Presented by Aracely Rosales on September 6, 2012 at the third annual Center for Health Literacy Conference: Plain Talk in Complex Times.

1. The Affordable Care Act –
Are We Ready?
Aracely Rosales
Chief Content Expert and Multilingual Director
Health Literacy Innovations
Improving Health Communication One Word At a Time™

2. Session Goals:
2
 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.

3. The Patient Protection & Affordable Care Act
3
In March 23, 2010, President Obama signed into law the
Patient Protection and Affordable Care Act

4. The Law Improves 4 Key Areas:
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1. Protects people from insurance abuse
2. Makes health care more affordable
3. Gives better access to care
4. Strengthens Medicare

5. The ACA Goals
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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

6. The ACA Challenges
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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?

7. The ACA
Opportunity for Health Literacy Strategies!
7
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

8. Making the Connection
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Understand the connection between the ACA & low
health literacy

9. What is health literacy?
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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

10. In Plain English
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An individual's ability to understand and act on health information.

11. Current Picture of US Health Literacy
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Today, more than 75 million people have low health literacy.

12. Current Picture of US Health Literacy
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In fact, according to the NAAL:

13. Future Picture of US Health Literacy
Due to the ACA
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 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

14. Current Picture of US Health Literacy
14
Individuals
with low levels of health literacy are least
equipped to benefit from the ACA
“Rates oflow 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 .

15. Understand the law’s focus on health literacy
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 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

16. Clarifying the Provisions
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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)

17. Health Literacy and its Impact on Coverage Expansion
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 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

18. Direct Provisions for Health Literacy
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19. Direct Provisions for Health Literacy
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20. Direct Mention of Health Literacy
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 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.

21. Indirect Provisions for Health Literacy
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22. The Challenge
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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

23. Implementing ACA
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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

24. The Health Literacy Solutions for Success
Already Required by ACA
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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

25. The Health Literacy Solutions for Success
Already Required by ACA
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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”

26. The Health Literacy Solutions for Success
Already Required by ACA
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EXAMPLE
To design easy-to-understand forms:
Explainall policies using the same plain-English terms
– defined in the glossary
Giving examples of specific coverage

27. The Health Literacy Solutions for Success
Already Required by ACA
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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

28. Diversity Challenges
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 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

29. Diversity Cultural Competence Solutions for Success
Already Required by ACA
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 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

30. Diversity Cultural Competence Solutions for Success
Already Required by ACA
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 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

31. Other Strategies for Successful
ACA Implementation
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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

32. Other Strategies for Successful
ACA Implementation
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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

33. Other Strategies for Successful
ACA Implementation for Diverse Audiences
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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

34. Other Strategies for Successful
ACA Implementation for Diverse Audiences
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35. Other Strategies for Successful
ACA Implementation for Diverse Audiences
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36. Other Strategies for Successful
ACA Implementation for Diverse Audiences
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37. Other Strategies for Successful
ACA Implementation for Diverse Audiences
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38. Other Strategies for Successful
ACA Implementation for Diverse Audiences
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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.

39. Implement National
Initiatives
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 Implement National
Initiatives

40. Implement Universal vs. Target Approach
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 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

41. Improve Health ACA exchanges information
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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

42. Improve Health Professional Skills
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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

43. Promote health care systems innovations
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 Implementation of policies and best practices:
• Cultural competence standards and models
• Language access practices
• Health literate systems

44. Use Available Resources
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The Patient Protection The Patient Protection The Patient Protection
Affordable Care Act The Patient Protection
Affordable Care Act Affordable Care Act
Resources Affordable Care Act
Resources Resources
Resources

45. Summary
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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

46. Summary
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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

47. References
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 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/

48. References
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 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