Exchanging Health Care Disparities for Equity

In 2019, the population receiving insurance through exchanges is projected to be 25 percent Hispanic, 11 percent black, and about one in four individuals will speak a language other than English in the home. But health insurance exchanges aren’t just an opportunity for these groups to access health coverage; exchanges are a chance to make a dent in health care disparities by shaping the health care that these groups receive.
The ACA and resulting regulations create minimum standards for Qualified Health Plans (QHPs) offered through health insurance exchanges. States can make tighter rules regarding provider networks, language access, cultural competency, and data collection by raising QHP standards.  Setting higher standards in these areas can help to ensure that health plans will meet the needs of minority populations within the state. Exchanges won’t be operational for more than a year, but many state Medicaid agencies have already used enhanced requirements with managed care organizations (MCOs) as a way to improve health equity. Health insurance exchanges may benefit from the experience of these Medicaid agencies, in setting QHP criteria.
Provider Networks: Having the right providers in a network can help minority patients, who may have lacked access to such providers previously, avoid using the emergency room when care can be better delivered in other settings.

• New Mexico ensures access to a diverse range of Medicaid providers experienced in care to the underserved by requiring that plans contract with safety net clinics and providers for Native Americans. Contracts for the Medicaid managed care program “Salud!” require that plans contract with Federally Qualified Health Centers, Title X family planning clinics, and all Indian Health Service clinics, tribal providers and urban Indian health centers. New Mexico also runs a successful demonstration project in which it reimburses managed care organizations for community health workers (or promotoras) who help patients navigate the health care system.
• Minnesota has also used contracting to ensure sufficient provider networks for racially and ethnically diverse and underserved populations. The state Medicaid agency requires all health plans to contract with all “essential community providers” (ECPs) that fall within their geographic area of service. Minnesota ECPs are health care providers that predominantly serve high-risk, special needs, and underserved individuals. This requirement is more stringent than a similar provision in the ACA, which requires that QHPs offered in state exchanges include a “sufficient” number of ECPs in their provider networks.

Language Access: With more and more people speaking a language other than English in the home, language differences are a big challenge for patient-provider communication.  The exchange can develop language guidelines to make sure that individuals get the information they need.

• In California, linguistic diversity led the Medicaid agency to develop a unique formula for threshold languages. If there are 3,000 enrollees in a county, 1,000 in a single zip code, or 1,500 in two contiguous zip codes speaking the same language, health plans must translate official documents into that language. Oral interpretation must be provided to all limited English proficient persons on a 24-hour basis, and plans must also assess and report on the language capabilities of its staff to encourage diversity and ensure language access.

Cultural Competence: Cultural beliefs and practices influence health behavior. Including cultural competency requirements in contracts may shift the way health plans and providers communicate with consumers and transform the health care experience for minorities.

• Kansas Medicaid contracts require that health maintenance organizations (HMOs) incorporate in their policies and services the values of (1) honoring members’ beliefs, (2) sensitivity to cultural diversity, and (3) fostering communication techniques that respect members’ cultural backgrounds. HMOs also are required to communicate these policies to subcontractors and foster cultural competency among providers.

Data Collection: Data collection and analysis allows states to refine quality-improvement strategies that target the needs of the population. New ACA data-collection standards for race, ethnicity, and language provide a blueprint for exchanges and enable states to measure and respond to health care disparities.

• In 2004, Michigan participated in a Health Resources and Services Administration pilot with three of its Medicaid MCOs, and tried to track and reduce health disparities among racial and ethnic groups. The MCOs were required to collect and report data on race and ethnicity in order to isolate differences in treatments and outcomes between groups.  Due to the initial success of the pilot, Michigan has expanded the requirement to all Medicaid MCO contracts in the state.

Developing these types of provisions in contracts with health plans can change the way health plans and providers interact with patients and ultimately the way minorities seek and receive health care. Does your state exchange expect to use contracting standards around provider networks, language access, cultural competency or data collection to improve health equity? Let us know in the health equity discussion page or in the comments below.
Special thanks to Amanda Richardson, former CDC Fellow at NASHP, for her initial research on this topic.