Racial and Ethnic Disparities in Access to and Utilization of Care among Insured Adults
Through its coverage expansions, the Affordable Care Act (ACA) provides an opportunity to reduce longstanding disparities in health insurance coverage for people of color, which may contribute to improvements in their access to and utilization of care. However, many factors beyond health insurance influence individuals’ ability to obtain care. As such, one key question is the extent to which people of color may continue to experience disparities in access to and utilization of care even after ACA implementation. To provide greater insight into this question, this analysis examines differences in access to and utilization of care for Black and Hispanic adults compared to White adults among those who are uninsured, enrolled in Medicaid, and privately insured. It is based on data from the 2014 Kaiser Survey of Low-Income Americans.
The findings show that, consistent with other research, both Medicaid and private coverage are associated with improvements in access to and utilization of care compared to being uninsured, and these differences generally hold true for White, Black, and Hispanic adults. However, privately insured Black and Hispanic adults fare worse than privately insured White adults along several measures of access to and utilization of care and have less confidence in their ability to afford medical costs. Fewer differences are seen between Blacks and Hispanics compared to Whites among uninsured adults and Medicaid enrollees, and where there are differences, Blacks and Hispanics fare better relative to Whites in most cases (Table 1).
|ES Table 1: Differences in How Black and Hispanic Adults Fare Relative to Whites with Same Coverage Type for Selected Measures of Access, Utilization, and Financial Confidence|
|Uninsured||Medicaid Enrollees||Privately Insured|
|Black compared to White||Hispanic compared to White||Black compared to White||Hispanic compared to White||Black compared to White||Hispanic compared to White|
|Access to Care|
|Usual Source of Care||Worse||Worse|
|Postponing/Going without Care||Better||Better|
|Postponing/Going without Care Due to Cost||Better||Better||Better|
|Utilization of Care|
|Use of Medical Services||Worse|
|Use of Preventive Services||Better||Worse|
|Confidence in Ability to Afford Medical Costs|
|Usual Medical Costs||Worse||Worse||Worse|
|Major Medical Costs||Worse||Worse||Worse|
Among uninsured adults, Hispanics are less likely than Whites to delay or forgo care and more likely to receive preventive care. Black uninsured adults also are less likely than White uninsured adults to delay or forgo care due to cost. These differences may reflect uninsured Hispanics greater reliance on clinics for care relative to Whites, since clinics often have outreach and supportive services to connect patients to care. They also may reflect cultural differences in perceived need for care.
Among Medicaid enrollees, Hispanic adults are less likely than White adults to delay or forgo care, although no significant differences are observed among the share delaying or going without care due to cost. Hispanic adults have less confidence than White adults in their ability to afford usual and major medical costs. The small number of disparities observed among Medicaid enrollees may reflect the program’s role serving diverse and vulnerable low-income populations. Medicaid provides supportive services that can help connect individuals to care, such as transportation and case management. Moreover, Medicaid managed care plans and providers have significant experience serving diverse populations and may provide services designed to address their specific needs.
More differences are seen among privately insured adults, particularly for Hispanics compared to Whites. Among privately insured adults, Blacks and Hispanics are less likely than Whites to have a usual source of care and a regular provider, and less likely to have confidence in the ability to afford usual and major medical costs. In addition, Hispanics are less likely than Whites to use medical services or receive preventive care. While these differences may, in part, reflect the fact that Black and Hispanic privately insured adults have lower incomes than their White counterparts, the findings also suggest that other factors beyond cost are a substantial barrier to care.
Overall, the findings suggest that gains in health coverage under the ACA will lead to improvements in access to care and utilization for White, Black, and Hispanic adults. They also highlight the importance of increased attention to addressing racial and ethnic disparities in access to and utilization of care among privately insured adults, particularly as the privately insured population becomes more diverse as a result of greater enrollment of people of color into private plans through the ACA Marketplaces. Continued efforts by insurers and providers to target the specific linguistic, cultural, and social and environmental needs of these groups will be important to achieving greater equity in access to and utilization of care. Such efforts may build on lessons learned from successful strategies in Medicaid, given the program’s longstanding experience serving a diverse population.