Advancing Health Equity through the ACA for Racially & Ethnically Diverse Populations Dennis P. Andrulis, PhD, MPH Senior Research Scientist, Texas Health Institute Associate Professor, UT School of Public Health AHA/Health Forum Leadership Summit July 26, 2013
Overview History, Scope, and Rationale of Our Work ACA Status & Implications for 2014 Challenges for Hospital Systems Roadmap to 2014 Moving Ahead: Leveraging Opportunities
History & Scope of Work 2008-2010 House & Senate Health Reform Bills Analysis 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 2012 ACA & Racial and Ethnic Health Equity Series: supported by W.K. Kellogg Foundation, The California Endowment, Kaiser Permanente 2013 2014 ACA & Health Equity Series (continued) Invited Presentations: NIH, IOM, GIH, CBC, NASHP, AHA, BCBS, AHIP, APHA, NAHSE, California Wellness Foundation, other state/local
60+ Provisions Addressing Racial/Ethnic Health Equity Affordable Care Act Health Insurance Marketplace Health Care Safety Net Health Care Workforce Research, Quality & Innovation Public Health & Prevention - Culturally & linguistically appropriate marketing, outreach, and education - Nondiscrimination - Special provisions for American Indians - Medicaid - CHIP - Health Centers - DSH Payments - Community Health Needs Assessment - Underserved Areas - Workforce Diversity - Cultural Competence Training - Model Cultural Competence Curricula - National Quality Strategy - PCORI - NIH/NIMHD - Innovation Center - ACOs - Medical Home - Agency OMHs - Race/Ethnicity Data Standards - Prevention & Public Health Fund - CTGs - Obesity - Cancer - Diabetes - Oral Health - Indian Health Care Improv. Act.
What track are ACA s equity provisions on? Some trains are well on their way. Others are just leaving. There are those parked in the roundhouse. And those that don t know a dynamite is coming!
Why Monitor ACA s Equity Provisions? Rapidly growing diversity. Continued disparities in access, quality, and health outcomes by race and ethnicity. Economic burden of disparities. But ALSO: The ACA has the potential to enfranchise at least 19 million racially and ethnically diverse individuals starting in 2014
ACA Status & Implications for Hospital Systems Preparing for 2014
Health Insurance Exchanges: Projected Enrollees by Race/Ethnicity & Language 29 million total enrollees; 42% will be Non-White 1 in 4 will speak language other than English at home Predicted Percent of Exchange Enrollees by Race and Ethnicity 6% White 25% 11% 58% Black Hispanic Other Source: Kaiser Family Foundation, A Profile of Health Insurance Exchange Enrollees, March 2011.
Medicaid Expansion: Progress & Implications for Diverse Populations State decisions will impact 15.1 million uninsured adults with incomes 138%FPL 1 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 & ethnicity 2 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.
Safety Net Systems: New Obligations, Requirements, & Opportunities Scheduled reductions in Medicare & Medicaid Disproportionate Share Hospital (DSH) Program Community Health Needs Assessment & Implementation Plan Medicare reimbursement tied to readmissions, hospital acquired infections, & value-based purchasing Delivery & innovation e.g., CMMI, ACOs, PCMHs Workforce support e.g., primary care enhancements, NHSC, residency training
1115 Medicaid Waivers Supporting Safety Net Intended to replace or propose an alternative to Medicaid expansion. Also includes an option to address safety net issues. 4 states (CA, FL, MA, TX) approved to utilize federal matching funds to cover uncompensated care costs and hospital delivery improvement initiatives. Example of safety net activities: infrastructure development, medical home implementation, quality improvement.
Emerging Hospital Response Scenarios Strong Systems Stable Systems Challenged Systems Medicaid Expansion + State Exchange Active Active Reactive No Medicaid + State/Partnership Exchange Active Reactive Struggling No Medicaid + Federal Exchange Reactive Struggling Struggling How hospital systems are responding to the ACA generally depends on their historical/financial performance and state s political climate
Questions & Challenges Ahead for Hospital Systems
What Questions & Challenges Do Hospitals Face? Rising Competitive Pressures Provider Shortages Declining Funding Safety Net & Other Hospitals Churning & Care Continuity Populations at the Margin
Rising Competitive Pressures Newly insured may present competitive threat for safety net hospitals Priority is to minimize erosion of existing market For public, community, and nonprofit hospitals their reputation serving diverse patients may help Trusted providers of care Experience providing enabling services Delivering culturally & linguistically appropriate services
Financial Concerns & Threats Reductions in Medicaid & Medicare DSH payments Proposed rule on method for DSH cuts for 2014 & 2015 Reductions will not be impacted by state Medicaid decisions given 2-3 year lag in data to determine allocations Budget request to delay cuts to 2015 Declining state & local budgets & support for hospital systems
Churning & Continuity of Care Churning = changes in insurance coverage among low income patients with fluctuating income Exchanges Medicaid Uninsured Severe impact on 2.2 million, poor, diverse patients in Medicaid opt-out states Raises questions of continuity of care & administrative burden at hospitals
Provider Shortages AAMC estimates that by 2020, there will be a shortage of 45,400 primary care physicians Shortage of subspecialists also expected, which will disproportionately impact diverse populations who already have trouble obtaining specialty care
Populations at the Margin CBO estimates 30 million adults will be uninsured in 2022 Exempt from mandate Individuals with incomes below poverty in Medicaid opt-out states Undocumented immigrants Immigrants on 5-year waiting period
Roadmap to 2014: Key Priorities for Hospital Systems in Adapting & Transforming
Key Priorities Gearing up for 2014 Enrollment: How to maintain existing & attract new paying patients? Capacity: How to respond to growing demand? Payment: How to adapt to new financing & payment models? Delivery: How to better collaborate, coordinate, and integrate care?
Enrollment: How to maintain existing & attract new paying patients? 1 st Priority: Retention of existing patients We are not trying to attract everyone, but to retain the uninsured who we already see, based on our quality, cultural competency, language services, and customer services. Emerging strategies e.g., hospital-based eligibility screening systems, dedicated & bilingual on-site enrollment staff, doorto-door outreach Role as Essential Community Provider Attracting newly ensured patients California Hospital Associations Guidebook on Outreach & Enrollment Strategies for California Hospitals Many focusing on systems enhancement and upgrades
Capacity: How to respond to growing demand? Staffing Scholarships & loan repayment for physicians, NPs, PAs offered through ACA e.g., National Health Service Corp Support for HBCUs & other minority institutions Beyond ACA, hiring additional NPs & PAs Infrastructure Support to modernize & update safety net institutions e.g., HIT
Payment: How to adapt to new financing & payment models? Medicare & Medicaid DSH Payment Reduction 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 Weighing Payment Options: Fee for Service vs. Pay for Performance
Delivery: How to better collaborate, coordinate, and integrate care? Patient Centered Medical Homes Key Features for Addressing Diversity/Equity: bilingual care providers; on-site language services; collaborate with culturally oriented CBOs; offer mobile or on-site care in diverse community settings Coordinating & Integrating Care Accountable Care Organizations Team-based care approaches Opportunities through CTGs, CMMI, PCORI
Moving Forward: Leveraging Equity Opportunities with Hospital Systems in the Era of Health Care Reform
Adapt CHNA for Broader Community Impact Opportunity to use Community Health Needs Assessment for broadly creating healthy communities and addressing disparities Collaboration and broad, community-wide approach Systematic approach to collecting and measuring data, including monitoring racial/ethnic disparities Resources in the Field: Public Health Institute s Best Practices for Community Health Needs Assessment and Implementation Strategy Development Community Commons Mapping Tool (www.chna.org) National CLAS Standard #12 on community assessments & integrating measures of diversity, equity, and language
Draw on OMH s Enhanced CLAS Standards 1. Ensure equitable quality of care & services 2. Governance & leadership to promote CLAS 3. Diverse leadership & workforce 4. Educate leadership & workforce on CLAS 5. Communication & language access 6. Availability of language access 7. Competence to provide language assistance 8. Easy-to-understand materials & signage 9. Infuse CLAS throughout organization 10. Organizational assessments 11. Demographic data collection 12. Community health needs assessment 13. Community partnership 14. Conflict resolution 15. Sustainability of CLAS
Engage Philanthropy to Address Priorities Philanthropic and foundation support will be critical to help safety net systems transition and adapt. Support may be provided to: Expand capacity Enhance health information technology; Hire more bilingual staff, interpreters, and build a more culturally competent workforce Outreach, education, and enrollment assistance Example: ACA Implementation Fund Project Collaboration of 8 national foundations to research and inform development of consumer-driven Navigator program for Colorado
Closing Remarks Equity is a central theme in the ACA with many new incentives and requirements for hospitals. Inattention to equity may lead to half empty programs. Health Insurance Health Care Access! Addressing workforce & service capacity will be of prime focus and a challenge in coming years.
Our Health Care Reform & Equity Team Dennis P. Andrulis, PhD, MPH Senior Research Scientist, Texas Health Institute Associate Professor, University of Texas School of Public Health Nadia J. Siddiqui, MPH Senior Health Policy Analyst, Texas Health Institute Maria R. Cooper, MA Health Policy Analyst, Texas Health Institute Lauren Jahnke, MPAff Consultant, LRJ Research & Consulting For questions, feedback, or to be added to our mailing list, please e-mail: nsiddiqui@texashealthinstitute.org. Website: http://www.texashealthinstitute.org/health-care-reform.html