A new study shows that in states with Medicaid expansion, racial disparities have shrunk for access to care. But NC lags and DHHS is trying to do something about it.

By Yen Duong

Two documents from the past month reflect the state of racial disparities in access to health care in North Carolina. A new report from the Commonwealth Fund, a health care policy nonprofit, showed that racial disparities in access to health care across the country have shrunk since the Affordable Care Act was implemented in 2014.

But that reduction in disparities is unevenly distributed.

“I think this is one of the few studies that actually looked at differences or improvements by race,” said Sara Collins, one of the authors of the study. “What is striking is the degree to which those differences have narrowed in coverage and access to health care.”

The same week, North Carolina’s Department of Health and Human Services and the North Carolina Institute of Medicine released Healthy North Carolina 2030, the result of a year of meetings with dozens of public health stakeholders across the state. The document lays out the state of public health today, goals for 2030 and metrics to measure progress toward those goals.

“The good news is that we have the lowest infant mortality rate ever in recorded history, which is amazing,” said state health director Dr. Elizabeth Tilson. “However, if you just look a little bit under that metric, you will see, though, our disparity ratio hasn’t changed, and still our black babies are dying at about two and a half times the rate of our white babies.”

Measuring access to care across race and ethnicity

The Commonwealth Fund report used three statistics to measure access to care:

Insurance coverage for adults under 65

Whether people skipped a doctor’s visit in the last year due to cost

Whether people had someone they considered a regular source of care

Nationally, from 2013 to today, the gap between uninsured rates narrowed from 9.9 to 5.8 percentage points between black and white populations, and from 25.7 to 16.3 percentage points between Hispanic and white populations.

However, that difference was mostly limited to states which have expanded Medicaid. In fact, a black person in an expansion state was more likely to have access to care than a white person in a non-expansion state, the Commonwealth report found. Though only 15 states, primarily in the Southeast, have not expanded Medicaid, Hispanics and black adults disproportionately reside in them: 46 percent of working-age black adults and 36 percent of working-age Hispanic adults.

The report also had a focus comparison on Louisiana and Georgia, two states which pre-ACA both had rates of uninsurance hovering at around 40 percent for both blacks and whites earning less than 200 percent of the federal poverty level. After Louisiana expanded Medicaid in 2016, the rate of uninsured dropped for both low-income black and white adults down to around 15 percent. The racial gap in insurance coverage dropped from 4.3 percentage points to 2.5 percentage points.

During the same period in Georgia, the rates of uninsurance for low-income adults dropped down to 33.1 percent for whites and 30.4 percent for blacks.

In North Carolina, Tilson said that the uninsurance gap between blacks and whites has remained steady, while the gap between Hispanics and whites has actually increased.

“I think what we’re seeing in North Carolina is what [we’re] seeing across the country: the ACA, without expansion, really tempers the impact on our minority populations,” Tilson said.

Why the gap has expanded in the past year

Though the national disparity gap narrowed since 2013, both gaps showed a slight increase since 2016, per the Commonwealth Fund. Collins suggested that the uptick in people lacking access to care was due to removing the individual mandate penalty, lack of federal funds for outreach during the ACA plan enrollment period, and the rise of non-ACA-compliant short term plans.

“I think [other reasons are] also just Congressional inaction on improving certain aspects of the law, such as enhancing subsidies [and] addressing at a federal level this Medicaid coverage gap,” Collins said. “And then finally, I think, most importantly, because of the numbers we’re seeing on Hispanics, that undocumented immigrants aren’t eligible for subsidized coverage or Medicaid.”

Tilson agreed that recent politics may have an impact on whether people seek coverage, especially the discussions around the “public charge rule”, which would penalize immigrants who come to the U.S. and then apply for government supports such as Medicaid or SNAP.

“It’s hard to know specifically, looking from the numbers,” Tilson said. “There has been a lot of conversation about ‘public charge,’ it may be people are fearful of accessing the public benefits that they’re eligible for.”

Moving from access to health care to Healthy North Carolina

Though the Commonwealth report focused just on three metrics for measuring access to health care, access is a “necessary condition, but it is not sufficient” to ensure health, said Collins.

“When you look at people who are racial minorities, because of long-standing issues of racial bias and implicit bias in the delivery system, they face an even greater hurdle in making that leap from coverage to a high quality care and health and good health outcomes,” Collins said.

In the North Carolina report, DHHS and stakeholders were concerned not just about access to insurance, but also about access to high quality care. Tilson said that disparities are one of their major concerns, and the study group wrestled with how to address them by tackling factors outside health care including food, housing, transportation and toxic stress.



The 65-page public report delves deeply into 21 health indicators, from poverty, adverse childhood experiences and incarceration rates to housing, drug overdose rates and life expectancy rates. While it took about a year to produce Healthy North Carolina with 10 years of goals, Tilson said the next year will bring about state and local five-year Health Improvement Plans, which will also require community input.

Expanding Medicaid would be a huge step in ensuring healthier North Carolinians, Tilson argued. For instance, expansion states have halved their infant mortality rates, on top of the disparity gaps highlighted by the Commonwealth report.

“When we see these health disparities, we know we are not improving the health and well-being of all North Carolinians, and that is our job,” Tilson said. “We as a society do not benefit from disparities. Economically, from a workforce perspective, in productivity, we all benefit when everybody is improving. [Addressing disparities] is our job and it’s the right thing to do for the state and our country.”