HIV POLICY UPDATE

July 10, 2024

States Improve on ACA to Enhance Health Equity 

Factors like poverty, pollution, crime and a lack of green spaces drive deep racial and ethnic disparities in health. Meanwhile, a lack of affordable, quality health care options make it difficult for those who are most impacted by environmental factors to receive comprehensive health care. These inequities are not driven by individual behavior but by systems and structures inside and outside of our health care system.

Progressive State Strategies Go Beyond the ACA

The Affordable Care Act (ACA) has endeavored to improve the quality of health care for health coverage sold through the marketplace by establishing a Quality Improvement Strategy program (QIS) and Quality Rating System (QRS). More recently, the federal government has started using these metrics to measure and advance health equity. Federal rules now require that all marketplace insurers collect clinical data by race and ethnicity and then develop a strategy to reduce health disparities.

Most state-based marketplaces have opted to stick closely to the federal approach even though they are authorized to supplement the federal minimum standards with state-specific quality measures. However, California and Washington are two exceptions to this rule.

California’s Improvement of QRS

The ACA’s QRS scores individual health plans on a scale of one to five. The scores are determined based on the insurers’ submission of data on the enrollee experience, plan efficiency, affordability and management, in addition to clinical data. Each plan must report 10 of these 28 measures by race and ethnicity. By 2025, that number is reportedly increasing to 15.

California has introduced a new custom Quality Transformation Initiative (QTI) that will further reduce health disparities. This QTI program offers two improvements on QRS:

  • California will penalize insurers who place below the 66th national percentile for four the following QRS-required clinical measures: controlling high blood pressure, comprehensive diabetes care, colorectal cancer screening and childhood immunization status.
  • Additionally, carriers will also be penalized for failing to report each enrollee’s primary spoken and written language and collecting less than 80 percent of its total enrollees self-reported race and ethnicity data.

Washington’s Improvement of QIS

The ACA’s QIS program requires that carriers who participate in the marketplace for at least two years design and implement both of the following:

1. A strategy to improve its performance in at least one of four key categories:

  • Health outcomes
  • Hospital readmissions
  • Patient safety and medical errors
  • The promotion of wellness and health

2. A strategy dedicated to reducing disparities among any of the following:

  • People of color
  • LGBTQ+ people
  • People with disabilities
  • People who live in rural areas
  • People otherwise adversely affected by poverty and inequality in health and health care

In 2022, Washington state began customizing its QIS requirements in the several ways. It chooses specific QRS clinical measurements for each coverage year and then requires that insurers provide the state with data and then implement a quality improvement strategy incorporating its own results. For 2024, carriers are required to submit QRS measurements for cervical cancer screenings and antidepressant medication management.

Washington also explicitly targets its known health disparities. Historically, the clinical evidence in the state showed racial and ethnic disparities in cervical cancer screening rates and antidepressant medication adherence. Whereas CMS requires insurers to report both measurements under the federal program, Washington goes further by requiring those measurement results to be reported by race and ethnicity, which allows these health disparities to be targeted for elimination.

Ending the HIV Epidemic with Better Data

Despite progress in reducing new HIV infections in the United States, new HIV infections continue to occur at an alarming rate, especially among minoritized populations. Quality reporting programs that do not rely on data stratified by race and ethnicity serve to reinforce the age-old systems and disparities that plague our nation.

Conclusion

The U.S. has laid out ambitious goals to end HIV domestically through the National HIV Strategy and Ending the HIV Epidemic Initiative. These goals will not be achieved without intentional efforts to address health inequities faced by racial and ethnic minorities. As you champion the adoption of customized approaches to federal standards within your practice and state, let’s work together to share best practices. Your voice is vital in continuing to advance the health equity victories of the ACA. It will take all of us to continue to move forward to their day where the HIV epidemic is a thing of the past.

Our policy committee is excited to partner with members on all issues of health equity as we continue to identify ways in which provider voices can help share our health care policies in this turbulent climate. If you are interested in joining our continuing conversations in this regard, please reach us at chauncey@aahivm.org.

View the latest Policy Update here.