Assessing New York’s Health Care Disparities Using Health Plan Quality Data – American Journal of Managed Care

Report on Health Disparity Reduction in New York’s Medicaid Managed Care Programs

A Case Study in Advancing Sustainable Development Goals 3 and 10

Introduction: Aligning Health Equity with Global Goals

Achieving universal health coverage and reducing inequality are central tenets of the United Nations Sustainable Development Goals (SDGs), particularly SDG 3 (Good Health and Well-being) and SDG 10 (Reduced Inequalities). Health care disparities driven by socioeconomic status, a key indicator of which is insurance type (commercial/private vs. Medicaid), represent a significant barrier to these goals. This report assesses the effectiveness of New York State’s extensive use of waiver programs and financial incentives within its Medicaid managed care system in reducing these disparities. Using the newly developed Health Insurance Disparities Index (HeIDI), this analysis compares the performance of New York’s Medicaid plans against national averages to determine progress toward providing equitable, high-quality care for low-income populations, including those with severe mental illness or substance use disorders.

Methodology for Measuring Progress on Health Equity

Study Design and Data Framework

The study employs the HeIDI methodology, which utilizes publicly available quality metrics to generate an annual disparity score. This approach directly supports the monitoring and accountability frameworks essential for tracking progress on the SDGs.

• Data Sources: The analysis draws on public quality metrics from the National Committee for Quality Assurance (NCQA) Healthcare Effectiveness Data and Information Set (HEDIS) and New York’s e–Quality Assurance Reporting Requirements (eQARR) for measurement years 2019-2023.
• Comparative Analysis: Performance of commercial/private health maintenance organizations (HMOs) is compared against Medicaid HMOs, both nationally and specifically within New York. This comparison serves as a proxy for income-based disparities, directly addressing the core of SDG 10.
• Specialized Population Focus: A separate analysis was conducted for New York’s Medicaid Health and Recovery Plan (HARP) plans, which serve individuals with severe mental illness or substance use disorder, a vulnerable population whose inclusion is critical to the SDG principle of “leaving no one behind.”

The Health Insurance Disparities Index (HeIDI)

The HeIDI calculation provides a standardized measure of the quality gap between insurance types. A score of 0 indicates perfect equity in the quality of care between Medicaid and commercial plan enrollees, aligning with the ultimate objective of SDG 3.8 (universal access to quality health care). Scores greater than 0 quantify the extent of the disparity. The index is calculated by:

1. Summing the weighted performance differences for each quality measure where commercial plans outperform Medicaid plans.
2. Dividing this sum by the weighted total of the commercial plans’ performance rates.
3. Excluding measures not publicly reported by New York to ensure a fair comparison.

Findings: New York’s Superior Performance in Reducing Health Disparities

Mainstream Medicaid Plans Outperform National Average

The results indicate that New York’s policy interventions have successfully narrowed the quality-of-care gap, making significant strides toward SDG 3 and SDG 10. Between 2019 and 2023, New York’s Medicaid plans consistently outperformed national Medicaid plans by a factor of two. The HeIDI score for New York was consistently 4.8 to 5.9 percentage points lower than the national score, signifying that care provided to Medicaid enrollees in New York is substantially more equitable compared to the national standard.

Specialized HARP Plans Demonstrate Enhanced Equity

The analysis of HARP plans, which serve some of the most disadvantaged Medicaid beneficiaries, further underscores New York’s commitment to equitable care. Key findings include:

• New York’s HARP plans consistently demonstrated superior, more equitable performance when compared to national mainstream Medicaid plans.
• Even with the profound challenges faced by the HARP enrollee population, these specialized plans outperformed national Medicaid plans by at least one point annually.

This success highlights a targeted approach to vulnerable populations that is fundamental to achieving the inclusive vision of the SDGs.

Discussion: Policy Drivers and Implications for SDG Advancement

Identifying Key State-Level Initiatives

New York’s superior performance in reducing health disparities can be attributed to a robust policy framework that actively promotes the goals of SDG 3 and SDG 10. These initiatives serve as a model for other states and jurisdictions. Potential drivers include:

• Value-Based Payment (VBP) and Quality Incentives: Strong financial incentives that link reimbursement to quality performance, encouraging plans to improve care for all members.
• Targeted Waiver Programs: The use of Section 1115 waivers, such as the Delivery System Reform Incentive Payment (DSRIP) program and the new Health Equity Reform program, to integrate physical and behavioral health and address health-related social needs.
• Enhanced Care Delivery Models: Programs like Health Homes facilitate improved care coordination for high-risk populations, leading to better outcomes and reduced inpatient admissions.
• Integration of Services: A focus on integrating physical and behavioral health services addresses the holistic needs of individuals, a cornerstone of comprehensive well-being under SDG 3.

The HeIDI Framework for Monitoring SDG Progress

The HeIDI tool offers a practical and accessible platform for states to monitor health care disparities and measure progress toward health equity. By leveraging publicly available data, it provides a cost-effective way for policymakers to identify gaps and assess the impact of interventions designed to advance SDG 3 and SDG 10. This study demonstrates its utility as a case study for New York, suggesting it can be replicated to foster accountability and drive improvement nationwide.

Conclusion: A Model for Achieving Health Equity

This report concludes that New York’s Medicaid managed care programs have made substantial and consistent progress in narrowing health care disparities compared to national benchmarks. The state’s strategic use of financial incentives, waiver programs, and integrated care models has resulted in more equitable health care delivery, directly contributing to the advancement of Sustainable Development Goal 3 (Good Health and Well-being) and Sustainable Development Goal 10 (Reduced Inequalities). These findings should compel health systems researchers and state policymakers to analyze and potentially replicate the characteristics of New York’s successful approach to Medicaid administration to accelerate progress toward universal health equity.

Analysis of Sustainable Development Goals in the Article

1. Which SDGs are addressed or connected to the issues highlighted in the article?

1. SDG 3: Good Health and Well-being
   • The article’s primary focus is on assessing the quality of healthcare and ensuring well-being for all. It specifically examines physical health services, mental health, and substance use disorders, which are central components of SDG 3. The study evaluates New York’s policies aimed at improving health outcomes for its Medicaid population, including those with severe mental illness.
2. SDG 10: Reduced Inequalities
   • The core theme of the article is the reduction of health disparities, which is a direct form of inequality. The study analyzes the gap in healthcare quality between different income groups, represented by enrollees in Medicaid (lower-income) versus commercial/private insurance plans (higher-income). The entire purpose of the Health Insurance Disparities Index (HeIDI) is to measure and track this inequality, aligning perfectly with the goal of reducing inequalities within and among countries.
3. SDG 1: No Poverty
   • The article explicitly links health disparities to poverty and socioeconomic status, stating they are “major social determinants of health (SDOH) driving these disparities.” The study focuses on the Medicaid program, a social protection system for low-income individuals. By assessing the effectiveness of Medicaid in providing high-quality care, the article addresses a critical aspect of mitigating the impacts of poverty on health and well-being.

2. What specific targets under those SDGs can be identified based on the article’s content?

1. Under SDG 3 (Good Health and Well-being):
   • Target 3.4: “By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being.” The article directly addresses this by evaluating quality measures for physical health (e.g., “controlling high blood pressure”) and by specifically analyzing New York’s Health and Recovery Plan (HARP) for “individuals with severe mental illness or substance use disorder.”
   • Target 3.5: “Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol.” The analysis of HARP plans, which provide “specialized services for adults with serious mental illness (SMI) and/or severe substance use disorder (SUD),” is a clear connection to this target.
   • Target 3.8: “Achieve universal health coverage, including financial risk protection, access to quality essential health-care services…” The article investigates whether state policies, waiver programs, and financial incentives lead to higher *quality* of care for Medicaid enrollees, moving beyond mere coverage to ensure the services provided are effective and equitable.
2. Under SDG 10 (Reduced Inequalities):
   • Target 10.2: “By 2030, empower and promote the social, economic and political inclusion of all, irrespective of… economic or other status.” The study’s focus on closing the healthcare gap for low-income populations (Medicaid enrollees) is an effort to ensure their inclusion in receiving high-quality health services, irrespective of their economic status.
   • Target 10.3: “Ensure equal opportunity and reduce inequalities of outcome…” The article evaluates whether New York’s policies have successfully reduced the “inequalities of outcome” in healthcare quality between different income groups. The HeIDI score is designed precisely to measure this gap in outcomes.
3. Under SDG 1 (No Poverty):
   • Target 1.3: “Implement nationally appropriate social protection systems and measures for all… and by 2030 achieve substantial coverage of the poor and the vulnerable.” Medicaid is a key social protection system in the United States. The article assesses the quality and effectiveness of this system in New York, contributing to the understanding of how such systems can be improved to better serve the poor and vulnerable.

3. Are there any indicators mentioned or implied in the article that can be used to measure progress towards the identified targets?

1. Health Insurance Disparities Index (HeIDI): This is the central indicator developed and used in the study. The article defines the HeIDI score as reflecting “the percentage-point difference in the quality of care received by Medicaid enrollees relative to commercial/private enrollees.” It serves as a direct measure of health inequality (SDG 10) and the quality of care for vulnerable populations (SDG 3, SDG 1).
2. Healthcare Effectiveness Data and Information Set (HEDIS) Measures: The HeIDI is built upon HEDIS measures. The article mentions that HeIDI uses “24 physical medicine–related and 15 behavioral health–related measures” from HEDIS. These are specific, validated indicators of healthcare quality. Examples provided include:
   • Controlling high blood pressure (outcomes-based measure)
   • Breast cancer screening (process-based measure)
   • Adolescent and childhood immunizations
   • Initiation of substance use disorder treatment (IET)
   • Engagement of substance use disorder treatment (IET)
3. Reduction in Hospital Utilization: The article implies this as an indicator of success for New York’s programs. It notes that the state’s Health Home program led to “at least a 25% reduction in inpatient admissions and emergency department visits for this high-risk population,” which indicates improved health management and outcomes.

4. Table of SDGs, Targets, and Indicators

Source: ajmc.com