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A new Commonwealth Fund has surprising findings following ACA’s major coverage expansions.
After the implementation of the Affordable Care Act’s (ACA) major coverage provisions, the disparities in healthcare access that blacks and Hispanics face compared to whites narrowed between 2013 and 2015, according to a new Commonwealth Fund report
ACA’s major coverage expansions and health insurance reforms took effect as of January 1, 2014. The coverage expansions include expanded income eligibility for Medicaid for people under aged 65 years and the availability of income-related tax credits for people who purchase plans through the health insurance marketplaces as well as subsidies that lower copays, coinsurance, and deductibles for people with low incomes who purchase marketplace plans. Some of the major insurance reforms brought about by the ACA include the prohibition against denying people coverage because of pre-existing conditions or charging them higher premiums because of health status or gender, and the requirement that plans available in the marketplaces must offer essential health benefits.
Reducing Racial and Ethnic Disparities in Access to Care: Has the Affordable Care Act Made a Difference? found that following the ACA’s major coverage expansions, disparities with whites narrowed for blacks and Hispanics, on three key indicators of healthcare access:
1. The percentage of uninsured adults aged 19 to 64 years
2. The percentage of adults aged 18 years and older who skipped needed care because of cost
3. The percentage of adults age 18 years and older who lacked a usual care provider.
Specifically, between 2013 and 2015, the black–white disparity among working-age adults who were uninsured narrowed by four percentage points, and the Hispanic–white disparity narrowed by seven points, according to the report. In terms of adults who went without needed healthcare because of costs, the black–white disparity narrowed by two percentage points over the two-year period, and the Hispanic–white disparity narrowed by three points. The black–white disparity in the share of adults without a usual source of care was reduced by nearly half, from eight percentage points to five points, while the Hispanic–white disparity narrowed from 24 points to 21 points.
“Disparities were narrower, and the average rate on each of the three indicators for whites, blacks, and Hispanics was lower in both 2013 and 2015 in the group of states that expanded Medicaid under the ACA by January 2015 than in the group of states that did not expand as of that time,” says co-author Pamela Riley, MD, the Commonwealth Fund’s vice president for delivery system reform. “Among Hispanics, disparities tended to narrow more between 2013 and 2015 in expansion states than nonexpansion states.”
There was much evidence to suggest that uninsured rates had declined among blacks and Hispanics as well as whites following the implementation of the ACA’s major coverage expansions, says Riley.
“We wanted to explore whether these coverage gains resulted in reduced racial and ethnic disparities in access to care among adults. In addition, we were interested in whether there were differences between the group of states that expanded Medicaid and the group of states that did not expand,” she says.
The findings led researchers to conclude that the ACA’s coverage expansions were associated with increased access to care across racial and ethnic groups, and reduced racial and ethnic disparities in access to care, with generally greater improvements in Medicaid expansion states.
Medicaid expansion has played a major role in reducing racial and ethnic disparities in coverage and access to care, says Riley.
“As the dominant form of care delivery in Medicaid, managed care organizations have a critical role to play in ensuring that this expanded coverage translates to improved access to care through ensuring stable enrollment and coordination with marketplace plans to reduce churn, making sure Medicaid beneficiaries have access to adequate provider networks, and supporting beneficiaries in connecting to and accessing a primary care home,” she says.
Based on the study, Riley offers 2 ways for healthcare executives to address disparities in healthcare
1. While insurance coverage may not eliminate disparities in healthcare access, it does help to reduce them. At present, 19 states have not expanded Medicaid under the ACA, says Riley.
“A decision by these states to expand Medicaid would have positive effects for black and Hispanic residents in terms of access to care and reducing disparities,” she says. “In addition, active coordination between Medicaid managed care plans and commercial and marketplace plans can help reduce churn due to changes in eligibility and ensure continuity of care.”
2. To maximize the potential of insurance coverage to narrow disparities, it is important to take steps to ensure that coverage translates into adequate access to care.
One example of this would be making sure that enrollees have access to adequate networks of primary and specialty care, Riley says. “Targeted culturally and linguistically appropriate programs that help newly insured people connect to the healthcare system may also be of benefit,” she says.