Will the Affordable Care Act eliminate health disparities?

Massachusetts' health reform may be a crystal ball for researchers and policymakers in forecasting the potential impact of the Affordable Care Act. Many see the ACA as the backbone of efforts toward closing the nation's health gap. Because minorities and low-income populations are more likely to be uninsured, health coverage is widely assumed to be the most essential strategy to eliminating disparities in health outcomes.

However, new research published Wednesday in the BMJ, examining use of joint replacement and preventable hospital admissions, shines fresh light on the complexities of achieving health equity. Two studies underscore previous indicators that racial and socioeconomic disparities persist even with nearly universal access to health coverage.

In his accompanying editorial "Advancing equity in healthcare: lessons from Massachusetts and beyond," also published in the medical journal, Marshall Chin, MD, MPH, the Richard Parrillo Family Professor of Healthcare Ethics at the University of Chicago Medicine, offers perspective on why expanding health coverage is a significant step in the right direction, but may not be enough. Chin, who is also director of the Robert Wood Johnson Foundation's Finding Answers: Disparities Research for Change program, outlines interventions he says must be implemented alongside health care reform to achieve health equity in America.

To eliminate differences in the quality of care and outcomes, Chin suggests policymakers:

• Create financial incentives that reward patient-centered care, excellent communication and shared decision making with patients
• Reward both high levels of quality and reductions in disparities and
• Provide additional support to "safety net" health care organizations caring for vulnerable populations.

Nearly a decade after implementation of health care reforms in Massachusetts, the state offers the ideal setting to examine the relationship between health insurance access and disparities in health status. Early research confirmed the positive impact of expanded coverage and reduced financial barriers among disadvantaged populations. But a closer look at care delivery for common conditions reveals that for many patients, obstacles remain. In one study of differences in rates of knee and hip replacement surgery (DOI: 10.1136/bmj.h440), researchers from Harvard Medical School and Boston University found that while greater access to health insurance was associated with increased use of the procedures among Hispanics and blacks, the same did not hold true for low-income patients when compared to those with higher incomes. A second study (DOI: 10.1136/bmj.h1480) found no association between Massachusetts' health care reforms and reduced racial and ethnic disparities in hospital admissions for diseases such as asthma, diabetes and heart failure.

While these latest findings are significant, the reasons for the disparities are still unclear. As debate continues around the power of the ACA to bring about real improvements in health outcome among minority and low-income populations, Chin sees the new insights as a good opportunity to discuss the critical next steps towards health equity.

"These two studies confirm that extra insurance coverage and generic efforts to improve the quality of care are helpful but will not eliminate differences in outcomes," said Chin. "Clinicians must identify and overcome the many health barriers faced by disadvantaged populations, including mistrust of the health care system and previous negative health care experiences."