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Discussion
Racial and ethnic disparities in health outcomes and health care are pervasive both across and within states. Transformative change will depend on policy and practice changes to make access to care more equitable and to ensure equal treatment in the delivery of care.
What Policy Changes Are Needed to Bridge the Gap?
While health systems alone cannot address all the structural inequities that contribute to differential health outcomes, there are a number of policy options for addressing unequal access to care and unequal treatment within health care facilities.
We group these federal and state policy priorities into four areas:
Ensuring universal, affordable, and equitable health coverage. Nearly 30 million people in the United States are still uninsured, and they are disproportionately people of color. Even those who have some coverage face rising levels of financial risk. Policy options include:
- Make the marketplace premium subsidies provided by the American Rescue Plan Act (ARPA) permanent and close the Medicaid coverage gap in the 12 states that have not expanded eligibility for the program. These two reforms, which are included in the Build Back Better bill currently before Congress, are estimated to reduce the number of uninsured people overall by 7 million,33 the number of uninsured Black Americans under age 65 by 1.2 million, and the number of uninsured Latinx/Hispanic people under age 65 by 1.7 million.
- Reduce deductibles and out-of-pocket costs for marketplace insurance plans. The pending legislation would reduce cost-sharing to almost zero for people with incomes under 138 percent of poverty in the marketplaces, lowering household spending on health care and improving access to needed care. Another bill, currently in the Senate, would increase eligibility for marketplace subsidies and eliminate or reduce deductibles for some marketplace plan enrollees by as much as $1,650.34
- Allow more workers in expensive employer health plans to become eligible for subsidized marketplace plans. Under current law, enrollees in employer coverage whose premiums exceed 9.8 percent of income are eligible for subsidized marketplace plans. The Build Back Better bill lowers that threshold to 8.5 percent of income.
- Mount aggressive, targeted outreach and enrollment efforts to reach the remaining uninsured, most of whom are eligible for Medicaid or subsidized private insurance.35 Tracking low enrollment by demographic group, like California does, could help in targeting outreach efforts more effectively.
- Lower immigration-related barriers to coverage. An estimated 3 million uninsured cannot enroll in Medicaid or subsidized marketplace plans because of their immigration status.36 The federal government could allow certain groups of undocumented, low-income immigrant adults and children to enroll in Medicaid or other affordable coverage, as several states already have done.37
- Promote more equitable treatment of enrollees in commercial insurance plans. Policymakers could require commercial insurers to: collect and report information on race and ethnicity during enrollment and make it linkable to claims data;38 meet ACA requirements for including essential community providers in their networks;39 and obtain health equity accreditation.
Strengthening primary care and improving the delivery of services. Communities that are predominantly Black and Latinx/Hispanic tend to have fewer primary care providers and lower-quality health care facilities than communities that are mostly white.40 Federal and state policymakers could start to reverse these inequities by raising payment for primary care providers and transitioning primary care reimbursement to value-based payment that enables investment in health promotion, disease prevention, and chronic disease management.41 For example, North Carolina now has a prospective Medicaid payment model that emphasizes primary care–based population health management, while Oregon and Washington are linking Medicaid payments to performance on equity measures.42
There are also opportunities to change how care is delivered and who delivers it:
- Ensure that telemedicine remains an option. The pandemic has already shown that telemedicine is an effective strategy for providing patients with convenient access to care.43
- Modernize medical licensing. Allow health care professionals to more easily practice across state lines.44
- Develop community-based health care workforces focused on team care. Offer financial assistance, such as loan repayment, to providers who serve in medically underserved communities. Expand community health worker programs to train individuals to provide basic health-related services and support within their communities.
Reducing inequitable administrative burdens affecting patients and providers. Americans seeking health care face far higher administrative hurdles than residents of other high-income nations.45 Recent research points to the negative impact these barriers have on access to care for lower-income individuals, including many people of color.46 Autoenrollment is one reform that could reduce the application burden associated with state Medicaid programs; it could help people get, and stay enrolled in, public coverage.47 If poorly designed, the quality reporting, care management, utilization review, and prior authorization programs instituted by public and private insurers can create unnecessary red tape and even financial penalties for underresourced providers. Administrators could audit oversight and accountability programs for their disproportionate impact on providers serving communities of color.
Investing in social services. The U.S. spends less on economic and social supports for children and working- age adults than most other high-income countries, and the lack of adequate investment in this area likely contributes significantly to racial and ethnic inequities in health outcomes.48 Federal and state policymakers could expand economic support for lower-income families by implementing unemployment compensation and Earned Income Tax Credit and child tax credit programs, as well as childcare, food security, and targeted wealth-building programs.49 Additional investments in affordable housing, public transportation, early childhood development, and affordable higher education also could help reduce racial and ethnic health inequities.50
Conclusion
Racial and ethnic equity in health care should be a top priority of federal and state policymakers. A good start would be to identify policies and proposed legislation that impede progress toward health equity.
Given that structural racism has played a significant role in shaping those policies that have spawned widespread health inequities, leaders at the federal, state, and local levels should reexamine existing laws and regulations for their impact on people of color’s access to quality care. And new reforms to ensure good insurance coverage and timely access to primary and specialty care need to target communities across the United States that have long been ignored.
Equally important is the development and use of equity- focused measures to monitor the progress of efforts intended to advance health equity and to engender accountability for achieving desired outcomes. And systems are needed to track whether states, health systems, and health plans are reducing racial disparities in clinical outcomes, coverage, access to clinicians, and a host of other health-related gaps.
Too often in the U.S., race and ethnicity are correlated with access to health care, quality of care, health outcomes, and overall well-being. This is a legacy of structural, institutional, and individual racism that predated the country’s founding and that has persisted to the present day, in large part through federal and state policy. By pursuing new policies that center racial and ethnic equity, expand access to high-quality, affordable care, and bolster the primary care workforce, we as a nation can ensure that the health care system fulfills its mission to serve all Americans.
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