W.K. Kellogg Foundation May 25, 2011 Asheville, North Carolina

1. Where Do We Go From Here?Maximizing the Potential of Health Care Reform to Reduce Racial & Ethnic Disparities Dennis P. Andrulis, PhD, MPH Senior Research Scientist, Texas Health Institute Associate Professor, University of Texas School of Public Health W.K. Kellogg Foundation May 25, 2011 Asheville, North Carolina

2. Background and Purpose • With support from the Joint Center for Political and Economic Studies, we conducted a comprehensive review of the Patient Protection and Affordable Care Act of 2010: • To identify and describe provisions specific to race, ethnicity and language; and general provisions likely to have a significant affect on diverse populations. • To assess status, challenges and opportunities of health care reform provisions for improving the health and health care of racially and ethnically diverse populations. • We are currently tracking implementation status and progress for provisions with explicit requirements for linguistic and cultural competence.

3. Health Equity & Cultural Competence • Health Equity • Health disparities/inequalities include differences between the most advantaged group in a given category—e.g., the wealthiest, the most powerful racial/ethnic group—and all others, not only between the best- and worst-off groups. Pursuing health equity means pursuing the elimination of such health disparities/inequalities. –Braveman, 2006 • 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.

4. Race, Ethnicity and LanguageSpecific Provisions:Over three dozen provisions in ACA onrace, ethnicity, cultural competence, language assistance and diversity.

5. Cultural Competence & Workforce Diversity • Cultural Competence • Model cultural competence curricula. • Cultural competence training for health professionals. • Culturally appropriate patient decision aids. • Culturally appropriate personal responsibility education for teen pregnancy prevention. • Culturally appropriate national oral health campaign. • Workforce Diversity • Increase diversity among health professionals. • Health professions training preference for cultural competence. • Investment in HBCUs & minority-serving institutions. • Collect & report workforce diversity data.

6. Data Collection & Disparities Research • Data Collection & Reporting • Collect racial/ethnic sub group data in population surveys. • Collect/report disparities data in Medicaid & CHIP. • Monitor disparities trends in federally funded programs. • Health Disparities Research • Examining disparities through comparative effectiveness research (CER). • Supporting research on topics of cultural competence and health disparities.

7. Cultural Competence in Health Insurance Reforms • Cultural & Linguistic Requirements of Exchanges and Participating Health Plans: • Non-discrimination in health insurance exchanges. • Culturally & linguistically appropriate summary of benefits. • Culturally & linguistically appropriate claims appeal process. • Incentive payments for cultural competence & reducing disparities.

8. General Provisions:Over three dozen general provisions with potentially major implications for racially/ethnically diverse populations

9. Health Insurance Reforms & Access to Care • Expansion of Medicaid eligibility to 133% FPL • Small business (<25 employees) tax credits • State-based health insurance exchanges • Support for Community Health Centers • Support for nurse-managed health centers, teaching centers & school-based clinics • Community health teams • Primary care extension programs • Pilots on regional emergency & trauma care

10. Public Health & Community Programs • Childhood obesity demonstration projects • National diabetes prevention program • Education campaign for breast cancer • Community transformation grants • Non-profit hospital community needs assessment requirement

11. Quality Improvement & Cost Containment • National Strategy for Quality Improvement • Developing & evaluating quality measures • Linking Medicare payments to quality outcomes • Pediatric Accountable Care Organizations • Reduction in Medicare & Medicaid Disproportionate Share Hospital (DSH) Payments

12. Implementation Opportunities & Challenges

13. Highlights • Great breadth of opportunities in ACA to reduce disparities and improve health equity. • Federal agencies, generally assigned leading responsibility for advancing and implementing these provisions. • Many provisions related to equity, cultural competence and language assistance have received appropriations and offer opportunities for community based organizations, county agencies and states to pursue funding. • However, important provisions, with a strong evidence base for need have not received appropriations as yet and may require state, county and community organizations to take innovative approaches to achieve their objectives.

14. Primary Care Opportunities • Community Health Centers • HRSA providing $10 million for new & expanded services for up to 125 FQHCs, a maximum of $80,000 for 1 year per award in 2011. • School-based Health Clinics • $50 million for each FY 2010-2013 for capital grants for facility construction, expansion and equipment. • Primary Care Extension Program • $120 million in 20011 to establish program to support and assist primary care providers to improve community health. • Health Professions Training Opportunities • HRSA grant programs for training in dentistry, primary care, & personal and home care aides, with preference given for experience in cultural & linguistic competence.

15. Prevention Opportunities • Community Transformation Grants • Over $100 million for 75 grants to help communities implement projects proven to reduce chronic diseases as well as health disparities. • Investment in Prevention • $750 million to reduce tobacco use, obesity and heart disease, and build healthier communities ($298 mil for community prevention, $182 mil for clinical prevention, $137 mil for public health, $133 mil for research). • Personal Responsibility Education • $75 million for states in 2011 to educate youth in culturally/linguistically appropriate ways to prevent teen pregnancy and sexually transmitted infections.

16. Opportunities in Health Insurance Programs • Community Based Care Transition Program • Funding in 2011 for eligible hospitals and community-based organizations that provide evidence-based transition services to Medicare beneficiaries with multiple chronic conditions to prevent hospital readmission. • CHIP Childhood Obesity Demonstration • $25 million in 2011 for a demonstration program to develop a model for reducing childhood obesity. • Medicaid Prevention and Wellness Initiatives • State grants in 2011 to provide incentives for Medicaid beneficiaries to participate in evidence-based programs to prevent/manage chronic disease. • State Health Insurance Exchanges • State planning and establishment grants for health insurance exchanges, which can also be used to set up a navigator program and provide appeals process and benefit summaries in culturally/linguistically appropriate ways.

17. Community Access & Prevention Opportunities (with no appropriations) • Community Health Teams (CHTs) • As states adopt medical home models, more low income & diverse individuals with chronic illness will be able to turn to a CHT to help them link with a full range of health and social services they may need. • Community Health Workers (CHWs) • Use of CHWs in health intervention programs associated with improved access, prenatal care, pregnancy and birth outcomes, health status, screening behaviors & reduced health care costs. • Oral Health Prevention Activities • Blacks, Hispanics, & AI/AN have poorest oral health access and outcomes & could significantly benefit from these programs.

18. Cultural Competence Opportunities (with no appropriations) • Model Curricula for Cultural Competency • Opportunity to test impact of a range of cultural competency training programs on health outcomes and to identify efficacy & effectiveness. • Facilitating Shared Decision Making • Patient decision aids are required to present up-to-date clinical evidence about risks and benefits of treatment options to meet cultural & health literacy requirements of populations.

19. Next Steps • Education around specific ACA language for priority areas. • Work with representative associations/organizations to educate and discuss strategies for pursuing priority areas. • Advocate for state, county and community innovation in health equity and reducing disparities. • Appropriations, appropriations, appropriations—assuring adequate funding for provisions. • Communicate with agencies likely to oversee identified priority areas about status and progress in adding content to these areas.

20. Contact Information Dennis P. Andrulis, PhD, MPH Senior Research Scientist, Texas Health Institute Associate Professor University of Texas School of Public Healthdpandrulis@gmail.com