Disparities-Related Opportunities and Challenges from National Health Reform Dennis P. Andrulis, PhD, MPH Senior Research Scientist, Texas Health Institute Associate Professor, University of Texas School of Public Health Nadia Siddiqui, MPH Senior Health Policy Analyst, Texas Health Institute October 6, 2011 | Issue Briefing | Washington, DC

The Safety-Net, Disparities, and Affordable Care Act Working to eliminate health disparities is a central goal of national health reform--dozens of provisions directly support this goal. Safety-net providers “organize and deliver a significant level of health care and related services to uninsured, Medicaid and other vulnerable populations.” Racially and ethnically diverse patients make up nearly two-thirds of those served by safety-net institutions. The Affordable Care Act holds much promise but substantial risk for the safety-net, and, by implication, it raises questions around who will care for diverse and vulnerable patients they have traditionally served.

Opportunities & Risks for Safety-Net in Serving Diverse Populations OpportunitiesRisks Health Insurance 32 million newly insured by 2019 Support for cultural/linguistic requirements in outreach & enrollment Increased competition among providers for formerly uninsured If private sector targets more lucrative markets, could be left with high cost patients Financing Reforms Substantial support for health centers and other safety net settings State grants for underserved areas Increases in Medicaid reimbursement for primary care $18 billion reduction in disproportionate share hospital program—which finances 22% of unreimbursed care at public hospitals Workforce Support Grant preference to institutions training minority professionals Support for workforce diversity and training in cultural competence Increase in scholarships for service in underserved areas Sufficiency of workforce expansion in relation to growth in insured Lack of appropriations—e.g., community health workers, cultural competence curriculum Delivery & Payment Innovation Improved care coordination for low- income Medical homes for Medicaid patients Payment programs to improve quality and continuity of care Many may lack infrastructure such as IT For some, low or negative operating margins/lack of capital may limit ability to innovate

Continuing and Growing Challenges Populations remaining at or beyond the margins—23 million uninsured—will continue to rely on the safety-net – 11 million undocumented immigrants – State/local safety-net financing possibly in jeopardy due to antipathy toward undocumented and myth that “uninsured problem is solved” Timeline – 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 Federal, State and Local Support – Budget cuts at all levels affecting safety net – State antagonism toward health care reform—e.g., lawsuits – Impending Supreme Court decision on insurance mandate – Change in presidential leadership?

Maintaining a Viable Safety-Net to Care for Racially and Ethnically Diverse Populations Continued federal, state, local and philanthropic support for safety-net providers to assist in transitioning and continued care to large numbers of uninsured Risk adjusting payments for health status—e.g. multiple chronic conditions, community/social determinants Reductions in disproportionate share hospital program linked to measurable reductions in uncompensated care Collaboration of safety-net institutions with other providers to leverage limited resources/take advantage of innovation opportunities