Health Policy – H. Shellae Versey

Health Disparities and ACA: Where are we now? Where could we be?

The logical sequel to “where are we now?” is “where could we be?” in relation to the Patient Protection and Affordable Care Act (ACA). We must remember that there are (at least!) two sides to every policy issue. Ignoring the political debate about whether ACA has been successful for a moment, let’s consider how ACA is impacting marginalized groups, and how it could be useful in closing gaps in care for those same groups. Essentially, let’s address two simple questions – What are health and health care disparities? And how does the ACA impact disparities?

What are health and health care disparities?
For the sake of simplicity, we will define health disparities as a disproportionately higher burden of illness, injury, disability and/or mortality experienced by one population group relative to another group. Of course, disparities are not mere differences, but are instead a particular type of health difference closely linked with social and economic factors, systematic oppression and/or environmental disadvantage. Health care disparities are differences between groups in health insurance coverage, access to care, and quality of care. Ok, so what does this have to do with ACA?

The ACA was passed with the primary goal of filling in gaps in the availability of affordable health coverage in the United States. Major provisions included documenting disparities through data collection and research, expanding preventive health benefits (especially for groups that previously had little access to preventive services) and the expansion of public health insurance (Medicaid/Medicare) benefits. Recall briefly that prior to the passing of ACA, certain groups meeting certain guidelines were “covered” and able to access Medicaid benefits. However, due to strict eligibility requirements, not everyone was able to qualify and access benefits (red portion of umbrella). However, post-ACA, modifications to Medicaid requirements expanded benefits to more people (blue portion of umbrella) and many of those that were previously excluded are now “covered” and able to access a reasonable array of heath benefits and services. Yes – Success!

Not so fast. While ACA is a national policy, Medicaid, the primary government-funded insurance program to provide health care to low-income individuals and vulnerable groups is state-run or managed by cooperative agreements between the federal and state government. Recall also that in 2012 the Supreme Court decided that while the Medicaid coverage expansion would be maintained, the Secretary would be limited in authority to enforce the expansion (in National Federation of Independent Business v. Sebelius), effectively making the expansion optional for states.

How does the ACA impact disparities?
In a nutshell, states are not required to expand Medicaid benefits, leaving those who would be “covered” well, holding an umbrella with a giant hole in it. In fact, as of August 2014, 28 states including the District of Columbia were expanding Medicaid to provide additional benefits and services; however, 21 states were not and 2 were undecided. It also just so happens that a sizable number of states not moving forward with Medicaid expansions at this time are also states located in the South, among the poorest states and home to large percentages (~50%+) of communities of color. States in the South and largely rural states also serve more older adults, have more Medicaid/Medicare patients and maintain the highest rates of chronic health burden.

Image Courtesy of Kaiser Family Foundation

Is it all making sense now? Rather than expanding coverage, in many states where health disparities are the most striking there is a widening coverage gap. For states opting not to implement the Medicaid expansion, millions of adults (nearly 4 million) will remain outside the reach of the ACA and continue to have limited, if any, option for health coverage. This creates issues not only for Medicaid reform, but for a growing group of individuals and families (holding the holey umbrella) who are essentially the working poor, the uninsured, the undocumented and those who can’t afford to buy private insurance on the Exchange.

Not the warm-fuzzy you were expecting? Well, I did say that there was hope, no? “Where could we be?” is the pressing question that will continue to shape our health care system as we think of new ways to deliver care. The beautiful thing about state-run Medicaid programs is that states have some autonomy, at least in those opting to expand Medicaid, to actually address change at the SYSTEM level. In New York State for example, a primary goal is to “break the mold” of the current Medicaid program to offer innovative new ways of delivering a mix of services to improve population health. Streamlining emergency Medicaid processes, developing new ways to provide supportive housing and providing competency training to the NYS healthcare workforce are just a few ways New York is taking on service integration and system reform. One can only hope that such innovation, especially as it relates to training the health care workforce, follows a structural competency model to highlight the underlying root of health inequalities and how we, as health professionals, can change them.

It is an exciting time to be engaged in Medicaid redesign as policy makers and public health researchers are actually thinking through and talking to one another about how to offer more community services for those caught in the gap and how to meet people in need where they are. System change is indeed a beautiful thing. It will be an interesting experiment to observe how it all plays out and what the changes associated with ACA will bring in the years to come.

Women’s Health and ACA: Where are we now?

As we enter into the third quarter of 2014, it seems like a good time to review the changes enacted by the Affordable Care Act (ACA) and what good/bad impacts these changes have had for women’s health and underserved groups. It’s a larger discussion than to be had here for sure, but engaging in the conversation is important in ensuring that we continue to push for not only accessibility, but equity in health care as well.

The passing of the ACA signals a significant advancement in women’s health and public policy in general, ensuring that millions of women now have access to affordable health coverage. Women no longer pay more than men just for being women (e.g., gender rating). Unbelievably, for the first time in history – this overt gender discrimination is now prohibited in federally funded health care. Women will also not be denied coverage for pre-existing conditions, such as a Caesarean section or having received medical treatment for domestic violence. Lifetime dollar-value caps are no more, maternity coverage is now considered an essential health benefit and preventive services have been expanded to include contraceptives, mammograms and cervical cancer screenings with no deductibles or co-pays. Although the contraceptive mandate has stirred controversy in public discourse, the fact that birth control is available on both public insurance and private plans without out-of-pockets costs represents progress. Employers (non-religious) are not only required to provide birth control as part of insurance plans offered to employees, companies must also – and this is a big one for anyone who has ever breastfed – offer hourly employees a clean, safe space in which to pump (e.g., not an office closet or restroom).

And what about older women? One of our fastest growing demographics? They benefit too through a host of programs to support caregivers (typically women). Dual-eligibles will also maintain a more integrated balance between Medicare/Medicaid and will be able cover more prescription drug costs.

With these benefits, its hard to imagine that the ACA is anything but a resounding success. Still, coverage gaps remain. Of the currently uninsured, approximately 20% are women. Furthermore, the failure of some states to expand Medicaid eligibility benefits will undoubtedly affect women’s health in profound ways. All in all, the report card is not yet conclusive as to whether individual mandates and state expansions fully address the needs of women in this country. There is a sizable proportion of women who will be excluded from receiving any benefits due to immigration status or costs associated with buying insurance on the individual marketplace.

Many women fall between a space where they fail to meet eligibility criteria for Medicaid and can’t afford to purchase private insurance on the exchange, even with tax credits and subsidies. And while primary care at federally qualified health centers is available, access and quality depend on geographic location. Its possible for women with limited options to continue to receive clinic and inpatient care at the remaining public hospitals and some non-profit hospitals that provide charity care, yet this is far from ideal and free clinics are few and far between. In addition to that, abortion is still not federally supported and accessibility and affordability varies on the health exchange. Drug coverage continues to be a priced at a premium and even though certain medications are subsidized by pharmaceutical companies, ultimately, mandating insurance coverage for the poor and underserved – many of whom are struggling to meet ends – is a difficult imperative. Ironically enough, the two ways in which the ACA was close to gaps – provide access and expanded benefits (at reduced cost) – are precisely the areas in which the most marginalized still find themselves lacking, with Medicaid expansions in many states (26) at a standstill.

Of course, its not simple to overhaul a national system that historically, was never intended to provide universal access to care. And the ACA shouldn’t be blamed for the complicated and dysfunctional system it took centuries to create. Some parts of the ACA are working; but others still need tweaking. For those of us working in the community and serving underserved populations, its important to not only understand these shortcomings, but also to advocate on behalf of women, children and the un(under)insured who may be navigating a complicated system or shut out altogether.