Since the adoption of the Affordable Care Act (ACA), the drop in the uninsured rate has been important yet the disparities between Black and white Americans remain substantial, according to a new paper by Harvard Kennedy School Professor Marcella Alsan.
Alsan, the first serving faculty member to be awarded the MacArthur Fellowship while at vlog, is the Angelopoulos Professor of Public Policy and an applied microeconomist studying health inequality. “My work focuses on two main questions—what are the origins of health inequalities and then what can be done to reduce them,” said Alsan in a recent interview.
Her paper published in the Oxford Review of Economic Policy examines the history of the market-based approach to health care delivery, especially the role of government. Alsan and co-authors, Harvard PhD students Katherine Ianni and Graeme Peterson, also look at the experience of Black Americans with health insurance in American history.
“Racial inequities are embedded not only in the practice of medicine, but also in the design of health insurance and the fragmented United States health care system,” the authors write. “The United States is unique among developed countries in that it predominantly relies on private firms for health insurance coverage through employer-sponsored insurance.”
“Racial inequities are embedded not only in the practice of medicine, but also in the design of health insurance and the fragmented United States health care system.”
Historically, Black individuals have been excluded from the American health care system in two significant ways. The paper notes that amid the Great Depression of the late 1920s, public opinion supported government intervention for health coverage, including free medical care for the poor.
President Franklin D. Roosevelt did not include universal health care in the final version of the Social Security Act of 1935, opening the door for commercial insurers to meet consumer demand through employer-sponsored insurance (ESI).
While enrollment in health insurance rose significantly during the 1940s this access was “anything but equal” since Black workers typically held jobs that lacked these generous benefits.
Additionally, tax policy changed in 1954 exempting ESI contributions from taxable income, creating yet another disparity for Black workers outside of the ESI system.
The U.S. government made progress on these issues in the 21st century, significantly through the expansion of Medicaid and passage of the ACA.
“2010 marked the most recent transformative point in health reform with the passage of the ACA,” the researchers note. “The ACA led to significant gains in access to insurance through Medicaid expansion and a number of market levers including guaranteed issue, premium subsidies, and the individual mandate.”
However, they caution, the ACA was no silver bullet. This was made clear through three epidemics the paper examined which disproportionately affected the Black population: maternal mortality, opioid use disorder, and COVID-19.
“While the system has undergone several changes over the last century, there is still far to go in achieving equitable coverage and access to care for minoritized groups,” the authors note. The cases studies also demonstrate that to fully eliminate racial health disparities requires addressing other sources of inequalities, such as wealth and income.
Addressing the “fragmented” health system in the United States, the authors focus on two critical areas: insurance coverage and quality of care.
“Our work suggests that further health reform focused on achieving universal coverage through a publicly financed system would significantly mitigate racial disparities in access to and utilization of care,” the authors say. “Policies that direct additional resources and support to providers serving high shares of Black patients may be an effective strategy to mitigating disparities.”
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Banner image: A patient with a pre-existing condition that made it impossible to find insurance that would cover her until the Affordable Care Act, is examined by a doctor during a routine checkup at a community health clinic in Miami, Florida. Photo by Joe Raedle/Getty Images