These health gaps are not immutable. Concrete changes to public policy, industry practices, and medical education could turn the health-care system into a force for greater equality. Here are five such changes:
First, when states are indifferent to whether their Black and Latino citizens have health coverage, the federal government should step in. According to research published earlier this year, 9 percent of white adults were uninsured in 2018, compared with 14 percent of Black adults and 25 percent of Latino adults. The coronavirus recession is making the coverage gap worse. Already, as many as 12 million Americans have lost insurance sponsored by their employer or a family member’s employer. Black, Latino, and other workers of color have faced especially steep declines in employment.
The Affordable Care Act did reduce disparities in insurance by setting up insurance exchanges and making more Americans eligible for Medicaid, but some states opted out of the latter—with terrible consequences for disadvantaged minorities. Indeed, an estimated 46 percent of Black working-age adults live in the 15 states that refused to implement the ACA’s expanded Medicaid benefits, leaving low-wage workers with no way to pay for their family’s care. The disparity rises when joblessness grows: Medicaid covers 36 percent of unemployed adults in states that expanded eligibility for the program, but only 16 percent in states that did not.
So far, federal inducements have not been enough to persuade states such as Texas, Georgia, and Florida to expand Medicaid. The next president and Congress can solve that problem by federalizing Medicaid and removing its administration from states. Such a change could yield universal enrollment standards and greatly reduce the racial health-insurance gap.
Second, policy makers can make insurance coverage meaningful by having Medicaid pay physicians and hospitals more. Having health coverage is necessary, but not sufficient, for patients to obtain good health care in a timely manner. Because Medicaid pays doctors less than Medicare or private insurance does, many doctors refuse to see—or delay appointments for—Medicaid patients. A 2014–15 survey showed that only 68 percent of family-practice physicians accepted new Medicaid patients, while 91 percent accepted those with private insurance. Some doctors did not accept new patients at all or didn’t accept insurance. Only a third of psychiatrists accepted new Medicaid patients.
In 2013 and 2014, the ACA temporarily raised Medicaid payments to primary-care doctors. This fee bump improved patients’ access to doctors. Just as predictably, when states returned to lower fee levels, Medicaid enrollees had more trouble making appointments. The lesson is clear: The federal government needs to permanently raise Medicaid payments to doctors. For hospitals, payment reforms should penalize poor performance on measures of health equity. For example, higher payments to hospitals could be tied to improvements in emergency-room wait times—which have often been found to be longer for Black patients than white ones.