**Transcript of Cyberseminar**

**Timely Topics of Interest**

**ACA-Health Equity/Disparities Connection**

**Presenter: Uche Uchendu, MD; Dennis Andrulis, PhD; Nadia Siddiqui, MPH**

**March 5, 2014**

*This is an unedited transcript of this session. As such, it may contain omissions or errors due to sound quality or misinterpretation. For clarification or verification of any points in the transcript, please refer to the audio version posted at www.hsrd.research.va.gov/cyberseminars/catalog-archive.cfm or contact Uchenna.Uchendu2@va.gov*

*Moderator:*And we have reached the top of the hour, so I would like to introduce Dr. Uche Uchendu.  She is the executive director of the Office of Health Equity for the Department of Veterans Affairs, and she will be introducing our speakers today.

*Dr. Uchendu:*Thank you Molly.  Greetings everyone, from the seat of our nation’s capital in Washington, D.C., where we are still thawing out from the most recent dose of snow and ice.  On behalf of the Office of Health Equity, I thank all of you for joining us for this session on Affordable Care Act health equity disparities connection.  With my prior exposure to a good dose of the work by Dr. Andrulis and Ms. Siddiqui on the linkage between Affordable Care Act and health disparities last summer at NIH’s National Institute of Minority Health Disparities course, I can assure you that you are in for a treat today.  

I think we will all agree that this discussion is timely, as our nation moves forward with the Affordable Care Act implementation, at a time when our directing health and healthcare disparities is crucial to elevating the whole health of each individual, in order to achieve a healthier nation.  The Office of Health Equity is therefore proud to sponsor this speaker session, and thanks to HSR& D for providing this excellent forum for the dialogue, and of course our presenters, for taking on this engagement.  

It is my pleasure to introduce Dr. Dennis Andrulis, a senior research scientist at the Texas Health Institute, and an associate professor at the University of Texas School of Public Health.  In his position, Dr. Andrulis leads the development of initiatives on urban health, healthcare for vulnerable populations, racial and ethnic disparities and cultural competence, working at community, state and national levels.  Dr Andrulis, who was previously associate dean of research at Drexel University’s School of Public Health, earned a PhD in educational psychology from the University of Texas at Austin, and a master’s of public health from the University of North Carolina at Chapel Hill.  

Our co-presenter today is Ms. Nadia Siddiqui, who holds a master of public health in health policy and management from the University of Arkansas for Medical Sciences, and a bachelor of arts in economics with honors from the University of Texas at Austin.  Ms. Siddiqui is a senior health analyst at the Texas Health Institute, where she conducts research and evaluation of national, state and local public health needs programs and policies.  She manages several programs, including a series of analyses on the implementation and implications of healthcare reform law for racial ethnic populations.  

Finally, I would like to highlight the history of involvement with vulnerable populations that provide us and communities with a special focus on diversity, disparities and equity research policy and dissemination of best practices through the National Conference series on quality health for culturally diverse populations, now in its 16th year.  I have given you abridged versions of their bios, and encourage you to see further details on the Texas Health Institute’s website, including multiple publications and presentations to their credit.  With that, I will turn it over to Dr. Dennis Andrulis and Ms. Nadia Siddiqui to take it from here.  Thank you.

*Dr. Andrulis:*Good morning all.  I think before we get started, there are a couple of questions that we’d like to pose to you.  I think we’re going to have someone else handle the questions.

*Moderator:*Great, thank you Dr. Andrulis.  Yes, we do have a whole question up on your screen, so please take just a moment and let us know, what is your primary role in VA?  Your responses do help us gauge the talk more specifically to our audience members.  It looks like the responses are streaming in, and we’re about at a 50 percent response rate.  I’m going to give people just a little bit more time to submit their responses.  If you are clicking “other” at the end of the presentation, we will have a survey where you’ll be given the opportunity to specify your role.  

All right, and it looks like the answers have slowed down a bit.  We have about 17 percent student trainees or fellows, three percent clinicians, about one-third of our audience is researchers, 13 percent policymakers or managers.  Another third refers to themselves as “other,” so thank you so much for those replies.  I’m going to go ahead and put up one more question that we have for you to answer today.  Here we go, so advancing racial and—oops, excuse me.  Advancing racial and 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?  

It looks like our answers are streaming in, and we have quite varied responses.  We’ve got just about a 50 percent response rate now, so I’m going to give people a little bit more time to get their answers in.  

All right, it looks like the responses have slowed down, so we have about 15 percent responding “less than ten,” about 21 percent saying “10 to 20,” ten percent reporting 21 to 30, and just over half saying more than 30.  I’d like to thank our audience members for providing those responses, and I’ll turn it back over to you, Dr. Andrulis.

*Dr. Andrulis:*Thank you.  Well that was interesting, both to learn a little bit about who you are out there in cyberspace, and also to understand the extent to which you have sense of the scope of equity within the law; what its emphasis is, where it’s focused.  As we see on the next slide, working to eliminate disparities is really a key aspect of the law.  It’s been a primary resource and point of focus for the law, ever since its vision became a reality in 2010.  There are over three dozen provisions in the law that are specific, really specific to race, ethnicity and equity.  We’re going to get into some of the specifics of that in a little bit.  

In addition to that, there are really dozens of other provisions that either are directly or indirectly related to, affected by, or intended to advance our racial ethnic health equity.  These are more general provisions; many of them are more general provisions, or provisions with specific parts of them, sub-parts as they played out in the realization of the vision and intent of the law to promote equity.  Nadia, I’m going to ask you to move onto the next slide here on the—

*Moderator:*Actually Dennis, if you want to advance the slides, you can just use that right-hand arrow that’s located in the left-hand corner of your screen.

*Dr. Andrulis:*I would be happy to do that.  My computer just crashed.

*Moderator:*Oh, I’m so sorry, okay.  No problem then.

*Dr. Andrulis:*If you can move onto the next slide, when I come back into control I’ll let you know.  Talk about technology glitches, so—

*Moderator:*Sure, I’d be happy....

*Dr. Andrulis:*I’m rebooting it, but it’ll take a little bit.  Let me move onto this next slide, and there are five areas that we have concentrated these provisions into.  God knows you can cut this in all sorts of different ways, but we felt that these five areas consolidated and represented the major areas of concentration for the law.  The Health Insurance Marketplace, clearly there are specific provisions related to that and attendant to it.  Healthcare safety net, there is a significant focus on that.  Healthcare workforce, much detail related to that; that set of provisions.  Public health and prevention, and research and quality innovation.  

As I said, we’ll get into some of the specifics on this as we move ahead.  Go down to the next slide.  On the overall progress of health equity objectives, this pie chart lays out—well what’s been happening with these provisions?  We hear a lot about the complexity of the law.  Within that law are all these actions and dynamics, or lack thereof, that have occurred over the course of the now three-and-a-half years since it was enacted.  The good news is that about half of them have been basically more fully funded or implemented.  

The issues around marketplace have really been advanced in a lot of ways.  There are requirements in the marketplace that are related to race, ethnicity and language that have been quite fully embraced, and put into language.  There’s much related to support to guide and encourage innovation that, again, we’ll get into.  However we—I want to also point out that although there has been 50 percent that have been supported, we have about 50 percent that have not been fully funded, or have not been funded at all.  The issues around partially-funded or implemented programs have focused in particular on capacity provisions; especially for underserved groups.  

Those are programs, not exclusively, but in large part fall into that middle ground.  Then there are a whole host of programs that have not been funded around training, community health workers, oral health; that basically they’ve received authorizations through the law, but Congress has appropriated zero dollars for these programs.  Onto the next slide please.  The progress for the ACA’s equity provisions fall into this bar chart description, where the one in the middle represents the workforce group where there are the most provisions.  

Many of the workforce provisions you see as they are described here, really are a mixed bag in terms of advancing.  Only about one-third have been fully funded.  The others are partially or not funded at all.  Then you have some proportional representation, with the marketplace representing the greatest progress. Some along public health and prevention, but mixed bag definitely with workforce, and some with research and quality.  

A theme that we will get back to that’s very important to consider in this is because many of these programs are subject to what happens with regard to congressional action, they are susceptible—and there’s a certain kind of, if not fragility, there is a question around the extent to which they will sustain and continue.  Next slide.  Why monitor these provisions?  You know many of these issues that we raised here I think are familiar to this audience; rapidly growing diversity, recognizing in about 15 years more than half of U.S. children will be non-white.  

By 2050 the issue of minority becomes—or the term “minority” becomes an odd term, as it already is in many quarters, as the majority of the U.S. population will belong to non-white racial ethnic groups.  Then you have the economic burden of disparities, Tom LaVeist and others at Johns Hopkins have estimated that the cost of health inequalities between 2003 and 2006 is $1.24 trillion, much of it related to the unnecessary medical expenditures that are related to this population.  

Then finally, it’s important to recognize that there is an unprecedented opportunity to enfranchise as many as 19 million racially and ethnically diverse individuals.  That includes those who are affected by other provisions of the law, but this is a major opportunity for these populations and these communities.  Can I have the next slide please?  Health Insurance Marketplace.  It’s important to recognize that the marketplace is an incredible opportunity to enfranchise populations that have been historically left out of the health insurance/healthcare system.  You have a projection of—well, it varies by state.  

We estimate that there are about—estimates have been generated that 42 percent, or over 12 million non-whites are eligible, and that about a quarter of them will not speak English at home, generally.  Then you see on this pie chart the fallout from—or the pattern of white, black and African-American, Hispanic, Latino or other.  I do want to note, before moving off this slide, that about 1.3 million uninsured Veterans, or 40 percent of them, are eligible for subsidized coverage.  About one-third are non-white.  It’s important to recognize that this group of Veterans will also be eligible to participate in the exchanges.  May I have the next slide please?  

How are the marketplace *[audio feedback]*—I’m sorry.  Yes?  How are the marketplaces addressing disparity?  Well there are many dimensions that we’ve uncovered, and have now become reference points for state-based exchanges.  We’re also considering it as in the context that as the federal government develops the federally administrated partnership exchanges.  These fall into roughly four groups, governance and leadership, the advisory board composition, the mission/vision objectives that are written in, planning and design.  

What’s the community feedback?  Tribal consultation issues and cultural competence training programs, evaluation.  What measures are being put into place to measure equity-related objectives and progress?  Then outreach and enrollment, through issues around what’s called trans-creation, where information is not just translated, but it’s translated to be culturally-attuned to the population.  Navigator programs, translated websites, etc, etc.  This information is based on seven leading states that we’ve focused on: Connecticut, Colorado, California, Maryland, New York, Oregon and Washington.  Some of them, like California, are leading states.  Next slide please.  

There’s still much work to be done here, as these recent clips from newspaper articles and others sources indicate, that there is quite a bit of recognition that populations that have been historically disenfranchised are not enrolling, or not being enrolled at the rate that has been projected, or has been hoped for.  These quotes around black community awareness, of Obamacare, benefits falling short of expectations, language remains a barrier in Latino healthcare enrollment, etc, really point up this lack of progress, to the extent that folks had intended.  There are many examples in the field about this, and there’s quite a bit of concern about it.  The next slide.  

For Medicaid expansion, we have a similar circumstance where the opportunities for communities and individuals of color to participate are significant and really groundbreaking.  According to the Kaiser Family Foundation, over 50 percent of individuals who would benefit from Medicaid expansion are people of color.  The Veterans and Medicaid expansion again, of 1.3 million uninsured Veterans, nearly half have incomes below 138 percent of the federal poverty level—are eligible for Medicaid if states expand.  That is one big “if” and moving on to the next slide, what we point out here on this coverage gap, that states, as many of you know, are so uneven in their determination to expand Medicaid.  

The most troubling part of it is that six of ten—for example, six of ten uninsured African-Americans reside in states that will not, as of now, be expanding, or are not expanding Medicaid.  That’s just a part of that disturbing puzzle.  You have a major gap that is going to occur here that will leave folks in these states, some covered by the exchanges, but then others that are simply not going to be covered at all.  Then you have some that’ll be covered by private insurance.  

That’s kind of set the background context to—now moving forward into what we’re discovering in some of the more details that Nadia will go into at this point.

*Nadia Siddiqui:*Thank you Dennis.  What Dennis has laid is a context for now, the dynamics that are emerging in the healthcare environment, the evolving healthcare settings, challenges that they face; the need for adaptation that they face now.  As Dennis mentioned, and we’ll see an influx of newly insured populations, but we will continue to have a large uninsured population.  As many of you know, the Congressional Budget Office estimates that by 2019 the net impact of the Affordable Care Act will be to insure 25 million individuals.  However, 32 million will remain uninsured for various reasons, including a third who will be undocumented immigrants, and many others.  

How does the ACA then build health system capacity to meet this growing need and demand?  That’s what the rest of our talk today will focus on.  What are the health system enhancements and opportunities for adaptation and advancement that the Affordable Care Act offers?  There are five areas that we’re really going to focus on today.  These five areas are really those areas that our work has investigated and focused on, because of their overlap with health equity priorities.  We’ll get into healthcare workforce investments, and the opportunities that the ACA creates, particularly around workforce diversity, around increasing supply providers in underserved areas.  

We’ll talk a little bit about capacity-building opportunities for underserved populations, payment and delivery innovations.  This in and of itself is a beast, and a huge topic area.  We’ll focus mainly on patient-centered medical homes in this context.  Health systems research, and in particular the opportunities around advancing health disparities research that the Affordable Care Act provides.  Quality and equity initiatives at the broader, national and federal level.  

I’d like to start off just by discussing a little bit about workforce investments that the ACA makes, primarily to grow the supply of primary care providers.  I’m sure many of you are already familiar with this, so we’ll go through this a little bit quickly.  The ACA does invest considerably in expanding the supply of primary care providers.  Back in 2010, a considerable amount of dollars came through from the Prevention and Public Health Fund.  In fact 70 percent of programs funded around primary care workforce came from the Prevention and Public Health Fund, and so what that fund did was it supported programs to expand primary care residency programs, to expand physician assistant programs, nurse workforce development and diversity grants were a part of it.  

Nurse practitioner training programs were also supported, as well as state healthcare workforce development grants.  The ACA also supports other providers and funds other healthcare providers, including, Dennis, mental health providers.  Community health workers was another group that was in the law explicitly, but we signed that—these providers unfortunately have not been funded to the degree that the ACA had intended for.  I think one of the key opportunities that the ACA has really afforded, and a unique window of opportunity, is given that it really raised the relevance and the importance of many primary care providers, including nurse practitioner/physician assistants, it’s created a unique opportunity and movement toward team-based approaches.  

This is something I think now that the country is coming to realize; a lot of media attention around it.  There’s considerable opportunity here, and a movement toward these team-based approaches that we just wanted to emphasize.  In addition to enhancing the supply of primary care providers, a movement toward more team-based approaches, which studies are linking to greater access for racially and ethnically diverse patients—improved access, improved patient satisfaction.  

The third area, and kind of investments the ACA is making, is around enhancing diversity and cultural competency.  They’re very explicit provisions in the law, including the investment, or reinvestment in minority-serving institutions, including historically black colleges and universities, Hispanic-serving institutions, as well as other minority-serving institutions.  A second area that the ACA supports for advancing diversity are almost these pipeline programs for training underrepresented minorities, the Centers for Excellence program, the Health Careers Opportunity Program and Scholarships for Disadvantaged Students are some examples.  

These programs, over the years, have shown a lot of success in training, in mentorship of high school students, community college students, of students early on in their careers; helping them transition into and enter into health professions, mentoring them to retain them in these programs, and ultimately to matriculate them.  There have been reports, studies of their promise, of their success.  The unfortunate news is that these are some of the programs that, while supported by the ACA, were severely underfunded.  This is certainly an area of concern in the workforce arena.  

Then finally, cultural competency training; we were actually quite pleasantly surprised and taken aback to even learn that the term “cultural competency” was in the Affordable Care Act on several occasions.  For us, very exciting opportunity to elevate the importance of cultural competency.  The unfortunate—again it’s a mixed bag.  Some provisions did receive funding, more in a general, broader sense.  For example, new demonstration to develop long-term care provider training competencies is a program that was funded within which there are requirements around developing cultural and linguistic competencies as well.  

Other provisions, such as developing model cultural competency curricula, creating an online clearing house to access and to disseminate and share such curricula for different providers, that unfortunately we didn’t see has made any progress, or received any funding to date.  Moving on to capacity building in underserved areas, as I’m sure many of you are familiar, the ACA really bolstered support for community health centers, for federally-qualified health centers.  It also intended to expand capacity, and build capacity in other community-based settings, nurse-managed health centers, school-based health centers, teaching health centers.  

Again, many of these centers were not funded to the full vision that the ACA had, but nonetheless this has been a significant area of investment and commitment of the ACA, which again offers a promising opportunity to enhance points of service for underserved racially and ethnically diverse individuals.  Also for many, many Veterans; four out of ten who live away from a VA facility, and who in many cases do access care in some of these locations, so a key point of opportunity and access for these populations.  

Two other provisions, and two other opportunities that I’d like to point out around capacity building in underserved areas are the National Health Service Corps and the redistribution of medical residency slots.  These may seem more like workforce provisions, but the reason why we’ve included them here is because they’ve contributed to almost the redistribution of providers to areas that really need that, that have shortages and could benefit from enhanced capacity.  The National Health Service Corps has considerably grown.  It’s been growing over the years; been reauthorized.  It’s grown three times post-ACA.  

What’s key to know is that those providers that are part of the Corps are far more reflective of the general population, far more diverse than general healthcare providers are.  This is a key opportunity and key vehicle to train racially and ethnically diverse providers.  Importantly, many of these providers end up practicing in community settings and rural settings in community health centers.  Forty-six percent of Corps members practice at community health centers.  

The redistribution of unused medical residency slots to underserved areas is also another important opportunity for redistributing providers to areas that really need—that they’re facing shortages, and could benefit from providers.  Regulations stated that 70 percent of these slots are to go to hospitals in states with lowest resident-to-population ratios, and 30 percent to hospitals located in rural or health professional shortage areas.  Again, very important for Veterans and their families, who may be residing in areas without a VA facility, and in some cases in these rural areas.  

What we came to learn was after the distribution took place, the hospitals receiving medical residents, half of them are located—half of these hospitals are located in areas where at least 50 percent of the population is non-white.  Extremely diverse areas that have—and low-income and underserved areas that are benefitting from this redistribution.  Payment and delivery innovations.  Again, this is a very, very broad topic; a lot of attention around this.  We wanted to take the time today to really focus on patient-centered medical homes, especially recognizing the leading role that many VA facilities are taking, particularly with your patient-aligned care teams and initiatives.  

We wanted to provide our health equity slant and perspective to patient-centered medical homes.  Through our review, what we’ve come to learn is that there are at least ten different occasions, ten different provisions within the Affordable Care Act which explicitly work to advance, encourage or incentivize health homes, or medical homes.  Of these ten different opportunities, at least six specify priorities, encourage the advancement of equity.  What we found was that medical homes are supported and advanced in context of state innovations through the health homes state option, through workforce provisions, so encouraging providers to practice in these setups, in these medical home setups.  

Research and innovation, promotion of outcomes research around medical homes, and also in context of payment and insurance, so within marketplaces and assuring that these settings are part of qualified health plans, and so forth.  As an example, what I wanted to present today was the fact that many medical home models and approaches, and even the state health home innovations that are taking place across the states are making a very explicit effort to address and advance health equity.  

Here is an example around these state innovations.  Section 2703 in the ACA created a state option to provide health homes for Medicaid enrollees with chronic conditions, to improve health outcomes.  There are 12 states, at various stages, with approved health home plans.  Many of these states, within their plans, have very explicitly cited their intent to integrate and to address cultural and linguistic diversity by—in particular advancing culturally and linguistically appropriate patient communication processes, culturally and linguistically appropriate individual and family support, use of evidence-based culturally sensitive wellness and prevention, and assuring that patient health assessments include measures around culture, around beliefs, around language and related preferences.  

Some of this is very, very important because as we’ve been going through some of the pact models, and looking more into what the Veterans Health Administration is doing around its patient-aligned care teams.  It was interesting to learn, and not a surprise, but that PACT rollout does vary, and that there are some facilities that are really leading among the VA system.  There are some that are lagging, and those that are lagging, there are several dynamics contributing to that, including patient demographics, health status, supply of staffing, and so forth.  I think there are many lessons that can come—that can be learned from the patient-centered medical homes that the ACA has supported.  

Then finally, before I move on from this point, I think we’re all familiar with the National Committee for Quality Assurances, standards, the six standards it sets for the patient-centered medical homes.  There’s one substandard that’s explicitly focused around assuring cultural and linguistic competence.  Again, these focus on the need to assess patient diversity, the need to assess language needs of patients, and the need to provide not just interpretation but timely interpretation, and access to trained bilingual staff and interpreters, as well as print materials that are not just translated, but print materials which may be developed in cultural contexts of the patients.  

All elements that I think many medical homes may already be doing, but for those that are not, I think these are certainly areas of opportunity for advancing and integrating equity.  Accountable care organizations is another innovation that’s in the limelight these days.  It holds great promise for improving quality, for holding providers accountable for cost and quality of a full continuum of care for patients.  CMS is supporting ACOs.  There’s the Medicare Shared Savings Program as well.  There’s certainly promise around them for improving quality.  There are also several concerns when it comes to disparities in health equity.  

In particular, the primary concern that’s currently out in the health policy realm that I’m sure many of you are familiar with is this idea that ACOs are primarily forming around, and will be forming around more well-to-do providers; those that are financially well-off, that might be seeing a more homogenous patient population, wealthier and so forth; leaving those with more costly patients, low-income, diverse patients outside of these arrangements.  Not only are we going to see then a rift in these kinds of providers, but also then a gap in disparities in the care that’s provided, or in the outcomes to patients, and disparities in the opportunities that these providers have.  

It’s absolutely important that ACOs not only require active monitoring of disparities, but in some cases even incentivize the need to reduce disparity, and make that a part of quality improvement; that these are tied objectives for improving quality.  Nonetheless, there are certainly examples of ACOs out there that are working to integrate hospitals and providers that are serving low-income communities.  There is an example out of Minnesota, of a social accountable care organization from Hennepin Health.  They’re doing some interesting things.  They are partnering with social service organizations to ensure appropriate care for a population with high rates of mental illness, chemical dependence and chronic disease.  

Under this model, they’ve seen not only savings, but what they’ve done is the savings that they’re making, they’re reinvesting into expanding social services to address the needs of the populations that they serve.  There are some interesting models out there.  I think explicitly addressing the unintended consequences for health disparities is absolutely important when it comes to these arrangements.  Health systems research; there are really two opportunities that I will highlight today, one of them being—the prime I would say is the Patient-Centered Outcomes Research Institute, PCORI, which makes one of its five priorities to address health disparities.  

Through *[background noise]* its various work groups and advisory groups, it’s come to identify at least five specific research areas for addressing disparities; the first around 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.  These are some explicit areas that PCORI is looking to fund some explicit research opportunities for comparative effectiveness research around interventions, around medications, around systems transformations and so forth.  

What we found very interesting, in reviewing about 147 comparative effectiveness research grants that were awarded, while only 14 percent fell under this health disparities priority, nearly half of these funded awards or grants included a secondary focus on diverse populations.  Somehow, half of these grants are in some way or another addressing racial and ethnic health disparities.  This is absolutely important, because PCORI really offers an unprecedented opportunity to address and advance health disparities research.  

There are challenges, I think, that Dennis will go over, around—they’re looking to fund projects that show measureable impact in a short turnaround.  For example, I know one project that may resonate with this group is—that you may be familiar with is the CAPriCORN initiative that was funded by PCORI.  It’s the Chicago Area Patient-Centered Outcomes Research Network.  CAPriCORN awarded $7 million in 2013 for 18 months to build a data infrastructure which was intended for use in improving patient health outcomes and lowering costs of treatment for certain diseases that they were finding to be high-cost, diabetes, heart disease, asthma I think are among some of those conditions.  

A collaborative of providers was funded, including two Veteran Health Administration hospitals.  What they were looking to do is capture—they were capturing data on a million patients across this collaborative; half of whom are racially and ethnically diverse.  Some important opportunities here we’re already seeing for collaboration, and for addressing disparities research within the Veterans’ population.  Another opportunity we wanted to highlight were Community Health Needs Assessments.  The ACA requires non-profit hospitals to conduct a Community Health Needs Assessment every three years and develop a strategy to address those needs.  

This is a really exciting opportunity that many communities are taking advantage of, thinking outside the box and innovating around.  It’s not just a hospital isolated conducting an assessment.  The communities are really working together with these facilities, collaborating to conduct assessments with providers almost integrating—different providers and partners integrating their priorities within the assessment, and working together then to develop solutions.  I think there’s some key opportunities here for collaborating with clinics and providers that serve primarily Veterans and their families, and also for monitoring and addressing disparities.  

Quality and equity initiatives; at the national/federal level it’s something else we wanted to just focus our attention on.  The National Quality Strategy in particular, which I’m sure many of you have heard and are familiar with, intends to improve the delivery of healthcare services, patient health outcomes and population health.  It’s a strategy that’s been developed.  There are six priorities that have been developed, of which two—well all of them apply, and can be aligned with health equity.  There are two really that explicitly—that the strategy itself says—has a health disparities or equity component.  

That’s priority two, around engaging patients and families, within which a key goal is that in partnership with patients, families and caregivers, and using shared decision-making process, there’s a need to develop culturally-sensitive and an understandable care plan.  Then priority three, effective communication and care coordination, another priority of the National Quality Strategy within which a key goal is to establish shared accountability and integration of communities and healthcare systems, to improve quality of care and reduce health disparities.  That moves us into other federal agency level initiatives.  

The ACA really I think elevated minority health issues, and the role of minority health offices, generally speaking.  Given the fact that the ACA elevated the federal Office of Minority Health; it established six agency-based offices of Minority Health within various HHS agencies.  It also elevated the National Center on Minority Health and Health Disparities to an institute level.  This really is almost symbolic, but also a concrete example of how the ACA is really working to elevate equity within the system at the national policy level, but then also in the trenches.  

There are significant opportunities for inter-agency collaboration, particularly with the VA.  I know there are efforts ongoing.  There are also, beyond the collaboration, there are also areas and actions of alignment that many of these offices are issuing.  For example, the National Standards on Culturally and Linguistically Appropriate Services, which the Office of Minority Health has issued, includes some federal standards that are being implemented.  

There’s also many recommendations in there that could be integrated into patient-centered medical home models: recommendations around assessing patient needs, by race, ethnicity, language, around medical interpreters, around language access issues, around building trust.  There’s a lot there, and so there are a lot of these agencies producing such great work.  We just wanted to highlight that.  The ACA really affords the opportunity not only to further advance, but now to align some of these equity objectives with what others are doing. With that, I will turn it back over to Dennis, to go over some challenges that we’re facing to advancing equity.

*Presenter:*Thank you, thank you Nadia.  Nadia has given an overall review of those opportunities, the scope and breadth of actions intended, and otherwise being realized through the law, or trying to be realized through the law.  In so laying that out, our intent was really to give you a sense of how issues around equity as they play out on disparities, race, culture, language, diversity, community, individuals all have a—are all comingled and perfuse throughout the provisions of the law.  

I think it’s important, as we move ahead, in terms of enfranchisement of populations, that these populations really will make the difference as to whether the Affordable Care Act’s vision actually is realized, and the success of the law will really in large part be based on the effectiveness of achieving equity in its implementation; because my computer is still a little quirky, I would ask that we just move on, and have someone else master this.  I don’t trust my computer at this stage of the game.  

If we could move onto the slide for funding and sustainability—more than half of the provisions, as we’ve mentioned, received substantially less than authorized, or no funding from the ACA.  There was so much advocacy around the issues that we’ve talked about here that it was impressive to see the level of detail and the extensiveness, and yet realizing it in the context of authorization and embedding language is, as you well know, different from actually getting, in many ways a recalcitrant Congress, to implement these programs and support them through funding.  

Uneven implementation is so clear within that.  We have some solid examples of the concerns around not only not receiving sufficient funds, or fewer funds than what were intended, but declining support for programs with minority health and health professions, for example.  The health career opportunity programs, or Centers of Excellence that are important efforts to advance minority health and increase the pool of professionals is at the very least not being realized to the full extent, if actually being thwarted.  

Then we have uncertain support for sustaining public health and prevention initiatives.  That is creating its own challenges as well.  Next slide.  On political antipathy, this has reached, as you well know, such—if I could use almost a screeching level that it plays now a disproportionate roll.  This political antipathy is playing out in multiple dimensions; through thwarting the implementation of the law, and through misinformation, distortion that I’ll also refer to in other capacities.  I think it’s important in the context of political antipathy.  Reluctance around the marketplace; it clearly is playing out, as you well know, as you can see and read in the headlines.  

In states not expanding Medicaid, over 2.5 million low-income diverse individuals are in that coverage gap.  Over 400,000 Veterans in the coverage gap as well, many of whom are from diverse communities.  Then as I said, misinformation, and confusion, and reluctant consumers generally, and of course language barriers.  All of these have consequences, these actions.  You have circumstances where, to date, state-based and state partnership marketplaces have nearly three times more funding for consumer assistance as do states that are being federally administered.  

In a recent poll from Pew, they have found that 59 percent of residents in states with state-based or state partnerships with marketplaces knew that a marketplace would be available to them, compared to 44 percent.  You see those discrepancies play out.  On the next slide we see a blatant example of this.  I was walking around Times Square not that long ago, and this was a billboard at Times Square on defunding Obamacare now.  Just this huge billboard in prominent display.  

The next slide.  On time; there is concern—there are a couple of perspectives on time; one having clearly to do with the actual rollout, and the time it takes, and the delays.  The other is that it takes time to develop a lot of these programs, or to show effectiveness, and because of that time factor, you see concerns.  For example, the Patient Centered Outcome Research Institute, as good as its content and its intent is, that there are concerns around showing results as soon as possible, because folks are impatient to see that.  

This is an area that it’s oftentimes difficult to show results; same thing with the Innovation Center, wanting to see results.  Certainly in cultivating partnerships, the primary care medical homes takes time to develop.  Some have suggested medical education might be needed for doctors in that capacity.  Of course, as was at the top, the whole rollout of the insurance exchanges and marketplaces have been delayed.  Equity is not a priority; the next slide.  It’s clear that as we’ve talked to people, we find that equity is down the list somewhere, saying, “Well we’ve got all these other things that we need to handle, and *[static]* less of an issue.”  

To some extent, it’s also relegated to “less important,” in terms of the rollout itself.  Not only does it not get the prominence or the priority, but oftentimes as I’ve said before, it’s given to Mikey in the back room.  It’s a sense of, “Give it to that person.  Let them figure it out.”  For something that should be mainstream, it is not, in many quarters.  Moving on to the next slide, it’s moving forward: leveraging the ACA to advance equity.  Then the slide that follows, advancing equity through marketplaces, it’s clear that there is a window of opportunity to advance equity, given the support and attention to marketplaces.  

We have identified these areas of leadership and governance, navigator/assister and recruitment, outreach and enrollment, language services, community engagement, measurement and evaluation.  These are all dimensions; some of them with requirements, others with guidance.  Some states embracing, like California and Connecticut; others still feeling their way through it.  At the same time, some of the leading states provide some direction for others to consider, as they themselves are looking to more fully engage and realize these areas.  On the next slide, building on promising—

*Moderator:*Dennis?  I’m sorry to—

*Dr. Andrulis:*Yes?

*Moderator:*- cut you off.  We do want to wrap up in the next minute or two, so we have time for questions.  Thank you.

*Dr. Andrulis:*I will do that.  Building on promising health systems investments, collaborative opportunities to expand care for Veterans, living in rural underserved areas, and looking at best practice models that are going on.  On the next slide, building on the ACA’s community-based initiatives to engage and reach diverse communities through the community transformation grants that were mentioned, innovation support, class.  There—in some of these community transformation grants—50 percent target diverse populations in one way, shape or form.  

It offers another significant dimension that had heretofore not received nearly the amount of attention.  On the next slide, monitoring impact of programs on disparities, evaluating payment and delivery reforms, and keeping in mind we want to close the gap, not see the gaps widen or just see a parallel increase or improvement or lack of improvement that doesn’t show any closing of the gap.  Then as we close that, education and advocacy for advancing equity, along the lines of what we just realized that it talked about; we see all the opportunities.  Community forums we’ve talked about and we’re now conducting a community forum, for example.  

We’ve laid out a strategy by which you can educate and inform.  State and local forms as well, on how to engage and take advantage of some of the opportunities; then continued advocacy around these areas that I mentioned, oral health, cultural competency, that have not been funded.  Then just on closing remarks, that many provisions are in place to advance.  Time, dollars, and launch challenges and other concerns are just not offering the opportunity.  There’s really a need for concerted, active efforts to keep these provisions alive and well, and keep them going.  Okay, I will stop here.

*Moderator:*Thank you so much.  Sorry to rush you at the end.  We will be taking questions from the audience now.  I know a lot of our attendees joined us after the top of the hour.  To submit your Q and A, go ahead and use that Q and A box that’s located in the upper right-hand corner of your screen.  I’m sorry, just on the right-hand corner of your screen.  Simply type into the lower box and press the speech bubble.  That will get your question asked and answered.  

The first question we have, let me pull that up, one of our attendees would like to know if you and Nadia are available for follow-up after today’s presentation.

*Dr. Andrulis:*That’s a hard question.  I will have to go on about that for a—no.

*Moderator:*[Laugh].

*Dr. Andrulis:*Yes, that we’d be happy to talk further about it.

*Moderator:*Excellent, and the next question, does the ACA have any specific provisions to address health disparities facing the LGBT community?  *[Pause]*

*Dr. Andrulis:*Nadia, I don’t know if they’re specific to LGBT or underserved populations, of which there are a number of provisions that can include the LGBT community.

*Nadia Siddiqui:*Right, you’re absolutely right.  We actually—our focus has primarily been around race, ethnicity and language.  What we’ve come to learn is that in the broader scope of underserved, and some of the broader terminology, that there may be opportunity to address some of the LGBT priorities as well.

*Dr. Uchendu:*Molly, if I might weigh in there quickly, there is some question in the provision under non-discrimination where the language actually incorporates the possibility of being able to include LGBT community in the underserved.

*Moderator:*Great, thank you all for those responses.  All right, well that is the last pending question we have right now.  For attendees, I’m going to put up our feedback surveys.  Please take just a moment and provide us with your responses.  It does help us further know what topics you are interested in, and what you’d like to learn more about.  I—

*Dr. Uchendu:*Molly?

*Moderator:*Yes?

*Dr. Uchendu:*I had a couple of comments, while you are putting those up.

*Moderator:*Mm-hmm.

*Dr. Uchendu:*Following back on some of the slides, I just wanted to mention, on the federal interagency alignment that actually the VA is actively involved with the Federal Interagency Health Equity Team, which has more than 14 federal agencies looking at advancing health equity further, in however shape or fashion that it fits within our agencies.  Then in addition, the VA also participates in the Federal Collaboration for Health Disparities Research, F-C-H-D-R, which is coached by the Office of Minority Health director in HHS, Dr. Nadine Garcia, and also the NIMHD director, Dr. John Ruffin.  

Finally, that under Patient Centered Outcome Research *[background noise]* Institute, PCORI, Dr. Jesse, who is the principal deputy under secretary for health in VHA service on that group, as well.

*Moderator:*Great, thank you for those additions.  Well I very much want to thank Dr. Uchendu for having the Office of Health Equity sponsor today’s presentation, and also extend our thanks to Dr. Andrulis and Siddiqui for presenting for us today, and lending your expertise to the field.  We very much appreciate it.  I also want to thank our attendees to join us—*[laugh]* I’m sorry.  I want to thank our attendees for joining us.  That does conclude today’s HSR and D cyber seminar.  For our presenters, feel free to log out.  For our attendees, please do complete the survey, and then feel free to exit the meeting.  Thank you all so much for joining us today.  Have a great day.

*Dr. Andrulis:*Our pleasure.

*Nadia Siddiqui:*Thank you.

*[End of Audio]*

Page 1 of 16