138 th APHA Annual Meeting Denver, Colorado November 8, 2010

1. Where Do We Go From Here?Maximizing the Potential of Health Care Reform to Reduce Racial & Ethnic Disparities 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 Jonathan P. Purtle, MPH, MSc Program Manager, Drexel University School of Public Health 138th APHA Annual Meeting Denver, Colorado November 8, 2010

2. Background and Purpose • With support from the Joint Center for Political and Economic Studies, we conducted a comprehensive review of the Patient Protection and Affordable Care Act of 2010: • To identify and describe provisions specific to race, ethnicity and language; and general provisions likely to have a significant affect on diverse populations. • To assess status, challenges and opportunities of health care reform provisions for improving the health and health care of racially and ethnically diverse populations. • To offer a template and user-friendly framework for documenting and tracking implementation timeline, appropriations and federal agency oversight responsibility.

3. Framework for Review Review of provisions addressing 12 key public health, health care system and health disparities priorities.

4. General Provisions:There are over three dozen general provisions with potentially major implications for racially/ethnically diverse populations.

5. General Provisions

6. General Provisions (continued)

7. General Provisions (continued)

8. Examples of Public Health Opportunities for Advancing Health Equity through General Provisions • 4001. National Prevention and Public Health Council will provide coordination and leadership at the federal level for public health and other services to consider evidence-based models, policies and innovative approaches for transformative models of public health and prevention. • 4003. The CDC will convene an independent Community Preventive Services Task Forceto review scientific evidence related to the effectiveness, appropriateness, and cost-effectiveness of community preventive interventions for the purpose of developing recommendations. Recommendations must address specific populations and social, economic and physical environments that can have broad effects on health disparities. • 4201. The CDC is authorized to award competitive Community Transformation Grantsto State and local governmental agencies and community-based organizations for the implementation, evaluation, and dissemination of evidence-based community preventive health activities to reduce chronic disease rates, prevent the development of secondary conditions, address health disparities and develop a stronger evidence-base of effective prevention programming.

9. Race, Ethnicity and LanguageSpecific Provisions:There are over three dozen provisions in ACA explicitly addressing race, ethnicity, cultural competence, language assistance and diversity.

10. Data Collection & Reporting • Example of Potential Public Health Obligation and Opportunity: • 4302. No later than 2 years after the date of enactment of this title, any federally conducted or supported public health program, activity or survey must collect and report data on race, ethnicity, and primary language for applicants, recipients or participants. Data must be sufficient to generate statistically reliable estimates by racial, ethnic, or primary language subgroups. In collecting these data, the OMB standards for measurement of race, ethnicity and language must be used at a minimum.

11. Workforce Diversity Example of Potential Public Health Obligation and Opportunity: 5303. Grants to promote public health dentistry shall give priority to applicants with experience in minority training with emphasis on cultural competence and health literacy; and who have placements in areas that serve health disparities populations.

12. Cultural Competence (CC) Example of Potential Public Health Obligation and Opportunity: 5307. Cultural Competency, Prevention and Public Health Grants will be established to develop, evaluate and disseminate research, demonstration projects, and model curricula for cultural competency proficiency, prevention, public health proficiency and reducing health disparities.

13. Table 4. Health Disparities Research Example of Potential Public Health Obligation and Opportunity: 6301. PCORI will identify national priorities for research, addressing practice variation and health disparities in terms of delivery and outcomes of care and the potential for new evidence to improve patient health and quality of care.

14. Table 5. Health Disparities & Prevention Example of Potential Public Health Obligation and Opportunity:  4102. CDC will create a public education oral health campaign with a priority to address oral health disparities in a culturally and linguistically competent manner.

15. Addressing Disparities in Health Insurance Reforms

16. Leveraging the Potential for Health Care Reform to Reduce Racial and Ethnic Health Disparities

17. Advancing the Health of Communities • Leveraging support for community-based strategies and engagement in reducing disparities. • Communities must be active and involved participants in setting overall objectives, specific goals and strategies for achieving them. 2. Promoting integrated strategies across health and social services to improve the health of diverse communities. • Need for direct, concerted research, policy and programs that seek to alter significantly the negative influence of social determinants in diverse communities.

18. Health Care Organization-Based Initiatives 1. Developing and testing model programs that link specific organizational efforts to reducing disparities and improving quality of care. • Organizations must be committed to support practitioners through more comprehensive and active engagement in caring for diverse patients. 2. Documenting and linking non-profit community needs assessment/benefit requirements to health care reform incentives to address disparities. • Need to reach beyond demonstrations and funding opportunities. • Require provider organizations to show evidence of working to reduce disparities—e.g. through education & community outreach 3. Preserving and transitioning the health care safety net. • Providing direct support for safety net hospitals, particularly in regions with large uninsured and undocumented populations. • Guidance for philanthropic organizations on ways to support safety net.

19. Individual Level Initiatives • Developing effective care/disease management and self management interventions and protocols for diverse patients. • New programs will need to address how and to what extent inattention to race- and culture-specific and language/literacy concerns may create impediments to care management and self management. • Mitigating the effects of overweight/obesity and negative environmental factors that may impede progress on reducing disparities. • Greater health care provider awareness of culture and challenges faced by diverse populations will be important for reducing disparities in care and adherence to treatment.

20. Conclusions • Great breadth of opportunities in ACA to reduce disparities and improve health equity. • However, for many provisions, depth in terms of detail, strategy for implementation, methods for implementation, and measurement/evaluation to assess progress, is still lacking. • Allocations and federal agency roles, likewise, are unspecified for many provisions. • As of 8/1/2010, nearly two-thirds of the diversity specific provisions lacked specificity around appropriations and timeline • About one in ten includes short term, but no long term funding plan

21. What will a new Congress mean for public health efforts to eliminate racial/ethnic disparities and advance health equity through ACA?

22. Next Steps • Education around specific ACA language for priority areas. • Work with representative associations/organizations to educate and discuss strategies for pursuing priority areas. • Appropriations, appropriations, appropriations—assuring adequate funding for provisions. • Track timing and process for rollout. • Communicate with agencies likely to oversee identified priority areas about status and progress in adding content to these areas.

23. AuthorsContact Information Dennis P. Andrulis, PhD, MPH Senior Research Scientist, Texas Health Institute Associate Professor, University of Texas School of Public Healthdpandrulis@gmail.com Nadia J. Siddiqui, MPH Senior Health Policy Analyst, Texas Health Institutensiddiqui@texashealthinstitute.org Jonathan P. Purtle, MPH, MSc Program Manager, Drexel University School of Public Health jpp46@drexel.edu Lisa Duchon, PhD, MPA Health Management Associates lduchon@healthmanagement.com

24. Presenter Disclosures Dennis Andrulis, PhD, MPH The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: No relationships to disclose