HLTH 349
ARTICLE REVIEW 4 INSTRUCTIONS
This assignment is based upon the article “Health Care Reform and Equity: Promise, Pitfalls,
and Prescriptions,” found in the Reading & Study folder of Module/Week 7.
Please respond to the following:
In Health Care Reform and Equity: Promises, Pitfalls, and Prescriptions, Kevin Fiscella
describes the causes of health care disparities. He argues (in 2011) that the current health care
reform activities (i.e., the passage of the Affordable Care Act) offer a unique opportunity for a
more equitable health care system. He further states health care reform that includes elements
from six health care domains: access, primary care support, enhanced health information
technology, new payment models, a national quality strategy informed by research, and federal
requirements for health care disparity monitoring are the keys to increased health care equity.
He cites several promises, pitfalls, and prescriptions in the six domains that can impact health
care equity, ultimately deciding that these, along with effective implementation, improved
alignment of resources with patient needs and revitalization of primary care can effectively
produce a more equitable system. Choose two (2) of the health care reform domains and
thoroughly discuss whether and how the promises, pitfalls, and prescriptions Fiscella provides
dilutes or enriches the biblical worldview of public and community health.
The assignment is to be written as a paper. One source should be given to support your response
in addition to citing the assigned article, which is already embedded in the course. You should
use APA format, 12 font, double space, and write between 450–500 words maximum.
REFLECTION
Health Care Reform and Equity:
Promise, Pitfalls, and Prescriptions
Kevin Fiscella, MD, MPH
ABSTRACT
Departments of Family Medicine and Community & Preventive Medicine, University
of Rochester, Rochester, NY
The United States has made little progress during the past decade in addressing
health care disparities. Recent health care reforms offer an historic opportunity to
create a more equitable health care system. Key elements of health care reform
relevant to promoting equity include access, support for primary care, enhanced
health information technology, new payment models, a national quality strategy
informed by research, and federal requirements for health care disparity monitoring. With effective implementation, improved alignment of resources with
patient needs, and most importantly, revitalization of primary care, these reforms
could measurably improve equity.
Ann Fam Med 2011;9:78-84. doi:10.1370/afm.1213.
INTRODUCTION
T
he United States has made little progress toward greater equity in
health care quality according to the annual National Health Care Disparities Reports.1 Recent health care reforms offer an historic opportunity to make inroads. In this commentary, I review key provisions of these
reforms, particularly those in the Patient Protection and Affordable Care
Act, often shortened to Affordable Care Act (ACA) of 2010,2 and discuss
their potential promise, pitfalls, and steps (prescriptions) needed to jumpstart progress toward more equitable health care (Table 1). I begin by briefly
reviewing causes of health care disparities and then discuss selected, key
health care reform provisions within 6 interlocking domains: access related to
insurance coverage and costs, strengthening primary care, improvements in
health information technology, changes in physician payment, adoption of a
national quality, and improved disparity monitoring and accountability.
CAUSES OF HEALTH CARE DISPARITIES
Conflict of interest: Dr Fiscella served on the Institute of Medicine Committee on Future Directions for
the National Health Care Quality and Disparities
Report and has consulted for the Health Resources
Services Administration.
CORRESPONDING AUTHOR
Kevin Fiscella, MD, MPH
1381 South Ave
Rochester, NY 14620
Kevin_Fiscella@URMC.rochester.edu
Health care disparities related to race, ethnicity, socioeconomic status
(SES), and markers of social disadvantage result from a complex confluence of patient, clinician, and system levels factors.3 These disparities
often reflect reciprocal influences between social stratification and ensuing
social disadvantage and worse health4; unconscious clinician bias toward
socially disadvantaged persons5,6; separate and often unequal care7-10; and a
health care system, including primary care,11 that is ill-equipped to address
the often complex needs of socially disadvantaged patients, who often
become underserved patients.12
Equitable health care means more than elimination of bias, it also means
creation of patient-centered systems of care that support healing and caring
relationships that are responsive to patients’ needs, wishes, and context.13
Improving equity requires aligning health care resources and capability with
patient needs, particularly patients who have been historically underserved.12
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Table 1. Promise, Pitfalls, and Prescriptions for Improved Equity Under Health Reform
Health Reform
Provision
Promise
Pitfall
Prescription
Need for robust primary care system
Revitalize primary care
Remaining 23 million uninsured
Universal coverage
Absence of “public option” undermines
cost control for care for previously
uninsured
Does not address barriers related to
stigma related to mental health care
May accelerate trends toward cost
shifting to patients for medical and
behavioral care, worsening disparities
Expansion of Medicare eligibility and
other public options
Access (insurance and costs)
Expanded coverage
Coverage for up to 32 million uninsured
Behavioral health parity
Reduced cost barriers
Elimination of co-payments for evidencebased preventive care
Reduce cost barriers
Revitalization of primary care including the safety net
Improved physician
Modest improvement in
Not sufficient to generate practice
payments
resources
adaptive reserve for transformation
Elimination in MedicarePotential to minimize sepaDoes not address gap between MediMedicaid payment
rate and unequal systems
care and private insurance payments.
differences
Bonus for work in shortage areas
National Health
Care Work Force
Commission
Improvement in federal
load repayment
Collaborative Care
Network
Piloting of new care
models
Modest impact on physician
maldistribution
Potential to influence work
force maldistribution
Improved recruitment to
shortage areas
Improvement in care coordination for underserved
Spark innovation
Too small to have significant effect
Depends on authority of commission to
affect key issues
Does not address retention following
fulfillment of commitment
Need for vibrant primary care safety
net to coordinate care
Modest investments may not be
sufficient
Practice change is a continuous process
Integrate behavioral health services into
primary care
Restrict cost sharing based on percent
family income
Major payment reform
Eliminate differences in payment by
insurance type.
Prohibit segregation of care based on
payment type within health care systems that receive federal funds.
Comprehensive strategy to primary care
and workforce issues
Address student selection, training,
payments, and quality of practice in
shortage areas
Enhance quality of practice and payment
Strengthen adaptive reserve of safety
net
Support innovation in all practices
Greater funding for practice-based
research for underserved
Funding for primary care extension
programs
State-operated health
insurance exchanges
Opportunity to promote new
care delivery models
Health information technology
Incentives for physicians
Acceleration of diffusion
and hospitals
nearing tipping point
Not all states will opt for innovation
Does not ensure improvement in
quality
Digital divide by practice and patient
Support for quality improvement collaboratives that leverage health information technology
Subsidies for safety-net practices and
training and support for patients in use
of health information technology
Payment model reform
Payment Advisory Board
National Pilot Medicare
Payment Program
Potential move from volume
to value payment
Potential for changes in primary care payment
Piloting of bundled
payments
Success dependent on members of
board
Major changes in needed in quantity
and type of financing for primary care
Relatively small change
Build in monitoring of effects on care
for underserved patients
Unknown impact of bundled payments
on primary care
Potential adverse impact on
underserved
National quality strategy
Formal national quality
Potential to integrate multiple
improvement strategy
elements of health reform
Reporting of perforImproved accountability for
mance by federal
programs for underserved
programs
Monitoring disparities
Enhance collection of
disparity data within
health care
Analyze disparities
trends
Potential for neglect of the physicianpatient relationship
Inadequate funding for implementation and PBRN research, particularly
in safety-net practices
Need to keep patient and relationships
at fore
Improved funding for practice-based
research, particularly safety-net
practices
Improved detection of
disparities
Assessing disparities does not assure
they are addressed
Identification of key disparities for targeted action
Monitoring alone is not sufficient
Build in continuous loops between
reporting, policy/intervention and
follow-up
DHHS should hold federally sponsored
programs accountable for progress in
addressing disparities
DHHS = Department of Health and Human Services; PBRN = practice-based research network.
H E A LT H C A R E R E F O R M A N D E Q U I T Y
ACCESS
Improving equity begins with improving health care
system access. System access is strongly affected by
insurance coverage and cost. Minority and low-SES
patients are more often uninsured than their counterparts.1 Lack of health insurance is a major contributor
to health care disparities14; health care disparities are
smaller in such health systems as the Veterans Affairs,
where access is more uniform.15 ACA provisions will
eventually expand insurance coverage to an estimated
32 million uninsured persons, but the Congressional
Budget Office estimates that health care reform may
still leave 23 million persons, including undocumented
immigrants, without any coverage.16
Recent reforms also offer potential for improving access to behavioral care for poor and minority
patients and for addressing disparities in behavioral
health utilization.1 Cost represents a key barrier. Parity
provisions in the Mental Health Parity and Addiction
Equity (MHPAE) Act of 2008 (https://www.cms.gov/
healthinsreformforconsume/04_thementalhealthparityact.asp) and ACA minimize cost differences between
behavioral and medical care. Specifically, MHPAE prohibits health plans from imposing deductibles, co-payments, and out-of-pocket limits on mental health and
substance abuse coverage that are higher than those
imposed for medical-surgical coverage. It also prohibits
restrictions on days of hospital coverage and duration and scope of behavioral treatment beyond limits
that health plans impose for medical-surgical coverage. Access to behavioral health care for underserved
groups could be further enhanced through creation of
integrated primary and behavioral health care similar
to the Veterans Affairs health system.17
Health care costs contribute to disparities, even
among the insured.18 Insurance deductibles and co-payments discourage appropriate health care use,19 affecting
those with the least income. ACA will eliminate patient
cost sharing for evidence-based preventive services
covered by Medicare and Medicaid. It also authorizes
Medicare coverage for annual health assessments and
eventually eliminates the so-called donut hole in Medicare part D prescription coverage. Prohibitions against
exclusions for preexisting conditions and lifetime limits
on spending by health plans may provide greater benefit
to low-SES patients who are more often affected by
chronic conditions.20 These changes may also reduce
physician decision-making time devoted to patients’ ability to pay21 and may incrementally move the country
toward improved health care equity. Potential benefits of
these changes, however, may be undermined by trends
toward increased patient cost sharing.22 Cost sharing
disproportionately affects low-income patients.23 Premiums for obtaining insurance though health insurance
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exchanges for the uninsured will be based on household
income, but many low-income workers may continue to
pay high premiums for employer-based coverage.
PRIMARY CARE
Access to primary care is associated with fewer disparities in outcomes.24 A robust primary care system is the
cornerstone for a more equitable health care system.
Longitudinal, caring relationships with patients provide
the opportunity to minimize stereotypes and foster
patient enablement and capability, potentially yielding
more equitable care.25,26
Revitalization of primary care is critical to health
reform success.27 ACA takes important, although modest steps, in addressing critical primary care needs:
payment reform, enhancing the training pipeline,
transforming practice, and buttressing the primary
care safety net. ACA provisions include establishment
of a National Health Care Workforce Commission,
increased support for workforce training (Title VII
and the Prevention and Public Health Fund), cultural
competency training, enhanced payments, expansion of
health centers, and piloting of new care models. ACA
also provides bonus payments to primary care physicians under Medicare and eliminates differences in
payments between Medicaid and Medicare for primary
care. It further provides Medicare bonuses to primary
care physicians who work in shortage areas, helping
to minimize geographically related disparities. These
reforms may begin to minimize disparities in resources
between primary care practices whose patient populations differ by social disadvantage. These reforms could
also conceivably reduce de facto segregation in health
care by insurance type (eg, faculty practices vs clinics),
although federal regulations prohibiting intra-institutional segregation of care by insurance type within
systems receiving federal funding may be needed. To
be sure, modest increases in payments alone will not be
sufficient to address the maldistribution of primary care
physicians, much less avert a primary care shortage.28
Poor and minority patients are at greater risk for
lacking primary care; those with access are more often
seen within resource-strapped safety-net practices,
such as federally qualified community health centers
(FQHCs), hospital clinics, and a small portion of community physicians.7,29 Strengthening the primary care
safety net is critical to ensuring access after expansion
of insurance coverage.
FQHCs are the most important source of primary
care for underserved patients, currently serving 20
million patients who are largely minority and of low
income.30 FQHCs will likely remain the key source for
primary care to underserved groups under health care
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reform.30 ACA invests heavily ($11 billion) in FQHC
expansion, potentially doubling the number of patients
served. Annual federal loan repayment for physicians
working in underserved areas increases to $50,000
(from $35,000), part-time practice is now permitted,
and teaching time within FQHC is now counted for
repayment. Furthermore, ACA supports establishing
new teaching health centers and provides new systems
of payment for this teaching.
These investments alone are not sufficient to ensure
transformation of care within FQHCs. Enhancement
in health center financing will be needed to generate
an adaptive reserve (ie, capability of practices to implement and sustain change)31 to facilitate FQHC practice
redesign.32 Federal support is needed to sustain and
advance quality improvements previously initiated
through the Health Disparities Collaboratives.33 Innovative training programs are also needed to develop
future medical home leaders for the underserved.34
ACA also supports establishment of the community-based Collaborative Care Network Program
to support local consortia of health care providers
(including health centers) to coordinate and integrate health care services for low-income uninsured
and underinsured patients. Potentially, this provision
could foster innovative, community-wide solutions
for care for underserved patients, including promotion of patient capability.35 Success will depend on the
strength of local partnerships and creation of sustainable models of primary care delivery that effectively
coordinate use of community resources.
ACA aims to transform health care quality (including
primary care) through a series of small but potentially
synergistic steps.27 It promotes piloting of new care
models, including medical homes, chronic disease management teams, and integration of medical and behavioral health care. State-run health insurance exchanges
provide states with the opportunity to establish new
primary care models. If successful, these models could
reinvigorate primary care while creating systems of care
that provide the time, resources, and capability needed
to respond to the needs of underserved patients.11,36
The path to transformation will not be easy. As
the Patient-Centered Medical Home National Demonstration Project has shown, transformation is a
slow, challenging process, requiring high motivation
and often external support.31 Toward this end, ACA
authorizes the creation, but no corresponding funding, for primary care extension programs designed to
assist primary care practices in quality improvement.37
Funding for this program is critical if primary care is
take full advantage of reforms. Without buttressing
key resources in primary care and addressing adaptive
reserve within practices,38 the combined stress of care
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for more (newly insured) patients coupled with pressure to transform practice, could undermine patients’
care, demoralize primary care clinicians, and hinder
progress toward a more equitable system.
HEALTH INFORMATION TECHNOLOGY
Adequate health information technology, including
availability of electronic health records (EHRs), is one of
the pillars for transforming primary care and improving
health care quality and equality.39 Adoption has been
relatively slow, but a tipping point may be near. By 2009,
44% of office physicians in the United States reported
use of some type of EHRs.40 With funding through the
American Recovery Reinvestment Act (ARRA) of 2009
(http://www.recovery.gov/About/Pages/The_Act.aspx),
physicians and hospitals will receive financial incentives
through Medicaid or Medicare for acquiring and engaging in federally defined meaningful use of EHRs. Federal
certification of EHR vendors for meaningful use should
spur improvements in EHRs.41 Features, if sufficiently
user-friendly, such as patient registries, reminders, decision support, computerized order entry, and electronic
prescribing, offer the potential for improving equity
through improved tracking, population management,
standardization of care, and possibly reduced decisionmaking bias.42 Establishment of regional Health Information Technology Extension programs and Beacon
Community Cooperative Agreement programs may further facilitate technology diffusion, infrastructure, and
exchange capabilities within regions across the country.
Slower diffusion of this technology to practices
serving minority patients, however, could have the
unintended consequence of worsening health care disparities by further widening inequalities in resources
between providers.43 In addition, powerful incentives
may be needed to promote effective information
exchange between systems and between patients and
providers. Last, in the absence of targeted initiatives,
the digital divide in knowledge and access to technology could worsen disparities when practices begin
to implement online scheduling, patient portals, and
patient health records.44
PAYMENT MODELS
New payment models may potentially promote equity
by fostering quality improvement, including the development of new care models, such as the patient home,
potentially better suited to meet the needs of poor and
minority patients.11 Payment systems that reward payment for health care value (ie, better quality relative to
cost) rather than volume might produce better alignment between patient needs and resources.
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ACA innovations designed to enhance value include
allowing providers who are organized as accountable
care organizations to share in cost savings, creation
of an innovation center within Centers for Medicare
and Medicaid Services (CMS), establishment of an
independent payment advisory board, reduction in
hospital payments for hospital-acquired conditions,
and establishment of a national Medicare pilot program
to develop and evaluate bundled payments (a type of
limited capitation). Provided that bundled payments
take into account the greater health care needs of
underserved patients and do not penalize safety-net
providers,45 they offer the potential for promoting
equity by redirecting resources to health care value and
population health. As with any major reform, however,
unintended consequences are possible. Implementation
of bundled payments could discourage accountable
care organizations from enrolling underserved patients
because these organizations may fear potentially higher
costs, unless payments take into account patients’ social
disadvantage in addition to case-mix.46 Bundled payments could also undermine the sustainability of small
private practices that often provide care to underserved
patients in many rural communities.
A NATIONAL HEALTH CARE QUALITY
STRATEGY
Equity represents a core dimension of health care
quality.47 Efforts to promote health care quality offer
potential for promoting equity, particularly if efforts
include explicit focus on addressing disparities48 or produce “zero defects.”49 ACA directs the Secretary of the
Department of Health and Human Services (DHHS) to
develop a national quality improvement strategy including selecting and reporting on uniform quality measures
by federally sponsored programs. The secretary has
charged the Agency for Healthcare Research and Quality (AHRQ) with leading this effort. The appointment
of quality improvement maven, Donald Berwick, to
lead CMS may further energize health care reforms.
ACA calls for equity to be one of the considerations in
the development and selection of quality of measures.
Improved measurement of quality and equity could
focus more attention and resources on addressing health
care disparities and aligning resources with needs.
A shift in federal research funding priorities is necessary, however, to fully enable a national strategy to
improve health care quality and reduce disparities.50 In
2007, the United States spent 4.5% of total health care
expenditures on biomedical research, but only 0.1%
on health services research.51 The National Institute
of Health (NIH) director, Francis Collins has made
research relevant to health reform an NIH priority,52
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but this new NIH priority presumably refers mainly to
comparative effectiveness research rather than research
designed to optimize health care delivery. The ACA
has also upgraded the National Center on Minority
Health to an NIH institute. Although this change bodes
well for improved community-based health disparities
research, it is not clear whether it will shift funding
toward health care disparities research. A center of innovation will be established within CMS. Even so, developing and implementing a national quality and disparity
strategy will require adequate and stable PBRN funding
(eg, to support practice facilitators who can boost practices’ adaptive reserve), particularly implementation of
new care models within safety-net practices.53 Given the
growing federal investment in FQHCs and their pivotal
role in addressing disparities, research funding is needed
to inform optimal care delivery models in these sites.
MONITORING HEALTH CARE DISPARITIES
ACA directs DHHS to evaluate health and health care
systems to enhance collection and reporting of health
care data by race, ethnicity, sex, primary language,
disability, and rural residence. Similar directives are
included in EHR meaningful use requirements. Availability of these data will facilitate better assessment and
implementation of interventions to address disparities by
health plans and hospitals.54 ACA directs DHHS to analyze data to detect and monitor trends in health disparities for each federally conducted or supported health
care or public health program or activity. These requirements may facilitate greater accountability for assessing
and addressing health care disparities within federally
sponsored programs. With sufficient commitment from
DHHS leadership, this requirement could potentially
result in a systematic effort by federally sponsored
programs to publicly report on and address health care
disparities within their programs. These efforts could
be aided by changes in the National Healthcare Quality Report and National Healthcare Disparity reports
recommended by the Institute of Medicine.55 Included
are national priorities in areas of quality and disparities,
improved actionability including accountability, and an
expanded quality framework that includes the domains
of health care access and health care infrastructure
required to improve quality and equity. Closing the
feedback loop between quality and equity reporting and
corrective federal, state, and local policies will be critical
given the enormous complexity of reforms.
CONCLUDING THOUGHTS
Health care reforms, many not slated for enactment
until 2014, offer an unprecedented opportunity to cre-
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ate a more equitable patient-responsive health care
system. ACA targets access by expanding insurance
coverage and the FQHC safety net. Further legislation
will be required to address access for the remaining 23
million uninsured. Other provisions related to costs
may improve equity, but trends toward greater patient
cost sharing may offset gains unless ways are found to
mitigate their impact on low-income persons.
Health reform also offers promise in a number of
areas besides system access, including primary care,
health information technology, payment reform, a
national quality strategy, and disparity monitoring.
Two fundamental challenges lie in the way. The first
challenge is aligning health care resources with patients
needs. At the level of the patient visit,11 practice,7 and
hospital,9 resources are misaligned.12 Health care reform
takes small steps toward addressing this problem, but
trends toward pay for performance and bundled payment could worsen this mismatch if they fail to account
for the needs of underserved patients and practices
serving them.56,57 Ultimately, systems of payments must
account for patient morbidity as well as patient complexity,58 including contextual capability related to language, culture, health literacy, and disempowerment.
The second challenge relates to revitalization of
primary care, particularly for underserved patients.
Whether health reform promotes equity may depend
partly on how health reforms affect key relationships,
not only between clinicians and patients, but also
between clinicians and other team members. This
means creating systems that provide the time, space,
and interpersonal relationships necessary to ensure
high quality primary care. It also means creating primary care teams in which all members’ experience and
training are optimally utilized.59 With the diffusion of
health information technology and emerging changes
in payment, transformation to team-based care may
prove to be primary care’s greatest challenge. Emerging data suggest that teams improve patients’ health
status.60 Transformation to team care, however, is
enormously challenging. Transforming primary care
requires not only major changes in medical training61
but also supportive infrastructure, such as primary care
extension programs and learning collaboratives. Federal agencies charged with implementing health reform
should take notice.
Assuming health care reforms survive the looming political and legal land mines during the next four
years, primary care will likely confront a period of
extraordinary change. Success in creating a more equitable and patient-responsive health care system may
depend in part on our ability as primary care clinicians
to seize these opportunities and champion systems of
care responsive to the needs of all patients.
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To read or post commentaries in response to this article, see it
online at http://www.annfammed.org/cgi/content/full/9/1/78.
Key words: Healthcare disparities; health care reform; primary care;
health policy
Submitted July 20, 2010; submitted, revised, October 18, 2010;
accepted November 7, 2010.
Acknowledgement: Adjuah van Keken assisted with the preparation of
this manuscript.
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