Advancing Equity Through Public Options: How Colorado is Designing Culturally Responsive Networks

In states across the country, the 2021 legislative session turned out to be pivotal for innovative health policy. We’ve written a lot on what states undertook at the start of this year, and now we’re going to take a deep dive into what those states can do next. 

USofCare is proud to have been a part of the Colorado coalition to help support and advance a piece of monumental health care legislation, a multi-year effort resulting in enactment of the Colorado Option. The Colorado Option has great potential to expand access to high-quality, equitable, affordable health care to Coloradans.

While there has been a lot of focus on the Colorado Option and other public health insurance options generally, less focus has been paid to specific provisions in the legislation that are geared towards reducing racial health disparities and improving equity. The Colorado Option approaches health equity in an innovative way and can be an example that other states and Congress can watch. 

The Colorado Option is the first effort to establish “culturally responsive” health care provider networks, which are required to be informed by and responsive to the unique cultural needs of diverse Coloradans. The new law provides a real opportunity to reduce health disparities and champion health equity within the system. 

Colorado officials have the chance to build on current requirements for cultural competence for health care providers and systems — which broadly focus on the ability of providers and organizations to account for how an individual’s race, ethnicity, cultural background, language proficiency and/or literacy defines and impacts their experience. 

The implementation of the Colorado Option presents another opportunity: to build a more sustainable system around cultural responsiveness beyond existing network adequacy standards — which strives to validate, understand, and affirm the different cultures of a diverse population in decision making and implementation. This blog provides an overview of how Colorado’s legislation aims to improve equity through a precedent-setting approach to ensuring culturally responsive networks. 

Overview of Colorado Option and Focus on Equity

The goal of the Colorado Option is to offer affordable, comprehensive coverage options for individuals to support access to care. Under the Colorado Option, issuers are required to reduce plan premiums by 15% over three years. Given USofCare’s research showing people’s concerns about costs, reducing premiums and further reducing out-of-pocket costs for Coloradans by offering more pre-deductible coverage for routine services, like primary care and behavioral health care, are significant wins for people. The standardized Colorado Option plans will be made available on the state’s individual and small group markets beginning January 1, 2023.

Included in the legislation are several measures specifically targeting racial health disparities and improving equity, including:

• A requirement for the Colorado Option to be “designed to improve racial health equity and decrease racial health disparities” including:
  • Improving perinatal health care coverage, which can address prominent racial and ethnic maternal health disparities, particularly among Black women. Access to comprehensive coverage and benefits is critical for a healthy pregnancy, birth, and postpartum period and has been shown to improve maternal health outcomes. Having access to medication, resources, providers, screenings, and preventive programming is essential for the health of both mothers and babies before, during, and after pregnancy. As one way to improve perinatal health coverage, the Colorado Division of Insurance (DOI) can include a broader range of providers, such as midwives and doulas, in plan networks. 
  • Providing first-dollar, pre-deductible coverage for certain high-value services, such as primary and behavioral health care. Providing affordable access to key health care services can help reduce unnecessary hospital admissions and emergency room utilization, and improve overall health. And specifically focusing on providing first-dollar coverage for services where there are gaps in access and utilization for communities of color, such as chronic disease management services to address issues like heart disease, hypertension, and diabetes, can also improve racial and ethnic health disparities. 
• The creation of a robust stakeholder engagement process and establishment of a diverse advisory board, with at least one-third of membership comprising of people of color and including members with expertise in health equity;  
• The inclusion of a majority of Essential Community Providers, such as federally qualified health centers (FQHCs) and rural health centers (RHCs), in plan networks. This step is critical for providing and sustaining access to care for a diverse population, particularly those who have been underserved by the health care system. For example, according to HRSA data, people who are racial or ethnic minorities accounted for about 62% of patients seen by FQHCs in 2020. 
• Charging DOI with completing an analysis of the public option’s impact on health equity, health plan enrollment, and insurance affordability, including data disaggregated by race, ethnicity, immigration status, sexual orientation, gender identity, age, and ability, to the extent possible; 
• A requirement for the Colorado Option to “have a network that is culturally responsive and, to the greatest extent possible, reflects the diversity of its enrollees in terms of race, ethnicity, gender identity, and sexual orientation in the area that the network exists;” and
• As part of the development of their network access plans, issuers providing the Colorado Option must include a description of their efforts to construct diverse, culturally responsive networks “that are well-positioned to address health equity and reduce health disparities.”
  • If an issuer is unable to achieve the network adequacy requirements, the issuer is required to file a corrective action plan describing efforts to achieve the requirements as an enforcement mechanism.

Colorado’s Approach to Building Culturally Responsive Networks 

DOI is required to establish rules for implementation of culturally responsive networks and related action plan requirements for issuers, with draft regulations scheduled to be released at the end of 2021 and adoption scheduled for early 2022. 

DOI is hosting a series of stakeholder meetings as they develop the regulations. The first of these meetings was held on September 14, where representatives from DOI outlined their goals and timeline, including the process for establishing and soliciting stakeholder feedback on draft regulations. 

Attendees representing various stakeholders and advocacy organizations provided feedback to DOI during the meeting, explaining how some Coloradans have experienced major barriers to accessing care that reveal inequities in the current system. Those include: insufficient distribution of providers; transportation barriers; language access and communication barriers; lack of providers trained to provide care to specific populations such as: LGBTQ+, individuals leaving the justice system, and people living with disabilities; lack of flexible provider hours to receive care; inaccurate provider directories that also lack sufficient provider details; and a lack of trust in providers who do not share lived experiences. 

As demonstrated through stakeholder engagement meetings, DOI and consumer advocacy groups are looking to other states, including California, DC, and New York, that have implemented some requirements around culturally and linguistically competent care as they identify requirements for the Colorado Option’s culturally responsive networks. DOI shared during its first stakeholder meeting that it is considering opportunities to incorporate demographic data collection efforts to learn more about existing differences in how various Coloradans experience health care, training requirements for providers, and language access requirements into their regulations. 

DOI is also looking to states that have been certified under the NCQA Multicultural Health Care Distinction, a nationally recognized evaluation of how well health plans and other organizations meet the needs of diverse populations. For example, California has comprehensive language access provisions for both providers and issuers to support effective communication and increased health literacy. Language access provisions are critical to increasing access to care and the quality of health care encounters. In a number of areas of the country, large portions of the uninsured population (up to 69%) reside in households with limited English proficiency (LEP), which has been linked to lower health literacy and worse health outcomes. To address this, issuers can be required to support increased health literacy and decision making among individuals with LEP through culturally responsive network development.

As DOI embarks on this first-in-the nation approach to building culturally responsive networks, they must also take into account the impact of existing barriers to the provision of equitable care. Such barriers include existing provider shortages, the historic underrepresentation of racial and ethnically-diverse providers, and access issues for individuals in the LGBTQ+ community who need safe, affirming care.  

DOI can also explore ways to ensure that issuers’ Colorado Option networks include virtual care options that work for those who seek them, when clinically appropriate. For example, virtual care can help maximize access for people with transportation barriers or inconsistent work schedules that present challenges to accessing timely in-person care, which is an impediment for people in areas with provider shortages and other underserved areas. Individuals who can benefit from virtual care options should have access to it. Meanwhile, those who require in-person access to care due to specific medical reasons, technology barriers, or otherwise, should also have an adequate network of in-person providers. Ensuring access to in-person and virtual providers is key in being responsive to the diverse needs of people. 

The Colorado Option provides the opportunity to advance equity and provide states with lessons learned for developing culturally responsive networks, whether in public option coverage or other sources of coverage. We look forward to tracking Colorado’s efforts and continuing to work with state partners in Colorado as implementation of the Colorado Option they worked tirelessly to pass moves forward.