In honor of Black History Month, for the February edition of CHIR’s monthly research roundup we reviewed new health policy research centering the experiences of Black people in the U.S. health care system, including structural racism in health care policy, the impact of state Affordable Care Act (ACA) implementation on racial and ethnic minority populations, and trends in coverage, care access, and health outcomes among Black Americans.

Ruqaiijah Yearby, Brietta Clark, and José F. Figueroa, Structural Racism In Historical And Modern US Health Care Policy, Health Affairs, February 2022. The authors looked at how structural racism in modern health care policy contributes to continuing health inequities, focusing specifically on health care coverage, financing, and quality.

What it Finds

Coverage

• Black and Latino people are 1.5 and 2.5 times more likely, respectively, to be uninsured than their white counterparts.
• While most Americans receive health coverage through their employer, racial and ethnic minority workers are disproportionately employed in low-wage jobs that often provide no or inadequate coverage with high premiums and cost-sharing. This has historical roots in labor policies that empowered unions to obtain health insurance for workers but excluded entire industries in which racial and ethnic minorities were more likely to be employed.
• Low-income racial and ethnic minorities are more likely to have employer-sponsored insurance (ESI) that exposes enrollees to high out-of-pocket costs, and due to the Affordable Care Act (ACA) these workers are not eligible for better coverage under subsidized marketplace plans.
• Although access to affordable coverage for people of color increased after the ACA’s Medicaid expansion, people of color make up 60 percent of the Medicaid coverage gap, with Black people more than twice as likely to fall into the gap. The authors suggest that deep-rooted racism helps explain why some states have yet to expand Medicaid, pointing out how opposition to expansion—associated with a lack of support among whites in non-expansion states—is fueled by assumptions about racial and ethnic minorities or “foreigners” benefiting from expanding Medicaid.

Financing

• The authors attribute financially driven racial inequity to the federal government’s lack of oversight regarding how funding distributed to states, insurers, and employers impacts racial and ethnic minority groups’ access to care, citing examples of payment systems that exacerbate inequities:
  • Although tax-exempt, nonprofit health care organizations tend to reside in predominately minority communities, and the lack of oversight by state and federal government allows such organizations to spend tax savings on employee and administrator benefits rather than investing in initiatives to improve access to affordable and high-quality care in those communities.
  • Payment reforms that reward providers based on quality rather than quantity of care provided have potential to alleviate health disparities, but they can also exacerbate disparities by penalizing safety-net providers who care for low-income minority individuals with poorer health status. Thus, such payment systems can result in fewer resources going to providers who disproportionately serve racial and ethnic minority populations.
  • The authors suggest that financial incentives the federal government provides to health care purchasers, such as tax exemptions for employers who pay premiums for their employees’ health coverage, should be linked to health equity requirements.

Quality

• Data show that patients of color are less likely than white patients to receive adequate care for a variety of health care services, including treatment for cancer, cardiovascular issues, kidney transplants, mental health conditions, and diagnostic screenings.
• Racial segregation persists in nursing homes: in 2013, 80 percent of total admissions of Black patients were concentrated in 28 percent of nursing homes. Because nursing homes primarily serving Black patients tend to have fewer resources, they typically perform worse on rehospitalization and successful discharge to the community, two quality measures. Within the same facility, Black patients have been shown to receive lower-quality care than white patients.
• People of color are more likely to live in areas with provider shortages, making it difficult to access quality care. The authors note that this is due in part to hospitals closing or relocating to more affluent, majority white areas, citing an association between the racial makeup of a hospital’s inpatient population and the probability of hospital closures.

Why it Matters
Examining racism in health care through a historical and structural lens helps us understand—and intervene in—the nature of racial health disparities. Systemic barriers to coverage, disparities in the quality of care, and health care financing that exacerbates inequities lead to a lack of health care access. By tracing the historical path of racism in health care, the authors demonstrate that our current system emerged due to laws, policies, and actions (or lack thereof) made by those in power. At the same time, as the authors note, there is not one racist stakeholder to confront or one racist policy that can be overturned in pursuit of health equity. Since structural racism permeates the health care system, fully addressing racial health disparities requires anti-racist structural change.

Pamela J. Clouser McCann and Ashley Jardina, When Rising Tides Don’t Lift All Boats Equally: Racial Inequality in Health Insurance after the Affordable Care Act, Journal of Political Institutions and Political Economy, February 10, 2022. Recognizing that states had considerable leeway regarding how to implement the ACA, researchers investigated the causal impact of state implementation choices on access to health insurance for three subpopulations: Black residents, Latino residents, and white residents. Researchers compared the impact of state choices on the health insurance status of nonelderly adults (ages 18-64) and a placebo group of adults 70 and older (who were eligible for Medicare). “Control” states effectively took no action: they did not expand Medicaid or develop a state-based marketplace, so they were automatically added to the federally facilitated marketplace (FFM) in 2014. “Treatment” states, or those that actively implemented the ACA, include (1) early ACA implementers (including, e.g., using 1115 waivers to expand Medicaid prior to the law’s enactment); (2) states that chose to expand Medicaid and develop a state-based marketplace (SBM); (3) states that joined the FFM and expanded Medicaid; and (4) states that developed an SBM without expanding Medicaid.

What it Finds

• For Black residents, the “most sustained improvement” in insurance rates occurred in states that expanded Medicaid and opted to run an SBM, where nonelderly Black residents had a 4.7-5.3 percent increased chance of having health insurance.
• Following ACA implementation, states that expanded Medicaid increased the probability that nonelderly Black residents would have health insurance by 15 percentage points.
• Coverage increases in FFM states plateaued for all three subpopulations from 2016 to 2019, which the authors suggest may indicate a distinction between the Trump and Obama administrations’ approaches to the ACA.
• Black and Latino residents’ coverage rates improved more than white residents in states operating SBMs, but insurance rates for white residents were at a much higher starting point pre-ACA.

Why it Matters
The ACA was enacted to improve health insurance coverage rates. But actions at the state level have resulted in uneven progress that has perpetuated historical inequities in coverage between populations of color and white populations. Variation in state actions and outcomes offers lessons for future health policy reforms that depend heavily on state implementation. And as the authors note, having health insurance is not synonymous with receiving quality health care. Still, policymakers should take note of the significant coverage gains for racial and ethnic minority residents in states that embraced ACA implementation.

U.S. Department of Health & Human Services’ Office of the Assistant Secretary for Planning & Evaluation (ASPE), Health Insurance Coverage and Access to Care Among Black Americans: Recent Trends and Key Challenges, February 22, 2022. Using data from the American Community Survey (ACS) and National Health Interview Survey (NHIS), ASPE examined trends in health insurance coverage, access to care, and health outcomes among Black Americans from 2011 to 2020.

What it Finds

• Compared to the broader U.S. population, Black Americans face disproportionately high levels of chronic disease, morbidity, and mortality, and have a lower life expectancy than non-Latino white Americans.
• ASPE’s data affirms that ACA implementation led to significant coverage gains for the nonelderly Black population, with the uninsured rate in this group dropping from 20 percent in 2011 to 12 percent in 2019.
  • Black Americans with incomes below 100 percent of the federal poverty level (FPL) experienced the greatest decrease in uninsurance rates (9 percentage points).
  • Post-ACA, fewer Black Americans reported challenges paying for medical care (27 percent in 2011 compared to 18 percent in 2020), worries about medical bills (25 percent in 2011 compared to 18 percent in 2020), or delaying prescription refills to save money (13 percent in 2011 compared to 9 percent in 2022). However, since 2013, these rates have been higher among Black Americans than white Americans.
• Alabama, Florida, Georgia, and Mississippi had the highest uninsured rates for Black adults in 2019—all states that have not expanded Medicaid under the ACA. According to ASPE, if the remaining 12 non-expansions states expanded Medicaid, roughly 957,000 non-Latino Black American adults would gain eligibility.
• Ongoing federal policy efforts to improve Black Americans’ access to care are generating encouraging results. For example, because of the enhanced marketplace subsidies currently in place under the American Rescue Plan Act (ARP), 66 percent of Black Americans are eligible for a HealthCare.gov plan with a $0 monthly premium.
• Nonetheless, racial health disparities have been exacerbated by the pandemic, as Black Americans have been at higher risk of hospitalization and death from COVID-19 than white Americans.

Why it Matters
Robust data collection on racial and ethnic minority groups’ access to health coverage and care is a critical step towards addressing health disparities. ASPE’s review captures long-term trends that show improvements—primarily in connection with federal social safety net programs like the ACA and ARP—but also demonstrates how our health care system continues to fail Black Americans, especially during a pandemic. Without congressional action, ARP subsidies are set to expire at the end of this year, jeopardizing the availability of affordable coverage for Black Americans who are disproportionately low-income. This study should sound the alarm to maintain the hard-won coverage gains of the ACA and ARP, and push for additional policies to ensure people of color have access to affordable, comprehensive health insurance.