Health Equity Opportunities and Funding Post-ACA: Assessing Progress; Following the Dollars Dennis P. Andrulis, PhD, MPH Senior Research Scientist Texas Health Institute & Associate Professor University of Texas School of Public Health 10 th Annual National Summit on Health Disparities Congressional Black Caucus Health Braintrust Meeting Washington, D.C. April 23, 2013
Overview Our ACA & Health Equity Series Equity Provisions, Implementation Progress, Opportunities, and Challenges Health Insurance Exchanges Health Care Safety Net Workforce Support and Diversity Data, Research, and Quality Public Health and Prevention Moving Forward
Our ACA & Health Equity Series Utilizing a health equity lens to monitor implementation of 60+ provisions in the ACA. Focus is on those specific to or with implications for racial/ethnic health equity across five areas. Rolling out reports on each of the five areas.
Health Insurance Exchanges Priority Areas We Are Tracking Non-Discrimination in Exchanges Requirements For American Indians Plain Language Requirement Culturally and Linguistically Appropriate Information, Benefits Summary and Glossary, and Claims Appeals Process Incentives in Health Plans for Reducing Disparities
Health Insurance Exchanges Progress & What We Know Enrollees: 29 million enrollees 42% will be Non-White 1 in 4 will speak a non-english language Leading State Progress: Many with an equity champion. Integrating equity from the get-go in Board, Mission, Advisory Groups As required, collaborating with tribes. Developing culturally & linguistically appropriate outreach. Predicted Percent of Health Insurance Exchange Enrollees by Race and Ethnicity 25% 11% 6% 58% White Black or African American Hispanic or Latino Other Source: Kaiser Family Foundation, A Profile of Health Insurance Exchange Enrollees, March 2011.
Health Insurance Exchanges Opportunities & Challenges Opportunities Navigator RFP $54 mil to 33 Partnership & Federal Exchanges. Collaborating with Exchange Boards, Stakeholders & Advisory Groups to feed them equity information and data. Cultural competency training & standards for navigators & assisters Equity criteria in active purchasing. Challenges General exchange & ACA implementation takes precedence over equity. Short deadlines, incomplete guidance. How to fund critical programs geared toward equity? How to effectively reach hardto-reach diverse populations-- e.g., those not familiar with insurance, linguistically isolated, lack of trust, mixed citizenship
Health Care Safety Net Priority Areas We Are Tracking Medicaid Expansion & CHIP Reauthorization Health Center Support Community Health Centers School-Based Health Centers Teaching Health Centers Nurse-Managed Health Clinics Requirements for Safety Net Hospitals Community Health Needs Assessment Disproportionate Share Hospital Payments
Health Care Safety Net Projections on Medicaid If All States Expand Medicaid: 15 million would be eligible 45% (6.8 mil) will be Non-White 20 States + DC Opting to Expand:* 3.4 mil Non-Whites will benefit from this expansion Percent Eligible for Medicaid in 2014, by Race and Ethnicity 54.9% 26 Undecided or Opt-Out States:* 3.4 mil Non-Whites not eligible And the 2.7 mil Non-Whites below 100% FPL will not be eligible for subsidies in exchanges. White 19.4% 18.7% Hispanic or Latino African American 7.0% Other This data point is current as of February 27, 2013. 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.
Health Care Safety Net Progress of Health Centers & Hospitals Community Health Centers Considerable new mandatory ACA funding But first federal cuts to discretionary funds since 2011 10 mil new patients will be served by 2015 (as compared to original estimate of 20 mil patients prior to $$ cuts) Other Health Centers Nurse-Managed Health Clinics: $15 of $50 mil funded Teaching Health Centers: $0 of $100 mil funded School-Based Health Clinics: $175 of $200 mil funded Safety Net Hospitals DSH payment cuts postponed by 1 year to 2015 Nonprofit Community Health Needs Assessment creating opportunities for broader community assessment & action
Health Care Safety Net Opportunities & Challenges Opportunities Community Health Needs Assessment for communitywide collaboration & impact Postponed DSH cuts to allow time to assess ACA impact on uninsured & develop sound reduction methodology Effective & innovative Medicaid outreach can turn uninsured patients at struggling safety nets to paying patients Challenges Rising competitive pressures & competing provider priorities Insurance volatility & continuity of care Declining federal, state, and local budgets Populations at the margin -- e.g., undocumented & people below poverty in Medicaid opt-out states
Workforce Diversity & Support Priority Areas We Are Tracking Increasing Supply & Diversity of Health Workforce Workforce Support for Safety Net Cultural Competency Education & Training Health Workforce Investment in Academic Settings Health Workforce Evaluation & Assessment
Workforce Diversity & Support Progress & What We Know Reauthorized many Title VII & VIII programs Reauthorized National Health Service Corps Grown 3 times post-aca 46% residents at CHCs 13% African American, 10% Hispanic, 9% Asian/Other Unused GME redistributed to areas with provider shortage. Half located in areas with >50% Non-Whites. Little to no support for cultural competency training. Continuing, but over the years declining, support for minority-serving institutions & programs.
Workforce Diversity & Support Opportunities & Challenges Opportunities Expanding Scope of Practice e.g., greater support & scope for Advance Practice Nurses & Physician Assistants Encouraging Interdisciplinary Team-Based Care e.g., recognizing role of community health workers. Evaluating Health Care Workforce Diversity Needs, Capacity, and Outcomes Challenges Provider shortages (45,400 PCPshortage in US by 2020), with major concerns in highly poor & diverse regions. Reluctance to pursue cultural competence training as priority. Greater need to recognize importance of supporting minority-serving institutions to address workforce needs.
Data, Research & Quality Priority Areas We Are Tracking Health Disparities Research Quality Innovations & Demonstrations Data Collection and Measures Federal Minority Health Actions
Data, Research & Quality Progress & What We Know Patient Centered Outcomes Research Institute (PCORI) Research Agenda, FOAs & Pilots, and Advisory Panel focused explicitly on health disparities. CMS Innovation Of 100+ innovations awards in May/June 2012, roughly 15% explicitly address equity objectives. Examples of Current Funding Opportunities AHRQ Patient-Centered Outcomes Research (PCOR) Mentored Research Scientist Development Award (K01) & Mentored Clinical Investigator Award (K08) - open until July 2016 AHRQ Mentored Career Enhancement Award in PCOR for Mid-Career & Senior Investigators (K18) open until Dec 2014; Preference for minority institutions.
Data, Resea rch, & Quality Opportunities & Challenges Opportunities Focus on patient-centered outcomes research (including comparative effectiveness research) Consider short-term metrics to assess impact and outcomes on equity. Explicitly link equity objectives to data, research, and quality efforts. Challenges Short timeline e.g., PCORI is only authorized until 2019, unless reauthorized. How to focus on measurable impact given short timeline? Considering potential adverse affect of exacerbating racial/ethnic disparities.
Public Health & Prevention Priorities We Are Tracking Board Community Health & Prevention Initiatives Public Health Initiatives for Diverse Children & Adolescents Chronic Disease Management Targeting Diverse Communities
Public Health & Prevention Progress & What We Know Prevention & Public Health Fund 2010, 69% spent on workforce & infrastructure 2011-2012, 40% spent on community prevention 2012, legislation to cut $5 bil/10 years from fund Funds many programs directly targeting communities of color e.g., CTGs, primary care workforce, and others. Community Transformation Grants For state/local agencies & CBOs to reduce chronic disease and address disparities 2011, 61 awards totaling $103 million. Of implementation grantees, all addressing low income; >50% target African Americans & Hispanics; 1 in 3 to address American Indian health
Public Health & Prevention Opportunities & Challenges Opportunities Most public health & prevention provisions include a focus on equity. Prevention & Public Health Fund supports a range of prevention and public health activities. Challenges Threats to Prevention & Public Health Fund (PPHF) termed a Slush Fund Temptation to use PPHF to plug holes in public health programs Sustainability of funds and programs we know not many programs have been funded at promised levels.
Summary of Opportunities Insurance Safety Net Workforce Quality Prevention Navigator FOA (open until June 2013) Involvement with exchange Boards, Advis ory Groups, and Focus Groups. Enrollment & outreach efforts. Broad approach for Community Health Needs Assessment. Delay in DSH affords ability to monitor impact of ACA on uninsured at safety nets. Team-Based Care Approach involving CHWs State Scope of Practice nurses, PAs in shortage areas Infusing cultural competency into existing primary care training Focus on Patient- Centered Outcomes Research (FOAs open until 2014 & 2016) Ability to show short-term measurable impact PCORI & CMS Innovation Center Track funding opportunities through Prevention & Public Health Fund
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 Rascati 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