State policies promoting equitable access and quality
Policies, laws, regulations, and health care reform proposals in five statesCalifornia, Illinois, Massachusetts, Pennsylvania, and Washingtonare moving those states toward universal health coverage and also are addressing other innovative strategies such as improving health care provider diversity, distribution, and cultural competence. Researchers from The Opportunity Agenda and Families USA say that while legislatures and governors in nearly two dozen states are considering significantly changing their approaches to health insurance coverage and health system regulation, few of those reforms have focused on inequality.
"Millions of people in the United States, principally racial and ethnic minorities, immigrants, and those who lack proficiency in English, face barriers to high-quality health care," say Opportunity Agenda research director Brian Smedley and his colleagues. "Such problems derive largely from the high rates of uninsurance among these groups, but it persists among them even when they are insured. They simply tend to receive a lower quality of health care. But by expanding health insurance coverage and addressing issues of access, quality, and cost, state-level health reforms have the potential to address inequalitythat is, to achieve equality."
Key findings of his research identified by Mr. Smedley include: 1) universal health insurance coverage is necessary to promote health care equity, but is not sufficient by itself; 2) several states are addressing health care inequality through innovative means; and 3) more must be done.
While people of color make up just one-third of the U.S. population, they comprise more than half of the nation's 47 million uninsured individuals. But insurance coverage alone doesn't eliminate health care gaps, the researchers contend. Rather, states can make health care more equitable for disparity populations by:
- Improving access to health care. States can expand opportunities for low- and moderate-income families to purchase private insurance or enroll in publicly subsidized programs, and can establish mechanisms making it easier for people to find affordable insurance. But even when insured, minority and low-income individuals are less likely to access health care as out-of-pocket costs rise and are more likely than are native-born white Americans to face cultural and linguistic barriers to care. The study says states can address these problems by establishing limits on copayments and other out-of-pocket costs in public insurance, by studying and responding to potential unintended effects of cost-sharing on utilization, by taking steps to increase diversity among the state's health care providers, and by providing incentives for health care systems to reduce cultural and linguistic barriers.
- Improving the quality of care. States can provide incentives for strategies such as pay-for-performance programs, performance measurement, and report cards that can reduce health care disparities. They also can promote collection of data on health care access and quality by patients' race, ethnicity, income or education level, and primary language.
- Empowering patients. All patients should be able to make decisions about their health care and to demand delivery of care consistent with their needs, preferences, and values. Such goals can be pursued by developing and strengthening patient education and health literacy programs and by supporting training and reimbursement of community health workers who can help patients navigate the system.
- Improving the state health care infrastructure. Mr. Smedley says the relative lack of health insurance among racial and ethnic minorities is associated with lower levels of health care resources such as practitioners, hospitals, and health care centers in communities of color. And even if states achieved universal health insurance coverage, communities of color still would need investments to improve their health care infrastructure. He says states can address this situation by reducing the financial vulnerability of health care institutions serving poor and minority communities, by creating or broadening incentives for health care professionals to practice in underserved communities, and by requiring cultural competency training for health care professional licensure.
- Improving state program and policy infrastructure. The study found states can better align health care resources with minority community needs by gaining community input, by establishing or enhancing state offices of minority health to increase visibility and coordination of state health disparity-elimination programs, and by strengthening Certificate of Need policies as a tool for reducing geographic disparities.
- Adopting or strengthening policies to address social and community-level health determinants. Almost all aspects of state policy in education, transportation, housing, commerce, and criminal justice influence the health of state residents and can have disproportionate impacts on marginalized communities. Thus, states can address community-level and social determinants of health by coordinating the work of state agencies and by promoting use of health impact assessment tools to evaluate the potential effects of government programs and initiatives in and outside the health care delivery sector.
While the five states studied are addressing disparities in a variety of ways, some common policy strategies emerged. First, they are expanding access to health insurance products by reducing financial barriers to coverage. They also are improving and evaluating outreach and enrollment efforts. To better evaluate the success of their actions, they are collecting data on health care access and quality measures by patient demographics. Successful states also are supporting safety-net institutions and are improving health care provider diversity, distribution, and cultural competence.
Things not being done
Mr. Smedley says the analysis also found things states could have been doing, but were not. Thus, none of the five states is implementing plans that would result in truly universal health insurance coverage or access. Many groups such as single and childless low-income adults, undocumented immigrants, and even some legal immigrants are not eligible for new state public insurance expansions.
Only Pennsylvania has sought to strengthen local community input and direct resources to meet community needs. And only Washington has sought to strengthen Certificate of Need programs as a tool for regulating health care resources by linking approval with a statewide health resources strategy.
The researchers say there are a number of recommendations that should be considered by a range of stakeholders including state policy-makers, health professionals, health consumer and advocacy groups, health plans, and businesses in their efforts to achieve equitable health care for all. Their recommendations include:
- Making universal health care a core goal. Uninsurance contributes to escalating health care costs and access problems, even for those who do have insurance. Mr. Smedley says that only by covering everyone in the population can states eliminate uncompensated costs and strengthen the health care infrastructures of underserved communities.
- Assessing how policies to expand coverage affect currently underserved groups. The five states studied have used different strategies to expand coverage. The researchers say that states considering such strategies should monitor their impact and take steps to correct them should they have a disproportionately negative impact on marginalized populations.
- Being an agent for change. State governments can leverage the power of other public and private stakeholders to help eliminate health care disparities.
- Reaching for low-hanging fruit. Many of the policy strategies being used in the five study states can be implemented through regulatory strategies or contractual requirements rather than through legislation. For example, federal law requires states to identify the race, ethnicity, and primary language of Medicaid beneficiaries and to provide this information to managed care contractors. Such information can be used to generate reports on how plans are faring with respect to health care equity.
- Actively monitoring implementation of new health expansion laws. Almost all the equity-related policies examined in the study require ongoing monitoring to ensure they actually are addressing disparities.
Mr. Smedley tells State Health Watch the researchers deliberately took a very broad focus, recognizing that states will face different circumstances as they address issues of health care cost, coverage, and quality. "We're offering a broad prescription," he says, "and states should consider and tailor the items to their own circumstances. For instance, Massachusetts was able to move its 2006 sweeping changes because of the particular circumstances there. This is a menu of elements that states should consider based on the circumstances in each state."
He acknowledges the possibility that as some states move forward with reforms, other states may be left behind and the gap could potentially grow even deeper. "We would encourage all states to look to see what they should do to expand coverage and address inequity," he says.
Because the problems tend to be complex, Mr. Smedley says there is no single magic bullet that will make a difference in every state. For that reason, he says, it is important to have a multipronged solution, especially since it's not always feasible to do several steps at once.
A good foundational building block, he says, is data collection and monitoring as those results can show the way to next steps. Quality scores can be sorted and reported by factors such as race, ethnicity, and economic status. Such reporting also can spur competition among health plans to do better and can help consumers make better choices about where to get their health care.
The timing of the study and report was not accidental, Mr. Smedley says. States currently are showing significant leadership in the challenge to increase coverage and quality. In the absence of federal leadership and action, he says, states "are in a great position to address equity issues in broader health care reform." The report came out now, he says, because many states are seriously considering health care reform legislation and they should be aware that they can also address equity as part of broader reform issues.
Download the report at http://www.commonwealthfund.org/publications/publications_show.htm? doc_id=679040. Contact Mr. Smedley at (202) 339-9315 or e-mail [email protected].
Policies, laws, regulations, and health care reform proposals in five statesCalifornia, Illinois, Massachusetts, Pennsylvania, and Washingtonare moving those states toward universal health coverage and also are addressing other innovative strategies such as improving health care provider diversity, distribution, and cultural competence.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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