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The Budget Office, 2011). While implementation of

The Affordable
Care Act: Effects on Health Care Disparities

Introduction

One
of the greatest challenges facing the United States healthcare system today is
disparities in access to quality health services. The US spends more on health
care than any other country, but those costs do not always translate into equal
opportunity for every individual to receive the highest quality of care and
services for better health outcomes (Squires & Anderson, 2015). The
distribution of health care varies greatly between different cultures and age
groups, as well as across the whole country geographically (Institute of
Medicine, 2002).

The
Patient Protection and Affordable Care Act (ACA), signed into law in 2010,
sought to address these issues in order to improve the access, cost, and
quality of health care services for all Americans.  It is the most
significant health care legislation since Medicaid and Medicare was established
in 1965 (Obama, 2016). The ACA’s goals are focused on making affordable health
insurance available to more people through subsidies, expanding the Medicaid
program to cover all adults with income below 138% of the federal poverty
level, and lowering the costs of health care in general through innovative
medical care delivery methods (Affordable Care Act, HealthCare.gov).  According to the US Congressional Budget
Office (CBO), the law provides an estimated 30 million uninsured, nonelderly
people with the opportunity to obtain coverage (Congressional Budget Office, 2013). The CBO
estimated the gross cost of insurance coverage provisions from 2010 to 2019 to
be $938 billion (Congressional
Budget Office, 2011).

While
implementation of the ACA varies from state to state, the legislation as a
whole sought to solve several problems that tie back to the central idea of
reducing the rate of uninsured citizens. The ACA protects people with
pre-existing conditions from being denied coverage or refused claims. It also
requires all residents to purchase health insurance coverage or be subject to a
penalty. To support those who cannot afford to purchase health insurance, the
ACA makes federal subsidies available through expansion of the Medicaid program
to include those under 133% poverty level for states that have chosen to expand
their programs and through health insurance exchanges.

It
is important to consider the potential role that the ACA plays in reducing
health disparities for under-represented minorities. Some populations,
particularly minority and low-income populations, are disproportionately
encumbered by shortened life expectancy, chronic diseases, infant mortality and
lack of or inadequate insurance coverage (Williams et.al, 2010). It is
important to ensure that that all Americans are provided with quality health
care regardless of their race, socioeconomic status, gender or age. This policy
synthesis will examine the ACA’s impact on changes in health disparities since
2014, when the law was implemented.

Improving
access to care is a key factor in eliminating health disparities. Racial and
ethnic groups suffer from the lack of access to quality health services, but
this lack of access does not occur in a vacuum. Issues ranging from the
physical & social factors of the environment contribute to health
inequalities and persist to be affected by the behavior, level of education,
and financial affairs of the people. The impact of the ACA on under-represented
minorities’ access and utilization of health care services will be explored.

 

Problem
Statement

The technology of medical care has
improved dramatically in the past century; yet for some populations in the
United States, health care has fallen short of important goals. The ACA
attempted to solve issues related to access, quality, and cost of health care
services, in order to provide universal and continuous access to affordable
health insurance and adequate coverage and care. Racial and ethnic groups, such
as African American people, lack adequate access to quality health services in
relation to non-Hispanic, White Americans. These health care disparities stem
from a number of problems, as well as underlying causes, related to dimensions
of access: affordability, accessibility, acceptability, availability, and
accommodation (Penchansky & Thomas, 1981).

One cause of minority populations having
unmet medical needs or delays in medical care is affordability. Financial
barriers 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 Whites
to live in poverty. In 2016, about 22% of Blacks and 20% of Hispanics were
poor, compared with 9% of Whites. (Poverty Rate by Race/Ethnicity, Kaiser
Family Foundation). Struggles to pay for medical visits and prescription drugs
contribute to the inaccessibility of obtaining quality care. Insurance coverage
can also be a barrier because racial and ethnic minorities are also
disproportionately uninsured compared to Whites. Blacks are twice as likely to
be uninsured, while Hispanics are three times as likely to lack insurance
coverage (Institute of Medicine, 2001). These populations are more vulnerable
to adverse health outcomes because when they finally do seek care, it may
result in late diagnosis, reduced survival rate, and possibly preventable human
suffering.

Physical accessibility can hinder the
ability to use health care services. Transportation barriers include access to
private transportation, access to public transportation, time and distance to
doctor’s office, and cost of transit (Syed, Gerber, & Sharp, 2013). Such
barriers may lead to delayed interventions because the patient cannot make
their appointment and therefore gives rise to poorer health outcomes.
Accessibility issues may also relate to socioeconomic factors such as
geographic location. Patients may be further affected if they live in
communities with limited or unreliable public transportation. Residents of
rural communities may need to travel long distances to reach urban locations
where they can get more specialized treatments. For regions where inclement
weather, such as heavy snowing, is quite prevalent, this can limit mobility for
patients to travel to their appointments.

Problems with availability can also result
in poor management of illness due to difficulty in scheduling care and long
wait times at appointments. Additionally, if a facility does not have adequate
technology and resources, relative to the demand, as well as enough providers
and staff, it can be problematic for patients’ needs to be addressed in a
timely fashion. Some facilities suffer in the area of provider productivity
because there are not enough physicians at the facility and they become limited
in how much time they have for quality interaction with their patients.
Furthermore, racial and ethnic minorities have higher likelihood of residing in
these areas where the health care facilities are providing substandard
services. In one study, when physicians were asked if they were able to provide
access to high-quality care for all of their patients, 27.8 percent of
physicians treating Black patients responded that they could not do so
(“disagreed”), as compared with 19.3 percent of physicians treating White
patients. They were also more likely than physicians treating White patients to
report that they could “not always” provide access for their patients to
subspecialists of high quality (24.0 percent vs. 17.9 percent) and nonemergency
hospital admissions (48.5 percent vs. 37.0 percent). Black patients and White
patients are to a large extent treated by different physicians. The physicians
treating Black patients may be less well trained clinically and may have less
access to important clinical resources than physicians treating White patients
(Bach et. al, 2004).

Acceptability is another barrier to
access, with respect to the health care provider and care facilities. In order
to be effective, there is a need for cultural competence in health care
settings. If racial and ethnic minorities can receive equal treatment in
relation to whites, this can help improve the quality of patient–physician
interactions, as the health care system becomes more culturally sensitive.
Offering language assistance services and addressing health literacy gap by
creating easy-to-read printed material are examples of incorporating cultural
competence. The underlying cause of acceptability problems can come from the
physicians and also from the patients. Some physicians may be racist toward
minorities and in turn, the minority patients may not trust the health care
system. Many racial and ethnic groups are aware that they are not being treated
fairly in the health care system and are more likely to express distrust of
health 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 perceive
African-Americans and members of low and middle patient socioeconomic status
(SES) groups more negatively on a number of dimensions than they did Whites and
upper SES patients. Patient race was associated with physicians’ assessment of
patient intelligence, feelings of affiliation toward the patient, and beliefs
about patient’s likelihood of risk behavior, and adherence with medical advice.
Physicians’ perceptions of patients’ personality, abilities, and behavioral
tendencies were affiliated with patient SES (2000).

Accommodation is another potential
limitation to accessing care.  Not all facilities provide appointment times
beyond regular weekday business hours. Individuals who experience this barrier
often cannot make their appointment because the time does not fit with their
work schedule, they may not have sick leave, or may have trouble finding
someone to care for their child or family member while they go to the
appointment. Health care facilities that are accommodating may extend their
operating hours to open late and on the weekends.

There are not many significant research
efforts to previously attempt to solve these issues, but in order to achieve
the best possible health outcomes, we need interventions that will not only
attack the problems with lack of access, but also the underlying issues that
contribute to differentials in health for racial and ethnic health care
disparities, even when controlling for gender, conditions, age, and
socioeconomic status.

 

Policy
Description

The ACA contains policies and regulations that impact one’s access
to equitable health care services through various means, including expanding
Medicaid to low-income individuals, requiring most plans to cover preventative
care, reducing cost-sharing for out-of-pocket expenses, offering premium tax
credits, improving chronic disease management, providing support to community
health centers, and diversifying the health care workforce, as well as
strengthening cultural competency. The following three provisions will be
discussed specifically in relation to the impact of the ACA on racial and
ethnic groups’ access to and utilization of health care services: Medicaid
expansion, support for community health centers, and improving the existing
workforce.

Expansion of Medicaid is a major component of the ACA as it
supported the goal of reducing the number of uninsured. Prior to ACA
implementation, many states’ coverage eligibility was limited to low-income
children, pregnant women, parents with extremely low incomes, and elderly and
disabled individuals. Under the current law, 31 states plus the District of
Columbia have expanded their Medicaid programs to include incomes up to 138%
federal poverty level (Status of State Medicaid
Expansion Decisions, Kaiser Family Foundation). Medicaid is an important source of coverage
for many racial and ethnic minorities. Blacks and Hispanics are
disproportionately affected by states that choose not to expand their Medicaid
program. In 2015, about 19% of Blacks and 31% of Hispanics had Medicaid
coverage (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 outpatient
facilities that provide care to medically underserved populations, such as
racial and ethnic minorities. The funding was increased to $3.6 billion annual
which was allocated to support the operation, expansion, and construction of
health centers in the nation (National Association of Community Health Centers,
n.d.). Community health centers are an essential part of our health care
system. The Kaiser Family Foundation reported 1375 health centers as providing
care to 24.3 million patients in 2015. One of six patients were Medicaid
beneficiaries. (Paradise, 2017).  Members of racial and ethnic minority
groups make up 62% of health center patients (National Association of Community
Health Centers, 2016). Thus, ACA’s support of community health centers assist
efforts to address health disparities. Community health centers are very
important because the care provided is tailored to the community being served.
The centers provide comprehensive primary health services to a patient
population of mostly lower income people. If community health centers were not
supported, it would be devastating to communities, as they depend on these
facilities 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, and
other supports for minorities interested in health careers. It also provides
scholarships for disadvantaged students who commit to working in medically
underserved areas and loan repayments for individuals who serve as faculty in eligible
and accredited health professions schools (Patient Protection and Affordable
Care Act, 2010). The significance of such provisions supports the concept of
acceptability, which is a barrier to access. The expected effect from this
provision is a more diverse workforce and improved cultural competency will
support improved patient-provider interactions and patients’ trust in the
health-care system.

Other expected effects from these ACA provisions could include
more low-income individuals being insured, more affordable insurance, lower
uncompensated care costs, decreased health disparities by race and geographic
region, as well as improved health outcomes.

The implementation of the ACA did not come without potential
unintended consequences. One example is the burden on the healthcare workforce
because increasing the number of individuals with coverage means that more
people will be going clinical appointments. Even though the ACA aims to improve
the existing workforce to better patient’s quality of care, there is already a
strain on the workforce due to growing health care worker shortage. Total
physician shortfall is projected to be between 61,700 and 94,700 physicians by
2025 and ACA-related expanded coverage is estimated to increase demand by
another 10,000 to 11,000 physicians (Association of American Medical Colleges, 2016).
This burden on the workforce also threatens patient-centered care because
providers may not be providing the best quality care to each patient because of
the competing demand to see all patients. Efficiency is also vulnerable because
patients visiting health centers in medically underserved areas might result in
longer waiting times or difficulty to schedule appointments.

Furthermore, burnout and occupational stress is also a risk for
healthcare workers dealing with high patient demand. In one study, researchers
concluded that in hospitals with high patient-to-nurse ratios, surgical
patients experience higher risk-adjusted 30-day mortality and failure-to-rescue
rates, and nurses are more likely to experience burnout and job dissatisfaction
(Aiken et. al, 2002). Unintended consequences such as these are significant to
the ACA because this can have a negative impact on the workforce that is
important to carrying out much of the ACA’s provisions and hinder the law from
being most effective to improve the health care system.

 

Implementation

The enactment of the ACA provided a unique
opportunity to address the underlying social, economic, and physical factors
which affect racial and ethnic groups’ access to and utilization of health care
services. Under the ACA, one major provision related to the law’s impact on
health disparities is Medicaid program expansion.

Medicaid expansion was meant to play a
significant role in reducing disparities, by increasing access to care for all
and decreasing the number of uninsured. This provision also resulted in the
establishment of health insurance marketplaces, a platform where consumers can research
and compare coverage plans and apply any subsidies they are eligible for. Marketplace
insurance is required to provide coverage for the ten essential health
benefits: emergency services, outpatient care, prescription drugs, laboratory
services, hospitalization, pediatric services (including oral and vision),
mental health and substance abuse disorder services, maternity and newborn
care, preventative and wellness services, and rehabilitative and habilitative
services and devices (“Essential Health Benefits”). Regulations for the
marketplace insurance plans protect the consumer from discrimination based on
pre-existing conditions.

The main implementation challenge for
Medicaid expansion was the Supreme Court’s ruling that states could not be
mandated to expand their Medicaid program. The result is differential access to
care among states. Currently, 19 states have decided not to expand their
Medicaid programs. Unfortunately, racial and ethnic minority groups are the
populations most negatively impacted from this ruling because a significant
portion of the non-expansion states are in the south and southeastern regions
of  the US and these regions have the highest proportions of people of
color (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 to
obtain access to quality health services because of locality.

As an unintended consequence, the
non-expansion states will benefit far less in the ACA provisions for Medicaid.
Despite this challenge, the Kaiser Family Foundation reports that 15.1 million
people have gained coverage from Medicaid expansion, including 11.9 million who
were newly eligible through the ACA. There are 277,000 Maryland residents who
enrolled as a result of the expansion (Medicaid Expansion Enrollment, Kaiser Family
Foundation, 2016). It is an unintended consequence that the Medicaid expansion
would be a counterproductive effort as it could actually be further exacerbate
disparities, even though its intent is to decrease disparities.

 

Community Health Centers—What is the new
ACA funding being used for?

 

 

Need to fix intro to include all three
parts (#2 community health, #3 improving workforce)

Conclusion

It has been over seven years since the ACA
was created. In some aspects, it might be too early to fully assess the law’s
effectiveness on the health care delivery system, but in other ways, this is a
good time to reflect on the progress made thus far and consider any
modifications that can be applied.  The ACA’s most significant impact on
changes to health disparities since its implementation has been the decrease in
the number of uninsured, from 44 million in 2013 to 27.6 million in 2016 (“Key
Facts About the Uninsured Population”, Kaiser Family Foundation, 2017).
Antonisse et. al reported the larger increases in health care coverage came
from states that expanded its Medicaid program under the law (2016).

For racial and ethnic minority groups, the
ACA not only sought to increase healthcare access, but it also contained
several provisions to address barriers to affordable quality care. Among these
provisions include support for community health centers and improving the
existing workforce by creating opportunities to diversify personnel, as well as
strengthening cultural competency. Reducing health disparities is an important
issue given that racial and ethnic groups, specifically Blacks and Hispanics
experience negative health outcomes at a disproportionate rate compared to
non-Hispanic White Americans. As discussed previously, barriers for these
groups to access care is linked to underlying causes from issues in dimensions
of access.

Health care reform is a convoluted,
multifaceted initiative that continues to be a critical topic of our times. As
the most significant health care legislation since Medicaid and Medicare was
established, the ACA is a major step to improving access to care by making
affordable quality care available to low-income individuals. With respect to
implementing provisions that support health disparities reduction, the ACA is
living up to its promise and most provisions discussed earlier are in progress.
Combating health disparities should be an important goal for the government and
I agree with the policies that have been implemented toward this goal. In order
to maintain progress towards reducing health disparities, the government must
develop innovative solutions to assist low-income individuals who reside in
Medicaid non-expansion states and fall in the coverage gap because racial and
ethnic groups account are disproportionately represented among uninsured adults
in the coverage gap (Garfield and Damico, Kaiser Family Foundation, 2017). Han
et. al. found that health outcomes for low-income adults in non-expansion
states, who are disproportionately represented by Blacks and rural residents, to
be worse compared to their counterparts in expansion states. Additionally,
low-income residents in the non-expansion states had less annual care
utilization and medical expenditures, but significantly higher out-of-pocket
expenditures compared to counterparts in expansion states (2015). Ultimately,
the ACA need not be repealed or replaced, but recognized as a key step to equal
care access for all. It is not the end goal, but a stride in the right
direction.