|By the Innovations Exchange Team|
Children of color and children of low-income families continue to have elevated rates of asthma, obesity, and other chronic health conditions. These conditions are influenced by social, economic, and environmental factors, so efforts to address them must use a multisector approach. Health plans are playing a key role in reducing disparities among children through data collection, health education, and disease management.
Innovations Exchange: What factors contribute to disparities in childhood asthma and obesity?
Kathryn Santoro: Low-income children and children of color often live in substandard housing and are disproportionately exposed to poor air quality, including environmental triggers inside the home and outdoor pollution. These children also tend to have risk factors for childhood overweight and obesity, including limited access to healthy foods and low levels of physical activity.
Considering that access to health care is essential to reducing disparities, what progress has been made to insure more children?
The Patient Protection and Affordable Care Act (ACA), enacted in 2010, has increased the number of insured children by about 2.5 million by preventing insurance companies from denying coverage for children with preexisting conditions or rescinding coverage when children get sick, and by allowing children to stay on their parent’s health plans until age 26. Another 1.5 million children have gained health coverage in the past year through strengthening of Medicaid and the Children’s Health Insurance Plan (CHIP), according to the Children’s Defense Fund. Nonetheless, more than 7 million children in the United States remain uninsured.
Full implementation of the ACA in 2014 will bring additional benefits for children. At that time:
State health insurance exchanges will be required to have a child-only coverage option to ensure access to coverage for children being raised by grandparents, children in families in which an insured parent is not offered dependent coverage, or children in households with mixed immigration status.
Children up to age 26 who age out of foster care will be eligible to continue receiving Medicaid.
Eligibility for Medicaid will be extended to 16 million children, parents, and childless adults with incomes below 133 percent of the federal poverty level ($30,657 for a family of four in 2012), including 1.6 million children who are currently eligible for CHIP.
Will other ACA provisions help reduce health disparities?
Several provisions aim to improve the delivery of services to low-income children and their families. One such provision establishes a grant program to provide voluntary, evidence-based, home-visiting services to young at-risk children and their families. This program will seek to improve maternal and newborn health, promote healthy child development, strengthen parenting skills, enhance school readiness, and prevent child maltreatment. Another provision covers “Bright Futures” services—the standard of pediatric well-child and preventive coverage recommended by the American Academy of Pediatrics—with no copayment in all public and private insurance.
Other ACA provisions will increase funding for community health centers to improve delivery of care for millions of children and families, and allocate funding to strengthen school-based health centers that provide comprehensive health coverage and other critical services to more than 1 million children across the country.
What Federal initiatives have been implemented to help reduce asthma and obesity in children?
The Coordinated Federal Action Plan to Reduce Racial and Ethnic Asthma Disparities, released in May 2012, acknowledges that asthma is a complex problem that requires the coordination of efforts by the Environmental Protection Agency, the Department of Housing and Urban Development, the Department of Health and Human Services, State and local public health agencies, community asthma coalitions, and asthma foundations and nonprofit organizations.
The White House released a report on childhood obesity in 2010 with 70 recommendations from 12 federal agencies, followed by the White House Task Force on Childhood Obesity: One Year Progress Report in 2011. The White House report calls for the involvement of the private sector including industry leaders, foundations and community organizations, parents, and teachers.
Why should health insurance plans address disparities?
Nearly 200 million Americans are insured privately. Health insurers are in a unique position to influence the quality of care that beneficiaries receive, including those from racial and ethnic minorities, and there is a business case for insurers to reduce health disparities. Pilot programs have shown that cost savings can be achieved through reduced emergency department visits and hospitalizations. Cost-saving strategies used for asthma reduction are described in two resources: Investing in Best Practices for Asthma: A Business Case and Asthma Return-on-Investment Calculator.
The Institute of Medicine’s 2003 report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care called on health plans to collect data on members' race and ethnicity. Between 2003 and 2008, the proportion of commercial health plans collecting this data doubled to 60 percent, according to a 2011 Health Affairs article. Collection of such data rose even faster among plans covering Medicaid and Medicare Advantage enrollees, reaching 94 percent and 83 percent, respectively.
To facilitate data collection, identifying disparities, testing programs, and disseminating results, 11 insurance companies—including Aetna, Cigna, HealthPartners, Humana, and Kaiser Permanente—covering more than 95 million lives formed the National Health Plan Collaborative in 2004. The collaborative, which currently has 16 members, works to engage other health care decisionmakers, such as major health care purchasers, health care providers, and policymakers, in efforts to reduce racial and ethnic disparities. The member plans are evaluating provider-, member-, and community-targeted approaches that use race, ethnicity, and language data to evaluate strategies for reducing gaps in care.
In addition, America’s Health Insurance Plans (AHIP), which manages the National Health Plan Collaborative, offers online clinical and nonclinical training modules that the Manhattan Cross Cultural Group created to enhance the cross-cultural communication skills of health care professionals. Quality Interactions: A Patient-Based Approach to Cross-Cultural Care provides physicians, nurses, case managers, and other health care professionals with tools and resources to address the health needs of a diverse population.
What initiatives have health plans developed to address disparities in obesity, which affects one in seven low-income children?
Both the National Institute for Health Care Management (NIHCM) Foundation and the AHIP Obesity Initiative have partnered with the Centers for Disease Control and Prevention on many activities to address disparities in obesity, including expert panels, educational webinars, publications, roundtables, and forums that enable health insurance plans to learn from each other’s efforts and work with other stakeholders to address the issue of childhood and adult obesity. These activities have led to the implementation of innovative programs in local communities in collaboration with schools, community groups, and policymakers.
In addition, several health insurance plans are participating in the Alliance for a Healthier Generation’s Healthier Generation Benefit Initiative. The initiative includes Aetna, Blue Cross Blue Shield of Massachusetts, Blue Cross Blue Shield of North Carolina, Capital District Physicians’ Health Plan, Highmark, Humana, and WellPoint. The alliance, a collaborative of the William J. Clinton Foundation and the American Heart Association, convened National medical associations, health insurers, and employers to offer comprehensive health benefits to children and families to prevent and treat childhood obesity. Health care professionals are working with children and their families on how to establish and maintain healthy lifestyles, with guidance from pediatricians and registered dieticians. The alliance will collect and share data on health outcomes, best practices, and strategies.
What initiatives have health plans developed to address disparities in asthma among children?
Asthma, a chronic condition that costs our nation $56 billion per year, disproportionately affects children, females, racial and ethnic groups, and low-income individuals. Research has shown that environmental facts influence asthma outcomes, which vary based on where individuals live, learn, work, and play.
Health plans have developed programs to help consumers control their asthma through education and environmental control, collaboration to deliver community-based care, and patient-centered care supported by measurement, monitoring, and promotion of evidence-based guidelines. These interventions have resulted in individualized and family-centered care, reduced emergency room visits and inpatient hospitalizations, and overall improvements in care.
In alignment with the Coordinated Federal Action Plan to Reduce Racial and Ethnic Asthma Disparities and the National Institutes of Health’s EPR-3 guidelines, several health plans are adopting culturally sensitive asthma management strategies to improve the lives of individuals with asthma. Examples of such innovative asthma programs include: AmeriHealth Mercy Family of Companies’ Healthy Hoops®—Fulfilling the Promise of Health, Kaiser Permanente’s The Colorado Asthma Experience, and Aetna’s Asthma Program for Medicaid Members in Delaware. Additional health plan–supported educational and environmental interventions to address pediatric asthma were highlighted in a recent NIHCM article.
What progress has been made to close the gaps described in the 2007 report that you coauthored for the NIHCM Research and Educational Foundation, Reducing Health Disparities Among Children?
Health plans continue to develop and fund new initiatives and programs to address health disparities among children across the country, and many have expanded their reach beyond the traditional health care system to address the social determinants of health. Reducing health disparities has been a focus of many public and private partnerships, and NIHCM continues to highlight these efforts through our “Promising Practices in Maternal and Child Health” database. Additional evaluation research will also be critical for determining which program components are effective and should be replicated. While the continued implementation of the ACA will play a key role in reducing disparities by increasing access to insurance, it will be important for all stakeholders to remain diligent to ensure children can in fact access high-quality, culturally appropriate health care services.
Disclosure Statement: Ms. Kathryn Santoro disclosed that the NIHCM Foundation received grant funding from the Health Resources and Services Administration that was relevant to the work described in this article. She disclosed no other relevant financial, business, or professional affiliations.
About Kathryn Santoro, MA
Ms. Santoro is Director of Policy and Development for the NIHCM Foundation. In this capacity, she leads NIHCM’s maternal and child health portfolio, including work funded by the Health Resources and Services Administration and the Centers for Disease Control and Prevention, as well as NIHCM’s Transforming the Health Care Landscape webinar series. Under these projects, she conducts research and analysis on health policy issues to improve practices used by health care decisionmakers and industry leaders. Before joining the organization in 2004, Ms. Santoro was a Communications Assistant with Robert Betz Associates, a health policy consulting firm, and a Project Consultant for Women in Government/Digene Corporation, where she led the development of a state-by-state report card on cervical cancer screening.