Health Disparities in the U.S. - Part 1
Bellevue and Auburn are two cities in Western Washington State separated by less than 25 miles. Residents of Bellevue live 10 years longer on average than their counterparts in Auburn. What factors and underlying context(s) account for this disparity? This question is far too broad/complex for a single brief post (innumerable academic articles, books and textbooks on this topic run to thousands of pages), so I decided to spend each of the next few posts discussing a specific element contributing to health disparities in the United States. The focus of this post is likely for many the most relevant/obvious contributor to health status – health insurance coverage.
Structure and coverage
The United States is one of the only industrialized nations which does not provide universal healthcare coverage to all residents. Instead coverage is obtained through a patchwork system of privately purchased, employer-sponsored or government subsidized private insurance plans and state/federal government administered insurance for low-income, disabled, military and elderly via programs including Medicaid, Medicare and Tricare. Historically this system has left many in the U.S. without access to insurance coverage. Prior to passage of the Affordable Care Act (ACA) in 2010 that introduced government subsidized private insurance and provided an opportunity for states to dramatically increase access to Medicaid, there were 46.5 million uninsured. The ACA enabled almost 20 million additional individuals to gain insurance coverage between 2014 and 2016, but the number of uninsured has risen by over 1 million since 2016 and stands at 27.9 million. This includes over 2 million people stuck in a ‘coverage gap’, who are unable to afford private insurance, and reside in states including Alabama, Florida, Georgia, Kansas, Mississippi, North Carolina, South Carolina, South Dakota, Tennessee, Texas, Wisconsin and Wyoming that have declined to expand Medicaid. As we can see there is a strong regional trend in that nearly all are southern states and (perhaps unsurprisingly) have high rates of uninsured (over 10%) compared with the national average (8.9%) and most other states.
Demographics
Insurance enrollment varies widely based on race and ethnicity. White (8% uninsured) and Asian/Native Pacific Islander (7%) are significantly less likely to be uninsured than Black (11%), Hispanic (19%) and American Indian/Alaska Native (22%) residents. Unsurprisingly, there is also an inverse correlation between income level and uninsured rate – over 36% those below the federal poverty line (FPL) (<$26,200 annual earnings for a family of 4) in states without Medicaid expansion are uninsured, as compared to only 7% of residents at or above 400% of FPL ($104,800 – family of 4). This disparity is much less significant in Medicaid expansion states with 16% at FPL uninsured as to 4% at or above 400% of FPL.
Health status and outcomes
Insurance coverage is a key predictor of health status and outcomes. Studies have consistently found those without health insurance are far less likely to access preventative care and medical screenings, have worse outcomes from chronic diseases such as diabetes, heart disease, renal disease, HIV and mental illness, receive fewer hospital services and are at higher overall risk of premature death. Insurance also reduces existing disparities between population groups driven by a lack of access to preventive services such as screenings. For example, African Americans are 20% more likely to get colorectal cancer than other population groups and often lack access to preventive screenings due to no or limited insurance coverage - a study estimated that gaining comprehensive health insurance would result in a 5% increase in colorectal screenings.
For next post: socioeconomic status and health