Advancing Equity in Health Services for Veterans: 

Potential, Progress, and Opportunities in the Era 

of 

Health Care Reform 

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

Office of Health Equity Cyberseminar 

Veterans Affairs

March 5, 2014
Poll Question

• Advancing racial and ethnic health equity is an 

objective reflected in the Affordable Care Act. 

How many provisions within the law do you 

think intend to advance health equity?

– Less than 10

– 10 to 20

– 21 to 30

– More than 30
ACA’s Vision and Promise

• Working to eliminate health disparities and 

advance health equity is central to the ACA.

• Over three dozen provisions directly address 

racial and ethnic health disparities, diversity, 

and cultural and linguistic competence.

• Dozens of other general provisions with major 

implications for racially and ethnically diverse 

populations.
ACA & Racial and Ethnic Health Equity Series

5 Reports, Nearly 60 Provisions on Advancing Health Equity

Report 1: 

Health 

Insurance 

Marketplace

- Culturally & 

linguistically 

appropriate 

marketing, 

outreach, and 

education

- Nondiscrimination 

- 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
Overall Progress of ACA’s Health Equity Objectives

More Fully 

Funded or 

Implemented 

48%

Partially Funded 

or Implemented 

29%

Not Funded or 

Implemented 

23%

Implementation Progress of ACA's Equity Provisions as of 

October 2013 (N = 56 Provisions)
Progress of ACA’s Health Equity Objectives by Priority

7 

3 

7 

4 

6 

3 

6 

3 

4 1 

1 

6 

4 

1 

Insurance

Marketplace

Safety Net Workforce Research & Quality Public Health &

Prevention

Implementation Progress of the ACA's Equity Provisions by Priority (N = 

56 Provisions)

More Fully Funded or Implemented Partially Funded or Implemented Not Funded or Implemented

N = 8 N = 7

N = 19

N = 11 N = 11
Why Monitor ACA’s Health Equity Provisions?

• Reasons you may already know:

– Rapidly growing diversity.

– Continued disparities in access, quality, and health 

outcomes by race and ethnicity. 

– Economic burden of disparities. 

– But did you know...

The ACA offers an unprecedented opportunity to 

enfranchise as many as 19 million racially & ethnically 

diverse individuals.
Health Insurance Marketplaces

Projected Enrollees by Race & Ethnicity

58%

11%

25%

6% White

Black or African American

Hispanic or Latino

Other

42% or over 12 million Non-Whites

25% will speak a language other than English at home

KFF. A Profile of Health Insurance 

Exchange Enrollees, March 2011.

*Veterans in the Marketplace*

Of 1.3 million uninsured veterans, 40% are eligible for subsidized coverage. 

One-third of uninsured veterans are Non-White.

Urban Institute, 2012
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/healthcare-reform.html
But there is still much work to be done...
Medicaid Expansion 

Projected Eligible by Race & Ethnicity

*Veterans & 

Medicaid 

Expansion*

Of 1.3 million 

uninsured 

veterans, 

nearly half have 

incomes below 

138% FPL and are 

eligible for 

Medicaid if states 

expand. 

Large proportion 

Non-Whites 

eligible.

Urban Institute, 2012
ACA Coverage Gap

• Only 26 States 

Expanding Medicaid.

• 4.8 million people in 

coverage gap.

• More than half are 

non-white.

• Impact of state 

Medicaid decisions 

varies for racial/ethnic 

groups.

• 218,000 uninsured 

veterans fall in 

coverage gap. 
Evolving Health Care Environment

Newly 

Insured 

(Marketplace 

& Medicaid)

Previously 

Insured 

(Employer & 

Other)

How Does the ACA Build Health System Capacity to 

Meet Growing Demand?

Coverage 

Gap & 

Uninsured
ACA Health System Reforms to Meet 

Growing and Changing Demand

Enhancing 

Health 

Systems

Health Care 

Workforce 

Investments

Capacity Building 

for Underserved 

Populations

Payment & 

Delivery 

Innovations

Health Systems 

Research 

Quality & 

Equity 

Initiatives 
Health Care Workforce Investments

Growing Supply of Primary Care Providers

• Primary Care Residency Expansion Program

• Expansion of Physician Assistant Program

• Nurse workforce development and diversity grants

• General and public health dentists 

• Mental health providers

• Community health workers
Health Care Workforce Investments

Movement Toward Team-Based Approaches
Health Care Workforce Investments

Enhancing Diversity and Cultural Competency

• Investment in minority-serving institutions through 2019

– Historically Black Colleges and Universities

– Hispanic Serving Institutions

– Tribal, Asian, Alaska & Hawaiian Native Institutions

• Support for training underrepresented minorities

– Centers for Excellence

– Health Careers Opportunity Program

– Scholarships for Disadvantaged Students

• Cultural Competency Training

– Model cultural competency curricula 

– New demonstration to develop long term care provider training 

competencies—including cultural & linguistic competency
Capacity Building in Underserved Areas

• Significant support for health centers and clinics

• National Health Service Corps

– ACA has grown the NHSC workforce three times

– 46% practice at community health centers

– 13% African American, 10% Hispanic, 9% Asian/PI & American Indian

• Redistribution of unused medical residency slots to 

underserved areas

– 70% to hospitals in states with lowest resident-to-population ratios

– 30% to hospitals located in rural or health professional shortage areas

– Half of the hospitals receiving medical residents located in areas 

where at least 50% of the population is non-white
Payment and Delivery Innovations

Patient Centered Medical Homes (PCMHs)

10 provisions in the ACA with explicit mention of “health homes” or “medical 

homes” of which 6 also specify priorities for advancing racial/ethnic equity. 
Payment and Delivery Innovations

State Innovations around Medical Homes

• Sec 2703 in the ACA created a state option to provide 

health homes for Medicaid enrollees with chronic 

conditions to improve health outcomes

• 12 States with approved health home plans:

• Current equity activities in state health homes:

– Culturally & linguistically appropriate patient communication

– Culturally & linguistically appropriate individual & family support

– Use of evidence-based culturally sensitive wellness and prevention

– Patient health assessment to include measures of language/culture

Alabama 

Missouri 

Idaho

 Iowa 

Maine 

New York

 Ohio 

 Oregon 

N. Carolina

Rhode Island

Washington 

Wisconsin 
Payment and Delivery Innovations 

Accountable Care Organizations (ACOs)

• ACOs to hold providers accountable for cost and 

quality of full continuum of care for patients.

• CMS Innovation Center testing 2 types of ACOs:

– Pioneer ACO Model

– Advance Payment ACO Model

• Many concerns around ACOs and its unintended 

consequences for health disparities

– E.g., practices with fewer profits, disproportionately 

serving low-income, diverse patients less likely partners

– ACOs require active monitoring of disparities

– Need for incentives to address disparities
Health Systems Research

Patient Centered Outcomes Research Institute

• One of five priorities is to “address disparities”

• PCORI’s specific research topics for addressing disparities:

– Health communications associated with competing treatments

– Heart attacks among racial and ethnic minorities

– Hypertension in minorities

– Interventions for improving perinatal outcomes 

– Reducing lower extremity amputations in minorities

• Of 147 comparative effective research grants:

– 14% explicitly address disparities

– Nearly half include a secondary focus on diverse populations or 

disparities
Health Systems Research 

Community Health Needs Assessment

• The ACA requires nonprofit 

hospitals to conduct CHNA 

every 3 years & develop 

strategy to address needs

• Potential for CHNA to address 

broad community needs and 

disparities

– Community-wide approach

– Health provider collaboration

– Opportunity to monitor disparities

Community Health Needs Assessment (CHNA):

A Community Opportunity to Address Disparities
Quality & Equity Initiatives

National Quality Strategy

• A national strategy to improve the 

delivery of health care services, 

patient health outcomes, and 

population health

• 6 NQS Priorities

• 2 explicitly aligned with addressing 

racial/ethnic disparities.

Priority Area Long-Term Goal

Priority 2. Engaging 

Patients and Families

In partnership with patients, families, and caregivers—and 

using shared decision making process—develop culturally 

sensitive and understandable care plans. 

Priority 3. Effective 

Communication and 

Care Coordination

Establish shared accountability and integration of 

communities and health care systems to improve quality of 

care and reduce health disparities. 
Quality & Equity Initiatives

Offices of Minority Health

• ACA’s commitment to equity at agency level

– Elevation of federal OMH

– Establishment of 6 agency-based OMHs

– Elevation of National Center on Minority Health and 

Health Disparities to Institute level at NIH

• Opportunities for inter-agency collaboration

• Areas or actions of alignment

– National Standards on Culturally and Linguistically 

Appropriate Services

– National Quality Strategy
Challenges to Advancing Health 

Equity through the ACA
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.
Political Antipathy

Antipathy toward the law may 

thwart progress to advance 

equity in many states.

• Reluctance around marketplace

• In states not expanding Medicaid...

– 2.6 million, low-income diverse individuals in coverage gap

– Over 400,000 veterans in coverage gap, many of whom are minority

• Misinformation, and confused & reluctant consumers 

generally; for some, language barriers.
Billboard on 42nd St. Near Times Square
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.
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?
Moving Forward:

Leveraging the ACA to 

Advance Equity
Advancing Equity through Marketplaces

• “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
Building on Promising Health System Investments

• Collaborative opportunities to expand care for 

veterans living in rural and underserved areas

– Federally qualified health centers

– Nurse-managed clinics

• Best practices and lessons from ACA supported 

PCMHs and other delivery system reforms
Building on ACA’s Community-Based Initiatives to Engage and 

Reach Diverse Communities

• 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.
Monitoring Impact of Programs on Disparities

• Evaluating payment and delivery reforms and 

innovations for their impact on racial/ethnic health 

disparities (e.g., PCMHs, ACOs)

• Are innovations...

– Closing the gap (i.e., benefits greater for populations 

facing disparities)

– Not changing the gap (i.e., all groups benefit equally)

– Growing the gap (i.e., benefits greater for those facing few 

disparities)
Education & Advocacy for Advancing Equity

• 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 ACAsupported activities.

• Continued advocacy around key disparities priorities:

– Oral health disparities 

– Cultural competency education

– Minority health professions programs
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.
Contact Information

Dennis P. Andrulis, PhD, MPH

Senior Research Scientist, Texas Health Institute

Associate Professor, University of Texas School of Public Health

dpandrulis@gmail.com

Nadia J. Siddiqui, MPH

Senior Health Policy Analyst, Texas Health Institute

nsiddiqui@texashealthinstitute.org

For more information, visit our website: 

http://www.texashealthinstitute.org/health-care-reform.html