Faces of Public Health: Dennis Andrulis
In January 2008, the Texas Health Institute received support from the Joint Center for Political and Economic Studies, a policy think tank with a particular focus on people of color, to track progress on efforts to advance racial and health equity through provisions of the Affordable Care Act (ACA). Shortly after the ACA became law, new support from the W.K. Kellogg Foundation and the California Endowment has led to a series of four reports that have assessed how well the law has been implemented in a way that addresses racial and ethnic health equity across five topic areas:
- Health insurance and exchanges;
- Health care safety net;
- Workforce support and diversity;
- Data, research and quality; and
- Public health and prevention.
To learn more about the reports’ findings, NewPublicHealth recently talked with Dennis Andrulis, PhD, MPH, the Senior Research Scientist at the Texas Health Institute and an Associate Professor at the University of Texas School of Public Health.
NewPublicHealth: How have the reports produced by the Texas Health Institute helped advance what we know about the ability of the Affordable Care Act to advance health equity?
Dennis Andrulis: The reports have provided an update of the progress, or lack thereof, in implementing race, ethnicity, language and equity provisions in the law. Did Congress appropriate dollars to support these provisions? If so, did the appropriations match the original requests and will they continue in future years?
The result is we have mapped out what we believe is a comprehensive overview of about 60 provisions related to health equity. Additionally, we have reported on the content and shape of related new initiatives, innovations, program support and other health care efforts.
NPH: What are some short-term and long-term efforts that your work indicated will help improve some health disparities?
Dennis Andrulis: First we need to have accurate and well-disseminated information about what’s in the law and the opportunities to change disparities that it provides.
We think foundations can play a major role at identifying and filling gaps. For example the W.K. Kellogg Foundation has recognized that the oral health disparities provision within the law was authorized but never really funded. So they’re providing strategic funding assistance to advance part of the agenda for reducing oral health disparities.
We’re also finding there is a great need for local and state agencies to get help their communities’ safety net to transition from a world of uncompensated indigent care to one where they can actually get compensated, meaning they may very well find themselves in more of a competitive environment or an environment that requires updating of much of their infrastructure.
Another area is building on the community-based initiatives and engaging and reaching diverse communities including Community Transformation Grants that have the potential to address barriers to improving health in the places where people live and work. Another critical opportunity is the community needs assessment requirements in the Affordable Care Act for non-profit health systems to conduct assessments on the health of their communities and then to come up with strategies by which they will address identified needs. Another important priority that often gets much less attention is development of metrics, measurement and monitoring to assess progress in reducing inequities. What kinds of metrics are being used to assure that the intent of the law is realized, for example?
NPH: How do your reports complement the disparities report released last year by the Centers for Disease Control and Prevention?
Dennis Andrulis: What we’ve developed is, I would say, a financial portrait as well as a structural, qualitative, process and content assessment. Some of the data in the CDC report complements ours by providing some key data. The CDC’s report also highlights where some of the major challenges remain. What our reports can do is offer the opportunity to look at the progress on those challenges of implementing the law.
For example, there are certain provisions that are intended to specifically address chronic diseases. The first step is to be able to identify and match up if there are major disparities occurring, how the law specifically or indirectly addresses those equity disparities issues. The next step is to look at whether those provisions of the law were actually funded and implemented. For example, have appropriations been allocated, and if so at what level? Then we look at what the level of work is right now—is there research under way, have policies changed, or are we moving to provide different services?
The report has implications for advocacy, for policy and for programs.
NPH: What’s next for the Texas Health Institute on the issue?
Dennis Andrulus: There have been two interesting developments as a result of our work. First, our design, reach and results have piqued the interest of national and state based organizations to learn about and expand on our work. Several foundations have asked us to address strategic concerns with specific states, as well as specific issues. For example, the Blue Shield California Foundation has now funded us to develop a report on safety net innovation and adaptation to assist the California safety net settings during this time of transition. Our work will bring lessons learned from settings and systems from across the country to provide new resources and ideas aimed at assisting California safety net hospitals in adjusting to new populations, responding to increased competitive demands and accountability and improving quality.
The San Francisco Foundation is supporting a review of navigator programs that help people understand and sign up for the Affordable Care Act, and the Sierra Health Foundation is interested in conducting a community forum that would inform local constituents about the ACA’s equity-related opportunities and challenges. Finally, and more broadly, we are also continuing to monitor implementation of the law and these equity provisions across states and communities, highlighting adaptations, adjustments and continued progress made in marketplaces, among safety net providers, in workforce capacity and public health and in improving quality as these actions affect equity.
One special point of focus is creating a report card on the equity provisions and actions of the marketplace, giving states and constituents the opportunity to assess and compare progress along five dimensions: leadership and governance; exchange design; navigator and assistance programs; training, outreach and enrollment efforts; and measurement and evaluation. We will continue tracking and reporting out progress in implementation of the law’s equity vision and provisions.
NPH: Do you think the entities charged with making the Affordable Care Act work are keeping enough of a focus on health equity?
Dennis Andrulis: That is something we are keeping our eye on. Equity at its core really is fundamental to the success of the law and we think the marketplace and the Medicaid expansions should be reflective in the number of diverse populations who are enrolled or have become eligible for Medicaid. One of the major concerns we’ve found in our discussions with people across the country is that equity is not a priority, with concerns around launching exchanges or expanding Medicaid as well as other priorities taking precedence.
But it seems to us that these efforts will be successful only if diverse populations and their communities actively take part in them and really understand the process and benefits. So, if you’re not paying attention to equity, how can outreach or communication with individuals with limited English proficiency or low health literacy be successful? How effective can these programs be if competence in understanding and addressing cultural norms and needs is not a considered? What does it mean in terms of technology and its role? We’re beginning to see a bit more attention, but it’s still at a very low level. One of the intended outcomes of our projects is to raise that awareness, working to provide information that providers, policymakers and communities and their advocates can use—and by working to disseminate key findings through media, professional venues and other means. By our actions and others dedicated to eliminating disparities we will strive to assure that that equity will become a common part of the dialogue around the marketplace, around Medicaid and around other provisions of the law that were intended to improve health for all.