III. Expanding Access to Care
Standing by itself, expanding health insurance coverage is certainly a necessary condition for achieving health equity; but it is not a sufficient one. Communities of color face a host of additional barriers when seeking access to quality health care. For example, physicians who serve predominantly racial and ethnic minority patients have greater difficulties accessing high-quality specialists, diagnostic imaging, and nonemergency admission of their patients to the hospital than physicians serving predominantly nonminority patients. Nearly one in five Latinas (18%) and one in ten African-American women reported not seeking needed health care in the last year due to transportation problems, compared to 5% of white women. These problems are the by-product of residential segregation and economic pressures that reward the concentration of services in outer suburbs and wealthier communities, and create disincentives for practice in urban centers.
In addition, some empirical evidence suggests that having a usual source of care is more strongly associated with better access to and receipt of primary care services than is insurance coverage. Yet more than half of Hispanic adults report not having a regular doctor even when insured--a rate that is 2.5 times greater than the proportion of whites. Moreover, when compared to whites, Hispanics and African Americans are much less likely to receive care in a private doctor's office and more likely to seek medical care in community health centers or hospital emergency rooms.
A. Community Health Center Expansion
Hidden jewels in the new federal law are provisions that increase funding for community health centers (CHCs). The ACA provides $11 billion to bolster and expand CHCs over the next five years. Of this amount, $1.5 billion will support major construction and renovation projects at CHCs nationwide, while $9.5 billion will create new health center sites in medically underserved areas and expand preventive and primary health care services at existing health center sites (including oral health, behavioral health, pharmacy and/or enabling By 2015, CHCs will double their current capacity and serve 40 million at-risk low-income individuals and reach approximately one-third of those currently considered medically disenfranchised.
Doubling the capacity has powerful implications. CHCs are the essential primary care medical homes for millions of vulnerable Americans. Because two-thirds of the patient population is non-white, the expansion should significantly increase access for millions of individuals of color. Moreover, the total capacity of community health centers will for the first time ever exceed the total number of uninsured. This is nontrivial. It means that even those individuals who cannot obtain affordable insurance under the ACA will still be able to obtain health care. In fact, it's the CHC expansion that has the potential to fulfill the age-old progressive mission of health care for all.
Community health centers are an incredibly good investment because they bring a unique and comprehensive approach that has delivered proven cost-savings, improved patient health, and reduced visits to hospital emergency rooms for over 45 years. National estimates of the impact of CHCs on controlling health care costs played an important role in Congress' decision to invest in the health center expansion. Empirical evidence also strongly suggests that expanding CHCs will create jobs and stimulate economic activity in some of the most economically disadvantaged communities in the country. A consequential value of expanding CHCs is to increase the “dollar efficiency” of the health care reform legislation.
However, several qualifications are in order. As CHCs expand their range and reach, patients will need better access to a continuum of care, including specialty services. While CHCs are able to provide primary care, they report difficulty in connecting their patients to diagnostic testing and specialty care, even when patients are insured. Indeed, 79% of CHCs report difficulty in obtaining specialist access for Medicaid patients, and 60% reported difficulty for Medicare patients. Having access to a specialist is especially important for populations of color, since they have higher rates of mortality and disproportionately suffer from conditions such as HIV/AIDS, diabetes, heart failure, and stroke. As Medicaid eligibility and coverage expand, improved access and communication between specialty care providers, local hospitals, and diagnostic facilities are critical to coordinate patient care beyond a health center's walls.
While potentially serious, these issues and impediments are not insurmountable. Beyond merely investing in health center growth, the ACA provides numerous opportunities for these entities to enter into more integrated and innovative community-based partnerships that broaden and secure patient access to the full continuum of health care services. The legislation provides new funding for networks comprised of a hospital and a CHC to provide comprehensive, coordinated, and integrated health care services for low-income populations. In addition, it provides funding for hospitals to form patient-centered medical homes and allows for community providers such as CHCs to support primary care practices within the hospital service areas. Furthermore, it provides funding to establish or expand primary care residency training programs in CHCs and encourages their permanent placement in these settings.
Collectively, these initiatives reflect the priorities of the Health Resources and Services Administration, the federal agency that oversees the CHC program. The agency has emphasized that collaboration is critical to ensuring the effective use of limited health center resources, providing a comprehensive array of services, and gaining access to critical assistance and support.
B. Workforce Development
As the number of the newly insured expands, many of those who gain health insurance coverage will be catching up on long overdue health needs. This pent-up demand is likely to strain the nation's health care workforce, particularly in communities where primary care providers are in very low supply already. Labor analysts estimate that as many as 7,000 additional primary care physicians are currently needed in medically underserved areas.
The ACA takes key immediate steps to address the sufficiency of the primary care workforce. First, the legislation attempts to increase the number of primary care clinicians largely through loan repayment programs, training grants, and expansions in the National Health Service Corps Program The NHSC scholarship program covers tuition, fees, and costs for students enrolled in a medical degree program. After graduation, scholarship recipients are expected to work for up to four years as a primary care physician in an area of need. Nearly half of NHSC clinicians fulfill their service commitment at community health centers.
Second, the ACA provides direct financial incentives to primary care providers. As discussed in Part II of the Article, Medicaid payment rates for primary care physicians will be raised to the level of Medicare payment rates for equivalent primary care services in 2013 and 2014; this change is intended to encourage physicians who already accept Medicaid insurance to continue accepting it, and to persuade those who do not to begin accepting Medicaid. Between January 1, 2011, and December 31, 2016, the legislation increases Medicare Part B payments for primary care services and provides providers a 10% bonus for performing certain primary care services.
Third, the legislation envisions that the nursing profession will play a large and critical role in directly providing primary care services. The ACA dedicates additional funds for Nurse-Managed Heath Centers Community-based clinics run by advanced primary care nurse practitioners have grown over the past couple of years, providing a full range of primary care services that are comparable to services provided by primary care physicians. Over half of the patients seen at NMHCs are women of color that are likely to have unmet health needs. Evidence-based research has shown that these advanced practice nurse providers at NMHCs provide high-quality primary care and women's health with outcomes that are similar to or better than other primary-care care and women's health providers.
While these workforce initiatives could provide much needed help to communities of color, it is likely that additional efforts will be needed to address both the current health professional shortage, and the increased demand for services resulting from the new legislation. Training programs will likely take many years to increase the primary care workforce, but the need for these providers will be more immediate. Future policy options to expand primary care providers in medically underserved communities should include: increasing funding for the NHSC; continuing financial incentives for all primary care physicians practicing in shortage areas; and increasing payment levels to primary care physicians caring for Medicaid patients in the early years of health reform. However, given the austerity fever currently sweeping Capitol Hill, additional congressional appropriations of this sort are highly unlikely.
C. Essential Community Providers
The new federal law requires that health plans competing in the health exchange include in their network of providers “essential community providers” who serve predominantly low-income and medically underserved populations. Originated as part of the Clinton health reform plan, the term describes health care providers that through legal obligation or mission, and patient population characteristics, play a significant role in providing health care for patients and populations at disparate risk for inadequate access. Examples of patient populations reached by essential community providers include uninsured and underinsured persons, residents of medically underserved urban and rural communities that experience primary health care shortages, persons with HIV/AIDS, high risk pregnant women and newborns, and farm workers and their families. The purpose of the provision is to assure that health plans competing within the health exchange, whose service areas include such providers (and therefore include at-risk populations who depended on them), will not exclude them from their provider networks.
A June 2011 HHS regulation follows the ACA and requires health plans to include a sufficient number of essential community providers who provide care to predominantly low-income and medically underserved populations. The rule defines essential community providers to include community health centers, public hospitals, sole community hospitals meeting disproportionate share adjustment payment thresholds, children's hospitals, among others. HHS is also considering broadening the definition to include additional providers that serve these populations.
In addition, HHS is currently debating whether to include broad contracting language that would either require a health plan to contract with all essential community providers in each plan's service area, or establish a requirement for issuers to contract with essential community providers on an any willing provider basis. The benefit of such a rule to communities of color is clear. It would allow continuity of care for enrollees with existing relationships with essential community providers such CHCs. In addition, to the extent that essential community providers serve people who are eligible for Medicaid, the presence of those providers in networks of health plans would allow people to maintain provider relationships in the event that an income change made them eligible for tax credits and private plans in the exchange, or vice versa.
However, the rule falls short in one important area--it fails to establish any parameters surrounding what constitutes network sufficiency for essential providers either by stipulating a provider to member ratio or with requirements related to geographic distribution. For now, the regulations leave states to determine participation requirements; however, the rule asks for comments on how HHS should define “sufficient.”
Finally, the provisions within the ACA that define health plan contracting duties and responsibilities miss an opportunity to deal with the very serious complaint of some African-American, Latino/a and Asian-Americans physicians that health plans effectively discriminate against them. Evidence supports the claim that health plans exclude a disproportionate number of physicians of color from physician provider networks nationwide, by using race neutral hiring and firing criteria; exclusion devalues the products of these physicians and the preferences of minority health consumers. Existing Civil Rights laws have proven to be ineffective in providing a remedy. Unfortunately, the ACA maintains the status quo.