healtcare bill

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PATIENT PROTECTION

AND AFFORDABLE CARE

ACT OF 2010:

Adancing Health Equity or

Racially and EthnicallyDierse PopulationsJULY 2010


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PATIENT PROTECTION

AND AFFORDABLE CARE ACT OF 2010:

Adancing Health Equity or Racially

and Ethnically Dierse Populations

JULY 2010

PREPARED BY:

DENNIS P. ANDRULIS, Ph.D., MPH

NADIA J. SIDDIQUI, MPH

TEXAS HEALTH INSTITUTE

JONATHAN P. PURTLE, MSc

DREXEL UNIVERSITY SCHOOL OF PUBLIC HEALTH

LISA DUCHON, Ph.D., MPA

HEALTH MANAGEMENT ASSOCIATES

SUPPORTED BY AND PREPARED FOR:

JOINT CENTER FOR POLITICAL AND ECONOMIC STUDIES


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Opinions expressed in Joint Center publications are those o the authors and do not necessarily refect the views o the o cers representinthe Board o Governors o the Joint Center or the organizations supporting the Joint Center and its research.

Joint Center or Political and Economic Studies, Washington, DC 20005

www.jointcenter.org

2010 by the Joint Center or Political and Economic Studies

All rights reserved. Published 2010

Printed in the United States.


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JOINT CENTER FOR POLITICAL AND ECONOMIC STUDIES 1

I. INTRODUCTION

Racial/ethnic disparities in health and health care in the UnitedStates are persistent and well documented. Communitieso color are ar worse than their white counterparts across arange o health indicators: lie expectancy, inant mortality,

prevalence o chronic diseases, sel-rated health status, insurancecoverage, and many others.1 As the nations populationcontinues to become increasingly diversepeople o color areprojected to comprise 54% o the U.S. population by 2050 andmore than hal o U.S. children by 20232 these disparitiesare likely to grow i le unaddressed. Recent health carereorm legislation, while not a panacea or eliminating healthdisparities, oers an important rst step and an unprecedentedopportunity to improve health equity in the United States.

Reorming the nations health care system was PresidentObamas top domestic priority when he was sworn into o ce in

January 2009. Te road to reorm was complex and uno ciallystarted in summer o 2009 when House and Senate committeesbegan to dra legislation. On November 7, 2009, the Houseo Representatives passed its health care reorm proposal, TeAordable Health Choices Act o 2009 (H.R. 3962). OnDecember 24, 2009, the Senate passed its own proposal orhealth care reorm, Te Patient Protection and Aordable CareAct (H.R. 3590)*, which was a merged version o the SenateFinance Committees Americas Health Future Act (S.1796)and the Senate Committee on Health, Education, Labor, andPensions Aordable Health Choices Act (S. 1697). Eorts to

reconcile dierences between the Senate and House bills werestymied by the death o Senator Edward Kennedy (D-MA), alielong proponent o health care reorm and critical orce insecuring a proposals passage in the Senate.

Faced with limited options and expecting that a compromisebill could not get Senate support, the House passed theSenates proposal and Te Patient Protection and AordableCare Act (ACA) was signed into law by President Obama onMarch 23, 2010 (Pub. L. No. 111-148). On March 30, 2010,the ACA was amended by Te Health Care and EducationReconciliation Act o 2010 (H.R. 4872). According to

* Te United States Constitution requires that all revenue-related billsoriginate in the House. Tus, since the Senates proposed health care reormlegislation contained revenue provisions, the ACA was attached to a bill thatoriginated in the House (H.R. 3590).

Tis report represents the nal document in a series. Analyses o thepotential implications o all major health care reorm proposals or racially/ethnically diverse communities are available online at http://www.jointcenter.org/hpi/pages/2009-publications.

Te Full text o the bill can be ound online at http://democrats.senate.gov/reorm/patient-protection-aordable-care-act-as-passed.pd

Congressional Budget O ce (CBO) estimates, the ACA, asreconciled by H.R. 4872, will reduce the decit by $143 billionover the next decade and decrease the number o non-elderlyuninsured by 32 million, leaving 23 million uninsured

approximately one-third o whom would be undocumentedimmigrants.3

Tis report provides a comprehensive review o general andspecic ACA provisions with the potential to signicantlyimprove health and health care or millions o diversepopulations and their communities. Te narrative that ollowsidenties these provisions, discusses why they are important,and considers challenges that may lie ahead in implementingthem. We have organized this presentation in three majorsections. Te next section discusses provisions that explicitlyaddress health disparities, such as those concerning data

collection by race/ethnicity, workorce diversity, culturalcompetence, health disparities research, health disparitiesinitiatives in prevention, and health equity in health insurancereorm, and discusses their implications or racially andethnically diverse communities. Section III describes generalprovisions, including health insurance reorms, access to care,quality improvement, cost containment, public health andsocial determinants o health, all o which are likely to havemajor implications or diverse communities.

An accompanying appendix identies these provisions, providesa timetable and, where identied in the legislation, the ederalagencies responsible or implementation, as well as allocationsas o June 30, 2010. Section IV discusses issues that will becritical in realizing the ull potential o health care reorm andhighlights questions and directions or the uture, particularlyin context o important priorities or reducing racial/ethnichealth disparities that were le unaddressed.


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PATIENT PROTECTION AND AFFORDABLE CARE ACT OF 2010: ADVANCING HEALTH EQUITY FOR RACIALLY AND ETHNICALLY DIVERSE POPULATIONS2

II. HEALTH AND HEALTH CAREPROVISIONS SPECIFIC TO RACE,ETHNICITY AND LANGUAGE

Te ACA includes numerous provisions that are explicitlyintended to reduce health disparities and improve the health

o racially and ethnically diverse populations. Tese includeprovisions originating not only rom the Senate bill, but alsothose embedded in the House bill that became law throughreconciliation. Te scope, detail, and ocus o these provisionsare wide-ranging and span across at least six domains.

A. Data Collection and Reporting by R ace,Ethnicity and Language

Te ability to identiy disparities and monitor eorts to reducethem has been limited due to a lack o specicity, uniormity

and quality in data collection and reporting procedures.4 Asexpressed by the Institute o Medicine (IOM)5, consistentmethods or collecting and reporting health data by race,ethnicity, and language are essential to inorming evidence-based disparity reduction initiatives, such as those whichaddress variations in quality o care or acilitate the provisiono culturally and linguistically appropriate services. Reliablepatient data by race/ethnicity are also necessary to ensurenondiscrimination in the provision o health care and inprovider adherence to civil rights laws.6 In addition tostrengthening existing eorts to collect data across the O ce oManagement and Budget (OMB) categories o race/ethnicity,improved data collection and reporting systems are necessary toobtain inormation on the health status and health care needso immigrant populations and the approximately 100 ethnicgroups with populations over 100,000 living in the U.S. 7

Te ACA contains several provisions aimed at improving datacollection and reporting procedures, each having the explicitintention o tracking and reducing health disparities (able 1).Te section entitled Understanding Health Disparities: DataCollection and Analysis, amends thePublic Health Serices Actto address this issue. No later than 2013, all ederally-unded

health programs and population surveys, such as the U.S.Census Bureaus American Community Survey, will be requiredto collect and report data on race, ethnicity, primary language,and other demographic characteristics identied as appropriateby the Secretary o Health and Human Services (HHS) orreducing health disparities. While the use o oversampling isauthorized to produce statistically reliable estimates, OMBcategories o race/ethnicity will be the minimum standardunless otherwise expanded by the Secretary or designee. Inaddition to collecting and reporting such data, the Secretary is

authorized to lead eorts to analyze data and monitor trendsin health disparities and disseminate ndings to ederal healthand human service agencies as well as the public. Tis provisionalso strengthens data collection and reporting mechanismsin the ederal-state Medicaid program and Childrens HealthInsurance Program (CHIP).

Table 1. Data Collection & Reporting byRace, Ethnicity and Language

Section No.

Require that population surveys collect and report dataon race, ethnicity and primary language

4302

Collect/report disparities data in Medicaid and CHIP 4302

Monitor health disparities trends in federally-fundedprograms 4302

Improvements in data collection and reporting by race,

ethnicity, and language in the ACA have the potential toenhance the evidence-base or new health equity improvementinitiatives or diverse communities, while, at the same time,raising awareness about the persistence o health disparitiesand the urgency or action among policymakers and the public.However, there are several potential barriers that could hinderimplementation eorts and the useulness o data collection andreporting procedures.

An overarching issue is how such data are collected. A healthcare organizations adherence to race/ethnicity reportingmandates does not necessarily entail uniormity or accuracy

in how it collects such data.8

Tere is a general consensusthat sel-reported race/ethnicity data are considerably moreaccurate than observational reporting o race/ethnicity byhealth care sta.9,10 A body o empirical evidence supports thisclaim, nding that health care sta oen misclassiy the race/ethnicity o people o color, particularly Hispanics/Latinos.11,12At the same time, however, sel-reporting race/ethnicity has itslimitations, especially when broad OMB categories or race/ethnicity are provided.13 For example, people o Middle Easternor Arab descent are oen categorized as Caucasian or white,a classication with which they may not sel-identiy.14 Tebroad categories o Hispanic/Latino and Asian American/

Pacic Islander also homogenize distinct ethnic groups withdisparate cultures, languages, and customs.15 Other challengesto sel-reporting may include patient perceptions o intrusionand provider concerns about undermining the quality onascent patient-provider relationships.8

Improvements to collecting data on patient race/ethnicity canbenet rom guidance rom HHS on how to collect these datato ensure uniormity o reporting as well as to preserve thequality o patient-provider relationships. Additionally, under


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the authority granted in the ACA, the Secretary o HHSshould require that data be collected on racial/ethnic groupsbeyond existing OMB standards. Finally, certain health careorganizations may not have su cient nancial and sta ngresources to eectively collect and report patient racial/ethnicdata.16 Tus, the ull realization o this objective may require

support to health care organizations rom ederal as well asprivate, non-prot and philanthropic sources. Te multi-payeradvanced medical home demonstration projects that will beimplemented through ACA may be one vehicle to promotestandardized reporting among public and private payers (SeeSection III, p. 8).

B. Workorce Diersity

Te 2004 IOM Report,In the Nations Compelling Interest:Ensuring Diersity in the Health Care Workorce, underscored

the importance o increasing racial/ethnic diversity in thehealth proessions to reduce health disparities.17 Concordancebetween patient-practitioner race/ethnicity has long beenrecognized as a strategy or improving the quality o care.18Furthermore, racially and ethnically diverse practitioners aremore likely to practice in medically underserved areas and treatpatients o color who are uninsured or underinsured.19 Diversityamong health researchers is also critical to pursuing a researchagenda on the elimination o racial/ethnic health disparities.20

Despite the eorts o the ederal government and privateoundations to improve workorce diversity, persisting

disparities exist between the racial/ethnic composition ohealth care workorce and the U.S. population.21 For example,while Hispanics comprise approximately 12 percent o theU.S. population, they account or less than our percent o allphysicians. Arican Americans comprise a relatively similarproportion o the nations population but only ve percent ophysicians.22 In the absence o ocused strategies to increasediversity in the health proessions, disparities between theracial/ethnic composition o the health proessions workorceand general population are likely to continue as the nationbecomes increasingly diverse.

For nearly 50 years, itles VII and VIII o thePublic HealthSerices Acthave been successul in increasing racial/ethnicdiversity in the health care workorce, improving culturalcompetence, and encouraging health care providers to practicein medically underserved areas.23,24,25 Trough reauthorizationand expansion o itle VII programs, the ACA has potential toimprove diversity in elds such as primary care, long-term care,and dentistry, with appropriations available as early as 2010.itle VII is also amended to authorize $25 million in grantsand assistance to mental and behavioral health proessionals

giving preerence to historically black colleges and universities(HBCUs) and institutions with a strong track record o servingdiverse populations. Increases in itle VII scholarships andloan orgiveness opportunities are made available throughthe section entitled, Health Care Proessionals raining orDiversity. itle VIII o thePublic Health Serices Actis also

amended to increase opportunities to improve diversity amongthe nursing proessions.

Eective in 2010, the ACA also provides $85 million insupport or programs to train low income individuals as homecare aides and in other health proessions. At least three osuch grants will be administered to ribal entities. Grants arealso made available to recruit and train community healthworkers, with an emphasis on providing education andoutreach in racially/ethnically diverse communities, as wellas to support Area Health Education Centers (AHECs) thattarget underserved populations. While the use o communityhealth workers represents a promising strategy to provideculturally and linguistically appropriate services (CLAS) andinormation26, the impact o such grants will be linked toappropriationsamounts which currently remain unspecied.Te ACA also calls or monitoring diversity in the health careworkorce, but does not speciy a strategy or doing so (able2).

Table 2. Workforce Diversity Section No.

Collect and publicly report data on workforce

diversity

5001

Increase diversity among Primary Care Providers 5301

Increase diversity among long-term care providers 5302

Increase diversity among dentists 5303

Increase diversity among mental health providers 5306

Health professions training for diversity 5402

Increase diversity in nursing professions 5309

Investment in HBCUs and minority-servinginstitutions 2104

Community-based training for AHECs targetingunderserved pops. 5403

Grants for Community Health Workers, providing CLAS 5313

Grants to train providers on pain care, including CLAS4305

Support for low income health profession/home careaid training

5507


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While provisions in the ACA represent promise or increasingracial/ethnic diversity in the health care workorce, ormidablechallenges surround implementation. itle VII and itle VIIIprograms address many o the nancial barriers that deterpeople o color rom pursuing costly degrees in the healthproessions. Tese programs do not, however, directly address

the institutional climate o colleges and universities that have alegacy o being historically white.27 Provisions in the ACA alsodo not address vast inequities in the quality o K through12education. In order to adequately prepare culturally diverseindividuals or success in higher-education health proessionsprograms, disparities in learning opportunities, particularlyin the sciences, need to be addressed at the pre-college level.28Lastly, there remain staunch opponents o a rmative actionpolicies. While the ACA secures appropriations or workorcediversity initiatives through 2014, support or these programs islikely to come under attack. Te continuity o these programs

will require a strong commitment rom Congressional leaders,as well as an abundance o data that demonstrate their benets.

C. Cultural Competence Educationand Organizational Support

Persons o color are more likely to report experiencing poorerquality and patient-provider interactions than whites, adisparity which is particularly pronounced among individualswhose primary language is other than English.29 Culturalcompetence training and education or health proessionals hasgained credibility as a strategy or improving the quality o caredelivered to culturally and linguistically diverse patients.30,31In addition to improving the quality o patient-providerinteractions in clinical settings, integrating the principles ocultural competence at the organizational level can assist indeinstitutionalizing racism and guiding culturally competentprogram development and evaluation. Te impact o broadeorts to improve access to insurance coverage and high qualitymedical care or low income populationsthe cornerstone ohealth care reorm legislationwill be lessened i these eortsare not grounded in cultural competence (able 3).

Table 3. Cultural Competence (CC)Education and Organizational Support Section No.

Develop & evaluate model CC curricula 5307

Disseminate CC curricula through onlineclearinghouse 5307

CC training for primary care providers 5301

CC training for home care aides 5507

Curricula for CC in working with individuals withdisabilities 5307

Loan repayment preference for experience in CC 5203

Transfer federal OMH to Office of the Secretary 10334

Create individual OMHs within federal HHS agencies 10334

Te health care reorm law allocates ve years o support toaid the development and dissemination o model culturalcompetence training and education curricula. Underthis section, a diverse group o stakeholdersincludingrepresentatives rom health proessional societies, experts inhealth disparities and cultural competence, and community-based organizationswill be consulted by the Secretary toevaluate existing, and develop new, cultural competencecurricula. Te materials will be disseminated via a Web-basedclearinghouse. Support is also provided or cultural competence

training or primary care providers and home care aides. TeACA also provides support or loan repayment options,giving preerence to individuals with experience in culturalcompetence training.

Additionally, the ACA promotes organizational culturalcompetence at the ederal level. Since being established in 1986,the HHS O ce o Minority Health (OMH) has advised theSecretar y and O ce o Public Health and Science (OPHS) onpolicies and programs to reduce and eliminate racial/ethnicdisparities in health and health care. A provision in the ACApromotes OMH rom OPHS to the O ce o the Secretary o

HHS. As a result, the Deputy Assistant Secretary or MinorityHealth will report directly to the Secretary and have enhancedauthority to carry out initiatives to improve the health o diversepopulations. Individual OMH divisions within key ederalHHS agenciessuch as the Centers or Disease Control andPrevention (CDC), the Agency or Healthcare Research andQuality (AHR), the Food and Drug Administration (FDA)and othersare also established. While the responsibilityand authority o these agency-based OMH divisions remain


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undened, they represent promise or integrating disparityreduction priorities into the ederal health agenda.

Te ACA makes signicant strides toward improving culturalcompetence at individual provider and institutional levels;however, questions remain regarding the extent to which

these initiatives will be embraced. At the individual-level,time-strapped practitioners may be reluctant to participate incultural competence training or to use Web-based educationmaterials unless they are provided with nancial incentives orcontinuing education credits. Tere is also a paucity o rigorousresearch on the impact o cultural competence strategies onhealth outcomes and reducing racial/ethnic disparities.32 Atthe organization-level, OMH divisions within HHS agencieswill need to be provided with su cient authority and resourcesto have a signicant impact. Additionally, given that the majordrivers o health disparities originate beyond the health caresector (e.g., employment, education, criminal justice), cross-agency collaboration between OMH divisions and departmentsoutside o HHS would enhance eorts to reduce disparities.33

D. Health Disparities Research

Since the establishment o the O ce o Research on MinorityHealth within the National Institutes o Health (NIH) in1990, the ederal government has steadily increased resources toinvestigate the causes o health disparities and develop strategiesto reduce them. In 2003, NIH unding or minority healthresearch exceeded $2.13 billion, accounting or approximately

12 percent o the total NIH budget.34 While research alonewill not reduce persistent health disparities, the ACA sustains,and enhances, developing an evidence base to inorm disparityreduction initiatives (able 4).

Table 4. Health Disparities Research Section No.

PCORI to examine health disparities through CER 6301

Increase funding to Centers of Excellence 5401

Promote NCMHHD to Institute status 10334

Support collaborative research on topics includingcultural competence

5307

Support for disparities research in post-partumdepression 2952

Support for disparities research in pain treatment/management 4305

For example, the ACA promotes the National Center on

Minority Health and Health Disparities toInstitute statusgranting it the authority to plan, coordinate, and evaluate alldisparity-related research within NIH. Increases in undingto Centers o Excellence are also made available to supporthealth disparities research. Furthermore, the ACA also createsa Patient-Centered Outcomes Research Institute (PCORI)

to carry out comparative eectiveness research (CER) and toexamine dierences in health care service outcomes amongpersons o color. By ocusing on racial/ethnic dierences inprocedural outcomes, CER has the potential to reduce healthdisparities at the national level, especially among patients ocolor who suer a disproportionately high burden o chronicdisease.35 Te success o CER initiatives is likely linked tosustainable unding. However, appropriations and a timelineor this provision are not specied in the legislation. Tereore,there is uncertainty as to whether unds will be su cient oridentiying associations between treatments and outcomes as

well as dierences by race/ethnicity. Finally, special attentionto diverse populations on pain treatment/management andpostpartum depressiona condition that disproportionatelyaects Arican American and Hispanic womenand supportor collaborative research on cultural competence are alsoprovided.36

At least three challenges exist to maximizing the e cacy ohealth disparities research: coordinating research eorts,translating research into policy and practice, and ensuringracial/ethnic diversity in clinical trials. Challenges surroundingcoordination were made evident in the IOM report,Examining

the Health Disparities Research Plan o the National Instituteso Health: Unfnished Business. Tis report examined the NIHresponse to a 2000 Congressional mandate to implementa Strategic Plan or health disparities research and oundthat, despite planning eorts, coordination challenges werenumerous and many gaps in disparities research remainedsuch as those addressing social and behavioral determinants ohealth and their interaction with biological processes.37

Various actors determine the extent to which evidence-based recommendations and practices are adopted in a healthcare setting, including the organizational culture, resource

constraints, and patient willingness to embrace change.38 Tesechallenges should be taken into consideration when devisingstrategies to translate health disparities research into practiceand policy.

Lastly, people o color have historically been under-representedin clinical trials.39, 40 I the PCORI is to be successul inachieving its goals, tailored strategies are needed to recruitandretain racial/ethnic subpopulations in clinical trials to developan evidence base or practices and outcomes among diversepatients.41


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E. Health Disparities Initiaties in Preention

Beyond the social and moral imperative to reduce racial/ethnic health disparities, the economic burden o disparities isimmense. Researchers estimate that, between 2003 and 2006,the cost o racial/ethnic disparities in direct medical costs and

lost productivity in the U.S. exceeded $1.24 trillion.42 Troughinnovative health education and preventive programs, healthcare reorm legislation oers the opportunity to stem disparitiesin premature death, disability, and acute and chronic disease(able 5).

Table 5. Health Disparities InitiativesPrevention

Section No.

National oral health campaign, with emphasis ondisparities 4102

Standardized drug labeling on risks & benefits 3507

Maternal & child home visiting programs for at-riskcommunities 2951

Culturally appropriate patient-decision aids 3506

Culturally appropriate personal responsibilityeducation

2953

Support for preventive programs for AI/ANs 10221

In addition to preventive eorts that seek to reduce disparitiesthrough interventions at ederal and community levels (seeSection III, Subsection E on Social Determinants o Health), theACA contains numerous prevention and education initiativesthat emphasize personal responsibility and individual healthbehavior. For example, support is provided or pregnancyand sexually transmitted inection prevention educationprograms targeting racially/ethnically diverse adolescents. Tisis particularly important given that women o color generallyhave higher rates o unintended pregnancy43 and that AricanAmericans are ten times as likely, and Hispanics almost threetimes as likely, as whites to have HIV/AIDS.44 Additionally,the law supports home visitation programs or maternal andchild care. By providing amilies with client-centered education,

parenting skills, and social support, home visitation programscan serve as an eective and relatively low-cost strategy toimprove prenatal and postnatal health outcomes, in additionto a variety o other long-term benets.45 Tese programs arelikely to serve as a valuable resource or low income women ocolor who are rst-time mothers, and oen have limited socialsupport networks.

Te ACA also authorizes a ve-year national oral healtheducation campaign, with an emphasis on racial/ethnicdisparities. Arican American children are nearly twice aslikely to report having air to poor oral health as whites, whileHispanic children are nearly our times more likely.46 TeACA also mandates an investigation o drug labeling standards

to improve patient decision making, a process that will beconducted in concert with health literacy, health equity andcultural competence experts. Standardizing and tailoring druglabeling would help meet the needs o the nearly 87 millionU.S. adults with low-literacy47 and the 24 million with limitedEnglish prociency (LEP)48 by assisting these groups in betteridentiying dosage inormation, risks and benets o drugs,and ultimately reducing medication errors. Additionally,support or culturally appropriate decision aids will assist thispopulation in making inormed medical decisions.

Te ACA also establishes theIndian Health Care ImprovementReauthorization and Extension Act o 2009 (S. 1790) as law.Te Act contains a multitude o distinct provisions whichaddress the health and health care needs o American Indiansand Alaska Natives (AI/AN).49 Examples o such preventiveprograms include those targeting substance abuse, diabetes, andsuicideall health-related problems that are disproportionatelyprevalent among the AI/AN population.50

F. Addressing Disparities in Health Insurance Reorms

Vast disparities in uninsured rates have long existed between

whites and other racial/ethnic groups. For example, AricanAmericans are nearly twice as likely to be uninsured thanwhites, while Hispanics are more than three times as likely tobe uninsured.51 While health insurance market reorms andexpansions in Medicaid hold promise to substantially reducedisparities in insurance status, targeted eorts are necessary toensure that culturally and linguistically isolated communitiesare enrolled and take ull advantage o benets or which theyare eligible. Failure to successully enroll these populationsis likely to put additional strain on already stressed saety netclinics and Disproportionate Share Hospitals (DSHs) (see

Section III, Subsection A onHealth Insurance Reorms andSection III, Subsection D on Cost Containment).

For scal years 2010 to 2013, the ACA provides $14 million insupport or outreach eorts targeting low income populations.While details o such eorts are not specied, community-based organizations, community health workers andpromotoresshould be central to any outreach eorts as they are wellpositioned to provide enrollment assistance to diverse lowincome populations.52 It is also required that outreach and


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enrollment activities or new national and state health insuranceexchanges (see Section III, Subsection A onHealth InsuranceReorms) be culturally and linguistically appropriate. Te ACAalso explicitly puts orth a mandate or nondiscrimination inederal health programs and exchanges. Te legislation alsorequires insurers to provide enrollees with a claims appeal

process and summary o benets that are culturally andlinguistically appropriate. While these provisions acknowledgethe distinct needs o diverse populations in health insurancemarket reorms, their success is likely to hinge upon the extentto which they are monitored and enorced ( able 6).

Table 6. Addressing Disparities inInsurance Coverage

Section No.

Remove cost-sharing for AI/ANs at or below 300%FPL 2901

Enrollment outreach targeting low incomepopulations

3306

CLAS/information through exchanges 1311

Nondiscrimination in federal health programs andexchanges 1557

Require plans to provide information in plainlanguage 1303

Incentive payments for reducing health/healthcaredisparities

1303

Summary of coverage that is culturally/linguisticallyappropriate 1001

Claims appeal process that is culturally/linguisticallyappropriate 1001

Finally, the ACA removes all cost-sharing requirements or AI/AN individuals at or below 300 percent o the ederal povertylevel (FPL). While AI/ANs have long been entitled to medicalcare through the Indian Health Service, the programs limitedresources has oen restricted access to care. Removing cost-sharing requirements should improve access to health insuranceand health care or the approximately 1.1 million AI/ANs thatare at or below 300 percent FPL.53


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III. GENERAL PROVISIONS WITHSIGNIFICANT IMPLICATIONS FORRACIALLY AND ETHNICALLY DIVERSEPOPULATIONS

Te new health care reorm law includes a number o general

provisionsconcerning health insurance reorm, improvedaccess to health care, quality improvement, cost containment,public health initiatives and social determinants o healthwhich are likely to benet low income and racially andethnically diverse communities. Tese provisions and theirimplications or diverse populations are summarized in thissection.

A. Health Insurance Reorms toExpand Coverage and Afordability

Individuals rom racially or ethnically diverse backgroundscomprise about one-third o the nations population; however,they make up over hal o the 47 million uninsured.54 In 2005,nearly two-thirds o Hispanic adults (15 million) and one-third o Arican American adults (6 million) were uninsuredcompared to 20 percent o white adults.55 Te new law containsa range o provisions or expanding health insurance coverage(able 7). Te CBO estimates that by 2019 these reormswould reduce the number o uninsured by 32 million.56

Table 7. Health Insurance Reforms Section No.

Individual requirement to have coverage 1501

Expand Medicaid income eligibility to 133% FPL 2001

Employer requirement to offer coverage 1513

Increase federal matching rates for Medicaid 2005

Small business (


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subsidies or individuals with incomes at or below 400 percentFPL. Given that nearly 50 percent o the 16 million uninsuredadults with incomes between 150 percent FPL and 399 percentFPL belong to communities o color, this policy is expectedto have a large impact on racially and ethnically diversepopulations.62

In addition, the new health care reorm law authorizes $6billion to establish Consumer Operated and Oriented Plans(CO-OPs) by July 1, 2013, to oster the creation o a non-prot, member-operated health insurance plan in each stateand the District o Columbia. While their creation oers astrategy to compete with private insurers, CO-OPs may acesignicant start up challenges. Additionally, CO-OPs may notbe a viable option or low income, diverse individuals lookingor aordable choices and coverage unless they can: establishsubstantial presence with bargaining power, prevent adverseselection by spreading risk broadly, and oer health coveragewith minimum cost-sharing.63

Finally, eective 90 days aer enactment until January 1, 2014,the ACA provides immediate assistance to individuals withpre-existing conditions, who have been uninsured or at leastsix months, by creating state-sponsored high-risk insurancepools and providing subsidized premiums. Removing barriersto insurance coverage based on illness or health status shouldimprove access to aordable insurance coverage or low income,racial/ethnic populations, who have disproportionately higherrates o morbidity. For example, nearly hal o all Arican

American adults suer rom a chronic condition or disability.64

Collectively, these reorms hold the promise o expanding accessto health insurance or millions o individuals and amilies.However, CBO and the Joint Committee on axation ( JC)estimate that by 2019, there will remain nearly 23 millionuninsured. An estimated one-third will be undocumentedimmigrants65 and a large portion will be poor and people romdiverse racial and ethnic heritage. Te success o the ACAshealth insurance reorm requires that uninsured individualsgenerallyincluding people o color and racially/ethnicallydiverse residentscomply with the individual mandate. As

the experiences with health care reorm in Massachusettsshowed, success hinges upon eective outreach, promotion,education, and decision-support that is culturally andlinguistically appropriate.66 An understanding o coverage andbenets, including what they entail, how they can be used,and or what services, will also be important or participationamong uninsured and low income communities o color. Inocus groups conducted in the wake o health care reorm inMassachusetts, the uninsured made it very clear that they notonly want inormation in writing, they want to talk to a person

who is able to help them through the complex decision-makingand enrollment processes.67 As 2014 approaches, an adequatenumber o community outreach workers will be necessary,as will the involvement o community-based organizations,representatives and stakeholders in achieving well-inormedand empowered communities o color who can participate

and benet rom health insurance reorms. SeeAddressingDisparities in Health Insurance Reorms in Section II, SubsectionF, or urther details.

B. Actions to Improve Access to Health Care

Access to timely and needed health and medical care is a majorchallenge or racially and ethnically diverse communities. Evenaer adjusting or age, insurance and income, communitieso color are less likely than their white counterparts to have ausual source o care. More than hal o Hispanic adults report

not having a regular doctor even when insureda rate that is2.5 times greater than the proportion o whites. Furthermore,compared to whites (77 percent), Hispanics and AricanAmericans are less likely to receive care in a private doctorso ce (44 and 62 percent, respectively) and more likely toseek care in community health centers (CHCs) or emergencydepartments. Recent data show that nearly two-thirds o CHCpatients are non-white.68

With the enactment o the ACA, the health care system,and the saety net in particular, is likely to ace even greaterdemand or its services. Embedded in the reorm legislation are

important actions or improving health care access that wouldbenet low income, racially and ethnically diverse patients(able 8). For example, the ACA expands unding or CHCsby $11 billion over ve years starting scal year 2011adoubling o current undingwith $9.5 billion or expandingtheir operational capacity or medical, oral, and behavioralhealth services, and $1.5 billion or providing capital support tobuild new sites and/or expand and improve existing acilities.69Given that CHCs predominately serve low income and diversepatients, this provision is especially important or ensuringthese populations have access to basic primary, dental, and

mental health care as well as support programs such as languagetranslation, transportation, and case management.70


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Table 8. Actions to Improve Access toHealth Care Section No.

Support for community health centers 10503

Nurse-managed health centers 5208

Community health teams 3502

Redistribute Graduate Medical Education slots 5503

Extends authorization of National Health ServicesCorps 5207

Teaching community health centers 5508

Innovative models in Medicare/Medicaid 3021

School-based health centers 4101

Pilot projects for emergency & trauma care 3504

As CHCs expand their scope and reach, patients will needbetter access to a continuum o care, including specialtyand tertiary services. Tis is especially important or peopleo color, who have higher rates o mortality, many cancers,and conditions such as asthma, diabetes, heart ailure, andstroke.71 A recent Commonwealth Fund report said that whileCHCs are able to provide primary care, they have di cultyconnecting their patients to diagnostic testing and specialty

care, even when patients are insured.72

Specically, 79 percento surveyed CHCs reported di culty in obtaining specialistaccess or Medicaid patients and 60 percent reported di cultyor Medicare patients. As Medicaid eligibility and coverageexpand under health care reorm, access barriers or patientswho rely on community health centers as their medical homecould worsen without eorts to improve specialty care linkages.Funding or CHCs should be structured to encourage andincentivize health centers, specialists and hospitals to provide aseamless continuum o coordinated patient care.

Te ACA also provides support or expanding primary care

by: increasing unding or the National Health Services Corpsby $1.5 billion over ve years (FY 2011-2015); providing$43 million in 2011 in grants to provide training to graduatemedical residents in preventive medicine specialties; andincreasing Medicaid payments or primary care servicesprovided by primary care physicians (amily medicine, generalinternal medicine or pediatric medicine) to 100 percent o theMedicare payment rates or 2013 and 2014. Tese initiativesare especially important given that an estimated 56 millionAmericans, a large majority o whom are people o color, are

considered medically disenranchisedor having inadequateaccess to a primary care physician regardless o insurancestatus.73 Tese initiatives are also important or addressing thelooming shortage o primary care providers and historically lowprovider participation in Medicaid that has contributed to gapsin care in low income and medically underserved communities.

Furthermore, the ACA expands access to care by supportinghealth promotion, prevention and education activities that takeadvantage o community assets and resources and go beyondtraditional medical settings and practices. Specically, the lawappropriates $50 million or each scal year between 2010through 2014 to support school-based health centers; providessupport or nurse-managed health clinics; provides grants tocreate Community Health eams to support medical homesor patients; and creates a medical home option or Medicaidenrollees with chronic conditions. Te ACA also eliminatescost-sharing or a wide range o preventive services underqualied health plans. ogether, these initiatives are importantor helping poor and racially/ethnically diverse residents,particularly the large proportions o Hispanics (54 percent),Asians (52 percent) and Arican Americans (44 percent) whooen delay or orgo routine and preventive care. 74,75 Te use oCommunity Health eams to support primary care providers inestablishing patient-centered medical homes are also importantsteps or ostering trust, understanding, and adherence tohealthy behaviors and preventive health practices as well asor addressing issues around coordination and continuityo care among low income, racially and ethnically diverse

communities.76

Given the requent concentration o services in urban areas, thenew law also provides unding or demonstration projects thatevaluate innovative models or emergency care systems, such asthe regionalization o emergency and trauma carean initiativewhich could signicantly expand access to care or the nationsgrowing poor and diverse communities in sprawling cities,suburbs and exurbs, as well as in historically underserved ruralareas with limited resources and capacity.

C. Quality ImprovementIt is well documented that the care received by racially andethnically diverse patients oen alls short on quality-relateddimensions, including saety, timeliness, eectiveness, e ciencypatient-centeredness and equity.77 Embedded in the healthcare reorm law are a number o provisions intended to improvequality o care, including a national strategy and support orhealth care providers in the delivery o evidence-based medicineand services ( able 9).


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Table 9. Quality Improvement Section No.

National Strategy for Quality Improvement 3011

Quality improvement technical assistance 3501

Interagency Group on Healthcare Quality 3012

Develop, improve & evaluate quality measures 3013

Link Medicare payments to quality outcomes 3001

Pediatric Accountable Care Organizations 2706

Te ACA authorizes the HHS Secretary to create a NationalStrategy or Quality Improvement in Healthcare by scal year

2011 through a transparent collaborative process that willimprove the delivery o health care services, patient outcomesand population health overall. Trough the Center or QualityImprovement and Patient Saety o AHR, the new lawauthorizes $20 million or scal years 2010 through 2014, ingrants or technical assistance to eligible health care providersor improving quality o care. In addition, AHR along withthe Centers or Medicare and Medicaid Services (CMS), arecalled upon to advise and assist the HHS Secretary in awardinggrants and contracts to develop, improve, update and expandquality measures where they do not exist (including thoseaddressing health equity and health disparities). A total o

$75 million is authorized or this purpose or each scal yearbetween 2010 and 2014.

As described in more detail in Section II, Subsection D onHealth Disparities Research, the law also creates a Patient-Centered Outcomes Research Institute, a non-protcorporation, to identiy research priorities and conduct researchthat compares the clinical eectiveness o medical interventionsand programs or diseases, disorders and health conditions.Furthermore, the ACA includes support or national Medicareand Medicaid pilot/demonstration programs to developand evaluate bundled payments or health services provided

or an episode o care. Aligning payment with quality ratherthan quantity o care in public programs to reduce hospitalreadmissions and health care-acquired conditions couldpotentially reduce racial/ethnic disparities in preventablehospitalizations and health care outcomes. Blacks are two toour times more likely than whites to be hospitalized or apotentially preventable condition. 78

Finally, the new law authorizes the creation o a new o cewithin CMS to improve care coordination or dual eligibles,eective March 1, 2010. Tis action could potentially improvecontinuity and quality o care or approximately 1.2 million lowincome elderly Arican Americans who are dual beneciaries oMedicare and Medicaid. 79

D. Cost Containment

As recent data show, disparities in health and health careimpose a signicant burden on individuals and communities,and account or considerable costs to society as a whole.80In addition to health insurance market reorms, improvinge ciency and reducing raud in the health care system areessential to curbing the growth o health care and prescriptiondrug costs and making health care more aordable. While suchimprovements would benet individuals across-the-board, the

implications would be particularly proound or low income,racially and ethnically diverse patients who are more likelythan whites to be unable to pay medical bills, be contacted by acollection agency or have outstanding medical debt.81 As such,the health care reorm law includes a number o provisions tocontain costs (able 10).

Table 10. Cost Containment Section No.

Interoperable systems of enrollment 1561

Reduce Medicaid DSH Payments 1203

Reduce Medicare DSH Payments 2551

Demonstration projects for HIT 6114

Strengthening Medicaid drug rebate programs 2501

Enhancing public program fraud screening 6401

First, the ACA considerably reduces Medicare and MedicaidDisproportionate Share Hospital (DSH) payments. Between2014 and 2020, Medicaid DSH allotments will shrink by$18.1 billion and in 2014 Medicare DSH payments will bereduced initially by 75 percent. Medicare and MedicaidDSH payments are signicant sources o nancial supportor saety net hospitals that disproportionately care or lowincome and uninsured patients. Medicaid alone allocated over$11 billion to these acilities in 2009.82 While it is arguedthat expanding health insurance should reduce the need orDSH support, parallel reorms in Massachusetts resulted in


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straining the health care saety net as low income people, bothuninsured and newly insured, were increasingly relying onsaety net institutions or care.83 It will, thereore, be importantto examine the distribution and scope o DSH payments,both preceding and ollowing implementation, especially inlocalities which currently have and are likely to continue to have

large uninsured and undocumented immigrant populations.Tis assessment will help determine the current role o DSHpayments in caring or vulnerable communities, as well asinorm the uture role and composition o the saety net andrelated access issues central to racially and ethnically diversecommunities.

Secondly, the new law supports actions to strengthen Medicaiddrug rebate programs, eective upon enactment. While manystates voluntarily provide prescription drug coverage throughMedicaid, a ederal mandate will ensure a minimum levelplaying eld or access to this benet, and could potentiallyimprove compliance with physician-recommended prescriptiondrug regimens among low income populations. However,ensuring equity in communities o color will require monitoringand comparing the distribution and utilization o Medicaidprescription drugs by small geographic areas.84

Finally, among other provisions, the new law simplieshealth insurance administration by authorizing thedevelopment o national standards or interoperable systemso enrollment; provides grants to state and local governmentsor demonstration projects or implementing inormation

technology or enrollment; and sets policies to reduceraudulent claims and waste in public programs (estimated toaccount or three to ten percent o total health care spending)through enhanced provider screening and oversight. 85

E. Public Health Initiaties

Racially and ethnically diverse communities have higherrates o morbidity and mortality as compared to their whitecounterparts across a broad range o disease conditions.Improving the health status o these populations will requireexplicit support or public health programs and policiesdesigned to improve health care knowledge, prevention, andadherence to treatment, as well as to overcome barriers in theareas o culture, language and health literacy.

One year ollowing enactment, the ACA mandates the creationo a National Prevention, Heath Promotion and PublicHealth Council to coordinate and promote health-relatedpolices across multiple sectors and agencies at the ederallevelincluding health, agriculture, education, labor, andtransportation (able 11). Te new law also creates a Prevention

and Public Health Fund, which will be appropriated $7 billionin unding or scal years 2010 through 2015 and $2 billionor each scal year thereaer, to support prevention, wellness,and other public health activities. Furthermore, the lawexplicitly acknowledges the need or the CBO to develop newmethodologies or scoring prevention and wellness. Neither

appropriations nor deadlines, however, are specied within thisSection.

Table 11. Public Health Initiatives Section No.

National Prevention & Public Health Council 4001

Prevention & Public Health Fund 4002

Childhood obesity demonstration projects 4306

National diabetes prevention program 10501

New methods for scoring prevention/wellnessprograms 4401

Education campaign for breast cancer 10413

In addition, the ACA authorizes $25 million (FY 2010-2014) in unding or demonstration projects to develop acomprehensive and systematic model or reducing childhoodobesity. Nearly one in our Arican American children (ages6-17) is overweight, compared with one in seven white

children.86

Rates or Arican American teenage girls areespecially alarming, with 40 percent being overweight or at riskor overweight.87 Recognizing these disparities, new modelsand programs will need to be culturally and linguisticallyappropriate and include measurable objectives or evaluatingnot only the success in curbing obesity rates, but also assessingany unintended psychosocial consequences.88

Acting through the CDC, the legislation also includes support($9 billion or each year between 2010 and 2014) or a nationalcampaign to increase knowledge about breast health. Giventhat Arican American women have the highest rates o breast

cancer mortality,89

this is an especially important objectiveor improving knowledge, screening behavior and adherenceto treatment among this population. Finally, through theCDC, the ACA mandates the creation o a National DiabetesPrevention Program to support community-based preventioninitiatives. Tis initiative also holds signicant importance orArican Americans, whose prevalence o diabetes is 65 percenthigher than whites, and or whom obesity rates are 50 percenthigher.90 However, neither appropriations nor a timeline arespecied or this provision.


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F. Social Determinants o Health

Disparities in health and health care are largely a product osocial and economic inequalities as well as those related tolocation (e.g., inner city, areas isolated rom needed services).Tereore, eorts to successully reduce health disparities

require an understanding o how polices beyond the traditionaldomains o health and health careeducation, transportation,housing, and employment, or exampleimpact health.Te health care reorm law incorporates strategies thatutilize a collaborative approach and span multiple sectorso the economy and ederal government to improve overallcommunity inrastructures and population health (able 12).

Table 12. Social Determinants of Health Section No.

Health Impact Assessments 4003

CPSTF review/recommend interventions in socialcontext 4003

Community Transformation Grants 4201

Non-profit hospital community needs-assessment 9007

Primary Care Extension Program 5405

Te new law tasks the Community Preventive Services askForce (CPSF) with developing topic areas or new preventive

interventions and recommendations that consider social,economic and physical environments o communities.92 Te lawalso authorizes the ask Force to review the health eects ointerventions at least once every ve years using methodologiesthat include Health Impact Assessments (HIAs). HIAs can bevaluable or evaluating potential adverse health consequencesassociated with policies and interventions across a range osectors beyond the health care system. For example, theycan monitor the health consequences o environmental riskactors, such as air pollution, heat exposure, and proximity totoxic wastes, as well as inorm policies that reduce exposureto environmental risk actors or asthma and other chronic

diseases.93 Racially and ethnically diverse communities aredisproportionately exposed to environmental degradation andhazards, and these disparities remain unchanged since theywere rst documented 20 years ago.94 Te eorts o the askForce, thereore, represent important steps or monitoringand improving the health and related social, economic andenvironmental conditions that characterize racially andethnically diverse communities. Te new law also encouragesprimary care physicians to address social determinants o healththrough community-based eorts.

Finally, the ACA, acting through the CDC, will awardcompetitive Community ransormation Grants (CGs) toencourage development o community inrastructures andprograms that support healthy liestyles in neighborhoods,schools, worksites, and restaurants, and to help communitiesprioritize strategies or reducing racial/ethnic disparities.

Community-centric eorts that look beyond the health caresector to improve community health have great potential toreduce longstanding social inequalities that adversely impactthe health o racial/ethnic sub-populations. However, severalprovisions embedded in the law that address these importantissues (e.g., HIAs, CGs), largely lack specicity, particularlyaround unding and whether su cient dollars will be madeavailable or meaningul impact in the community.


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IV. LEVERAGING THE POTENTIAL OFHEALTH CARE REFORM TO REDUCEDISPARITIES

Health care reorm, as envisioned within the scope and sweep othe ACA, oers the greatest opportunity in at least a generation

to improve health equity and reduce disparities. From reducingnancial barriers to access and improving quality to its manyrace, ethnicity and language-specic provisions, the newlaw directly targets longstanding, entrenched problems thathave rustrated progress in improving patient outcomes andpopulation health. I implementation achieves the intendedobjectives, this law will have a proound impact on reducingracial/ethnic health disparities or decades to come.

At the same time, the ACA is not a disparities panacea. Manypriorities or improving health and health care or raciallyand ethnically diverse populations and communities remainunaddressed, unclear or not ully realized. Nonetheless, aspresented in the ollowing narrative, the ACA oers a platormto improve the delivery o health care at the communityand provider levels or diverse populations. Te communitydiscussion in particular highlights the need to create incentivesand initiatives that integrate health services and treatment withhousing, transportation and other programs. Te intended goalis developing evidence-based, community-ocused strategies toeliminate the causes and perpetuation o disparities in illnessand disease.

A. Adancing the Health o Communities

Te goals o improved access, nancial aordability and greaterquality o care that lead to improved health or residents lieat the heart o health care reorm and the laws provisionsrefect these priorities. oward these goals, specic language inthe ACA supports Community ransormation Grants thattarget neighborhood-level concerns. Other initiatives includecommunity needs and health impact assessments that willassist or direct public health and health care institutions tomeasure and report the community benet o their services to

the populations and neighborhoods they serve. Nonetheless,addressing the legacy o segregation and entrenched communitybarriers will require greater attention to social determinants andother issues o place that perpetuate disparities, and whichcannot be eliminated by the health care sector alone. wo areaso concentration could urther the vision and goals o healthcare reorm.

Leeraging support or community-based strategies andengagement in reducing disparities. Progress towardeliminating racial/ethnic health disparities will requirecommunities to be active and involved in setting overallobjectives, specic goals and strategies or achieving them.Examples o this recognition at the ederal level are evident,

or example, in a Center or Medicare and Medicaid Servicesinitiative that requires the involvement o community healthworkers in Medicare diabetes disease management or diversepopulations. Health care provider organizations have alsoacknowledged that achieving health and public health goalswill, in large part, depend on active community engagementthroughout planning, implementation and review.95Community-based participatory research has also gainedprominence among investigators. And yet, while there is greateracknowledgement o the critical role o community engagemenin addressing health disparities, active participation o aected

populations in the planning and assessment o community-based initiatives is oen missing.

Health reorm provides a platorm or individuals, providersand researchers to learn rom and inorm diverse communitiesto ensure that policy ts the context where people live andwork. Such collaboration can begin to address a litany oneighborhood and health care barriers such as communitydistrust and skepticism about attention to community needs,while educating health care proessionals about communityhealth priorities, and empowering individuals to become activeparticipants in designing what works best or their settings.

Embedding community engagement requirements into health-related initiatives will help assure that the context remainsront and center.

Promoting integrated strategies across health and socialserices to improve the health o dierse communities.Poverty, inadequate transportation, unsae neighborhoods,ood insecurity, segregation and other circumstances o placetake such signicant tolls on individual and communityhealth and well being that their eects oen impede, i notnegate, eorts to improve the health o racially and ethnicallydiverse communities.96 In act, in many communities, ailure o

state and local governments and the private sector to addressand resolve a broad range o social problemshousing,homelessness, violence, domestic abuse and other conditionsand circumstanceshas le many community hospitals, theiremergency rooms and clinics to deal with the consequences:disease, disability and death.97 Working to reduce other socialdisparities that greatly infuence short-, intermediate- and longterm-health will require direct, concerted research, policy andprograms that seek to alter signicantly the negative infuenceo social determinants on diverse communities.


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Te ACAs provisions or Community ransormation Grantsand other related initiatives oer opportunities to test orbring to scale innovative community-based strategies thatcoordinate social and health services to t individual andamily circumstancesi adequately unded. Communityaccountability or these ederally-sponsored initiatives should

include setting goals or reducing health disparities, developingmeasures to assess progress, and rewarding success andimprovement.

B. Health Care Organization-based Initiaties

As health equity, including reducing disparities, is animportant objective o the new law, organizations willace new opportunities and challenges in implementingrelated provisions. Saety net providers may be especiallywell positioned to take advantage o new incentives given

their mission, location and history. But other healthcareorganizations may be much less amiliar with eectivelyaddressing the needs o racially and ethnically diverse patients.Moreover, certain health care system or service programsand policies may create or perpetuate what has been called,institutionalized racism in health care.98 As stated by the IOM,it is importantto examinethe health care system, broadlydened, to determine whether there are policies and practices inplace that have the eect o discriminating against communitieso color.99 Further, the best eorts o health care proessionalswill be limited i not negated without knowledgeable andormal commitment rom their practice settings. Analysis andresearch have similarly reinorced this priority, acknowledgingthe dierences o communicating between racial/ethniccultures and the culture o medicine.100

Tis section identies two specic organization-basedinitiatives intended to assure eective implementation ohealth care reorms vision or diverse patients and populations.In discussing related roles and responsibilities, a nalrecommendation in this section discusses the importance opreserving one specic sector with considerable experience incaring or large numbers o immigrants and other diverse and

underserved populationssaety net organizations.Deeloping and testing model programs that link specicorganizational eforts to reducing disparities and improvingquality o care. Many research, program and policy expertsas well as community representatives contend that reducingdisparities requires signicant involvement and support ohealth care organizations.101 In essence, individual practitionersor single divisions within a health care setting can go only so arin addressing language needs, improving cultural competence

and reducing disparities. For sustainable success to occur,these organizations must commit to supporting practitionersthrough more comprehensive and active engagement in caringor diverse patientsa conclusion implied in the spectrum orelated priorities identied in the ACA. And yet, beyond a ewstudies and positive evidence around addressing the needs o

patients with limited English prociency, little inormationexists that validates these assumptions. Similarly, there is littleguidance available that providers can use to adapt and apply totheir unique settings.

Within the new health care reorm law, research anddemonstration projects aim to undertake and documentinitiatives to improve quality o care and outcomes or raciallyand ethnically diverse patients (e.g., high perormance healthsystems that integrate race, culture and language into servicesand structure, and demonstrate improved care processes andoutcomes or these patients). Rigorous testing, measurementand assessments o structure, process and patient outcomesshould accompany these eorts. Strategies may ocus onbuilding programs around specic disease conditions anddiverse patient populations and investment in organizationinrastructure and service, program and management unctions.

Documenting and linking non-prot community needsassessment/benet requirements to health care reormincenties to address disparities. As noted, the ACAintroduces numerous incentives and/or requirements or healthcenters, clinics and hospitals with the explicit goal o reducing

disparities. Some eorts are designed to support monitoringpatterns in disparities, while others, such as improvingworkorce diversity and cultural competence education, areintended to increase the cultural mix o practitioners and createmore inormed and skilled health care proessionals. Still othereorts are designed to make navigation o access to insuranceand services more culturally and linguistically appropriate.

aking actions to reduce disparities through improving culturalcompetence has gained visibility and importance in recentyears. Saety net acilitiespublic and certain non-prothospitals and community health centers, in particularhave

implemented important training, education and serviceprograms to improve care or diverse communities andpatients. However, it is ar rom certain whether health careorganizations generally, to date, have undertaken many or, insome cases, any o these or related actions. Moreover, theircurrent capacity, drive or increasing market share, or nancialconstraints or concerns may lead them to not see culturalcompetence, language assistance specically, nor disparitiesmore broadly, as priorities.


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Health care reorm introduces or strengthens leverssuch as community benet and certain race- and culture-oriented incentives that, i eectively used, can work tobring organizations to recognize the need or elevating theimportance o what it takes to improve the health o raciallyand ethnically diverse patients. However, it may well be

necessary to signicantly reach beyond demonstrations andunding opportunities to require provider organizations toshow evidence o working to reduce identied disparitiesin the communities they serve through training, education,community outreach, service, language assistance and otherprograms.

Presering and transitioning the health care saety net.For decades, public and non-prot hospitals, communityhealth centers and ree or reduced ee clinics have played acore and central role in caring or uninsured, Medicaid andracially and ethnically diverse populations in the U.S. Manyhave served vital roles in providing underserved populationswith lie-saving services such as trauma and emergency care,specialty services such as burn and neonatal intensive care,and emergency response as well as primary care. However,while the ACA provides substantial resources to support andexpand community health centers, the role o and assistancerelated to other saety net sectors who serve a critical role incaring or diverse patients and communities is more open inot uncertain or dierent reasons. Saety net hospitals greatlydependent on Medicaid and Medicare DSH payments arescheduled or signicant reductions to nance the health care

reorm legislation. Many philanthropic and other organizationsthat support ree or reduced ee clinics may be questioningthe need or continued support or such services with thenancial enranchising o so many historically uninsuredindividuals.102 Tese sectors will remain critical to maintaininga viable and essential saety net, particularly as health carereorm, or the most part, excludes an estimated 12 millionundocumented immigrants. Others such as lawul residentsand immigrants may not participate based on choice, distrustor other reasons. Additionally, there is an extended transitionperiod during which many will remain uninsured. Finally, theextensive experience o hospitals and clinics in caring or diversecommunities and populations may well be lost.

Preserving a strong saety net o hospitals, community healthcenters and clinics will need to be at the core o uture healthcare priorities. Tis will likely require direct support to saetynet hospitals, particularly in regions with large uninsuredand undocumented immigrants, to continue their servicesor underserved patients. Tese providers may also requirehelp in adapting health inormation systems and other critical

components o their inrastructure as they work to balancetheir continued saety net and essential community providerunctions with a more mainstream and integrated role in healthcare. Finally, philanthropic and other organizations supportingsaety net clinics may need guidance that reinorces both theirimportant role and the most benecial application o their

resources, including new ideas or leveraging their saety netrolee.g., new saety net partnerships and collaborationsinthe era o health reorm.103

C. Indiidual-leel Initiaties

Research and experience documenting the incidence andprevalence o disparities-related conditions, as well as theirconsequences or racially and ethnically diverse patients,provided a substantial evidence base or many o the initiativesincluded within the ACA. However, knowledge gaps remain as

to why disparities in outcomes remain. Tis section identiestwo research and service priorities that build on the intent andobjectives o health care reorm.

Deeloping efectie care/disease management and selmanagement interentions and protocols or dierse

patients. Even beore health care reorm, considerable eortswere underway to develop a strong evidence base or caremanagement and sel management o chronic disease. Akey goal is to improve patient understanding and adherenceto treatment, and promote greater individual and amilyinvolvement with care. New programs included in the

ACA need to address how and to what extent inattentionto race, culture, language and literacy concerns may createimpediments to care management and sel management.Adoption o clinically valid interventions based in culturalcompetence should contribute signicantly to improvingoutcomes, reducing medical errors due to misunderstandingand resistance, and decreasing unnecessary costsall centralgoals o health care reorm. Perormance reporting and pay-or-perormance or other incentives may be appropriate tools toencourage practitioners to adopt culturally competent, evidencebased practices.

Mitigating the efects o oerweight/obesity and negatieenvironmental actors that may impede progress on reducingdisparities. A historic lack o access to timely health care hascontributed to deep-rooted disparities in health status andoutcomes. Health care reorm will likely have a signicantand positive impact on reducing these barriers. However,higher rates o overweight and obesity among racially/ethnically diverse populations104, and the socio-economic andenvironmental conditions that contribute to these rates, have


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the potential to signicantly impede progress in closing thehealth disparities gap, particularly or consequences o thiscondition, or example chronic diseases such as diabetes. At thesame time such conditions may be acting as a counterweight toprogress in reducing disparities on other ronts.

Individuals and amilies with limited resources, many o whomare disproportionately rom racially and ethnically diversecommunities, will struggle to reduce their health risks rombeing overweight or obese without greater practitioner/healthcare organization comprehension o their culture and thechallenges they ace. Moreover, as community-based initiativesare implemented under the ACA, as described earlier, theirpotential eectiveness may be limited without including eortsto expand access to aordable, nutritious ood, sae places toexercise in disadvantaged neighborhoods, provide culturallyand linguistically appropriate consumer education, and positivereinorcement rom local public health and medical providers.Strategically linking many o health care reorms goals withactions to address this urgent priority among diverse residentsmay be necessary to show true progress in reducing disparities.


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V. CONCLUSION

Te ACA and its provisions to improve access, aordabilityand quality o carein supporting comprehensive action toimprove health and health services or racially and ethnicallydiverse patients and communitieslays a strong oundation

or eliminating the legacy o health disparities. In lookingorward, this new law has the potential to seed, promote andguide diversity initiatives in this country or decades to come.Realizing its vision will do much to promote the longstandingpromise o equality and equity or all.


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NOTES & REFERENCES

1 Smedley, B, Stith, A., Nelson, A. (eds). (2003). Unequalreatment: Conronting Racial and Ethnic Disparities inHealth Care. Institute o Medicine Washington, DC, 2001.

2 US Census Bureau. (August 14, 2008). An older andmore diverse nation by midcentury. Retrieved June 16, 2010,rom http://www.census.gov/newsroom/releases/archives/population/cb08-123.html.

3 Congressional Budget O ce. (2010). Cost estimatesor health care legislation. H.R. 4872, Reconciliation Acto 2010 (Final Health Care Legislation). Retrieved June 16,2010, rom http://www.cbo.gov/pdocs/113xx/doc11379/AmendReconProp.pd.

4 Smedley, B. ( June 23, 2009). Addressing racial and

ethnic health inequities: ri-Committee discussion draor health care. House Energy and Commerce Committee,Health Subcommittee. Retrieved June 16, 2010, rom http://energycommerce.house.gov/Press_111/20090623/testimony_smedley.pd.

5 Ulmer, C., McFadden, B., & Nerenz, D.R. (2009). Race,ethnicity, and language data: Standardization or healthcare quality improvement. Subcommittee on StandardizedCollection o Race/Ethnicity Data or Healthcare QualityImprovement, Institute o Medicine. Retrieved June 16, 2010,rom http://www.nap.edu/catalog.php?record_id=12696.

6 Perot, R.. & Youdelman, M. (2001). Racial, ethnic, andprimary language data collection in the health care system: Anassessment o ederal policies and practices. New York: TeCommonwealth Fund. Retrieved June 16, 2010, rom http://www.commonwealthund.org/Content/Publications/Fund-Reports/2001/Sep/Racial--Ethnic--and-Primary-Language-Data-Collection-in-the-Health-Care-System--An-Assessment-o-Fed.aspx.

7 Brittingham, A. & de la Cruz, G.P. (2004). Ancestry: 2000.US Census Bureau. Retrieved June 16, 2010, rom http://www.

census.gov/prod/2004pubs/c2kbr-35.pd.

8 Perot, R. & Youdelman, M. (2001).

9 Ibid.

10 Hasnain-Wynia, R., Pierce, D. & Pittman, M.A. (2004).Te Commonwealth Fund. Who, when, and how: Tecurrent state o race, ethnicity, and primary language datacollection in hospitals. Retrieved June 16, 2010, rom http://www.commonwealthund.org/Content/Publications/Fund-Reports/2004/May/Who--When--and-How--Te-Current-

State-o-Race--Ethnicity--and-Primary-Language-Data-Collection-in-Ho.aspx.

11 Smith, .W. (1997). Measuring race by observationand sel-identication. National Opinion Research Center.University o Chicago. GSS Methodological Report, No. 89.Retrieved June 16, 2010, rom http://cloud9.norc.uchicago.edu/dlib/m-89.htm.

12 Moscou, S., Anderson, M.R., Kaplan, J.B., et al. (2003).Validity o racial/ethnic classications in medical records data:An exploratory study. American Journal o Public Health,

93(7): 10841066.

13 Billheimer, L.. & Sisk, J.E. (2008). Collecting adequatedata on racial and ethnic disparities in health: Te challengescontinue. Health Aairs, 27(2): 383-391.

14 Lopez, A. (2002). Middle Eastern populations inCaliornia: Estimates rom the Census 2000 SupplementarySurvey. Center or Comparative Studies in Race and Ethnicity,Stanord University. Retrieved June 21, 2010, rom http://ccsre.stanord.edu/reports/report_10.pd.

15 Flores, L. & Moon, D. (2002). Rethinking race, revealingdilemmas: Imagining a new racial subject in race traitor.Western Journal o Communication, 66(2): 181207.

16 Perot, R. & Youdelman, M. (2001).

17 Smedley, B.D., Butler, A.S. & Bristow, L.R. (2004). In theNations Compelling Interest: Ensuring Diversity in the Health-Care Workorce. Washington, DC: Institute o Medicine.

18 Cohen, J.J., Gabriel, B.A., & errell, C. (2002). Te caseor diversity in the health care workorce. Health Aairs, 21(5):

90-102.19 Kington, R., isnado, D. & Carlisle, D.M. Increasingracial and ethnic diversity among physicians: An interventionto address health disparities? in, Smedley, BD., et al. (2001).Te Right Ting to Do, Te Smart Ting to Do: EnhancingDiversity in the Health Proessions. Washington, DC: NationalAcademy Press.


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20 Cohen, J.J., Gabriel, B.A., & errell, C. (2002).

21 Ibid.

22 Smedley, B.D., Butler, A.S. & Bristow, L.R. (2004).

23 American Public Health Association. (2009). PublicHealth Services Act itle VII and itle VIII: Why are theseprograms so important? Retrieved June 21, 2010, rom http://www.apha.org/NR/rdonlyres/13E647B5-E51B-4A47-91A8-652EE973A2DB/0/itleVIIanditleVIII.pd.

24 Green, A.R., et al. (2008). Providing culturally competentcare: Residents in HRSA itle VII unded residency programseel better prepared. Academic Medicine, 83(11): 1071-1079.

25 Rittenhouse, D.R., et al. (2008). Impact o itle VIItraining programs on community health center sta ng andNational Health Service Corps participation. Annals o FamilyMedicine, 6(5): 397-405.

26 Witmer, A., Seier, S.D., Finocchio, L., et al. (1995).Community health workers: integral members o the healthcare work orce. American Journal o Public Health, 85(8 Pt 1):1055-1058.

27 Smedley, B.D., Butler, A.S. & Bristow, L.R. (2004).

28 errell, C. & Beaudreau, J. (2003).

29 Mead, H., et al. (2008). Racial and ethnic disparities in

US health care: A chartbook. New York: Te CommonwealthFund.

30 Beach, M.C., Saha, S., & Cooper, L.A. (2006). Terelationship o cultural competence and patient-centerednessin health care quality. New York: Te CommonwealthFund. Retrieved June 21, 2010, rom http://www.commonwealthund.org/~/media/Files/Publications/Fund%20Report/2006/Oct/Te%20Role%20and%20Relationship%20o%20Cultural%20Competence%20and%20Patient%20Centeredness%20in%20Health%20Care%20Quality/Beach_rolerelationshipcultcomppatient%20

cent_960%20pd.pd.

31 O ce o Minority Health. (2002). National standardsor culturally and linguistically appropriate services in healthcare. Washington, DC: US Department o Health and HumanServices.

32 Brach, C. & Fraserirector, I. (2000). Can culturalcompetency reduce racial and ethnic health disparities? Areview and conceptual model. Medical Care Research andReview, 57(1): 181-217.

33 Rashid J.R., Spengler. R.F., Wagner, R.M., et al. (2009).

Eliminating health disparities through transdisciplinaryresearch, cross-agency collaboration, and public participation.American Journal o Public Health, 99(11):1955-1961.

34 Tompson, G.E., Mitchell, F. & Williams, M.B. (2006).Examining the Health Disparities Research Plan o the NationaInstitutes o Health. Washington, DC: Institute o Medicine.

35 Federal Coordinating Council or ComparativeEectiveness Research. ( June 30, 2009). Report to the Presidenand the Congress. Retrieved July 6, 2009, rom http://www.hhs.gov/recovery/programs/cer/cerannualrpt.pd.

36 Howell, E., et al. (2003). Racial dierences in reportedpostpartum depression. AcademyHealth Meeting Abstract,20(236). Retrieved June 21, 2010, rom http://gateway.nlm.nih.gov/MeetingAbstracts/ma?=102275218.html.

37 Tompson, G.E., Mitchell, F. & Williams, M.B. (2006).Examining the Health Disparities Research Plan o the NationaInstitutes o Health: Unnished Business. Washington, DC:Institute o Medicine.

38 Davis, D.A. & aylor-Vaisey, A. (1997). ranslating

guidelines into practice. A systematic review o theoreticconcepts, practical experience and research evidence in theadoption o clinical practice guidelines. Canadian MedicalAssociation Journal, 157(4): 408-416.

39 King, .E. (2002). Racial disparities in clinical trials. NewEngland Journal o Medicine, 346(18):1400-1402.

40 Murthy, V.H., Krumholz, H.M. & Gross, C.P. (2004).Participation in cancer clinical trials: race-, sex-, and age-baseddisparities. Journal o the American Medical Association,291(22):2720-2726.

41 Baylor College o Medicine. (2010). EliminatingDisparities in Clinical rials. Retrieved June 21, 2010, romhttp://www.bcm.edu/edict/home.html.

42 LaVeist, .A., Gaskin, D.J. & Richard, P. (2009). Teeconomic burden o health inequalities in the United States.Washington, DC: Te Joint Center or Political and EconomicStudies. Retrieved June 21, 2010, rom http://www.jointcenter.org/hpi/sites/all/les/Burden_O_Health_FINAL_0.pd.


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43 Finer, L. & Henshaw, S. (2006). Disparities in rates ounintended pregnancy in the United States, 1994 and 2001.Perspectives on Sexual and Reproductive Health, 38(2): 9096.

44 Centers or Disease Control and Prevention. (2008).HIV/AIDS surveillance report: Cases o HIV inection and

AIDS in the United States and dependent areas, by race/ethnicity, 2007. Retrieved June 21, 2010, rom http://www.cdc.gov/hiv/topics/surveillance/resources/reports/2007report/deault.htm.

45 American Academy o Pediatrics, Council on Childand Adolescent Health. (1998). Te role o home-visitationprograms in improving health outcomes or children andamilies. Retrieved June 28, 2010, rom http://aappolicy.aappublications.org/cgi/reprint/pediatrics;101/3/486.pd.

46 Dietrich, ., et al. (2008). Racial and ethnic disparities in

childrens oral health: the National Survey o Childrens Health.Journal o the American Dental Association, 139(11): 1507-1517.

47 Vernon, J.A., et al. (2007). Low health literacy:Implications or national health policy. Retrieved June 21, 2010,rom http://www.nps.org/askme3/pds/Case_Report_10_07.pd.

48 US Census Bureau. (2007). Population 5-years or olderwho speak English less than very well.

49 US Congress. S. 1790: Indian Health Care ImprovementReauthorization and Extension Act o 2009. Dorgan, B.Retrieved June 21, 2010, rom http://www.govtrack.us/congress/bill.xpd?bill=s111-1790.

50 O ce o the General Counsel, US Commission on CivilRights. (2004). Native American health care disparities brieng.Retrieved June 21, 2010, rom http://www.law.umaryland.edu/marshall/usccr/documents/nativeamerianhealthcaredis.pd.

51 Centers or Disease Control and Prevention. (2008).Behavioral Risk Factors Surveillance Systems. Adults aged 18-

64 who have any kind o health care coverage. Retrieved June21, 2010, rom http://apps.nccd.cdc.gov/BRFSS/race.asp?cat=HC&yr=2008&qkey=880&state=UB.

52 Kaiser Family Foundation. (2010). Optimizing Medicaidenrollment: Perspectives on strengthening Medicaids reachunder health care reorm. Retrieved June 21, 2010, rom http://www.k.org/healthreorm/upload/8068.pd.

53 James, C., Schwartz, K., & Berndt, J. (2009). A prole oAmerican Indians and Alaska Natives and their health coverageKaiser Family Foundation. Retrieved June 21, 2010, romhttp://www.k.org/minorityhealth/upload/7977.pd.

54 Smedley, B.D. (2008). Moving beyond access: Achieving

equity in state health care reorm. Health Aairs, 27(2): 447-455.

55 Doty, M.M. & Holmgren, A.L. (2006). Health CareDisconnect: Gaps in Coverage and Care or Minority Adults:Findings rom the Commonwealth Fund Biennial HealthInsurance Survey. New York: Commonwealth Fund Issue Brie.

56 Kaiser Family Foundation. (2010). Summary o CoverageProvisions in the Patient Protection and Aordable CareAct. Retrieved June 15, 2010 rom http://www.k.org/healthreorm/upload/8023-R.pd.

57 Kaiser Family Foundation. (2009). Medicaid and stateunded coverage income eligibility limits or low-incomeadults, 2009. State Health Facts. Retrieved November 4,2009, rom http://www.statehealthacts.org/comparereport.jsp?rep=54&cat=4.

58 Kaiser Family Foundation. (2009). Health insurancecoverage o the total population, states (2007-2008), US(2008). State Health Facts. Retrieved November 4, 2009, romhttp://www.statehealthacts.org/comparetable.jsp?typ=2&ind=125&cat=3&sub=39&sortc=6&o=a.

59 Doty, M.M. & Holmgren, A.L. (2006).

60 Lowrey, Y. (2007). Minorities in Business: ADemographic Review o Minority Business Ownership. SmallBusiness Administration. Retrieved November 6, 2009, romhttp://www.sba.gov/advo/research/rs298tot.pd.

61 Kaiser Family Foundation. (2009). Health Reorm andCommunities o Color: How Might it Aect Racial and EthnicHealth Disparities? Facts on Health Reorm.

62 Ibid.

63 Wick, E. (2002). Health insurance purchasingcooperatives. Te Commonwealth Fund. Retrieved October2, 2009, rom http://www.commonwealthund.org/~/media/Files/Publications/Issue%20Brie/2002/Nov/Health%20Insurance%20Purchasing%20Cooperatives/wicks_coops%20pd.pd.


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64 Mead et al. (2008). Racial and ethnic disparities in U.S.health care: A chartbook. New York: Te CommonwealthFund.

65 Mertens, M. (March 24, 2010). Health Care or AllLeaves 23 Million Uninsured. NPR. Retrieved June 29, 2010

rom http://www.npr.org/blogs/health/2010/03/health_care_or_all_minus_23_m.html.

66 Raymond A. (2007). Te 2006 Massachusetts HealthCare Reorm Law: Progress and Challenges Aer One YearImplementation. Retrieved June 10, 2010 rom http://masshealthpolicyorum.brandeis.edu/publications/pds/31-May07/MassHealthCareReormProgess%20Report.pd.

67 Ibid.

68 National Association o Community Health Centers.

(2007). Access Denied: A Look into Americas MedicallyDisenranchised. Last r

healtcare bill

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