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Ensuring Equity: A Post-Reform Framework to Achieve High Performance Health Care for Vulnerable Populations

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.

The Post-Reform Health Care Environment for Vulnerable Populations

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.

Care Systems
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.

Community Resources
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.

A Policy Framework for Moving Forward

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:

  • Creating enough willing providers for Medicaid beneficiaries. There is a shortage of providers, particularly specialty providers, to care for Medicaid beneficiaries. To some extent, these shortages may be reduced through more efficient and effective models of referral and care coordination. Underlying barriers can potentially be addressed through payment reforms that financially reward provider networks for delivering optimal care to Medicaid beneficiaries (e.g., Medicaid accountable care organizations (ACOs), or ACOs that include Medicaid providers; Medicaid health homes and medical homes; and enhanced payments for caring for vulnerable populations); through more equitable Medicaid payment rates; and through other policy levers, such as requirements relating to Medicare Conditions of Participation or nonprofit status, to encourage provider participation in Medicaid. Additional efforts may be required to develop the workforce pipeline, such as an expansion of medical education debt relief for primary care providers, specialists, dentists, and others practicing in health centers, safety-net hospitals, and medically underserved areas. Ensuring adequate and high-quality provider networks for vulnerable populations may also require helping providers to develop the capacity to care for and meet the complex needs of vulnerable populations; an example might be supporting networks of shared resources among communities of safety-net providers.
  • Making insurance more stable, so that gaps and abrupt changes in coverage can be reduced. Vulnerable individuals are at risk for significant disruptions in their care when their income or employment changes, often because it could alter their eligibility for subsidized insurance. This could be a particular challenge when transitions occur between Medicaid and private health plans in the exchanges. There are a number of possible steps that can be taken to ensure continuity of care: guaranteeing year-long coverage periods, providing access to the same insurance plans in exchanges and in Medicaid, merging small-group and individual exchanges, placing a high priority on coordinating eligibility and enrollment for all forms of subsidized insurance through the exchanges, and ensuring that adequate numbers of essential community providers are included in both Medicaid and the subsidized plans.
  • Affordability and protection from high out-of-pocket health care costs. Even if health insurance premiums are made affordable, low-income families and patients may remain at high risk for medical debt or unable to access medical services if there are major gaps in plan benefits or high cost-sharing. To protect consumers from excessive out-of-pocket health care costs, insurance benefit designs should have positive incentives to use more-effective care and have reasonable income-related limits on overall out-of-pocket cost exposure.

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:

  • Ensuring the financial stability of the safety net while stimulating higher performance. We believe that the traditional safety-net system—including health centers, clinics, and hospitals serving a high share of uninsured and Medicaid patients—will continue to play a critical role in our health care delivery system by serving local communities with comprehensive, high-quality care. These organizations will continue to furnish access to those people who remain uninsured. Steps need to be taken, especially in the current rapidly evolving health care environment, to ensure that adequate resources remain for the safety-net system to continue to deliver services to vulnerable populations. These may include maintaining and/or consolidating current funding streams and re-examining reimbursement formulas. That said, financial resources must be used to maintain, stimulate, and reward higher performance among safety-net providers.
  • Promoting greater clinical integration in safety-net health care systems. The clinical integration of services across settings—clinics, hospitals, specialty care providers, and long-term care facilities—is essential for the delivery of high-quality, coordinated, efficient care. This is true whether integration occurs within the context of an actual integrated health care delivery system or it is achieved less formally. Efforts should be made to promote greater integration through payment reform and regulatory changes that explicitly encourage collaboration and affiliation, both among traditional safety-net providers and with other health care providers and systems in low-income communities. Safety-net providers should also be encouraged to participate in, and the federal government and state Medicaid programs should promote, emerging efforts to establish accountable care systems that serve vulnerable populations.
  • Focusing on comprehensive, coordinated, team-based primary care for all providers serving vulnerable populations. Care delivery models for vulnerable populations should reflect the most effective strategies identified by the latest empirical research. There is evidence that much of the disparity in care experienced by vulnerable populations could be eliminated through the provision of patient- and family-centered primary care that emphasizes team-based care, care coordination, care management, and preventive services (e.g., care delivered through health homes and patient-centered medical homes). 

    It is important to note that providers serving vulnerable populations need to be especially capable of managing conditions and circumstances that are disproportionately prevalent within vulnerable populations, among them chronic disease, disability, mental illness, substance abuse, pregnancy, and low health literacy. The integration of medical care and mental health care delivery within Medicaid will be especially important. In addition, provider and patient incentives, together with technical assistance and supports, can facilitate the adoption of appropriate care models for vulnerable populations, including those with long-term care needs. The effectiveness of such incentives will be maximized through the participation of both government and private payers and the alignment of their incentives. Additionally, efforts may be needed to increase the number of physicians and allied health professionals available to deliver such care.

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:

  • Fostering an infrastructure of community-based support services. Because of the non-health services that many vulnerable individuals require to fully access and benefit from the health care system, all providers serving these populations should be able to link their practices with community-based services, including transportation, language interpretation, social services, housing assistance, nutritional support, and legal services. Additional evidence needs to be generated to identify the most effective ways to link to and deliver these services.
  • Aligning efforts between the health care delivery system and public health services. Many of the medical issues that disproportionately affect vulnerable populations, such as obesity, diabetes, asthma, depression, and smoking-related illnesses, can be prevented or mitigated with effective public health and community-focused strategies. To develop effective approaches for improving population health, providers serving vulnerable populations and state and federal government agencies should promote coordination between the health care delivery system and local public health resources and programs.

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.

Publication Details



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.