1. 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 141 st Annual APHA Meeting, November 4, 2013, Boston, MA Project Support: WK Kellogg Foundation, The California Endowment, & Kaiser Permanente

2. 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 - Non- discrimination - Special provisions for American Indians Report 2: Health Care Safety Net - Medicaid - CHIP - Health Centers - DSH Payments - Community Health Needs Assessment Report 3: Health Care Workforce - Primary Care - Underserved Areas - Workforce Diversity - Cultural Competence - National Healthcare Workforce Commission Report 4: Public Health & Prevention - Prevention & Public Health Fund - CTGs - Obesity - Cancer - Diabetes - Oral Health - American Indian Health Report 5: Research, Quality & Innovation - National Quality Strategy - PCORI - NIH/NIMHD - CMS Innovation - ACOs - Medical Homes - Agency OMHs - Race/Ethnicity Data Standards

3. ACA’s Overall Progress on Advancing Equity More Fully funded or Implemented Partially Funded or Implemented Not Funded or Implemented Health Insurance Marketplace 7018 Safety Net 3317 Workforce Diversity 76619 Data, Research, Quality 43411 Public Health & Prevention 64111 Total 27 (48%) 16 (29%) 13 (23%) 56

4. ACA Status & Implications for Advancing Health Equity as we Approach 2014

5. 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 Source: KFF. A Profile of Health Insurance Exchange Enrollees, March 2011.

6. 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/health- care-reform.htmlhttp://www.texashealthinstitute.org/health- care-reform.html

7. Medicaid Expansion: Projected Eligible by Race and Ethnicity *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. 6.8 million or 45% of New Medicaid Eligible are Non-White. * In 29 States Moving toward Expansion, 3.8 million Non-Whites. **

8. ACA Capacity Initiatives to Meet New Demand Enhancing Capacity Primary Care Workforce Support Minority Health Professions (HBCUs) Enhance Capacity in Underserved Areas (NHSC) Health Center Support (FQHCs, NMHC, School & Teaching Health Centers) Payment & Delivery Innovations (ACOs, PCMHs, 1115 Waivers)

9. Access to Care in the Safety Net

10. Challenges to Advancing Health Equity through the ACA

11. 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. concerns.

12. 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.

13. Billboard on 42 nd St. Near Times Square

14. 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.

15. 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?

16. 2014 & Beyond: Actions and Opportunities for Advancing Equity

17. “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 1. Monitoring & Adapting Marketplace Implementation to Advance Equity

18. 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.

19. 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 2. Addressing Gaps in Access & Capacity to Meet Needs of a Growing Diverse Patient Population

20. 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. 3. Building on ACA’s Community-Based Initiatives to Engage and Reach Diverse Communities

21. 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 4. Advancing Metrics, Measuring, & Monitoring

22. 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 ACA- supported activities. Continued advocacy around key disparities priorities: –Oral health disparities –Cultural competency education –Minority health professions programs 5. Education & Advocacy for Advancing Equity

23. 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.

24. 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