dennis p. andrulis, phd, mph senior research scientist texas health institute &
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Dennis P. Andrulis, PhD, MPH Senior Research Scientist Texas Health Institute & Associate Professor University of Texas School of Public Health. Affordable Care Act and Opportunities for Advancing Health Equity: Taking Vision and Promise to Reality. - PowerPoint PPT PresentationTRANSCRIPT
Dennis P. Andrulis, PhD, MPHSenior Research Scientist
Texas Health Institute&
Associate ProfessorUniversity of Texas School of Public Health
Advancing Equity through Health Care Reform: A State-Federal Discussion of Promising State PoliciesNational Association of State Health Policy (NASHP)
May 31, 2012 | Washington, D.C.
ACA’s Vision, Promise and Background Monitoring and Tracking Design Status of Diversity & Equity Provisions
▪ Health Insurance Exchanges▪ Safety Net▪ Workforce Diversity▪ Public Health & Prevention▪ Research, Data and Quality
Where do we go from here?
Working to eliminate health disparities and advance health equity is central to the Affordable Care Act (ACA) of 2010.
Over three dozen provisions that directly address disparities, diversity and cultural/linguistic competence.
Dozens of other provisions with major implications for racial/ethnic disparities and equity.
Tracking will continue into 2013.
Good Moderate Poor
Health InsuranceProvisions well on their way in
implementation – e.g., final rules
issued, research, service or
demonstration grants awarded
Provisions in starting phases
of implementation–
e.g., interim rules issued, RFPs/RFAs
announced, planning grants
awarded
Provisions not yet
implemented due to timeline,
without appropriations, and/or being
contested in the Supreme Court
Safety Net
Workforce
Quality & Research
Public Health & Prev.
Overall Level of Progress
Tracking 62 provisions specific to race, ethnicity, language and diversity as well as
general provisions with major implications for racially and ethnically diverse populations.
For each of the 62 provisions, we are conducting:▪ Extensive analysis of legislative language in ACA▪ Analysis of federal registry, policy reports, peer-review
literature▪ Review of related national, state, local models & best-
practices▪ Review of early successes and lessons learned▪ Opportunities and challenges
To fill gaps, we are conducting interviews with:▪ National experts and advocates▪ Representatives from federal and state government▪ Representatives from racial/ethnic organizations▪ Health plans, hospitals, health centers and other grantees
GoodModera
te Poor
Non-discrimination in Federal Programs
√
Use of Plain Language in Health Plans
√
State Exchanges
- C/L Summary of Benefits √
- C/L Info. & Navigators in Exchanges
√
- C/L Claims Appeals Process √
Remove cost-sharing for AI/AN √
Market Incentives for Reducing Disparities
√
Overall Level of Progress
Note: Other broader provisions not listed here but that we are tracking to understand their implications for diverse communities include: Medicaid expansion; large and small employer provisions; high risk pools; individual mandate and CHIP reauthorization.
TX
FL
NMGA
AZ
CA
WY
NV
AK
OK
MSLA
MT
TN
Adapted from: National Conference of State Legislatures, Federal Health Reform: State Legislative Tracking Database. http://www.ncsl.org/default.aspx?TabId=22122; Politico.com; Commonwealth Fund Analysis.
WA
ORID
SD
ND
MNWI
MI
IA
AR
IL
OH
WVVA
AL
PA
NY
ME
MA
NHVT
HI
Legislation signed into law post-passage of ACA
UTCO
KS
NEIA
MO
ILIN
KY
WVVA
NC
SC
DCMD
DE
NJ
CTRI
State exchange in existence prior to passage of ACA
13 States & DC with Legislation to Establish Exchanges, as of May 2012
C/L Summary of Benefits & Uniform Glossary Final Rules & Guidance:
▪ C/L summaries when >10% of population in county literate in same non-English language
▪ Existing template & glossary in English, Spanish, Tagalog, Chinese and Navajo
Models: ▪ Kaiser Permanente and its Virtual Translation Center; ▪ NY’s Medicaid Managed Care Plan provides translated documents if >5% of county’s
population speak the same foreign language.
C/L Internal & External Claims Appeals Processes Interim Final Rules:
▪ 10% threshold for C/L; ▪ Oral interpretation requirement for assistance in filing claims and appeals.
Models: ▪ LA Care which has an online repository of translated claims & appeals documents.
continued…
C/L Information, Outreach and Navigators Final Rules:
▪ Application, forms , notices, outreach & education must meet plain language standards;
▪ Must also indicate availability of language services in translated taglines; ▪ C/L competence of navigators in enrollment, providing referrals, handling
complaints, conducting outreach and other functions.
Forthcoming Rules: ▪ Standards for C/L competency of navigators.
Models:▪ California State Exchange is planning outreach campaigns targeting
Latinos, African Americans and other racial/ethnic minorities along with a statewide C/L competent Consumer Assistance Program
GoodModera
te Poor
Community Health Center √Other Health Centers Support* √Non-Profit Community Benefit √Primary Care Extension Program
√
Community Health Teams √
Overall Level of Progress
* Comprised of Nursed-Managed Centers, School-Based Health Centers, Teaching Health CentersNote: We are also tracking Reductions to Medicare/Medicaid DSH Program and its Implications for Diverse Patient Populations.
IRS Guidelines: Specifies that the assessment represent broad interests of the
community including input from “leaders, representatives, or members of medically underserved, low income, and minority populations, and populations with chronic disease needs, in the community served by the hospital facility.”
Opportunities: Involve community to identify & prioritize unmet needs Encourage collaboration in health care community
Models (California’s Tulare Regional Medical Center): Qualitative data from five focus groups was compiled into 6 key areas
for action, which included Culturally and Linguistically Appropriate Services.
“Specific attention needs to be paid to improving healthcare experiences and promoting better adherence to medical recommendations for the Valley’s culturally diverse residents.”
$18 billion reduction phased in 2014-202010 in Medicaid disproportionate share hospital program—which finances 22% of unreimbursed care at public hospitals
State/local safety-net financing possibly in jeopardy due to antipathy toward undocumented and myth that “uninsured problem is solved”
Financial pressures on safety-net in caring for 52 million uninsured between now and 2014, given growth in uncompensated care, low profit margins, and location of many in high-poverty areas
Risks to safety net’s ability to compete for newly insured patients and participate in systems innovation
GoodModerat
e Poor
Increasing Diversity Among Providers 1 √
Health Professions Training for Diversity √
Redistribute Graduate Medical Education Slots √
Community Workforce Infrastructure Investments 2
√
Collect & Publicly Report Data on Workforce Diversity
√
Cultural Competence Training in Health Professions3
√
Model Cultural Competence Curricula √
Community Health Workers √
Overall Level of Progress
1. Includes support for: primary care physicians; long term care providers; dentists; mental health providers; and nursing professions.
2. Includes: National Health Services Corps; loan repayment; & investments in AHECS & HBCUs.
3. Includes: cultural competence training for home care aides & pain care providers & other professions.
To date, $1.25 Billion of Prevention Fund dollars have been used to fund a variety of health-related programs with workforce and community-based health care interventions
▪ $1 Billion for 2012 in question
In all States, the federal government spent $198 M last year to create new residency positions for primary care doctors and ramp up training capacity for physicians
Trust for America’s Future
California, Texas, New York, Illinois, Florida Total ACA Funds Used - $1.26 Billion $32.6 M for health professions workforce demonstration
projects, which will help low income individuals receive training and enter health care professions that face shortages.
$7.2 M for the expansion of the Physician Assistant Training Program, a five-year initiative to increase the number of physician assistants in the primary care workforce.
$2.55 M to support teaching health centers, creating new residency slots in community health centers.
$1.4 M to support the National Health Service Corps, by assisting in repaying educational loans of health care professionals in return for their practice in health professional shortage areas.
Healthcare.gov – 3/15/2012
GoodModera
te Poor
Data by Race, Ethnicity & Language √
Patient-Centered Outcomes Research Institute
√
NIMHHD & OMHs in HHS Agencies √
Hospital Value-Based Incentive Program √
National Quality Strategy & Interagency Group
√
Centers of Excellence √
Health Impact Assessments √
Develop, Improve & Evaluate Quality Measures
√
Disparities Research in Post-Partum Depression
√
Cultural Competency Research √
Overall Level of Progress
Health Disparities is 1 of 5 PCORI Priorities – Draft Research Agenda includes a focus on comparative effective research to: Reduce disparities in health outcomes Assess benefits/risks of treatment Identify strategies to overcome barriers such as culture and
language Identify best practices for racial/ethnic sub-populations.
Release of PCORI Funding Announcement (PFA) related to Disparities (Deadline: July 21, 2012) Anticipate to fund 14 contracts totaling $12 million Awards for “studies that will inform the choice of strategies to
eliminate disparities” See: http://www.pcori.org/assets/PFA-Addressing-Disparities-05222012.pdf
GoodModera
te Poor
Community Transformation Grants √
Maternal & Child Home Visiting √
Personal Responsibility Education √
Reauthorization of Indian Health Care Improv. Act
√
National Prevention Strategy & Fund √
Obesity, Diabetes, Cancer Programs √
National Oral Health Campaign √
Culturally Appropriate Decision Aids √
Overall Level of Progress
61 Awards to 36 States
35 Implementation Grantees: All intend to address low-income populations > 50% intend to target African Americans & Hispanics/Latinos 1 in 3 will address health issues of American Indians/Alaska
Natives Nearly all target children & 1 in 5 will address older adults
26 Capacity-Building Grantees: Establish or strengthen community coalitions Conduct community health assessments, including diverse
populations Develop community-based solutions that also address disparities
??? Supreme Court Decision ???
For many health equity objectives in ACA, the seeds have been sown. It is the opportunities that need to be seized.
Dennis P. Andrulis, PhD, MPHSenior Research Scientist, Texas Health Institute
Associate Professor, University of Texas School of Public Health
Nadia J. Siddiqui, MPHSenior Health Policy Analyst, Texas Health Institute
Maria Rascati Cooper, MAHealth Policy Analyst, Texas Health Institute
Lauren Jahnke, MPAffConsultant, LRJ Research & Consulting
Ebbin Dotson, PhDExecutive Director, Adjunct Professor
University of Texas School of Public Health
For inquiries, please contact Dr. Andrulis ([email protected]) or Nadia Siddiqui