Overview ACAs Vision, Promise, and Background Design to Monitor - - PDF document

3/19/2013 1

The Affordable Care Act & Opportunity for Advancing Racial & Ethnic Health Equity

Taking Vision and Promise to Reality

Presenters:

Dennis P. Andrulis, PhD, MPH, Senior Research Scientist Nadia J. Siddiqui, MPH, Senior Health Policy Analyst Maria R. Cooper, MA, Health Policy Analyst Texas Health Institute Lauren R. Jahnke, MPAff, Consultant LRJ Research & Consulting

8th National Conference on Quality Healthcare for Culturally Diverse Populations March 7, 2013 | Oakland, California

Funded by: W.K. Kellogg Foundation, The California Endowment, and Kaiser Permanente Community Benefit National Program Office

Overview

• ACA’s Vision, Promise, and Background
• Design to Monitor ACA through an Equity Lens
• Implementation Progress of Equity Provisions

– Health Insurance Exchanges – Health Care Safety Net – Workforce Support and Diversity – Data, Research, and Quality – Public Health and Prevention

• Where Do We Go from Here?

3/19/2013 2

ACA’s Vision and Promise

• Working to eliminate health disparities and

advance health equity is central to the Affordable Care Act (ACA) of 2010

• Over three dozen provisions directly advance

racial and ethnic health equity, diversity, and cultural and linguistic competence

• Dozens of other general provisions with major

implications for racially and ethnically diverse populations

History & Scope of Work

2008 2010

• Joint Center Report: Advancing Health Equity for

Racially and Ethnically Diverse Populations

• Joint Center Report: Advancing Health Equity for

Racially and Ethnically Diverse Populations

2011

• Federal agency progress on ACA & Equity
• Health Affairs article on ACA & Safety Net
• Federal agency progress on ACA & Equity
• Health Affairs article on ACA & Safety Net

2012- 2014

• ACA & Racial and Ethnic Health Equity Series:

Comprehensive Tracking of implementation progress, emerging guidance & programs

• ACA & Racial and Ethnic Health Equity Series:

Comprehensive Tracking of implementation progress, emerging guidance & programs

• Obama vs. McCain Health Care Proposal Analysis
• House & Senate Health Reform Bills Analysis

3/19/2013 3

Design

• Utilized a “health equity lens” to monitor

implementation of 60+ provisions in the ACA with mention of or implications for racially and ethnically diverse populations across five areas:

– Health Insurance Exchanges – Health Care Safety Net – Workforce Support and Diversity – Data, Research, and Quality – Public Health and Prevention

Methodology

• Extensive review of peer-reviewed research and

national/state policy reports for each provision

Literature Review

• Federal rules and guidance
• Funding opportunity announcements
• Workgroups, collaborative opportunities

Federal Policy and Actions

• State and local progress and programs
• Related legislative actions
• Emerging opportunities and challenges

State and Local Actions

• Federal and state government
• Hospitals, health centers, health plans
• Community organizations, advocates
• Academia and experts

Interviews with nearly 70 individuals

3/19/2013 4

Cultural and Linguistic Requirements in Health Insurance Exchanges

Project Objectives

• To track the progress of ACA provisions we

identified on exchanges and health plans in an exchange

• To identify and synthesize related resources
• To highlight model activities that we found in

selected states

• To develop recommendations for states, health

plans, federal agencies, and others to ensure effective implementation of cultural and linguistic requirements of the ACA

3/19/2013 5

ACA Provisions Examined

1. Section 1311(b): Establishment of State Exchanges 2. Section 1311(i): Culturally, Linguistically Appropriate Information in Exchanges 3. Section 1311(e): Plain Language Requirement for Health Plans 4. Section 1001: Culturally, Linguistically Appropriate Summary of Benefits and Uniform Glossary 5. Section 1001: Culturally, Linguistically Appropriate Claims Appeals Process 6. Section 1311(g): Incentive Payments in Health Plans for Reducing Disparities 7. Section 2901: Remove Cost Sharing for Indians below 300 Percent of the Federal Poverty Level 8. Section 1557: Non-Discrimination in Federal Programs and Exchanges

Exchange-Related Provisions

• 1. Section 1311(b): Establishment of State Exchanges

All states will have exchanges to facilitate the purchase of qualified health plans for individuals and small businesses by January 1, 2014 States can operate their own exchanges, have the federal government do it, or have a state-federal partnership exchange

• 2. Section 1311(i): Culturally, Linguistically

Appropriate Information in Exchanges

ACA and subsequent regulations require the navigator programs, applications, forms, notices from exchanges and health plans,

• utreach and education, and other information from exchanges to be

accessible to limited English proficient people and be culturally and linguistically appropriate

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State Exchange Decisions State Case Studies

• Reviewed exchange planning activities for states that stood
• ut in considering C/L competence and ones that were most
• ften cited for their progress
• Other considerations: states in different regions of the

country, relatively higher percentages of non-white and LEP populations

• Seven states chosen: California, Colorado, Connecticut,

Maryland, New York, Oregon, Washington

– all have state-based exchanges due to federal and partnership exchanges being less developed at this time

• Purpose is to provide a snapshot of selected states’ progress

in implementing the exchange provisions, and to offer experiences and models that may be useful to other states

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Summary of Case Studies - 1

Progress Related to Racial & Health Equity Actions in Exchange Development & Planning by Case Study State

CA CO CT MD NY OR WA

Diversity in board composition mentioned in the exchange legislation

Y Y Ni Y

(1)

Y Ni

Vision, mission, or values statements specifically cite diversity and disparity

• bjectives or needs

Y Ni Y Ni Ni Y Y

Diversity specified for stakeholder advisory groups

Y Ni Ni Y Ni Y Ni

Community meetings or focus groups held that target or consider racial, ethnic, and language needs

Y Y Y Y Y Y Y

*Tribal consultation policy and consulting with federally recognized tribes

Y Y Y

(2)

Y Y Y

Input from advocacy groups representing communities and patients of color

Y Y Y Y Y Y Y

Summary of Case Studies - 2

Progress Related to Racial & Health Equity Actions in Exchange Outreach, Education, and Enrollment by Case Study State

CA CO CT MD NY OR WA

*Targeted outreach and education planned for limited English proficient and specific racial and ethnic groups

Y Y Y Y Y Y Y

*Navigator/assisters program will focus on specific racial, ethnic, and language needs in enrollment

Y Y Y Y Y Y Y

*Training materials to be developed for cultural and linguistic competency of navigators/assisters

S S S Y Y S S

3/19/2013 8

Summary of Case Studies - 3

Progress Related to Racial & Health Equity Actions in Exchange Website, QHPs, and Evaluation by Case Study State

CA CO CT MD NY OR WA

*Planning for Internet web portal to provide access for limited English proficient people (such as taglines indicating availability of languages services)

Y Y Y Y Y Y Y

Planning to take cultural and linguistic competency measures into account in selecting qualified health plans for the exchange

Y (3) Ni (3) Ni Ni (3)

Planning to evaluate the success of measures addressing diversity and disparities in the exchange after operational and use the assessment for improvement

Y S Ni S Ni Ni Ni

Summary of State Progress

• The case study states have made steady progress in

incorporating C/L competency in their exchanges as required by the ACA, and in additional areas

• Many other states have been slower to get started due to

factors such as the Supreme Court cases and the elections causing delays in state government planning

• All case study states have had multiple meetings with

consumers and stakeholders, input from advocacy groups representing communities of color, are planning for targeted

• utreach, are planning for C/L competent navigators and
• ther assisters, and are planning for accessible web portals

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State Challenges Ahead

• Short deadlines and many complexities for start-up
• Funding issues and sustainability
• Reaching people who may not be familiar with

health insurance including non-English speakers, non-literate, diverse cultural groups, young adults, rural areas, mixed-citizenship families

• Educating people on the insurance mandate and the

available subsidies in the exchange

• Building trust

ACA Provisions for Health Plans

1. Section 1311(e): Plain Language Requirement for Health Plans

• Health plans in an exchange must periodically submit certain information to the

exchange in plain language and make them available to the public, and all applications and notices to enrollees must be in plain language

2. Section 1001: Culturally, Linguistically Appropriate Summary of Benefits and Uniform Glossary

• Must provide standard SBC and glossary to enrollees, employers, and others at certain

times, and in non-English languages that meet 10% threshold (already in effect and applies to all health plans)

3. Section 1001: Culturally, Linguistically Appropriate Claims Appeals Process

• Internal and external appeals processes must be C/L appropriate (already in effect and

applies to all health plans; threshold languages apply to this as well)

4. Section 1311(g): Incentive Payments in Health Plans for Reducing Disparities

• One of the activities listed for rewarding quality through market-based incentives in

the exchanges (federal guidelines not released yet so not clear on who/how)

3/19/2013 10

Summary of Health Plan Progress

• Health plans interviewed and in literature reviews

have all made good progress on implementing plain language and C/L competency measures, but there may be others that have not

• Many plans started relevant activities pre-ACA due

to Medicaid rules, customer needs, and/or for quality efforts

• Many resources are available for plain language

writing and implementing language access programs that can help other health plans and exchanges

Health Plan Challenges Ahead

• Short timelines, incomplete federal regs/guidance
• Most health plans used to marketing to employers

and not directly to individuals, but if in an exchange, will need to reach individuals as well

• Diverse populations predicted to be a significant

portion of exchange enrollees, with attendant cultural and linguistic needs

• Must translate/transcreate documents to be C/L

competent, and decide if will offer in more than the minimum threshold languages and how to distribute

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Guidance Moving Forward

1. Fully integrate diversity and equity objectives in exchange mission, objectives, and planning 2. Work with trusted advocates and representatives who are reflective of diverse communities and are culturally and linguistically competent to provide appropriate and targeted

• utreach, education, and enrollment in the exchange

3. Ensure culturally and linguistically appropriate information, resources, and communication is provided by the exchange 4. Actively share and disseminate information on experiences, promising practices, and lessons learned in addressing diversity and equity in exchange planning 5. Use active purchasing to ensure good value and high quality in health plans sold through the exchange and a reasonable number

• f choices at each benefit level

Conclusions & Areas for Future Study

• The states and health plans profiled reveal many

useful activities and best practices that can help

• thers not as far along
• Much work has been done, but much more left this

year to fully implement exchanges

• Future study on C/L competency in outreach and

education, navigator and other assisters’ training and activities, and program evaluation should reveal useful lessons

3/19/2013 12

Supporting and Transitioning the Health Care Safety Net Provisions

• Expansion of Public Programs

– Medicaid Expansion (§2001) – CHIP Reauthorization and related outreach support (§2101; §10203)

• Support for Health Centers and Clinics

– Community Health Centers (§5601) – Nurse-Managed Health Clinics (§5208) – Teaching Health Centers (§5508) – School-Based Health Centers (§4101)

• New Requirements for Safety Net Hospitals

– Reduction in Medicaid DSH Payments (§2551) – Reduction in Medicare DSH Payments (§3133) – Non-Profit Hospital Community Needs Assessment (§9007)

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Expansion of Public Programs

• Medicaid

– ACA required states to expand Medicaid income eligibility to 138% FPL, or risk losing all federal matching funds – Supreme Court ruled that states could not be coerced, thus making expansion OPTIONAL! – ACA provides 100% federal funding for new enrollees for first 3 years, with matching funds declining to 90% in 2020

• Children’s Health Insurance Program (CHIP)

– Reauthorizes CHIP until at least Oct. 1, 2015 – Adds $40 mil. to existing outreach and enrollment funds

State Decisions on Medicaid

• 24 states + DC will expand
• 14 states will not expand
• 12 states undecided
• 24 states + DC will expand
• 14 states will not expand
• 12 states undecided

3/19/2013 14

Medicaid Eligibility by Race & Ethnicity

54.9% 19.4% 18.7% 7.0% 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% White Hispanic or Latino African American Other Percent of Population with Income below 138% FPL who will be Eligible for Medicaid in 2014, by Race and Ethnicity

Source: Kenney, G.M., Zuckerman, S., Dubay, L., Huntress, M., Lynch, V., Haley, J., & Anderson. (2012). Not Opting in to the Medicaid Expansion under the ACA: Who are the Uninsured Adults Who Could Gain Health Insurance Coverage? Timely Analysis of Immediate Health Policy Issues. Robert Wood Johnson Foundation and Urban Institute.

6.8 million or 45% of Newly Eligible are Non-White

Who will be left out of Medicaid?

24 States + DC Opting for Medicaid 14 States Opting Out 12 States Undecided

< 138% FPL 3.4 mil 2.7 mil 0.7 mil < 100% FPL n/a 2.1 mil 0.6 mil

Table produced with data from: Kenney, G.M., Zuckerman, S., Dubay, L., Huntress, M., Lynch, V., Haley, J., &

• Anderson. (2012). Not Opting in to the Medicaid Expansion under the ACA: Who are the Uninsured Adults Who

Could Gain Health Insurance Coverage? Timely Analysis of Immediate Health Policy Issues. Robert Wood Johnson Foundation and Urban Institute.

• ~ 3.4 million Non-White diverse individuals in states expanding Medicaid

will be eligible and potentially covered. ~ 2.1 million Non-White diverse individuals with incomes below 100% FPL will have no source of new coverage under the ACA, in opt-out states. This represents roughly half of all those left uninsured from Medicaid opt-out. Number of Racially & Ethnically Diverse Individuals with Incomes Below 138% FPL & 100% FPL by State Decision Regarding Medicaid

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Health Centers & Clinics

• Considerable new support and funding for health

centers through the ACA

• But cuts to discretionary funding for health centers

which started in FY 2011, represent the first federal funding setback in almost 30 years!

• While ACA intended to increase capacity of health

centers to serve 20 million new patients, funding cuts will only allow for 10 million new patients by 2015

• Given two-thirds of health center patients are racially

and ethnically diverse, they are likely to feel the brunt

Community Health Centers

Funded by 2 streams:

• Annual discretionary

($2.2 bil before ACA)

• ACA established

Community Health Center Fund ($11 bil, FY 2011-2015) In FY 2011, discretionary funding reduced by $600 mil. Over 5 years, this will mean a $3 billion cut to health centers. ACA funding is being redirected to offset losses in supporting operations and service capacity originally funded by discretionary funds.

Note: HCTF refers to Health Center Trust Fund. Fiscal year funding in nominal dollars. Does not include the $1.5 billion of the HCTF committed for capital development projects. Source: Kaiser Family Foundation. Community Health Centers: The Challenge of Growing to Meet the Need for Primary Care in Medically Underserved Communities, March 2012. See: http://sphhs.gwu.edu/departments/healthpolicy/dhp_publications/ pub_uploads/dhpPublication_3B043800-5056-9D20-3D5DCAA18AC4BD43.pdf.

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Other Health Centers & Clinics

• Nurse-Managed Health Clinics

– Authorized$50 mil in FY 2010 & SSAN for FY 2011-14 – Only received $14.8 mil in FY 2010

• Teaching Health Centers

– Authorized $100 mil for FY2010-2012; no funding to date – THC Graduate Medical Education Payment program has received $20 mil of the $230 mil authorized

• School-Based Health Centers

– Appropriated $200 mil in FY 2010-2013 – Received $175 mil

Safety Net Hospitals

• ACA reduces Medicaid DSH payments by $18 billion between

2014–2020, with larger cuts in latter years; Medicare DSH spending is reduced by $22 billion over 10 years

– DSH payments help to defray costs of caring for low-income and uninsured patients at hospitals—e.g., Medicaid DSH program finances 22% of unreimbursed care at public hospitals – Cuts were added to the ACA with the assumption that through Medicaid and insurance expansion, the number of uninsured would go down, and these sources of funding would not be needed for hospitals; Supreme Court decision on Medicaid altered the reality!

• Strengthens the community benefit obligation of nonprofit

hospitals by requiring a Community Health Needs Assessment every 3 years, including mapping solutions for addressing identified needs.

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The Safety Net at Crossroads

Safety Net Providers

Rising Competitive Pressures Declining Funding Populations at the Margin Patient Insurance Volatility Outreach & Education Continuity

• f Care

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

–Key Informant

Three Emerging Scenarios for Safety Net Hospitals

Scenario 1: Strong Institutions & Active Adaptation Scenario 2: Stable Institutions, Reactive Adaptation Scenario 3: Challenged Institutions, Less Supportive Environments States active in exchange development and Medicaid expansion Financially strong institutions Groundbreaking demonstrations and innovation Seeing DSH cuts as less draconian and less

• f a priority as

compared to competitive issues Financially stable institutions, but slower to adapt to reform for various reasons, such as being in less progressive states or places where reform is

• n a parallel trajectory.

Some innovation Concerned about impact of DSH payment cuts. Financially challenged providers In states opposed to Medicaid expansion, these institutions will be especially hurt Little focus on innovation More focus on retaining existing patients Very concerned about DSH payment cuts

3/19/2013 18

Guidance Moving Forward - 1

• Addressing DSH payment reductions in the

context of optional Medicaid expansion

– In states not expanding Medicaid, there is potential for erosion of DSH funds, with little change in uninsured – Can federal government account for state Medicaid decision in their allocation of DSH dollars? – At the state level, states should:

• Target DSH payments to hospitals with greatest uncompensated

care and uninsured burden

• Consider linking DSH to services primarily used by uninsured
• Consider underinsured in allocations
• Consider investing DSH dollars to increase Medicaid payments for

hospitals

Guidance Moving Forward - 2

• Developing integrated systems of care

– Especially important to ensure continuity of care for patients expected to churn and hop from month-to-month from being uninsured to covered through exchanges or Medicaid; also important to ensure access to specialty care – To achieve this, hospitals, health centers, and other players will need to work to address:

• Governance and control
• Technology and other infrastructure needs
• Design of payments and incentives including risk sharing
• Adaptation to new delivery models
• Development of measures of effectiveness

– Emerging Models: Cambridge Health Alliance; Colorado Regional Collaborative Organizations; and Los Angeles County health center partnerships

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Guidance Moving Forward - 3

• Building the Community Health Needs

Assessment to create healthier communities

– Opportunity to utilize these assessments for broadly creating healthy communities and addressing disparities – Steps for taking a broader approach include:

• Collaboration and broad, community-wide approach
• Systematic approach to collecting and measuring data, including

monitoring racial/ethnic disparities

– Emerging resources in the field:

• Public Health Institute’s “Best Practices for Community Health Needs

Assessment and Implementation Strategy Development”

• Consensus Statement from APHA, ASPH, ASTHO, NACCHO,

NALBOH, NNPHI, and PHF on “Maximizing Community Health Impact of Community Health Needs Assessment…”

Guidance Moving Forward - 4

• Engaging state and local philanthropy to

complement the ACA in supporting the safety net

– Philanthropic and foundation support will be critical to help safety net systems transition and adapt. Support may be provided to:

• Expand capacity at health centers—e.g., increasing staff, facility

improvement, and extended hours;

• Enhance health information technology;
• Hire more bilingual staff, interpreters, and build a more culturally

competent workforce

• Outreach and education, which is culturally and linguistically

appropriate, related to enrollment, access to care, and continuity related issues

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Enhancing & Diversifying the Nation’s Health Care Workforce

Why Focus on Workforce Diversity?

Dentists Dental Hygienists Dental Assistants % of U.S. Population No. % No. % No % White 138,866 76.3% 137,795 88.9% 217,288 69.2% 65.6% Black 637 3.5% 3,410 2.2% 20,410 6.5% 12.2% Asian 235 12.9% 4,340 2.8% 14,758 4.7% 4.5% Hispanic 116 6.4% 7,440 4.8% 55,892 17.8% 15.4%

Total U.S. Dental Professionals by Race and Ethnicity, 2007

RNs* (2008) MDs** (2008) PAs*** (2007) % of U.S. Population No. % No. % No % White 2,549,302 83.2% 353,311 75% 75,408 77.2% 65.6% Black 165,352 5.4% 29,775 6.3% 7,606 7.8% 12.2% Asian 169,454 5.5% 60,090 12.8% 5,382 5.5% 4.5% Hispanic 109,387 3.6% 25,717 5.5% 8.053 8.2% 15.4% AI/AN 18,099 0.6% 2,515 0.5% 470 0.5% 0.8% Total U.S. Nurses, Physicians, & Physician Assistants by Race & Ethnicity, 2007-2008

Source: U.S. Census Bureau, American Community Survey, 2007 as cited in: National Healthcare Disparities Report, 2009, AHRQ

*The Registered Nurse Population, Findings from the 2008 National Sample of Registered Nurses. September 2010. HHS/HRSA; **Diversity in the Physician Workforce: Facts & Figures 2010, AAMC; ***Xiaoxing, H, et al. National trends in the United States of America physician assistant workforce from 1980 to 2007. Human Resources for Health, 7.

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Provisions

1. Increasing Supply & Diversity of Health Workforce

– Loan repayment programs; Training support for primary care physicians, physician assistants, direct care workers, dentists, mental health providers, nurses, and community health workers

2. Workforce Support for Safety Net

– National Health Service Corps; Interdisciplinary, community-based linkages; Redistribution of GME slots to underserved communities

3. Cultural Competency Education & Training

– Cultural competence in pain care management; Cultural competency training & model curricula; workforce demonstrations

4. Health Workforce Investment in Academic Settings

– HBCUs & minority-serving institutions; Centers of Excellence; Health care professionals training for diversity

5. Health Workforce Evaluation & Assessment

– National Health Care Workforce Commission; State health care workforce development grants

Supply & Diversity of Workforce

• Titles VII & VII of Public Health Services Act mainly geared

toward helping to increase supply & diversity in workforce

– Title VII: encourage health care workers to practice in underserved areas, increase number of primary care providers, increase number of under-represented minorities – Title VIII: aimed at training advanced practice nurses & increasing number of minority students in nursing programs

• ACA reauthorizes & strengthens Title VII & VII Programs,

particularly those aimed at increasing supply and diversity of primary care providers. For example:

– Primary Care Training & Enhancement Program was authorized $125 mil & such sums as necessary for FY 2010-2013, and by 2012, already received $315 mil from discretionary & other funds. – General, pediatric & public health dentists were appropriated $30 mil & such sums as necessary for FY 2010-2013, received $52 mil by 2012.

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Workforce Support for Safety Net

• ACA reauthorizes & increases funding for National Health Service

Corps (NHSC), originally authorized under PHSA to encourage medical residents to commit to serving in medically underserved areas

– ACA has grown the NHSC workforce three times – 46% practice at community health centers – 13% African American, 10% Hispanic, 9% Asian/PI & American Indian

• Authorizes redistribution of unfilled Graduate Medical Education

(GME) residency positions to areas with provider shortages

– Rule issued: 70% of slots to hospitals in states with lowest resident- to-population ratios; 30% to hospitals located in rural or health professional shortage areas – Of 58 hospitals which received increases in slots, half located in cities

• r localities where more than 50% of population is Non-White

Cultural Competence

• Authorizes HRSA to establish new grants program to train health

care professionals in diagnosis, treatment, or management of acute or chronic pain. Explicit requirement to address cultural, linguistic, literacy and geographic barriers. No funding to date.

• Authorizes a grant program to develop, evaluate, and disseminate

research, demonstration projects, and model curricula for cultural competency to reduce health disparities. No funding to date.

• Creates new demonstration grants program to develop training

competencies—including for cultural & linguistic competence and sensitivity—for geriatric & long term care. Of $15 mil authorized, $13 mil received in FY 2010-2012.

3/19/2013 23

Investment in Academic Settings

• $ 255 mil in mandatory funding for minority-serving institutions

through 2019:

– $100 mil for Hispanic Serving Institutions – $100 mil for HBCUs & Predominantly Black Institutions – $35 mil to Tribal Colleges & Universities & Native American colleges – $15 mil to Alaska & Hawaiian Native Institutions – $5 mil to Asian American & Pacific Islander Institutions

• Increases funding for Centers of Excellence which aim to enhance

diversity of health workforce. In FY 2010-2012, $150 mil was authorized, though only $72 mil was received.

• Scholarships for Disadvantaged Students (SDS), received $145 mil in

FY 2010-2012.

• Health Careers Opportunity Program (HCOP), received $$59 mil in FY

2010-2012

Workforce Assessment & Evaluation

• National Healthcare Workforce Commission

– ACA authorized the creation of a new entity to coordinate health care workforce activities, evaluate workforce needs, and identify solutions. – In Sept 2010, 15 Commission members were announced – No funding to date – Strictly not permitted to conduct business without federal funding

• State Healthcare Workforce Development Grants

– Competitive HRSA grant program to award planning grants to conduct analysis of workforce needs and identify solutions, resources, partners, at the state level – While $158 mil authorized in FY 2010, only $6 mil appropriated – Such sums as necessary for FY 2011-2012, but $0 appropriated

3/19/2013 24

Remaining Challenges - 1

• Continued shortage of health professionals,

especially in highly diverse areas

– AAMC estimates that by 2020, following ACA’s insurance expansion there will be a shortage of 45,400 primary care physicians – Largest increases in demand are expected in many states with large diverse populations—e.g., Texas, Mississippi, Oklahoma – Demand will also be greater in regions which currently have larger number of uninsured and fewer primary care providers – Shortage of subspecialists also expected, which will disproportionately impact diverse populations who already have trouble obtain specialty care

Remaining Challenges - 2

• Limited dedicated funding for workforce innovation

– Provisions other than those focused on primary care workforce supply have either not been funded or have received limited funding—e.g., National Healthcare Workforce Commission, State Planning Grants, Cultural Competency Training, and community health workers

• Reluctance to pursue cultural competence as priority

– Several unfunded provisions focus on cultural competency – Interviews revealed cultural competency is not a priority in many health care settings, citing the need to tie it to quality of

• care. “What moves institutions is reimbursement for quality of

care.”

3/19/2013 25

Challenges Ahead - 3

• Greater need to recognize importance of working

with and supporting community-based settings & minority-serving institutions

– Community-based settings such as health centers, community clinics, and community hospitals offer an opportunity to both train and serve diverse individuals – Minority-serving institutions, in many cases, are the only avenue in some diverse communities for achieving higher education and pursing health profession careers

Moving Forward - 1

• Expanding Scope of Practice

– To address primary care shortages, particularly in diverse settings, states may consider giving Advanced Practice Nurses (APNs) and Physicians Assistants (PAs) greater latitude to practice – Research shows that care provided by APNs & PAs is “as safe and effective as care provided by doctors” and that APNs can provide ~80% of care that primary care physicians provide

• Encouraging Interdisciplinary Team-Based Care

– Team-based approaches involving culturally diverse and bilingual community health workers, case managers, nurses – Approach is linked to greater quality of care and patient satisfaction – Also linked to greater adherence, improved general health, lower ED visits and hospital readmissions

3/19/2013 26

Moving Forward - 2

• Leveraging Resources provided through the ACA with

Philanthropic Support

– Can provide scholarship and loan assistance for under-represented minorities; mentorship programs; support workforce assessments at state/local levels; cultural competency training, etc.

• Evaluating Health Care Workforce Diversity

Needs, Capacity, and Outcomes

– Workforce diversity should be incorporated in any national, state, or local assessments of health care workforce supply and demand – Collaborating with other partners in the community to undertake assessment—e.g., Community Health Needs Assessment requirement for nonprofit hospitals – Need to assess effectiveness of recruitment & retention programs aimed at diverse students and faculty – Need for evaluation of cultural competency efforts

Preview of Our Reports on:

Data, Research, & Quality and Public Health & Prevention

3/19/2013 27

Data, Research, & Quality

Provisions

Level of Progress

Good Moderate Poor Patient-Centered Outcomes Research Institute

• Center for Medicare and Medicaid Innovation
• Hospital Value-Based Purchasing Program
• Data by Race, Ethnicity and Language
• National Strategy for Quality Improvement
• Interagency Group on Health Care Quality
• Minority Health in HHS Offices
• Pediatric Accountable Care Organizations
• Disparities Research in Post-Partum Depression
• Develop, Improve & Evaluate Quality Measures
• Cultural Competency Research & Curriculum
• Data, Research, & Quality:

Progress, Challenges, & Next Steps

• Need for adequate support and funding to sustain programs in long-run –

e.g., the Offices of Minority Health in federal agencies and PCORI which is

• nly authorized until 2019.
• Need to ensure that data, research, and quality initiatives explicitly link to

disparities objectives. Of all grantees that have been funded through various ACA grants, only some explicitly address health equity.

• Given short term funding for several ACA initiatives, it is important for

researchers to focus on measurable impact.

• Need to monitor the impact of these programs to ensure they do not

have the adverse affect of exacerbating racial/ethnic disparities—e.g., hurting financially-strapped hospitals which disproportionately serve low- income minority patients by penalizing them for lower quality.

3/19/2013 28

Public Health & Prevention

Good Moderate Poor Community Transformation Grants ($103 m)

• Maternal & Child Home Visiting ($91 m)
• Personal Responsibility Education ($154 m)
• Clinical & Community Prev. Services Taskforce
• National Prevention Strategy & Fund ($515 m)
• Obesity, Diabetes, Cancer Programs ($36 m)
• Reauthor. of Indian Health Care Improv. Act
• National Oral Health Campaign
• Provisions

Level of Progress

Public Health & Prevention: Progress, Challenges, and Next Steps

• All provisions funded have shown at least some emphasis on

health equity or disparities

• Under some provisions, the majority of grant programs to

states, communities, and non-profits have explicit focus on health disparities:

• All 3 Childhood Obesity Demonstration Project grantees; the majority
• f personal responsibility education grantees; at least 2/3 of CTGs
• Funding
• Threats to Prevention and Public Health Fund – “slush fund”
• County or state health departments tempted to use funds to “plug

holes” in existing programs

• Questions remain re: sustainability of funds and ACA supported

programs

3/19/2013 29

Where Do We Go from Here?

Governmental Roles & Functions

• Continuing to track federal guidance,

congressional action, budget implications

– Federal announcements, emerging guidance, and reports – Congressional deliberations around ACA – Financing actions—e.g., impact of sequestration

• Documenting the evolving role and scope of

state/local governments in ACA implementation

– Government role in exchange development – State oversight in advancing ACA related opportunities – Financing decisions—e.g., safety net funding

3/19/2013 30

Health Care Providers & Communities

• Health sector response and actions

– ACA planning, initiatives, and innovations

• Emerging community-based efforts and

concerns

– Engagement of diverse communities in implementation and innovation – Early indicators of impact—e.g., enrollment

Next Steps

• Given the evolving nature of implementation,

THI will continue to monitor progress of equity and diversity provisions

• THI will produce new updates and analysis on the

five reports, to be released in Fall 2013

• For questions or feedback, please contact Nadia

Siddiqui at nsiddiqui@texashealthinstitute.org

• To access reports and resources, visit:

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