Study: Need for more research to elucidate factors in health care access inequities

Despite improved access to health care, racial and ethnic minority populations still have disparate access compared to non-Hispanic Whites, according to a new study published in Obesity journal.

"As obesity rates continue to climb in the United States, certain groups bear a more significant burden- racial and ethnic minority populations and those from lower socioeconomic status. Our research demonstrates that Medicaid expansion improves access to care for non-Hispanic White patients significantly more than for those from racial and ethnic minority groups. Multi-sector approaches are necessary to improve health care for racial and ethnic minority groups," said Fatima Cody Stanford, MD, MPH, MPA, MBA, FAAP, FACP, FAHA, FAMWA, FTOS, associate professor of medicine and pediatrics, Harvard Medical School, and Massachusetts General Hospital, MGH Weight Center, Department of Medicine-Neuroendocrine Unit, Department of Pediatrics-Division of Endocrinology, Nutrition Obesity Research Center at Harvard, Boston, Mass. Stanford is the corresponding author of the study.

The study's authors explain that although Medicaid expansion has improved coverage and access to care across all racial and ethnic groups, baseline disparities between racial and ethnic groups persist without significant improvements in the racial and ethnic disparities regarding coverage and having a usual source of care. These disparities may be magnified in adults with obesity, and the interplay of obesity and race may contribute to excess disease.

Researchers used 2011–2017 data from the Behavioral Risk Factor Surveillance System (BRFSS) to evaluate changes in health care access outcomes among adults with obesity, according to their state's Medicaid expansion status. The BRFSS is the largest, annual telephone survey administered by local health departments.

Three health care access outcomes were examined, including if participants had a usual source of primary care, whether the cost was a barrier to care within the past year, and the length of time in seeing a physician for a routine check-up. Researchers restricted the study to adults aged 18 years and older with a body mass index greater than or equal to 30 kg/m² and household incomes less than or equal to 138% of the Federal Poverty Line (FPL). Researchers set no upper age limit, given that those over the age of 65 years who qualify for Medicare may still have supplemental insurance through Medicaid.

Results showed that adults with obesity within 138% FPL in Medicaid expansion states were more likely to be Hispanic (37.8% vs. 20.2%), less likely to be Black (19.5% vs. 32.1%), more likely to have less than high school graduation (38.3% vs. 32.4%), and more likely to have any insurance coverage (72.4% vs. 64.7%) compared with adults with obesity within 138% FPL in states that did not expand Medicaid. Researchers observed no significant differences in trends in access to a usual source of care, inability to see a doctor owing to cost, or having a recent routine check-up between expansion and non-expansion states in the pre-expansion period, confirming the validity of the Difference-in-Differences approach.

"Both racial/ethnic minorities and individuals with obesity experience a range of healthcare-related inequities. This study shows that persons within both categories experience significant disparities in health care access and health outcomes. This study reinforces countless others supporting the importance of addressing these and other health care disparities in persons with obesity and racial and ethnic minorities," said Director of the National Center for Weight and Wellness Scott Kahan, MD, MPH. Kahan was not associated with the research.

The study's authors observe that additional work is needed to further clarify the pathways through which the Affordable Care Act Medicaid expansion decreased disparities in access to care for patients with obesity. Further work is also required to assess whether improvements in health care access translate into improved outcomes for patients with obesity.

Other study authors include Karla N. Kendrick and Kenneth J. Mukamal, Division of General Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Mass; Felippe O. Marcondes, Harvard Medical School and Division of General Internal Medicine, Massachusetts General Hospital, Boston, Mass.

The study, titled "Medicare Expansion and Health Care Access for Individuals with Obesity in the United States," will be published in the September 2022 print issue.