Eliminating racial and ethnic disparities in health and health care is a moral imperative in which there is no single silver bullet. These disparities have a long history in the U.S. and are both a symptom of broader structural inequality and a mechanism by which disadvantage persists. The ACA has significant and far-reaching consequences for all Americans; it takes important first steps especially for persons of color.
Medicaid was created in 1965 as the nation's safety net insurance, and the new legislation makes many changes to that program. For the first time, childless low-income adults will be eligible for coverage; geographical disparities in eligibility will be eliminated, and the income threshold for eligibility will be raised. Other programmatic changes enhance the value of the basic Medicaid program, moving it in a more preventative-focused direction. Conventional insurance expansions alone could worsen conditions in communities of color because of transportation barriers, long travel times, lack of culturally competent providers, higher cost sharing, and thinner coverage.
Starting in 2014, many more persons of color will become eligible for highly subsidized private insurance. The ACA's expansion of public and private insurance is monumental, but it will still leave about 23 million residents uninsured. The new law greatly improves safety net access for the uninsured; first, by doubling the capacity of community health centers. Second, it does so by encouraging community-based collaborative networks that provide comprehensive, coordinated and integrated health care services for low-income populations. By stitching together better and improved safety net programs with insurance coverage expansion, the national goal of truly universal coverage finally looks within reach. But, because political capital and public coffers have been depleted in the monumental effort to enact the ACA on the heels of an extreme recession, the ultimate success of these coverage expansion provisions remains a decidedly open question.
Health disparities-specific provisions of health care reform hold the potential to diversify the health care workforce, monitor and detect health disparities, and advance the knowledge base about the causes and patterns of disparities through research. However, unfortunately, the ACA either ignores or allocates insignificant resources to causal factors that disproportionately affect communities of color - such as policies and practices of health care systems, the legal and regulatory context in which they operate, and the behavior of people who work in them.
Finally, on a more promising note, the Obama Administration adds a new and complementary approach beyond the ACA. Specifically, for the first time, the federal government has coordinated federal effort to address structural problems that cause health inequity. Most of these federal efforts focus on the intersection of race and place and include cross-agency initiatives in areas such as environmental justice, food deserts, transportation, and healthy neighborhoods, among many others. These have long been the concern of health equity and social justice advocates alike.
[a1]. Associate Professor, University of St. Thomas, School of Law. J.D., Stanford Law School; LL,M., Georgetown University Law Center; M.A. (Economics), Northwestern University.