Gamechanger: Medicaid Expansion in Low-Income Populations

Background

Since it was signed into law in 2010, the Patient Protection and Affordable Care Act has been the subject of much political controversy. One polarizing provision of the Affordable Care Act (ACA) is the expansion of Medicaid. Though Medicaid expansion was passed federally,  the adoption of the expansion remains at the discretion of each state. Today, 31 states have adopted Medicaid expansion while 20 states have either not expanded or are still debating the issue.  

Under current federal regulations, states must provide Medicaid coverage for children younger than 6 years of age with family income up to 133% of the federal poverty level, children ages 6 to 18 years with family income at or less than 100% of the federal poverty level, pregnant women, and low-income elderly persons (Kaiser Family Foundation). The ACA (1) expanded Medicare eligibility to uninsured, non-disabled adults without children whose family income is at or below 138% of the federal poverty level and (2) established state health insurance exchange programs that offer a variety of low-cost options for enrollment with variable benefit packages (Chesney, 313). These new provisions are projected to result in insurance coverage for 33 million uninsured people by 2022.

why expansion matters: Medicaid and access to care

"Medicaid is the largest provider of health insurance for children and adults in the United States and provides critical financial support for the nation's safety net clinics, hospitals, and long-term care facilities that serve the poor and underserved." 
- Mary Chesney, PhD, RN, CPNP


Medicaid is the nation's largest provider of health insurance for children and adults. It insures over 65 million Americans, provides financial support for the nation's safety net institutions, and is central to increasing access to care for many of the most disadvantaged individuals and families in the United States.

Medicaid expansion significantly impacts access to care, health outcomes, and quality of care in vulnerable populations. Thirty-one million children (one in three) and more than 60% of residents in nursing homes depend on Medicaid to receive health care services (Center on Budget and Policy Priorities).  Health insurance coverage is associated with better health outcomes because it grants individuals regular access to care and fosters greater and more appropriate use of health services. These factors, in turn, improve the likelihood of disease screening and early detection, the management of chronic illness, and effective treatment of acute conditions such as traumatic brain injury and heart attacks (Kaiser). Therefore, the ultimate result of Medicaid expansion is better health outcomes.

setting the landscape: medicaid expansion by state

Though the benefits of Medicaid expansion are well documented, states have taken variable approaches to ACA Medicaid Expansion. A recent study examined ACA-related experiences among low-income adults in three states with markedly different ACA policies: Arkansas, Kentucky, and Texas (Sommers, 1010). The objective of the study was to assess the experiences of low-income adults in each of the three states and explore connections between state policy and enrollment in low-income populations.

The Medicaid expansion policies of Kentucky, Arkansas, and Texas are compared in the table below.

State	Medicaid Expansion Adopted?	State Marketplace?	Outreach Efforts?
Kentucky	Yes, traditional Medicaid expansion	Yes	Yes, aggressive outreach by governor’s office, navigators, and in-person assisters
Arkansas	Yes, private option	Yes, federal-state partnership Marketplace	Yes, in-person assistance only; ACA promotion strictly prohibited
Texas	No	No	No, ACA promotion and use of navigators are strictly restricted

Because of their disparate policies, Kentucky, Arkansas, and Texas have seen different results regarding ACA applications and enrollment among low-income adults. Study results indicate that low-income adults in Kentucky - and to a lesser extent in Arkansas- are much more likely to apply and enroll in Medicaid or other Marketplace plans than low-income adults in Texas (Sommers, 1011). These results reinforce the importance of accessible care in granting health insurance to those who need it the most.

The high accessibility and promotion of Medicare and the Marketplace has created a 52% decrease in the number of uninsured Kentuckians since 2013 (Duckett). According to a report published by the Kentucky Cabinet for Health and Family Services, 75% of Kentuckians who had signed up for coverage during the 2014 open enrollment session (391,000 Kentuckians) indicated that they had been uninsured prior to gaining insurance through the state exchange.

final take-aways

Kentucky's success with ACA applications and enrollment is accredited to the state's adoption of the Medicaid expansion, the commission of a state marketplace, and aggressive outreach efforts that used a mix of the governor's office, in-person assistance, and navigators to assist applicants throughout the enrollment process. Similar measures in other states (Maryland, West Virginia, etc.) have also seen positive results. In contrast, states such as Texas who have restricted ACA expansion efforts have seen markedly less progress regarding declines in the uninsured population (17% in Texas compared to over 50% in Kentucky, Maryland, and West Virginia).

This unprecedented coverage is especially significant for those who previously did not qualify for Medicaid but could not afford private insurance. Through the expansion, individuals who fall in this coverage gap are granted access to Medicaid or low-cost private insurance plans that can save their lives in the long run.As a result, one can infer that the best way for states to improve access to care for low-income populations is to adopt Medicaid expansion. The expansion of these provisions will increase access to care, foster positive health outcomes, and help push disadvantaged populations toward health equity. 

sources

Chesney, Mary. "Affordable Care Act: Medicaid Expansion Key to Increasing Access to Care." Journal of Pediatric Health Care 27 (2013): 312-15. Web.

Duckett, Philethea, Artiga, Samantha. "Health Coverage for the Black Population Today and Under the Affordable Care Act." Kaiser Family Foundation (2013). Web.

Paradise, Julia. "Medicaid Moving Forward." Kaiser Family Foundation (2015). Web.

Sommers, B. D., B. Maylone, K. H. Nguyen, R. J. Blendon, and A. M. Epstein. "The Impact Of State Policies On ACA Applications And Enrollment Among Low-Income Adults In Arkansas, Kentucky, And Texas." Health Affairs 34.6 (2015): 1010-018. Web.

Closing the Gap: Increasing Truvada PrEP Awareness

Background

HIV/AIDS disproportionately affects members of the LGBT community, and despite 30 years of research, there are still 50,000 new cases of HIV each year, two-thirds of which are among gay and bisexual men. - HRC Blog

On July 16, 2012, Truvada PrEP became the first FDA-approved drug for reducing the risk of sexually-acquired HIV in HIV-negative individuals who are at high risk for contracting HIV.

Truvada is an oral pill that contains two medicines that are useful in preventing HIV: tenofovir and emtricitabine. Covered by both Medicaid and most private insurances, Truvada has been proven to reduce the risk of HIV infection by 99% when taken daily, 96% when taken 4 or more times per week, and 76% when taken twice per week (US Centers for Disease Control). 

In San Francisco and Miami, two cities with large LGBT populations, pilot studies proved that Truvada usage significantly reduced the incidence of new HIV cases. A Kaiser PrEP study followed 657 mostly gay and bisexual men who were referred for evaluation and decided to start PrEP. To date, there have been no new HIV diagnoses among the 657 participants during the 2 and 1/2 years of follow up (Kaiser Permanente). 

The Kaiser study is promising for HIV prevention because it extends what is known about PrEP from the controlled setting of clinical trials and shows that it can work in the "real-world". (Volk, 1202). 

Communities of Color

Black males account for 1-in-4 new HIV infections
in the United States though they only make up
1-in-500 Americans, overall. - Reuters.com

PrEP's success has significant implications for communities of color, which experience disproportionately high rates of HIV infection and mortality due to AIDS. Heterosexual black women and black gay and bisexual men are two groups most at risk for contracting HIV in the United States. Of the 1.1 million Americans infected with HIV, almost 50% (510,000) are Black (Centers for Disease Control).

The stark statistics concerning HIV and communities of color reflect large systematic and structural barriers and health disparities that underserved, minority communities face every day. Historical and contemporary inequalities in housing, education, employment, health care, and the rate of mass incarceration only reinforce these disparities.

Truvada Usage Gap

Thus, despite Truvada's life-changing benefits, lack of knowledge among health care providers, poor media coverage, and stigma have slowed the adoption of the drug, particularly in communities of color. In addition, many potential users have been driven away from health care and other services by negative experiences, overall distrust, and homophobia.

The persistence of abstinence-only education, failed incarceration policies, and resistance to harm-reduction programs combine to make the risk of acquiring, transmitting, and dying of HIV/AIDS higher in communities of color. Stigma is part of the problem as well. Many people within the Black community - particularly regular churchgoers - report that they would delay diagnosis and treatment due to embarrassment about sexually transmitted infections (Robinson). 

As a result, many of the people who could benefit from Truvada are not using it, either voluntarily or because they don't know that it exists. This creates a critical gap between Truvada's potential and actual usage and begs the question: What needs to be done to spread awareness, increase usage, and ultimately close the gap?

Closing the Gap: A Call to Action

Much of the burden of closing the gap and reaching the LGBT community rests on health care providers; however, an equally yoked portion of these endeavors necessitates grassroots efforts in which individuals work within communities to spread awareness and reach people where they are.

YES, YOU CAN BRIDGE THE GAP!

Two Simple Ways to Advocate

1. Get informed: Know your status, read unbiased literature, find out where to refer friends and family members for more information, ask your health care provider about Truvada PrEP. 

2. Share information: Adopt the "Each One Teach One" mindset by telling family and friends about the information that you've learned (particularly those that are high-risk for HIV), join advocacy or information groups such as PrEP-O-Licous, and share relevant updates and information on social media.


SOURCES

Kaiser Permanente San Francisco. Division of Research - HIV Care and Prevention. Large Study of PrEP Use in Clinical Practice Shows No New HIV Infections. Kaiser Permanente Share. N.p., 1 Sept. 2015. Web. 29 Oct. 2015. <http://share.kaiserpermanente.org/article/large-study-of-prep-use-in-clinical-practice-shows-no-new-hiv-infections/>.

Robinson, Russell, and Aisha Moodie-Mills. "HIV/AIDS Inequality: Structural Barriers to Prevention, Treatment, and Care in Communities of Color." Center for American Progress. University of California, Berkeley, 27 July 2012. Web. 29 Oct. 2015.

Volk, Jonathan, Julia Marcus, Tony Phengrasamy, Derek Blechinger, Dong Nguyen, Stephen Follansbee, and C. Bradley Hare. "Clinical Infectious Diseases." No New HIV Infections with Increasing Use of HIV Preexposure Prophylaxis in a Clinical Practice Setting 61.10 (2015): 1601-603. No New HIV Infections with Increasing Use of HIV Preexposure Prophylaxis in a Clinical Practice Setting. Oxford University Press. Web. 29 Oct. 2015.

United States. Centers for Disease Control. Department of Health and Human Services. PrEP Guidlines. N.p.: n.p., 2014. Centers for Disease Control. Web. 29 Oct. 2015. <http://www.cdc.gov/hiv/pdf/prepguidelines2014.pdf>.

Depicting Obesity in Black America

DEPICTING OBESITY IN BLACK AMERICA

Overview

Obesity is a major health problem for millions of Americans. Dietary patterns, physical inactivity, medication use, and other exposures contribute to the prevalence of obesity in America. In an article, "Is Fat the New Normal?" Sherry Rauh likens obesity among Americans to tallness among basketball players.

African American adults are 1.5 times as likely to be obese compared 

with white adults, and over 75% of African Americans are overweight

compared with 67.2% of White Americans. 

(State of Obesity - RWJ Foundation)

"If you're tall enough to stand out in a crowd, you're probably aware of your tallness - maybe even self-conscious about it. But imagine that you're in a room full of basketball players. Suddenly, you don't seem so tall anymore. Your above average height feels normal." - S. Rauh

Rauh suggests that if we equate "normal" with average, it's not a stretch to say that in America, it's normal to be obese. The average or "normal" American adult's BMI is 28.6, which signifies overweight.  The new normality of excess weight makes it very difficult for Americans to recognize what obesity looks like. This poses a serious concern in populations such as African Americans where obesity is highly prevalent. 

Rush University MC Study

A study conducted by researchers from the Rush University Medical Center in Chicago, recruited sixty-nine African American women from a low income neighborhood of Chicago and asked them to identify which of the nine women (shown below) were overweight, obese, and "too fat". The consensus was that of the nine women shown, only 8 and 9 were "too fat" (Boosely).

Implications

This simple study conveys a larger disagreement between cultural and medical definitions of "healthy" in the African American community. This disconnect poses a much larger problem considering the effect of obesity on quality of life and risk for other chronic diseases such as diabetes, heart disease, hypertension, and some types of cancer. Since these illnesses are already disproportionately prevalent in minority populations, measures must be taken to mend this disconnect and push African Americans toward health equity. 

What could be done?
1. Examination of social determinants of health that contribute to African American obesity. Determinants such as income, neighborhood, educational attainment, food advertising, and access to parks, grocery stores, and green space all play a critical role in the overall health of a community. African American communities face significant disparities in these determinants. Therefore, to help African Americans live healthier lives, these disparities must be eradicated. This will require strategic programs, policies, and neighborhood revitalization efforts that increase the availability and access to healthy food and safe space to be physically active in African American communities.

2. Development of culturally relevant healthy living and weight loss programs tailored to meet the unique needs of African Americans. To enhance cultural relevance and appeal to African Americans, these programs should solicit input from population members, use culturally relevant intervention content, incorporate population media figures, utilize culturally relevant forms of physical activity, and address specific population linked barriers to activity (Conn). For example, Steps to Soulful Living, a weight loss intervention for African American women, successfully reduced participants' weight by 8 - 15 pounds using these strategies (Karanja).

3. Use of nontraditional partners to increase health education in minority and low income communities. Instead of relying on traditional health education providers such as hospitals and clinics, providers should use nontraditional sources such as churches, community centers, sorority and fraternities, and barbershops/salons to conduct successful lifestyle interventions in settings that are both familiar and comfortable in the Black community (Kennedy et al).

Sources:
Boseley, Sarah. "Do You Know What Fat Looks Like?" Editorial. Obesity: The Shape We're In Blog. The Guardian, 10 Sept. 2014. Web. 29 Sept. 2015.

Conn, Vicki S., Keith Chan, JoAnne Banks, Todd M. Ruppar, and Jane Scharff. "Cultural Relevance of Physical Activity Intervention Research with Underrepresented Populations." Int Q Community Health Education34.4 (2013): 391-414. NCBI. U.S. National Library of Medicine. Web. 30 Sept. 2015.

Karanja, N., VJ Stevens, JF Hollis, and SK Kumanyika. "Steps to Soulful Living (steps): A Weight Loss Program for African-American Women." Ethnicity and Disease 12.3 (2002): 363-71. National Center for Biotechnology Information. U.S. National Library of Medicine. Web. 30 Sept. 2015.

Kennedy, Betty, Jamy Ard, Louis Harrison, Beverly Conish, Eugene Kennedy, Erma Levy, and Phillip Brantley. "Cultural Characteristics of African Americans: Implications for the Design of Trials That Target Behavior and Health Promotion Programs." Ethnicity and Disease 17 (2007): 548-54. Cite Seer X. Pennsylvania State University. Web. 30 Sept. 2015.

Rauh, Sherry. "Is Fat Normal in America? A Surprising Reason Why We're Gaining Weight." WebMD. WebMD, n.d. Web. 29 Sept. 2015.

The State of Obesity: Racial and Ethnic Disparities in Obesity. Rep. N.p.: Robert Wood Johnson Foundation, 2014. Web. 30 Sept. 2015.

Shifting the Health Equity Focus from Accessibility to Outcomes

Access to Care < Health Outcomes?

Background

Source: http://www.nyas.org/

It is well documented that racial and ethnic minorities face worse health and health care disparities than any other group. Several socioeconomic factors such as neighborhood, educational attainment, and income level lead to a lesser standard of health care and worse health outcomes in minority communities. To address these disparities, several health care organizations have begun to develop interventions focused on narrowing the gap between social determinants of health and health equity. For years, the focus these interventions has been access to care, which hemmed on the belief that issues such as lack of insurance, cost of services, and availability of providers were the major sources of disparity. However, difficulties in reducing these disparities have prompted public health and healthcare practitioners to look elsewhere.

A Shift in Focus

"Health organizations can promote and sustain equity by broadening the scope of health care systems and promoting interventions that focus on the core contributors to disease."

In the article Achieving Health Equity by Design, authors from the American Medical Association suggest health practitioners shift their health disparities work from efforts to increase cultural competence, patient safety, and health literacy to those that target equity in health outcomes. The authors suggest that instead of focusing on efforts to "retrofit the current healthcare system to make it more accessible to patients," health care organizations should focus more on the factors that cause disproportionate lack of access and sustained treatment in minority communities. This shift requires health care organizations to adopt unconventional methods to provide education and services in places where racial and ethnic minorities live and work. Some health care organizations have already begun to move toward this framework.

Source: media.npr.org

For example, in 2010, the CDC piloted barbershop hypertension management programs in Los Angeles and St. Louis to implement system-level hypertension control interventions for African American men. These programs trained barbers and stylists in the African American community to become community blood pressure specialists who measure and record blood pressure readings of customers, provide information about hypertension,a nd make referrals to providers. Barbershops were specifically targeted because, in the African American community, barbershops are quintessential, gender-specific places for gathering and fellowship. An evaluation of the barbershop intervention found that African American men who received service through the intervention had a decrease in blood presure and an increase in hypertension treatment and control. These results show promise for future collaborations between heatlh care organizations and nontraditional partners such as faith-based organizations, fraternities and sororities, and barbershops. Through these partnerships, health care organizations can circumvent social determinants of health and move minority communities toward health equity. 

Sources:

Centers for Disease Control and Prevention. A Closer Look at African American Men and High Blood Pressure Control: A Review of Psychosocial Factors and Systems-Level Interventions. Atlanta: U.S. Department of Health and Human Services; 2010.

Wein, Harry. "Barbers Help Black Men Beat High Blood Pressure - NIH Research Matters National Institutes of Health (NIH)." NIH Research Matters. National Institutes of Health, n.d. Web. 23 Sept. 2015.


Wong, Winston F., Thomas A. LaVeist, and Joshua Sharfstein. "Achieving Health Equity by  Design." The Journal of the American Medical Association 313.14 (2015): 1417-1418. JAMA Network. American Medical Association. Web. 23 Sept. 2015.