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 Affordable Care Act and Opportunities for Advancing Health Equity:Taking Vision and Promise to Reality Advancing Equity through Health Care Reform: A State-Federal Discussion of Promising State Policies National Association of State Health Policy (NASHP) May 31, 2012 | Washington, D.C.

2. Overview • 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?

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 that directly address disparities, diversity and cultural/linguistic competence. • Dozens of other provisions with major implications for racial/ethnic disparities and equity.

4. Track Record of Analyzing Health Care Reform with a Racial/Ethnic Disparities and Health Equity Lens Tracking will continue into 2013.

5. Tracking Design:Overall Status of Implementation Tracking 62 provisions specific to race, ethnicity, language and diversity as well as general provisions with major implications for racially and ethnically diverse populations. Overall Level of Progress

6. Tracking Design: In-Depth Analysis of Implementation Progress • 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

7. A. Health Insurance 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.

8. Health Insurance State Exchanges 13 States & DC with Legislation to Establish Exchanges, as of May 2012 NH WA VT ME MT ND AK MN OR NY ID WI MA SD RI WY MI CT PA IA NJ OH NE NV DE IN IL MD UT WV IA VA CO DC CA KS MO KY IL NC WV VA TN SC OK AZ AR NM GA AL MS HI LA TX FL State exchange in existence prior to passage of ACA Legislation signed into law post-passage of ACA 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.

9. Health Insurance: Example of Progress & OpportunitiesCultural & Linguistic Requirements in Exchanges • 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.

10. Health Insurance: Example of Progress & OpportunitiesCultural & Linguistic Requirements in Exchanges 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

11. B. Safety Net Overall Level of Progress * Comprised of Nursed-Managed Centers, School-Based Health Centers, Teaching Health Centers Note: We are also tracking Reductions to Medicare/Medicaid DSH Program and its Implications for Diverse Patient Populations.

12. Safety Net: Example of Progress & OpportunitiesNon-Profit Hospital Community Needs Assessment • 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.”

13. Safety Net Challenges in Caring for Diverse Patients • $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

14. C. Workforce Diversity Overall Level of Progress • 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.

15. Workforce Diversity: Example of Progress & OpportunitiesPublic Health & Prevention Fund • 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

16. Workforce Diversity: Example of Progress & OpportunitiesState 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

17. D. Research, Data & Quality Overall Level of Progress

18. Research, Data, & Quality: Example of Progress & OpportunitiesPatient Centered Outcomes Research Institute (PCORI) • 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

19. E. Public Health & Prevention Overall Level of Progress

20. Public Health & Prevention: Example of Progress and OpportunitiesCommunity 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

21. Where do we go from here? ??? Supreme Court Decision ???

22. Advancing Equity: Priorities that Remain Despite a Supreme Court Decision

23. “Gains in Health System Seen as Lasting” For many health equity objectives in ACA, the seeds have been sown. It is the opportunities that need to be seized.

24. 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