public health – 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.

Studying intersectionality quantitatively

I came across a blog recently that details the complexity involved in studying intersectionality from a quantitative perspective. Anyone who has encountered such questions in their own work can identify with the frustrating nature of accounting for an anti-categorical approach that is already quite complicated in theory. And yes, I said anti-categorical. As a quantitative researcher, “anti-categorical” is paradoxical to what we do. We live by quantifying things!

So what is one to do if so quantitatively-inclined? How can we, as scholars, accurately represent intertwined identities in research? The very notion that social categories (e.g., race, SES, gender, sexual orientation) are not independent and unidimensional but rather multiple and mutually constitutive, is both reasonable and rational, but very difficult to measure. Over the years, I have had many conversations with people (just like me) who are overwhelmed at the idea of accounting for intersectionality from a quantitative perspective. “Oh the categories!” Or perhaps, “What size N would we need to have for something like that?!” While easily mind boggling, these questions also reflect a fundamental misunderstanding of the intersectional perspective.

Let’s review. First, as a health researcher it is important to acknowledge that the intersectionality framework did not originate from public health research, nor was it designed to specifically predict health outcomes or processes. However, its utility lies in the potential to examine and explore health disparities. The standard method of studying disparities is a comparative approach (e.g., Black/White or male/female differences). While useful to some extent, a comparative approach misses what I consider to be the most critically important questions. WHY are there mean differences between these two groups on say, chronic disease? To what extent is within-group variation shared between both groups? In other words, comparing health outcomes between two groups (A and B) can only give you half (at best) of the big picture. If we are concerned with preventative health strategies and fundamental causes, then we must also be concerned about questions that address the origins of such disparities.

Therefore, a significant challenge for intersectionality researchers is to adapt a perspective originally designed as an analytical theory into a model that might be useful to empirically examine say, social inequalities in health. Tall order, huh? Lisa Bowleg eloquently addresses this issue in a 2012 American Journal of Public Health publication:

“Thus, for public health and other social science researchers, the absence of theoretically validated constructs that can be empirically tested poses not only a major challenge but also tremendous opportunities for advancing the study of intersectionality from a public health perspective.”

Nice way to take lemons and make lemonade. Did you catch that? As public health researchers, there are great opportunities to uncovering ways to study intersectionality! So, back to the original question of how to actually do that in practice. There are several possibilities. Bowleg suggests more use of qualitative or mixed-methods research in public health research (I’m a fan of this idea). Given that I research intersections, I have devoted considerable thought to the topic and one approach that has been very rewarding and fruitful for me is within-group analysis. I’m sure you might be thinking, “But how can we possibly find out anything interesting about ____ people if we don’t compare them to ____ people??!” Ah yes. I’ve encountered different variations of this question over the years, and to that I reply, “It’s simple. No one group is monolithic.”

In essence, we are all complex and if I am concerned with Black women’s health, for example, I cannot fully understand Black women if I am only comparing health outcomes between Black and White women. Within-group research (studying only one group) allows us to understand the wonderful complexity that exists within a group of people who share one social identity. For example, Black women are extremely diverse. However, that diversity can easily get lost if you don’t take into account education, class background, geographic location, and other features of the social context that shape the human experience. Furthermore, there is a tremendous amount to be learned from understanding variability between risk and resiliency. Not all Black women develop diabetes, cardiovascular disease and die young, but some do. Why? And why does upward mobility not yield the same beneficial effects in terms of infant mortality for educated Black women, as for White women? These important questions require a thoughtful and deliberate approach to not only examining disparities, but actually doing something to help prevent them.

Natalie Sabik and I will be presenting our work on intersectionality and physical functioning among older African American women at the Intersections of Race, Culture, Health and Mental Health Conference at Boston College, October 18-19th.

Note: Just ordered Evelyn Simien’s Black Feminist Voices in Politics – an intersectional analysis. Can’t wait to read!