CMS Office of Minority Health: Working To Achieve Health Equity through Understanding, Solutions, and Action

CMS Office of Minority Health: Working To Achieve Health Equity through Understanding, Solutions, and Action Cara V. James, PhD CMS Office of Minority Health September 2015

A Quick Overview of Health Disparities

What is a Health Care Disparity? Clinical Appropriateness and Need Patient Preferences Quality of Health Care Group A Group B Difference The Operation of Healthcare Systems and Legal and Regulatory Climate Discrimination: Biases, Stereotyping, and Uncertainty Disparity SOURCE: Figure 1. Differences, Disparities, and Discrimination: Populations with Equal Access to Healthcare. Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, Summary. Brian Smedley, Adrianne Stith, and Alan Nelson, Eds. Washington, DC. Institute of Medicine, 2002.

Types of Health Disparities Racial and Ethnic Gender Socioeconomic Status Geographic Sexual Orientation

Distribution of U.S. Population by Race & Ethnicity, 2010 Asian 5% American Indian/ Alaska Native 1% Black, Non Hispanic 12% Some Other Race 0.2% Native Hawaiian and Other Pacific Islander 0.2% Two or More Races 2% Hispanic 16% White, Non Hispanic 64% SOURCE: 2010 U.S. Census Total U.S. Population = 308.7 million

Fair or Poor Health Status by Race & Ethnicity, 2011 Percent Reporting Fair or Poor Health 13% 14% 14% 15% 10% 8% 9% All Nonelderly Adults White, Non Hispanic Asian Hispanic Multiracial American Indian/Alaska Native SOURCE: Table 50. Respondent assessed health status, by selected characteristics: United States, selected years 1991 2011. Health, United States, 2012. http://www.cdc.gov/nchs/hus.htm. Black, Non Hispanic

Diagnosed Diabetes Among Adults Age 20 Years & Older by Race & Ethnicity, 2011 Percent with Diagnosed Diabetes 9% 9% 6% 6% 7% All Adults Age 20 Years & Older White, Non Hispanic Asian Hispanic Black, Non Hispanic SOURCE: CDC, National Center for Health Statistics, Division of Health Interview Statistics, data from the National Health Interview Survey. http://www.cdc.gov/diabetes/statistics/prev/national/menuage.htm

Serious Mental Illness in Past Year Among Adults by Race & Ethnicity, 2012 Percent Reporting Serious Mental Illness 8.5% 4.1% 3.4% 4.2% 4.2% 4.4% 1.8% 2.0% All Adults Native Hawaiian and Other Pacific Islander Asian Black, Non Hispanic White, Non Hispanic Multiracial Hispanic American Indian/Alaska Native NOTE: Serious Mental Illness (SMI) is defined as having a diagnosable mental, behavioral, or emotional disorder that met criteria in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM IV) and resulted in functional impairment that substantially interfered with or limited one or more major life activities. SOURCE: SAMHSA. National Survey on Drug Use and Health. http://www.samhsa.gov/data/nsduh/2k12mh_findingsanddettables/2k12mhf/nsduhmhfr2012.htm#sec2 2

No Usual Source of Care for Nonelderly Adults by Race & Ethnicity, 2010 2011 Percent Reporting No Usual Source of Care 33% 20% 21% 22% 22% 24% 16% All Nonelderly Adults White, Non Hispanic Asian Black, Non Hispanic American Indian/Alaska Native Two or More Races Hispanic SOURCE: Table 72. No usual source of health care among adults 18 64 years of age, by selected characteristics: United States, average annual, selected years 1993 1994 through 2010 2011. Health US, 2012. National Center for Health Statistics, Centers for Disease Control and Prevention. http://www.cdc.gov/nchs/hus/contents2012.htm#072.

Adult Hospital Admissions Rate for Uncontrolled Diabetes by Race & Ethnicity, 2009 Admissions Rate per 100,000 Population 62.4 34.0 20.9 7.8 13.5 23.9 All Adults Asian & Native Hawaiian and Other Pacific Islander White, Non Hispanic American Indian/Alaska Native* Hispanic Black, Non Hispanic NOTE: Data are for adult population only and reflect admissions for uncontrolled diabetes without complication. *Data for AI/AN reflect services from the Indian Health Service, direct service Tribal hospitals, Contract Health Service hospitals, and community hospitals. SOURCE: National Healthcare Disparities Report, 2012, available at: http://www.ahrq.gov/research/findings/nhqrdr/nhqrdr12/index.html.

Adults with Any Mental Illness* Who Received Treatment in the Past Year by Race & Ethnicity, 2010 39% 44% Percent Who Received Treatment 28% 27% 16% All Adults White Hispanic Black Asian NOTE: Any Mental Illness (AMI) is defined as having a diagnosable mental, behavioral, or emotional disorder, other than a substance use disorder, that meet the criteria found in the DSM IV. SOURCE: SAMHSA, Center for Behavioral health Statistics and Quality (formerly the Office of Applied Studies), National Survey on Drug use and Health, 2009 and 2010.

Changes in Quality of Care Disparities Over Time: Summary by Race and Ethnicity, 2014 9% 14% 6% 12% Improving 85% 79% 86% 84% Same Worsening 6% 7% 8% 4% Black vs. White Asian and PI vs. White American Indian/Alaska Native vs. White Hispanic vs. Non- Hispanic White NOTES: Improving means disparity is becoming smaller over time; worsening means disparity becoming larger over time. Data on all measures are not available for all groups. Totals may not add to 100% due to rounding. Time period differs by measure and includes oldest and newest years of available data. SOURCE: AHRQ, National Healthcare Disparities Report, 2014.

Social Determinants of Health Social Gradient Early Life Social Exclusion Work Unemployment Social Support Addiction Food Stress Transportation Environment/Community Health Insurance English Proficiency Health Literacy SOURCE: Richard Wilkinson and Michael Marmot, eds. Social Determinants of Health: The Solid Facts, 2 nd Edition. Denmark; World Health Organization, 2003. Available at http://www.euro.who.int/eprise/main/who/informationsources/publications/catalogue/20020808_2.

Nonelderly Adult Uninsured Rate by Race & Ethnicity, 2011 Percent Uninsured 31% 24% 16% 13% 14% 15% 16% 20% All Nonelderly Adults White, Non Hispanic Multiracial Asian Native Hawaiian/Other Pacific Islander Black, Non Hispanic Hispanic American Indian/Alaska Native SOURCE: Eligible Uninsured data developed by HHS/ASPE from the 2012 American Community Survey (ACS).

Fair or Poor Health Among Adults by Income and Race & Ethnicity, 2011 All Adults Hispanic White, Non Hispanic Black, Non Hispanic Below Poverty 100% 199% FPL 200% 399% FPL 400% FPL or More 4% 5% 4% 7% 9% 8% 11% 11% 15% 14% 15% 19% 22% 21% 21% 25% SOURCE: Table 50. Respondent assessed health status, by selected characteristics: United States, selected years 1991 2011. Health, United States 2012. http://www.cdc.gov/nchs/hus/contents2012.htm#050

Other Languages Spoken at Home in the United States, 2011 More than 60 million people speak a language other than 1. Spanish 37.6 million English at home 2. Chinese 2.9 million 3. More Tagalog than 251.6 million (42%) speak English less than very 4. Vietnamese 1.4 million well (LEP) 5. French 1.3 million Top 10 Languages in US other than English: 6. Korean 1.1 million 7. German 1.0 million 8. Arabic 0.95 million 9. Russian 0.91 million 10. French Creole 0.75 million SOURCE: Language Use in the United States: 2011. U.S. Census Bureau. Data from 2011 American Community Survey

Top 10 Languages Spoken at Home by English Speaking Ability, 2011 Spoke English Very Well Spoke English Less than Very Well Vietnamese (4) Chinese (2) Korean (6) Russian (9) Spanish (1) French Creole (10) Arabic (8) Tagalog (3) French (5) German (7) 40% 44% 45% 52% 56% 57% 63% 67% 80% 83% 60% 56% 56% 48% 44% 43% 37% 33% 20% 17% SOURCE: U.S. Census Bureau, 2011 American Community Survey. 17

Health Literacy Defined as the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. (Healthy People 2010) Problems particularly prevalent among elderly, minorities, immigrants and the poor. Health literacy problems have been linked to poor glycemic control among diabetics, increased hospitalization rates among ER patients, and other problems. SOURCE: Health Literacy Fact Sheets. Center for Health Care Strategies, Inc. http://www.chcs.org/publications3960/publications_show.htm?doc_id=291711. Accessed June 18, 2007

Take Home Messages Regarding Health Disparities 1. Disparities exist in health status, access to care, quality of care, and health outcomes, there is still much we don t know, due to a lack of data. 2. Regardless of how they fair in the aggregate, all racial groups have problems. 3. Racial groups are not monolithic, and health differs within racial groups. 4. Cost of not addressing disparities is large and apt to get worse, as the population changes. 5. Many factors aside from race impact health and health care. 6. A myriad of efforts are underway to address disparities, but we still have a long way to go to eliminate disparities.

Where You Live Matters!

Uninsured Rates by State, 2013 WA OR NV CA ID AZ UT MT WY CO NM ND SD NE KS OK MN WI IA IL MO AR MS MI OH IN KY TN AL VT NY PA WV VA NC SC GA ME NH MA RI CT NJ DE MD DC AK TX LA FL HI United States: 15% Uninsured < 10% Uninsured (9 states, and DC) 10 14% Uninsured (25 states) 15 22% Uninsured (16 states) SOURCE: U.S. Census Bureau, 2013 American Community Survey.

Persons of Color by State, 2013 WA OR NV CA ID UT AZ MT WY CO NM ND SD NE KS OK MN WI IA IL MO AR MS VT NY MI PA OH IN WV VA KY NC TN SC AL GA ME NH MA RI CT NJ DE MD DC AK HI TX LA FL United States: 37% Population SOURCE: U.S. Census Bureau, 2013 American Community Survey. Less than 15% (8 states) 15 25% (17 states) 26 49% (21 states) More than 50% (4 states, and DC)

Heart Disease Death Rate in the U.S. and Select States by Race, 2010 Death Rate per 100,000 Population USA Minnesota Texas Mississippi 277 251 241 225 228 179 181 177 179 119 120 105 106 86 72 106 Total White Black Other SOURCE: Kaiser State Health Facts. http://kff.org/state category/health status/. Accessed on February 1, 2014

State Policies that Can Affect Health Medicaid Eligibility SNAP and TANF Benefits, and Allowances Transportation and Urban Planning Unemployment Benefits

What is CMS OMH Doing?

Sec. 10334 of the ACA and the HHS Offices of Minority Health

CMS OMH Mission and Vision Mission To ensure that the voices and the needs of the populations we represent (racial and ethnic minorities, sexual and gender minorities, and people with disabilities) are present as the Agency is developing, implementing, and evaluating its programs and policies. Vision All CMS beneficiaries have achieved their highest level of health, and disparities in health care quality and access have been eliminated.

CMS Health Equity Framework Path to Equity Increasing understanding and awareness of disparities Developing and disseminating solutions Implementing sustainable actions 28

Addressing Health Disparities at All Levels Division of Cancer Prevention and Control, National Center for Chronic Disease Prevention and Health Promotion. (2011). Social Ecological Model. Retrieved March 17, 2015. From http://www.cdc.gov/cancer/crccp/sem.htm. 29

Current CMS OMH Efforts to Achieve Health Equity Strengthening CMS Data & Systems Improving CMS data on race and ethnicity and other demographics MCBS Measuring the provision of Culturally and Linguistically Appropriate Services Developing methods to identify beneficiaries who are sexual and gender minorities Building the Business Case for Health Equity Creating an evidence base that demonstrates the economic/financial return on investing in health equity Developing & Disseminating Data Products & Tools Quarterly data briefs ResDAC training module for health disparities researchers 30

New Data Collection Standards Required by Section 4302 of the Affordable Care Act for the following: Race Ethnicity Primary Language Sex Disability Secretary has the authority to add other categories (e.g. socioeconomic status and sexual orientation)

Medicare Health Outcomes Survey Respondents, 2013 2014 Guamanian or Chamorro 0.2% Native Hawaiian 3% Other Asian 5% Vietnamese 8% Samoan 1% Asian Indian 11% Other Pacific Islander 6% Chinese 23% Korean 6% Japanese 13% Filipino 24% Total Asian & NHOPI Respondents = 26,495 32

Current CMS OMH Efforts Continued From Coverage to Care (C2C) An effort to help consumers understand their coverage and connect with the primary care and preventive services that are right for them. Visit marketplace.cms.gov/c2c. CMS Equity Plan for Improving Quality in Medicare The development of a strategic plan that identifies multilevel solutions to reduce disparities in Medicare.

From Coverage to Care (C2C) C2C is an effort to help educate consumers about their new coverage and to connect them with primary care and preventive services that are right for them so they can live long, healthy lives. Resources online and in print include the Roadmap, Discussion Guide, videos, and more. C2C builds on existing networks of community partners to educate and empower newly covered individuals. 34

From Coverage to Care Resources Visit http://marketplace.cms.gov/c2c Roadmap Poster Roadmap Consumer Tools Insurance card Primary vs. Emergency Care Explanation of Benefits Pull out steps Discussion Guide Video vignettes Enrollment Toolkit Print copies available from the CMS Clearinghouse 35

Coverage to Care Roadmap Online at marketplace.cms.gov/c2c 36

C2C Enrollment Toolkit Why it s important to get covered. Remind consumers about the benefits of using coverage to stay healthy. What consumers need to know before they enroll. Use Step 2 Understand Your Coverage to help consumers when selecting a plan. Things to consider when picking a plan. Talk about cost sharing, provider networks, and prescription drug coverage. What to do after getting coverage. Remind consumers to pay premiums, pick a provider, review plan documents, ask questions.

CMS Quality Strategy Goals

Priority 1: Expand the collection and analysis of standardized data CMS OMH will facilitate the collection, analysis, and reporting of standardized data on race, ethnicity, language, sexual orientation, gender identity, and disability status.

Priority 2: Evaluate disparities impacts and integrate equity solutions across CMS programs CMS OMH will work with colleagues to increase understanding of the disparities impacts of CMS programs and to build equity solutions into ongoing and future programs.

Priority 3: Develop and disseminate promising approaches to reduce health disparities CMS OMH will develop, test, and diffuse promising approaches to reducing health disparities. We will start by focusing on readmissions and improving nursing home care for vulnerable populations.

Priority 4: Increase the ability of the health care workforce to meet the needs of vulnerable populations CMS OMH will promote a culturally competent workforce and multidisciplinary teams by building the science and business case for community health workers and by building capacity for providers to meet national CLAS standards.

Priority 5: Improve Communication and Language Access for Individuals with Limited English Proficiency and Persons with Disabilities CMS OMH will help improve communication for vulnerable populations by assessing language access needs, educating providers, and sharing best practices.

Priority 6: Increase physical accessibility of health care facilities CMS OMH will measure the physical accessibility of health care facilities for people with disabilities and identify effective strategies to improve access.

Looking Ahead Evaluating Progress We will assess the priorities and activities for their impact on: Increasing awareness of disparities in health and health care, Engaging and activating stakeholders/target audiences in disparities focused efforts, and Reducing health care disparities Success requires the support and engagement of many partners. 45

Conclusion A journey of a thousand miles begins with a single step. (Lao tzu, 604 BC 531 BC) Together we can ensure that all Americans have access to quality affordable health coverage, and that health disparities are eliminated.

Conclusion A journey of a thousand miles begins with a single step. (Lao tzu, 604 BC 531 BC) Together we can ensure that all Americans have access to quality affordable health coverage, and that health disparities are eliminated.