Dennis P. Andrulis, PhD, MPH Senior Research Scientist Texas Health Institute &

1. Dennis P. Andrulis, PhD, MPH Senior Research ScientistTexas Health Institute & Associate ProfessorUniversity of Texas School of Public Health Advancing the Vision of Health Equity and the Affordable Care Act: Where are We and Where are We Going? Affordable Care Act and the Business Case for Reducing Health Care Disparities American Medical Association (AMA) September 28-29, 2012 | Chicago, Illinois

2. Overview • ACA’s Vision, Promise and Background • Design to Monitor ACA through an Equity Lens • Status of Diversity & Equity Provisions • Health Insurance & Exchanges • Health Care Safety Net • Workforce Support & Diversity • Research, Data and Quality • Public Health & Prevention • Priorities for Advancing Equity through ACA

3. 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/ethnic health equity, diversity and cultural/linguistic competence. • Dozens of other general provisions with major implications for racially/ethnically diverse populations.

4. History and Scope of Work on Equity and Health Care Reform Tracking will continue through 2013.

5. Tracking Design:Overall Status of Implementation Tracking 62 provisions specific to race, ethnicity, language and diversity & general provisions with major implications for diverse populations across 5 major areas:

6. Tracking Design: Analysis of Implementation Progress • For each provision, we are reviewing: • Legislative language in ACA • Federal registry, policy reports, peer-review literature • Related national, state, local models & best-practices • Early successes and lessons learned • Opportunities and challenges • Additionally, we are conducting interviews with: • National experts and advocates • Representatives from federal and state government • Representatives from organizations representing diverse communities • Health plans, hospitals, health centers and other grantees

7. A. Health Insurance & Exchanges • Provisions: • State Exchanges • Navigator Program & C/L Information • C/L Summary of Benefits • C/L Claims Appeals Process • Use of Plain Language in Health Plans • Non-discrimination in Federal Programs • Remove cost-sharing for AI/AN • Market incentives for Reducing Disparities

8. A. Health Insurance State Exchanges – Overall Progress 15 States + DC with State Exchanges, as of July 2012 Exchange prior to ACA (2) Exchange thru legislation (12) Exchange thru E.O. (3) Pending legislation (2) Level 1 Planning Grant (24) Will not establish State Exchange Source: Adapted from Commonwealth Fund Health Insurance Exchanges by State Interactive Map, July 2012.

9. A. Health Insurance State Exchanges – Equity Highlights • Uncertainty of attention and priority given to equity in exchange planning across states. • However...some states such as California, Maryland and Washington are working to actively integrate racial/ethnic equity into their exchange planning by, for example:

10. A. Health InsuranceCultural & Linguistic Requirements in Exchanges • C/L Information, Outreach and Navigators • Issued Final Rules with emphasis on: • Plain language standards for information, education and outreach; • Ensure availability of language services in translated taglines; • Cultural 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

11. Health InsuranceCultural & Linguistic Requirements for Health Plans • 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.

12. B. Health Care Safety Net • Provisions: • Medicaid income eligibility expansion • Disproportionate Share Hospital (DSH) payment reductions • Community Health Center support • Support for other health centers/clinics* • Nonprofit Community Benefit * Comprised of Nursed-Managed Centers, School-Based Health Centers, Teaching Health Centers

13. Health Care Safety Net State Medicaid Expansion – Initial Projections as of July 2012

14. Health Care Safety Net Challenges in Caring for Diverse Patients • Potentially very significant adverse effect on diverse communities in states not choosing to expand Medicaid per ACA • This will be compounded by the $18 billion reduction in Medicaid disproportionate share hospital program which will be phased in 2014-2020 (The program finances 22% of unreimbursed care at public hospitals.) • Financial pressures on safety-net hospitals 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

15. Health Care Safety Net Actions to Successfully Reform the DSH Program • Evaluate current formula for distributing DSH funds • Allocate DSH funds to hospitals providing most care to uninsured • Improve transparency by requiring hospitals to disclose how they use DSH funds • Impose accountability standards for hospitals receiving DSH funds • Require hospitals receiving DSH dollars to adopt more community-based, consumer-friendly procedures particularly for low income, diverse communities

16. Health Care Safety Net State Innovations to Support the Safety Net • Medicaid Section 1115 Waiver Programs • California “Bridge to Reform”: $2 bil. in support each year for 2010-2014 • Provide comprehensive care to ~ 500,000 low-income adults ineligible for Medi-Cal. • Expand Safety Net Care Pool for uncompensated care & support safety net hospitals. • Improve managed care services, care coordination & outcomes for seniors & disabled. • Texas “Transformation Waiver”: • Allow the state to expand Medicaid managed care • Preserve federal hospital funding historically received as Upper Payment Limit (UPL) payments—supplemental payments to make up the difference between what Medicaid pays for a service and what Medicare would pay for the same service.  Replacing the UPL payment methodology are two funding pools – the Uncompensated Care and Delivery System Reform Incentive Payment (DSRIP) pools.  • Require participation in a regional healthcare partnership

17. C. Workforce Support & Diversity • Provisions: • Increasing Diversity Among Providers1 • 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 • Support for Community Health Workers • Includes support for: primary care physicians; long term care providers; dentists; mental health providers; and nursing professions. • Includes: National Health Services Corps; loan repayment; & investments in AHECS & HBCUs. • Includes: cultural competence training for home care aides & pain care providers & other professions.

18. Workforce Support & Diversity Federal Progress • In FY 2010, Workforce initiatives received $503.3 mil (49% of the total ACA appropriations) • Majority of dollars came through Prevention & Public Health Fund • Half the monies ($250 mil) to boost supply of primary care providers • In FY 2011, Workforce initiatives received $376.3 mil (15% of the total ACA appropriations) • Majority of dollars directly appropriated for workforce initiatives • $137 mil provided through the Fund & geared toward public health workforce and mental health training • New law passed in Feb 2012 has cut the Fund by ~ $5 bil over 10 years – exact appropriations for FY2012 – 2014 are still uncertain.

19. Workforce Support & DiversityState Level Programming • 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

20. D. Research, Data & Quality • Provisions: • Data in Federal Surveys by Race, Ethnicity & Language • Patient-Centered Outcomes Research Institute (PCORI) • 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

21. Research, Data, & QualityExample:Patient Centered Outcomes Research Institute • 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. • September 17, 2012: Release of Second Cycle of PCORI Funding Announcement related to Disparities • 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/FINAL-PFA-Addressing-Disparities-v3.pdf

22. E. Public Health & Prevention • Key provisions we are tracking: • Community Transformation Grants • Maternal & Child Home Visiting • Personal Responsibility Education • Reauthorization of Indian Health Care Improvement Act • National Prevention Strategy & Fund • Obesity, Diabetes, Cancer Programs • National Oral Health Campaign • Culturally Appropriate Decision Aids

23. Public Health & PreventionExample: Community Transformation Grants • 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

24. Priorities for Advancing Health Equity through ACA

25. Reality Check!! Questions for State/Local Government and Communities Moving Forward • Capacity of state/local government agencies and offices to take advantage of opportunities.  • Available public health and safety net infrastructure to address need.  • Reductions in state/local government personnel encourage supplementation of displaced staff rather than expansion. • Presence of well-placed or influential champions for ACA equity/diversity initiatives. • Sustainability of ACA supported initiatives.

26. 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, MAHealth Policy Analyst, Texas Health Institute Lauren Jahnke, MPAffConsultant, LRJ Research & Consulting Ebbin Dotson, PhDExecutive Director, Adjunct ProfessorUniversity of Texas School of Public Health For inquiries, please contact Dr. Andrulis (dpandrulis@gmail.com) or Nadia Siddiqui (nsiddiqui@texashealthinstitute.org). Health Care Reform & Equity Team