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Families USA 2011 Annual Health Care for All
This document analyzes racial and ethnic disparities in access to healthcare in Massachusetts before and after the implementation of Chapter 58. It finds that while coverage rates increased and some health outcomes improved for minorities after reform, significant disparities remained, especially for Spanish-speaking Hispanics. BRFSS survey data showed coverage and a usual source of care increased from 2005 to 2009 for minorities but access issues due to cost and finding providers who accept low-income patients persisted. Focus groups and interviews identified ongoing barriers including immigration status, language barriers, lack of knowledge about insurance options, and lack of culturally competent outreach. The lessons learned are that while reform increased compliance, continuous enrollment assistance is still needed and disparities continue to be a challenge
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Families USA 2011 Annual Health Care for All
- 1. Racial and Ethnic Disparities in Access to Care in Massachusetts: Pre-and Post-Chapter 58 Brian Rosman, Health Care For All Sabrina Aggarwal, JSI
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- 4. Chapter 58 -Coverage Source: Urban Inst. surveys for MA Div. of Health Care Finance and Policy
- 5. Health Improvements? “Statisticallysignificant 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
- 6. Comparison Massachusetts Chapter58 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
- 7. Disparities Provisions Massachusetts • 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
- 8. Goals • Toevaluate 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
- 9. Methods • Used2005 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
- 10. Percent reporting healthcoverage (adjusted): 2005 vs. 2009 95.4% 95.2% 91.6% 86.6% 91.1% 90.2% 86.9% 78.4% 100.0% 95.0% 90.0% 85.0% 80.0% 75.0% 2005 2009 NH White* Hispanic, overall* Hispanic, English Hispanic, Spanish •Significant difference (p<0.05) from 2005 to 2009 Estimates adjusted for income, education, employment, disability status, age, gender, health status
- 11. Percent reporting usualsource of care (adjusted): 2005 vs. 2009 88.2% 90.1% 89.6% 86.5% 81.6% 84.2% 78.0% 65.6% 100.0% 94.0% 88.0% 82.0% 76.0% 70.0% 64.0% 2005 2009 NH White* Hispanic, overall* Hispanic, English Hispanic, Spanish* •Significant difference (p<0.05) from 2005 to 2009 Estimates adjusted for income, education, employment, disability status, age, gender, health status
- 12. Percent reporting notseeing a doctor due to cost in past year (adjusted): 2005 vs. 2009 11.0% 9.7% 8.3% 11.1% 8.9% 7.2% 7.0% 8.1% 12.0% 10.0% 8.0% 6.0% 2005 2009 NH White Hispanic, overall Hispanic, English Hispanic, Spanish •Significant difference (p<0.05) from 2005 to 2009 Estimates adjusted for income, education, employment, disability status, age, gender, health status
- 13. Coverage and access disparities still exist among Hispanics Immigration policies Key = Social = Political =Environmental = Economic Health insurance in Private Sector Expensive Health insurance tied to Employment in U.S. Complexity of public insurance system Knowledge of state programs Marital Status & Family Structure Language barriers Distrust of the system Difficulty finding provider Parental Citizenship & immigration status Documentation requirements Low-Income Knowledge & attitudes towards health care system Type of industry and/or firm determines health insurance and income Culturally competent outreach & enrollment assistance
- 14. Lessons • Oncehealth 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
Editor's Notes
- #9 This paper examined the state’s progress in reducing health disparities coverage and access through comprehensive health reform. We used a two-prong approach in this study – first using BRFSS data, and then second using qualitative data to augment our quantitative findings in the form of interviews and focus groups conducted and gathered by the authors. Our overall goal in writing this paper was to evaluate how racial and ethnic disparities in coverage and access to care decreased after Ch. 58. Since very limited information is available about newly insured minority populations, we conducted focus groups to augment what information is available through BRFSS.
- #10 As just mentioned, we used BRFSS data from both 2005 and 2009 in order to compare coverage and access rates in 2005 – the year before MA health reforms were enacted, and then again three years after the reforms for adults under the age of 65. In our analysis we compared the state’s Hispanic population with non-white Hispanics as the comparison group. We looked at the effects of English proficiency, low education and low-income with regards to the Hispanic population. BRFSS is a state-based system of telephone surveys conducted on health-related topics among adults ages 18 and older in collaboration with the CDC. Using a weighting system to adjust for differences, it derives representative population-based prevalence estimates. The survey is administered in English, Spanish, and other languages. In order to measure health coverage and access to care, 3 outcome variables were used with yes/no responses. Along with the quantitative data, we did focus groups because very little information is available about the newly insured, especially minority groups. We collected info from those who recently obtained coverage and those who had been insured for at least one year under health care reform. Our 20 in-depth interviews were conducted with newly insured Hispanic individuals between 150 and 300 percent of the FPL
- #11 We ran a regression analyses to produce adjusted prevalence estimates, and disparities persisted – particularly for Hispanic-Spanish speaking adults. Even when controlling for differences in education, income, etc. a difference in coverage still existed between Whites and Hispanics. As documented in previous studies of MA health care reform, there has been a significant increase in coverage among state residents from 88.3% in 2005 to 93.9% in 2009. Comparison of BRFSS data across the US show that MA currently has the highest proportion of individuals reporting health insurance coverage. As you can see from the graph, which I think is telling, the non-Hispanic White and Hispanic populations have both experienced increases in coverage. However, compared to non-Hispanic Whites in 2005, coverage among Hispanics overall was 3.3% lower, and even greater among Spanish-Speaking Hispanics – 11.8.4%. In 2009, the disparity decreased by at least ten percent, but a significant disparity still existed. As you can see the increase in coverage among Hispanics in the 4 year period was more than double that experienced by non-Hispanic Whites partly reflecting the underlying racial disparity in the pre-reform environment.
- #12 So these next two graphs deal with access to care – measured in terms of having a usual source of care. Again in this graph we see the largest increase among the Hispanic population from 2005 to 2009 from 65.6% to 81.6%. The most significant disparity is still among Hispanics who completed the survey in Spanish. Still, pre and post reform you can see that the disparity between non-Hispanic whites and Hispanics decreases overtime drastically.
- #13 Cost remains a key barrier to care, though there has been a small, significant decrease over time. Nevertheless a disparity exists between non-Hispanic White and Hispanic adults with Hispanics. 11.1% of those completing the BRFSS survey in Spanish reported not seeing a doctor in the past year due to cost – a rate that increased significantly since 2005 (8.1% pre reform and 11.1% post-reform) suggesting that Spanish-speaking Hispanics may be more likely to be uninsured than the white population
- #14 Our qualitative interviews help to explain why so many Hispanics continue not to have a regular source of care and why cost remains such a significant barrier to care. We created this conceptual model to show the large system forces and individual factors at force – and how they all play into each other. For example, coverage disparities are affected by: -Familiarity with insurance mandate -Questions about affordability of coverage -Complexity of enrollment and re-enrollment process -Loss of employer-based insurance Decision to purchase and use health insurance is influenced by: -Attitudes towards coverage -Community-based organizations – do they exist to provide enrollment support -Language differences Hispanics are less likely to find a provider Long waits, changing doctors, doctors not accepting Medicaid patients Hispanics may have difficulty finding a provider due to language barriers Concerns over confidentiality, interpreters Costs associated with finding a provider Co-pays and premiums
- #15 Obviously as MA health reform legislation was the primary model for national health reform, it offers important lessons for strategies to reduce disparities nationally. Once Ch. 58 was mandated, we saw that people felt a civic duty to comply – and overall Mandating coverage improved access, but did not completely eliminate disparities. Improvements in access seen for all racial/ethnic groups, but greatest for Hispanic ethnicity. However, disparities in access persist ESPECIALLY for Spanish-speaking Hispanic adults. Typically what accounts for disparities in coverage are differences in education and income – hence when we adjusted the rates, the coverage rates were similar for English-speaking Hispanics and non-Hispanic whites. But differences persisted among Spanish-speaking Hispanics and non-Hispanic whites even when controlling for these demographic differences. What this shows is that language barriers is a huge component in the enrollment process – and a huge barrier overall to get Hispanics enrolled and covered. Thus three important lessons: existing outreach and enrollment programs for Medicaid and CHIP may not be sufficient to meet the complex cultural, language needs of the Hispanic population. First, even though MA has a large number of outreach and enrollment grant programs and provider groups that assume responsibility for Hispanics, they are underfunded and do not serve all Hispanics. Second, enrollment is not a single step process for many Hispanics who need to reenroll annually. Third, and finally, it is important to maintain a safety net for those left outside the reformed health financing system