Month: January 2015

This blog post is cross-posted from my post published on the “Voices” blog of the Leonard Davis Institute of Health Economics at the Wharton School of the University of Pennsylvania.

As the Affordable Care Act’s health insurance marketplaces begin their second year of open enrollment, LDI examines the current and potential impact of the ACA on the health of minority populations. This fourth post of a five-part series describes the current initiatives to diversify the health care workforce with greater minority participation.

Racial and ethnic minorities are underrepresented in the American health careworkforce, something that has changed little in the past 20 years. Why does that matter? According to the U.S. Health Resources and Services Administration(HRSA), it matters because [underrepresented] minority health professionals, particularly physicians, disproportionately serve minority and other medically underserved populations, and because minority patients tend to receive better interpersonal care from practitioners of their own race or ethnicity, particularly in primary care and mental health settings.

The data reveal severe underrepresentation among certain minority groups in thehealth care workforce.  Although non-Hispanic Blacks make up 12.2% of the population, they account for 6.3% of active physicians, 5.8% of registered nurses(RNs), and 4.2% of physician assistants (PAs).  Hispanics make up 16.3% of the population, yet they account for 5.5% of physicians, 3.9% of RNs, and 4.7% of PAs. In contrast, non-Hispanic Whites and Asians make up 68.4% of the population, 86.5% of physicians, 83.2% of RNs, and 90.8% of PAs.

The Affordable Care Act recognized the importance of workforce issues when it created the National Health Care Workforce Commission, which has yet to meet because Congress has not authorized its funding. Beyond this commission, the ACA also established or updated a number of other programs that may have an impact on the racial and ethnic composition of the health care workforce. These include:

• A $4 billion investment between 2010-2015 into the existing National Health Service Corps (NHSC), which offers scholarships and loan repayments to health professionals who work in poor or rural areas. About one third of professionals who currently receive NHSC support are racial and ethnic minorities.
• Expanded loan repayments and scholarship funding for disadvantaged students, many of who are members of underrepresented minority groups. The ACA reauthorized theHealth Careers Opportunity Program (HCOP), which received funding of $60 million over five years; the Scholarships for Disadvantaged Students program, which received $47 million a year; and Nursing Workforce Diversity Program, which received $16 million a year.  HCOP was not reauthorized in 2015.
• Reauthorization of Title VII Centers of Excellence (COE), which received $23 million in 2010-2015. This has funded 19 awards to historically Black Colleges and Universities (HBCUs), Hispanic COEs, Native American COEs, and “other” health professions schools that meet the program requirements. Grants support programs that enhance the academic performance of underrepresented minority students, support minority faculty development, and facilitate research on minority health issues.
• Creation of the Health Profession Opportunity Grants (HPOG) program, which received $67 million over five years.  HPOG provides education and training in allied health professions to recipients of Temporary Assistance for Needy Families (TANF) or other low-income people. Over five years, 32 organizations (included five Indian Tribal entities) received grants.
• Grants to support the Community Health Workforce (community health workers), who work in “medically underserved communities, particularly racial and ethnic minority populations.” As mentioned yesterday, this provision has not received funding from Congress.

Although the ACA recognized the importance of increased diversity in the health care workforce, the impact of its programs will limited by reductions in the funding originally authorized, the time-limited scope of the legislation, and the long pipeline needed to change the racial/ethnic distribution of health care professionals. Programs that can “feed” the pipeline at early educational levels (such as PennLDI’s SUMR program) will be needed to make a substantial impact on diversity. Ironically, HCOP, a program that funded initiatives at K-12, baccalaureate, and post-baccalaureate levels, was discontinued because the federal budget “is prioritizing investing in programs that have a more immediate impact on the production of health professionals by supporting students who have committed to and are in training as health care professionals.” Nevertheless, the inclusion of diversity programs and goals the ACA is an encouraging direction. As racial and ethnic minorities become an even larger portion of the population in the near future, these programs will need to be implemented earlier and longer in the educational process.

This blog post is cross-posted from my post published on the “Voices” blog of the Leonard Davis Institute of Health Economics at the Wharton School of the University of Pennsylvania.

As the Affordable Care Act’s health insurance marketplaces begin their second year of open enrollment, LDI examines the current and potential impact of the ACA on the health of minority populations. This third post of a five-part series examines how new models of care delivery encouraged by reform will affect minority populations.

Although most of the public attention on the ACA focuses on covering the uninsured, the law also funds a variety of initiatives to improve the way care is delivered. The Centers for Medicare and Medicaid Services (CMS), along with a growing contingent of private payors and providers, are testing new payment and delivery models. These arrangements transfer more performance risk to providers, create incentives for care coordination of high-risk populations, and expand the role of primary care. The implication for providers, who are becoming more at-risk for patient outcomes, is that they must take a more active role in managing their sickest patients – often, these patients are racial and ethnic minorities.

Among familiar programs such as Medicare ACOs and Shared Savings Programs, value-based purchasing and bundled payments, there are several programs focusing on Medicaid and CHIP populations. Since 60% of Medicaid beneficiaries are racial and ethnic minorities (and half are Black or Hispanic), these programs have potential to address longstanding health disparities. Here we highlight just a few examples of the initiatives that have direct implications for minority health.

Less likely to have access
Minority groups, Blacks and Hispanics in particular, are less likely to have access to adequate emergency mental health treatment. The Medicaid Emergency Psychiatric Demonstration, authorized under the ACA, provides $75 million to reimburse private psychiatric hospitals for treating Medicaid patients who experience a mental health emergency. In the past, Medicaid has not paid for these services in “institutions for mental disease” (IMDs) unless the patient was previously admitted to a general hospital for the same condition. Under the three-year program, 11 states and DC are testing whether Medicaid coverage will reduce emergency department utilization, improve discharge planning, and improve transitions of care that will decrease readmissions. An initial report to Congress found that the vast majority of beneficiaries were determined eligible to participate in the demonstration as a result of suicidal thoughts or gestures. The demonstration runs through December 31, 2015.

Chronic disease burden
Minorities bear a disproportionate burden of chronic diseases such asdiabetes and hypertension. The Medicaid Incentives for the Prevention of Chronic Diseases Model, also authorized under the ACA, funds 10 states to implement prevention programs around smoking cessation, weight loss and control, lowering cholesterol and blood pressure, and avoiding or managing diabetes. An initial report to Congress found that states had run into implementation and coordination challenges around how to enroll patients and deliver economic incentives. All states are giving participants monetary incentives in the form of cash, gift card or other money-value item, or flexible spending account funds. Incentives range from $20 to $1,150 annually to reward participants for program participation and for achieving specified health outcomes. States are also incentivizing participating providers. Most states are conducting the program as a randomized controlled trial with incentivized and non-incentivized patients. The program runs through the end of this year.

Disparities in prenatal care
Racial and ethnic minority women face significant disparities in prenatal and maternal care. The Enhanced Prenatal Care Models program, also authorized under the ACA, tests four models of prenatal care interventions: group visits to encourage peer-to-peer learning and support, visits to birth centers that provide team-based care and counseling, and visits to maternity care homes – which appear to be patient-centered medical homes adapted for maternal needs. Across 20 states and four years, $41.4 million will fund 182 providers, state agencies, and managed care organizations to implement the program in Medicaid and CHIP populations. CMS expects that this amount will fund the cost of enhanced care for90,000 women.

All of these programs are ongoing, so their impact on minority health is still speculative. We will keep an eye out for final evaluations in the coming years. That some of these programs are focused on Medicaid beneficiaries and other low-resource groups underscores their potential to improve population health for minorities and economically disadvantaged groups. The latest progress report on CMS’ Innovation Center can be found here.

Community health workers
The ACA also encourages delivery system innovation through its workforce provisions, which we will review in more detail tomorrow. One section encourages the use of community health workers (CHWs) in underserved communities through grants from the Centers for Disease Control and Prevention (although no funds have been appropriated as yet.) CHWs share an ethnic, linguistic, cultural or experiential connection with the population served, and may improve outcomes for chronically ill, poor, and primarily minority patients. The Patient-Centered Outcomes Research Institute (PCORI), established by the ACA, recently awarded $1.9 million to Penn’s Center for Community Health Workers to use CHWs to improve outcomes among low-income chronically ill patients. If successful, this new model of care may be able to address longstanding disparities in outcomes that cannot be ameliorated by improved insurance coverage alone.

This blog post is cross-posted from my post published on the “Voices” blog of the Leonard Davis Institute of Health Economics at the Wharton School of the University of Pennsylvania.

As the Affordable Care Act’s health insurance marketplaces begin their second year of open enrollment, LDI examines the current and potential impact of the ACA on the health of minority populations. This second post of a five-part series describes the benefits and shortfalls of the Medicaid expansion.

As originally passed, the ACA included a national expansion of Medicaid eligibility to 138% of poverty. However, the Supreme Court made expansion optional, and thus far, 28 states have decided to expand their programs. Although millions have gained coverage under the expansion, as many as four million uninsured people remain in the “coverage gap.” As shown below, they earn too little to be eligible for subsidies on the health insurance marketplaces, and they fall outside of their state’s present Medicaid eligibility limits.

People left in the gap are disproportionately racial and ethnic minorities. According to the Kaiser Family Foundation, 44% of uninsured adults in the coverage gap are White non-Hispanics, 24% are Hispanic, and 26% are Black. While some of this distribution reflects the level of uninsurance among minority groups, it also reflects the racial composition of the states that have not expanded Medicaid (Texas and Florida, for example).

The Urban Institute recently modeled the effects that the ACA would have in 2016 under conditions of partial and full Medicaid expansion. The results vividly illustrate the impact of both the ACA and the Supreme Court decision on minority coverage.

The authors explain:

Uninsurance rates are projected to fall for each racial/ethnic group with current Medicaid expansion decisions under the ACA. This narrows racial and ethnic coverage differences between whites and each minority group, except for blacks. This is because a disproportionately large share of blacks lives in nonexpansion states. If all states were to expand their Medicaid programs, uninsurance rates are projected to fall further for all racial and ethnic groups, with blacks experiencing a marked reduction in uninsurance rates and a narrowing of the difference between black and white uninsurance rates.

Just having a Medicaid card does not assure access to care. The ACA tried to address concerns that there would not be enough providers to see new Medicaid patients in two ways: by temporarily increasing primary care payment rates, and by increasing funding to community health centers. Provider participation in Medicaid has been limited, in part, by reimbursement rates that were 59% of Medicare rates. The ACA included a provision that “bumped” Medicaid fees for primary care up to Medicare levels for the first two years, with full federal funding. The increase expired on Jan. 1, 2015, and most states chose not to continue the bump with state funds. The effect of this two-year increase on provider participation rates and access to care is not yet known.

Community health centers have long been safety net providers for the uninsured and for Medicaid enrollees. According to the Kaiser Family Foundation, in 2011, 39% of patients seen in community health centers were covered by Medicaid, and 36% were uninsured. The ACA provided $11 billion over five years in funding to build new CHCs and expand the capacity of existing CHCs, who see a disproportionate percentage of racial and ethnic minorities. This funding will expire at the end of this fiscal year.

Tomorrow we will continue our series by reviewing new models of health care delivery funded or encouraged by the ACA and their potential impact on minority health.

This blog post is cross-posted from my post published on the “Voices” blog of the Leonard Davis Institute of Health Economics at the Wharton School of the University of Pennsylvania.

As the Affordable Care Act’s health insurance marketplaces begin their second year of open enrollment, LDI examines the current and potential impact of the ACA on the health of minority populations. This first post of a five-part series describes the current state of insurance coverage and health disparities among racial and ethnic minorities.

Prior to the ACA, racial and ethnic disparities in health and health carewere widespread and well-known. They included documented differences in insurance coverage, access to care, the prevalence of chronic diseases, and overall health. As major provisions of the Affordable Care Act take root, let’s take a look at some measures of health equity and outcomes.

Uninsured level
First, there’s the level of uninsurance. Although the link between insurance coverage and health outcomes is not direct, it is a good measure of access to care. In 2010 (prior to the ACA), the National Health Insurance Surveyfound that non-elderly Blacks (20.8%) and Hispanics (31.9%) had much higher rates of uninsurance than non-elderly White non-Hispanics (13.7%). The Kaiser Family Foundation noted the ACA’s potential to reduce this disparities because 94% of uninsured Blacks have incomes low enough to be eligible for premium subsidies or coverage under (fully) expanded Medicaid. Similarly, KFF noted the ACA’s potential impact on Hispanics, with more than a third of uninsured Hispanics eligible for premium subsidies and more than half qualifying for expanded Medicaid. In a subsequent post, we will discuss how the ACA’s potential impact on coverage for racial and ethnic disparities has been limited by some states’ refusal to expand their Medicaid programs.

With this potential in mind, how has the ACA done thus far in increasing insurance rates among minorities? New data from the NHIS reveal that in the first six months of 2014, uninsurance rates dropped from 18.9% to 13.7 % for Blacks, from 30.3% to 26.2% for Hispanics, from 13.8% to 11.6% for Asians, and from 12.1% to 10.5% for non-Hispanic Whites. The latest Gallup poll http://www.gallup.com/poll/180425/uninsured-rate-sinks.aspxreports drops of 6.9 percentage points for Blacks and 6.3 percentage points for Hispanics since the end of 2013.

Racial/ethnic minorities face a wide array of disparities in behavioral risk factors, chronic diseases, and health outcomes. One of the hopes is that increased insurance coverage will help reduce these glaring disparities, but the evidence linking coverage and health does not unambiguously point towards this hope being fulfilled.

Prevalence of diabetes
The stakes are quite high for minority populations. According to the CDC, the prevalence of diabetes is higher among Blacks (10.9%) and Hispanics (9%) than among Whites (6%). The rate of HIV infection among Black (84 per 100,000 population) and Hispanic (30.9 per 100,000 population) adults is much higher than Whites (9.1 per 100,000 population) adults. Blacks have a higher rate of hypertension (41.3%) than Whites (28.6%) and Hispanics (27.7%). Further, the rate of controlled blood pressure is lower among Hispanics (34.4%) and blacks (42.5%) than Whites (52.6%).

The difference in quality of life between Whites and Blacks, as measured by the years of life free from disability caused by chronic disease, has decreased in the 21st century but remains significant at six years. Furthermore, a higher proportion of Blacks (21.3%) and Hispanics (31%) self-rate their health as “fair” or “poor” compared with Whites (13.%).

It is much too early to tell the extent to which the ACA will affect these health disparities. Beyond increasing coverage rates, the ACA’s requirement that plans cover recommended preventive services without cost-sharing may boost screening rates for hypertension, diabetes, and cancer.

The subsequent posts in this series will take an in-depth look at how the Affordable Care Act approaches the challenge of reducing health disparities: the benefits and shortfalls of Medicaid expansion, new models of care management and delivery, initiatives to diversify the health care workforce, and access to health services for American Indians.