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
National Institute on Minority Health and Health Disparities
2013 NIMHD Translational Health Disparities Course
• 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.
National Institute on Minority Health and Health Disparities
2013 NIMHD Translational Health Disparities Course
60+ Provisions Addressing Disparities in the ACA
National Institute on Minority Health and Health Disparities
2013 NIMHD Translational Health Disparities Course
2010 Report Outlining ACA’s Opportunities & Requirements for Addressing Health Disparities
National Institute on Minority Health and Health Disparities
2013 NIMHD Translational Health Disparities Course
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!
National Institute on Minority Health and Health Disparities
2013 NIMHD Translational Health Disparities Course
• 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.
National Institute on Minority Health and Health Disparities
2013 NIMHD Translational Health Disparities Course
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
National Institute on Minority Health and Health Disparities
2013 NIMHD Translational Health Disparities Course
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
National Institute on Minority Health and Health Disparities
2013 NIMHD Translational Health Disparities Course
• 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
National Institute on Minority Health and Health Disparities
2013 NIMHD Translational Health Disparities Course
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.
National Institute on Minority Health and Health Disparities
2013 NIMHD Translational Health Disparities Course
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
National Institute on Minority Health and Health Disparities
2013 NIMHD Translational Health Disparities Course
• $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
National Institute on Minority Health and Health Disparities
2013 NIMHD Translational Health Disparities Course
• 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.
National Institute on Minority Health and Health Disparities
2013 NIMHD Translational Health Disparities Course
• 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
National Institute on Minority Health and Health Disparities
2013 NIMHD Translational Health Disparities Course
Workforce Capacity & Diversity in the ACA
National Institute on Minority Health and Health Disparities
2013 NIMHD Translational Health Disparities Course
• 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
National Institute on Minority Health and Health Disparities
2013 NIMHD Translational Health Disparities Course
ACA & Disparities Data, Research, & Quality Improvement Opportunities
National Institute on Minority Health and Health Disparities
2013 NIMHD Translational Health Disparities Course
Tangible Opportunities for Addressing Disparities through Research & Innovation
National Institute on Minority Health and Health Disparities
2013 NIMHD Translational Health Disparities Course
• 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?
National Institute on Minority Health and Health Disparities
2013 NIMHD Translational Health Disparities Course
ACA & Public Health Programs Addressing Disparities
National Institute on Minority Health and Health Disparities
2013 NIMHD Translational Health Disparities Course
• 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
National Institute on Minority Health and Health Disparities
2013 NIMHD Translational Health Disparities Course
Aligning CLAS Standards with
the ACA to the ACA to Address
Disparities
National Institute on Minority Health and Health Disparities
2013 NIMHD Translational Health Disparities Course
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
National Institute on Minority Health and Health Disparities
2013 NIMHD Translational Health Disparities Course
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.
National Institute on Minority Health and Health Disparities
2013 NIMHD Translational Health Disparities Course
Dennis P. Andrulis, PhD, MPHSenior Research Scientist, Texas Health Institute
Associate Professor, University of Texas School of Public [email protected]
Contact Information
Nadia J. Siddiqui, MPHSenior Health Policy Analyst, Texas Health Institute
Website: http://www.texashealthinstitute.org/health-care-reform.html