Abstract
This brief essay studied the uninsured and the health care disparities they face. Essential Affordable Care Act provisions and their effects were studied. Critical factors affecting the health care of the uninsured were identified; these included race, ethnicity, income, socioeconomic status, culture, language and income. Several research studies concluded that while access to health care has improved, the quality of this care has not improved for the uninsured. Although the number of uninsured has been reduced dramatically since 2010, insurance costs continue to increase significantly. Failure of states to expand Medicaid benefits has limited uninsured patients’ health care options. Free health clinics often handle health care needs of the uninsured. Major organizations have offered several recommendations to improve the health care situation for the uninsured. This population faces severe health care disparities based on several factors that impact their lives and the quality and availability of the health care they receive.
Keywords: uninsured, health care disparities, Affordable Care Act (ACA), access and quality of U.S. health care, Medicaid reduction impact, free health clinics, factors affecting the uninsured, major health organizations and the uninsured
Introduction
As a result of the [Patient Protection and] Affordable Care Act, 20 million adult Americans have obtained health insurance from 2011 to 2016, including 8.9 million White, 4 million Hispanic, and 3 million Black adults ages 18-64 from the start of open enrollment in October 2013 through early 2016 (“2015 national healthcare,” 2016).
The Affordable Care act (ACA) (often nicknamed Obamacare) offers several possibilities to improve health care and begin to remove disparities among disadvantaged populations and make medical coverage affordable and accessible (Adepoju, Preston, & Gonzales, 2015, p. S665; Mitchell, 2015, p.e68). A 2017 poll found most Americans support universal health care. About 40% do not want the ACA to be completely eliminated, and approximately 31% want President Trump to find a replacement before repealing the ACA. Although several provisions of the ACA are welcomed, the survey found most objected to requiring Americans to have health insurance of any kind (Alonso-Zaldivar, R. & Swanson, E. (2017). Those who are uninsured and have limited financial resources are especially vulnerable. Unfortunately, data on the affordability of quality health care are limited (“2015 national healthcare,” 2016).
The uninsured face severe health care disparities based on several factors that impact their lives and the quality and availability of the health care they receive.
Factors Influencing This Issue
The uninsured are often also members of specific ethnic and cultural populations. Race, ethnicity, income and socioeconomic status generally are considered interrelated factors. This essay explores these interlaced influences to underscore the links between the uninsured and other factors that impact their health care options.
Mitchell (2015) discovered that, compared to white Americans, those who are uninsured or underinsured tend to lack regular sources and access to care and receive poor quality of care. About 50% of these individuals are “in lower socioeconomic brackets [with] limited education in historically underrepresented racial and ethnic groups, who have . . . experienced oppression, discrimination, and social and economic inequalities. [Consequently,] they experience higher rates of disease, [higher death rates] and negative health outcomes” (pp. e66, e68). Researchers found most uninsured are in low-income working families, and about 50% have incomes below 200% of poverty (The Kaiser Commission).
In the U.S. Department of Health & Human Services, the Agency for Healthcare Research and Quality in 2015 (the last year complete data are available) found:
▪ health care access has improved, influenced by reduced numbers of those without health insurance.
▪ health care quality generally has improved but there are discrepancies nationwide; variables include timeliness, efficiency, effectiveness, patient priorities and safety.
▪ racial and socioeconomic disparities influence especially health care access and also quality.
The Uninsured and the Affordable Care Act
Several medical organizations and their recent surveys indicate generally medical care access has improved with the ACA, but “access is worse and there has been no improvement in lessening disparities” especially for populations such as the uninsured (Gold, 2014, pp. 1-2).
The ACA reduced the number of uninsured dramatically. In 2010 there were about fifty million uninsured (Mathew, 2013, p. 72). By 2014, uninsured rates dropped 7.1 % for Hispanics, 5.1 % for Blacks and 3 % for Whites (Buchmueller, Levinson, Levy, & Wolfe, 2016, p. 1418).
Kamimura, A. et al. (2016) reported that after ACA was introduced, the percentage of uninsured individuals dropped from 18% to 9%. Unfortunately, research results forecast that by 2019, between 36 and 45 million people will remain uninsured, approximately 12 to 15% of the projected 2020 U.S. population (p. 119). While the ACA may reduce the number of uninsured, it is not likely to reduce insurance costs. Health care costs and insurance premiums are expected to continue to rise (Mathew, 2013, p. 72).
Several states that have high instances of poverty and racial/ethnic populations have not expanded Medicaid insurance coverage to close the gap in insurance coverage, thus widening Medicaid health assistance deficiencies (Adepoju, Preston, & Gonzales, 2015, p. S665). This is the situation for many poor blacks living in southern states who are uninsured (Mitchell, 2015, p. e72). Nationwide, uninsured rates for Black and Hispanic adults have decreased noticeably compared to White adults (8% vs. 4%) (Buchmueller et al., 2016, p. 1416). Many uninsured (about 48%) indicate high insurance costs prevent them from receiving preventive care and treatment for major diseases and chronic conditions. Unfortunately, the uninsured often are ineligible for public coverage and their employers often provide no medical coverage (“Key Facts,” 2015).
The uninsured in states that have not expanded Medicare coverage tend to use free clinics or emergency services for their medical needs rather than apply for ACA benefits. Researchers identified several factors that are barriers that perpetuate this practice: older adults, language and cultural restrictions especially in Latino populations, lack of information and instructions on how to apply for ACA benefits, lack of ACA knowledge and promotion by free clinic workers and, of course, cost.
Uninsured patients may not use ACA benefits because they struggle to understand English and health care terminology. Training for caregivers and medical literacy efforts for the uninsured are expected to improve ACA’s effectiveness (Adepoju, Preston, & Gonzales, 2015, p. S666; Kamimura, A. et al., 2016, p. 119). Despite efforts by community health care and social workers, low-income populations and likely the uninsured generally are not aware of the free health screenings and preventive care ACA offers (Adepoju, Preston, & Gonzales, 2015, p. S666).
A related barrier to insurance coverage is immigration restrictions on illegal and also legal immigrants who must wait five years for coverage (Kamimura, A. et al., 2016, pp. 119, 120). U
Although the ACA encourages integrated medical service delivery systems to coordinate patient care to offer innovation and transformation, the growth of medical homes and accountable care organizations (ACOs) has been stagnant, especially in racial and ethnic minority populations who are often uninsured or underinsured (Adepoju, Preston, & Gonzales, 2015, pp. S665-666).
Major Organizations’ Stance on This Issue
Generally, major health organizations encourage broader health care for disadvantaged groups such as the uninsured. Several health organizations have offered suggestions and recommendations to reduce disparities and achieve more equitable and quality health care: (Gold, 2014, p. 2-5; “Reducing disparities in health care”, n.d.; “2015 national healthcare;” Powell, 2016).
▪ educate medical professionals about disparities and the need for cultural competency and flexibility.
▪ improve the diversity of the medical workforce.
▪ improve data collection and analysis techniques to include race, ethnicity, sex, primary language and disability to better assess and plan improved health care and disparity reduction.
▪ give unbiased access to quality, culturally-specific and competent care for vulnerable populations.
▪ provide incentives to boost health care quality and availability for minorities and the uninsured.
▪ use the ACA provisions to reward physicians based on quality and not quantity of patient care.
▪ determine how quality health care and insurance coverage factors impact disparities.
▪ consider how expanded coverage and delivery reform could help remove disparities.
▪ examine social and economic inequalities and racial and ethnic discrimination activities to determine links to the uninsured and steps needed to equalize essential medical care and services.
▪ coordinate social systems programs to handle routine daily needs that impact health care.
▪ provide preventive care and early diagnosis for chronic conditions and ailments.
▪ strengthen primary care.
▪ educate uninsured patients about their health needs and programs available to them.
▪ monitor and assist medical facilities providing health care to endangered patients.
▪ use a team approach to help facilitate and coordinate important health care services.
Personal Opinion Statement
In my mind, the U.S. health care system has increased the number and severity of inequalities and disparities, especially those that affect disadvantaged groups such as the uninsured and underinsured. Although the ACA was a significant step in providing universal health insurance to equalize access to health care, universal quality of care remains unequal. Disparities originate outside the health care system. For example, poor education leads to low-wage jobs, substandard housing, poor diet, neglect of chronic diseases and preventive health care. Promoting accountable care organizations who are rewarded based on patient outcome and not merely number of patient contacts should continue to be encouraged. Relieving the problems of the uninsured and underinsured requires more than just attention to health care services. Changes made by President Trump to the nation’s health care system are expected to impact the uninsured directly.
The uninsured face severe health care disparities based on several factors that impact their lives and the quality and availability of the health care they receive.
References
Adepoju, O. E., Preston, M. A., & Gonzales, G. (2015). Health care disparities in the
post--Affordable Care Act era. American Journal of Public Health, 105, S665-S667. doi:10.2105/AJPH.2015.302611
Alonso-Zaldivar, R./ & Swanson, E. (2017, Jan 27). AP-NORC poll: Broad worries
about potential health care loss. The Associated Press. Retrieved from http://bigstory.ap.org/article/e29c6e3426754988bfaaf8fbc143d865
Buchmueller, T. C., Levinson, Z. M., Levy, H. G., & Wolfe, B. L. (2016). Effect of
the Affordable Care Act on Racial and Ethnic Disparities in Health Insurance Coverage. American Journal of Public Health, 106(8), 1416-1421. doi:10.2105/AJPH.2016.303155.
Gold, M. (2014 March). Reducing health care disparities: Where are we
now? Retrieved from https://www.ama-assn.org/sites/default/files/media-browser/public/public-health/reducing-health-care-disparities-report_1.pdf
The Kaiser Commission on Medicaid and the Uninsured. (2015 Oct). Key facts about
the uninsured population. Menlo Park, CA.: The Henry J. Kaiser Family Foundation. Retrieved from http://files.kff.org/attachment/fact-sheet-key-facts-about-the-uninsured-population
Kamimura, A., Tabler, J., Chernenko, A., Aguilera, G., Nourian, M.M., Prudencio, L., &
Ashby, J. (2016). Why Uninsured Free Clinic Patients Don’t Apply for Affordable
Care Act Health Insurance in a Non-expanding Medicaid State. Journal of Community Health, 41, 119-126. doi: 10.1007/s10900-015-0076-3
Mathew, O.P. (2013). Health care crisis and neonatal care. In O.P. Mathew (Ed.), Inside
health care: Neonatal Intensive care – who decides? who pays? who can afford it? (pp. 72-90). Sharjah, United Arab Emirates: Bentham Books.
Mitchell, F. M. (2015). Racial and Ethnic Health Disparities in an Era of Health
Care Reform. Health Social Work, 40 (3), e66-e74. doi:10.1093/hsw/hlv038
Powell, A. (2016 Feb 22). The costs of inequality: Money = quality health care = longer
life. Retrieved from http://news.harvard.edu/gazette/story/2016/02/money-quality-health-care-longer-life/
Reducing disparities in health care. (n.d.). Retrieved from https://www.ma-assn.org/delivering- care/reducing-disparities-health-care
2015 national healthcare quality and disparities report and 5th anniversary update on
the national quality strategy. (2016 May). Retrieved from https://www.ahrq.gov/research/findings/nhqrdr/nhqdr15/executive-summary.html
OTHER RESEARCH MATERIALS THAT COULD BE HELPFUL FOR A LONGER ESSAY:
~French, M. T., Homer, J., Gumus, G. and Hickling, L. (2016), Key Provisions of the
Patient Protection and Affordable Care Act (ACA): A Systematic Review and Presentation of Early Research Findings. Health Serv Res, 51: 1735–1771. doi:10.1111/1475-6773.12511 or http://onlinelibrary.wiley.com/doi/10.1111/1475-6773.12511/full
~Moy, E., & Freeman, W. (2014). Federal Investments to Eliminate Racial/Ethnic Health-
Care Disparities. Public Health Reports (1974-), 129, 62-70. Retrieved from http://0-www.jstor.org.library.unl.edu/stable/23646788
~ http://jamanetwork.com/data/Journals/JAMA/935156/jvp160023.pdf.gif
~ https://www.facs.org/health-care-disparities
~ https://www.ama-assn.org/sites/default/files/media-browser/public/public-health/ncapip-immigration-reform-march2013_1.pdf
~ https://www.minorityhealth.hhs.gov/npa/files/Plans/HHS/HHS_Plan_complete.pdf
