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Health Equity Forum: Executive Director Article – February 2016

Covered California Poised to Prioritize Health Disparities Reduction and Improve Quality

By Sarah de Guia, Executive Director, CPEHN

For decades, CPEHN and other health advocates have led the charge in arguing for a more comprehensive focus on reducing health disparities. Years of data show the pervasiveness of health disparities particularly among communities of color and limited English proficient communities. Recent data from the Agency on Quality Health Care Research shows that disparities have actually worsened among certain populations.[1]

Now, Covered California is proposing to take action! At the recent Board meeting, Covered California presented recommendations to require health plans to meet concrete, enforceable health disparities reduction goals. Specifically, the plans will be required to reduce health disparities in target areas including diabetes, hypertension, asthma, and behavioral health.

With this effort, California has the opportunity to lead the nation by ensuring that health equity is not only important but central to all of its quality improvement strategies and to the exchange’s ability to achieve its mission of reducing health disparities in our state. Chronic conditions are the leading cause of death in the United States and the biggest contributor to health care costs. According to the California Health Care Foundation, about 40% of adults in California — over 11 million people — reported having one or more chronic condition, and about 3 million adults reported having two or more.[2] Disparities experienced by communities of color in illness and death rates associated with chronic diseases such as diabetes, hypertension, asthma, and mental health are persistent. For example, in California Latinos and African Americans have twice the prevalence of type 2 diabetes and are twice as likely to die from the disease.[3] The prevalence of current asthma among American Indians and Alaska Natives is three times greater than the state average. African Americans have exceptionally higher rates of asthma prevalence (40%), four times higher asthma ED visit and hospitalization rates, and two times higher asthma death rates.[4] And approximately 1 in 10 American Indians and Alaskan Natives, African Americans, and Latinos experienced serious psychological distress in the past year.[5]

In addition to requiring plans to work towards reducing health disparities, Covered California will also be requiring health plans to improve their data collection efforts. By 2019, health plans will be required to achieve 80 percent self-reported racial/ethnic identity of their enrollees. This direct reporting is critical to accurate assessments and data analysis to help understand true disparities.

While these provisions are a great first step, CPEHN has urged Covered California to ensure health equity is an integral component of all of Covered California’s key quality improvement initiatives by requiring plans to track and trend disparities in all quality initiatives and conducting health disparities assessments to ensure quality improvement interventions are not worsening disparities or leaving existing disparities in place. Rather than continuing to see quality improvement and disparities reduction as separate objectives, especially given the fact that the majority of Covered California enrollees (60%) are from communities of color, we argue that health equity and quality improvement must be linked. Even the Centers for Medicare and Medicaid Services now recommends that agencies evaluate disparities impacts and integrate equity solutions across all programs.[6] Without an explicit focus on disparities reduction, quality interventions run the risk of leaving disparities constant or could have unintended consequences and worsening health care disparities by creating pressure for providers to avoid caring for people who are perceived to be high-risk patients.[7]

Making equity a central component of Covered California quality improvement initiatives will help to ensure those initiatives are actually meeting overall quality improvement goals. Covered California will vote on this important issue at the April 2016 Board meeting. CPEHN will be there front and center to inform and support this initiative. Please stay tuned for more information about how you too can advance these concrete goals towards achieving health equity in Covered California.

[1] 2014 National Healthcare Disparities Report, Agency on Quality Health Care Research (AHRQ), May 2015. Click here to download the report. 

[2] “Californians with the Top Chronic Conditions: 11 Million and Counting,” California Health Care Almanac 2015. California Health Care Foundation, April 2015.

[3] “Burden of Diabetes in California,” California Department of Public Health Chronic Disease Control Branch, September 2014

[4] Asthma in California: A Surveillance Report, May 2013. California Department of Public Health:

[5] “Californians with the Top Chronic Conditions: 11 Million and Counting,” California Health Care Almanac 2015. California Health Care Foundation, April 2015.

[6] “The CMS Equity Plan for Improving Quality in Medicare,” September 2015.

[7] “Quality improvement efforts under health reform: How to ensure that they help reduce disparities – not increase them,” RM Weinick, R Hasnain-Wynia – Health Affairs, 2011.