Originally published for Harbage Consulting (June 27, 2018) Pride month is a time to honor the achievements and contributions of the LGBTQ (lesbian, gay, bisexual, transgender, and queer) community. Marked by the Stonewall Riots in June of 1969, the month provides the opportunity to celebrate the unprecedented gains in LGBTQ equality, while also reflecting on the work left to be done. The LGBTQ community has experienced a monumental expansion of rights and equality over the past decade, including marriage equality and official recognition of LGBTQ partnerships, however access to health coverage and care continues to be a challenge. The LGBTQ community has poorer health outcomes and greater health care needs than their straight counterparts. LGBTQ people also have higher poverty rates and less access to private health insurance and are therefore more likely to rely on Medicaid and other public programs. Due to the historical lack of access to state and federal marriage recognition and the rights and benefits provided by it, until 2013, LGBTQ people had not been able to secure health benefits through their spouse’s or partner’s employer benefits. Still, in 2014, almost 9% of LGBTQ couples reported being denied when trying to add their partner/spouse to their employer-sponsored health plan. Employment discrimination has also impacted the insurance rates of LGBTQ people. Currently, only 22 states and the District of Columbia have non-discrimination employment laws that protect LGBTQ people from being fired based on their sexual orientation and only 20 states include gender identity protections. The lack of employment protections has pushed many LGBTQ people into low-wage jobs that do not offer health insurance or unemployment benefits. Underscoring all of these statistics is the fact that the LGBTQ community is also more likely to live in poverty. 2013 data showed that 20.8% of LGBTQ adults lived in poverty, compared to 16.25% of the general adult population. And this statistic becomes even more dire for children in LGBTQ families. Children in same-sex couple households are almost twice as likely to be poor as kids in married, heterosexual couple households. For these populations, access to Medicaid is a life-saver. ACCESS TO MEDICAID CRITICALLY IMPORTANT TO LGBTQ COMMUNITY According to the Williams Institute, about 1.2 million LGBTQ adults are enrolled in Medicaid as their primary source of health insurance. And due to the Affordable Care Act’s Medicaid expansion, the uninsured rate of the LGBTQ population decreased from 27% to 17% since 2014. Following are several key reasons why Medicaid’s role in the health care system is so critical for the LGBTQ community: LGBTQ People Have Greater Health Care Needs. The LGBTQ community experiences more physical health challenges and is more likely to rate their health as poor than straight or non-transgender people. They also have higher rates of risk factors for chronic conditions, such as higher obesity rates, smoking rates, and drug use. Furthermore, HIV and AIDS continue to impact gay and bisexual men, as well as transgender women. Medicaid is the largest source of health insurance coverage for people living with HIV and AIDS, covering more than 40% of the population. Several states implemented specific Medicaid waiver programs to provide additional services for people living with HIV/AIDs. As of 2012, 13 states had home and community-based services (HCBS) waivers that expanded health care services for people living with HIV/AIDS, and four states included HIV/AIDS as a qualifying condition for their Medicaid health homes programs, which provides extra care coordination and care management services. Medicaid expansion also significantly increased access for people living with HIV/AIDS. Finally, the Ryan White HIV/AIDS Program plays an important role providing access to critical HIV care and treatment services to those who are uninsured and underinsured. LGBTQ people also experience greater incidences of mental illness. According to NAMI, LGBTQ individuals are almost 3 times more likely than others to experience a mental health condition such as major depression or generalized anxiety disorder. They also have higher rates of suicide; it is estimated that 30-50% of transgender people attempt suicide in their lifetime. Due to the discrimination and stigma LGBTQ people face, in addition to a lack of family support, ensuring access to mental health services is one of the most pressing issues facing the LGBTQ community, especially for transgender individuals. LGBTQ People Experience Ongoing Barriers to Access to Care. Despite their greater health care needs, LGBTQ people have more challenges accessing health care services than non-LGBTQ people. This is due to several factors, including discrimination and lack of cultural competence among providers, as well as lack of coverage of specific health care services and availability of providers. Fear of discrimination also leads LGBTQ people to not seek care, postpone care, or hide their sexual orientation or gender identity from their health care providers. Transgender people overwhelmingly face this challenge, as many providers are unsure how to treat transgender people, from basic interactions such as using the correct name or preferred pronouns, to more complicated issues, such as screening transmen for cervical and breast cancer (if relevant). One study noted that almost 40% of transgender people have faced some type of harassment or discrimination when seeking routine health care, and many report being denied care outright or encountering violence in health care settings. Even when LGBTQ people have Medicaid or private insurance coverage, specific health care services may not be covered by their policy. This is especially true for transgender people. For example, in 2017, about half of the insurers in the marketplace excluded specific treatments or services that transgender people may seek when medically transitioning. Or insurers may not cover a “gender-specific” screening or treatment (for example, for prostate or cervical cancer) when the patient’s gender marker differs from the gender typically treated. While the Affordable Care Act included a slate of anti-discrimination reforms that have improved access to health care services and treatments, LGBTQ people continue to be impacted by discrimination and stigma in the health care sector. MORE WORK TO BE DONE While Medicaid provides a critical pathway to health coverage for LGBTQ people, offering high quality, timely access to needed services — including eliminating discrimination and stigma — will need to be addressed to improve health care outcomes for the LGBTQ community. Harbage Consulting is committed to ensuring that Medicaid and the health care safety net remain strong for the LGBTQ community and the millions of others who rely on it.

Excerpt from blog post originally published by Harbage Consulting (June 12, 2018) In recent years, there has been an increasing emphasis on improving health outcomes by addressing the social determinants — the environmental and social conditions, like access to safe and affordable housing, education and employment opportunities, and good nutrition – that influence people’s overall health. While siloed programs and funding streams, conflicting priorities, and lack of coordination and communication across agencies have historically impacted the ability of public programs to work together effectively to address social determinants, Medicaid programs across the country are beginning to tackle the challenge. Over the past several years, Harbage Consulting has supported clients in implementing innovative Medicaid initiatives that address the social determinants in an effort to improve health outcomes. California's Medicaid Health Homes Program is an exmaple of a program we have been proud to contribute to that link people to the social supports they need to lead healthier lives. CALIFORNIA'S HEALTH HOMES PROGRAM The California Health Homes Program (HHP) is designed to connect Medi-Cal patients who have multiple chronic conditions and/or a serious mental illness to an enhanced set of care management and coordination services. One of the core services provided under the HHP is ensuring that patients are connected to community resources and social service agencies that help them address their non-medical needs, such as accessing nutrition programs, employment training, and legal services. The HHP also places a strong emphasis on connecting patients to housing and transportation supports, as these are major barriers to improving patients' health. The HHP is in its early stages and Harbage Consulting is supporting the California Department of Health Care Services (DHCS) with program design and implementation. This includes policy analysis as well as developing communication and outreach materials for providers, Medi-Cal members, and community-based organizations.

Originally published by Harbage Consulting (April 3, 2018) Since the implementation of the Affordable Care Act, states have been creating new health care initiatives or expanding benefits and services of public health programs. Educating consumers – as well as providers, advocates, caregivers, and other stakeholders serving them – about these new public health care programs or benefits has been a critical element of success. In today’s world, having an easy-to-navigate website with clear and understandable information is an important tool to support that education work. Harbage Consulting originally developed CalDuals.org in 2012 as one piece of a broader outreach and education campaign to help dually-eligible beneficiaries in California navigate changes in how they receive their Medicare and Medi-Cal (California’s Medicaid program) benefits through the Coordinated Care Initiative (CCI). Last year, Harbage Consulting redesigned the CalDuals website into a more user-friendly and modern resource hub. To ensure the website meets the needs of those who use it, we used the following best practices to guide the redesign. ENGAGE STAKEHOLDERS EARLY AND OFTEN A defining feature of our work on CCI has been the early and frequent engagement of stakeholders. Our website redesign was informed by a specially-created workgroup consisting of active stakeholders with first-hand knowledge of how the website was being used and how it could be improved. The CalDuals workgroup consisted of advocates, providers, and stakeholders who met regularly to help determine the goals, primary audiences, layout, and other key features for the new site. The workgroup was engaged throughout the entire process, from reviewing wireframes to testing the site before it launched. IDENTIFY TARGET AUDIENCES Identifying our target audiences dictated the layout, priority content, and features for the new website. We had the benefit of stakeholder feedback, as well as several years of anecdotal feedback and analytical user-data. We had several target populations for the new CalDuals website, all with different information needs. CalDuals’ target audiences, like many other health care programs, are: 1) consumers, 2) health care providers, and 3) advocates and other stakeholders, such as the public and lawmakers. With our target audiences in mind, we organized the site by population, to give each audience their own navigational pathway, landing pages, tailored menus, button items, and submenus. ENSURE ACCESSIBILITY Since CalDuals’ target population includes both people with disabilities and beneficiaries from diverse communities, physical and language accessibility were a top priority throughout the site redesign. In addition to meeting the accessibility requirements required by law, we recommend going beyond the basic accessibility rules to design a truly tailored and accessible site. Physical Accessibility: To ensure people with visual impairments or other disabilities would be able to use and navigate the site, we used 14pt or larger font. In addition to a high-contrast color scheme, we also included a contrast tool that readers can use to improve readability. We also tested the site using adaptive technologies, such as screen readers. Language Accessibility: We developed a dedicated page for each language within the site for CalDuals users speaking one of 13 threshold languages. Because language accessibility is a high priority for the populations served by the CCI program, we chose to place access to the language options at the top of the page for maximum visibility. We hired a professional translation company to translate the content on our site, and we recommend not relying on auto-translation tools. FOCUS ON STRUCTURE AND NAVIGATION Today’s consumers want less text-heavy pages and more graphic-focused, simple pages. During the redesign, we carefully balanced the need to provide key information without overwhelming visitors with unnecessary or irrelevant information. Create Landing Pages: We prioritized the topics of importance to the readers (identified by our stakeholder workgroup) in the menus and left less important pages to a submenu. We also used buttons to highlight individual items that are important or new that otherwise may not make sense to include in the menu. Leverage Analytics: We used analytics data to determine the most popular content and frequently visited pages and prioritized content for each audience. Pages that were no longer visited or infrequently used, but that needed to be available for transparency and historical purposes, were filed into an archive section. CalDuals continues to be an important source of educational resources for the CCI, sharing enrollment information, serving as a policy archive, and as a mechanism for stakeholder feedback. We continue to add resources and program information as the CCI evolves and reaches more consumers.