Addressing Provider
Access Barriers in
Communities of Color
Opportunities and Challenges in the
Affordable Care Act
Nadia J. Siddiqui, MPH
Senior Health Policy Analyst
Texas Health Institute
January 23, 2015 | Washington, D.C. | Families USA Health Action Conference
Setting the Context
 Working to advance health
equity is central to the ACA.
 Over 3 dozen provisions directly
address health disparities,
diversity, cultural/linguistic
competence.
 Dozens of other general
provisions that work to advance
racial/ethnic health equity.
60+ Provisions on Advancing Health Equity
Health Equity Provisions Cut Across 5 Primary Priorities:
Health
Insurance
Health Care
Safety Net
Health Care
Workforce
- Culturally &
linguistically
appropriate
marketing,
outreach, and
education
- Medicaid/CHIP
- Primary Care
Provider Supply
- NurseManaged Clinics
- Loan &
Scholarships for
Underserved
- Nondiscrimination
- School Based
Health Clinics
- Pipeline
Programs
- Special
provisions for
American Indians
- Community
Health Needs
Assessment
- MinorityServing
Institutions
- DSH Payment
Cuts
- Cultural
Competency
Marketplace
- Community
Health Centers
Public
Health &
Prevention
Research,
Quality &
Innovation
- Prevention &
Public Health
Fund
- National
Quality Strategy
- CTGs
- NIH/NIMHD
- Obesity
- CMS Innovation
- Cancer
- ACOs
- Diabetes
- Medical Homes
- Oral Health
- Agency OMHs
- American
Indian Health
- Race/Ethnicity
Data Standards
- PCORI
Overall Realization of ACA's
Health Equity Provisions (56 Provisions)
Last Updated: December 2013
Not
Realized
23%
More Fully
Realized
48%
Partially
Realized
29%
“Realization” measured in terms of the extent to which a provision
received funding or was implemented through regulations,
taskforces, or other activity.
Source: Texas Health Institute, Research Last Updated December 2013. Funded by W.K. Kellogg Foundation
Implementation Progress of ACA’s Health Equity
Advancing Provisions by Topic (56 Provisions)
Lasted Updated: December 2013
N = 19
6
N = 11
N = 10
6
1
9
Health Insurance
Reforms
4
N=5
1
3
1
Access to Care
& Safety Net
More Fully Realized
1
4
3
7
Workforce Supply
& Diversity
N = 11
4
Research &
Innovation
Partially Realized
6
Public Health &
Prevention
Not Realized
Source: Texas Health Institute, Research Last Updated December 2013. Funded by W.K. Kellogg Foundation
Multi-Pronged Approach to
Addressing Provider Shortages
Provider Incentives
• Financial support (e.g., loan repayment, scholarships)
Systems Support
• Advance practice professionals (e.g., NPs, PAs)
• Interdisciplinary, team-based care models
• Other: telemedicine, HIT, extended hours, transportation
Community-Wide Initiatives
• Pipeline education programs
• Regional collaboration
• Essential community providers & network adequacy
Provider Incentives
National Health Service Corps
o Reauthorized by ACA through FY 2015, $1.5
Billion; FY 2015 budget invested an additional
$3.9 Billion through FY 2020

Up to $50,000 in loan repayment and scholarships for
health professionals who work 2 years in HPSA

Students to Serve (S2S) Loan Repayment Program:
$120,000 over 4 years to medical students in exchange
for 3 years in underserved area

Matching funds to states for loan repayment programs
o Grown 3 times: 9,200 NHSC providers, serving 9.7
mil patients; One-third non-white providers
Provider Incentives
Other Incentivizing Strategies
o Visa Waivers for Foreign Medical Graduates to
serve in underserved communities
o Partnering with community settings—e.g., health
centers, clinics, and hospitals in rural or
underserved areas—to serve as “rotation sites”
for medical residents & providing stipends
o
e.g., Rural Physician Associate Program
o Recruitment financial incentives – e.g., signing
bonuses
o Career development support and opportunities
Systems Support
Advanced Practice Professionals
Systems Support
Advanced Practice Professionals
o ACA Support:

PAs: $30 million for 700 new PAs by 2015

NPs: $31 million for 600 new NPs by 2015;
$15 million for 10 nurse-managed health clinics to
support training of 900 NPs and serve 94,000 patients

State workforce development: $5.6 million to help
states increase primary care workforce by 10-25%
o HRSA estimates that projected increases in NPs and
PAs between 2010-2020 could potentially reduce the
expected shortage of primary care providers in 2020
by about two-thirds
Systems Support
Advanced Practice Professionals
 Primary care provided by NPs is “as safe and effective as care
provided by doctors”1
 NPs can provide up to 80% of care that primary care physicians
currently provide 2
 NPs/PAs are often more reflective of communities
 NCQA medical home recognition standards permit NPs and PAs
to lead medical homes where allowed by state law
 NPs/PAs associated with smaller or rural community health
centers as well as those with highest uninsured rate 3
 NPs/PAs more involved with preventive patient education vs
physicians who are more involved with complex care 3
1.
2.
3.
IOM, The Future of Nursing: Leading Change, Advancing Health, 2010
Santoro & Speedling. Investing in the Future of Health Care Workforce. 2012
Leighton Ku et al, Community Health Centers Employ Diverse Staffing Patterns, Health
Affairs, January 2015
Systems Support
Embracing Interdisciplinary, Team-Based Care
 Physician led teams, supported by NPs/PAs, nurses,
medical assistants, clerical staff, case managers, social
and community health workers
 Team members performing “top of their license”
 Physician focus on complex cases; NPs/PAs providing
majority of routine, primary, and preventive care
 Critical role of culturally competent health coaches or
community health workers
 Health literacy

Health insurance and systems navigation

Addressing social, behavioral, and economic barriers
Systems Support
Other Systems-Level Facilitators
Community-Wide Initiatives
Building a Diverse, Health Professions Pipeline
o Investment in “pipeline” from K-12 to postgraduate
o Targeting traditionally underrepresented
minority and economically disadvantaged
students
o Programs provide:




Health career awareness
Mentorship
Scholarships
Shadowing or training in community settings
Community-Wide Initiatives
Title VII Programs Reauthorized by the ACA
o Physicians who graduate from a Title VII Program are
2-4 times more likely than other graduates to serve in
an underserved area.
o Scholarships for Disadvantaged Students

Supports a large number of nurse practitioners

60% underrepresented minorities
o Health Careers Opportunity Program

Dramatic funding cuts, phased out in FY 2015

2012-13: 7,100 trainees (51% African American, 24% Hispanic)
o Centers of Excellence

Decline in funding over the years

2012-13: 7,600 trainees (43% Hispanic, 26% African American)
Building Regional Collaborations
o Partnerships between academic institutions
and community-based clinics in urban,
suburban, and rural settings to build the
“pipeline”
o Accountable Care Communities
o
e.g., UW Accountable Care Network - spans 46
cities and neighborhoods with 700+ primary care
providers, 4,000 specialists, 573 clinics, 20
hospitals
o
e.g., Hennepin Health Social ACO - hospitals,
clinics partnering with social service organizations
to address broader social determinants that
influence health care access and outcomes
In Closing…
o ACA creates a unique “Window of Opportunity”
for expanding and building a diverse, culturally
competent health professions workforce to
address provider shortages.
o BUT Authorized ≠ Appropriated!
o Limited funding for many programs, along with
active and passive resistance to the law
threaten to deflect resources and delay or
diminish the law’s vision and potential.
Points to Consider Moving Forward
 Reassessing “Scope of Practice” laws for advanced
practice professionals and identify room for flexibility &
innovation
 Advocating for and assuring support for the health
professions pipeline, especially targeting students from
diverse racial, ethnic, and socioeconomic
backgrounds
 Looking to collaborative solutions that encourage
clinical-academic-community partnerships across
urban, suburban, and rural settings
 Building on the ACA’s support to address provider
shortages through team-based, medical home,
telemedicine, accountable care, and other systems
innovations
Thank You!
Nadia J. Siddiqui, MPH
Senior Health Policy Analyst
Texas Health Institute
nsiddiqui@texashealthinstitute.org
http://www.texashealthinstitute.org/health-care-reform.html
Texas Health Institute’s ACA & Health Equity Team:
Dennis Andrulis, PhD, MPH, Senior Research Scientist
Maria Cooper, MS, Health Policy Analyst
Lauren Jahnke, MPAff, Health Policy Consultant
Anna Schellhase, Graduate Health Policy Intern
Nadia Siddiqui, MPH, Senior Health Policy Analyst