Disparities in Health Measures By Race and Ethnicity Among Beneficiaries in Medicare Advantage: A Review of the Literature

During the past decade, Medicare Advantage enrollment has increased steadily, with particularly rapid growth among people of color. Today, just over half of all eligible Medicare beneficiaries are enrolled in Medicare Advantage plans, with higher enrollment rates among Black, Hispanic, and Asian and Pacific Islander beneficiaries than among White beneficiaries. As of 2021, 59% of Black Medicare beneficiaries, 67% of Hispanic beneficiaries, and 55% of Asian and Pacific Islander beneficiaries were enrolled in a Medicare Advantage plan as compared with 43% of White beneficiaries.

Despite the relatively high Medicare Advantage enrollment rates among people of color relative to White beneficiaries, little is known about whether there are racial and ethnic disparities in quality of care and health care experiences among Medicare Advantage enrollees.

A previous KFF review of 62 studies compared Medicare Advantage and traditional Medicare on measures of beneficiary experience and quality of care. The prior review identified relatively few studies that examined differences among beneficiaries by race and ethnicity between Medicare Advantage and traditional Medicare, making it difficult to compare the experiences of people of color across the two sources of Medicare coverage.

This review examines differences in measures of quality of care and beneficiary experience between people of color in Medicare Advantage plans and White Medicare Advantage enrollees or the total Medicare Advantage population. The analysis synthesizes findings from 20 identified studies that were published during the 5-year period between January 2018 and April 2023. These 20 studies collectively report on 46 different measures of quality of care and beneficiary experience, but not all studies examined all groups or included all measures. All differences described in this report are statistically significant unless noted otherwise (e.g., for results that are reported as similar). Most of the studies (17 of 20) controlled for differences in enrollee health status and other demographic characteristics in some fashion. (See Methods for additional information about the criteria used to select studies, Appendix Table 1 for a complete list of measures included in these studies, and Appendix Table 2 for more a detailed description of each study.)

While the scope of this review is limited to Medicare Advantage enrollees, the racial and ethnic disparities in quality of care and beneficiary described in this report mirror disparities in health and health care in traditional Medicare, the overall Medicare population, and more broadly, the U.S adult population.

Key Takeaways

Black enrollees: Results are less favorable for Black Medicare Advantage enrollees than White Medicare Advantage enrollees on more than half (24) of the 46 measures examined for this group in 19 studies. Results were more favorable on eight measures, similar on five measures, inconsistent across studies on two measures, and for seven measures, study authors described differences as not practically significant. For example:

• Preventive service use: a higher share of Black Medicare Advantage enrollees than White enrollees received breast cancer screenings, colorectal cancer screenings, and pap smears, but a lower share of Black enrollees received prostate cancer screenings and flu vaccines.
• Hospitalizations: a higher share of Black than White Medicare Advantage enrollees were admitted to the hospital for an ambulatory care sensitive condition – a measure of potentially preventable hospitalizations – and a higher share of Black than White enrollees were readmitted to the hospital within 30 days.
• Mental health: a lower share of Black than White enrollees with depression were treated with antidepressant medication and remained on the medication for at least 12 weeks.
• Experiences with care: a lower share of Black than White Medicare Advantage enrollees reported seeing a specialist in the past year, but similar shares of Black and White enrollees reported having well-coordinated care and getting needed prescription drugs.
• Plan ratings: a lower share of Black than White enrollees were enrolled in higher-rated Medicare Advantage plans.

Hispanic enrollees: Findings are less favorable for Hispanic than White Medicare Advantage enrollees on more than a third (16) of the 42 measures examined for this group in 17 studies. Findings were more favorable on eight measures, similar on five measures, inconsistent across studies on three measures, and for 10 measures, study authors described differences as not practically significant. For example:

• Preventive service use: a higher share of Hispanic than White Medicare Advantage enrollees reported getting screenings for breast cancer, but a lower share received flu vaccines.
• Disease management: a lower share of Hispanic than White Medicare Advantage enrollees received follow-up care after emergency department visits for certain conditions, such as for mental health and a set of multiple high-risk chronic conditions.
• Experiences with care: a lower share of Hispanic than White Medicare Advantage enrollees reported getting appointments and care quickly.
• Hospitalizations: Hispanic and White enrollees had similar rates of hospital readmissions and hospitalizations for ambulatory care sensitive conditions.
• Plan ratings: A lower share of Hispanic than White enrollees were enrolled in higher-rated Medicare Advantage plans.

Asian and Pacific Islander enrollees: Findings are less favorable for Asian and Pacific Islander enrollees than White enrollees on nine of the 36 measures in 13 studies. Findings were more favorable on seven measures, similar on seven measures, inconsistent across studies on three measures, and for 10 measures, study authors described differences as not practically significant. For example:

• Preventive services: a higher share of Asian and Pacific Islander than White enrollees received a flu vaccine, while similar shares received colorectal cancer screenings.
• Disease management: a higher share of Asian and Pacific Islander enrollees than White enrollees received statin therapy as part of their diabetes care, but a lower share of Asian and Pacific Islander enrollees with a new episode of alcohol or other drug dependence initiated treatment for alcohol or other drug dependence.
• Hospitalizations: Asian and Pacific Islander and White enrollees had similar rates of hospitalizations for ambulatory care sensitive conditions.

American Indian and Alaska Native enrollees: Less than half of the studies identified in this review (9 of 20 studies) presented findings for American Indian and Alaska Native Medicare Advantage enrollees, and collectively, they included fewer measures (25) than studies of Black (46), Hispanic (42) or Asian and Pacific Islander (36) Medicare Advantage enrollees. Findings were less favorable for American Indian and Alaska Native enrollees that White Medicare Advantage enrollees on seven measures, more favorable on four measures, similar on 12 measures, inconsistent across studies on one measure, and for one measure, study authors described differences as not practically significant. For example:

• Preventive services: a higher share of American Indian and Alaska Native enrollees than White enrollees received breast cancer screenings, and similar shares received a flu vaccine.
• Disease management: a lower share of American Indian and Alaska Native enrollees than White enrollees had their blood sugar and blood pressure controlled as part of diabetes care.

Gaps in the research and data present challenges in understanding the experiences of specific racial and ethnic groups in Medicare Advantage plans.

• Medicare Advantage insurers do not report data on prior authorization rates and denials by race or ethnicity, or the use of supplemental benefits for the overall Medicare Advantage population or by race or ethnicity.
• None of the studies examine outcomes of care such as mortality rates or hospital-acquired infections.
• None examine the use of post-acute care among Medicare Advantage enrollees by race and ethnicity.
• None of the studies report findings for Native Hawaiians or other Pacific Islanders separately from other groups, and none of the studies compare measures of quality of care and beneficiary experience between people identifying as two or more racial or ethnic groups with White enrollees.
• None of the studies present stratified estimates for all of the racial and ethnic groups listed in current federal minimum standards. Studies also varied in how they identified race and ethnicity, with some using self-identified data and others using imputed race/ethnicity data.
• Few studies stratify race/ethnicity findings among Medicare Advantage enrollees by gender or rural residence.
• None of the studies stratify findings among Medicare Advantage enrollees by race/ethnicity and dual eligibility status, even though people of color comprise a disproportionate share of Medicare Advantage enrollees who are dual-eligible individuals.

With more than half of Black, Hispanic, and Asian and Pacific Islander beneficiaries enrolled in Medicare Advantage plans, the studies in this review provide some insight into how well Medicare Advantage plans are serving people of color relative to White enrollees. However, the relatively small number of studies coupled with gaps in research present challenges for beneficiaries in making coverage decisions and for policymakers in understanding how best to make Medicare Advantage work well generally and for people of color.