Transcript Slide 1

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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
Session 4286. Implementing Health Equity 2020 at the Frontline
APHA 139th Annual Meeting and Exposition
Washington, DC | November 1, 2011
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Overview
• ACA’s Vision, Promise and Background
• Status of Diversity, Cultural Competence & Equity
Provisions
• State and Local Actions and Initiatives
• Continuing and Growing Challenges
• Moving Forward
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ACA’s
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and Promise
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• 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.
Track Record of Analyzing Health Care Reform with a
Disparities title
and Health
ClickRacial/Ethnic
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styleEquity Lens
Aug 2008*
Comparative
Report on
Health Reform
Proposals of
Obama vs.
McCain
2008
2009*
Analysis
of House
& Senate
Health
Reform
Bills
Jan 2009
President Obama
inaugurated
July 2010*
Release of
Comprehensive
Report on ACA &
Health Equity
May 2011†
Report on
Progress &
Status of
ACA’s
Cultural
Competence
Provisions
Oct 2011
Health
Affairs
article on
ACA,
Safety Net
& Diversity
2011 – 2013§
Tracking
Implementation
Progress,
Opportunities &
Challenges for
Health Equity &
Diverse
Populations
2013
Mar 2010
ACA Enacted
* Supported by Joint Center for Political and Economic Studies.
† Supported by SRA International.
§ Supported by The California Endowment & other foundations.
2012
Presidential
Elections &
Supreme Court
Decision
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Authorized and Appropriated
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Provisions
Cultural/Linguistic
Requirements
– Health Care Workforce
• Loan repayment programs with preference to providers having training or
experience in C/L competence or from R/E backgrounds
– Data Collection and Reporting
• Establishment of standards for collecting and reporting data by race, ethnicity,
and primary language in federally supported public health programs, activities
or surveys
– Health Insurance
• Uniform, C/L appropriate explanation of coverage
• C/L appropriate claims appeals process
• Navigator to provide C/L information on exchanges, enrollment, etc
– Public Health Programs
• Community Transformation Grants for chronic disease and disparities
• Culturally-tailored personal responsibility education on teen pregnancy
Authorized and Appropriated
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Provisions
Major Implications
• Health Insurance
– Expansion of Medicaid eligibility to 133% FPL
– Reauthorization of CHIP
– State Health Insurance Exchanges
• Access to Health Care
– $11 billion for Community Health Centers
– Grants to expand trauma centers– at least 40% of funds to safety net
– Maternal and child home visiting programs for at-risk populations
• Quality and Systems Innovation
– Medical Home demonstration programs for care coordination
– Aligning payment with quality and continuity of care
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State
Actions
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Equity
• California’s “Bridge to Reform” 1115 Medicaid Waiver
– Expands county-based Health Care Coverage Initiative (HCCI) for adults with
incomes between 133-200% FPL
– Support for county hospitals to improve quality of care through infrastructure
updates (e.g., IT) and systems innovation (e.g., care coordination)
– Support to enhance care delivery for high burden diseases at public hospitals
• Texas’ 1115 Medicaid Waiver Proposal
– Expands Medicaid managed care to other counties across the state
– Transitions to quality-based payments for managed care and hospitals
– Diverts savings into a pool to cover uncompensated care for hospitals and
safety net providers
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State
Progress
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on Cultural
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Competence
States with Cultural Competence Legislation
2000-2011
Dark Blue : legislation requiring (WA, CA, NJ, NM, CT) or strongly recommending (MD) cultural
competence training, which was signed into law.
Purple : legislation which has been referred to committee and is currently under consideration.
Royal Blue : legislation which died in committee or was vetoed.
Source: Think Cultural Health, 2011
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Local/Community
Progress
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& Programs
• Philanthropic Funding Pools
– e.g., 5 health philanthropies in Kansas formed an “Affordable Care Act
Opportunity Fund” to assist state/local organizations in implementing
ACA
• Community Networks for Medical Homes
– Community health center collaboration with private practices to
extend medical home services to diverse and vulnerable populations
• e.g., Models in Montana, North Carolina, Indiana
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National/Academic
Progress
& Programs
• National Initiatives
e.g., National Quality Forum (NQF)
– Analyzing and establishing valid measures to evaluate
disparities and cultural competence across diverse settings
and populations, known as Healthcare Disparities and
Cultural Competency Consensus Standards
• Academic Initiatives
e.g., Xavier University in New Orleans, LA
– Evaluating 12 online cultural competency training
programs
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Authorized
Provisions,
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Appropriated
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• Cultural Competence Education
– Model cultural competency curricula
• Health Care Workforce
– Community health workers, defined as providing C/L appropriate
outreach and health education
– Community health teams to support medical homes in providing
culturally appropriate, patient-centered care
• Public Health Programs
– C/L appropriate oral health education campaign
– Pain management education addressing C/L barriers
Populations
remaining
at or
beyond
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Master
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stylethe margins
• 23 million uninsured, of which 11 million
undocumented immigrants
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Risks
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• $18 billion reduction in 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
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Timeline
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• Timeline
– Impending Supreme Court
decision on insurance mandate
– 27 States with Lawsuits
– Change in presidential
leadership
• Budget
– Budget cuts at all levels
affecting safety net and
disparities-related
programs
States that have Filed a Federal
Lawsuit in Response to the
Affordable Care Act, 2011
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Click
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styleCare Reform
Advancing
EquityMaster
in the Eratitle
of Health
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.
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What
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Monitor
Educate
• Rollout of
appropriations
• Progress and status
of implementation of
funded and
unfunded
provisions—e.g.,
grants, taskforces,
advisory issuances,
executive orders, etc.
• Policymakers,
federal, state and
local agencies, and
foundations &
philanthropies on
specific language and
importance of
equity/disparities
priorities in ACA
• Education on status,
progress and
challenges in
implementation
Advocate
• For federal
appropriations
• For private,
philanthropic
support
• For state/local
innovation in health
equity and reducing
disparities
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• With support from The California Endowment and other
Foundations, we will:
– Track the status of implementation of equity, diversity and cultural
competence provisions in ACA as well as general provisions with major
implications for diverse populations, given changing health care environment.
– Identify emerging opportunities for funding, advisory groups, taskforces, and
other issuances, and ways in which to tap them.
– Recommend ways to leverage federal funding—or a lack thereof—with state
and local resources from public and private sources.
• Report will be unveiled at the upcoming National Conference
on Quality Health Care for Culturally Diverse Populations in
October 2012, in Oakland, California.
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titlePhD,style
Dennis P. Andrulis,
MPH
Senior Research Scientist, Texas Health Institute
Associate Professor, University of Texas School of Public Health
[email protected]
Nadia J. Siddiqui, MPH
Senior Health Policy Analyst, Texas Health Institute
[email protected]
Our Recent Publications
Andrulis DP and Siddiqui NJ. Health Reform Holds Both Risks and Rewards for
Safety-Net Providers and Racially and Ethnically Diverse Patients. Health Affairs,
2011, 30(10).
Andrulis DP, Siddiqui NJ, Purtle, JP and Duchon L. Patient Protection and Affordable
Care Act of 2010: Advancing Health Equity for Racially and Ethnically Diverse
Populations. July 2010. Supported and released by the Joint Center for Political
and Economic Studies.
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Presenter
Disclosure
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Dennis P. Andrulis, PhD, MPH
The following personal financial
relationships with commercial interests
relevant to this presentation existed during
the past 12 months:
No Relationships to Disclose.
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Cultural
Competence
Master title style
A set of attitudes, skills, behaviors, and policies that enable
organizations and staff to work effectively in cross-cultural
situations. It reflects the ability to acquire and use knowledge
of the health-related beliefs, attitudes, practices, and
communication patterns of clients and their families to
improve services, strengthen programs, increase community
participation, and close the gaps in health status among
diverse population groups.
(Cross et. al. 1989 and Lavizzo-Mourney and Mackenzie 1996 as cited in Cultural Competence:
A Journey, Bureau of Primary Health Care. HRSA, US DHHS, n.d.)
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Source: M, Beach. Patient-centeredness and cultural competence: their relationship and role in
reducing health disparities. Commonwealth Fund 2006