Health Policy$ense

Insurance Expansion, Access and Minority Health – A Complicated Relationship

Will Expanding Health Coverage Improve The Health Of Minority Populations?

Expanding health coverage and reducing disparities in uninsured populations is an important part of the Affordable Care Act (ACA). Will this ensure access to health services as well as improve the health of minority populations? That’s less clear.

New data from the National Health Interview Survey, released in August 2015, shows that the uninsured rate dropped from 2012 to 2015 for adults aged 18-64; among Latinos, it decreased from 41.3% to 28.3%, and among Blacks, from 23.6% to 15.6%. Still, it remains higher than the uninsured rate among whites, which now stands at 8.7%.

As LDI Executive Director Dan Polsky noted at the 2015 Martin Luther King, Jr. Health Equity Symposium, “we’re moving in the right direction, but there are still things we need to accomplish if we are going to eliminate and address these disparities.” He singled out the impact of state decisions to expand Medicaid under the ACA. “It turns out that [Medicaid non-expanding] states are disproportionately populated by African Americans without health insurance. […] If all the states that didn’t expand expanded, the gap between blacks and whites would drop an additional 50 percent.”

According to the Kaiser Family Foundation, 94% of uninsured Blacks have incomes low enough to make them eligible for premium subsidies or fully-expanded state Medicaid programs. With uninsured Hispanics, more than one third are eligible for premium subsidies and more than half qualify for fully-expanded Medicaid.

But just having Medicaid coverage may not be enough to ensure access. Providers are reluctant to accept Medicaid beneficiaries because of the 59 cents on the dollar that Medicaid pays in comparison to Medicare. The ACA provided a two-year “fee bump” to encourage primary care physicians to see new Medicaid patients, and evidence from LDI and the Urban Institute suggests that it was successful. But the increase was short-term, and most states chose to return to pre-ACA levels of reimbursement in 2015.

In relation to the Medicare population, in mid-2015 the Centers for Medicare and Medicaid Services (CMS) announced a new “Equity Plan” for improving the quality of care delivered to minorities and other underserved beneficiaries.

Uninsured rates have decreased, but has minority health improved through the reforms brought by the ACA?  In an Annals of Internal Medicine editorial LDI Adjunct Senior Fellow Austin Frakt unpacks the complex and ambiguous relationship between health insurance coverage and health outcomes. Recent research on the potential impact of insurance expansion on undiagnosed chronic conditions suggests that the ACA could have significant effects on chronic disease identification and management. Washington Post’s Wonkblog has more on the existing evidence on how health insurance affects health.  

Insurance is necessary, though not sufficient, to reduce disparities in access and improve health. However, taking steps to improve minority health requires changing the health care system to make it more responsive to the medical needs and socioeconomic challenges of minority populations. It will also require going outside the bounds of the health care system—through alternative actors such as community health workers, or through policies that address social factors such as poverty, income inequality and low educational attainment.

LDI resources on minority health

LDI has a five-part blog series that examines the current and potential impact of the ACA on minority health.

  • Part I (Overview) details the decline in uninsurance and the persistently high prevalence and poorer outcomes of minorities with diabetes
  • Part II (Medicaid) covers the high proportion of minorities who fall into the “coverage gap” in non-expanding states and the barriers that new Medicaid beneficiaries face
  • Part III (New Models of Delivering Care) explores the potential impact of ACOs, shared savings, bundled payments and community health workers to address minority health
  • Part IV (Workforce Diversity) measures the nation’s progress on full representation of minorities in the health professions and details current efforts to achieve representation
  • Part V (American Indians/Alaskan Natives) covers the current state of health care access and quality for these populations and new programs/benefits under the ACA