The Budget Office, 2011). While implementation of
The AffordableCare Act: Effects on Health Care DisparitiesIntroductionOneof the greatest challenges facing the United States healthcare system today isdisparities in access to quality health services. The US spends more on healthcare than any other country, but those costs do not always translate into equalopportunity for every individual to receive the highest quality of care andservices for better health outcomes (Squires & Anderson, 2015). Thedistribution of health care varies greatly between different cultures and agegroups, as well as across the whole country geographically (Institute ofMedicine, 2002).ThePatient Protection and Affordable Care Act (ACA), signed into law in 2010,sought to address these issues in order to improve the access, cost, andquality of health care services for all Americans. It is the mostsignificant health care legislation since Medicaid and Medicare was establishedin 1965 (Obama, 2016).
The ACA’s goals are focused on making affordable healthinsurance available to more people through subsidies, expanding the Medicaidprogram to cover all adults with income below 138% of the federal povertylevel, and lowering the costs of health care in general through innovativemedical care delivery methods (Affordable Care Act, HealthCare.gov). According to the US Congressional BudgetOffice (CBO), the law provides an estimated 30 million uninsured, nonelderlypeople with the opportunity to obtain coverage (Congressional Budget Office, 2013). The CBOestimated the gross cost of insurance coverage provisions from 2010 to 2019 tobe $938 billion (CongressionalBudget Office, 2011).Whileimplementation of the ACA varies from state to state, the legislation as awhole sought to solve several problems that tie back to the central idea ofreducing the rate of uninsured citizens. The ACA protects people withpre-existing conditions from being denied coverage or refused claims. It alsorequires all residents to purchase health insurance coverage or be subject to apenalty.
To support those who cannot afford to purchase health insurance, theACA makes federal subsidies available through expansion of the Medicaid programto include those under 133% poverty level for states that have chosen to expandtheir programs and through health insurance exchanges.Itis important to consider the potential role that the ACA plays in reducinghealth disparities for under-represented minorities. Some populations,particularly minority and low-income populations, are disproportionatelyencumbered by shortened life expectancy, chronic diseases, infant mortality andlack of or inadequate insurance coverage (Williams et.al, 2010). It isimportant to ensure that that all Americans are provided with quality healthcare regardless of their race, socioeconomic status, gender or age. This policysynthesis will examine the ACA’s impact on changes in health disparities since2014, when the law was implemented. Improvingaccess to care is a key factor in eliminating health disparities. Racial andethnic groups suffer from the lack of access to quality health services, butthis lack of access does not occur in a vacuum.
Issues ranging from thephysical & social factors of the environment contribute to healthinequalities and persist to be affected by the behavior, level of education,and financial affairs of the people. The impact of the ACA on under-representedminorities’ access and utilization of health care services will be explored. ProblemStatementThe technology of medical care hasimproved dramatically in the past century; yet for some populations in theUnited States, health care has fallen short of important goals. The ACAattempted to solve issues related to access, quality, and cost of health careservices, in order to provide universal and continuous access to affordablehealth insurance and adequate coverage and care. Racial and ethnic groups, suchas African American people, lack adequate access to quality health services inrelation to non-Hispanic, White Americans. These health care disparities stemfrom a number of problems, as well as underlying causes, related to dimensionsof access: affordability, accessibility, acceptability, availability, andaccommodation (Penchansky & Thomas, 1981).One cause of minority populations havingunmet medical needs or delays in medical care is affordability.
Financialbarriers for low-income families are reported as lack of insurance coverage,poor access to services, and unaffordable costs, even for those with insurance(Devoe et. al, 2007). Blacks and Hispanics are more than twice as likely as Whitesto live in poverty.
In 2016, about 22% of Blacks and 20% of Hispanics werepoor, compared with 9% of Whites. (Poverty Rate by Race/Ethnicity, KaiserFamily Foundation). Struggles to pay for medical visits and prescription drugscontribute to the inaccessibility of obtaining quality care. Insurance coveragecan also be a barrier because racial and ethnic minorities are alsodisproportionately uninsured compared to Whites. Blacks are twice as likely tobe uninsured, while Hispanics are three times as likely to lack insurancecoverage (Institute of Medicine, 2001).
These populations are more vulnerableto adverse health outcomes because when they finally do seek care, it mayresult in late diagnosis, reduced survival rate, and possibly preventable humansuffering.Physical accessibility can hinder theability to use health care services. Transportation barriers include access toprivate transportation, access to public transportation, time and distance todoctor’s office, and cost of transit (Syed, Gerber, & Sharp, 2013). Suchbarriers may lead to delayed interventions because the patient cannot maketheir appointment and therefore gives rise to poorer health outcomes.Accessibility issues may also relate to socioeconomic factors such asgeographic location. Patients may be further affected if they live incommunities with limited or unreliable public transportation.
Residents ofrural communities may need to travel long distances to reach urban locationswhere they can get more specialized treatments. For regions where inclementweather, such as heavy snowing, is quite prevalent, this can limit mobility forpatients to travel to their appointments.Problems with availability can also resultin poor management of illness due to difficulty in scheduling care and longwait times at appointments. Additionally, if a facility does not have adequatetechnology and resources, relative to the demand, as well as enough providersand staff, it can be problematic for patients’ needs to be addressed in atimely fashion.
Some facilities suffer in the area of provider productivitybecause there are not enough physicians at the facility and they become limitedin how much time they have for quality interaction with their patients.Furthermore, racial and ethnic minorities have higher likelihood of residing inthese areas where the health care facilities are providing substandardservices. In one study, when physicians were asked if they were able to provideaccess to high-quality care for all of their patients, 27.8 percent ofphysicians treating Black patients responded that they could not do so(“disagreed”), as compared with 19.3 percent of physicians treating Whitepatients. They were also more likely than physicians treating White patients toreport that they could “not always” provide access for their patients tosubspecialists of high quality (24.0 percent vs. 17.
9 percent) and nonemergencyhospital admissions (48.5 percent vs. 37.0 percent). Black patients and Whitepatients are to a large extent treated by different physicians. The physicianstreating Black patients may be less well trained clinically and may have lessaccess to important clinical resources than physicians treating White patients(Bach et. al, 2004).Acceptability is another barrier toaccess, with respect to the health care provider and care facilities.
In orderto be effective, there is a need for cultural competence in health caresettings. If racial and ethnic minorities can receive equal treatment inrelation to whites, this can help improve the quality of patient–physicianinteractions, as the health care system becomes more culturally sensitive.Offering language assistance services and addressing health literacy gap bycreating easy-to-read printed material are examples of incorporating culturalcompetence. The underlying cause of acceptability problems can come from thephysicians and also from the patients.
Some physicians may be racist towardminorities and in turn, the minority patients may not trust the health caresystem. Many racial and ethnic groups are aware that they are not being treatedfairly in the health care system and are more likely to express distrust ofhealth care and feel stressed by the discrimination they receive. Van Ryn and Burke noted that physicians’perceptions and attitude toward patients was influenced patients’socio-demographic characteristics. Physicians tended to perceiveAfrican-Americans and members of low and middle patient socioeconomic status(SES) groups more negatively on a number of dimensions than they did Whites andupper SES patients. Patient race was associated with physicians’ assessment ofpatient intelligence, feelings of affiliation toward the patient, and beliefsabout patient’s likelihood of risk behavior, and adherence with medical advice.Physicians’ perceptions of patients’ personality, abilities, and behavioraltendencies were affiliated with patient SES (2000).Accommodation is another potentiallimitation to accessing care.
Not all facilities provide appointment timesbeyond regular weekday business hours. Individuals who experience this barrieroften cannot make their appointment because the time does not fit with theirwork schedule, they may not have sick leave, or may have trouble findingsomeone to care for their child or family member while they go to theappointment. Health care facilities that are accommodating may extend theiroperating hours to open late and on the weekends.There are not many significant researchefforts to previously attempt to solve these issues, but in order to achievethe best possible health outcomes, we need interventions that will not onlyattack the problems with lack of access, but also the underlying issues thatcontribute to differentials in health for racial and ethnic health caredisparities, even when controlling for gender, conditions, age, andsocioeconomic status.
PolicyDescriptionThe ACA contains policies and regulations that impact one’s accessto equitable health care services through various means, including expandingMedicaid to low-income individuals, requiring most plans to cover preventativecare, reducing cost-sharing for out-of-pocket expenses, offering premium taxcredits, improving chronic disease management, providing support to communityhealth centers, and diversifying the health care workforce, as well asstrengthening cultural competency. The following three provisions will bediscussed specifically in relation to the impact of the ACA on racial andethnic groups’ access to and utilization of health care services: Medicaidexpansion, support for community health centers, and improving the existingworkforce.Expansion of Medicaid is a major component of the ACA as itsupported the goal of reducing the number of uninsured.
Prior to ACAimplementation, many states’ coverage eligibility was limited to low-incomechildren, pregnant women, parents with extremely low incomes, and elderly anddisabled individuals. Under the current law, 31 states plus the District ofColumbia have expanded their Medicaid programs to include incomes up to 138%federal poverty level (Status of State MedicaidExpansion Decisions, Kaiser Family Foundation). Medicaid is an important source of coveragefor many racial and ethnic minorities. Blacks and Hispanics aredisproportionately affected by states that choose not to expand their Medicaidprogram. In 2015, about 19% of Blacks and 31% of Hispanics had Medicaidcoverage (Distribution of the Nonelderly with Medicaid by Race/Ethnicity,Kaiser Family Foundation). The ACA also made provisions to support community health centers.It established the Community Health Center Fund (CHCF) to award grants to outpatientfacilities that provide care to medically underserved populations, such asracial and ethnic minorities.
The funding was increased to $3.6 billion annualwhich was allocated to support the operation, expansion, and construction ofhealth centers in the nation (National Association of Community Health Centers,n.d.
). Community health centers are an essential part of our health caresystem. The Kaiser Family Foundation reported 1375 health centers as providingcare to 24.3 million patients in 2015. One of six patients were Medicaidbeneficiaries. (Paradise, 2017). Members of racial and ethnic minoritygroups make up 62% of health center patients (National Association of CommunityHealth Centers, 2016). Thus, ACA’s support of community health centers assistefforts to address health disparities.
Community health centers are veryimportant because the care provided is tailored to the community being served.The centers provide comprehensive primary health services to a patientpopulation of mostly lower income people. If community health centers were notsupported, it would be devastating to communities, as they depend on thesefacilities to improve the community’s health.Additionally, the ACA supports the Center of Excellence program,which develops a minority applicant pool to enhance recruitment, training, andother supports for minorities interested in health careers. It also providesscholarships for disadvantaged students who commit to working in medicallyunderserved areas and loan repayments for individuals who serve as faculty in eligibleand accredited health professions schools (Patient Protection and AffordableCare Act, 2010). The significance of such provisions supports the concept ofacceptability, which is a barrier to access.
The expected effect from thisprovision is a more diverse workforce and improved cultural competency willsupport improved patient-provider interactions and patients’ trust in thehealth-care system.Other expected effects from these ACA provisions could includemore low-income individuals being insured, more affordable insurance, loweruncompensated care costs, decreased health disparities by race and geographicregion, as well as improved health outcomes.The implementation of the ACA did not come without potentialunintended consequences. One example is the burden on the healthcare workforcebecause increasing the number of individuals with coverage means that morepeople will be going clinical appointments. Even though the ACA aims to improvethe existing workforce to better patient’s quality of care, there is already astrain on the workforce due to growing health care worker shortage.
Totalphysician shortfall is projected to be between 61,700 and 94,700 physicians by2025 and ACA-related expanded coverage is estimated to increase demand byanother 10,000 to 11,000 physicians (Association of American Medical Colleges, 2016).This burden on the workforce also threatens patient-centered care becauseproviders may not be providing the best quality care to each patient because ofthe competing demand to see all patients. Efficiency is also vulnerable becausepatients visiting health centers in medically underserved areas might result inlonger waiting times or difficulty to schedule appointments. Furthermore, burnout and occupational stress is also a risk forhealthcare workers dealing with high patient demand.
In one study, researchersconcluded that in hospitals with high patient-to-nurse ratios, surgicalpatients experience higher risk-adjusted 30-day mortality and failure-to-rescuerates, and nurses are more likely to experience burnout and job dissatisfaction(Aiken et. al, 2002). Unintended consequences such as these are significant tothe ACA because this can have a negative impact on the workforce that isimportant to carrying out much of the ACA’s provisions and hinder the law frombeing most effective to improve the health care system.
ImplementationThe enactment of the ACA provided a uniqueopportunity to address the underlying social, economic, and physical factorswhich affect racial and ethnic groups’ access to and utilization of health careservices. Under the ACA, one major provision related to the law’s impact onhealth disparities is Medicaid program expansion.Medicaid expansion was meant to play asignificant role in reducing disparities, by increasing access to care for alland decreasing the number of uninsured.
This provision also resulted in theestablishment of health insurance marketplaces, a platform where consumers can researchand compare coverage plans and apply any subsidies they are eligible for. Marketplaceinsurance is required to provide coverage for the ten essential healthbenefits: emergency services, outpatient care, prescription drugs, laboratoryservices, hospitalization, pediatric services (including oral and vision),mental health and substance abuse disorder services, maternity and newborncare, preventative and wellness services, and rehabilitative and habilitativeservices and devices (“Essential Health Benefits”). Regulations for themarketplace insurance plans protect the consumer from discrimination based onpre-existing conditions.The main implementation challenge forMedicaid expansion was the Supreme Court’s ruling that states could not bemandated to expand their Medicaid program. The result is differential access tocare among states. Currently, 19 states have decided not to expand theirMedicaid programs.
Unfortunately, racial and ethnic minority groups are thepopulations most negatively impacted from this ruling because a significantportion of the non-expansion states are in the south and southeastern regionsof the US and these regions have the highest proportions of people ofcolor (Population Distribution by Race/Ethnicity, Kaiser Family Foundation,2016). These regions also have the highest proportions of uninsured individuals(Distribution of the Nonelderly Uninsured by Federal Poverty Level (FPL),Kaiser Family Foundation, 2016). Thus,the people who are in these non-expansion states are not being supported toobtain access to quality health services because of locality.As an unintended consequence, thenon-expansion states will benefit far less in the ACA provisions for Medicaid.Despite this challenge, the Kaiser Family Foundation reports that 15.1 millionpeople have gained coverage from Medicaid expansion, including 11.
9 million whowere newly eligible through the ACA. There are 277,000 Maryland residents whoenrolled as a result of the expansion (Medicaid Expansion Enrollment, Kaiser FamilyFoundation, 2016). It is an unintended consequence that the Medicaid expansionwould be a counterproductive effort as it could actually be further exacerbatedisparities, even though its intent is to decrease disparities. Community Health Centers—What is the newACA funding being used for? Need to fix intro to include all threeparts (#2 community health, #3 improving workforce)ConclusionIt has been over seven years since the ACAwas created. In some aspects, it might be too early to fully assess the law’seffectiveness on the health care delivery system, but in other ways, this is agood time to reflect on the progress made thus far and consider anymodifications that can be applied.
The ACA’s most significant impact onchanges to health disparities since its implementation has been the decrease inthe number of uninsured, from 44 million in 2013 to 27.6 million in 2016 (“KeyFacts About the Uninsured Population”, Kaiser Family Foundation, 2017).Antonisse et. al reported the larger increases in health care coverage camefrom states that expanded its Medicaid program under the law (2016).For racial and ethnic minority groups, theACA not only sought to increase healthcare access, but it also containedseveral provisions to address barriers to affordable quality care. Among theseprovisions include support for community health centers and improving theexisting workforce by creating opportunities to diversify personnel, as well asstrengthening cultural competency.
Reducing health disparities is an importantissue given that racial and ethnic groups, specifically Blacks and Hispanicsexperience negative health outcomes at a disproportionate rate compared tonon-Hispanic White Americans. As discussed previously, barriers for thesegroups to access care is linked to underlying causes from issues in dimensionsof access. Health care reform is a convoluted,multifaceted initiative that continues to be a critical topic of our times. Asthe most significant health care legislation since Medicaid and Medicare wasestablished, the ACA is a major step to improving access to care by makingaffordable quality care available to low-income individuals. With respect toimplementing provisions that support health disparities reduction, the ACA isliving up to its promise and most provisions discussed earlier are in progress.
Combating health disparities should be an important goal for the government andI agree with the policies that have been implemented toward this goal. In orderto maintain progress towards reducing health disparities, the government mustdevelop innovative solutions to assist low-income individuals who reside inMedicaid non-expansion states and fall in the coverage gap because racial andethnic groups account are disproportionately represented among uninsured adultsin the coverage gap (Garfield and Damico, Kaiser Family Foundation, 2017). Hanet. al. found that health outcomes for low-income adults in non-expansionstates, who are disproportionately represented by Blacks and rural residents, tobe worse compared to their counterparts in expansion states. Additionally,low-income residents in the non-expansion states had less annual careutilization and medical expenditures, but significantly higher out-of-pocketexpenditures compared to counterparts in expansion states (2015). Ultimately,the ACA need not be repealed or replaced, but recognized as a key step to equalcare access for all. It is not the end goal, but a stride in the rightdirection.
