Health Reform and Its Potential Impact on Racial and Ethnic Health Disparities

1. Health Reform and Its Potential Impact on Racial and Ethnic Health Disparities Cara V. James, Ph.D. Director, Disparities Policy Project Henry J. Kaiser Family Foundation October 21, 2010

2. What are Health Disparities?

3. Clinical Appropriateness and Need Patient Preferences Group A Difference Quality of Health Care The Operation of Healthcare Systems and Legal and Regulatory Climate Group B Disparity Discrimination: Biases, Stereotyping, and Uncertainty What is a Health Care Disparity? SOURCE: Figure 1. Differences, Disparities, and Discrimination: Populations with Equal Access to Healthcare. Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, Summary. Brian Smedley, Adrianne Stith, and Alan Nelson, Eds. Washington, DC. Institute of Medicine, 2002.

4. Racial and Ethnic Gender Sexuality Geographic Socioeconomic Status Types of Health Disparities

5. Disparities Differ in Size and Geography

6. New AIDS Cases United States (11.58) Highest: Minnesota (36.98) Lowest: Montana (0.00) No Health Coverage United States (2.18) Highest: North Dakota (4.59) Lowest: Hawaii (0.92) No High School Diploma United States (3.11) Highest: District of Columbia (11.76) Lowest: New Hampshire (0.82) Range of Disparity Scores • Smoking • United States (0.59) • Highest: South Dakota (1.98) • Lowest: Florida (0.39) • Cancer Mortality • United States (0.86) • Highest: Maine (2.14) • Lowest: Nevada (0.60)

7. The Social Gradient Stress Early life Social Exclusion Work Unemployment Social Support Addiction Food Transportation Health Insurance Health Literacy Language Proficiency Social Determinants of Health Richard Wilkinson and Michael Marmot, eds. Social Determinants of Health: The Solid Facts, 2nd Edition. Denmark; World Health Organization, 2003. Also available online at http://www.euro.who.int/eprise/main/who/informationsources/publications/catalogue/20020808_2.

8. Black, Non-Hispanic American Indian/Alaska Native White, Non-Hispanic Asian and Native Hawaiian/Pacific Islander Hispanic Black, Non-Hispanic American Indian/Alaska Native White, Non-Hispanic Asian and Native Hawaiian/Pacific Islander Hispanic Black, Non-Hispanic American Indian/Alaska Native White, Non-Hispanic Asian and Native Hawaiian/Pacific Islander Hispanic Less than High School High School More than High School Infant Mortality Rates for Mothers Age 20+, by Race/Ethnicity and Education, 2005 DATA: National Center for Health Statistics, National Vital Statistics System, National Linked Birth/Infant Death Data. SOURCE: Health, United States, 2008, Table 19.

9. Disparities exist in health status, access to care, quality of care, and health outcomes, there is still much we don’t know, due to a lack of data. Regardless of how they fair in the aggregate, all racial groups have problems. Racial groups are not monolithic, and health differs within racial groups. A myriad of efforts are underway to address disparities, but we still have a long way to go to eliminate disparities. Cost of not addressing disparities is large and apt to get worse, as the population changes. Many factors aside from race impact health and health care. Take Home Messages Regarding Health Disparities

10. Why Should We Care About Health Disparities?

11. CHART 11 Distribution of U.S. Population by Race/Ethnicity, 2008 (0.4 million) (2.3 million) (4.5 million) (13.2 million) (46.9 million) (199.5 million) (37.2 million) Total U.S. Population = 304.1 million NOTES: Data do not include residents of Puerto Rico, American Samoa, Guam, the U.S. Virgin Islands, or the Northern Mariana Islands. Totals may not add to 100% due to rounding. All racial groups and individuals reporting “two or more races” are non-Hispanic. DATA: Table 3: Annual Estimates of the Population by Sex, Race and Hispanic Origin for the United States: April 1, 2000 to July 1, 2008 (NC-EST2008-03). Population Division, U.S. Census Bureau.

12. What Might Health Reform Mean for Health Disparities?

13. Expand health coverage Reduce health care costs Improve health care quality Expand health care workforce Health Reform Goals

14. Nonelderly Health Coverage by Race/Ethnicity, 2008 DATA: 2009 March Supplement, Current Population Survey. SOURCE: Kaiser Family Foundation Analyses

15. Distribution of Nonelderly Uninsured by Race/Ethnicity, 2008 Total Nonelderly Uninsured Population = 45.7 million DATA: 2009 March Supplement, Current Population Survey. SOURCE: Kaiser Family Foundation Analyses

16. Expansions in public programs such as Medicaid Individual mandate Employer “mandate” Creation of Health Insurance Exchanges Changes to the private market Coverage Expansions

17. Medicaid Expansions

18. Expanded Access to Medicaid for Low-Income Individuals 2009 Medicaid Eligibility Levels Vary by Categorical Status 100% FPL Note: Medicaid income eligibility for most elderly and individuals with disabilities is based on the income threshold of Supplemental Security Income (SSI). Source: Based on a national survey conducted by the Center on Budget and Policy Priorities for KCMU, 2009.

19. Expanded Access to Medicaid for Low-Income Individuals New Medicaid Eligibility Floor 133% FPL 100% FPL Note: Medicaid income eligibility for most elderly and individuals with disabilities is based on the income threshold of Supplemental Security Income (SSI). Source: Based on a national survey conducted by the Center on Budget and Policy Priorities for KCMU, 2009.

20. Distribution of Nonelderly Uninsured Below 133% FPL by Race/Ethnicity, 2008 Total Nonelderly Uninsured Below 133% FPL = 22.1 million DATA: 2009 March Supplement, Current Population Survey. SOURCE: Kaiser Family Foundation Analyses

21. Current and Projected Medicaid Coverage Rates by Race/Ethnicity American Indian/Alaska Native Two or More Races NHOPI White Hispanic Asian Black DATA: 2008-2009 March Supplement, Current Population Survey. SOURCE: Kaiser Family Foundation Analyses

22. Creation of Health Insurance Exchanges and Changes to Private Coverage

23. Large Employers (More than 50 employees) Required to provide coverage or pay a fee of $2,000 per full-time employee, minus first 30 Small Employers (50 or fewer employees) Exempt from penalties for not offering coverage Employers with no more than 25 employees and wages less than $50,000 receive a tax credit up to between 35% and 50% of their contribution towards coverage Employer “Mandate”

24. Changes to individual market: Ban gender rating Ban exclusion of pre-existing conditions Ban variations in premiums based on health status Identify maternity care as an essential benefit to be covered by all plans in the exchange. Premium credits and cost-sharing subsidies will be helpful to many people purchasing coverage in the exchange Health Exchange

25. Premium Credits Tied to the second lowest cost Silver plan Provided on a sliding scale (between 2% and 9.5% of income) Cost Sharing Subsidies Will reduce cost sharing by 94% to 70%, depending on income Premium Credits and Cost Sharing Subsidies

26. Poverty Status of Nonelderly by Race/Ethnicity, 2008 33.3 million 166.4 million 44.7 million 1.7 million 0.7 million 4.3 million 11.7 million DATA: 2009 March Supplement, Current Population Survey. NOTE: FPL in 2009 was $18,310 for a family of three. SOURCE: Kaiser Family Foundation Analyses

27. Workforce Provisions

28. Workforce Expansion Provisions • Expands the existing workforce • Removes cap on National Health Service Corps, expands primary care, dental, and geriatric workforce, and adds funding for training mental and behavioral health workers • Increases reliance on other health care providers • Nurse-managed clinics, community health worker program in IHCIA • Establishes the National Health Care Workforce Commission

29. Expansions for Underserved Communities • Increasing the number of diverse physicians from underserved communities • Establishes Area Health Education Centers • Focused on underserved communities, will train people to work in these communities, and will recruit and train people from the community into the health professions.

30. Provisions Specific to Racial and Ethnic Health Disparities

31. Requires the collection of data on race, ethnicity, language, geographic location, socioeconomic status (including income and education) and disability Required the Secretary to develop curricula for cultural competency for individuals with disabilities Provides loan repayment and the development and implementation of strategies to recruit individuals from underrepresented minority populations, disadvantaged backgrounds and rural backgrounds Also permanently reauthorizes the Indian Health Care Improvement Act. Establishes offices of minority health in all agencies of HHS and elevates NCMHD to an institute Disparities-Specific Provisions in the Bill

32. Health Reform and American Indian and Alaska Natives

33. Provisions Specific to American Indians and Alaska Natives • Exemption from penalties for individual mandate • No cost sharing for Native Americans with incomes below 300% FPL in the Exchanges or Medicaid • Discounting of certain income in determining Medicaid and subsidy eligibility • Special enrollment times for Medicaid and the Exchanges • At least $500,000 in grants will be given to tribes and other tribal organizations to reduce teen pregnancy

34. Health Reform and the Indian Health Care Improvement Act

35. The Indian Health Care Improvement Act • Provides authorization for hospice, assisted living, long-term, and home- and community-based care. • Makes it easier for tribal-run facilities to recover costs from third parties • Establishes a Community Health Representative program for urban Indian organizations to train and employ Indians to provide health care services. • Directs the IHS to establish comprehensive behavioral health, prevention, and treatment programs for Indians.

36. Other Provisions

37. Quality improvement efforts National quality strategy, comparative effectiveness, and medical malpractice Health Information Technology Increased investment, new requirements for providers, and interoperability Funding for federally qualified health centers Increase in funding by $11 billion over next 5 years Prevention efforts National strategy for prevention, grants for reducing chronic disease, coverage of preventive services in Medicare, and incentives for wellness programs Other Provisions

38. Increases the maximum amount for which an individual is eligible to receive in Pell grants Adding $84 million annually to the College Access and Challenge Grant Program Extends the investment in HBCUs and other minority serving institutions Removes commercial banks from student loan process Reduces the maximum income percentage devoted to loan repayment from 15% to 10%, and reduces point at which loans are forgiven from 25 years to 20 years. Education Changes

39. Who is Left Out?

40. Coverage Restrictions for Immigrants Under Current Reform Proposals

41. State Responsibility and Flexibility

42. Medicaid Eligibility Children Pregnant Women Parents of children SNAP and TANF benefits, and allowances Child-Friendly Firearm Laws (e.g. assault weapon bans, safe storage requirements) Ease of Medicaid and CHIP enrollment practices State Policies that Affect Health

43. NH VT WA ME MT ND MN MA OR NY ID SD WI RI MI CT WY PA NJ IA NE OH IN NV DE IL WV UT VA MD CO CA KS MO KY NC DC TN OK SC AR AZ NM AL GA MS TX LA AK FL 4 – 15% (12 states) HI 16 - 25% (12 states) 26 - 39% (13 states) 40 - 80% (13 states and DC) U.S. Total = 37% Minority Source: Kaiser Family Foundation analysis of March 2009 Current Population Surveys, U.S. Census Bureau. Proportion of Nonelderly Who Self-Identify as a Person of Color, by State

44. Costs vs. Coverage • Congressional Budget Office estimates bill will cost $938 billion over ten years. • Should reduce budget deficit by $124 billion over ten years • Should cover approximately 32 million when fully implemented

45. Implementation Timeline

46. What happens this year? Extension of coverage the children under 26 Eliminating pre-existing conditions in children $250 rebate for Medicare beneficiaries who reach the doughnut hole Establishment of high-risk pool for people with pre-existing conditions January 1, 2014 Health Exchanges are up and running Individual and employer mandates takes effect Medicaid expansions are implemented Subsidies and premium credits become available Timeline for Implementation

47. Concluding Thoughts about Health Reform and Disparities • Implementation: Despite its length, the bill is a skeleton, and the rules and regulations coming from HHS are extremely important • Affordability and Scope of Coverage: Still central concerns for people of color, many of whom are low-income • Primary Care and Prevention: investments in building primary care infrastructure and prevention important but may not be sufficient • Excluded Populations: Many people will not qualify for assistance because of their immigration status. Safety-net providers will still be critical

48. Thank You!