Click to edit Master title style 138 th APHA Annual Meeting Denver, Colorado November 8, 2010 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 Jonathan P. Purtle, MPH, MSc Program Manager, Drexel University School of Public Health

Click to edit Master title style 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. – To offer a template and user-friendly framework for documenting and tracking implementation timeline, appropriations and federal agency oversight responsibility.

Click to edit Master title style Framework for Review Race, Ethnicity and Language-Specific Priorities A. Data Collection and Reporting by Race, Ethnicity & Language B. Workforce Diversity C. Cultural Competence Education and Organizational Support D. Health Disparities Research E. Health Disparities Initiatives in Prevention F. Addressing Health Disparities in Health Insurance Reforms General Priorities A. Health Insurance Reform B. Access to Health Care C. Quality Improvement D. Cost Containment E. Public Health Initiatives F. Social Determinants of Health Review of provisions addressing 12 key public health, health care system and health disparities priorities.

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General Provisions Health Insurance Reforms Sec. Require individual coverage1501 Expand Medicaid income eligibility to 133% FPL 2001 Employer coverage requirement1513 Increase federal matching rates for Medicaid 2005 Small business (<25 employees) tax credits 1421 Multi-state plan option10104 Temporary high risk pools1101 Consumer Operated and Oriented Plans (CO-OPs) 1322 State-based American Health Benefit Exchanges 1311 Improving Access to CareSec. Support for community health centers Nurse-managed health centers5208 Community health teams3502 Redistribute Graduate Medical Education slots 5503 Extends authorization of National Health Services Corps 5207 Teaching community health centers5508 Innovative models in Medicare/Medicaid 3021 School-based health centers4101 Pilot projects for emergency & trauma care 3504

Click to edit Master title style General Provisions (continued) Quality ImprovementSec. National Strategy for Quality Improvement 3011 Quality improvement technical assistance 3501 Interagency Group on Healthcare Quality 3012 Develop, improve & evaluate quality measures 3013 Link Medicare payments to quality outcomes 3001 Pediatric Accountable Care Organizations 2706 Cost ContainmentSec. Interoperable systems of enrollment1561 Reduce Medicaid DSH Payments1203 Reduce Medicare DSH Payments2551 Demonstration projects for HIT6114 Strengthening Medicaid drug rebate programs 2501 Enhancing public program fraud screening 6401

Click to edit Master title style General Provisions (continued) Public Health & PreventionSec. National Prevention & Public Health Council 4001 Prevention & Public Health Fund4002 Childhood obesity demonstration projects 4306 National diabetes prevention program New methods for scoring prevention/wellness programs 4401 Education campaign for breast cancer Social DeterminantsSec. Health Impact Assessments4003 Community Preventative Services Task Force to review/recommend interventions in social context 4003 Community Transformation Grants4201 Non-profit hospital community needs- assessment 9007 Primary Care Extension Program5405

Click to edit Master title style Examples of Public Health Opportunities for Advancing Health Equity through General Provisions National Prevention and Public Health Council will provide coordination and leadership at the federal level for public health and other services to consider evidence-based models, policies and innovative approaches for transformative models of public health and prevention The CDC will convene an independent Community Preventive Services Task Force to review scientific evidence related to the effectiveness, appropriateness, and cost-effectiveness of community preventive interventions for the purpose of developing recommendations. Recommendations must address specific populations and social, economic and physical environments that can have broad effects on health disparities The CDC is authorized to award competitive Community Transformation Grants to State and local governmental agencies and community-based organizations for the implementation, evaluation, and dissemination of evidence- based community preventive health activities to reduce chronic disease rates, prevent the development of secondary conditions, address health disparities and develop a stronger evidence-base of effective prevention programming.

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Data Collection & Reporting ProvisionsSection No. Require population surveys to collect racial/ethnic sub-group data4302 Collect/report disparities data in Medicaid and CHIP4302 Monitor health disparities trends in federally-funded programs4302 Example of Potential Public Health Obligation and Opportunity:  No later than 2 years after the date of enactment of this title, any federally conducted or supported public health program, activity or survey must collect and report data on race, ethnicity, and primary language for applicants, recipients or participants. Data must be sufficient to generate statistically reliable estimates by racial, ethnic, or primary language subgroups. In collecting these data, the OMB standards for measurement of race, ethnicity and language must be used at a minimum.

Click to edit Master title style Workforce Diversity Provision DescriptionSection No. Increase diversity among health care providers5301, 5302, 5303, 5306, 5309 Health professions training on diversity and/or CLAS5402, 5403, 4305, 5313, 5507 Investment in HBCU and minority-serving institutions2104 Collect and publicly report data on workforce diversity5001 Example of Potential Public Health Obligation and Opportunity: Grants to promote public health dentistry shall give priority to applicants with experience in minority training with emphasis on cultural competence and health literacy; and who have placements in areas that serve health disparities populations.

Click to edit Master title style Cultural Competence (CC) Provision DescriptionSection No. Develop, evaluate & disseminate model CC curricula5307 CC training for health care providers5301, 5507 Loan repayment preference for experience in CC5203 Federal agency role and support for CC10334 Example of Potential Public Health Obligation and Opportunity: Cultural Competency, Prevention and Public Health Grants will be established to develop, evaluate and disseminate research, demonstration projects, and model curricula for cultural competency proficiency, prevention, public health proficiency and reducing health disparities.

Click to edit Master title style Table 4. Health Disparities Research Provision DescriptionSection No. Patient-Centered Outcomes Research Institute (PCORI) to examine health disparities through CER 6301 Increase funding to Centers of Excellence5401 Promote National Center for Minority Health and Health Disparities (NCMHHD) to Institute status Support research on topics disparities and cultural competence5307, 2952, 4305 Example of Potential Public Health Obligation and Opportunity: PCORI will identify national priorities for research, addressing practice variation and health disparities in terms of delivery and outcomes of care and the potential for new evidence to improve patient health and quality of care.

Click to edit Master title style Table 5. Health Disparities & Prevention Provision DescriptionSection No. National oral health campaign, with emphasis on disparities4102 Standardized drug labeling on risks & benefits3507 Maternal & child home visiting programs for at-risk pops.2951 Culturally appropriate patient-decision aids3506 CLAS personal responsibility education2953 Support for preventive programs for AI/ANs10221 Example of Potential Public Health Obligation and Opportunity: CDC will create a public education oral health campaign with a priority to address oral health disparities in a culturally and linguistically competent manner.

Click to edit Master title style Addressing Disparities in Health Insurance Reforms Provision DescriptionSection No. Remove cost-sharing for AI/ANs at or below 300% FPL2901 Enrollment outreach targeting low-income populations3306 CLAS/information through exchanges1311 Nondiscrimination in federal health programs/Exchanges1557 Require plans to provide information in "plain language”1303 Incentive payments for reducing disparities1303 Summary of coverage that is culturally/linguistically appropriate1001 Claims appeal process that is culturally/linguistically appropriate1001

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Advancing the Health of Communities 1.Leveraging support for community-based strategies and engagement in reducing disparities. Communities must be active and involved participants in setting overall objectives, specific goals and strategies for achieving them. 2. Promoting integrated strategies across health and social services to improve the health of diverse communities. Need for direct, concerted research, policy and programs that seek to alter significantly the negative influence of social determinants in diverse communities.

Click to edit Master title style Health Care Organization-Based Initiatives 1. Developing and testing model programs that link specific organizational efforts to reducing disparities and improving quality of care. Organizations must be committed to support practitioners through more comprehensive and active engagement in caring for diverse patients. 2. Documenting and linking non-profit community needs assessment/benefit requirements to health care reform incentives to address disparities. Need to reach beyond demonstrations and funding opportunities. Require provider organizations to show evidence of working to reduce disparities—e.g. through education & community outreach 3. Preserving and transitioning the health care safety net. Providing direct support for safety net hospitals, particularly in regions with large uninsured and undocumented populations. Guidance for philanthropic organizations on ways to support safety net.

Click to edit Master title style Individual Level Initiatives 1.Developing effective care/disease management and self management interventions and protocols for diverse patients. New programs will need to address how and to what extent inattention to race- and culture-specific and language/literacy concerns may create impediments to care management and self management. 2.Mitigating the effects of overweight/obesity and negative environmental factors that may impede progress on reducing disparities. Greater health care provider awareness of culture and challenges faced by diverse populations will be important for reducing disparities in care and adherence to treatment.

Click to edit Master title style Conclusions Great breadth of opportunities in ACA to reduce disparities and improve health equity. However, for many provisions, depth in terms of detail, strategy for implementation, methods for implementation, and measurement/evaluation to assess progress, is still lacking. Allocations and federal agency roles, likewise, are unspecified for many provisions. – As of 8/1/2010, nearly two-thirds of the diversity specific provisions lacked specificity around appropriations and timeline – About one in ten includes short term, but no long term funding plan

Click to edit Master title style What will a new Congress mean for public health efforts to eliminate racial/ethnic disparities and advance health equity through ACA?

Click to edit Master title style Next Steps Education around specific ACA language for priority areas. Work with representative associations/organizations to educate and discuss strategies for pursuing priority areas. Appropriations, appropriations, appropriations—assuring adequate funding for provisions. Track timing and process for rollout. Communicate with agencies likely to oversee identified priority areas about status and progress in adding content to these areas.

Click to edit Master title style 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 Jonathan P. Purtle, MPH, MSc Program Manager, Drexel University School of Public Health Lisa Duchon, PhD, MPA Health Management Associates

Click to edit Master title style Presenter Disclosures Dennis Andrulis, PhD, MPH The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: No relationships to disclose