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The Health 202: Obamacare improved (but didn't fix) the uninsured gap between black and white Americans

with Paulina Firozi


There are deep and abiding health disparities between white and minority Americans. But in one small but significant way, Obamacare flipped them.

Black Americans living in states that expanded their Medicaid programs are now more likely to be insured compared with white Americans living in states that shunned Medicaid expansion, according to a study released this morning by the Commonwealth Fund.

This wasn’t the case before President Barack Obama signed the Affordable Care Act a decade ago. Uninsured rates have long been much higher among African Americans than whites, regardless of where they lived.

But the ACA and a subsequent Supreme Court decision allowing states to reject its expansion of Medicaid to those earning up to 133 percent of the federal poverty level means states now basically fall into two buckets. The pro-expansion states have seen more improvements in health and reductions in racial disparities than the anti-expansion states.

Just look at the 31 states that had expanded Medicaid by 2018. In that year, 10.1 percent of their black residents were uninsured. That’s several points lower than the 12.3 percent uninsured rate among whites living in non-expansion states.

But in 2013, the year before the ACA’s major provisions went into place, the black uninsured rate was higher across the board when compared with white uninsured rates.

Now, a black person living in Colorado, which expanded Medicaid, is more likely to be covered by a health insurance plan than a white person in Texas, which rejected expansion. This comparison doesn’t hold true for every single state — in Kansas, for example, the white uninsured rate has dropped below 10 percent — but it does underscore Obamacare’s outsize gains for minorities.

Those findings are detailed in the new Commonwealth study, which examined whether Obamacare has helped minorities buy health coverage and access care at rates more equal to whites. They found the biggest improvements in Medicaid expansion states, but there were positive trends throughout the country.

Consider these trends between 2013 and 2018. The country’s overall uninsured rate fell from 20.4 percent to 12.4 percent, but for blacks it dropped from 24.4 percent to 14.4 percent. Meanwhile, the gap between black and white uninsured rates declined 4.1 percentage points.

Progress on expanding health coverage has recently stalled and may even be reversing. But if more states expand Medicaid — as Kansas’s Democratic governor and a top Republican lawmaker proposed last week — minorities could see further gains, said Sara Collins, a vice president at Commonwealth and a co-author of the study.

But Collins also stressed that black Americans can face additional obstacles to getting good care, even after getting insurance.

“Because of bias in the delivery system, they face an even greater hurdle in making that leap to higher-quality care and good outcomes,” Collins said.

Now that the ACA has been in place for six years, other researchers have had time to examine the effects of expanding Medicaid to a larger swath of the public. They’re finding a range of positive outcomes, even as Republican policymakers have complained the program is too costly to run.

Harvard and Vanderbilt researchers recently found that adults living in south states with Medicaid expansion experienced lower rates of physical and mental health decline.

And my Washington Post colleague Lenny Bernstein reported last week that Medicaid expansion may have saved as many as 8,132 people from fatal opioid overdoses, virtually all involving heroin and fentanyl, according to another new study. The research, published in JAMA Network Open, found an association between the decline in overdose deaths in the 32 states and the District of Columbia that had expanded Medicaid at the time of the study.

“The researchers concluded that additional access to drug-abuse treatment was linked to a 6 percent lower overdose rate for states that allowed more people to enroll in Medicaid than in states that did not,” Lenny wrote.

— There's a vigorous debate going on in the Democratic presidential primary about how to bridge the uninsured gap left by Obamacare. More African American voters who identify as Democrats support a public option to compete with private plans over a single, government-sponsored plan, according to a national Washingon Post-Ipsos poll of black Americans conducted Jan. 2-8.


AHH: America’s Health Insurance Plans, the powerful insurers trade group, filed an amicus brief calling on the Supreme Court to take up a case that seeks to overturn the Affordable Care Act, siding with the Democratic-led states defending the law.

“The district court’s original decision to invalidate the entire ACA was misguided and wrong,” Matt Eyles, AHIP's president and chief executive, said in a statement. “We urge the Supreme Court to grant certiorari and remove the overhanging legal uncertainty that undermines the stability of coverage for nearly 300 million Americans, and that inhibits greater and faster progress to improve coverage and care for everyone.”

In the brief, AHIP argues sending the case back to the lower court “casts a long shadow of uncertainty over ACA-based investments and denies health insurance providers, states, individuals, and other stakeholders of much-needed clarity. Invalidation of the ACA would wreak havoc on the health care system.”

In a separate brief, the American Hospital Association and other hospital groups also argued against delaying the case. “Left without clarity as to whether the entire ACA will be wiped off the books, hospitals and healthcare providers will have to spend the years it will take for this case to wind through the district court, back up to the court of appeals, and again to this Court, questioning whether they should invest in initiatives that rely on the ACA’s provisions,” the groups write in the brief. “The Court should step in—now—to avoid that unnecessary and untenable result."

OOF: Democratic presidential hopeful Mike Bloomberg says he would ban the sales of all flavored e-cigarette products if elected president. 

He unveiled a plan to direct the Food and Drug Administration to accelerate its review of e-cigarettes, and to push to reduce the amount of nicotine to “non-addictive levels” in traditional cigarettes, as well as in e-cigarettes and other tobacco products. The plan would also push health insurers to cover counseling and cessation treatments to make it easier for smokers to quit. 

His campaign cited Trump’s move to backtrack from a promised ban on all such flavored products. 

“President Trump has mastered the art of the broken promise — on issues from health care to gun safety — and e-cigarettes have been no exception. Trump promised to remove flavored e-cigarettes from the market back in September, but instead he has bent over backwards to protect the tobacco lobby’s profits,” Bloomberg said in a statement. “We need a leader who will stand up to the industry and protect our children’s health.” 

OUCH: Doctors ages 40 to 54 are seeing higher burnout rates than their younger and older colleagues, the Wall Street Journal’s Brianna Abbott reports. 

A recent survey of 15,000 physicians found nearly half of Generation X physicians said they felt burned out, compared with 39 percent of baby boomer doctors, ages 55 to 73, and 38 percent of millennial physicians, ages 25 to 39. These doctors are pointing to bureaucratic tasks such as charting and paperwork and the number of hours at work as top reasons fueling burnout.

“Roughly half of all the doctors surveyed also said that they would be willing to take a substantial pay cut to achieve a better work-life balance,” Brianna adds.

“Burnout is often described as long-term, unresolved, work-related stress that leads to cynicism, detachment, exhaustion and lack of a sense of personal accomplishment,” she writes. “… Burnout is particularly pervasive among health-care workers, such as physicians or nurses, researchers say. Risk for burnout among physicians is significantly greater than that of general U.S. working adults, and physicians also report being less satisfied with their work-life balance, according to a 2019 study published in Mayo Clinic Proceedings.” 


— Rep. Ann Kirkpatrick (D-Ariz.) announced she would take a leave from Congress to seek treatment for alcohol dependence. 

“I am finally seeking this help after struggling to do so in the past, and I am ready to admit that I, like countless other Americans, suffer from this disease,” Kirkpatrick wrote in a statement. “Hard work and determination — which have brought me success in life — have not been enough to win this battle.”

“The Arizona Democrat said in a statement that she would begin treatment next week after suffering a ‘serious’ fall that was linked to drinking,” Politico’s Sarah Ferris reports. “… Kirkpatrick, who missed a historic floor vote on Wednesday to transit impeachment articles to the Senate, did not say how much time she is expected to be away from Washington. But she made clear she intended to keep her seat.”

— And here are a few more good reads:


Health care data-sharing rules touch off intense lobbying fight (Politico )

Lawmakers press Trump officials to change federal marijuana rules (The Hill )


U.S. Targets Drug Pricing, No-Poach Deals for Antitrust Action in 2020 (Wall Street Journal )

FDA Drug Approvals Require Less Rigorous Evidence, Study Finds (Bloomberg)


Is it safe to eat romaine lettuce from Salinas again? CDC says E. coli scare 'appears to be over' (USA Today)


Science and engineering report shows continued loss of U.S. dominance (Ben Guarino)



  • The Council for Affordable Health Coverage holds its 3rd annual Price of Good Health Summit. 


House Speaker Nancy Pelosi (D-Calif.) on Jan. 15 announced seven House members to serve as impeachment managers in the Senate impeachment trial. (Video: Reuters)