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

1. Affordable Care Act of 2010 and Opportunities for Advancing Health Equity: Taking Vision and Promise to Reality 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 Session 4286. Implementing Health Equity 2020 at the FrontlineAPHA 139th Annual Meeting and Exposition Washington, DC | November 1, 2011

2. Overview • ACA’s Vision, Promise and Background • Status of Diversity, Cultural Competence & Equity Provisions • State and Local Actions and Initiatives • Continuing and Growing Challenges • Moving Forward

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 Aug 2008* Comparative Report on Health Reform Proposals of Obama vs. McCain Oct 2011Health Affairs article on ACA, Safety Net & Diversity 2011 – 2013§ Tracking Implementation Progress, Opportunities & Challenges for Health Equity & Diverse Populations July 2010*Release of Comprehensive Report on ACA & Health Equity 2009*Analysis of House & Senate Health Reform Bills May 2011†Report on Progress & Status of ACA’s Cultural Competence Provisions Jan 2009President Obama inaugurated Mar 2010 ACA Enacted 2012 Presidential Elections & Supreme Court Decision 2008 2013 * Supported by Joint Center for Political and Economic Studies. † Supported by SRA International.§ Supported by The California Endowment & other foundations.

5. From Vision to Reality…

6. Authorized and AppropriatedProvisions with Cultural/Linguistic (C/L) Requirements • Health Care Workforce • Loan repayment programs with preference to providers having training or experience in C/L competence or from R/E backgrounds • Data Collection and Reporting • Establishment of standards for collecting and reporting data by race, ethnicity, and primary language in federally supported public health programs, activities or surveys • Health Insurance • Uniform, C/L appropriate explanation of coverage • C/L appropriate claims appeals process • Navigator to provide C/L information on exchanges, enrollment, etc • Public Health Programs • Community Transformation Grants for chronic disease and disparities • Culturally-tailored personal responsibility education on teen pregnancy

7. Authorized and AppropriatedGeneral Provisions with Major Implications for Health Equity • Health Insurance • Expansion of Medicaid eligibility to 133% FPL • Reauthorization of CHIP • State Health Insurance Exchanges • Access to Health Care • $11 billion for Community Health Centers • Grants to expand trauma centers– at least 40% of funds to safety net • Maternal and child home visiting programs for at-risk populations • Quality and Systems Innovation • Medical Home demonstration programs for care coordination • Aligning payment with quality and continuity of care

8. State Actions to Advance Equity • California’s “Bridge to Reform” 1115 Medicaid Waiver • Expands county-based Health Care Coverage Initiative (HCCI) for adults with incomes between 133-200% FPL • Support for county hospitals to improve quality of care through infrastructure updates (e.g., IT) and systems innovation (e.g., care coordination) • Support to enhance care delivery for high burden diseases at public hospitals • Texas’ 1115 Medicaid Waiver Proposal • Expands Medicaid managed care to other counties across the state • Transitions to quality-based payments for managed care and hospitals • Diverts savings into a pool to cover uncompensated care for hospitals and safety net providers

9. Dark Blue : legislation requiring (WA, CA, NJ, NM, CT) or strongly recommending (MD) cultural competence training, which was signed into law. Purple : legislation which has been referred to committee and is currently under consideration. Royal Blue : legislation which died in committee or was vetoed. State Progress on Cultural Competence States with Cultural Competence Legislation2000-2011 Source: Think Cultural Health, 2011

10. Local/Community Progress & Programs • Philanthropic Funding Pools • e.g., 5 health philanthropies in Kansas formed an “Affordable Care Act Opportunity Fund” to assist state/local organizations in implementing ACA • Community Networks for Medical Homes • Community health center collaboration with private practices to extend medical home services to diverse and vulnerable populations • e.g., Models in Montana, North Carolina, Indiana

11. National/Academic Progress & Programs • National Initiativese.g., National Quality Forum (NQF) • Analyzing and establishing valid measures to evaluate disparities and cultural competence across diverse settings and populations, known as Healthcare Disparities and Cultural Competency Consensus Standards • Academic Initiatives e.g., Xavier University in New Orleans, LA • Evaluating 12 online cultural competency training programs

12. Continuing and Growing Challenges…

13. Authorized Provisions, but NOT Appropriated • Cultural Competence Education • Model cultural competency curricula • Health Care Workforce • Community health workers, defined as providing C/L appropriate outreach and health education • Community health teams to support medical homes in providing culturally appropriate, patient-centered care • Public Health Programs • C/L appropriate oral health education campaign • Pain management education addressing C/L barriers

14. Populations remaining at or beyond the margins • 23 million uninsured, of which 11 million undocumented immigrants

15. Risks for the Safety Net • $18 billion reduction in 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

16. Timeline and Budget • Timeline • Impending Supreme Court decision on insurance mandate • 27 States with Lawsuits • Change in presidential leadership • Budget • Budget cuts at all levels affecting safety net and disparities-relatedprograms States that have Filed a Federal Lawsuit in Response to the Affordable Care Act, 2011

17. Moving Forward…

18. Advancing Equity in the Era of Health Care Reform

19. What can we do?

20. Our Future Work • With support from The California Endowment and other Foundations, we will: • Track the status of implementation of equity, diversity and cultural competence provisions in ACA as well as general provisions with major implications for diverse populations, given changing health care environment. • Identify emerging opportunities for funding, advisory groups, taskforces, and other issuances, and ways in which to tap them. • Recommend ways to leverage federal funding—or a lack thereof—with state and local resources from public and private sources. • Report will be unveiled at the upcoming National Conference on Quality Health Care for Culturally Diverse Populations in October 2012, in Oakland, California.

21. Contact 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 Our Recent Publications Andrulis DP and Siddiqui NJ. Health Reform Holds Both Risks and Rewards for Safety-Net Providers and Racially and Ethnically Diverse Patients. Health Affairs, 2011, 30(10). Andrulis DP, Siddiqui NJ, Purtle, JP and Duchon L. Patient Protection and Affordable Care Act of 2010: Advancing Health Equity for Racially and Ethnically Diverse Populations. July 2010. Supported and released by the Joint Center for Political and Economic Studies.

22. Presenter Disclosure Dennis P. 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.

23. Cultural Competence A set of attitudes, skills, behaviors, and policies that enable organizations and staff to work effectively in cross-cultural situations. It reflects the ability to acquire and use knowledge of the health-related beliefs, attitudes, practices, and communication patterns of clients and their families to improve services, strengthen programs, increase community participation, and close the gaps in health status among diverse population groups. (Cross et. al. 1989 and Lavizzo-Mourney and Mackenzie 1996 as cited in Cultural Competence: A Journey, Bureau of Primary Health Care. HRSA, US DHHS, n.d.)

24. Source: M, Beach. Patient-centeredness and cultural competence: their relationship and role in reducing health disparities. Commonwealth Fund 2006