Rescinding ACA May Worsen Racial Health Disparities, COVID-19

If the Patient Protection and Affordable Care Act (ACA) protections for pre-existing condition coverage are rescinded, COVID-19 could leave many Americans without health insurance, a disproportionate number of whom are people of color, according to a new Oregon Health & Science University (OHSU) study that draws concern for racial health disparities.

The cross-sectional study published in the Journal of the American Board of Family Medicine analyzed EHR data from OCHIN, a network of 396 community health centers across 14 states. 

The researchers found that a third of over 7,500 patients, a majority of whom were people of color, treated for COVID-19 at community health centers between March and October 2020 did not have a pre-existing condition prior to contracting the virus.

Specifically, the researchers found that non-Hispanic Asian patients, Hispanic patients, and non-Hispanic Black patients treated for COVID-19 were less likely to have pre-existing conditions compared to the entirety of community health center COVID-19 patients studied.

If COVID-19 is considered a pre-existing condition and the ACA protections regarding pre-existing conditions are taken away, those who rely on public insurance, a disproportionate amount of whom are people of color, could be forced to pay out-of-pocket for short-term and long-term effects of COVID-19.

Therefore, if the ACA’s protection of pre-existing condition coverage is eliminated, health disparities could be exacerbated, explained the study's lead author, Nathalie Huguet, PhD, assistant professor of family medicine at the OHSU School of Medicine.

"Our findings highlight that minority patients would be most impacted if the ACA mandate differentiating coverage based on pre-existing conditions was altered or revoked and COVID-19 was designated a pre-existing condition,” the study authors wrote.

This study comes as the Supreme Court considers another legal challenge to the ACA which was signed into law by then-President Barack Obama in 2010. The court heard arguments in the November 2020 California v. Texas case and is expected to rule sometime in this year.

President Joe Biden signed an executive order on January 28 that urged federal agencies to re-examine policies that weaken protections for Americans with pre-existing conditions, including COVID-19 complications.

Prior to COVID-19, 27 percent of Black individuals and 29 percent of Hispanic individuals were enrolled in Medicaid, almost three times the number of White Medicaid beneficiaries (11 percent). If the additional features of the ACA are dismantled, such as Medicaid expansion, racial health disparities could grow more, the study noted.

“These reductions will likely be worse for minority patients, especially those suffering from long-term COVID-19 effects,” the authors wrote.

Medicaid expansion from 2013 to 2016, the first few years that the ACA was in effect, lowered uninsurance rates for nonelderly Hispanic and Black individuals by almost ten percentage points each—from 30 percent to 19 percent for Hispanic individuals and from 19 percent to 11 percent for Black individuals, Avalere researchers shared.

What’s more, Black, Asian, and Hispanic residents experienced higher unemployment rates compared to the overall unemployment rate in 2020, which places this group at an additional risk for losing health coverage through employer-sponsored plans, the study noted.

In fact, a 2020 report from Avalere found that the percentage of health insurance loss due to COVID-19 was approximately double for Asian, Black, and Hispanic individuals compared to White individuals.

“While any single policy change is unlikely to fully eliminate the longstanding inequities in healthcare, considering racial disparities in coverage in policy discussions may mitigate these challenges and facilitate increased access to care,” the Avalare researchers concluded.