Improving Health Communication One Word At a Time™

Aracely Rosales Chief Content Expert and Multilingual Director

Health Literacy Innovations

The Affordable Care Act – Are We Ready?

Session Goals:

Explore the link between the ACA, plain language, health literacy, and culture

List potential barriers consumers with limited literacy face when seeking health insurance coverage

Describe ways to adapt communication strategies to be culturally appropriate for your audience.

2

In March 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act

The Patient Protection & Affordable Care Act

3

1. Protects people from insurance abuse

2. Makes health care more affordable

3. Gives better access to care

4. Strengthens Medicare

The Law Improves 4 Key Areas: 4

The ACA Goals

The goals include:

Expand Medicaid to more qualified low-income people

Expand insurance to 32 million Americans

Create Health Insurance Exchanges

• Consumers offered options/prices allowing comparison-shopping

5

The ACA Challenges

Some of goals include:

Expand Medicaid to more qualified low-income people

Expand insurance to 32 million Americans

• How to successfully bring health care to consumers new to the health care system?

Create Health Insurance Exchanges

• How to make these effective?

6

The ACA

Opportunity for Health Literacy Strategies!

Some of goals include:

Get more low-income people, who qualify, apply for Medicaid

Expand insurance to 32 million Americans

• How to successfully bring new health insures to a complicated system?

Provides Health Insurance Exchanges

• How will these be effective?

The answer: Health Literacy Strategies! Plain Language Techniques! Cross Cultural Communication Techniques

7

Making the Connection

Understand the connection between the ACA & low health literacy

8

What is health literacy?

The ACA definition of health literacy is consistent with Healthy People 2010:

“The degree to which individuals have the capacity to

obtain, process, and understand basic health information and services needed to make

appropriate health decisions.”

-- Healthy People 2010

9

In Plain English

An individual's ability to understand and act on health information.

10

Current Picture of US Health Literacy

Today, more than 75 million people have low health literacy.

11

Current Picture of US Health Literacy

In fact, according to the NAAL:

12

Future Picture of US Health Literacy Due to the ACA

Today’s 75 million Americans with low health literacy

+ 2014 - expansion of health care to 32 million Americans new

to health care through exchanges

-----------------------

= Hundreds of millions of new Americans with low health literacy who will try to access a complicated health care system

13

Current Picture of US Health Literacy

Individuals with low levels of health literacy are least equipped to benefit from the ACA “Rates of low literacy are disproportionately high among lower-income Americans eligible for publicly financed care through Medicare or Medicaid.” M. Kutner et al.

The Health Literacy of America’s Adults: Results from the 2003 National Assessment of Adult Literacy. U.S.

Department of Education, National Center for Education. Washington DC, 2006.

14

Understand the law’s focus on health literacy

The provisions fall into six health and health care topics in the legislation

1. Coverage expansion 2. Equity 3. Workforce 4. Patient information at appropriate reading levels 5. Public health and wellness 6. Quality improvement:

• innovation to create more effective and efficient models of care • chronic illnesses requiring extensive self-management

15

Clarifying the Provisions

ACA provisions acknowledges the need to:

Communicate health and health care information clearly

Promote prevention

Be patient-centered

Assure equity and cultural competence

Deliver high-quality care

Focus on health literacy (direct & indirect)

16

Health Literacy and its Impact on Coverage Expansion

More affordable coverage is available through the new Exchanges by 2014. Now consumers can -

Look for and compare private health plans. Get answers to questions about your health coverage options. Find out if they are eligible for health programs or tax credits that make coverage

more affordable. Enroll in a health plan that meets their needs.

Individuals can enroll in private or public health insurance coverage Small employers will have better choice of plans and insurers at a lower cost More than 32 million Americans new to health care enter the system:

States have the option to cover more people on Medicaid and expand coverage to lower income qualified people.

More individuals with pre-existing conditions will have coverage options Young adults can to stay on their parent’s plan until they turn 26 years old

17

Direct Provisions for Health Literacy

18

Direct Provisions for Health Literacy

19

Direct Mention of Health Literacy

Provisions touch on issues of: • Research dissemination • Shared decision-making • Medication labeling • Workforce development

All four suggest the need to communicate effectively with consumers, patients,

and communities to improve the access and quality of health care. None of these provisions create explicit health literacy programs, specify

implementation or regulatory supports, or expand further on the term “health literacy” beyond its mention.

However, all provisions are consistent with the themes of patient-centeredness and overall quality improvement that are found more broadly throughout the legislation.

20

Indirect Provisions for Health Literacy

21

The Challenge

New inexperienced health care consumers will have greater difficulty with:

Understanding eligibility guidelines for various insurance programs

Participating in the buy-in process of the exchange or high-risk pools

Providing supplemental identification and citizenship documentation needed for enrollment

Understanding which services are covered

Recognizing cost-sharing and premium responsibilities

Choosing a health care provider

22

Implementing ACA

None of these reforms will fully succeed without:

Improving efforts to make all information understandable-plain language

Targeted efforts to enroll under-resourced diverse populations

23

The Health Literacy Solutions for Success Already Required by ACA

Consumer Education and Assistance

ACA provision calls for:

Development and utilization of uniform explanations of coverage documents

• A mandate that could be strengthened with explicit linkages to:

Health literacy principles Plain language use and techniques

24

The Health Literacy Solutions for Success Already Required by ACA

Clear and Consistent Information to Consumers About Their Health Insurance Coverage

When? Deadline: September 23, 2012 Why? For Information when coverage – is renewed, changes, information on demand, when shopping for coverage How? Use the short, easy-to-understand Summary of Benefits and Coverage (SBC)

A list of definitions (called the “Uniform Glossary”) explaining terms such as “deductible” and “co-payment”

25

The Health Literacy Solutions for Success Already Required by ACA

EXAMPLE To design easy-to-understand forms:

Explain all policies using the same plain-English terms – defined in the glossary

Giving examples of specific coverage

26

The Health Literacy Solutions for Success Already Required by ACA

Use of Information Technology and Reducing Burden on Employers and Insurers: Establishment of internet portal to help individuals and businesses: Interact with the insurance exchange Understand eligibility guidelines for Medicaid/CHIP/Medicare/high-risk pools The final rule ensures that in the vast majority of cases, the SBC can be provided:

• Electronically • Post it on its website • Provide it by email • Electronic disclosure is expected to reduce costs • Consumer safeguards are designed to ensure actual receipt by individuals

http://cciio.cms.gov/resources/other/index.html#sbcug

27

Diversity Challenges

Starting in 2014, Medicaid could be serving 80 million Americans — or a quarter of the U.S. population — each year after 2014.

This “expansion population” will likely: • Be racially and ethnically diverse • Be predominantly childless adults • Have high levels of substance abuse and prior jail involvement • Require care management for complex physical and behavioral health

needs.

Addressing health literacy, language and culture could be a significant issue for this population

28

Diversity Cultural Competence Solutions for Success Already Required by ACA

Diversity and cultural competency. The Affordable Care Act expands initiatives to increase racial and ethnic diversity in the health care professions. It also strengthens cultural competency training for all health care providers. Health plans will be required to use language services and community outreach in underserved communities. Improving communications between providers and patients will help address health disparities particularly in Hispanic communities, which currently have high numbers of uninsured people.

To have information presented by the national and regional exchanges be: • Culturally appropriate

• Linguistically appropriate Translation of all materials

Interpretation services as needed

29

Requirements to make insurance and enrollment information consumer friendly for: Readable web and print materials Media such as phone, television, radio, social media, and in-person outreach

Use of community-based organizations Culturally specific media campaigns “Promotores,” lay health workers Individual insurance brokers

Diversity Cultural Competence Solutions for Success Already Required by ACA

30

Other Strategies for Successful ACA Implementation

Simplifying Medicaid enrollment information is not a new- Health Literacy Innovation’s -National Survey of Medicaid Health Literacy Standards:

90% -some type of health literacy standard.

67% -at least a sixth-grade reading level

22% -reading level to be even lower

96% -simple enrollment forms

82% -states offer one-on-one enrollment assistance

72 % provide onsite assistance, counseling and/or a toll-free helpline

Many racial and ethnic eligible for Medicaid or CHIP are not enrolled:

• 80% eligible uninsured African-American

• 70 % of eligible uninsured Latino children

31

Other Strategies for Successful ACA Implementation

The Centers for Medicare and Medicaid Services (CMS) has: Released readability guidelines for Medicaid print materials

to states Mandated certain contract requirements around

communication standards for Medicaid managed care plans.

However, these guidelines lack: Strong enforcement Uniform oversight from any particular federal or state agency

32

Other Strategies for Successful ACA Implementation for Diverse Audiences

ACA provisions, that could be helpful to make a case:

1. Eliminate and remove a common administrative burden and impediment to participation

2. Use a new, uniform method for determining income eligibility

3. Streamline citizenship documentation requirements

4. Set up an electronic enrollment processes

33

Other Strategies for Successful ACA Implementation for Diverse Audiences

34

Other Strategies for Successful ACA Implementation for Diverse Audiences

35

Other Strategies for Successful ACA Implementation for Diverse Audiences

36

Other Strategies for Successful ACA Implementation for Diverse Audiences

37

Other Strategies for Successful ACA Implementation for Diverse Audiences

The ACA offers consumer protection which allows them to:

Choose a health plan that best suits their needs, provided is in their preferred language

Appeal a plan’s denial of coverage for needed services, provided they get help to understand and act on it.

Select an available primary care provider of their choosing, provided they understand the guidelines, and have access to that information in their preferred language.

38

Implement National Initiatives

Implement National Initiatives

39

Implement Universal vs. Target Approach

Make the business case for: • Health literacy, plain language, cultural competence, language access

Educate:

• The public and health professional: Mandate requirements Target ACA exchanges to ensure they use clear health communication

techniques

Address vulnerable populations such as:

• People with special needs, • Diverse minorities (hard to reach). • Use appropriate channels of communication

40

Improve Health ACA exchanges information

Make sure information is: Clear and actionable In the language of the target client

but-also easy to read or in plain language Support informed consumer decision

making

41

Improve Health Professional Skills

Improve Health Professional Skills to improve provider/client communication:

Require professional trainings

Develop targeted training curriculums

Provide tools and Resources to produce and simplify information

Use the right technology and tools to help save time and resources

42

Promote health care systems innovations

Implementation of policies and best practices:

• Cultural competence standards and models

• Language access practices

• Health literate systems

43

Use Available Resources 44

The Patient Protection Affordable Care Act Resources

The Patient Protection Affordable Care Act Resources

The Patient Protection Affordable Care Act Resources

The Patient Protection Affordable Care Act Resources

Summary

ACA creates opportunities for health literacy in all of the key domains of health and health care:

1.The Coverage Expansion -32 millions Americans

Low income Americans need to understand their options and navigate the enrollment process.

2.Equity:

Paying attention to cultural differences, language, and, literacy.

3.Workforce:

There are provisions in ACA related to disparities, cultural competency, patient-centeredness and health literacy

45

Summary

4. Health Care Information:

Patient information must be at appropriate reading

5. Public Health and Wellness:

The preparation of consumer must be done with low literacy in mind

6. Quality Improvement:

Develop, test and spread best practices to improve quality and reduce costs

This presents many new opportunities for making the case for investments in health literacy, language and culture

46

References

AHRQ Report—Literacy and Health Outcomes (2004) www.ahrq.gov/clinic/epcsums/litsum.htm

AMA Foundation Health Literacy www.ama-assn.org/ama/pub/about-ama/our-people/affiliated-groups/ama-foundation/our-programs/public-health/health-literacy-program.shtml

Fox, S. & Fallows, D. (2003) Internet Health Resources. Washington, DC: Pew Internet & American Life Project www.pewinternet.org/Reports/2003/Internet-Health-Resources.aspx

Healthy People 2010, Health Communication, Objective 11-2 www.healthypeople.gov/Document/HTML/Volume1/11HealthCom.htm

Health Literacy Innovations Resources http://www.healthliteracyinnovations.com/resources/

47

References

NLM Bibliography—Understanding Health Literacy and Its Barriers (2004) www.nlm.nih.gov/pubs/cbm/healthliteracybarriers.html

The Health Literacy of America’s Adults: Results from the 2003 National Assessment of Adult Literacy (2007) http://nces.ed.gov/pubsearch/pubsinfo.asp?pubid=2006483

The Joint Commission Report: “What did the Doctor Say?:” Improving Health Literacy To Protect Patient Safety (2007) www.jointcommission.org/PublicPolicy/health_literacy.htm

Medical Library Association “Top 10” Most Useful Consumer Health Websites www.mlanet.org/resources/medspeak/topten.html

IOM Report (2004) – Health Literacy: A Prescription To End Confusion

www.iom.edu/report.asp?id=19723

IOM Report—Health Literacy: A Prescription To End Confusion (2004) www.iom.edu/CMS/3775/3827/19723.aspx

Health Literacy Implications of the Affordable Care Act Commissioned by: The Institute of Medicine, Authored by: Stephen A. Somers, PhD, Roopa Mahadevan, MA

48