The Affordable Care Act (ACA) reduced the ranks of uninsured Americans, but a recent study shows that many U.S. states did little to close racial gaps in health coverage.
Researchers found that in the two years after the ACA came into force, some U.S. states showed large reductions in the number of Black, Hispanic and low-income residents who were uninsured.
Other states, however, showed little change. And in many, at least 20% of Black residents and 40% of Hispanic residents remained uninsured as of 2016 (the final year of the study period).
The findings, experts said, highlight the pitfalls of giving states a lot of leeway in implementing the ACA.
For one, states can decide whether to accept federal funds to expand their Medicaid programs, which provide health insurance to low-income residents.
And that decision seemed to explain much of the state-to-state variation in this study, said lead researcher Dr. Gregory Lines, of Harvard Medical School and Cambridge Health Alliance in Boston.
At the study's endpoint, 18 states had not expanded Medicaid, and they typically showed relatively small improvements in health coverage for Black, Hispanic and low-income residents.
For example, in West Virginia -- which did expand Medicaid -- the percentage of Black and Hispanic adults without insurance dropped by 60%. In contrast, the decline was 20% or less in many of the states that had not expanded Medicaid.
Massachusetts was among the states at the bottom of the list for improvements. But Lines said there is an important distinction: Massachusetts had already launched its own health care reform before the ACA -- and was, in fact, the model for the federal law.
Since the state had already done much to cut the ranks of the uninsured, Lines said, there was little room left for improvement.
So by 2016, the study found, the highest rates of "uninsurance" were largely concentrated in states that had not expanded Medicaid. Of the 15 with the highest percentage of uninsured Black residents, for example, 13 were non-expansion states.
The findings, recently published in the journal Health Equity, do not cover more recent years -- during which additional states have expanded Medicaid.
As of July 2021, 12 states remain holdouts, according to the Kaiser Family Foundation.
Stan Dorn is director of the National Center for Coverage Innovation at Families USA, a nonpartisan health care advocacy organization.
He agreed that states' decisions over Medicaid are likely the most important reason for the findings.
But states also varied widely in the efforts they devoted to implementing the ACA, said Dorn, who was not involved in the research.
Some states got behind the law, he said. That included setting up their own "exchanges," in addition to the federal one, where residents could buy private insurance. It also included public outreach, Dorn said, to make sure people knew that coverage options and financial assistance were available.
And since enrolling in a health plan can be a confusing process, some states hired patient "navigators" to guide people. That help, Dorn said, likely made a difference.
"It can be easy for people to give up, especially if they're not used to dealing with insurance issues," he said.
It all points to a broader issue, according to Lines: Leaving health reform up to the discretion of states leads to uneven results -- and cannot solve the national problem of racial inequities in health care.
"Health care reforms that don't rely as heavily on the whims of individual states are clearly needed," he said.
Dorn made a similar point. He said the federal system, in which states have a good deal of autonomy, can have advantages.
"Individual states can do wonderful things, and lead the way for the rest of the country," said Dorn, citing Massachusetts' health care reform as an example.
But, he added, the "shocking variability" seen in this study illustrates the disadvantages of giving states wide discretion.
"There should be minimum standards that states need to live up to," Dorn said. "Your ability to receive health care shouldn't depend on which state you happen to live in."
The Kaiser Family Foundation has more on shopping for health insurance.
SOURCES: Gregory Lines, MD, internal medicine physician, Cambridge Health Alliance, Cambridge, Mass., and instructor, medicine, Harvard Medical School, Boston; Stan Dorn, JD, director, National Center for Coverage Innovation, Families USA, Washington, D.C.; Health Equity, online, July 21, 2021