Here is a paper that American Military University refused to publish. I am putting this on the internet for my friend.

Uninsured and Under insured:

Bridging the Racial and Ethnic Disparities through the Affordable Care Act and the Effect on the Medical Community


XXXXXXXXXXXXXX-please email for author

A Master’s Thesis

Presented to the Faculty of the Graduate School of

American Military University

In Partial Fulfillment of

Requirements for the Degree of

Master’s in Public Health Administration

September 2015

Charles Town, WV

The author hereby grants Student in Revolt the right to display these contents for educational purposes.

The author assumes total responsibility for meeting the requirements set by United States copyright law for the inclusion of any materials that are not the author’s creation or in the public domain.

Copyright 2015 by XXXXXXXXX-email for author

All rights reserved.









To Christopher, without you this would not have been possible.  You are my inspiration, my rock and my support. I love you.



I would like to acknowledge a few people in helping me with this part of my journey:

To Dr. Scott Gwara, Professor of English at South Carolina University: Thanks big brother for the insight you gave me on the paper.  You are the best!

To Jillian Elliott, Administrator for Heath Centers for Women, JPS Health Network: Thank you for the mentoring and the push to always do better.  You have been a big help to me and I am forever grateful.

Finally to my children: You have been my biggest support.  Without it I would not have been able to accomplish this goal.  I have one thought for you both.  Reach for the stars and live your dreams.  I love you both so much.  Thank you.


Uninsured and Underinsured: Bridging the Racial and Ethnic disparities through the Affordable Care Act and the Effect on the Medical Community

XXXXXXXXXX-email for Author, Masters of Public Health Administration

American Military University, September 20, 2015

Charles Town, West Virginia

Professor Karen Cieslewicz

Uninsured and underinsured persons in America has nearly doubled in the last two decades.  This was the call for reform.  In reforming the health care system, the Affordable Care Act has been implemented.  However, the claim for the difference in the health care delivery has claimed racial and ethnic disparities.  This thesis will look at the insurance nightmare and compare that to the current implementation of the Affordable Care Act and the effects on the medical community to see if racial and ethnic disparities have decreased.

Table of Contents



Chapter                                                                                                        Page


Chapter 1



Literature Review………………………………………………9


Chapter 2

The Affordable Care Act………………………………………17

Where minority health starts…………………………………..19

Health Languages………………………………………………20

Chapter 3

How does the Affordable Care Act embody racial and ethnic disparities?…22

Why are Racial and Ethnic Disparities in Health care Important?……26

Using Federal Data to Eliminate Disparities………………….28

Policy Implications…………………………………………….33

The Behavioral Risk Factor Surveillance System (BRFSS) used by

Common wealth……………………………………………..34


Access to healthcare…………………………………………………39

What does reform mean for minority health?………………………………..40

Table of Contents


Chapter                                                                                                            Page

Chapter 4

Projected numbers………………………………………………..44


Recommendations for further study and corrective action………46



Appendices of Tables (see list of tables)……………………….54

 List of Tables


Table 1…………………………………………………………………54

Table 2…………………………………………………………………55

Table 3…………………………………………………………………56

Table 4…………………………………………………………………57

Table 5………………………………………………………………….58

Table 6………………………………………………………………….59

Table 7………………………………………………………………….60

Table 8………………………………………………………………….61

Chapter 1


In the last two decades much controversy has ensued over racial and ethnic disparities in health care.  Many researchers in recent years to prove the existence of such disparities.  It is a well-documented that minorities experience a lower quality of health care than white Americans.   This simple reality is not only integrated into our current healthcare system, but also integrated in our nation’s history of discrimination and unequal societal determinants, such as socioeconomic factors to education levels, or heritage.  In order to ameliorate racial and ethnic disparities in our health care system, the internal and external stressors should be studied as part of a holistic approach to health care, taking into consideration social classes as part of the problem.  This thesis will look at the disparity gap and look how the Affordable Care Act has helped to close it.  It likewise considers the effects of disparities on the medical community.


Racial and ethnic minorities have been shown to receive poorer quality of health care compared to their non-minority counterparts.  Health disparities are experienced by populations experiencing greater life-obstacles, including geographical location in relation to a health care facility, cost of medical care, transportation, and language barriers. According to Healthy People 2020, the American health care goals went from reducing health disparities to eliminating health disparities: “achieving health equity, eliminate disparities, and improve the health of all groups” (Healthy People 2020, n.d.).  Although the focus in the past was the elimination of disease, the future focus is on health as a whole, since the absence of disease is not always indicate good health.  Other determinants impact health such as education, access to quality food, safe and decent housing, clean water, and transportation.  Furthermore, ethnic groups have sets of diseases to which they are more susceptible.  Such health susceptibilities, coupled with demographics, education, risk-taking behaviors and so on, also contribute to disparities in the health care system. Changes the dynamics of this system, with all its implications, remains a national challenge.

Literature Review

Thesis Statement: Has the Affordable Care Act bridged the racial and ethnic disparities in health care?

Article: Flores, G; Tomany-Korman, SC. (2008). Racial and ethnic disparities in medical and dental health, access to care, and use of services in US children. Pediatrics. 2008 Feb; 121(2):e286-98. Retrieved from

  1. Minority children will outnumber white children by the year 2020. This study objectives were to identify “racial/ethnic disparities in medical and oral health, access to care, and use of services in US children, and determine whether these disparities have changed over time” (Flores & Tomany-Korman, 2008).
  2. The evidence shows that children are just as much risk of racial and ethnic disparities in health care as their parents.
  3. Children are at much higher risk for being uninsured due to parental neglect, lack of understanding and education.

Limitations: Despite the increased number of pediatricians in the US, the racial disparities still exist.  There is much more research to be done to see if the racial and ethnic disparities are because of the parent or the child.  This study does not specifically state this item.

Article: Nelson, Alan. (2002). Unequal treatment: confronting racial and ethnic disparities in health care. Journal of the National Medical Association Vol. 94, NO. 8, August 2002. Retrieved from

  1. This study was done to “assess the extent of racial and ethnic differences in the quality of health care received by patients, not attributable to known factors such as access to care, ability to pay, or insurance coverage; evaluate potential sources of these disparities, including the role of bias, discrimination, and stereotyping at the provider, patient, institutional, and health system levels” (Nelson, 2002). The additional requirement was to provide recommendations for interventions and corrective actions.
  2. Racial and ethnic disparities exist even when all other factors are equal. This might be due to the death rates in African-Americans from diabetes, heart disease and cancer are higher than in those of their White counterparts.
  3. Many sources contribute to the health disparities such as bias and stereotyping.
  4. Racial and ethnic minorities are underrepresented in the medical community.

Limitations: Many minorities are at higher rates for refusal of treatment and non-compliance.  This may or may not be considered a contributing factor for the inequality of care.  Many items may actually make the minority groups mistrust those that are in the medical community which may be contributing to the refusal of treatment.

Article:  Ungar, Laura. (2015). Uninsured rates drop dramatically under Obamacare. Retrieved from

  1. The number of American adults without health insurance fell “16.5 million from five years ago, when Obamacare was signed into law, the largest drop in four decades” (Ungar, 2015).
    2. The drop was significant enough to make a difference in the amount of uninsured. That is about a 35% projected decline from years past.

Limitations: Just because the number of uninsured has dropped does not mean that all insured get care.  There are not enough providers to ensure those that have insurance have care.  The facilities also may or may not take the Obamacare insurance.  For example, the Tarrant County hospital does not accepts many of these insurances.  This creates more out of pocket for these people.

Article: Gorman, Anna. (2015). Many who got Obamacare subsidies now face big tax bill. Retrieved from

  1. The subsidies have to be paid back if people underestimate their income. This is becoming a problem as many Americans are repaying large subsidies from their tax returns.
  2. This action has become burdensome to many families who depend on the tax refunds for extra income. Many have been vocal in stating that they should have opted to pay the penalty.
  3. The laws pertaining to this have been neatly hidden in 2400 pages of a health care law that have many facets to this.

Article: US Department of Health & Human Services (DHHS). (2015). National healthcare quality & disparities reports. Accessing: Introduction and methods. Retrieved from

  1. Many Americans have access to good health care. The problem is not that people do not have access to adequate health care now, it is the fact that there are barriers to getting adequate care.
  2. Some people in our country do not qualify for medical coverage (i.e. Illegal immigrants). Although the roles for lack of insurance has gone down, the access to care has not changed.

Limitations: There are only so many providers that can adequately provide care for the growing population of insured people.  Just because people have insurance, does not mean that they will be seen.  The access to care has not changed for the better but has only changed to overload the doctor’s offices.


The history of American health care constitutes is an epic narrative related to national progress, industrialization, and working class wealth. Modern health care emerged from the Industrial Revolution of the 1800’s and early 1900’s.  As America Grew, so did industry, workers, and work-related injuries.  Employer-based health care system has its roots in laws protecting workers.  In the steel mills, according to Toland, “more than 10 percent of steel workforce was injured or killed on the job” (Toland, 2014). In these jobs, many men had access to company doctors that were employed by the company.  According to Toland, the “modern group insurance can be traced to 1910, when mail-order retailer Montgomery Ward solicited what is now considered the nation’s first multi-employee health insurance policy” (Toland, 2014).  The cost of health care, at the time, was relatively inexpensive and therefore affordable by workers.  Lost wages that hurt a family more than not having health insurance.  During this time, since most surgeries and clinical processes were done at home, there was no need for hospital coverage.  Physicians and insurance companies were not on board with community health care since many thought that insurance companies would control too much of expenditures and practice methods, essentially eroding the delicate health care system. The idea of health care as a unified concept died in the Senate and with the states.  The Depression followed shortly afterwards.

A single truth remains and has been the same in 1929 as it is today:  a person without a job cannot pay for health services.  During the Depression President Roosevelt tried to turn the country around with a slate of social programs.  Many succeeded, such as Blue Cross, though the insurance began to change after World War II. Companies needed to attract workers returning from war.  To be more competitive, they offered employer-based health insurance, now the cornerstone of the modern health insurance industry.  Unfortunately this development left two vulnerable groups of people without health care: those that could not work due to health issues, age or disability and those that had low paying jobs unable to afford it.  The Medicare/Medicaid system emerged in response to these inequities. These government insurance programs help the disabled, indigent and sick.  Roosevelt felt that no nation could be strong if its citizens were weak and sickly.

In 1915 a bill was passed that concentrated on health insurance.  This bill offered items such as hospital stays, maternity leave, and doctors’ visits and so on.  Moreover, a death benefit provision shared the cost among the government, the worker and the employer.  Introduced by Senator Robert Wagner (D-NY), the Wagner Bill of 1939 proposed a national health care plan.  Roosevelt did not fully support this initiative and when the 1938 election brought conservatives to the table, any hope of socialized medicine vanished.

In 1943, the former Wagner bill became incorporated in the Wagner-Murray-Dingell Bills of 1943.  In this set of bills, the call for compulsory national health insurance and a costly payroll tax came into play. The National Association for the Advancement of Colored People (NAACP), fully, if reluctantly, supported this bill.  The NAACP reasoned that there were no checks in place to ensure “equitable distribution of funds in the states where Negros and Whites [were] forced to use separate hospitals, clinics and other health services” (Hoffman, 2003).    Unfortunately, parts of this bill did not last long, and the legislation never passed in the Senate.  The fear was that the African-American and other minority population would be shorted funds and health care services based on race and ethnicity.  Accusations of racial redlining in the second half of the twentieth century have effectively led to health care rationing.

Universal health care has been a center point in the Civil Rights Movements.  The NAACP, has put their own doctors and medical professionals in the forefront to help in the fight for equitable and universal health care.  Within the Civil Rights movement, they called for the elimination of “inadequacies in health care” (Hoffman, 2003), a demand that addressed limitations on minority and poor Americans. Minority groups were largely affected.  Many hospitals of the time did not accept Medicaid, a rejection that conveyed neglect for, and perhaps contempt of, the poor.  Many federal lawsuits that mandated more community hospitals to be opened specifically for the poor in the urban areas. The indigent were often forced to seek care in rural areas. The rise of diseases associated with African-American continued to plague minority communities.  Basic preventative care would have reduced and eliminated the most prevalent diseases, but reasonable access to preventative care forced many to wait until a medical problem required treatment.  This neglect cost taxpayers millions more than need be, and created a social condition that still exists when minorities seek care in hospital emergency rooms (ER).

In the 1960’s and 1970’s the authors of “Our Bodies, Ourselves” argued that profit-driven medicine had led to an epidemic of unnecessary hysterectomies, while women without access to primary care died of preventable cervical and uterine cancers…The authors declared “we believe that health care is a human right and that a society should provide free healthcare for itself…health care cannot be adequate as long as it is conceived of as insurance’” (Hoffman, 2003).  This premise formed the basis of not only the minority health movement but that of the women’s movement in health care equality.

When Truman became president (1945), he put health care back in the center of people’s lives.  His plan differed from Roosevelt’s 1938 initiative, in that Truman was committed to a single health care provider across the board-insurance available to all American citizens of all classes, incomes, and ethnic identities.  Truman argued that his plan was not socialized medicine, as we know socialized medicine today.  Many thought socialized medicine would lead to other parts of life being socialized.  Coming out of the communist, and particularly Stalinist’s, era, socialism remained immediately repellent to most Americans. These bills did not pass, and when Republicans took over, the idea was dropped all together.  Abandoning universal coverage left the employer-based health insurance in place, a major deficiency in today’s health care system.

Many of Truman’s ideas for universal health insurance failed due to the influence of interest groups. Having Blue Cross alternative was deemed socialist, and Americans resisted increasing government control in their personal lives.  Communism and the protracted Cold War made many fearful of government influence. Interest groups fought to keep the government out of health care and in the hands of private insurers, unless one needed Medicare/Medicaid assistance.  An interest group does not always protect the interests of all people, and in most cases, ensured the rights of the elite.  Many have called health care a “play thing for the rich” (Bauman, 1992). Opponents of national health care have always claimed that a patient would get lost in the system, but patients are lost anyway.  Because national health care is considered un-American, it has failed for nearly a century.  However, the recent reforms of the Obama administration were a victory for a national plan, although admittedly not without its problems.

Failing to unify grass roots movements attitudes of the elite toward health care must be taken into account.  Some social failings might be due to lack of strong leaders on the part of minorities, and weak interest in reform among elites.  Since the calamitous upheavals of the 1960’s, the focus on a universal health care system has re-emerged, but even in light of the ongoing Civil Rights campaigns, the failure to set specific provisions for minorities has beset and advance.  Nevertheless, access to equitable and adequate health care has been a primary focus of the current Obama administration.  Part of the mission is to change the perception of health care as a right, and not a privilege for the elite.  A new attitude towards social health, it is thought, may change opinion about insurance reforms.

Chapter 2

The Affordable Care Act

Instead of crafting the legislative for the Hose and the Senate to vote on, President Obama decided to provide an outline and leave the legislative branch to fill in and address the specific requirements.  The House took the lead on this proposal, and their proposed legislation contained provisions for health care exchanges.  While controversial, these exchanges were established to address the minority and indigent health care needs.  Exchanges provided a market for pricing insurance, and low-income families would qualify for subsidies according to income.  According to the Kaiser foundation, the Affordable Care Act was supposed to bridge the racial and ethnic disparities, since people of color tend to lack health insurance disproportionately.  Research shows, however, that subsidies help those with low incomes tend to put financial burdens on minorities.  While exchanges are government-subsidized, a family that cannot afford the cost even with the subsidy is fined for not having mandated insurance.

Extending the Medicaid roles by adjusting the poverty guidelines was viewed as a good compromise.  This approach captured many people that fell between the Medicare/Medicaid roles and those of private insurance.  Part of the responsibility finance these additional subsidies fell to the states.  Yet many of the states had budget, contractions and therefore simply could not afford to add more people to Medicaid roles.  Even so, when the Supreme Court ruled in support of the Affordable Care Act, they left the implementation of the expansions up to the states. According to the Kaiser foundation, “under the ACA, this five year waiting period (for lawfully present immigrants) and exclusion of some categories of lawfully present immigrants will remain in place for Medicaid” (The Kaiser Foundation, 2013).  At present, illegal immigrants are not currently eligible for Medicaid and remain barred from even applying to state exchanges.  They would, of course, be exempt from the tax imposed by lack of insurance.   However, these illegal immigrants are eligible for CHIP prenatal care and children of illegal immigrants are eligible for CHIP and Title V, regardless of citizenship.

Table 2 (see appendix) shows the current non-elderly population by race/ethnicity in 2011.  Nationwide, the numbers of black, Hispanic and others add up to about 41 percent.  However, in Table 3 (see appendix), this breaks down the minorities by state.  This table shows significant concentrations of minorities on the East Coast, mid-plains and the South, and part of the West Coast. From California to Texas, the southern states, constitute more than 50 percent of the current population.  This Percentage leaves the East Cost, mainly from New York to Louisiana with approximately 30-49 percent of the minority population.  The concentration lies those border-states which receive numbers of illegal immigrants as well as lawfully present immigrants.

Table 4 shows US born citizens, Naturalized Citizens and Non-Citizens.  The minority group usually has one full-time worker in the family.  However, in comparing incomes, Whites are twice as minorities not to be poor.  Because many white families have more than one full-time worker and tend to be better educated, the group as a whole lacks insurance less often.

Minorities have incomes of less than “138 percent of the poverty level and about 62 percent” of them qualify for subsidies (The Kaiser Foundation, 2013).  This number still leaves many, due to the lack of funds, looking to Medicaid and other forms of insurance to defray the cost of their medical coverage-if they have it.  Yet the growing number of minorities and diversities are changing the face of health care.  Since minorities cover a significant percentage of the population and according to Kaiser, are “projected to make up the majority of the population by 2050” (The Kaiser Foundation, 2013), the gap in the coverage and the differences in the accepted coverage are astounding.  Both the lack of funds for health insurance and dearth of employer-sponsored health insurance are a growing problem.  This trend suggests that minority populations will be either uninsured or under insured more often than Whites.  If the population expands as Kaiser has predicted, a majority of the nation’s families will either lack insurance or not have adequate coverage.  The exchanges are the potential to cover most, if not all, people regardless of race and ethnicity.

Where Minority Health Starts

Compared to the white population, minorities have demonstrably worse health indicator outcomes, such as life expectancy, infant mortality and chronic disease.  In considering the origin of this disparity, most people learn self-care preservation behaviors in childhood. Parents all want what is best for their children.  However, not all parents have the same resources to raising their child in healthy environments.  Parent’s education levels, income, and lifestyle play a major role as determinants of healthy habits.

Years ago, a doctor made a house calls, an obsolete practice, even though one place to make a consequential impact on health care is in the home. Inside the home professionals can determine the resources needed for good health.  This direct assessment would be most effective for parents of newborn children and infants.  Home-based nurse visits improve child health, especially in the African-American community, according to a study conducted nationwide by the Nurse-Family Partnerships.  Nurses are introduced to the family prior to birth, during birth, and up to two years after birth.  This nurse-family partnership lowers the risk of child abuse, helps to the development of healthy habits, and fosters good prenatal care.  The health of the child and eventually the adult starts in the womb.  According to Schubert, the medical-based home models are superior to those used by non-professionals or peer mentors.  These medical professionals provide tools to help the parent promote the health of the child, and not do the work for them.  Schubert goes on to explain that “every family in the UK gets a visit from a nurse or midwife after the birth of a child…they maintain a relationship that combines in home and in clinic visits until the child is 5 years old” (Schubert, 2014).   Schubert alleges that such visits improve the health of the community, making it a priority for health benefits and raising the standard of health.  The impact could lead to lower hospitalizations and decreased need to use unaffordable services.  For example, patients that have had in-home care for at least a little while are less likely to use the emergency room (ER) inappropriately.  The overall health of the family improves, and socialization puts less stress on the family.

Where a person lives may or may not increase or decrease health outcomes and life expectancy.  Children born to parents with higher incomes are more likely to be healthy compared to their counterparts in poorer families, where resources are not as readily available.  Children of poor families are also more likely to be obese or overweight that those of higher incomes.  Poor families are less likely to value higher education and health care, even if insured.  Research on this issue suggests that if health care is prioritized, children are more likely to grow up valuing it.  If, however, households do not prioritize health care, children will not ultimately value it, bestowing their indifference to future generations.

 Health Languages

Health languages is a simple phrase for a complex issue involving minority population and their health care.  Using everyday words in a negatively drives a wedge between a provider and the patient.  As the technology advances and patients become more health conscious, their involvement with health care becomes more engaged. The way a provider uses a word can negatively impact how the patient views his health, and how compliant they will be.  This effect impacted enrollments in the Affordable Care Act exchanges, because people did not understand the professional health languages or the plan that they intend to sign up for.

If English is not the primary language that is spoken in the home, non-fluency may add to the inability of minorities to access the health care system.  English fluency is an obvious fix, but the way medical language is received by patients is crucial.  The language we normally use in patient interactions may have negative consequences on minorities for accessing and negotiating the health care system.  If patients do not understand the health care system, regardless of insurance, they are not likely to select adequate health care services.

 Chapter 3

How does the Affordable Care Act embody racial and ethnic disparities?

Racial and Ethnic disparities in the United States has been a long standing problem in which certain groups have less access to adequate health care services, a deficiency shown to result in poor health outcomes.  A health disparity is a “high burden of illness, injury, disability, or mortality experienced by one population group relative to another group” (The Kaiser Foundation, 2012). A health care disparity refers to “differences between groups in health insurance coverage, access to and use of care, and quality of care” (The Kaiser Foundation, 2012).  Based on a middle class society and way of thinking, the current health care system favors those with money and adequate insurance.  Health disparities emerge when those of lower economic status endeavor to achieve a middle class lifestyle’s representative of the poet-war American dream.  Poorer citizens attempt to gain middle class prosperity not only health care but also in other lifestyle choices.  Escaping the average day with its relentlessness, if average, stresses, appeal to the poorer class, even if such striving entails risk-taking.

Health determinant factors generally encompass things like maintaining a healthy weight, eating a balanced diet, exercising and so on.  The inequality represented by available health care providers has been a battle.  Many health care providers set up in affluent neighborhoods where the average person is insured.  Few providers set up shop in the poor neighborhoods due to the higher crime rates, threats to the safety, and reduced revenue from Medicaid reimbursements.  Even minority doctors from these neighborhoods avoid establishing businesses in them for the same reasons white doctors do.  One result of this segregation is that many of the patients seeking better health care do not have transportation to and from these superior clinics.  This situation pushes patients to find providers in rural areas that are not likely to take the uninsured or under insured.

The populations most susceptible to health care disparities are minorities, which Kaiser refers to them as ‘vulnerable populations’ (Kaiser, 2012).  These groups include populations not well integrated into the health care system, and those using the ER more frequently due to lack of insurance or inability to cover the copay or deductible.  Since health disparities have been an ongoing problem in the United States. The population is expected to be even more racially and ethnically diverse by 2050, so covering patients will require political and financial consensus.  Because disparities persist over a lifetime and remain inter-generational, health disparities are costly to the nation.  Not only do they raise the average costs of health care, but they also create unacceptable social inequalities.  Since people of color make up a disproportionate percentage of the lower incomes, the gap between insured and the under- or non-insured continues to grow disproportionately.

Minorities face barriers to accessing care and receive less effective are when they do get it.  Current research also shows that the limited proficiency in English also impeded access health care because non-native speakers do not understand how to access the system.  Many patients in America’s poorest places have between second-and fifth-grade reading and comprehension levels.  Many patients do not understand what is spoken to them, let alone the basics of their chronic diseases.  It is very difficult to explain to a patient the complexities of a disease if they do not understand how they first contracted it, and how to prevent the disease from progressing when they do not have access to adequate food and clean water.  Such populations have higher instances of chronic disease and worse health outcomes.  Minorities seldom seek preventative care to maintain health.  Research proves that for the cost of one average ER visit, a patient can see a primary care provider nineteen times.  Over nineteen appointments a provider may have prevented or deterred a disease that sent the patient to the ER in the first place.

In the past medical professionals practiced disease treatment:  patients were treated once diagnosed with chronic diseases.  The focus in recent years has been on preventative medicine.  This approach to medical care shows promise for minority health in that providers try to prevent chronic diseases by recommending lifestyle changes. Practitioners include, but are not limited to, navigators, health coaches and other professionals working with a health care team on a holistic approach to health.

The lack of providers has been on the rise not only in the US but all over the world, although the provider-patient ratio is better here than abroad.  The Affordable Care Act initiated a decline in primary care providers because family health is becoming less lucrative compared to specialties.

Patient-centered medical home care initiative was designed to route patients to primary care providers instead of the over utilized ER and to coordinate care throughout the medical community. The effort formed part of the change to electronic medical records, which enabled providers to coordinate care across facilities and better serve patients as a result. Moving patients effectively through the healthcare system functioning as one unit instead of multiple disjointed settings increased the quality of care. Many new ideas were likewise established, such as the patient navigator, whose is to call two weeks prior to an appointment, ensuring that all labs were done, and reminding patients of scheduled appointments. Despite the availability of these navigators and advances made possible by the Affordable Care Act more generally, racial and ethnic disparities remain, according to Natale-Pereira, Enard, Nevarez & Jones (2011).  While all Americans have the right to healthcare in the US healthcare system, minorities do not access the healthcare system as often as whites, and when they do, they have inferior healthcare outcomes.  The navigator endeavors to overcome racial, language and ethnic barriers, thereby negotiating a complex or unfamiliar system. According to Natale-Pereira et al., the system is failing even with the implementation of navigators.

However, at least one other study documented significant improvement. Ellie Rizzo at the Cleveland Clinic conducted a one-year pilot study on navigation and diabetes patients. Of 108 total patients studied, Accenture reported about “32 percent improvement in abnormal blood glucose levels and had a 52 percent increase in the completion of self-measured metrics. The pilot study also achieved a 50 percent decline in no-show appointments, such as regular ophthalmology and podiatry exams” (Rizzo, 2014).

Navigators contact patients individually to discuss health, treatment outcomes, and treatment options. Patients feel valued and come to understand that someone cares about their health. This attention in turn helps those with low-level education or with language barriers to access the healthcare system more effectively. According to Balderson and Safavi, patient navigation is more than just a counseling call. Navigators’ help patients understand treatment options, coordinate appointments, and monitor care. They also help the uninsured confronting barriers to their health, such as understanding the disease process or the optional treatments for disease. They may express concern over babysitting arrangements, travel to appointments, and the cost of medicine. Without solutions to these basic problems, patients unable to understand the system or with language barriers may give up and refuse to go for treatment (Balderson and Safavi, 2013). A six-month study Balderson and Safavi concluded,

patient navigation support helped reduce no-show and cancellation rates by 3 percent compared to a control group of patients; the revenue generated by the program paid for the salaries of two full-time patient navigators in just over three and a half months; each full time navigator added $150,000 in additional hospital revenue per year; extrapolating from these results, two full time navigators across seven high-cost priority areas, such as head and neck cancers, colon cancer and diabetes, could yield approximately 2.1 million per year” (Balderson & Safavi, 2013).

This outcome proves that the patient navigation works for those patients challenged by accessing the system.

Healthcare disparities also may be reduced through better education. Educational programs targeting patients on a personal level have been shown to be effective. When patients think that someone cares enough to call them and help them navigate the healthcare options, they feel less vulnerable and exposed to indifference and neglect. While the elimination of disparities has become a national objective, little has been done to monitor, let alone address, them.

Concern is growing out of the past racial and ethnic differences in the delivery of healthcare.  Racial and ethnic minorities have long since had a clear divide in health care access as well as health care quality.  It has been shown that “racial and ethnic minorities are less likely to be beneficiaries of publicly funded health insurance aid, even when insured, may face additional barriers to care due to other socioeconomic factors such as high co-payments, geographical factors, and inefficient transportation” (Smedley, Stith, & Nelson, n.d.).  The other factors may be of typical stereotyping the individual based on economic and social factors.

Why are Racial and Ethnic Disparities in Healthcare Important?

Despite the major advances in the diagnosis and treatment of chronic diseases, evidence of racial and ethnic disparities document that minorities receive inferior care and treatment options, and have a higher morbidity and mortality rate than non-minority counterparts. Many research models suggest that minorities with unequal treatment have worse health outcomes, a fact perhaps explaining why some providers limit minority patients. Minority groups face limitations in the quality of care and equal access to attentive providers because of socioeconomic factors such as transportation, money and child care. In’s Race, Ethnicity, Culture, and Disparities in Healthcare, Egede observes a “relationship between perceptions of health care discrimination and use of health services. Approximately 5% of respondents (to California Health Interview Survey) reported experiencing some form of discrimination” (Egede, 2006). Out of a reported 54,968 respondents, those that perceived discrimination were less likely to receive preventative care services. Although 5% of respondents’ perceived discrimination, the report not conclude that they were denied preventative care. Egede conceded that, although his findings were significant, his research design had some limitations. The effects of race/ethnicity may represents more of a perceived hurdle than originally thought.

This conclusion would not contradict the evidence of healthcare disparities, which have been proven by research and data. The study of racial variations in healthcare assumes that race is a biological category and affects the health of a population. However, far from being merely genetic or biological, racial variation also embraces social constructs as an independent variable in population health. It might be an easier to view ethnicity as expressing cultural differences. For a particular race, this perspective interprets individual variation as a determinant of disparities in healthcare, and conveys how minority populations are perceived to access healthcare. In some cultures, doctors are only used if the family cannot deal with the sickness without one. Preventative care may not be a family priority. On the one hand, if a person growing up visits a doctor regularly, he or she will likely pass that experience on to their offspring. On the other hand, if an individual’s goal is survival alone, and medical care is not sought for health and well-being, this person will likely visit a primary provider only if necessary. An ER visit or hospital stay usually precedes this visit.

According to Egede, “the United States Department of Health and Human Services Office of Minority Health defines culture as integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups” (Egede, 2006). Using culture as a healthcare determinant can explain the failure to seek healthcare services among minorities. The lack of providers and insurance differences in other countries may keep poor immigrants from accessing the American healthcare system. Furthermore, racial and ethnic disparities are generally consistent across illnesses and services rendered, as reported in many published studies.

Using Federal Data to Support Local Programs

            Most statistical evidence concerning racial and ethnic disparities comes from national organizations. However, local public health departments devise programs to eliminate disparities, fixes in the form of community partners, agencies, health care clinics and providers.  Sequist and Schneider (2006) suggest models that make sense of the federal data and help to focus efforts on ameliorating racial and ethnic disparities and providing equitable access to healthcare. In our current health system, data is collected by two entities, delivering healthcare and the other monitoring it. Data ethnic and racial identities collected by agencies from applications made on the healthcare exchanges is used for comparative purposes. However, neither Medicaid nor Medicare reports racial and ethnic differences to the federal government.  The misclassification of individuals may also skew such reporting, since only the U.S. Census classifies and reports ethnic and racial minorities. Sequist & Schneider allege that, “misclassification of non-black minority individuals may bias estimates of health status or mortality” (2006).

Medicare rolls could produce an unbiased estimate of the racial and ethnic differences, but a lack of non-black minorities makes it difficult to obtain a reliable sample to assess healthcare outcomes, and the bias may impair the reporting. These people tend to live clustered in one geographical location. Counties therefore have better racial and ethnic descriptions for their local populations. Unfortunately, federal databases leave out preferred languages and immigrant status, reliable determinants that impact healthcare access and equality Sequist &Schneider (2006) suggest that improvements in the race and ethnic identifiers in healthcare access points, such as plan enrollments, will better serve minority populations. This approach would also enhance accurate reporting of disparities rather than relying on incomplete data for statistical analyses. At the same time, disparities should be handled without labeling people, who might be reluctant to seek care because of social stigma created by such profiling.

Health disparities create harmful health effects. According to the Robert Wood Johnson Foundation, “racial and ethnic minorities represent about one-third of the US population and, according to the latest Census Bureau projections, will become the majority population by 2042” (2011). One-third of the American population, once they get into primary care, will have poor health outcomes and prognoses. Minorities also have higher mortality rates, including infant mortality. Chronic diseases are more prevalent in this group as well, perhaps due to lack of preventative care and regular health maintenance. Medications affect races differently. Unaware of appropriate treatments for minority patients, many providers may treat them like non-minorities, potentially overlooking crucial life-saving factors.

The cost of disparities remains high. The Robert Wood Johnson Foundation states, “African-Americans and Hispanics, with the cost burden of three preventable conditions-high blood pressure, diabetes and stroke-was about $23.9 billion in 2009 … Health inequities were estimated to contribute $1.2 trillion in lost wages and productivity between 2003 and 2006” (2011).  These figures include loss of time at work, productivity, paid sick leave, and early demise, but do not include the out-of-pocket cost of healthcare premiums and co-pays. The ACA attempted to cover the health care premiums, but high deductibles were yielding the same inferior medical care.

A person’s health status is interdependent with other factors, including stressors: racial profile of genetic inheritance, socioeconomic factors such as status, income, education and living conditions, risk-taking behaviors like alcohol consumption, and personal environment. Since many experiencing healthcare disparities live at or below the poverty level, healthcare often seems less important than finding a place to stay for the night. This reality may be contributing to the homeless population, who naturally endure non-racial healthcare disparities simply because of their poverty. Without a stable income, one cannot live in the better neighborhoods with good schools and aspirant families. This observation fits into Maslow’s hierarchy of needs. The first step is basic needs, which motivate people to find what they lack: air, food, shelter, warmth, sex and sleep. The second step is security, a place to call home as much as general concepts like law, stability, and freedom from fear. The medical community bears the responsibility to recognize the basic medical and social needs of a patient’s health.

While the ACA helps reduce the insurance disparities, the patient as a whole needs to be cared for. Based on this responsibility alone, health disparities will continue to exist and possibly worsen over time. Green, Lewis & Bediako suggest that, “public health professionals must address basic needs—individual and environmental factors that determine consciousness and health behaviors—before health promotion becomes a priority for individuals in our communities” (2005). Taking this approach would burden healthcare professionals with more than patient treatment. Healthcare professionals can, as one solution, partner with outside resources for further support of their patients. Since socioeconomic status appears to be the significant factor in healthcare disparities, it may be important to modify existing models and theories or develop new frameworks for care. Perhaps a new model would empower patients to rise above their situation and help themselves. Until healthcare professional attend all aspects of a patient’s life, they will continue to express frustration with patients and consequently overlook opportunities for holistic treatment. These patients may then become frustrated and see their provider as non-caring because they feel rushed during appointments. This mutual frustration feeds the sense of social entrapment, which encourages expensive trips to the ER.  Green, Lewis and Bediako propose a health promotion program that integrates a social work component addressing the basic needs of the people and motivating them towards self-actualization in Maslow’s Hierarchy of Needs.

Quality of life measures may be put in place to reduce racial and ethnic disparities. It may be difficult to measure quality of life, however, because perception of the quality of life differs for each person. One final advance might be tracking whether healthcare professionals enter accurate data while filling out paperwork, and share that data for analysis. Healthcare professionals are already overtaxed by paperwork and compulsory protocols. Environmental and interpersonal factors must be addressed before health disparities can be reduced or eliminated.  This goal may not be possible, or even feasible. Since Maslow’s Hierarchy of Needs plays a role in health, health disparities could be addressed effectively if providers actually understood the correlation.

Education also impacts health disparities. According to the Robert Wood Johnson Foundation, “US adults living at or below the federal poverty level ($22,350 for a family of four in 2011) are more than five times as likely to say they are in poor or fair health compared to those whose incomes are four times the poverty level” (2011). Individuals without a sound financial footing and reliable income are less likely to live in safe neighborhoods, eat healthy foods, or enjoy safe play areas for their children. These people tend to have shorter life spans.  Living conditions, of course, exacerbate health conditions in minorities. In lower socioeconomic neighborhoods, fast food restaurants tend to predominate. The lack of grocery stores and fitness centers (recreational centers) impact healthy living. Many of these neighborhoods are in crowded, polluted areas, sometimes located next to or near waste dumps. Impoverished minorities may also live in insect- or rodent-infested or homes, putting their health at risk. Stress adds to health disparities. A powerful reaction with many physiological repercussions, stress is more prevalent in the racial and ethnic minority groups than in non-minority ones.

One purpose of ACA was to eliminate health disparities. The expansion of the Medicaid program and implementation of the health insurance exchanges offered health insurance for people that did not previously have it. This benefit, however, did not account for many millions that lost coverage due to policies that did not meet ACA standards. ACA subsidies were meant to improve minority healthcare, since Blacks and Hispanics were among the most uninsured populations. The uninsured were disproportionately those with low incomes and lack of education. The disparities among the insured are lower, a significant result of the ACA exchanges. ACA enrollment has reduced the number of uninsured Blacks and Hispanics, and there has been a significant increase in the insured overall. Research has shown, however, that disparities will persist. A large number of people cannot afford the deductibles and co-pays. The Common Wealth Fund analyzed “historical differences among white, black, and Hispanic adults. We analyzed two measures: not having a usual source of care, and going without needed care because of cost among adult’s ages 18 to 64 in 2012 and 2013” (Hayes, Riley, Radley & McCarthy 2015). This study was undertaken in the two years leading up to the inception of ACA.

The analysis offer by the Common Wealth Fund study showed that the availability of insurance reduced the number of uninsured, but further study is needed to determine healthcare disparities among the insured: adequate benefits, access to providers, and protection from high deductibles, and unaffordable out-of-pocket premiums and co-pays. Minorities are more likely to go without care due to the expense, and then expect treatment in a local ER. Ironically, the cheaper but still unaffordable premiums and co-pays drives up our healthcare costs in ER payments. Going without care is often higher among uninsured patients than among the insured.

Policy Implications

While a beneficial social program, health insurance may not equalize care, since citizens still face many barriers in gaining access to affordable health care. Taking age, education, income, and gender into consideration, disparities are lower among the insured over the uninsured. But it has been suggested that health insurance along will not eliminate the extant disparities. Still more likely to live in poverty and lack basic health insurance, minorities may still mistrust the medical community, due to issues like the Tuskegee experiment. Coupled with the lack of health insurance, poor education, and reduced socio-economic advantages, African-Americans are especially vulnerable. ACA requires that basic requirements are met from the healthcare exchanges to ensure that everyone has basic coverage, and while ACA offers subsidies, the costs may still be too high for the indigent. The growing trend of higher deductibles, premiums, and co-pays encourage the sick to go without care. Because the penalty for not insurance remains lower than the deductible, premium, and co-pays combined, the poor are sometimes tempted not to enlist on an ACA exchange. Furthermore, if a family is struggling to put food on the table, high deductibles or premiums may impact the quality of their diets.  Food and shelter may seem more important than healthcare, as not everyone qualifies for food stamps or other government nutrition programs. The implementation of the ACA has decreased disparities, but remaining inequalities suggest the need for more healthcare providers, and the current shortage will impede any broad expansion.

The Behavioral Risk Factor Surveillance System (BRFSS) Used by Common Wealth

            This study of approximately 400,000 adults over age 18 was conducted in 2012 and 2103 by telephone, include land-lines and cell phones. The data collected over two years was combined for this study, which precluded adults over age 65 since they qualify for Medicare. Adults were asked “whether they did not visit a doctor when needed within the previous 12 months because of costs, and whether they have one or more than one person they think of as their personal doctor or health care provider” (Hayes et al, 2015). The following results were analyzed by race/ethnicity and income:

  • Low income: less than 200% of the federal poverty level as defined in the ACA regulations.
  • Middle income: 200 percent to 399 percent of poverty.
  • Higher income: 400 percent of poverty or higher plus the status of uninsured or not at the time the questionnaire was asked (Hayes et al, 2015). Each design was adjusted to 95 percent confidence intervals of about 1-2 percentage points.

In doing a cross reference with the CDC’s BRFSS for 2013, the National Health Interview Survey is conducted on a yearly basis. The records are unweighted which gives each survey the same weight and consideration. This methodology helps make the data unbiased and accurate. Approximately 34 percent of those living in the US fall under the 200 percent poverty level.  Obviously, some states have higher levels, and Arizona leads all states, with about 44 percent of its citizens at poverty level at or below 200 percent. According to Kaiser, about 41 million Americans were uninsured in 2013 (Kaiser, n.d.). The uninsured rates, according to Levy, have dropped (see Table 5). The number of people receiving employer-based healthcare coverage has risen.


According to Ungar, “the number of American adults without health insurance fell 16.5 million from five years ago, when Obamacare was signed into law, the largest drop in four decades” (Ungar, 2015). This number does not include new roles from Medicaid, but only counts healthcare exchanges and employer-based coverage. Having adults up to age 26 on parental healthcare plans has lowered some enrollment numbers, as well as purchases on the exchanges, since this population tends to be healthier. Ungar goes on to explain that the drop is more significant in those states that expanded Medicaid (Ungar, 2015). Those that did not have insurance?  Well, let us say that the penalty is “$95, or 1% of income above a certain threshold (roughly $20,000 for a couple” (Luhby, 2015). Those that received subsidies must calculate their actual income. If they underestimated their income, their tax returns will be considerably smaller as the IRS levies its taxes. According to Luhby, “H&R Block projects 3.4 million taxpayers will have to pay back part of their premiums” (Luhby, 2015). Obviously, those who overestimated will get a larger refund, and some may see no change. Underestimating income could persuade many not to re-enroll, incurring a penalty of about $975, versus paying premiums of almost $11,000. The government did not advertise the tax penalties for receiving subsidies, which millions of Americans received. The subsidies were reconciled through the tax system, which was complex and unpopular. According to Gorman, more than half of the enrollees underestimated their income, leading them to make restitution to the IRS.

The 132 S.CT at 2580 (King v. Burwell) provides an unaffordability exemption that “excuses low income individuals for whom the annual cost of health coverage exceeds eight percent of their projected household income. Individuals must purchase health care coverage by an exchange, employer-based coverage, Medicaid or Medicare or pay a penalty. The IRS put into place the tax credit availability to qualifying individuals that have health care coverage. In King v. Burwell, the decision to allow for subsidies to continue to get the care that they need. As a critical component in reducing healthcare disparities, subsidies allow lower-income participants to afford disproportionately expensive healthcare costs. King v. Burwell challenged the legality of the government subsidies, because 30 states did not expand the Medicaid and host their own exchanges. Because about 90% of the uninsured live in states not covered by exchanges, subsidies obtained through the federal exchanges offered affordable insurance. These states have the greatest healthcare disparities and adverse health outcomes.

The Supreme Court’s ruling to allow states to opt out of the exchanges impedes the impact of the Affordable Care Act, leaving millions of Americans at a disadvantage. The disparities differ from state to state, depending on the Medicaid expansion. As the Supreme Court upholds the Affordable Care Act, the shortage of doctors has now become the focus of the Association of American Medical Colleges. The AAMC estimates that the “United States faces a shortage of 46,000-90,000 doctors by 2025 … because doctor training takes between five and ten years, we must act  now if we are going to avoid serious physician shortages in the future” (AAMC, 2015).

Over the last few years, the ACA has changed how doctors and patients interact. When the ACA was enacted, physicians were not burdened with formerly problematic administrative restrictions. Teaching hospitals, which are beneficial in helping with the over flow of patients, according to the AAMC provide “nearly 40 percent of hospital-based charity care” (AAMC, 2012). Now that millions of Americans have insurance, they may get treatment before showing up in the ER. But even the insured may not get the care they need. With nearly 32 million more people now insured, a serious shortage of medical staff and physicians has materialized, worsened by the aging population. According to the AAMC, “every day for the next 19 years, 10,000 baby boomers will turn 65” (AAMC, 2012). The shortage of doctors includes specialists, and the shortages are already becoming acute. One problem lies in Residency training programs, the number of which needs to increase to take on newly insured patients.

Congress must find a way to make the medical community meet the needs of the insured.  Providing insurance implies access health care, a current need that cannot be met because of the shortage of physicians. With the inception of ACA, patients flooded to doctors’ offices, straining an already burdened healthcare system. Given the time to train new doctors, nurses and other health professionals, meeting shortages before, and especially after, Affordable Care Act has worsened. Individuals now face longer wait times, doctors have to comply with prior authorizations and DME (durable medical equipment) forms, and so on.  These issues will increase the frustration with the healthcare system. Healthcare shortages that have been ongoing for decades are unlikely to ease up soon. Patients waiting for insurance cards and the promise of free or reduced medical care are feeling the pinch. According to Anderson, by 2030, 72 million Americans will be 65 or older … health professionals are highly concentrated in urban locations” (2014). Even using Physician Assistants (PA) or Nurse Practitioners (NP) will not significantly ease this shortage. A higher number of patients as well as staff shortages means long shifts and burnouts among the nursing staff. Heavy workloads increase health disparities, and excessive work creates high turnover rates. With the lack of compensation or lower compensation, the workload problem will not improve. Even worse, ACA requires far more paperwork, and support staff hired for administration grew faster than the number of nurses and doctors. ACA regulations have even forced many hospitals to lay off non-medical personnel as a means to control costs.  Correspondingly, new pay-for-performance requirements will affect the way people are hired.  The reduction in reimbursements will eventually require some hospital sections to close down and perhaps even entire hospitals. These unforeseen outcomes will generate increased health disparities not just for minorities, but for all patients, insure or not.

Healthcare workers also face potential discrimination, as the ACA does not protect healthcare workers’ Right of Conscience, a policy of safeguarding workers’ rights to refuse to participate in a treatment that violates their religious or cultural beliefs. A birth-control mandate or similar faith-based conviction would be protected by Right of Conscience. Americans should be worried about the implications of this infringement. Workers may soon be forced to pick between their jobs or their moral convictions.

As the ACA is implemented, a major overhaul of the healthcare system would be needed, and consolidating healthcare systems may represent a successful approach. Many hospitals belong to a system, and very few remain independent of corporate influence. With the increasing costs caused by regulations, many physicians are closing private practices and joining larger physician groups and hospital systems to avoid paying substantially more overhead. The closure and re-location of physicians’ offices affect patient care, and health disparities can increase for those without transportation. In many parts of the country, physicians are refusing to accept some insurance, asking for cash payment in advance of service. While small, the number of practices requiring cash payments is rising.  Overhead costs can be reduced by eliminating patient billing and insurance claims, and practices can set their own prices without regard for negotiated reimbursements.

In order to raise the quality of healthcare, the system is moving from a fee-for-service to a pay-for-performance model based on measured healthcare outcomes. If a provider improved the quality of healthcare by improving patient outcomes, money would be paid for successful services. However, shortages in nursing staff and the higher patient-to-nurse ratio cause morbidity and mortality to rise with an increased number of patients. With 34 million newly insured patients, this scenario likely means reduced care. Many hospitals are already seeing increased workloads resulting in unsafe conditions. Many healthcare employees work in economically depressed areas in which poverty rates affect payments. The lack of medical professionals exacerbates insufficient payments resulting from fewer patients being seen.

Access to Health Care

Greater access to healthcare and the decrease in healthcare disparities underlie the ACA mission. A fear remains that higher demand for services may create a bottleneck in healthcare when enrollees on the exchanges encounter diminished services or the disappearance of currently existing networks. Many physicians will not participate in the exchanges, as here in Tarrant County, Texas, where even the county hospital rejects legitimate coverage. Reimbursement rates for the ACA exchanges is significantly lower than the employer-based commercial insurance. The lack of physicians contracting with the exchanges and of available services for nearly 34 million newly insured has already created a bottleneck of services and diminished the availability of care and access to quality care. Lower fees affect everyone, not just minorities. Furthermore, worker shortages continue to inhibit access to care and intensifies healthcare disparities. Wait times for new patients have increased. Half of primary care physicians are not accepting new patients, and those accepting them are reluctant to admit those with insurance bought on exchanges. Many hospitals and physician offices require high deductibles and co-pays to be remitted in advance of care, a demand limiting access to care and ultimately defeating the stated mission of the ACA. The denial of essential treatment for patients and the long waits they endure represent de facto healthcare rationing.

What Does Reform Mean for Minority Health?

In the past the lack of insurance was a huge barrier to eliminating healthcare disparities, but disparities continue even with the inception of the AC. ACA funding for thousands of new healthcare clinics only confronts part of the problem, since the all disparities cannot be dealt with by any single solution. Disparities not only result from a lack of insurance but also from a shortage of healthcare providers representing the communities they serve. For a minority community in particular, providers must understand and engage all the issues related to noncompliance or failure to keep a scheduled appointment. Errickson et al. explains that healthcare disparities are not necessarily related to healthcare but rather to issues unlikely to cease with healthcare reform (Errickson, Alvarez, Forquera, Whitehead, Fleg, Hawkins, Browne, Newsom & Schoenbach, 2011). For example, according to the Errickson et al. study, when violence and high-risk behaviors remove young men from communities, it is more difficult to have strong families due to the absent parent and the socioeconomic reality of households led by a single female. Reduced male partners leads to disparities in stable housing, stable relationships, poverty, nutrition, medical care and other related factors that make disparities more common (Errickson et al. 2015). Without strong families, health communities are almost impossible to achieve. Prisons, for example, tend to be socialization grounds for many minority men. This socialization, coupled with low literacy rates or mental health complications, can encourage young men to become criminals. Upon release, they can have a range of diseases leaving them in far worse condition than before incarceration. They return to their families and passing on these diseases to partners and children, thereby increasing healthcare disparities. Errickson et al. suggests that community-based help may ameliorate healthcare disparities and maintain strong and healthy communities.

After social issues, the biggest hurdle in overcoming healthcare disparities is financial.  In the wake of the ACA, the healthcare system addressed financial issues by enabling subscribers to qualify for subsidies. However, this approach did not consider the whole picture, programmatically by counting household income and not assets. The exchanges, which determine eligibility, derive financial information and determine enrollments from prior year’s tax returns. So if an individual is eligible for a $600 plan and has a subsidy of $400.00, his or her cost is $200.00; the government issues a check to the insurer for the $400.00. But if an individual underestimates his income, he must repay the government in the form of tax interceptions. It has been suggested that those making over 400% of the poverty level should shop for insurance outside of the exchanges, since a family of four may making only $195 above the subsidy level (401% of the poverty level) ends up paying almost $1600 more annually for the same plan as a family at 400% of poverty level or lower. Several sources suggest that limiting income is the best strategy to qualify for subsidies.  However, it may back fire when income is reported for the year on income tax.  Income tax is the actual amount of income made, not just an estimate.  There have also been several undercover videos and reports about how agents of the system encourage people to lie about their income which causes people to lose their tax refunds in repayment to an already broke government.  The subsidies were a big part of the average American being able to afford monthly payments to the insurance companies.  This coupled with the high deductibles, the average American is finding out that the Affordable Care Act is not so affordable.  This leaves people in a lurch when it comes to deductibles and premiums.  With a failing economy and high cost of mandated health care, this is a recipe for a disaster of catastrophic proportions.

Chapter 4


  1. Projected numbers

Since the inception of the Affordable Care Act, there has been little relief to those that that truly cannot afford the cost of health care.  These are the people that make too much for the Medicaid expansion but do not make enough money to afford the rest of the health care.  Approximately “16.4 million uninsured gained health insurance under the Affordable Care Act for a 35% reduction in uninsured as of March 2015” (, 2015).  The numbers projected include Medicaid, Marketplace, and CHIP data.  The report states that the “true uninsured rate is, for anyone, an educated guess at best” (, 2015).  The accurate count of numbers is a true estimate of who is currently uninsured.  In retrospect, if the prior statement was true, then the number of insured could be exaggerated as well.  The Affordable Care Act was supposed to be sustained by the young and healthy.  This would have been a possible scenario, but part of the law allowed for young adults aged 19-26 to stay on their parents insurance.  This blow might have upset the balance of the ACA.

Millions of people enrolled in employer-based health care mas mandated by the ACA.  This also lowered the number of people in the pool to help fund the older, sick Americans.  The actual numbers are for enrollment in the marketplace, Medicaid and CHIP roles.  This does not in any way take into account the privately insured people through employment.  So, the numbers of uninsured are inaccurate.  The rate rose in 2013, due to many people losing their employer-based plans due to the mandates of basic health coverage.  According to, the “more accurate uninsured rate pre-ACA was 15%…reports a rate of 12.3% currently” (, 2015).

Table 6 shows quarterly estimates of the uninsured rates.  As you can see, in Q1 2012-Q3 2013, the rate started at 20.3%.  The projected number as of Q1 2015, is now 13.2%.  The reported coverage base line is 14,100,000.  This number is a bit hard to comprehend as the number of actual uninsured was estimated, so there is no real tangible number to compare it to.  People will not report whether or not they have insurance due to the tax penalty that is now imposed on citizens only.  This number does not include illegals that are undocumented as they are exempt not only from the health care coverage mandate, but the tax penalty as well.

There is a greater decline of uninsured African-Americans and Latinos then Whites.  The biggest drop was that of the African-American community.  Table 7 shows the baseline uninsured rates across the measured time frames.  Each shows a start rate of over 14%.  The biggest report of uninsured to start is the Latinos.  All reports have lead us believe that the highest uninsured rate was in the African-Americans.  Table 8 shows the baseline of uninsured by poverty level.  The largest group of decline was in the 139%-400% of the federal poverty level.  This seems to be the biggest group to where most people are uninsured.  The Medicaid expansion covers those under the 138% poverty level, but not in all states.  This would be limited to those states that did not opt out.  The largest group of uninsured seem to be the lower middle class to upper middle class people.  This group also is the group at present that seems to be funding the brunt of the Affordable Care Act with the increased federal tax regulations.


Having health insurance indeed does reduce the racial and ethnic disparities in key health outcome measures and affordability, however, Hispanics are less likely than Caucasian or African-Americans to have a usual source of primary health care.  The biggest disparity until now was reported in the African-American community.  However, research into this topic with several sources citing that Hispanics are now the biggest uninsured.  This may be taking into account the flood of illegal aliens from Mexico and other Latin American countries.  This study does not specifically state if this includes children.  That being said, insurance alone is not likely to reduce the differences in access across all of the racial group spectrum.

Closing the gap with the remaining uninsured may be more difficult in that the ACA needs to make sure that individuals and families are protected against high deductibles and co-pays.  The disparities continue to grow especially in those 22 states that have opted out of Medicaid expansion.  This may be likely to continue as the mandate rules get stricter.  This may be further undermined by legal challenges that continue to succeed and change the face of the large health care bill.  Due to the lack of education, income and other issues, African-Americans and Hispanics are disproportionately more likely than their Caucasian counterparts to be uninsured.  This group is also more likely to go without care due to the high cost of health care.  Although the insurance mandate has promised access to care have increase the expectations of being treated.  This, however, is not the case.  The insurances are available but the access to care has not changed.

Recommendations for further study and corrective action

The recommendations for further study in this new endeavor are enormous.  There needs to be research done on the actual access to care not that the ACA has opened the floodgates to primary care.  The insurance availability does not grant access to adequate and equal health care for all.  This was the intended action but the resulting disaster has made a bigger mess of the health care system then it was when the ACA started.

Corrective action could be taken as follows:

  • The health care exchanges should be limited to three types of insurance plus Medicaid, Medicare and CHIP. This would eliminate the need for the hundreds of exchanges that have popped up to help Americans get health care.  The exchanges should be Basic, Moderate, and High.  Obviously paying more in premiums with the moderate and high plans.  Lowering the prices of the premiums and deductibles would also help.  This could eventually negate the need for subsidies paid for by the government and allow people to keep more of their taxes.
  • Training of medical professionals should be more condensed rather than 10 years for a physician. These programs could be combined to train physicians in half the time.
  • Nursing personnel can be trained in a vocational training situation. This would be true for RN and LPN types of positions.  The current regimen for an RN is 3 years.  Unnecessary courses could be eliminated and more hands on training could be done to speed up the process of helping to fill the shortfall.  The states could also allow for LPN’s to challenge the RN state exams with 15 years of expertise.  This could help in the nursing shortages.  The government could also eliminate the paybacks of student loans in exchange for 5 years of service.
  • The reconstruction of NP and PA positions could be done to help alleviate the shortages in the provider arena. There truly only needs to be one staff physician to oversee the floor.  The floor could them be filled with NPs and PAs to help alleviate the shortages.
  • Explain to people getting insurance that just because they have insurance does not mean they will be seen. This is a big misconception among those that are newly insured
  • Conclusion

Although the ACA has opened many doors for people that previously would not have access to health care, it has created a multitude of problems.  These problems range from not enough providers to the actual cost of premiums and co-pays.  Although the ACA was a step in the right direction, the forethought and planning was poor.  The execution was also poor.  The health care website did not work for many to sign up to begin with.  The marketplace signups also did not explain that if premiums were not kept paid, then the person would lose their insurance.  This sometimes would leave them repaying not only subsidies but the tax penalty on top of it.

The lack of providers and medical support staff is staggering.  The lack of providers prior to the ACA inception being at around 40,000 is only going to make it worse by opening flood gates to newly insured and overloading already packed doctor’s offices.  Physicians are reluctant to work with the ACA insurances and many hospitals, to include the county hospitals, will not accept the ACA insurances.  This is true even if the ACA states that a certain doctor accepts the insurance, the facility may not.  This creates a bottleneck with care and puts excessive bills on patients because of the deductibles, patients are expected to pay this prior to being seen.  Co-pays and deductibles are normally collected at the time of service.  The old days of billing later have gone by the wayside and patients are expected to pay up front.  This also creates a financial burden and affects those most financially vulnerable and cannot afford health care.  This may be one of the reasons for the health disparity.

Bridging the gap of racial and ethnic disparities may need to be carefully studied and applied.  The true nature of the disparity will never be fully resolved as long as we are a capitalist nation.  This would only work at present if we become socialist or communist.  Since Obama refused to model the health care bill after other countries that have universal health care, he has created a mess that may never be fixed in its entirety.  The recommendation to follow would be to follow Finland’s universal health care, as many of their people are deemed to be the happies and their infant mortality rate is the lowest in the world at around 2.1%.  Until there is true equality and not a shortage of health professionals in the system, the disparities are likely to continue to exist and even get worse.  Health care should be viewed as a right and not a privilege of the rich.  Health care has evolved but needs to continue to evolve to meet the needs of the citizens of America rather than the agendas of the politicians we elect.


American College of Physicians (ACP). (2010). Racial and ethnic disparities in health care,                       updated 2010. Retrieved from

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 Appendices: Tables (Sorry Tables are not loading-please see websites)

Table 1


US Department of Health & Human Services (DHHS). (2015). National healthcare quality & disparities reports. Accessing: Introduction and methods. Retrieved from

Table 2


US Department of Health & Human Services (DHHS). (2015). National healthcare quality & disparities reports. Accessing: Introduction and methods. Retrieved from

Table 3


US Department of Health & Human Services (DHHS). (2015). National healthcare quality & disparities reports. Accessing: Introduction and methods. Retrieved from

Table 4


US Department of Health & Human Services (DHHS). (2015). National healthcare quality & disparities reports. Accessing: Introduction and methods. Retrieved from

Table 5


US Department of Health & Human Services (DHHS). (2015). National healthcare quality & disparities reports. Accessing: Introduction and methods. Retrieved from

Table 6

Reference: (2015). Obamacare enrollment numbers as of March 2015. Retrieved from

Table 7

Reference: (2015). Obamacare enrollment numbers as of March 2015. Retrieved from

Table 8

Reference: (2015). Obamacare enrollment numbers as of March 2015. Retrieved from

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