Strategy for improving health care for uninsured, low-income, and minorities in the US

A new set of strategies released today by the Commonwealth Fund Commission on a High Performance Health System could dramatically improve how the U.S. health care system serves vulnerable populations—those in the U.S. who are uninsured, low-income, or members of racial and ethnic minority groups.

According to the new report, Ensuring Equity: A Post-Reform Framework to Achieve High Performance Health Care for Vulnerable Populations, closing the health care divide will require a three-pronged policy framework that ensures adequate access to health care and financial protection, strengthens the health care system's ability to serve vulnerable populations, and supports coordination between the traditional health care system and the resources outside of the health care system that vulnerable groups rely upon.

The report highlights the significant divide between vulnerable populations and their more secure counterparts in rates of receiving recommended screening and preventive care, control of chronic diseases, and hospital admissions for conditions that may be preventable with good primary care and community health outreach. For example:

• Just four of 10 low-income adults receive all recommended screening and preventive care, compared with six of 10 higher-income adults.
• Nearly three of 10 (29%) uninsured adults diagnosed with diabetes do not have it well controlled, twice the rate of the insured (15%).
• Black adults are hospitalized for heart failure at rates (959 per 100,000) more than twice the rate for Hispanic adults (466 per 100,000), and nearly three times the rate for white adults (349 per 100,000).

The authors note that Affordable Care Act provisions targeted at vulnerable populations will go a long way toward improving health care for these groups, primarily through expanded health insurance, increased financial support for community health centers, and reforms that should improve health care quality and allow for people in vulnerable groups to receive better coordinated health care. However, vulnerable groups will remain at risk for poor health outcomes unless crucial issues beyond health insurance coverage like access to health care, affordability, care coordination, and the financial stability of safety-net hospitals are addressed.

A Policy Framework for Vulnerable Populations

In the report, the 17-member Commission lays out a policy framework that builds on Affordable Care Act reforms to create a more equitable health care system. The Commission comprises experts and leaders representing every sector of health care, as well as the state and federal policy arena, the business sector, professional societies, and academia.

The framework's overarching strategies revolve around ensuring adequate access and financial protection, strengthening the care delivery systems serving vulnerable populations, and coordinating the traditional health care system with outside resources also affecting vulnerable groups. Highlights of the framework include:

• Create enough willing providers for Medicaid beneficiaries. To alleviate the shortage of providers, and particularly specialty care providers, willing to serve Medicaid patients, the Commission recommends considering payment reforms to reward high-quality networks of providers for providing optimal care for Medicaid beneficiaries, more equitable Medicaid payment rates, and developing the workforce needed to care for vulnerable populations.
• Stabilize health insurance coverage. The report recommends limiting gaps and disruptions in health insurance that come from job or income changes by actions such as guaranteeing year-long coverage periods, providing access to the same insurance plans in exchanges and in Medicaid, merging small-group and individual health insurance exchanges, 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.
• Limit out-of-pocket health care costs. The Commission recommends protecting consumers—particularly low-income families who may struggle with out-of-pocket costs despite affordable premiums—from excessive out-of-pocket health care costs through insurance benefit designs with incentives to use effective care and reasonable income-related limits on overall out-of-pocket spending.
• Ensure the financial stability of the safety net while stimulating higher performance. Ensure adequate funding for the safety-net system to continue to provide services to vulnerable populations, and use those financial resources to stimulate and reward higher performance.
• Promote greater clinical integration in safety-net care systems. Payment reform and regulatory changes that explicitly encourage collaboration and affiliation should be used to encourage providers to work together across health care settings and assure coordinated care for patients. In addition, safety-net providers should be encouraged to participate in accountable care systems that serve vulnerable groups.
• Focus on comprehensive, coordinated, team-based primary care for all providers serving vulnerable populations. The report cites evidence that much of the disparity in care experienced by vulnerable populations can be eliminated if they receive patient- and family-centered primary care that emphasizes team-based care, care coordination, care management, and preventive care. In addition, coordination with mental health and substance abuse services are particularly important for vulnerable patients. Government and private payers could promote team-based care for vulnerable groups by giving incentives for providers and patients and offering technical assistance and supports.
• Foster an infrastructure of community-based support services. All providers serving vulnerable populations should be able to link their practices with community-based services like transportation, translation, or nutritional support, which they may need to fully access and benefit from the health care system to help meet their patients' needs.
• Align efforts between the health care delivery system and public health services. Providers serving vulnerable populations, as well as state and federal government agencies, should promote coordination of efforts between the health care delivery system and local public health resources and programs to develop effective approaches to addressing medical issues that affect vulnerable groups like obesity, diabetes, and asthma.

"The Affordable Care Act is a big step forward in terms of addressing the significant needs of vulnerable groups and the health care providers who serve them," said Commonwealth Fund President Karen Davis. "However, the inequity in our health care system is significant and—as laid out in the Commission's new report—more work must be done in order to close that gap and assure that we have a health care system that provides all of us with access to high quality health care."