Racial and Ethnic Disparities in Access to Care in Massachusetts: Pre-and Post-Chapter 58

Brian Rosman, Health Care For All

Sabrina Aggarwal, JSI

Compare…

…and contrast

Chapter 58 - Coverage

Source: Urban Inst. surveys for MA Div. of Health Care Finance and Policy

Health Improvements?“Statistically significant improvements due to health reform in prevention-related quality indicators were noted in lower hospital admission rates, including decreased admissions for diabetes complications, heart disease, hypertension, infections, and asthma.”

Source: Kolstad and Kowalski, “The Impact of an Individual Health Insurance Mandate on Hospital and Preventive Care: Evidence from Massachusetts,” NBER 2010

Massachusetts Chapter 58 Medicaid expansion Premium subsidies Insurance market reforms Individual mandate Employer responsibility Disparities provisions

Affordable Care Act Medicaid expansion Premium subsidies Insurance market reforms Individual mandate Employer mandate Disparities provisions

Comparison

Disparities ProvisionsMassachusetts• Office of Health Equity• Community outreach

grants• Community Health

Centers• Community Health

Workers

Affordable Care Act• Office of Minority Health• Consumer Assistance

Programs, Navigators• Workforce Diversity,

Cultural Competence• Community Health Centers• Community Trans-

formation Grants, Collaborative Care Networks

Goals• To evaluate the extent to which access to care

improved for Hispanics in MA• To evaluate the extent to which racial/ethnic

disparities in access to care decreased after Chapter 58

• To find out about newly insured minority populations in MA since very limited information is available

• To augment quantitative findings from BRFSS data since it does not offer a full explanation of why disparities coverage persists

Methods• Used 2005 and 2009 Behavioral Risk Factor

Surveillance System (BRFSS) survey data for MA• Conducted four focus groups with newly insured

individuals, including one conducted in Spanish and one with enrollment specialists from safety net providers

• 20 in-depth interviews with Hispanics from a variety of countries

• Key informant interviews with state agencies and key stakeholder groups

Percent reporting health coverage (adjusted): 2005 vs. 2009

•Significant difference (p<0.05) from 2005 to 2009

Estimates adjusted for income, education, employment, disability status, age, gender, health status

91.6%

86.6%

95.4%

90.2%

86.9%

95.2%91.1%

78.4%75.0%

80.0%

85.0%

90.0%

95.0%

100.0%

2005 2009

NH White* Hispanic, overall* Hispanic, English Hispanic, Spanish

Percent reporting usual source of care (adjusted): 2005 vs. 2009

•Significant difference (p<0.05) from 2005 to 2009

Estimates adjusted for income, education, employment, disability status, age, gender, health status

86.5%

81.6%

90.1%88.2%

78.0%

89.6%

84.2%

65.6%64.0%

70.0%

76.0%

82.0%

88.0%

94.0%

100.0%

2005 2009

NH White* Hispanic, overall* Hispanic, English Hispanic, Spanish*

Percent reporting not seeing a doctor due to cost in past year (adjusted):

2005 vs. 2009

•Significant difference (p<0.05) from 2005 to 2009

Estimates adjusted for income, education, employment, disability status, age, gender, health status

8.3%

7.2%

8.9%

9.7%

11.0%

7.0%

11.1%

8.1%

6.0%

8.0%

10.0%

12.0%

2005 2009

NH White Hispanic, overall Hispanic, English Hispanic, Spanish

Coverage and access disparities still exist among

Hispanics

Immigration policies

Key

= Social

= Political

=Environmental

= Economic

Health insurance tied to Employment in U.S.

Health insurance in Private Sector

Expensive

Complexity of public insurance system

Knowledge of state programs

Difficulty finding provider

Language barriers

Marital Status & Family Structure

Distrust of the system

Parental Citizenship & immigration status

Documentation requirements

Low-Income

Knowledge & attitudes towards health care

system

Culturally competent outreach & enrollment

assistance

Type of industry and/or firm

determines health insurance and

income

Lessons • Once health coverage was mandated, people

wanted to comply and improvements were seen• Coverage issues continue: individuals have a

hard time enrolling on their own• Access issues continue: difficult to find a

provider, let alone one who speaks Spanish and accepts low-income patients

• Disparities remain a key challenge esp. for Spanish-speaking Hispanics; and one-time outreach and enrollment is not enough