2013 nimhd translational health disparities course...2013 nimhd translational health disparities...

2013 NIMHD

Translational Health Disparities Course

Module 2

2010 Affordable Care Act: Summary & Review of Policies that

Address Health DisparitiesAddress Health Disparities

Nadia Siddiqui, MPH

Senior Health Policy AnalystTexas Health Institute

National Institute on Minority Health and Health Disparities

2013 NIMHD Translational Health Disparities Course

• ACA’s Vision and Promise

• Why Monitor the ACA Using a Disparities Lens?

Overview

• Why Monitor the ACA Using a Disparities Lens?

• How Does the ACA Address Health Disparities?• Progress

• Opportunities & Obligations

• Challenges

• Moving Forward



• Working to eliminate health disparities and advance health equity is central to the ACA.

• Over three dozen provisions directly address

ACA’s Vision and Promise

• Over three dozen provisions directly address racial and ethnic health disparities, diversity, and cultural and linguistic competence.

• Dozens of other general provisions with major implications for racially and ethnically diverse populations.



60+ Provisions Addressing Disparities in the ACA



2010 Report Outlining ACA’s Opportunities & Requirements for Addressing Health Disparities



Progress of ACA’s Disparities Provisions

Some are well on their way.

Others are just getting started.getting started.

There are those waiting to start.

And those that have been hit hard!



• Reasons you may already know:• Rapidly growing diversity.

Why Monitor Progress of ACA’s Disparities Provisions?

• Rapidly growing diversity.

• Continued disparities in access, quality, and health outcomes by race and ethnicity.

• Economic burden of disparities.

• But did you know…The ACA has potential to enfranchise as many as19 million racially & ethnically diverse individuals starting in 2014.



Health Insurance MarketplacesProjected Enrollees by Race & Ethnicity

42% or over 12 million Non-Whites25% will speak a language other than English at home

58%11%

25%

6%White

Black or African American

Hispanic or Latino

Other



How Do the Marketplaces Plan to Address 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



• How to elevate disparities to a priority level when focus is on exchange startup, IT, benefit design, etc.

What Challenges do Marketplaces Face in Addressing Disparities?

• How to effectively reach a range of diverse individuals:

• Culturally or linguistically isolated

• Not familiar with concept of insurance

• Low literacy and low health literacy

• Mixed-citizenship

• Distrust of government, federal programs, new law

• Training navigators & outreach workers



Medicaid Expansion:State Variation in Impact on Health Disparities

• State decisions will impact 15.1 million uninsured adults with incomes ≤138%FPL1

• Of which 45% or 6.8 million will be Non-White• Of which 45% or 6.8 million will be Non-White� 3.8 million Non-Whites will have Medicaid in states expanding

� 3.0 million Non-Whites will lose out in states not expanding, of which 2.2 million <100%FPL will not be eligible for exchange subsidies

• Impact of state Medicaid expansion varies widely by race & ethnicity2

• 60% of uninsured Blacks & 44% of Hispanics eligible for Medicaid live in states opting out

Sources: 1. Based on data from: Kenney, GM et al. Opting in to the Medicaid Expansion under the

ACA. Urban Institute & RWJF, August 2012; 2. KFF. The Impact of Current State Medicaid

Expansion Decisions on Coverage by Race & Ethnicity, July 2013.



How Will the Safety Net Adapt & Meet Demand?Safety Net Providers at a Crossroads

“How do [safety net providers] net providers] navigate this new system while keeping their souls intact?”

–Key Informant



• $11 billion investment in FQHCs in FY 2011-2015 –facing major funding cuts!

• Discretionary funding cuts = $3 billion reduction

ACA & Health Centers

• Sequestration imposed 2% cuts

� FY 2013 = $120 million less funding

� 900,000 fewer patients served – 6 in 10 minorities.

• Nurse Managed Health Clinics – received 30% funding

• New Teaching Health Centers – not funded

• School Based Health Centers – received all funding



• Decline in funding for unreimbursed costs –i.e., Medicaid & Medicare DSH payment reductions

ACA & Safety Net Hospitals

• New reporting requirements – e.g., CHNA

• How hospital systems adapt generally depends on their finances & resources, state’s political climate, and stance on Medicaid & Exchanges.



• The ACA requires nonprofit hospitals to conduct CHNA every 3 years & develop

Community Health Needs Assessment (CHNA):A Major Safety Net Opportunity to Address Disparities

every 3 years & develop strategy to address needs

• Potential for CHNA to address broad community needs and disparities• Community-wide approach

• Collaboration

• Collect data by race/ethnicity

• Monitor disparities



Workforce Capacity & Diversity in the ACA



• AAMC estimates that by 2020, there will be a shortage of 45,000+ primary care physicians

• Workforce diversity programs declining in priority

Challenges for Workforce Capacity & Diversity

• Workforce diversity programs declining in priority and funding

• Little data or evidence on effectiveness of diversity & cultural competency programs

• Little growth in graduation of health professions students from minority institutions



ACA & Disparities Data, Research, & Quality Improvement Opportunities



Tangible Opportunities for Addressing Disparities through Research & Innovation



• How to sustain new programs with a significant disparities focus?

• PCORI is only authorized until 2019

Challenges to ACA’s Disparities Research

• New OMHs in HHS Agencies have limited funding

• How to focus on measurable impact in short-term?

• e.g., PCORI funding tends to be for limited time frame

• How to monitor the impact of these programs?

• Effectiveness & link to outcomes?

• Adverse affect of exacerbating disparities?



ACA & Public Health Programs Addressing Disparities



• Funding & Support• Prevention & Public Health Fund termed a “slush fund”• County/state health departments using Fund to “plug holes”

Challenges to Addressing Disparities through ACA’s Public Health Programs

• County/state health departments using Fund to “plug holes”• Sustainability of funding for ACA supported programs • Some priorities not funded – e.g., oral health campaign

• Capacity� Uncertainty around capacity of state/local government agencies to

take advantage of ACA’s opportunities

• Partnership Development• Lengthy process – especially when pulling in sectors such as

transportation and others• Limited timeframes and resources



Aligning CLAS Standards with

the ACA to the ACA to Address

Disparities



Enhanced National CLAS StandardsNo. Themes Standards

1 Core Principle Ensure equitable quality of care & services

2-4 Governance,

Leadership,

Governance & leadership to promote CLAS; Diverse

leadership & workforce; Educate leadership &

workforce on CLASLeadership,

Workforce workforce on CLAS

5-8 Communication &

Language Assistance

Communication & language access; Availability of

language access; Competence to provide language

assistance; Easy-to-understand materials & signage

9-

15

Engagement,

Improvement,

Accountability

Infuse CLAS throughout organization; Organizational

assessments; Demographic data collection;

Community health needs assessment; Community

partnership; Conflict resolution; Sustainability of CLAS



Closing Remarks

• Equity is a central theme in the ACA with many new opportunities and obligations addressing disparities.addressing disparities.

• Inattention to equity may lead to “half empty programs”.

• Health Insurance ≠ Health Care Access!Need to monitor access gaps & disparities.



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

Associate Professor, University of Texas School of Public [email protected]

Contact Information

[email protected]

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

[email protected]

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

2013 nimhd translational health disparities course...2013 nimhd translational health disparities...

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