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7 Legislative Actions to Reduce Health Disparities T he final panel of the day focused on the Patient Protection and Affordable Care Act (ACA) of 2010 and the provisions within the law that address health disparities. Three congressional staff mem- bers shared their expertise on those aspects of the law that have the poten- tial to reduce health disparities among people of color. THE SENATE PERSPECTIVE Senate Health, Education, Labor, and Pensions Committee Craig Martinez is a health policy adviser to the Senate Health, Edu- cation, Labor, and Pensions Committee. His legislative portfolio includes public health, prevention, preparedness, and health disparities. Noting that Senator Tom Harkin refers to the ACA as a “starter home” for providing health care to all Americans, Martinez acknowledged that much work remains to be done to address health disparities. Nonetheless, the ACA is a critical first step, and a number of provisions in the law relate to low-income communities and communities of color. Health Insurance Affordability Ensuring that people can afford health insurance is an important piece of addressing health disparities, Martinez explained. One component of the effort to make insurance affordable is the provision of subsidies to low- income individuals. These subsidies can then be used to purchase coverage 85

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86 HOW FAR HAVE WE COME IN REDUCING HEALTH DISPARITIES? that includes preventive services and out-of-pocket costs. The ACA will lead to new coverage for 32 million Americans who are currently uninsured. The law also addresses the challenge of the acquisition of insurance for those living with preexisting conditions. Under the new law, it is no longer allowable to drop a patient if he or she gets sick. It is also no longer allow- able to deny coverage in the first place. Access to Health Care Services Community health centers (CHCs) are an important source of care for individuals in low-income communities, said Martinez. The ACA provides additional support for the creation and expansion of CHCs, including sup- port for nurse-managed health centers and improved access to case manage- ment services. School-based clinics are also provided support through the ACA, as schools are often the only point of access for child health services in low-income communities. Martinez indicated that health information technology should be used to facilitate enrollment for services in low- income communities of color and to give patients greater control over the decisions involved in their access to health care services. Workforce Preparation The ACA creates a new commission to focus on workforce issues. The commission will consider both worker competence and workforce diversity. Martinez explained that it is clear that individuals in low-income communi- ties have inadequate access to medical specialists and to health care profes- sionals trained in cultural competence. Cultural competence, in fact, should be promoted among all health care providers. The ACA contains initiatives to ensure that medical schools provide training in cultural competence to students as preparation for their future work with patients from different cultural contexts. Improving Quality of Health Care Services The creation of quality measures that assess both health care provision and health outcomes is the fourth piece of the ACA relevant to achieving reductions in health disparities. It is not enough, Martinez said, to have health insurance and access to care in communities of color. The quality of health care must also be considered. Chronic disease management, particu- larly in low-income communities of color, is also critical.

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87 LEGISLATIVE ACTIONS TO REDUCE HEALTH DISPARITIES Prevention The ACA contains a variety of provisions focusing on the role of pre- vention in the promotion of better health. The law led to the creation of a national health council to promote prevention. The council is predicated on the idea that it is not enough to consider only health care when the discus- sion is about the improvement of health outcomes for all. Rather, the built environment itself—access to parks, good public transportation, and job opportunities—should be considered. The council’s membership includes the U.S. Department of Health and Human Services (HHS) as well as other federal agencies such as the U.S. Department of Housing and Urban Devel- opment (HUD) and the U.S. Department of Transportation. The Community Transformation Grants (CTGs) that are included in the ACA also focus on improvements to the built environment. Although there is a strong evidence base for the importance of considering the built environment to improve health, many members of the Senate did not under- stand the connection. The provisions that focus on improvements to the built environment remained in the final bill, however. Consistent funding streams for preventive services are also included in the law, as is maintenance of the public health infrastructure. Community preventive services such as disease prevention and safety net programs, which have consistently been underfunded in the past, are seen to be impor- tant continued investments in the ACA, explained Martinez. Data Collection Standards The collection of race and ethnicity data across federal agencies is essential to get a better sense of the degree of health disparities in the United States. The availability of good data also provide the ability to evaluate subpopulations; for example, not all Asian American populations are alike, said Martinez. Data collection efforts should be coordinated across agen- cies so that a clearer picture of what is occurring in communities of color can be obtained. Federal Minority Health Agencies A number of actions relating to the elevation of federal agencies focus- ing on minority health are a part of the ACA, including elevation of the Office of Minority Health within HHS to the HHS secretary’s office. This gives the office more prominence in the public realm and more clout to accomplish those efforts aimed at achievement of reductions in health dis- parities in communities of color.

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88 HOW FAR HAVE WE COME IN REDUCING HEALTH DISPARITIES? Other federal agencies, including the Centers for Disease Control and Prevention (CDC), Health Resources and Services Administration, Substance Abuse and Mental Health Services Administration, Agency for Healthcare Research and Quality, Food and Drug Administration, and Centers for Medicare and Medicaid Services (among others), are tasked to create an Office of Minority Health within each agency. This will allow bet- ter coordination of efforts across agencies on initiatives to improve health in communities of color. Finally, the National Center on Minority Health and Health Dispari- ties within the National Institutes of Health (NIH) is now elevated from a center to a formal institute; the center is now known as the National Insti- tute on Minority Health and Health Disparities (NIMHD). This provides NIH with greater authority to coordinate health disparities research and provides access to greater resources to continue to focus on the health issues affecting communities of color. Martinez concluded by noting that although much remains to be done to reduce health disparities, advances are being made under the ACA. What is important to remember, he said, is that the health insurance provisions will have a positive effect on the residents of low-income communities and communities of color. Senate Committee on Finance Kelly Whitener is a health policy adviser to the Senate Committee on Finance. She is also a former Peace Corps volunteer and former community mental health worker. The Committee on Finance focuses primarily on the cost aspects of the ACA. Whitener explained that the committee considers Medicare, Medic- aid, and the Children’s Health Insurance Program (CHIP). Thus, the pro- visions of the bill relevant to this committee were more narrowly focused than the provisions described in the previous presentation. One major outcome of ACA, previously mentioned by Craig Martinez, is the improvement of data collection requirements. More specifically, data collection requirements are now more uniform across programs; in the past, for example, Medicaid and CHIP had different requirements. Because the populations served by these programs are similar, it makes sense for data collection requirements to be more uniform. Whitener stated that the Medicaid program typically receives much less attention than the Medicare program. Therefore, several provisions to improve health disparities in the Medicare program were extended to apply to Medicaid and CHIP as well. This allows the Centers for Medicare and Medicaid Services (CMS) to bring parity across the programs. The major accomplishment of health reform from the perspective of the

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89 LEGISLATIVE ACTIONS TO REDUCE HEALTH DISPARITIES Committee on Finance is improved coverage for low-income Americans. In particular, Whitener said, those childless adults who today do not have access to coverage will be able to get coverage. As Martinez mentioned, 32 million people currently without health insurance will have health care coverage, and 14 million of those will have coverage through Medicaid. Those 14 million people have incomes less than 133 percent of the federal poverty rate. For many, if not most, of these people, this will be the first time that they have a source of health care coverage. Although much good news is in the ACA, some issues were not ade- quately addressed in the final legislation, said Whitener. Language and translation services in Medicare, Medicaid, and CHIP were not addressed, for example. It is difficult to provide the best possible care without using the languages that people are most comfortable with. Whitener hopes that this issue, among many others, can be addressed in future legislation. THE HOUSE OF REPRESENTATIVES PERSPECTIVE The final panelist was Bernardette Arellano, a legislative assistant from the office of Congressman Mike Honda of California. She is responsible for the labor/HHS component of the Appropriations Subcommittee. Arellano highlighted several changes in the reconciliation bill that improved some health disparities provisions in the final Senate bill that was signed into law. (Because of the way that the ACA was passed by Congress, the usual process in which a conference committee resolves differences between the House bill and the Senate bill did not occur.) Institutions Serving Minority Populations First, funding in support of historically black colleges and universities and other institutions serving minority populations was extended through 2019. In particular, programs focusing on math, science, technology, and engineering were targeted for extension. Funding for Territories An important issue for Congressman Honda, an Asian American, was the increase in federal funding for the territories (for example, Guam, American Samoa, and the Northern Mariana Islands). The caps on Med- icaid funding were raised, and territories can also elect to operate a health exchange under the language of the reconciliation bill. Arellano noted that although Americans in general have little aware- ness of the problem of health disparities in the United States, even less awareness of the problem of health disparities for citizens living in the

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90 HOW FAR HAVE WE COME IN REDUCING HEALTH DISPARITIES? territories exists. Each island has very few physicians, no oncologists, no access to podiatric services, and very limited health care access compared with the availability of physicians and access on the mainland. Funding for Community Health Centers The reconciliation bill increased funding for Community Health Cen- ters (CHCs) to $11 billion. As stated earlier, CHCs are the primary point of access to health care in low-income communities of color. Data Collection Arellano expressed the need for a richer picture of the differences within racial and ethnic minority communities and praised the final Sen- ate bill for its emphasis on data collection. For example, wide-ranging differences exist between Cambodian Americans and Japanese Americans; without adequate data collection, it is difficult to address those differences. Issues to Be Addressed in the Future Like the previous panelists, Arellano outlined several issues that future legislation will need to address to reduce health disparities. Echoing earlier comments, the final bill did not address language and translation services in Medicare, Medicaid, and CHIP. The House bill also extended Medicaid coverage to legal immigrants during the first 5 years of their residency in the United States. This exten- sion of coverage, however, was not a component of the final bill, likely because of political pressures about immigration reform, said Arellano. She noted that exclusion of legal immigrants—called “citizens in waiting” by Congressman Honda—from a public program designed to keep them and their children healthy is difficult to justify. Finally, Arellano noted that HHS has a wide range of ACA-related regulations to be promulgated. It is critical that the agency hear from members of the public about their concerns with the proposed regulations. DISCUSSION Cara James of the Kaiser Family Foundation asked about the demon- stration projects that are built into the ACA. The findings from those dem- onstration projects are likely to affect health disparities in a variety of ways; for example, the Medicare pay-for-performance measures are designed to improve health care quality, which in turn should affect disparities in care. How will the findings of these projects be considered, disseminated, and

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91 LEGISLATIVE ACTIONS TO REDUCE HEALTH DISPARITIES used as a feedback loop? Kelly Whitener responded that a large number of demonstration projects, each with its own timeline and focus, are operating in different states. For those projects with positive preliminary feedback, Congress can make the case that those projects should be continued. Whitener described, as an example, a demonstration project under Medicare focused on diabetes that has a component serving Native Ameri- cans. This demonstration project has worked extremely well in Montana, which has a large Native American population, but has not done so well at other sites. The Senate could therefore push to continue the project for Native Americans. What is helpful, said Whitener, is to have outside groups and experts suggest the good programs to be evaluated. Pattie Tucker of CDC offered the REACH (Racial and Ethnic Approaches to Community Health) demonstration projects as an example of a successful community-based program that went from making changes in the lives of individuals participating in community programs to changes at the policy level. The challenge is that completion of this transition from changes in individual and community behaviors to broader policy changes during the 5-year grant cycle is difficult. If some projects receive additional funding, CDC hopes to see more dramatic changes in those communities. Newell McElwee of Merck & Co., Inc., asked about the workforce diversity provisions included in the ACA and its tasks. Craig Martinez said that the overall goal of the workforce commission outlined in the legislation is to provide to Congress and HHS comprehensive, unbiased information on how to better align federal health care resources with national needs. Its purpose is to assess what the workforce looks like today, what the work- force needs are, what needs are unmet, and what must occur to further develop this workforce. Anne Kubisch of the Aspen Institute asked about the federal inter- agency collaborations around place and communities that are under way. These collaborations include the Sustainable Communities Initiative that brings together HUD, the U.S. Department of Transportation, and the Environmental Protection Agency; the Promise neighborhoods funded by the U.S. Department of Education; and the Choice neighborhoods program funded by HUD. She wondered about the leadership for this work and the role that outside groups such as the Institute of Medicine Roundtable can play in making sure that these programs are implemented as effectively as possible. Martinez described the organizational culture of federal agencies, say- ing that different departments are happy in their “silos” and that it can be difficult for them to interact with each other. At the same time, programs across different departments can give a “bigger bang for our buck” when they work together. One example is the Prevention Council, which ACA legislation mandated to be made up of the secretaries of the federal agen-

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92 HOW FAR HAVE WE COME IN REDUCING HEALTH DISPARITIES? cies. Additionally, the Prevention Council is a priority for Senator Harkin. This requires a change of culture, however, and that can be scary for people. Whitener added that a wealth of knowledge about what is actually happening in communities and how programs are having an impact on people is being obtained by the agencies. Because Congress is a very action- oriented place, she said, it is useful to have that knowledge so that a prob- lem can be fixed when it is presented. For example, an effort to coordinate transportation among Medicaid facilities, schools, and clinics would keep four different vans from going to the same neighborhood to pick up neigh- bors and separately take them to various places simply because they receive funding through separate funding streams. Therefore, it is helpful when outside groups or experts can present a problem and suggest solutions on which Congress can act. Bernardette Arellano added that allowing federal agencies some flex- ibility allows for creativity, but it also means that Congress must give up some control. Under a friendly administration, much can be done to work in the interest of low-income people. She also said that use of the report lan- guage that accompanies a spending bill can be a very powerful strategy to encourage a federal agency to act. For example, report language suggested the creation of an interagency task force on viral hepatitis. Even though direct funding may not be provided, when Congress expresses support for something via report language, an agency director will closely look at that language and parcel out funding for the project. Report language can therefore be a powerful tool.