Will the Affordable Care Act Help Eliminate Disparities?

Many provisions of the Affordable Care Act are designed to overcome health outcome disparities caused by social factors associated with race, ethnicity, language, and culture. Will they work?

There is a growing sense that the promising provisions of this Act either are not being implemented or are being seriously undermined by deficit reduction efforts. Furthermore, if we can succeed in fighting off cuts and attacks at the federal level, much of the promise of the ACA will be lost should state level efforts ignore the disparities elimination agenda.

There are two main policies in the ACA that can be associated with disparity elimination.First, there is a big expansion of insurance coverage. Medicare is to expand to cover currently ineligible adults and a new system is instituted to subsidize care for families up to 400% of the federal poverty level. This latter is to be implemented through state level exchanges.

Second, following research showing that we can insure everyone and many will still not have access to quality medical care, the ACA includes provisions designed to overcome disparities through research, planning, provider training, language sensitivity, community initiatives, improved medical infrastructure, and an expanded Indian Health Services system.

Will these efforts finally succeed in reducing or eliminating disparities? The answer to this question will depend largely on two other questions: will the new programs be funded and will implementation at the state level carry through on these promising beginnings?

To begin with, funding for these important provisions is under attack in the Congress. Medicare is facing reductions not expansions. Efforts to eliminate funding for the Affordable Care Act are in full flower in the House. If the current frenzy to cut funding continues it is difficult to see how the expansions of health care coverage can actually succeed.

Many of the anti-disparity provisions are to be financed from a Prevention Fund created in the ACA. The current House Appropriations bill entirely eliminates this Fund and the Administration’s deficit reduction plan makes billions of dollars of cuts to the Fund. Indian Health Service funding is not being expanded. Resources for research, planning, and associated safety net programs all are under deficit reduction pressure.

Even if we can succeed in fighting back against the deficit sharks, we will face an even more daunting task at the state level. While there are some notable exceptions, most of the state level planning to implement ACA Exchanges completely ignores the disparities elimination agenda. Part of the problem is that exchanges will provide services through private insurance companies and most of these companies see elimination of disparities as someone else’s problem. At best in these states there is minimal lip service to federally required language sensitivity but opportunities to require insurance company participation in this agenda largely are being ignored.

State level exchanges will be governed by rules established by the Department of Health and Human Services. Preliminary rules are being processed now by HHS. However, the disparities associated provisions of these rules are fairly weak, with confusing and dysfunctional language access standards and no requirements that insurance companies use quality improvement plans and provider networks to help expand medical access among long neglected populations.

Further information about these rules can be found in two other articles lower down on this blog page: “Left in the Dark” and “New State Health Insurance Exchange Rules Must be Strengthened,” both by Jill Reese.

Almost every advocacy group office I visit has a poster on the wall featuring a 1966 quotation from Martin Luther King: “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” We all need to heed this admonition and weigh in now in order to make sure that the chance to do something about this problem is not lost.

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