By Kristen Ukeomah

Winter is finally over, and health policy research is in full bloom. In March, we read about disparities in health insurance coverage for people of color, medical debt, and preventive service usage among private health plan enrollees.

Jesse C. Baumgartner, Sara R. Collins, David C. Radley, Inequities in Health Insurance Coverage and Access for Black and Hispanic Adults, The Commonwealth Fund. Researchers evaluated changes in health coverage and access for Black and Hispanic adults from 2013–2021 to assess the Affordable Care Act’s (ACA) impact on health coverage disparities across race and ethnicity.

What it Finds

• The disparities in uninsured rates between Black, White, and Hispanic adults have significantly narrowed since the ACA took effect. Between 2013–2021:
  • Uninsured rates for Hispanic adults decreased by 15.7 percentage points;
  • Uninsured rates for Black adults decreased by 10.9 percentage points; and
  • Uninsured rates for White adults decreased by 6.3 percentage points.
• The largest coverage gains among Black and Hispanic adults compared to their White counterparts occurred between 2013–2016, following implementation of many of the ACA’s market reforms and Medicaid expansion, and between 2019–2021, when enhanced premium subsidies and continuous Medicaid coverage took effect.
• In states that expanded Medicaid under the ACA, uninsured rates were lower and racial/ethnic coverage disparities were narrower.
• Across racial and ethnic groups, adults were less likely experience cost-related barriers to care over the past eight years:
  • The Black-White disparity has dropped from 8.1 to 4.7 percent; and
  • The Hispanic-White disparity has dropped from 12.7 to 8.9 percent.
• Across racial and ethnic groups studied, adults in Medicaid expansion states were more likely to have a usual source of care, such as a primary care provider, than adults in non-expansion states. There was also less disparity between Black and White adults reporting a usual source of care in expansion states.

Why it Matters

The ACA has made significant strides in reducing racial and ethnic disparities in health insurance coverage as well as health outcomes. In addition to coverage gains among historically underserved populations following the ACA’s Medicaid expansion and market reforms, COVID-era policies to maintain continuous Medicaid coverage and expand marketplace financial assistance have been associated with similar impacts on health disparities. The unwinding of continuous Medicaid coverage and a potential showdown over enhanced marketplace subsidies may threaten this progress, and policymakers will need to consider ways to prevent a backslide. The authors of this study propose, for example, creating a federal fallback option in states that have not expanded Medicaid, allowing states to extend continuous Medicaid eligibility, establishing an auto-enrollment mechanism for health insurance, and making permanent the enhanced Marketplace premium subsidies.

Michael Karpman, Most Adults With Past-Due Medical Debt Owe Money to Hospitals, Urban Institute. Using data collected through Urban Institute’s Health Reform Monitoring Survey (HRMS) in June 2022, this study analyzed the share of working age adults (ages 18-64) with past-due medical bills, and assessed past research to identify trends in hospitals’ provision of charity care.

What it Finds

• The ACA requires non-profit hospitals to establish Financial Assistance Policies (FAP) that determine if patients are eligible for “charity care” before seeking to collect payment.
  • Non-profit hospitals, on the whole, spend a smaller aggregate share of their expenses on charity care than public and for-profit hospitals, and more financially successful non-profit hospitals spend a lower share of net income on charity care than less successful non-profit hospitals.
• Over 100 million adults have medical or dental bills that are either past due or being paid off over time.
  • Almost two-thirds of adults with past-due medical debt have incomes below 250 percent of the federal poverty level (FPL)—roughly the income level many hospitals set as a ceiling when determining eligibility for discounted or free care.
  • Black and Hispanic/Latinx adults were more likely than White adults to report past-due medical debt.
  • Adults with disabilities were nearly twice as likely to have past-due medical debt compared to those without disabilities.
• Most adults with past-due medical debt owe at least some of that debt to hospitals, and adults with past-due hospital debt typically have more medical debt than those with debt from non-hospital providers.
• Most adults with past-due medical debt, including those with incomes under 250 percent FPL, reported being contacted by a collection agency, while fewer reported the hospital filing a lawsuit against them (5.2 percent), garnishing their wages (3.9 percent), or seizing funds from their bank account (1.9 percent).
• About 36 percent of adults with past due hospital bills reported that they worked out a payment plan with hospitals, while only 21.7 percent of adults with past-due hospital bills reported receiving discounted care.
  • Adults with incomes under 100 percent FPL were less likely to have worked out a payment plan with hospitals.
  • Adults with incomes below 250 percent FPL were just as likely to have received discounted care as those with higher incomes, indicating that lower income adults with past-due hospital bills were either ineligible for charity care, unaware of this option, were unsuccessful in applying for charity care, or received care at a hospital that had not established a FAP.
  • Almost half of non-profit hospitals have reported patients who likely would qualify for charity care under their FAP owe them bad debt.
  • Only 5.8 percent of adults with past-due hospital bills, and only 9.2 percent of adults with incomes below 100 percent FPL, indicated the hospital offered them assistance with applying for Medicaid.

Why it Matters

Medical debt impacts both personal and financial health. Despite federal requirements for non-profit, tax-exempt hospitals to set up FAPs and screen patients for charity care before taking certain collection actions, this study suggests that poor enforcement, a lack of clarity, and varying data collection has limited the impact of these rules on improving care access. The author calls for federal laws and regulations that build on state efforts to bolster standards around charity care and other community benefits, improve charity care reporting, and limit aggressive debt collection. At the state level, the author recommends coverage access and affordability reforms, such as expanding Medicaid, establishing Marketplace subsidy wraps, and eliminating the “firewall” for people with employer-sponsored plans to reduce consumers’ risk of incurring medical debt. The study also describes a need for further research to evaluate the efficacy of consumer protection laws and the impacts of medical debt on patients in general and vulnerable groups in particular, including monitoring enforcement of the No Surprises Act.

Krutika Amin, Brett Lissenden, Allison Carley, Gregory Pope, Gary Claxton, Matthew Rae, Shameek Rakshit, and Cynthia Cox, Preventive Services Use Among People With Private Insurance Coverage, Peterson-KFF Health System Tracker. The ACA requires most private health plans to cover a set of preventive services at no cost-sharing to enrollees (“ACA preventive care”). In light of Braidwood Management v. Becerra, a lawsuit threatening this popular ACA provision, researchers evaluated utilization of ACA preventive care to predict the impact of a court ruling invalidating the coverage requirement.

What it Finds

• In 2018, 60 percent of the privately insured population (approximately 110 million people) receive some ACA preventive care.
  • Women, children, and older adults were more likely to receive ACA preventive care.
  • The share of individuals who received ACA preventive care was roughly similar across all private insurance markets, including the large employer market (61 percent), the small employer market (57 percent), and the individual market (55 percent).
  • The most common ACA preventive care received included vaccinations, well women and well child visits, cancer screenings, and screenings for heart disease.

Why it Matters

After this study was published, a federal judge in Texas struck down the requirement for private insurers to cover a set of services recommended by the U.S. Preventive Services Task Force without cost sharing, including, for example, certain cancer screenings and HIV prevention medication. The cost of care often deters people from receiving care. Widespread utilization of ACA preventive care by the privately insured shows that this ruling—if allowed to stand—could have a significant impact on access to preventive services if insurers force consumers to pay out of pocket for this lifesaving care.

Though not covered in this month’s research roundup, there were also great articles from the JAMA Health Forum on the rising cost of employer-based health insurance and the burden it places on employees, and from the Brookings Institution on bipartisan policy options for reducing health care costs.