Affordable Care Act and Racial and Ethnic Disparities

Barriers to Care in an Ethnically Diverse Publicly Insured Population: Is Health Care Reform Enough?

By Call, Kathleen T. PhD; McAlpine, Donna D. PhD; Garcia, Carolyn M. PhD, MPH, RN; Shippee, Nathan PhD; Beebe, Timothy PhD; Adeniyi, Titilope Cole MS; Shippee, Tetyana PhD
Medical Care, August 2014

Background: The Affordable Care Act provides for the expansion of Medicaid, which may result in as many as 16 million people gaining health insurance coverage. Yet it is unclear to what extent this coverage expansion will meaningfully increase access to health care.

Objective: The objective of the study was to identify barriers that may persist even after individuals are moved to insurance and to explore racial/ethnic variation in problems accessing health care services.

Results: All enrollees reported barriers to getting needed care; enrollees from minority cultural groups (Hmong and American Indian in particular) were more likely to experience problems than whites. Barriers associated with cost and coverage were the most prevalent, with 72% of enrollees reporting 1 or more of these problems. Approximately 63% of enrollees reported 1 or more access barriers. Provider-related barriers were the least prevalent (about 29%) yet revealed the most pervasive disparities.

Conclusions: Many challenges to care persist for publicly insured adults, particularly minority racial and ethnic groups. The ACA expansion of Medicaid, although necessary, is not sufficient for achieving improved and equitable access to care.

Comment by Don McCanne MD from Physicians for a National Health Program :

This is yet one more study that shows that insurance alone will not achieve equitable access to care, particularly for minority racial and ethnic groups. Let’s provide a little bit more perspective.

When we say that health care should be equitable, what do we mean? Does that mean that we compromise the quality of care for those who are receiving the very best in order to free up resources for those who are experiencing barriers to access? No, it means that we should bring everyone up to the same high standard. One important step is to improve the performance of the financing system by eliminating much of the administrative waste. That would free up resources that could be used to reduce the barriers of cost, coverage and capacity - barriers that the populations in this and other studies face.

Does equitable health care mean that we should prohibit allowing individuals to buy their way to the front of the queue? No, it means that we should use regional planning, capacity adjustment, and queue management techniques so that we reduce excessive queues for everyone.

Often the claim is made that there are many other socioeconomic factors besides insurance coverage that result in impaired access to care. That is true. Merely providing optimal coverage will not in itself correct all of the other factors. But in that claim is the implicit suggestion that we should accept deficiencies in coverage and access because we can’t fix the access problems anyway. That view represents an unacceptable ethical compromise in our current dialogue on reform.

Insurance systems that include financial barriers to care due to both cost sharing and uncovered services, and that impair access due to limitations of networks and limitations in regional capacity are a major cause of inequitable access and coverage. Creating an equitable financing system is the first and perhaps most important step in improving access to high quality care for everyone. Society has an obligation to address the other socioeconomic issues, but not by tossing aside the assurance that health care will be there for those who need it.