The topic of health care disparities, and how health care reform will affect them, has driven a number of journal articles in the recent months. The evidence indicates that the Affordable Care Act, as originally intended, would reduce disparities in coverage and in clinical care. But now we have to ask what the real-world results will be in the wake of the Supreme Court ruling making Medicaid expansion optional for states. While it is impossible to tell how many states will reject Medicaid expansion (and the significant federal dollars attached to it), the ruling is likely to increase the numbers of people who remain uninsured.
According to the Congressional Budget Office that could mean 4 million more uninsured people in 2014 than originally projected. They would be disproportionately poor and minorities, and that could limit the positive impact the ACA has on reducing health disparities. Based on the greater number of uninsured from the updated CBO projections, a back-of-the-envelope calculation suggests that the Supreme Court's ruling has diminished the ACA's role in reducing health care disparities by 10-20%. One should consider recent articles in this new light:
Modeling the ACA's Impact on Disparities
In the May 2012 issue of Health Affairs, Lisa Clemans-Cope and colleagues at the Urban Institute use a microsimulation model to estimate how the ACA will affect coverage
by race and ethnicity. They found that racial and ethnic differentials in coverage could be greatly reduced, potentially cutting the 8 percentage-point black-white differential in uninsurance rates by more than half and the 19 percentage-point Hispanic-white differential by just under one-quarter. They caution that these effects will depend on effective state policies to attain high enrollment in Medicaid and the Childrens Health Insurance Program and the new insurance exchanges. Coverage gains among Hispanics will probably depend on adoption of strategies that address language and related barriers to enrollment and retention in California and Texas, where almost half of Hispanics live. However, Governor Perry of Texas has stated his opposition to expanding Medicaid. [Title: The Affordable Care Act's Coverage Expansions Will Reduce Differences in Uninsurance Rates by Race and Ethnicity]
Lessons from Massachusetts Will gains in coverage translate into decreased disparities in care? One study looks at the experience of Massachusetts before and after it implemented near-universal coverage in 2006. In
the July 2012 issue of Medical Care, Amresh Hanchate and colleagues examine whether the Massachusetts health reforms, similar to the ACA in many ways, affected income and racial/ethnic disparities among the non-elderly in the rate of inpatient surgeries. They focused on procedures primarily dependent on outpatient referrals, reasoning that changes in the procedure rate could represent improved access to outpatient care. The study found that lower income areas saw
8% greater gains in procedures, compared to 4% gains in higher income areas, and Hispanics and blacks had gains of 22% and 21% respectively, compared to 7% for non-Hispanic whites. This is consistent with relatively larger gains in insurance coverage among these subpopulations. Curiously, when the researchers accounted for changes seemingly unrelated to the reform, (by comparing the procedure rate among Medicare recipients), the differential gains between blacks and whites disappeared, but the gains for Hispanics remained. [Title: Massachusetts Reform and Disparities in Inpatient Care Utilization]
Different Impact on Ethnic/Racial Groups The possibility that insurance expansion could have a different impact on different ethnic/racial groups emerged in another recent study. In the June 2012 issue of Health Services Research, Margarita
AlegrÍa and colleagues explored the role of insurance coverage in reducing racial and ethnic disparities in the use of mental health services. Using data from national epidemiological studies, they estimated service disparities in the presence and absence of insurance, taking clinical need into account. Then they estimated use of behavioral health services with the expansion of coverage envisioned by the ACA. The study found little baseline disparity in access to services between Hispanics and whites, but found significant disparity between blacks and whites, with the greatest disparity between blacks and whites on Medicaid. Even with expanded coverage, they estimate that about 10% fewer blacks needing behavioral health services will receive services compared to non-Hispanic whites. These results remind us that coverage alone may not be enough to reduce health disparities, and that more tailored interventions might be needed for some groups. [Title: The Impact of Insurance Coverage in Diminishing Racial and Ethnic Disparities in Behavioral Health Services]
Policy Window Romana Hasnian-Wynia and Anne C. Beal strike a hopeful chord about the original ACA in an editorial in the August 2012 issue of Health Services Research
They see a "policy window" and an "unprecedented" opportunity to address health disparities with the passage of the ACA. In addition to initiatives that require collection of race and ethnicity data and cultural competency training of providers, the ACAs provisions for Medicaid expansion and health insurance subsidies is expected to reduce the disproportionately high levels of uninsurance among minority groups. In the research arena, the ACA elevates the National Center on Minority Health and Health Disparities to an Institute and creates the Patient-Centered Outcomes Research Institute (PCORI), which includes addressing disparities among its national priorities. [Title: The Path to Equitable Health Care]
