States’ refusal to expand their Medicaid programs as originally envisioned by the Affordable Care Act (ACA and now commonly called Obamacare) may diminish that law’s role in reducing health care disparities by 10% to 20%, according to a report from the Leonard Davis Institute of Health Economics (LDI).


Writing in the LDI Health Economist, Wharton health care management professor Dan Polsky and LDI Health Policy Program associate director Janet Weiner based their estimate on Congressional Budget Office figures indicating four million more people than originally expected will remain uninsured in 2014 when the law fully takes effect. They say this group “would be disproportionately poor and minorities.”

Commenting on that report, Julia Lynch, a Penn political science professor who studies public attitudes about health care inequities, notes the national press pays little attention to this issue because “for most people, the ACA was not about reducing health care disparities.” She points out that although many of the law’s provisions directly address disparities, the framing used to sell it to Congress and the public largely focused on its potential pocketbook and market benefits for the middle class and insurance companies.

“Insurers were the key players that needed to be brought onboard, and for them it’s not about reducing disparities,” Lynch says. “It’s about increasing their market and protecting themselves from radical risk. The one group for whom access-related disparities were an issue was state Medicaid administrators. They knew what this was about and, it turns out, a number of their states filed suit because they don’t want to do it.”

Some individual states, in their Supreme Court lawsuit, hoped to overturn the entire ACA. To their surprise, the high court upheld the overall law but struck down the provision that empowered the federal government to make the planned expansion of Medicaid mandatory.

Jointly funded by the federal and state governments, Medicaid is a $430 billion-a-year health insurance program for the poor. It currently covers about 70 million people, and estimates released just prior to the June court ruling indicate the mandated ACA provisions would have expanded the program to cover about 17 million more low-income individuals.

But since June, some 15 states have announced that either they will not expand their Medicaid programs or they are leaning in that direction.

“The extent of the impact will depend on which states fail to implement the expansions,” says Karin Rhodes, director of the emergency care policy and research department at Penn’s Perelman School of Medicine, and a researcher studying disparities in access to health care. “For example, if Massachusetts failed to implement, it would not have a big impact as they only have 6% uninsured, whereas in Texas almost a quarter of people lack health insurance — so it will have a bigger impact. Moreover, those without health insurance are disproportionately Hispanic, African American and young adults. So we can expect a decrease in equity of access and an increase in health disparities in states that have high rates of uninsured and reject Medicaid expansions.”


In health services research, community disparities have long been recognized as one of health care’s most important issues. The annual National Healthcare Disparities Report by the federal Agency for Healthcare Research and Quality (AHRQ) concludes that “racial and ethnic minorities and poor people often face more barriers to care and receive poorer quality of care.”

For example, AHRQ found that in 2011, African Americans received worse care than whites for 41% of the AHRQ health care quality measures. The report also notes that while the general quality of care is improving across the U.S., disparities are not.

Evidence from other recent studies shows that insurance itself plays a role in defining some disparity patterns. One of the arguments for the ACA’s Medicaid expansion provision was laid out in a Kaiser Foundation study by Marsha Lillie-Blanton and Catherine Hoffman, which cited “evidence that a sizable share of the differences in whether a person has a regular source of care could be reduced if Hispanics and African Americans were insured at levels comparable to those of whites.”

This summer, a new Johns Hopkins study detailed in the Journal of General Internal Medicine further underscored what a dramatic difference insurance coverage can make. A team led by Derek Ng studied the outcomes for a diverse group of 13,000 patients admitted to three Maryland hospitals with acute cardiovascular events over a period of 14 years. The findings show that race was not associated with an increased risk of death — but insurance coverage was.

Uninsured or underinsured heart attack patients had a 31% higher risk of death than those with private insurance; arteriosclerosis patients were 50% higher; and stroke patients 25%. These cardiovascular diseases are a major component of the mortality disparity between low-income African Americans in urban neighborhoods and people of all races living in healthier neighborhoods.

“Our findings,” wrote Ng and his co-authors, “suggest that a lack of health insurance, or being under-insured, is a major cause of insufficient treatment and subsequent premature death.”


Just a month before the Supreme Court’s June ruling, a study in Health Affairs calculated that as a result of the Affordable Care Act’s full implementation with Medicaid expansion, “racial and ethnic differentials in coverage could be greatly reduced, potentially cutting the eight-percentage-point black-white differential in uninsurance rates by more than half and the nineteen-percentage-point Hispanic-white differential by just under one-quarter.”

The bottom line on exactly how much the Medicaid expansion will be curtailed won’t be known until sometime after the upcoming national elections. But for health policy researchers like Karin Rhodes, the general trajectory of the economic and health implications seem clear.

“We are not yet at the stage where we let people die in the streets,” she said. “So [patients] will still present for health care, frequently to an emergency department. But without preventative care, they will arrive sicker and have worse outcomes. This is one of the current system failures the ACA is designed to remedy. People who present late in their disease are also in need of more high tech, critical care and end of life care — so in the long run we will spend more — for even worse outcomes.”