How the Affordable Care Act Can Advance Health Equity in Times of National Crisis

Atyya Chaudhry, MPP, AMCHP Senior Program Manager, Health Systems Transformation, Region VII Liaison

The COVID-19 pandemic has exposed and exacerbated longstanding racial and ethnic disparities and health care disparities that continue to persist in the United States. This includes higher uninsured rates among people of color. Despite this inequity, implementation of the Affordable Care Act (ACA) has led to significant reductions in disparities in accessing health care. ACA provisions and the recent Medicaid expansion has facilitated some notable achievements:

• The gap between Black and White adult uninsured rates dropped 4.1 percent, and the gap between Hispanic and White uninsured rates fell 9.4 percent.  
• Medicaid expansion, which now has been adopted by 39 states, is linked to decreased disparities in measures of maternal and infant health for Black and Hispanic communities.
• Black and Hispanic adults experienced reduced financial barriers to accessing health care, and more reported increases in accessing the usual sources of care.
• The uninsurance rate among postpartum women fell by 41 percent overall; specifically, for postpartum women in Medicaid expansion states, the uninsurance rate fell by 56 percent.
• The uninsurance rate among children fell by 2.9 percent.

In 2016, some ACA-related improvements began to regress. This is because unfavorable policy changes subsequently led to a drop in levels of national coverage and a dilution in some consumer protections. The economic fallout of the pandemic amplifies the importance of the ACA and Medicaid.  

Medicaid is responding to the persistent racial and ethnic disparities now aggravated by the pandemic and will continue to be essential in its role as the nation’s first responder for MCH populations. With rising job losses, particularly in Black communities and among women of color, Medicaid plays a critical role in providing health care coverage. In April 2020, the Center for Children and Families at Georgetown University conducted an analysis of Medicaid enrollment. The study showed that 21 states increased their Medicaid enrollment at rates ranging from 0.9 percent to 6.5 percent; children were enrolled in the program at similar rates of increase since the pandemic. Early data from May 2020 indicate that states will continue to increase their Medicaid enrollment. Medicaid recently has exercised flexibilities to enable the program to be a safety-net provider as the public health crisis continues:

• Since a national public health emergency was declared in March 2020, states have been quick to seek temporary Medicaid COVID-19-related waivers and state plan amendments (SPAs) to expand coverage for testing, apply less restrictive income and reporting requirements, and expand presumptive Medicaid eligibility.
• Critically, states gained the ability to ramp up access to and availability of health care services via telehealth. Some states also are using waiver and SPA flexibility to provide temporary housing to beneficiaries.
• Since the Families First Coronavirus Response Act passed in March 2020, states are eligible to receive an increase in their Medicaid Federal Medicaid Assistance Percentage, if they meet certain criteria. One criterion is that states may not disenroll any individual from the Medicaid program who was previously enrolled in Medicaid or gained coverage during the pandemic. This Medicaid disenrollment freeze is especially critical for ensuring that maternal and child health (MCH) populations can maintain their coverage. Pregnant women enrolled in Medicaid are now able to receive health care coverage beyond 60 days postpartum, until the public health emergency declaration expires. 

The Medicaid program’s flexibility and the enhanced accessibility of health care via telehealth services demonstrate how efficiently health care can transform to respond to a national public health crisis. Moreover, significant increases in Medicaid enrollment demonstrate that this program fills a critical health insurance gap as the pandemic continues. As the country continues to grapple with COVID-19, MCH programs should partner with state Medicaid programs to ensure health care services continue to be flexible, responsive, and accessible to MCH populations.