Realizing the Vision of Health Equity in the
Affordable Care Act: Assessing Progress &
Building Opportunities for the Future
Dennis P. Andrulis, PhD, MPH
Senior Research Scientist, Texas Health Institute
Associate Professor, UT School of Public Health
&
Nadia J. Siddiqui, MPH
Senior Health Policy Analyst, Texas Health Institute
141st Annual APHA Meeting, November 4, 2013, Boston, MA
Project Support: WK Kellogg Foundation, The California Endowment, & Kaiser Permanente
ACA & Racial and Ethnic Health Equity Series
5 Reports, Nearly 60 Provisions on Advancing Equity
Report 1:
Health
Insurance
Marketplace
- Culturally &
linguistically
appropriate
marketing,
outreach, and
education
- Nondiscrimination
- Special
provisions for
American
Indians
Report 2:
Health Care
Safety Net
Report 3:
Health Care
Workforce
- Medicaid
- Primary Care
- CHIP
- Underserved
Areas
- Health Centers
- DSH Payments
- Community
Health Needs
Assessment
Report 4:
Public
Health &
Prevention
Report 5:
Research,
Quality &
Innovation
- Prevention &
Public Health
Fund
- National
Quality Strategy
- Workforce
Diversity
- CTGs
- NIH/NIMHD
- Obesity
- CMS Innovation
- Cultural
Competence
- Cancer
- ACOs
- Diabetes
- National
Healthcare
Workforce
Commission
- Medical Homes
- Oral Health
- Agency OMHs
- American
Indian Health
- Race/Ethnicity
Data Standards
- PCORI
ACA’s Overall Progress on Advancing Equity
More Fully
funded or
Implemented
Partially
Funded or
Implemented
Not Funded or
Implemented
Health Insurance
Marketplace
7
0
1
8
Safety Net
3
3
1
7
Workforce
Diversity
7
6
6
19
Data, Research,
Quality
4
3
4
11
Public Health &
Prevention
6
4
1
11
27
(48%)
16
(29%)
13
(23%)
56
Total
ACA Status & Implications for
Advancing Health Equity as we
Approach 2014
Health Insurance Marketplaces
Projected Enrollees by Race & Ethnicity
42% or over 12 million Non-Whites
25% will speak a language other than English at home
6%
White
25%
Black or African American
58%
Hispanic or Latino
11%
Other
Source: KFF. A Profile of Health Insurance Exchange Enrollees, March 2011.
How Are Marketplaces Addressing Disparities?
Source: Andrulis DP, Jahnke LR, Siddiqui NJ, and Cooper MR. Implementing Cultural and Linguistic Requirements in Health
Insurance Exchanges, 2013. Texas Health Institute: Austin, TX. Available at: http://www.texashealthinstitute.org/healthcare-reform.html
Medicaid Expansion:
Projected Eligible by Race and Ethnicity
• 6.8 million or 45% of New Medicaid Eligible are Non-White.*
• In 29 States Moving toward Expansion, 3.8 million Non-Whites.**
Percent of Population with Income below 138% FPL who
will be Eligible for Medicaid in 2014, by Race and Ethnicity
54.9%
19.4%
18.7%
7.0%
White
Hispanic or Latino African American
Other
*Source: Kenney, G.M., Zuckerman, S., Dubay, L., Huntress, M., Lynch, V., Haley, J., & Anderson. (2012). Not Opting
in to the Medicaid Expansion under the ACA: Who are the Uninsured Adults Who Could Gain Health Insurance
Coverage? Timely Analysis of Immediate Health Policy Issues. Robert Wood Johnson Foundation and Urban Institute.
**Data extrapolated from Kenney et al., 2012.
ACA Capacity Initiatives to Meet New Demand
Minority
Health
Professions
Enhance
Capacity in
Underserved
Areas
(NHSC)
(FQHCs, NMHC,
School & Teaching
Health Centers)
(HBCUs)
Primary Care
Workforce
Support
Health Center
Support
Enhancing
Capacity
Payment &
Delivery
Innovations
(ACOs, PCMHs,
1115 Waivers)
Access to Care in the Safety Net
Challenges to Advancing Health
Equity through the ACA
1. Funding & Sustainability
• More than half of the provisions received
substantially less than authorized or no
funding from the ACA.
• Declining support for minority health and
health professions.
– HCOP & COE programs
– HHS’ minority health initiatives
• Uncertain support for sustaining
public health & prevention initiatives.
2. Political Antipathy
Antipathy toward the law may thwart
progress to advance equity in many
states.
• Antagonism to Marketplace
• In states not expanding Medicaid…
– 2 million, low-income diverse individuals will fall through cracks
– 60% of uninsured African Americans in states not expanding
– 44% of uninsured Hispanics in states not expanding
• Undocumented immigrants left at margins
• Misinformation, and confused & reluctant consumers
generally; for some, language barriers.
Billboard on 42nd St. Near Times Square
3. Time
• ACA’s broader provisions are priority,
but will equity issues be integrated?
– Health insurance marketplaces
– Medicaid expansion
• Measurable outcomes in short run (2-3 years)
– Patient Centered Outcomes Research Institute
– CMS Innovation Center
• Cultivating partnerships and collaborations
takes time not available under many ACA
provisions.
4. Equity is Not a Priority
• Implementing ACA’s insurance provisions takes
center stage, likely to limit attention to equity and
diversity.
• Many minority health & underrepresented minority
health professions provisions with declining support.
• Cultural competence is not a
priority – almost no support!
• How to reframe equity in context
of mainstream priorities?
2014 & Beyond:
Actions and Opportunities for
Advancing Equity
1. Monitoring & Adapting Marketplace
Implementation to Advance Equity
• “Window of Opportunity” to advance equity
given support & attention to marketplaces.
• Equity must be integrated early on & be ongoing:
–
–
–
–
–
–
Leadership & governance
Navigator & assister recruitment & training
Outreach & enrollment
Language services and assistance
Community engagement
Measurement & evaluation
Variation in Marketplaces & Implications for Equity
• Most Progressive, with both Medicaid expansion
and state-run Marketplace.
• Somewhat Progressive, with Medicaid expansion
and/or state-run or partnership Marketplace, in
challenging political environment.
• Least Progressive, opposed to the ACA with federal
Marketplace and/or no Medicaid expansion.
2. Addressing Gaps in Access & Capacity to Meet
Needs of a Growing Diverse Patient Population
• Assisting in transitioning the safety net
–
–
–
–
Infrastructure support for delivery & payment reform
Actions to support care for remaining uninsured
Monitoring & reassessing DSH payment reductions
Tracking 1115 waiver innovation and potential models
• Supplementing existing workforce support
–
–
–
–
Supply of providers in underserved & diverse areas
Minority-serving institutions & HBCUs
Health professions programs for under-represented minorities
Cultural competency education & training
3. Building on ACA’s Community-Based Initiatives
to Engage and Reach Diverse Communities
• Offers opportunity to break new ground in
bringing communities more directly into health
and health care programs.
• Offers direct role for philanthropy and private
sector to leverage and expand, sustain, and
evaluate community efforts.
4. Advancing Metrics, Measuring, & Monitoring
• Monitoring ACA programs for impact,
outcomes, and effectiveness by race & ethnicity
–
–
–
–
Marketplace implementation
Enrollment in exchanges & Medicaid
Navigator & assister programs
DSH payment reduction impacts
• Texas Health Institute to develop Report Card on
Implementation Progress of Marketplace Initiatives for
Advancing Racial & Ethnic Equity
5. Education & Advocacy for Advancing Equity
• Community forums to educate audiences on the ACA
& opportunities to bridge disparities.
• State and local forums on “how to” effectively
integrate diversity and equity into various ACAsupported activities.
• Continued advocacy around key disparities priorities:
– Oral health disparities
– Cultural competency education
– Minority health professions programs
Closing Remarks
• Many provisions in place to advance equity.
• BUT time, dollars, launch challenges,
misinformation, and active and passive resistance to
the law threaten to deflect resources and delay or
diminish the law’s equity vision and potential.
• Need for active advocacy and efforts to keep equity
high on the health care reform agenda and
across priorities reflected in the ACA.
Our Health Care Reform & Equity Team
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 R. Cooper, MA
Health Policy Analyst, Texas Health Institute
Lauren Jahnke, MPAff
Consultant, LRJ Research & Consulting
For questions, feedback, or to be added to our mailing list, please e-mail:
nsiddiqui@texashealthinstitute.org.
Website: http://www.texashealthinstitute.org/health-care-reform.html