Slide 1

Report
Dennis P. Andrulis, PhD, MPH
Senior Research Scientist
Texas Health Institute
&
Associate Professor
University of Texas School of Public Health
Affordable Care Act and the Business Case for Reducing Health Care Disparities
American Medical Association (AMA)
September 28-29, 2012 | Chicago, Illinois

ACA’s Vision, Promise and Background

Design to Monitor ACA through an Equity Lens

Status of Diversity & Equity Provisions
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Health Insurance & Exchanges
Health Care Safety Net
Workforce Support & Diversity
Research, Data and Quality
Public Health & Prevention
Priorities for Advancing Equity through ACA

Working to eliminate health disparities and
advance health equity is central to the Affordable
Care Act (ACA) of 2010.

Over three dozen provisions directly advance
racial/ethnic health equity, diversity and
cultural/linguistic competence.

Dozens of other general provisions with major
implications for racially/ethnically diverse
populations.
2008
• Series of analyses of House & Senate Health Reform Bills (Joint Center)
2010
• Report: 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 Provisions in ACA
• Health Affairs article on ACA & Risks/Opportunities for Safety Net
2012
• Tracking Implementation Status and Progress of ACA’s Provisions Specific
to & with Major Implications for Racial/Ethnic Health Equity
(W.K. Kellogg, The California Endowment, Kaiser Permanente)
Tracking will continue through 2013.
Tracking 62 provisions specific to race, ethnicity, language and
diversity & general provisions with major implications for
diverse populations across 5 major areas:
A. Health
Insurance &
Exchanges
B. Health
Care Safety
Net
D. Data,
Quality and
Research
C. Workforce
Support &
Diversity
E. Public
Health &
Prevention

For each provision, we are reviewing:
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
Legislative language in ACA
Federal registry, policy reports, peer-review literature
Related national, state, local models & best-practices
Early successes and lessons learned
Opportunities and challenges
Additionally, we are conducting interviews with:
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▪
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National experts and advocates
Representatives from federal and state government
Representatives from organizations representing diverse communities
Health plans, hospitals, health centers and other grantees

Provisions:
▪ State Exchanges
▪ Navigator Program & C/L Information
▪ C/L Summary of Benefits
▪ C/L Claims Appeals Process
▪ Use of Plain Language in Health Plans
▪ Non-discrimination in Federal Programs
▪ Remove cost-sharing for AI/AN
▪ Market incentives for Reducing Disparities
15 States + DC with State Exchanges, as of July 2012
Exchange prior to ACA (2)
Exchange thru legislation (12)
Exchange thru E.O. (3)
Pending legislation (2)
Level 1 Planning Grant (24)
Will not establish State
Exchange
Source: Adapted from Commonwealth Fund Health Insurance Exchanges by State Interactive Map, July 2012.

Uncertainty of attention and priority given to equity in
exchange planning across states.

However...some states such as California, Maryland and
Washington are working to actively integrate racial/ethnic
equity into their exchange planning by, for example:
Explicit mention of diversity/equity in exchange objectives
Diverse representation on exchange Board of Directors
Engagement of diverse community stakeholders in planning
Presence of a champion for racial/ethnic equity and diversity

C/L Information, Outreach and Navigators
 Issued Final Rules with emphasis on:
▪ Plain language standards for information, education and outreach;
▪ Ensure availability of language services in translated taglines;
▪ Cultural 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

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.

Provisions:
 Medicaid income eligibility expansion
 Disproportionate Share Hospital (DSH) payment
reductions
 Community Health Center support
 Support for other health centers/clinics*
 Nonprofit Community Benefit
* Comprised of Nursed-Managed Centers, School-Based Health Centers, Teaching Health Centers

Potentially very significant adverse effect on diverse communities in states
not choosing to expand Medicaid per ACA

This will be compounded by the $18 billion reduction in Medicaid
disproportionate share hospital program which will be phased in 2014-2020
(The program finances 22% of unreimbursed care at public hospitals.)

Financial pressures on safety-net hospitals 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

Evaluate current formula for distributing DSH funds

Allocate DSH funds to hospitals providing most care to
uninsured

Improve transparency by requiring hospitals to disclose how
they use DSH funds

Impose accountability standards for hospitals receiving DSH
funds

Require hospitals receiving DSH dollars to adopt more
community-based, consumer-friendly procedures particularly
for low income, diverse communities

Medicaid Section 1115 Waiver Programs
 California “Bridge to Reform”: $2 bil. in support each year for 2010-2014
▪ Provide comprehensive care to ~ 500,000 low-income adults ineligible for Medi-Cal.
▪ Expand Safety Net Care Pool for uncompensated care & support safety net hospitals.
▪ Improve managed care services, care coordination & outcomes for seniors & disabled.
 Texas “Transformation Waiver”:
▪ Allow the state to expand Medicaid managed care
▪ Preserve federal hospital funding historically received as Upper Payment Limit (UPL)
payments—supplemental payments to make up the difference between what Medicaid
pays for a service and what Medicare would pay for the same service. Replacing the
UPL payment methodology are two funding pools – the Uncompensated Care and
Delivery System Reform Incentive Payment (DSRIP) pools.
▪ Require participation in a regional healthcare partnership

Provisions:
 Increasing Diversity Among Providers1
 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
 Support for Community Health Workers
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.

In FY 2010, Workforce initiatives received $503.3 mil (49% of
the total ACA appropriations)
 Majority of dollars came through Prevention & Public Health Fund
 Half the monies ($250 mil) to boost supply of primary care providers

In FY 2011, Workforce initiatives received $376.3 mil (15% of
the total ACA appropriations)
 Majority of dollars directly appropriated for workforce initiatives
 $137 mil provided through the Fund & geared toward public health
workforce and mental health training

New law passed in Feb 2012 has cut the Fund by ~ $5 bil over
10 years – exact appropriations for FY2012 – 2014 are still
uncertain.

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

Provisions:
 Data in Federal Surveys by Race, Ethnicity & Language
 Patient-Centered Outcomes Research Institute (PCORI)
 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

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.

September 17, 2012: Release of Second Cycle of PCORI
Funding Announcement related to Disparities
 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/FINAL-PFA-Addressing-Disparities-v3.pdf

Key provisions we are tracking:
 Community Transformation Grants
 Maternal & Child Home Visiting
 Personal Responsibility Education
 Reauthorization of Indian Health Care Improvement Act
 National Prevention Strategy & Fund
 Obesity, Diabetes, Cancer Programs
 National Oral Health Campaign
 Culturally Appropriate Decision Aids

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
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 & self-management
programs for diverse patients.

Capacity of state/local government agencies and offices to
take advantage of opportunities.

Available public health and safety net infrastructure to
address need.

Reductions in state/local government personnel encourage
supplementation of displaced staff rather than expansion.

Presence of well-placed or influential champions for ACA
equity/diversity initiatives.

Sustainability of ACA supported initiatives.
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]).

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