Edward L. Schor, Julia Berenson, Anthony Shih, Sara R. Collins, Cathy Schoen, Pamela Riley, M.D., Cara Dermody
E. L. Schor, J. Berenson, A. Shih, S. R. Collins, C. Schoen, P. Riley, and C. Dermody, Ensuring Equity: A Post-Reform Framework to Achieve High Performance Health Care for Vulnerable Populations, The Commonwealth Fund, October 2011.
The Commonwealth Fund Commission on a High Performance Health System has defined equity as a core goal of a high performance health system. However, in the United States, there has been a growing health care divide between vulnerable populations—defined in this report as people without health insurance, low-income families, and racial and ethnic minorities—and the rest of society. Decades of research has demonstrated that vulnerable Americans are more likely to be in poor health and to experience worse health care outcomes.
The Patient Protection and Affordable Care Act (Affordable Care Act) represents substantial progress in addressing the needs of vulnerable populations, most notably by expanding health insurance coverage and bolstering those parts of the health care system that serve the vulnerable. Yet significant additional work remains to be done. This report from the Commission examines the continuing problems facing vulnerable populations and offers a policy framework for moving forward. The framework features three overarching strategies to close the health care divide: 1) ensure that insurance coverage affords adequate health care access and financial protection; 2) strengthen the care delivery systems serving vulnerable populations; and 3) coordinate health care delivery with other community resources, including public health services.
Insurance Coverage, Access to Care, and Financial Protection
Through the expansion of Medicaid eligibility and subsidized health coverage through health insurance exchanges, the Affordable Care Act will significantly reduce the number of vulnerable individuals defined by insurance status. Extending health insurance coverage is a critical and necessary step toward equitable access. However, insurance alone is often not sufficient and does not guarantee access to high-quality care, particularly with regard to low-income families and racial and ethnic minorities. While Medicaid coverage is a vast improvement over no insurance at all, many states struggle to maintain, much less expand, an adequate network of providers for Medicaid beneficiaries. The Affordable Care Act addresses this in part by requiring Medicaid reimbursement for certain primary care services to be at parity with Medicare reimbursement for two years, but access to specialty care in particular remains a concern.
Further, among low- and moderate-income families, changes in income and employment can lead to changes in eligibility for subsidized insurance coverage, which can in turn create gaps in coverage. Such gaps and transitions in coverage can disrupt provider relationships and continuity of care. Likewise, low-income families may be at risk for abrupt changes in out-of-pocket costs for health insurance and health care when minor fluctuations in income place them in higher income-eligibility categories.
Access to care will also depend on how insurance coverage is designed—for example, whether it provides essential benefits and protection from high out-of-pocket costs, thus lowering the risk of medical debt and financial stress resulting from illness. The Affordable Care Act includes income-related provisions targeting affordability; it is important that these are implemented effectively to protect vulnerable populations.
Traditional safety-net providers—public and other mission-driven hospitals, as well as federally qualified health centers (FQHCs) and other community clinics—have historically played a critical role in providing otherwise unavailable or unaffordable care to vulnerable populations. Not only are safety-net providers able to deliver more affordable care, they are often better able to meet the complex social, cultural, and linguistic needs that are more prevalent within vulnerable populations.
In the current environment, many safety-net providers are struggling to sustain their operations and meet the increased demand caused by the economic downturn. Although the Affordable Care Act provides additional financial support to community health centers, the financial outlook for safety-net hospitals is much grimmer. Post-health reform, safety-net hospitals will receive new revenues from newly insured populations, countered by an anticipated significant drop in other revenue streams, such as disproportionate share hospital (DSH) payments from Medicare and Medicaid. For many providers, there will likely be a loss of net revenue that will not only endanger viability, but jeopardize access to care for individuals who remain uninsured post-health reform and for newly insured low-income populations whose special needs for targeted medical and social services are often better addressed by safety-net providers.
Safety-net providers also face the same issue as all other providers in the U.S.: health care system fragmentation that hinders their ability to deliver high-quality, high-value care. For those served by safety-net providers, fragmented care delivery is especially troublesome, as these patients tend to be sicker, have more complex medical and behavioral problems, and often require legal and other social supports. Vulnerable patients may disproportionately benefit from greater clinical integration among providers and from a focus on team-based primary care and population-based strategies to improve health. The Affordable Care Act has several provisions to stimulate delivery system reform across the entire health care system, but further steps will likely be necessary.
The health of low-income and minority populations is heavily dependent on resources outside the traditional health care system. These include not only services that enable them to fully access health care, such as transportation and language interpretation, but also environmental factors, such as access to healthy food, a safe home and workplace, and accessible places for exercise. In addition, traditional public health activities, such as infectious disease control and community vaccination programs, are often critical for the health of vulnerable populations.
The Affordable Care Act provides limited funds to strengthen the overall public health infrastructure, which has been under financial stress during the current economic crisis. Largely unaddressed, however, is the need for explicitly linking and aligning the health care delivery system with community resources and public health services for vulnerable populations.
If we are to achieve equity in our health care system, additional policy interventions are required to address remaining gaps in care for vulnerable populations post-health reform. To that end, the Commission on a High Performance Health System offers a framework to help guide the development of specific policies and practices that will be required to ensure vulnerable populations receive care from high performance health care delivery systems, ones that provide high-quality health care at a reasonable cost and achieve good health for all. The key tenets of the framework are:
1. Ensure that insurance coverage results in adequate access and financial protection. It is clear that insurance coverage is necessary but not sufficient to guarantee access. Key issues to address include:
2. Strengthen the care delivery systems serving vulnerable populations. Traditional safety-net providers and other providers serving vulnerable populations must strive to deliver high-performance care. Key issues to address include:
3. Coordinate health care delivery system efforts with other community resources, including public health services. Improving the health of vulnerable populations will require not only improving health care delivery systems, but also linking these systems with non-health service providers and aligning them with public health efforts. Key issues to address include:
The Commission on a High Performance Health System believes that this framework is only an initial step in closing the health care divide for vulnerable populations. Utilizing this framework as a starting point, the Commission will identify, evaluate, and offer specific policy recommendations in the months and years ahead. While we recognize that additional resources are scarce, it is imperative that we address the needs of our vulnerable populations, whose problems are exacerbated by current economic conditions. At the same time, not all of the policy solutions discussed in this report increase health care spending. Some, such as delivery system changes to promote clinical integration and foster team-based primary care, and better alignment of efforts between health care and public health, may even hold the potential of slowing the growth of health care spending in the future.
A core founding value of the United States is equality of opportunity to live a healthy and productive life. We believe that our nation can and must do better to care for our vulnerable populations, and we are committed to taking action to achieve this goal.