click to edit master title style dennis p. andrulis, phd, mph senior research scientist, texas...
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Dennis P. Andrulis, PhD, MPHSenior Research Scientist, Texas Health Institute
Associate Professor, University of Texas School of Public Health&
Nadia J. Siddiqui, MPHSenior 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
Click to edit Master title styleClick to edit Master title styleOverviewOverview• 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
Click to edit Master title styleClick to edit Master title styleACA’s Vision and PromiseACA’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.
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Track Record of Analyzing Health Care Reform with a
Racial/Ethnic Disparities and Health Equity Lens
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
2008 2013Jan 2009President Obama
inaugurated
2009*Analysis of House & Senate
Health Reform
Bills
Mar 2010 ACA Enacted
2011 – 2013§Tracking
Implementation Progress,
Opportunities & Challenges for
Health Equity & Diverse
Populations
July 2010*Release of
Comprehensive Report on ACA &
Health Equity
2012Presidential Elections &
Supreme Court Decision
Oct 2011Health Affairs
article on ACA,
Safety Net & Diversity
May 2011†Report on Progress & Status of
ACA’s Cultural
Competence Provisions
* Supported by Joint Center for Political and Economic Studies.† Supported by SRA International.§ Supported by The California Endowment & other foundations.
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Authorized and AppropriatedProvisions with Cultural/Linguistic (C/L) Requirements
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
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Authorized and AppropriatedGeneral Provisions with Major Implications for Health Equity
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
Click to edit Master title styleClick to edit Master title styleState Actions to Advance EquityState 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
Click to edit Master title styleClick to edit Master title styleState Progress on Cultural CompetenceState Progress on Cultural Competence
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.
Source: Think Cultural Health, 2011
States with Cultural Competence Legislation2000-2011
Click to edit Master title styleClick to edit Master title styleLocal/Community Progress & ProgramsLocal/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
Click to edit Master title styleClick to edit Master title styleNational/Academic Progress & ProgramsNational/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 Initiativese.g., Xavier University in New Orleans, LA – Evaluating 12 online cultural competency training
programs
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Click to edit Master title styleClick to edit Master title styleAuthorized Provisions, but NOT AppropriatedAuthorized 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
Click to edit Master title styleClick to edit Master title stylePopulations remaining at or beyond the marginsPopulations remaining at or beyond the margins
• 23 million uninsured, of which 11 million undocumented immigrants
Click to edit Master title styleClick to edit Master title styleRisks for the Safety NetRisks 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
Click to edit Master title styleClick to edit Master title styleTimeline and BudgetTimeline 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
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Click to edit Master title styleClick to edit Master title styleAdvancing Equity in the Era of Health Care ReformAdvancing Equity in the Era of Health Care Reform
Click to edit Master title styleClick to edit Master title styleWhat can we do?What can we do?
Click to edit Master title styleClick to edit Master title styleOur Future WorkOur 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.
Click to edit Master title styleClick to edit Master title styleDennis P. Andrulis, PhD, MPHSenior Research Scientist, Texas Health Institute
Associate Professor, University of Texas School of Public [email protected]
Nadia J. Siddiqui, MPHSenior Health Policy Analyst, Texas Health Institute
Our Recent PublicationsAndrulis 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.
Click to edit Master title styleClick to edit Master title stylePresenter DisclosurePresenter DisclosureDennis 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.
Click to edit Master title styleClick to edit Master title styleCultural CompetenceCultural 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.)
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Source: M, Beach. Patient-centeredness and cultural competence: their relationship and role in reducing health disparities. Commonwealth Fund 2006