
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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.”
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$18 billion reduction phased in 2014-202010 in Medicaid disproportionate
share hospital program—which finances 22% of unreimbursed care at
public hospitals
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State/local safety-net financing possibly in jeopardy due to antipathy
toward undocumented and myth that “uninsured problem is solved”
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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
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Risks to safety net’s ability to compete for newly insured patients and
participate in systems innovation
Overall Level of Progress
Good
Increasing Diversity Among Providers 1
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Health Professions Training for Diversity
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Redistribute Graduate Medical Education Slots
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Moderate
Community Workforce Infrastructure Investments 2
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Collect & Publicly Report Data on Workforce Diversity
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Poor
Cultural Competence Training in Health Professions3
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Model Cultural Competence Curricula
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Community Health Workers
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1.
2.
3.
Includes support for: primary care physicians; long term care providers; dentists; mental health
providers; and nursing professions.
Includes: National Health Services Corps; loan repayment; & investments in AHECS & HBCUs.
Includes: cultural competence training for home care aides & pain care providers & other professions.
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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
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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
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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
Overall Level of Progress
Good
Data by Race, Ethnicity & Language
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Patient-Centered Outcomes Research Institute
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NIMHHD & OMHs in HHS Agencies
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Hospital Value-Based Incentive Program
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Moderate
National Quality Strategy & Interagency Group
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Centers of Excellence
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Health Impact Assessments
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Develop, Improve & Evaluate Quality Measures
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Poor
Disparities Research in Post-Partum Depression
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Cultural Competency Research
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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.
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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
Overall Level of Progress
Good
Community Transformation Grants
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Maternal & Child Home Visiting
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Personal Responsibility Education
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Reauthorization of Indian Health Care Improv. Act
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National Prevention Strategy & Fund
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Obesity, Diabetes, Cancer Programs
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Moderate
Poor
National Oral Health Campaign
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Culturally Appropriate Decision Aids
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61 Awards to 36 States
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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
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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 ???
Creating Healthy
Communities
• Leveraging support for community
initiatives.
• Promoting an integrated approach to
health and social services.
Transitioning
Health Care
Organizations
• Supporting the safety net to update
infrastructure and participate in system
innovations.
• Ensuring diversity and equity are
organizational priorities.
Promoting
Individual
Health
• Ensuring adequate provider education on
cultural competence to enhance patient
adherence.
• Creating effective care or self-management
programs for diverse patients.
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, 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 Rascati Cooper, MA
Health Policy Analyst, Texas Health Institute
Lauren Jahnke, MPAff
Consultant, LRJ Research & Consulting
Ebbin Dotson, PhD
Executive Director, Adjunct Professor
University of Texas School of Public Health
For inquiries, please contact Dr. Andrulis ([email protected]) or
Nadia Siddiqui ([email protected]).