Since the implementation of the Affordable Care Act (ACA), more than 16.5 million people — particularly low-income Americans and people of color — have enrolled in an insurance plan for the first time, giving proponents of the health care law reason to praise it as a tool in protecting marginalized populations. A new study, however, points out that will take much more than Obamacare itself to close the persistent racial and socioeconomic disparities in health care access.
Researchers affiliated with D.C.-based advocacy organization Alliance for a Just Society analyzed 1,200 low-income patients in 10 states, nine of which have an uninsured rate well above the national average of 17.3 percent. Four of the states examined accepted the optional expansion of Medicaid, a joint federal and state government program that extends public insurance coverage to low-income people, under the ACA.
The research team found that a host of issues impede people of color’s access to health care — including language barriers, lack of Internet, a dearth of primary care providers, and confusion about health care plans. A quarter of Latinos — a group for which a significant amount of Obamacare enrollment outreach has been targeted — said it has been more than a year since they’ve seen a physician. Forty-five percent of Native Americans also said they had a personal physician, compared to 85 percent of their white counterparts.
The study’s authors suggest that, even though the health care reform law is extending insurance coverage to some people of color who previously went uninsured, that’s not the only measure of success in this area. The people who are gaining insurance under Obamacare need more information to help them navigate the health insurance industry, as well as better access to providers.
“People look at enrollment but the bigger problem is access to care. The new enrollees haven’t had health care before so this notion of going to the doctor is not ingrained, and there’s no intermediary step that tells people to get up to speed and prevent or intervene the chronic diseases they might have,” Gary Delgado, principal investigator in this study, told ThinkProgress. “A significant percentage of African Americans and Latinos don’t have what’s called a medical home, so they continue to get service in the emergency room. They no longer pay enormous fees but that doesn’t count as ongoing health care.”
Technological barriers also play a role. “The question of Internet access still looms large for access to care because that’s the way that insurance companies want to communicate,” said Delgado, who is also a visiting scholar at the Institute for the Study of Social Change at the University of California, Berkeley.
Historically, people of color have been less likely to be insured and have died younger than their white counterparts. The direct and indirect costs of health disparities amount to more than $1.24 trillion over the course of three years in the form of years of healthy life lost, loss of productivity, and additional burden on American taxpayers, according to data collected by researchers at Johns Hopkins University, Bloomberg School of Public Health. These disparities partly stem from patients’ failure to detect their ailments early enough.
In theory, the Affordable Care Act should have given minority groups more opportunities to receive the preventative health care that can eventually reduce instances of chronic diseases that have historically afflicted those groups disproportionately. While community health centers have been found to be effective tools in closing those gaps on the ground, vast differences still persist between the primary care hubs located in minority neighborhoods and those that serve white patrons, especially in the months since the client base in minority neighborhoods have expanded. According to Delgado, waiting times for people of color are longer.
Hospitals also haven’t been able to keep up with the influx of new enrollees. The overcrowding and shuttering of community hospitals, particularly those in places where a significant number of African Americans and Latinos live, can increase patients’ likelihood of dying by five percent. Studies have cited patient waits of up to 24 hours for bed assignments and the divergence of ambulances away from emergency rooms at a rate of one vehicle per minute. The distance to the nearest emergency centers can have a concrete effect: Children living more than a mile from an emergency care facility, for example, utilize its services 11 percent less than children living in other areas.
In some centers, Spanish-speaking residents reportedly had more difficulty connecting with nurses and doctors. Experts attribute that dilemma to the paucity of Latinos working in the U.S. health care system and lack of cultural competency that would translate into better service. Subsets of the black population have faced similar issues. A 2012 study found that about two-thirds of primary care doctors harbor unconscious biases toward their African-American patients, leading those doctors to spend less time with their black patients and involve them less frequently in medical decisions.
The disparities don’t stop at the hospitals. Insurance companies have worked to circumvent a provision of the Affordable Care Act that forbids them from turning away people with preexisting conditions by shifting exorbitant drug costs — particularly those for HIV — to members of that population, ultimately discouraging them from enrolling in certain plans. A study conducted earlier this year found that one in four plans placed HIV medication in a category that would require consumers to shoulder at least 30 percent of the costs instead of paying a standard co-pay. The authors of that study noted that similar issues arise when it comes to mental illness, cancer, diabetes, and other conditions that disproportionately affect minority groups.
“Despite enrollee out-of-pocket limits that are included in the ACA and reduced cost-sharing for people with very low income levels, some plans are placing extremely high co- insurance on lifesaving medications, and putting all or most medications in a given class, including generics, on the highest cost tier. This creates an undue burden on enrollees who rely on these medications,” a January letter to U.S. Health and Human Services Secretary Sylvia Burwell from 300 advocacy groups read.
In their report, the research team suggests a host of changes that include monitoring insurers’ quality improvement plans, strengthening community-based health care programs that have historically served minority communities, expanding and extending the role of navigators in showing new enrollees how to use their insurance coverage, and offering free translation and interpretation services to those who speak little English.
However, Delgado contends that even with changes in hospitals and community clinics, nothing would make as much a difference in closing racial and socioeconomic gaps in quality of health care as Medicaid expansion, a contentious policy that has lawmakers divided along party lines.
The GOP-controlled states that have refused to expand their Medicaid programs have created a coverage gap that leaves low-income people with any access to affordable insurance and that disproportionately affects black Americans. The Kaiser Family Foundation recently estimated that if every state accepted the expansion, more than 40 percent of uninsured people of color would gain coverage.