Racial and ethnic minority enrollees in Medicaid managed care plans reported worse experiences of care than their white counterparts with identical coverage, a new study in the February issue of Health Affairs indicates.
Few recent studies have singled out disparities within and between Medicaid-managed care plans. To the authors’ knowledge, this is the first study to evaluate the patient experience of care in a multi-state sample of Medicaid managed care enrollees and to compare within-plan and between-plan disparities after the Affordable Care Act.
Based on data from 2014 through 2018 on 242,274 non-elderly Medicaid managed care enrollees in 37 states, researchers delved into racial and ethnic disparities in four experience-of-care measures: access to needed care, access to a personal doctor, timely access to checkup or routine care and timely access to specialty care.
“What we found was that compared to white enrollees, racial and ethnic minority Medicaid managed care enrollees reported significantly worse experiences of care on all four patient experience metrics,” the study’s first author, Kevin H. Nguyen, Ph.D., an investigator at the Brown University School of Public Health in Providence, Rhode Island, told Fierce Healthcare. "Those differences were largely attributable to within-plan disparities.”
The study was part of Health Affair's February issue focused on the intersection of racism and health. “We’re delighted to be part of the special issue on racism and health,” Nguyen said.
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The overall adjusted disparities for Black enrollees ranged between 1.5% and 4.5%, 1.6%–3.9% for Hispanic or Latino enrollees, and 9%–17.4% for Asian American, Native Hawaiian, or other Pacific Islander enrollees.
For all outcomes, the disparities were less in plans with the highest percentages of Hispanic or Latino enrollees, and for some outcomes, there were smaller disparities in plans with the highest percentages of Asian American, Native Hawaiian, or other Pacific Islander enrollees.
“Understanding what is driving these differences can inform interventions,” Nguyen told Fierce Healthcare.
In comparison to within-plan disparities, between-plan disparities were relatively lower across racial and ethnic minority enrollees.
The authors acknowledged that the study had several limitations. A small percentage of respondents did not identify their race or ethnicity or age and thus were excluded. In addition, as a result of limited sample sizes, the authors did not provide estimates in the main analysis for American Indian or Alaska Native enrollees or enrollees reporting other race.
Further limitations revolved around expectations of care, which also may lead to varied responses across racial and ethnic groups and should be factored into the interpretation. Finally, even though some studies have indicated differential patterns of patient experience of care from those with limited English proficiency, the authors could not produce similar estimates of heterogeneity in their data due to the lack of an indicator for preferred language.
Nonetheless, the authors highlighted that “Medicaid managed care plans are uniquely positioned to address racial and ethnic disparities in patient experience of care. Many states use plan contracts as a primary lever to address such disparities in Medicaid.”
Interventions to mitigate racial and ethnic inequities in care experiences include
gathering comprehensive race and ethnicity data, adopting health equity performance metrics, engaging enrollees at the plan level and implementing multi-sectoral initiatives to dismantle structural racism.
Other various strategies at the state level focusing on health disparities include “efforts to improve plans’ cultural competency (for example, identifying preferred languages for communication), enrollee engagement (such as targeted outreach and development of programs to address identified disparities) and provider engagement (for example, promoting culturally and linguistically diverse provider networks).”
The authors acknowledged that existing racial and ethnic inequities in access to care intensified due to the COVID-19 pandemic and the ensuing economic fallout. During this crisis, “rising unemployment and subsequent loss of employer-sponsored coverage have disproportionately affected racial and ethnic minority groups and particularly Black and Hispanic or Latino communities.”
They added that “because these changes have led to accelerated growth in Medicaid managed care enrollment, Medicaid managed care plans will continue to play a critical role in addressing racial and ethnic disparities throughout and after the pandemic.”
Nguyen pointed out that this research is also important because it prioritizes the patient’s voice in identifying disparities in Medicaid. "That’s the broad picture," he said.