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ACA Programs, Seen to Address Health Disparities, Now in Jeopardy

Analysis  |  By Tinker Ready  
   January 26, 2017

Improvement in care has been seen for privately insured low-income patients and for those at federal health centers. Whether those programs will survive the GOP's plans for the Affordable Care Act is uncertain.

Despite a push to address health care disparities, inequity in delivery and outcomes remains a problem.

Minorities are still more likely than whites to be uninsured and experience bad outcomes. "Blacks and American Indians and Alaska Natives fare worse than Whites on the majority of examined measures of health status and outcomes," according to a 2016 report from the Kaiser Family Foundation.

"Disparities in health and health care remain a persistent challenge in the United States," the report notes.

Coverage for Chronically Ill Rose 5% Under ACA

Now, just as the Trump administration is setting the groundwork to repeal and replace the ACA, two new studies suggest that some Affordable Care Act provisions may be getting at the disparity problem.

Whether those programs will survive the GOP's plans for the ACA is uncertain.

While many of the Obamacare programs are too new to have generated much data yet, one program at Blue Cross Blue Shield of Massachusetts has taken an approach that is similar the ACA accountable care organizations.

Researchers from Harvard Medical School examined the impact of the insurers "Alternative Quality Contract"on spending, as well as process and outcome measures. They compared changes for higher and lower income enrollees from 2006 to 2012. Quality improved for all enrollees, but the improvement in some measures was higher for low income enrollees.

The trend could suggest "a potential narrowing of disparities," according to the team's findings published in the current issue of Health Affairs.

"The hope is that the lessons we can draw from the early Massachusetts experiment… can be useful for other states, other payers, even Medicare, as they embark on payment reform," said Zirui Song, a clinical fellow at Harvard Medical School and lead author of the study.

The authors describe the Blue Cross program as a population-based, global budget model that has "two-sided incentives: It rewards physicians for savings below the risk-adjusted budget (shared savings) but also requires them to share in deficits with Blue Cross Blue Shield of Massachusetts for spending above the budget (shared risk)."

The insurer's website includes a video endorsement of the approach from Sandra L. Fenwick, the CEO of Children's Hospital Boston.

The Blue Cross study looks at privately insured patients, but another study in the same issue of Health Affairs examined outcomes before and after first year of the ACA's Medicaid expansion.

The focus of this study was on the 1,057 federally-funded health centers, with roughly half of those in Medicaid expansion states. The report notes that about 72% of the patients who use these centers have incomes below the poverty level.

Researchers looked at changes in insurance coverage for clinics and found a 11-percentage point decline in uninsured patients and a corresponding 12 percentage point increase in Medicaid coverage. They found that after the expansion in 2014, about 23% of the centers patient population were uninsured in expansion states, compared to 39% in nonexpansion states.

After looking at data from millions of patients, the researchers found improvement in asthma treatment, BMI screening, Pap testing, and blood pressure control. The study was led by Megan Cole, a PhD candidate at the Brown University School of Public Health.

The paper concludes that gains in quality may be even greater for newly expanding states, since baseline uninsurance rates in these states were higher than rates in states that previously expanded. At the same time, the paper reports that, quality may erode at centers in states that elect not to expand.

"As we move forward and think about changes in health reform it will be important to consider how potentially reversing some of these polices the could impact health centers," Cole said.

The impact if the coverage is rolled back. Despite data that some of the ACA provisions could address disparities, the future of those program remains unclear.

Alternative payment models like the one at Blue Cross Blue Shield of Massachusetts may live on in the private sector, but it is uncertain how much changes to the ACA with impact on ACO effort at Center for Medicare and Medicaid Services. In terms of Medicaid, the Republican position is to move responsibilities for the joint state and federal program to the states through block grants.

Hospitals are increasingly looking upstream at how the health of their patients is impacted by access to care and social factors like poverty, unemployment, education and housing. Both studies suggest that ACA program can help boost outcomes for low-income patients who face many of these challenges.

At the same time, the need for such research is highlighted in a report from the National Academies, the venerated Washington DC think tank. That report concludes: "Funding is needed to support research that studies the effects of—and effective strategies to address—the health-related harms of structural racism and implicit and explicit bias across categories of race, ethnicity, gender, disability status, age, sexual orientation, gender identity, and other marginalized statuses."

Tinker Ready is a contributing writer at HealthLeaders Media.

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