Written by Tim McBride, professor at the Brown School and co-director of the Center for Health Economics and Policy
Health disparities has been an important topic for public health researchers for years, with much or most of the focus on disparities across racial groups in the US, where we see wide disparities on almost every outcome measure. In the St. Louis area and region, health disparities remains a critical topic where if anything the disparities are more pronounced.
Despite a great deal of attention on health disparities in recent years, some aspects of the disparities discussion have received less attention. On the positive side, the Affordable Care Act (ACA), passed in 2010 (and with most aspects of implementation beginning after 2014) may be making historic inroads to narrow disparities. However, a new concern is that these gains are being dissipated by an uneven implementation of the ACA, in particular since the expansion of Medicaid is a voluntary decision left up to the states, and only 32 of the 51 states (including DC) have adopted a Medicaid expansion (see map).
For the most part, the states that have NOT adopted an expansion of Medicaid are states with some of the worst existing health disparities, which means that in some ways, disparities will be exacerbated, since health will be improved in places where health and economic status is already better, and health status will not improve, or may get worse in the 19 states that have not expanded Medicaid, including Missouri.
The ACA has many provisions that will improve health disparities, perhaps largely not on the radar even for many public health researchers. Most important, the ACA has led to the biggest reduction in the uninsured rate ever recorded (from 17.6% to 10.4% from third quarter 2013 to third quarter 2015), a drop of 15 million, according to the Urban Institute. Of biggest importance for the health disparities discussion is that the expansions of coverage have been the largest for those below 138% of the poverty line (15.6%, compared to 0.9% above 400% of poverty), and for nonwhite, non-Hispanic persons (8.5% increase) and Hispanics (12.4%) as compared to white non-Hispanics (5.2%).
In addition to the provisions extending health insurance coverage to millions, the ACA has explicit provisions designed to address health disparities, it reduces out of pocket costs and expands prevention for the elderly under Medicare, while also encouraging improvements in the supply of health providers in underserved areas. Perhaps most notable is that access to preventive care is provided for free or at low costs by law under the ACA.
Despite these gains, the lack of a Medicaid expansion in 19 states may exacerbate disparities in these areas. Ten of the 19 states are in the South, with a high proportion of uninsured that are nonwhite, and where health disparities has contributed to disturbing health outcomes, particularly for chronic diseases such as obesity, diabetes, heart disease, and many others.
Missouri and St. Louis present a case in point about how the lack of a Medicaid expansion may be exacerbating disparities, while in other states (such as neighboring Illinois), disparities are narrowing. The St. Louis region includes counties in Illinois in which the Medicaid program was expanded to include very low-income childless adults, as well as counties in Missouri where the Medicaid program was not expanded to cover these low-income adults. The St. Louis region has a consistent pattern of racial disparity that is now widely understood after Ferguson, and the work of the For the Sake of All project, led by Jason Purnell at Washington University.
There are wide differences between Missouri and Illinois counties in terms of uninsured rates by racial, age, and income groups (as shown by the recent findings from the American Community Survey). Since Illinois has expanded Medicaid to cover all adults at or below 138% of the Federal Poverty Level (FPL), uninsured rates for this group in 2014 were 13.7% in Madison County, IL, and 16.4% in St. Clair County, IL. In contrast, the uninsured rates for St. Louis City and County as well as St. Charles County ranged between 21.8% and 25.7%.
Racial gaps are starkly evident: in all four counties plus the City of St. Louis, Hispanic populations are two to three times as likely to be uninsured as White populations. In all places except St. Charles County, African-Americans are more than twice as likely to be uninsured as Whites.
When we examine Black populations separately by age, we find that the uninsured rates are often (but not always) highest among the 18-to-24-year-old age group. In the City of St. Louis, rates peak at 44.4% for 25-to-34-year-olds. Rates are higher in St. Louis City and County for almost every age group than they are in the Illinois counties, likely due in part to the expansion of the Medicaid program in Illinois.
Does this all matter in terms of overall health? Apparently it must, because while in 1990 Missouri ranked at about the median (24th) in overall health rankings according “America’s Health Rankings,” by 2016 Missouri had slipped to 36th in that ranking. In contrast, Illinois has seen a slight improvement in its ranking (from 34th to 28th).