The Affordable Care Act and the Chasm of Health Disparities. [INSIGHT]

By David R. Morse – President and CEO / New American Dimensions, LLC

The Affordable Care Act of 2010 (ACA) may do more to decrease disparities in access to health care than anything since the Civil Rights Act of 1964.

It is expected to reduce the number of uninsured people in the United States from about 58 million to approximately 26 million in 2019, largely due to increased access to free or subsidized health insurance through Medicaid, the Children’s Health Insurance Program (CHIP), and the state-based health insurance exchanges that will be set up for small-employer and individual purchasers.

And according to a recent study in Health Affairs, about half of the newly insured under the ACA will be non-white. The will reduce the number of African Americans without insurance from 22% to about 10%; for Hispanics, the uninsurance rate is expected to drop from 33% to 21%. The study calculated that the ACA would cut the black-white uninsurance rate differential by more than half and the Hispanic-white coverage differential by about a quarter.

Increasing access to health insurance is a major part of the battle. But it is not the whole story. In 2002, a report issued by the Institute of Medicine (IOM), Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, found that even when accounting for differences in health care coverage, socioeconomics, language ability, and a host of other variables, African Americans and Hispanics received a lower quality of healthcare than whites. Among the reasons cited were biases, prejudices , stereotyping, and uncertainty in clinical communications. A study by the Canadian Institute for Advanced Research found that social determinants such as poverty, racism, discrimination, residential segregation, and environmental conditions accounted for about 60% of healthcare outcomes.

People of color in the United States experience higher rates of diabetes, hypertension, obesity, asthma, HIV/AIDS and certain types of cancer than whites. African Americans experience higher rates of mortality from heart disease, cancer, cerebrovascular disease and HIV/AIDS than any other U.S. racial or ethnic group. Hispanics are almost twice as likely as whites to die from diabetes and some Asian-American populations have rates of stomach, liver and cervical cancers that are much above the national average. Minority groups experience rates of preventable hospitalization that is often double that of whites, and African American children are more than four times as likely to die from asthma than white children. ”

Extremely comprehensive in scope, ACA calls for not only increased access to affordable insurance coverage, but expanded data collection and reporting on disparities, increasing access to community health centers, improving chronic disease management, the establishment of six offices of minority health within the Department of Health and Human Services and a focus on developing a more diverse, culturally and linguistically competent health care workforce — currently Hispanics and African Americans each make up only about 6% of physicians. Importantly, health care professionals will be incentivized to achieve better health outcomes at a lower cost.

Clearly, there are important gains yet to be made. Of the 26 million projected to remain uninsured after the Act’s passage, 38% will be Hispanic — in large part due to the fact that undocumented immigrants will be not be eligible for coverage either through the public insurance that the Act mandates or the through the exchanges (Hispanics make up about 82% of the undocumented). And legal immigrants will be ineligible for all benefits except health insurance subsidies during the first five years of their residency. The situation will get complicated, given that so many Hispanics live in families of mixed immigration status. According to the Pew Hispanic Center, in 2009, there were 4 million U.S.-born children and 1.1 million foreign born children of unauthorized immigrant parents.
Barring any major immigration reform, the issue of covering undocumented residents is unlikely to be resolved anytime soon, given the strong emotions that it arouses on both sides of the aisle. It’s already been three years since, when during President Obama’s speech on healthcare, South Carolina Rep. Joe Wilson (R) broke with years of protocol and yelled out “You lie!” when the President said the ACA legislation would not mandate coverage for undocumented immigrants.

As key mandates of the ACA are enacted in 2014, there will continue to be some big questions that will need to be answered. Beyond basic demographics, what will these newly-insured patients look like? How intense will national, state and local outreach efforts be to enroll eligible people into Medicaid and CHIP and the new exchanges? How aggressively will health care practitioners focus on overcoming linguistic and cultural barriers, particularly in California and Texas, where about half of Hispanics live? How will providers cope with the mammoth influx of Americans insured under Medicaid? And how will safety-net providers such as emergency rooms acquire the competence to manage a patient base that will represent a higher percentage of undocumented immigrants than ever before.

Perhaps the greatest challenge faced by health care professionals will be to make Americans aware that we do indeed have a disparities problem. A study conducted last year by Jennifer Benz et al found that only 59% of Americans were aware of racial and ethnic disparities in health care. An important finding was that there was wide divergence by race and ethnic group — 89% of African Americans and 72% of Hispanics said they were aware of disparities between their group and whites, compared to a little over half of whites.

According to Allison Hoffman, a professor of law at UCLA who specializes in health policy, the United States spends the most, per person, on health care in the world. Yet the United States does not even rank among the top 10 in several important health measures. Wrote the IOM, “The U.S. health care delivery system does not provide consistent, high-quality medical care to all people … Health care harms patients too frequently and routinely fails to deliver its potential benefits. Indeed, between the health care that we now have and the health care that we could have lies not just a gap, but a chasm.”

The Supreme Court’s decision to uphold ACA means that the rules of marketing game have changed. As Gregg DiPietro points out, because of the law’s focus on efficacy and cost, the target market moves beyond physicians, patients and payers to incorporate administrators, support staff, and purchasing groups. For pharmaceutical companies, who have traditionally emphasized efficacy and safety, the dialog will focus more on value. Says DiPietro, pharmaceutical marketers “must now create a value story around their products based on both clinical and economic outcomes.”

If we are to count ourselves among the great nations of the world, than we Americans arguably have a moral imperative to increase the quality of health care for all. As multicultural marketers, we can help. There is a need to educate about disparities. There is a need to get the word out to medically underserved folks as to how they can take best advantage of the new health care options. And there is clearly a need for more research that looks into the impact of race, ethnicity and sexual orientation on how one navigates — and is navigated — through the health care system.

ACA goes a long way toward getting us on track. But we still have a long way to go.