Going to where

the puck is going to be Presented by Carmen Nevarez, MD, MPH

October 15, 2013

Latinos and the ACA

• My Story

• ACA

• Latinos and ACA

Colton, California

What is the Affordable and Accountable Care Act of 2009?

And why do we need it?

Obamacare • What ACA is – Healthcare Reform

– Affordable and Accountable Care Act

– Obamacare

– Focused primarily (but not exclusively) on health care financial incentives

• What it isn't – Single payor

– Panacea

– finished

What does health reform do

• Insurance reform

• Payment reform

• System changes

• Prevention elements

Insurance Reform

• Insurance rate regulation

• Insurance companies cannot deny coverage

• Insurance companies cannot drop clients because of pre-existing conditions

• Insurance companies must include children to age 24

• Many other elements

Payment reform

• Pay for performance strategies

• Medicare will no longer pay for 30 day readmissions

• Organizations that assume risk get higher payments

System changes

• Health organizations must adopt EHRs

– supports better analysis

• best practices

• fraud

• Quality

• Payment for outcomes not output

Prevention elements

• Prevention & Public Health Fund

• Community Transformation Grants

• Public education campaigns

• Community Health needs assessments

• Nutritional Labeling

• …many other elements

Economic analysis—

Why health reform was needed

Compared to

other major

federal

expenditure

areas; health

expenditures

keep rising while

defense has

decreased and

social security

leveled off.

US spending trends

US Health

spending

significantly

higher than other

countries: US 17.6%

Switzerland 11.2%

Canada 11.4%

Germany 11.6%

France 11.6%

Sweden 9.6%

UK 9.6%

Italy 9.3%

Korea 7.1%

How does US spending

compare

Current health

expenditures at

$3,000,000,000,000

At current rate of

growth, in 10 years

projected to be 30%

higher or

$4,500,000,000,000

How much does the US spend

Schroeder SA. NEJM 2007;357:1221-1228.

Schroeder SA. NEJM2007;357:1221-1228. Numbers of U.S. Deaths from Behavioral Causes, 2000.

Public health

spending

was only 3%

of all health

related

spending in

the US in

2010

How much is spent on Prevention

75% HEALTHCARE COSTS ATTRIBUTABLE TO PREVENTABLE CONDITIONS

Public Health and Obamacare Changing the landscape

Triple Aim

Commercial health insurance coverage

expansion

• CBOs help engage local residents about

opportunities and benefits of health

coverage

• Health networks need to ensure access for

all of the populations

–Geographic

–Special needs populations

Public program health coverage eligibility

simplification

• Medi-Cal expansion

• Programs will cover special needs

populations

–Special needs children

–Dual eligible

• Some populations not eligible

–Higher income

–Immigration status

Health care delivery and expansion

• Primary care medical home capacity

expansion

• FQHC expansions

• Reduce inappropriate ER use for non-

urgent issues incl. dental & mental health

–Expand primary care

Evidence-based health care quality

improvement

Use HIT to connect safety-net providers to

reduce disparities

Determine measures that attain Triple Aim

Goals

–quality

–cost

– improved clinical outcomes

Investments in prevention

• Connect medical care to Community-

based prevention

• Address social determinants to improve

health

• Build community capacity to support prevention and wellness programs

Improve Population Health

• What does this mean?

– Clinical definition: those “enrolled in the care of a specific provider, health system, insurer or health care delivery network

– Public Health definition: those defined by a geography (community), those that share a specific attribute (disable, elderly)

Why will population health improve

• Medical care will be connected to

environmental factors and other factors

that influence health

Potential roles What is happening across the country

• Robust enrollment

• Prevention services

• High risk case management

• Population disease management

• Health screenings

• Prevention campaigns

Numbers of U.S. Deaths from Behavioral Causes, 2000.

Schroeder SA. NEJM2007;357:1221-1228.

Challenges/Opportunities for Latinos

• Population/Demographics

• Food

• Fertility

• Community

POPULATION / DEMOGRAPHICS

Latino Population

• In California, there are approximately 14 million Latinos, which make up nearly 38% of the state’s total population.

• Despite these numbers, there

continues to be disparities in access to health care & health insurance due to a number of barriers.

Disparity: Lack of Insurance

• Latinos are more likely than any other ethnic group not to have insurance.

• According to the Health Initiative of the Americas 32% of Latino adults are uninsured nationally, roughly 1 in 3 Latinos in California are uninsured.

• By the year 2050 Latinos are expected to make up over 30% of the nation.

• Undocumented individuals are barred from participating in federally funded insurance programs. It is estimated that 3 million of those reside in California

Disparity: Language & Cultural Barriers

• Latinos have reported having a lack of comfort with health care facilities and/or services.

• This can stem from cultural barriers as well as the fact that while Latinos represent more than 1/3 of the state’s population, they account for only 5% of the California physicians.

Disparity: Health &

Wellness

• On average Latino adults consumer fewer serving of fruits and vegetables than recommended, often because there is a lack of access to fresh produce in many of the neighborhoods where they live or produce is too expensive.

• 2/3 of Latinos also report eating fast food at least one time per week.

Disparity: Health &

Wellness

• Less than ½ of Latino adults in California get a minimum of 30 minutes of moderate physical activity 5 days a week recommended.

• 32% report that they do not engage in any physical activity or exercise.

• Nearly 69% of low-income Latino adults in the state are overweight or considered obese. This excess weight is associated with increased incidents chronic diseases such as: cardiovascular disease & type 2 diabetes.

Disparity: Health &

Wellness

Wellness programs are offered broadly in the employer-based insurance market, but Latinos are often employed in job sectors less likely to provide health coverage or other employee benefits & have less access to these wellness programs.

FOOD

Salud Tiene Sabor Program

• Project implemented at Mercado la Paloma located in

South Los Angeles, CA

• Collaborative effort among partner organizations

• Seven independently-owned restaurants offering a

variety of ethnic foods

• Serves low-income, Latino neighborhood

Mercado La Paloma

Food & Beverage Environment

Assessment

Pioneering Menu Labeling

• Provides nutritional information

• Feasible & sustainable for independently-owned

restaurants

• Incubator environment

• Informs state & federal menu labeling policies

Significance of Menu Labeling

Sabor Evaluation Research Questions

• Does program impact nutrition knowledge, restaurant owners’

preparation & consumers purchase of healthier meals?

• How do recipe modifications & menu labeling increase healthy meal

preparation/eating in Latino communities?

• Does program impact vendors’ sales data & return on investment?

• What changes/additional resources are needed for sustainability?

• How does Sabor inform replication to other venues & communities?

• How does Sabor inform state & federal policy implementation?

Vendor Interviews

• 5 interviews conducted in Spanish, 2 in English

• 6 of 7 vendors made changes to foods & beverages to

make them healthier

• Overall satisfaction with menu labeling program

• Staff members need training on communicating nutritional

information

• Resources needed to update menu boards

• More advertising of Smart Menu program to attract health

conscious customers

• No notable change in costs & profits (5)

• Fruits & vegetables are more expensive (3)

• Increased profits due to smaller portions (2)

Patron Surveys

• 6 surveys (29 in Spanish, 31 in English)

• 8% of respondents live in zip codes within 5 miles of the

Mercado

• 65% saw calorie information on menu board when ordering

• 76% strongly agree consumers have right to know

nutritional content of restaurant meals

• Nearly 50% eat out at restaurants at least 3 times/week

• 42% eat at Mercado restaurants

• 42% eat at chain fast food restaurants

¡ Buen Provecho !

FERTILITY

Impact of Teen Births

• Costs -

• Opportunities lost

Teen Birth Rate in California, 1991-2008

Teen Birth Rate in California and United States, 1991-2008

Teen Birth Rate in California, Texas, and United States, 1991-2008

Teen Birth Rate in California, United States, and Other Western Nations, 2004-2008

Teen Birth Rate in California, United States, and Other Western Nations, 2004-2007

Timeline of Teen Pregnancy Prevention Programs in California

Cal-SAFE (2000–present)

I&E (1974–present)

AFLP (1985–2009)

TPPGP (1996–2001)

Cal-Learn (1994–present)

MIP (1995–2009)

Family PACT (1997–present)

TeenSMART (1998–2008)

1974 … 1985 … 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000

CCG (1996–present)

Historical and Projected Teen Birth Numbers in California

Teen Pregnancy Prevention Investments vs. Taxpayer and Societal Cost Savings in California

Teen Birth Rate by Race and Ethnicity in California, 2000-2008

Female 15-19 Population by Race and Ethnicity in California, 2008

Teen Birth Numbers by Race and Ethnicity in California, 2008

Historical and Projected Teen Birth Numbers in California

Teen Birth Rate in California, United States, and Other Western Nations, 2004-2008

COMMUNITY

Community Assets

• Latino communities tend to be more cohesive

• Strong family orientation

• Less smoking, drug use

• Educational opportunity is strong community value

• Good health attitudes, habits are contagious

ACA: Are Latinos Making Progress?

• Latino awareness and support for ACA increased from 59% in 2010 to 67% in 2012.

• Over 300,000 new mostly Latino enrollees in the ACA precursor low income health program.

• $385M to expand services in >1200 community health centers.

• 24 communities with over 8M Latinos awarded $25M in CTGs to improve health conditions and equity.

• Latino policymakers, officials, advocacy organizations, and communities are advancing ACA-bolstering state and local policies and system changes for health and equity in schools, neighborhoods, and workplaces.