Medicaid was created in 1965 during President Lyndon B. Johnson’s administration. It was part of a larger response to address racial injustice and poverty, Johnson’s War on Poverty. Despite the intent of addressing racial injustice by expanding access to medical care, racism remained a structural element within the Medicaid program that continues to separate the health outcomes of Black and Brown Medicaid enrollees from their white counterparts.
Even so, Medicaid expansion aided in reducing the coverage gap among Black and Hispanic individuals who have less access to employer-sponsored coverage. In states that have not expanded Medicaid the coverage gap exists for those with incomes that do not allow them to qualify for Medicaid or subsidies on the Marketplace. The fact that Medicaid offers both a benefit to Black and Brown people through expanded coverage, while simultaneously perpetuating health disparities among the same groups is a paradox that highlights larger systemic issues within our American health care system.
Black, Hispanic, American Indian, and Alaska Native (AIAN) Medicaid beneficiaries experience poorer outcomes and experience more barriers to health care than white beneficiaries.
From provider willingness to accept Medicaid as a source of payment, to use of services, management of preventive care and chronic diseases, maternal and infant health care, to quality of care and expenditures, Black, Hispanic, and AIAN Medicaid beneficiaries have poorer outcomes.
Higher racial bias means lower Medicaid investment
Racial and ethnic disparities in outcomes are associated with increased costs. A Medicaid and CHIP Payment and Access Commission (MACPAC) fact sheet, describing several studies, determined that states with higher perceived racial bias spend less on Medicaid enrollees than states with lower rates of racial bias.
In a cross-sectional study of US Medicaid enrollees in 3 states, on average, annual spending on Black adult (19 years or older) Medicaid enrollees was $317 lower than White enrollees, a 6 percent difference. Among children (aged 18 years or younger), annual spending on Black enrollees was $256 (14 percent) lower. Adult Black enrollees also had 19.3, or 4 percent, fewer primary care encounters per 100 enrollees per year compared with White enrollees.
Among children, the differences in primary care utilization were larger. Black enrollees had 90.1 fewer primary care encounters per 100 enrollees per year compared with White enrollees, a 23 percent difference. Black enrollees had lower utilization of most other services, including high-value prescription drugs, but higher emergency department use and rates of HEDIS preventive screenings.
Medicaid expansion did not address disparities in quality of care
Disparities in health access, treatment, and health outcomes experienced by Black Americans have not changed much, even after Medicaid expansion. Though the Patient Protection and Affordable Care Act (2010) sought to reduce discrimination, Medicaid expansion became optional. In states that expanded Medicaid, even though coverage increased at a greater rate for Black individuals than white individuals, there were noticeable disparities in access and quality. Medicaid expansion had positive effects on access to health care and health outcomes for white childless adults, but the same positive effects were not experienced by Black and Hispanic counterparts. Expanded coverage does not address lack of quality.
Nonelderly, uninsured Black Americans were more likely than their white counterparts to have incomes that placed them within the coverage gap in states that had not expanded Medicaid.
As the Public Health Emergency (PHE) has ended and Medicaid unwinding continues, Latinx and Black individuals, are predicted to be disproportionately impacted. Not just during Minority Health Month, but every month, it is important that advocates understand the impact that structural racism has had on Black and Brown people and how they access care.
