Since its creation by the Institute of Medicine (IOM) in 2007, the Roundtable on the Promotion of Health Equity and the Elimination of Health Disparities has been fostering dialogue on racial and ethnic disparities in health and health care, examining the development of programs and strategies to reduce disparities, and encouraging the emergence of new leadership focused on health equity. For the past several years, a prominent topic of discussion within the roundtable has been the Patient Protection and Affordable Care Act (ACA), which was signed into law by President Barack Obama on March 23, 2010. The ACA has multiple provisions specific to race, ethnicity, and language and other provisions with significant implications for racially and ethnically diverse populations (Andrulis et al., 2010). Many observers view the ACA as the best opportunity in a generation to promote health equity.
On April 22, 2013, the roundtable held a workshop at the Mark Twain House and Museum in Hartford, Connecticut, titled Achieving Health Equity via the Affordable Care Act: Promises, Provisions, and Making Reform a Reality for Diverse Patients. Sponsored and hosted by the Connecticut Health Foundation (see Box 1-1), the workshop addressed many issues surrounding the ACA, including
- Expansion of coverage, delivery systems, and access points;
- Service delivery and payment reform, including the patient-centered medical home model;
- Public–private partnerships; and
- Challenges to the safety net.
The Connecticut Health Foundation, which supported and hosted the workshop Achieving Health Equity via the Affordable Care Act: Promises, Provisions, and Making Reform a Reality for Diverse Patients, was created in 1999 to improve the health status of people in Connecticut. As Sanford Cloud, the chair of the foundation’s board, said in his opening remarks at the workshop, the foundation uses “strategic communications, leadership cultivation, and public policy to expand health equity.”
Shortly before the workshop, the foundation announced a new 5-year strategic plan directed toward an integrated strategy centered on expanding health equity for all Connecticut residents. The plan establishes two broad goals and six underlying objectives.
Goal 1: Leverage opportunities to advance health equity in reforming health care.
- Objective 1: Promote health insurance enrollment and navigation support systems that will increase and maintain coverage.
- Objective 2: Foster the inclusion of mental, oral, and physical health in an integrated health care system.
- Objective 3: Increase system accountability by advancing the development and integration of quality standards and measurement protocols into primary care delivery models.
- Objective 4: Maximize the role of the safety net in an integrated health care system.
Goal 2: Strengthen leadership and network capacity to promote health equity in health care access and delivery.
- Objective 1: Cultivate diverse, skilled health equity leaders who advocate for and effect change in private, public, and nonprofit sectors.
- Objective 2: Advance public policies that promote health equity by establishing a health advocacy entity.
All of these goals and objectives were discussed at the workshop, which in part used the state of Connecticut as a case study to investigate the implementation of the ACA.
In the course of discussing these issues, it became clear that the detailed implementation of the ACA will be critical in achieving the objective of reducing health disparities. As Patricia Baker, president and chief executive officer of the Connecticut Health Foundation, said in her opening remarks at the workshop, “health equity could get lost in the scope, urgency, and
politics of health reform.” The many provisions of the ACA bear promise, she said, but “we all know that the devil is in the implementation details.” Connecticut was the location of the workshop so that the state’s experiences could serve as a “laboratory” for in-depth consideration of the issues associated with implementation of the ACA.
The workshop was widely attended by local policy makers, representatives from philanthropic organizations, journalists, health care professionals, academic researchers, and members of the interested public. The day was structured with four panels following the keynote speaker. As always, statements in this summary are those of the workshop presenters rather than the roundtable or the IOM.
For the purposes of this summary, the definition of health equity used in the planning and implementation of this workshop is from the Connecticut Health Foundation. “We see health equity not just as an aspiration, but as a framework for understanding problems and generating solutions that will help more people, especially populations of color, gain access to better health care.”1
The definition of health disparities used in this summary is that used in the IOM’s 2003 report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care: “racial or ethnic differences in the quality of health care that are not due to access-related factors or clinical needs” (2003, p. 4).
Connecticut has been a leader among the states in implementing the ACA, said Governor Dannel Malloy, who spoke at the workshop’s opening session. It has developed a state-based exchange, has supported the expansion of Medicaid, and has taken other steps to expand health equity among Connecticut residents. As a result of these and other initiatives, 170,000 to 200,000 of the 286,000 to 344,0002 uninsured people in Connecticut will be eligible for credits or Medicaid in gaining health care coverage (Connecticut Health Policy Project, 2012).
“We cannot afford to provide health care in the same manner in which we have delivered it.”
—Connecticut Governor Dannel Malloy
2 Estimates of the number of uninsured in Connecticut vary according to different data sources.
“Preparing the state’s health care system to provide much greater access to medical care for that many people raises questions of capacity, timeliness, and expense,” said Malloy. In the past, many of these people have relied on emergency rooms. Individuals and institutions alike will therefore need to learn a new set of behaviors on how to access the health care system and how to maneuver through it. “This is going to take a tremendous amount of time and effort on everyone’s part.” However, the current system imposes expenses on those who are insured, those who are not insured, and the institutions that provide care. “We cannot afford to provide health care in the same manner in which we have delivered it over the past many years,” said Malloy.
Connecticut, like other states, has constrained finances, Malloy said, which “gives real urgency to the work that we’re undertaking.” The state is nearing the limits of its ability to match the services that it wants to give its citizens with the services that it can afford. “Implementation of this law gives us an opportunity to stay on par with where we would like to be,” said Malloy.
Implementation of the ACA will require that everyone knows about the act, said Nancy Wyman, the lieutenant governor of Connecticut, in her opening remarks at the workshop. That will require a large-scale outreach effort that encompasses everyone in the state. “We have to get into the churches, we have to get into the streets of Hartford and New Haven and Bridgeport, and make sure that all people know that this3 is available.” At the same time, the state will need to control costs through partnerships and through efficiencies in implementation, she added.
“We have to get into the churches, we have to get into the streets of Hartford and New Haven and Bridgeport, and make sure that all people know that this is available.”
—Lieutenant Governor Nancy Wyman
Congressman John Larson, representative from the First District of Connecticut, noted that the ACA continues to face political headwinds. The politics of health care is “not for the faint of heart,” said Larson, who was instrumental in the legislation’s passage. “It is going to take the Institute of Medicine, concerned citizens, and everyone else to make sure that we understand the difficulty of the task at hand and the necessity to make sure that we get it right.”
3 Refers to health insurance under the ACA.
“It is going to take the Institute of Medicine, concerned citizens, and everyone else to make sure that we understand the difficulty of the task at hand and the necessity to make sure that we get it right.”
—Congressman John Larson
Over the course of the workshop, several themes emerged in the presentations of speakers and the ensuing discussions among workshop participants4:
- The ACA creates many opportunities to reduce health disparities through expanded coverage, reduced costs, improved quality, and other broadly based health care reforms.
- The ACA contains many provisions aimed specifically at reducing health disparities through measures such as enhanced data collection, greater workforce diversity, increased cultural competency, and health disparities research.
- The numbers of uninsured people in a state can be dramatically reduced, but doing so will require comprehensive and personalized outreach.
- Information technologies can provide powerful tools to increase insurance coverage and keep people covered.
- The concept of a patient-centered medical home offers multiple opportunities to advance health equity.
- Safety net organizations will continue to be critical to the reduction of health disparities under the ACA.
- The commitment of a state’s elected leaders is having and will continue to have a major impact on the state-by-state implementation of the ACA.
- Both bottom-up, community-based efforts and top-down policy leadership will be essential if the ACA is to succeed in reducing health disparities.
- Implementation of the ACA will encounter difficulties, but these difficulties can be expected to decline over time.
4 These themes are based in part on the concluding remarks of Antonia M. Villarruel, associate dean for research and global affairs at the University of Michigan School of Nursing and chair of the roundtable, and Patricia Baker at the workshop.
- Achieving health equity is a broader goal than reducing health disparities, but the ACA’s focus on health disparities represents a critical step toward equitable coverage and health outcomes for all Americans.
After this introductory chapter, Chapter 2 provides a general overview of the ACA and its potential to reduce health disparities. Chapter 3 summarizes the presentation of the workshop’s keynote speaker, Jennifer DeVoe, who delved into several major problems that the ACA addresses and potential ways of solving those problems. Chapter 4 examines the issues associated with patient-centered medical homes, which offer a particularly promising way to achieve greater equity in health care.
Chapter 5 examines the institutions that collectively serve as a safety net for patients and at the roles that they will play under the ACA. Finally, Chapter 6 provides four different perspectives on a critical aspect of the ACA: the need to engage the consumers of health care in the implementation of the act.