This month, in celebration of the Department of Health and Human Services Office of Minority Health’s National Minority Health Month, advocates, providers, communities and other key stakeholders are working to raise awareness about racial and ethnic health disparities across the country and the role that social determinants play in advancing a health equity agenda for vulnerable populations. Social determinants of health are “the structural determinants and conditions in which people are born, grow, live, work and age.” They include factors like socioeconomic status, education, the physical environment, employment, and social support networks, as well as access to health care.

Getting Local: Partnering for Community Health

In step with this broader understanding of how social determinants influence health equity, Community Catalyst’s Children’s Health Initiative recently launched a new project, Partnering for Community Health. The project works in multiple states focusing on building the capacity of local community efforts while connecting them with state health advocates to improve health equity outcomes through community collaborations. Through these collaborations, the community organizations can inform state advocates on Medicaid and social services policy needs, including Medicaid defense. In March, Community Catalyst staff visited Shelby, North Carolina, one of the project sites, to meet with the local leadership partners Benchmarks and NC Child and other organizations engaged in this work. The experience reminded us of the richness of local work and that advancing health equity is about consumer engagement at every level—starting with the individual up to the system.

Shelby, NC: A Snap Shot

In Shelby, Sun Drop is the local soda - a high octane version of Mountain Dew with a hint of pulpy orange juice - and it personifies Shelby. Shelby is not unlike many small towns in the South - it has a warm familiarity with an extra jolt of something special. In Shelby, folks know each other and, if they don’t, they’ll ask your family name and try to find the connections quickly. The Shelby community feels like family. For instance, one of our hosts, Chris, (the project’s “community quarterback”) could barely sit down for lunch because family and old coworkers were constantly pulling him aside to catch up at the restaurant where we were eating.

In Shelby, the impacts of social determinants of health are ever-present at Graham Elementary School. According to the Robert Wood Johnson Foundation’s Country Health Rankings & Roadmaps, Cleveland County, where Shelby and Graham Elementary reside, ranks 89th out of 100 in the state for health outcomes.  As evidenced by the school’s attendance zone, Graham Elementary School includes most of Shelby’s low-income housing communities and these class and racial differences could be impacts of student health outcomes. Social determinants of health research show the greater one’s income, the lower one’s likelihood of disease and premature death. Race, racial prejudice, and race discrimination also impact health outcomes.

These determinants have jump-started this school into being a hub of change as a community school, where it serves an integrated focus on academics, health and social services, and youth and community development and engagement. This charge started with the school’s principal, who can easily identify where the fixes need to happen, and then makes them happen. Even her efforts to turn a pile of dirt into a welcoming grassy entrance have made a world of difference. And she hasn’t stopped there. In fact, she was late meeting up with us during our site visit because she was helping a student’s mother get to a counseling appointment. It’s this natural ability to see opportunity to address the things that impact student health outcomes that makes Graham Elementary a prime location for aligning services and supports to address social determinants of health. For our state partner, NC Child, their engagement with the community informs their Medicaid defense advocacy, understanding that Medicaid services are of primary importance to people in communities like Shelby.

Outside of Graham Elementary, the Shelby community is fueled by positive energy that will make the community school project successful in further advancing health equity outcomes in the next three years. It’s this energy that allows the community to recognize and realize health equity every single day.

Communities as Change Agents

From our short tour of the community work in Shelby, it is a clear reminder that communities have a key role to play in reducing health inequities for vulnerable populations and in paving the way for innovative approaches that connect children and families to the health and social services they need to be healthy. State advocates will be instrumental in deepening their engagement with communities, too – learning from their work and advocating for the tools that they need to be successful. We are excited to support this collaboration each step of the way.

During this tumultuous time in our country’s history, when the President of the United States is sowing division and fear by scapegoating immigrants, shutting America’s doors to desperate refugees and demonizing people of the Islamic faith, advocates in Maryland are doing their part to, as George Costanza from “Seinfeld” would say, “do the opposite.” 

The Maryland Citizens Health Initiative (MCHI) has been working for the past two years to create the Maryland Faith Health Network, a pilot project with the LifeBridge Health system that is based on the successful Congregational Health Network in Memphis, TN. The Maryland Network connects the three hospitals in the LifeBridge system with trained volunteers from local faith communities to work together to better serve ailing members. So far, MCHI is working with over 65 congregations, including the Muslim Community Cultural Center of Baltimore (MCCCB), where Earl El-Amin serves as the Imam.

Visiting MCCCB, one is struck by its peaceful surroundings in an urban park. As you make your way up the steps, two deer pose on the lawn. The MCCCB board meets in the Center’s library, a work of love that was built by one of their members who is a retired teacher. Expressing the same concerns and frustrations as every other congregation with which MCHI has met, the MCCCB board talks about how difficult it can be for congregations to know when their members are in the hospital. Sometimes members forget to call and then wonder why nobody from the congregation visited them. The Maryland Faith Health Network provides a way to bridge this gap.

Abdul-Rahmaan Waajid serves as the Faith Liaison – the connective tissue – between the LifeBridge hospitals and the MCCCB congregation. With the patient’s permission, when a member of the Network is admitted to the hospital, LifeBridge will call Mr. Waajid, who then coordinates visits, phone calls, transportation, and other needs that arise during recovery. A National Registered Paramedic, Mr. Waajid is passionate about CPR training and making sure that people are prepared to help during a crisis.

Even as some find it convenient to divide us from our neighbors of other faiths or ethnicities, the Maryland Faith Health Network is doing the opposite. It is reaching out to people of all faiths and providing them with a way to pull together to help one another through a crisis. This is real leadership. This is what makes America great. George Costanza would be proud.

Stephanie Klapper is the Deputy Director for Community Outreach at the Maryland Citizen’s Health Initiative.

Members of Congress spent the last two weeks at home in their districts hearing once again from their constituents that Republicans’ repeated attempts to repeal the Affordable Care Act and gut Medicaid is not what they want. Facing continued public pressure to answer tough questions about how constituents will be able to access and afford life-saving care, some members, like Florida Congressman Brian Mast, went so far as to offer continued support for retaining the ACA’s provisions that prohibit insurers from charging people with pre-existing conditions more for their coverage. Apparently, Republican leaders in the House of Representatives weren’t listening.

Last night, an amendment to the American Health Care Act (AHCA) surfaced as an alleged deal to bridge the gap between the party’s more moderate members, who are concerned about weakening benefits and striping coverage from their constituents, and members of the Freedom Caucus, whose primary concern is reducing the federal deficit even if that means increasing the number of uninsured people by 24 million.

We don’t have many details about this amendment beyond this outline, but here’s what we can conclude:

  1. It keeps intact the cuts to Medicaid totaling $880 billion, despite vocal opposition from stakeholders like hospitals, providers and state policymakers.
  2. It allows states to get rid of the essential health benefits, which would take us back to the days of plans without coverage for maternity care, substance use disorders or mental health services. This means, for example, that women will have to pay more for coverage that actually meets their health care needs.  
  3. It gives states the option to restore the pre-ACA status quo and charge people with pre-existing more for their coverage if the state establishes a high-risk pool or participates in the federal high-risk pool under the AHCA. This would dramatically decrease the affordability of plans for people with pre-existing conditions and would lead to premium increases upwards of tens of thousands of dollars for coverage that is unlikely to meet their health care needs.

Protecting people with pre-existing conditions is undoubtedly one of the most popular provisions of the ACA, and allowing states to take away these key protections only makes this bad bill worse. The Trump Administration and Republican leadership have proven once again that their only interest is to pass a bill for a political win so that they can move on to the rest of their agenda.

Let’s keep reminding them that this bill is terrible for consumers, and it’s time to move forward in a bipartisan way to improve the ACA, protect and strengthen Medicaid, and advance a health reform agenda that addresses the real needs of their constituents!

Recently, the Medicare-Medicaid Coordination Office (MMCO) released three new evaluation briefs on the Financial Alignment Initiative (FAI), demonstrations designed to test models of care with states that align Medicare and Medicaid financing and services – medical, social, behavioral and long-term services and supports (LTSS) – for the dual eligible population. Currently there are a total of 13 states participating in the FAI. This initiative came into being thanks to the establishment of the MMCO through provisions of the Affordable Care Act (ACA). As these three briefs outline, these innovations are now starting to show promising preliminary results. A summary of all three briefs is available here.

With every sign from the current administration and leadership in Congress pointing to continued efforts to either roll back or undercut progress on so many fronts made possible by the ACA, it is important to monitor and evaluate ACA-established innovations that are demonstrating benefit to health care consumers, especially some of our most vulnerable populations. In addition to highlighting progress, these evaluations are also important in order for stakeholders and advocates to learn from the challenges outlined, as we work to create a system that is responsive to the needs of consumers.

The evaluation briefs discuss beneficiary experience in the FAI overall, early findings on care coordination (which is the foundation of the FAI) and special populations enrolled in two of the early demonstrations. The latter brief evaluates the experience of three sub-groups of enrollees in the demonstrations in Massachusetts and Washington state: those who are using LTSS, both at home and in institutions; enrollees with behavioral health needs, including those with serious and persistent mental illness; and people from linguistic, ethnic and racial minority groups.

The methods used for evaluation were a mix of beneficiary focus groups, including a few Black-only and Hispanic-only focus groups to identify any unique experiences of racial, ethnic and linguistic minorities enrolled in the demonstrations; interviews with key stakeholders such as state officials, federal officials, health plans and consumer advocates; data from the CAHPS survey and from the required reporting by states and health plans.

As we celebrate National Minority Health Month in April, it is also worth noting the elevation of health equity in the evaluations. A high proportion of dually eligible consumers who are served by these Medicare-Medicaid demonstrations are from communities of color. The evaluation findings suggest that while interpreter services were available for care coordination services when needed, it is more helpful when care coordinators are bilingual. Similarly, the evaluation also reports that Limited-English-proficient (LEP)enrollees valued having providers who spoke their language, which influenced their selection of and satisfaction with their demonstration health care provider network. In addition, many focus group participants spoke of cultural preferences and the need for their care coordinator to receive training to be sensitive to these preferences. For example, two participants in the Washington demonstration said some Hispanics are averse to discussing certain medical procedures and end-of life planning.

Beyond health equity, other key findings from the three evaluations included:

Beneficiary Experience findings:

  • Overall, enrollees have greater access to a broader and more flexible range of services, including home care and home modification services
  • A majority of beneficiaries report improved quality of life and a more coordinated and patient-centered approach to their care
  • Beneficiaries continue to experience issues regarding limited access to providers (including behavioral health providers), particularly regarding the size and scope of provider networks

Care Coordination findings:

  • Plans contracted to be part of the FAI reported investing heavily in hiring linguistically and culturally competent staff and in providing training to care coordinators on the needs of special populations, such as enrollees with Alzheimer’s disease and other dementias
  • In the early implementation phase of the FAI, beneficiaries lacked understanding and awareness of the care coordination benefit, but this has begun to improve
  • Care coordination workforce experienced significant turnover, and there was a need for additional training given the large volume of passively enrolled beneficiaries in the FAI
  • Many beneficiaries who understood their care coordinator’s role reported satisfaction with the relationship

Special Populations – MA and WA:

  • Findings show that demonstration services have helped at least some beneficiaries achieve a wide range of improvements in their lives, from managing chronic conditions to increasing community engagement
  • Focus groups reveal that care coordination was generally helpful; but many beneficiaries had difficulty differentiating between their care coordinator and other services or were unaware of a wide range of supports available
  • Patient-centered care and patient engagement is important to focus group participants, but some indicated they had difficulty finding providers with whom they felt comfortable

Regardless of where the efforts to protect and improve health care take us in the coming months and years, the evidence is beginning to show that innovative models of care hold promise and need to continue. We encourage CMS to continue to evaluate the consumer experience in the FAI, including how consumers are involved in their health care as well as understanding the impact of their role in health plan consumer advisory councils, which were required under the demonstrations.  

The findings from these evaluations start to weave a story together of what an effective model of care can look like for vulnerable populations and emphasize the importance of investing in those good models of care. Let’s amplify the consumer voice and most importantly engage consumers in their care and in the health care system.

"What's My Motivation?"

As a reality TV star playing himself, President Trump probably never had to rely on "method acting.” But as the White House and the House Republican leadership scramble to put their Humpty Dumpty health plan together again, one might reasonably inquire as to their motivation. After all, both the president and Speaker Ryan declared they were moving on after the debacle (for them) on the House floor last month. 

It is possible the president doesn't want the notoriety he gained from his star turn on “The Apprentice” to be superseded by a new reputation as "the biggest loser." But there is really no need to turn to armchair psycho-analysis to explain the hard pivot back to health care since the president has helpfully made his motivation clear. It is almost as if someone explained to him that the big tax cut for the wealthy he is trying to enact would not be possible unless he funded it by raiding the funding for health benefits for millions of children, seniors, people with disabilities and working families. We really don't have to speculate on this point. The president's public statements have made his Robin-Hood-in-reverse- intentions all but crystal clear. For example, just recently he said in the Wall Street Journal: “If the health plan is signed, ‘we get hundreds of millions of dollars in savings that goes into the taxes,’…”

And Speaking of Motivation

The president also apparently believes that he can motivate Congressional Democrats to aid him in this wealth transfer to the top by threatening to blow up the non-group insurance market if they don't play along. The incendiary device he is threatening to detonate would be to drop the administration's appeal in House vs. Price.

This is the lawsuit the House filed against the Obama administration alleging that, in the absence of an appropriation, it was improper for the administration to reimburse insurers for the cost-sharing reductions (CSRs) they are required to give to certain low- and moderate-income Marketplace enrollees. The insurers are required to provide the CSRs regardless of whether the federal government reimburses them. However, unless it is clear the reimbursement will continue, many carriers might decide to abandon the marketplaces and leave people without affordable insurance options. Even if they choose to stay, the loss of federal payments could force insurers to raise premiums by about 20 percent to make up for the loss. This in turn would make coverage less affordable for people who are not eligible for Premium Tax Credits, meaning fewer (and sicker) people would be insured.

Of course, the administration cannot carry out this threat on its own. It requires collusion from Congress. If the Republican leadership in the House and Senate decide to appropriate funds for the cost sharing subsidies, then the final outcome of the lawsuit will not affect insurance premiums.

We don't know what Congress will do or whether the administration will make good on their threat. However, one thing we do know is that in addition to being cruel and irresponsible, the tactic is illogical and doomed to failure. It is more likely to blow up in the faces of the administration and congressional Republicans than it is to motivate the Democrats to capitulate.

To understand why, go back to the initial observation that the effort to resurrect the GOP healthcare bill is motivated by Republicans’ desire to redirect funds away from health benefits to pay for tax cuts for the rich. Starting from this premise means any resulting bill must necessarily inflict a lot of pain on many of people. In essence, Trump has said to the Democrats in Congress, "I've taken the people who have non-group insurance hostage, and I'll undermine their health benefits unless you help me undermine the health benefits of a much larger number of people, especially those on Medicaid."

This is obviously bad deal on its face. And far from rushing to rescue the Republicans from their own folly, Democrats are rushing to defense of the CSRs. Democrats are demanding tCongress approve the funding when it returns from recess to complete the 2017 appropriations process (funding for many government operations runs out April 28th and must be extended to avoid government shutdown).

A Motivated Public

In fact, there's no evidence the Democrats are even slightly tempted to aid and abet in the effort to hijack people's health benefits. But even if they were, the fact that their colleagues across the aisle are continuing to get pummeled back home for their attack on health care is a powerful disincentive.

The bottom line is Republicans have badly miscalculated. They have tried to bootstrap people's dissatisfaction with specific shortcomings of the ACA into a more generalized attack on the health security of millions. But people aren't buying it. The number of people who would be hurt if something like AHCA were to become law far exceeds the 24 million who would lose coverage. It includes their families, the health care workers who would lose jobs, and the health care providers who would face a drop in revenue and a spike in uncompensated care – especially those who live in rural areas. Not only is the Republican health care plan wildly unpopular, but, by a 2-1 margin, polls show voters will blame the Republicans for the damage they are trying to cause.

So what happens next? The Democrats have not (yet) actually gone as far as saying they would shut down the government if CSRs are not funded. Nor have they ever said they would not negotiate with the Republicans on health reform. But one thing is clear: Thanks to the popular uprising in defense of health care, the precondition of any negotiation must be for Republicans to abandon their effort to use health benefits as a piggybank to pay for tax cuts.

With thanks to Quynh Chi Nguyen, policy analyst, for her assistance.