Since taking office, the Biden-Harris Administration has redoubled efforts to expand health care access for underserved communities. The Administration has issued several Executive Orders that aim to address inequities and discrimination faced by , Lesbian, Gay, Bisexual, Transgender, Queer, and Intersex (LGBTQI+) individuals, people with disabilities, and the Medicaid-eligible population. The Department of Health and Human Services’ (HHS) Strategic Plan for 2022 – 2026 and Equity Action Plan and the Center for Medicare & Medicaid Services’ (CMS) and Framework for Health Equity 2022 – 2032 align with the Administration’s stated goal to address barriers and inequities in health access, services, and outcomes. Several proposed HHS regulations, including the long-awaited Nondiscrimination in Health Programs and Activities Rule (implementing Section 1557 of the Affordable Care Act), work toward this vision. This blog will highlight how the Administration has laid the groundwork for improving health equity, particularly within Medicaid and the Children’s Health Insurance Program (CHIP), and where it has more work to do.
Commitment to demographic data collection
For decades, members of underserved communities have raised concerns about lack of equity in access to Medicaid and CHIP programs and services. State and federal agencies need data to identify these issues in real time and create targeted solutions. Demographic data — including race, ethnicity, primary language, age, disability, sex, variations in sex characteristics, gender identity, and sexual orientation — can illustrate the different ways different populations experience, access, and utilize health programs. Particularly for programs that serve the public, like Medicaid and CHIP, demographic data is crucial to determine whether access, quality, and outcomes are equitable for historically underserved populations. As one example of its importance, demographic data on the race and ethnicity of COVID-19 vaccine recipients showed the ways in which systems of vaccine distribution and access created inequitable treatment and outcomes for Black, Latinx, and Indigenous communities. Data then empowers agencies to address inequities and enforce civil rights laws: attention to identified gaps invigorated efforts to increase vaccine availability and accessibility among Black, Latinx, and Indigenous communities. When used proactively, demographic data collection can lessen the burden on the affected communities to repeatedly call attention to inequities and discrimination themselves.
The Biden-Harris Administration has included demographic data collection in its priorities from day one, and HHS has followed suit. Executive Order 13985 on Advancing Racial Equity and Support for Underserved Communities established the White House Equitable Data Working Group, which issued a report on gaps and recommendations for demographic data collection in federal programs, including within HHS. E.O. 13985 also charged each agency with creating an equity plan, which HHS published in April 2022. HHS’s Equity Action Plan includes five major goals for the agency, one of which solely focuses on increasing capacity across the agency to consistently collect demographic data to identify and address inequities.
Data plays a central role in many of the agency’s forward-looking equity goals. HHS’s Strategic Plan for 2022 – 2026 relies on demographic data to measure progress toward many of its stated objectives, either directly or indirectly. For example, in Objective 3.4, HHS directly commits to “leverage data to inform the development of effective and innovative prevention and intervention models to address neglect, violence, trauma, and violence.” Objective 1.3 addresses “removing barriers to healthcare access to advance health equity and reduce disparities;” and demographic data is required to understand the impact of interventions on reducing disparities. CMS’s Strategic Plan and Framework for Health Equity 2022 – 2032 also put demographic data collection front and center. The first pillar of the CMS Strategic Plan is “health equity” and includes the priority “Expand and standardize the collection and use of data.” Similarly, Priority 1 of the CMS Framework for Health Equity is to “Expand the Collection, Reporting, and Analysis of Standardized Data” throughout CMS programs. With this priority-setting, CMS commits to use demographic data to “measure progress against a baseline” and work toward consistent improvement in defined quality metrics in Medicaid and CHIP.
Focus on access in enrollment and eligibility
CMS Administrator Chiquita Brooks-LaSure and Center for Medicaid & CHIP Services (CMCS) Administrator Daniel Tsai have emphasized the need to reduce administrative burdens for those eligible for Medicaid and CHIP. – such as paper documentation, verification by mail, lengthy call center wait times, and poorly designed websites or mobile apps – reduce the likelihood that eligible individuals can enroll and access health care.
HHS’s Equity Plan acknowledges that administrative burdens contribute to health disparities. As one example, lack of access to care in the postpartum period can cause or exacerbate health problems, especially for Black and Indigenous people, who disproportionately experience compounding inequities and discrimination in postpartum care. In its Equity Plan, HHS commits to working with states to expand postpartum coverage to twelve months, eliminating the need for eligible individuals to re-verify eligibility or re-apply in the event of losing coverage. This action helps eligible individuals stay enrolled and preserves access to health care during a period when regular access to care has critical and long-term positive effects. As of this writing, twenty-six states have implemented expanded postpartum coverage, and eight additional states plan to do so.
CMS has also prioritized equity in enrollment through its recent proposals and requests for information. The Proposed Rule on Streamlining the Medicaid, Children’s Health Insurance Program, and Basic Health Program Eligibility Determination, Enrollment, and Renewal Process would extend outreach efforts to Medicaid- and CHIP-eligible individuals, reduce common administrative hurdles, and promote exchange of information between insurance affordability programs. These actions increase the likelihood that eligible families and individuals get and stay covered.
CMS’s Request for Information on Access to Care and Coverage for People Enrolled in Medicaid and CHIP; and Request for Information on Promoting Efficiency and Equity within CMS Programs seek information on enrollee and Medicaid-eligible persons’ experiences in access to inform future CMS policy. The requests for information focus on uncovering health disparities and center the lived experiences of underserved populations in doing so. CMS’s renewed focus on elevating the concerns of underserved communities in particular demonstrates a recognition that BIPOC and LGBTQ+ populations, people who are limited English proficient (LEP), people with disabilities, and people living in rural areas disproportionately experience barriers to access. CMS policies designed to reach those with the greatest barriers to access will boost access for the entire eligible population.
Tracking quality through metrics
HHS and CMS recognize that focus on quality of care throughout its health care programs has a crucial impact on health equity for BIPOC, LGBTQI+, and LEP individuals, as well as people with disabilities, who are more likely to use these programs. Throughout the HHS Strategic Plan and the CMS Framework for Health Equity, the agency emphasizes measurement of quality, including culturally and linguistically competent, accessible care, throughout the health care delivery system. For example, Objective 1.2 of the Strategic Plan addresses implementation of national standards for culturally and linguistically appropriate care as well core clinical measures. These standards can be used by agencies, programs, communities, and other entities to better understand health access and outcomes across populations. They can also bring better clarification to health inequities and set parameters for potential solutions.
CMS’s Proposed Rule to Improve Medicaid and CHIP Quality Reporting Across States builds directly on this groundwork. The Proposed Rule establishes core quality measures for children’s health, behavioral health for adults, and for individuals who access care through health homes enrolled in Medicaid and CHIP. These quality measures identify key indicators of health and require tracking of health disparities across specific populations, which would allow the agency to create targeted interventions to advance health equity. CMS will require states to report publicly on these measures beginning in 2024.
Advancing equity through nondiscrimination
Nondiscrimination is a basic tenet of quality health care. Bias, ignorance, discrimination, or mistreatment of individuals based on race, ethnicity, language, sex and variations in sex characteristics, sexual orientation, gender identity, age, disability, income, pregnancy status, and other factors are indicators of poor quality health care as well as civil rights violations. Yet, they continue to impede access to care at alarming rates.
In recognition of the continued harm caused by discrimination and bias, the Biden-Harris Administration proposed a new version of the rule implementing the nondiscrimination provision of the Affordable Care Act. HHS’s Proposed Rule on Nondiscrimination in Health Care Programs and Activities would strengthen both access and quality of health care for BIPOC, LEP, and LGBTQ+ individuals, and PWD by clarifying the scope and application of nondiscrimination protections. The Proposed Rule would bolster protections for LEP individuals and PWD, who must be provided language and accessibility supports throughout the health system. It also seeks to greatly improve access to care for transgender and other gender diverse individuals by regulating gender-affirming and transition-related health care in insurance networks and coverage.
Conclusion
The Biden-Harris has made significant progress addressing health equity in its first two years. The vision set out by the HHS Equity Plan, Strategic Plan, and CMS Framework for Health Equity apply broad concepts of equity, quality, and accessibility to specific areas of the Medicaid and CHIP programs with the goal of advancing health equity for all. The proposed rules on Nondiscrimination, Streamlining Medicaid and CHIP, and Quality Reporting should be finalized without delay to ensure these goals become a reality. We hope to see the Administration continue to make progress on these issues and put more of these concepts into action in the coming years.
