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Medicaid expansion hasn’t lessened race-based care disparities, study finds


Black enrollees receive lower spending, have fewer primary care visits than whites

Expanding access to Medicaid was supposed to reduce race-based disparities in health care among low-income Americans. But results of a recent study suggest that goal has not been met, especially when it comes to primary care.

The study looks at Medicaid services use among nearly two million Black and white Medicaid enrollees in three states in 2016. It found that after adjusting for factors such as age, gender, health status and usual source of care, average annual spending on adult Black enrollees was $317, or 6% less than for whites. Among children (18 years and under) the difference was $94, or 14%.

The authors found similar differences in use of primary care services. After adjusting for demographic characteristics and health status, Black adults had 17.3, or 4%, fewer annual primary care visits per 100 enrollees compared to whites. Among children the gaps were larger, with Black children having 111.8, or 28% fewer primary care visits per 100 enrollees per year than whites.

The same patterns emerged for use of prescription drugs. After adjusting for demographic characteristics and health status, adult Black enrollees filled 16% fewer prescriptions per 100 enrollees annually than White adults. Black enrollees also were less likely to fill prescriptions for asthma medication, diabetes medication, and statins. However, adult Black enrollees filled more prescriptions for antihypertensives than white enrollees.

Black children enrolled in Medicaid also filled fewer prescription drugs compared with whites, and those with asthma or diabetes filled fewer prescriptions for managing those conditions.

The only medical service included in the study used more by Black enrollees than whites was the emergency department, where Black adults had 14% more visits, and children 8% more than did whites.

The study also revealed that despite Black enrollees lower use of medical services and less primary care, they had higher rates of HEDIS preventive care screenings after adjusting for demographic characteristics and health status. For example, compared with adult White enrollees, adult Black enrollees were 17% more likely to receive a breast cancer screening, 21% more likely to receive a cervical cancer screening, and 29% more likely to get screened for chlamydia. Rates of HEDIS preventive care measures were also higher among Black children than White children enrolled in Medicaid.

The authors say that despite the greater access to care made possible by Medicaid expansion in most states, “the results of this study suggest that coverage alone does not eliminate racial disparities.” They note that Black and white enrollees initiated care at similar rates, which implies that race-based differences in care utilization tended to emerge after care began.

That finding, in turn, “may be consistent with evidence that even when access barriers are overcome, Black patients receive worse care and experience the health care system as a result of medical racism…and differences in how physicians perceive them.”

The study, “Disparities in Health Care Spending and Utilization Among Black and White Medicaid Enrollees,” was published online June 10 in JAMA Health Forum.

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