Affordable Care Act Won't End Disparities

Creative, individualized programs are needed to improve healthcare for minorities

Shari Roan is an award-winning health writer based in Southern California.

In the "what's-in-it-for-me?" discussion about Obamacare, perhaps the most overlooked aspect of the bill is how it will help people who have long suffered the worst health and had the fewest opportunities for decent care. The Affordable Care Act includes provisions aimed at addressing health disparities among minority populations.

But despite expanded access to care and health insurance coverage, the law won't eliminate health disparities, according to an analysis by experts at the Robert Wood Johnson Foundation. Disparities exist independent of cost and marketplace issues, Dr. Marshall Chin, the Richard Parrillo Family Professor of Medicine at the University of Chicago, told TakePart.

"Clearly the Affordable Care Act will help a lot of people," Chin says. "More people will have access to care—getting their foot in the door. But once you have your foot in the door, it's about having the highest quality care possible."

For example, he says, "We know that oftentimes people who have Medicaid insurance go to under-resourced facilities. While we have to keep our foot on the pedal to make sure they get access to care, we have to spend more time as a nation thinking about how to tailor care so that everyone receives the best quality care."

Beginning in January, 2014, everyone living at or below 133 percent poverty will be eligible for Medicaid under the Affordable Care Act. Of the 24 million people who will pick up health insurance under the law, almost half are minorities.

The law also prevents insurance companies from denying coverage to people with pre-existing conditions. Members of ethnic minority groups are more likely than whites to have pre-existing conditions and thus will benefit the most from this aspect of the law.

Blacks and Hispanics are also less likely to have employer-sponsored health insurance. Under the ACA, government-regulated health insurance exchanges will be set up to accommodate those consumers.

The law also authorizes data collection to examine how healthcare resources are used according to race, ethnicity, language, gender and disability status in order to identify where disparities persist.

"That will help shine the light on problems where we know, from previous studies, that quality of care differs based on factors such as race, ethnicity and socioeconomic status," says Chin, who is the director of the Robert Wood Johnson program entitled "Finding Answers: Disparities Research for Change." With this data, he adds: "People can see in their own backyard where there is a problem that has to be addressed."

Under the ACA, grants will be issued to increase the number of minority workers in healthcare occupations. The law also provides $11 billion in funding for community health centers—places that will primarily serve minority groups.

But many health disparities exist independent of expanded access to care and insurance coverage. Studies show racial and ethnic minority patients are less likely to receive kidney dialysis, the report notes. Infants born to black women are 1.5 to three times more likely to die than infants born to women of other ethnicities. Blacks are more likely than whites to die of heart disease and stroke.

The entire healthcare system is burdened by these disparities. Among blacks and Hispanics, the cost burden of three preventable conditions—high blood pressure, diabetes and stroke—totaled $23.9 billion in 2009, according to a study by the Urban Institute. Blacks are hospitalized at a rate nearly double that of whites.

Eliminating these stark disparities could prevent about one million hospitalizations and save about $6.7 billion per year, according to the Agency for Healthcare Research and Quality.

And, Chin notes, decades of research and pilot programs have produced solid strategies for addressing health disparities. Clinics should have healthcare personnel who speak the language of the patients they serve and understand the culture, the report notes. Treatments should be customized to meet the needs of a community. For example, some clinics and hospitals serving large minority populations have established programs in which nurses call patients monthly to check on their progress and answer questions.

At Cooper Green Mercy Hospital in Birmingham, Ala., for example, patients diagnosed with high blood pressure can watch videos featuring fellow patients in the community who are also being treatment for the condition. On the tapes, these patients share their experience with treatment, thereby promoting adherence to treatment and trust in the healthcare system.

The idea is to teach patients about their health and empower them with tools to remain healthy, Chin says.

"People too often have a one-size-fits-all approach, whereas we are all individuals," he says. Someone with diabetes, for instance, needs to adopt a healthier lifestyle along with getting good medical care and medications. But, Chin says: "If you're poor you are going to have a different set of barriers for healthy eating than someone is affluent."

The U.S. healthcare system has not been set up for such an individualized, community approach, however. Healthcare providers are typically paid on a fee-for-service model. They aren't reimbursed for giving patients advice on exercise, diet or stress reduction. That model makes it harder to address disparities, Chin says.

"Right now, we have a system that doesn't have very good incentives for that," he says.

More work is needed to devise incentives for healthcare providers to keep their communities as healthy as possible. Fighting disparities in healthcare will take more than just a single program or strategy to reach a particular group of people, Chin says.

"You don't want to just put in a program and say, okay, we're addressing disparities,' " he says. "The idea is to raise the quality of healthcare provided across the board. How can we make sure that care is delivered in the best possible way for everyone?"

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