qotd: ACA and racial and ethnic disparities

Medical Care
August 2014
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

Abstract

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.

Research Design:

Data are from a 2008 cross-sectional mixed-mode survey (mail with
telephone follow-up in 4 languages), which is unique in measuring a
comprehensive set of barriers and in focusing on several select
understudied ethnic groups. We examine racial/ethnic variation in cost
and coverage, access, and provider-related barriers. The study adhered
to a community-based participatory research process.

Subjects:

Surveys were obtained from a stratified random sample of adults enrolled
in Minnesota Health Care Programs who self-report ethnicity as white,
African American, American Indian, Hispanic, Hmong, or Somali (n=1731).

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.

http://journals.lww.com/lww-medicalcare/Abstract/2014/08000/Barriers_to_Care_in_an_Ethnically_Diverse_Publicly.8.aspx

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Comment by Don McCanne

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.