Health Reform's Next Act: A Focus On Achieving Health Equity

Mar 18, 2011

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Brian D. Smedley, Ph.D., is vice president and director of the Joint Center for Political and Economic Studies Health Policy Institute.

When President Barack Obama met with the nation's governors last month and offered to allow states to establish their own plans to reform health care in place of the Patient Protection and Affordable Care Act, he insisted that states meet or exceed the same goals established in the health overhaul to expand insurance coverage, improve the quality of care and contain rapidly escalating healthcare costs.

The president might also insist that states show progress toward eliminating health inequities -- differences in the opportunity to have good health that exist between rich and poor Americans, and whites relative to most non-whites.

These health inequities exist literally from the cradle to the grave, in the form of higher rates of infant mortality; disease and disability; and earlier death for many people of color and the poor relative to whites and higher-income groups.

While a large share of Americans would undoubtedly be saddened by these statistics, few understand how health inequities hurt all of us. They have a tremendous human toll, to be sure. Too many families are robbed of loved ones prematurely or suffer as a result of unnecessary disease or disability. But they also carry a significant economic burden for the nation. A study released by the Joint Center for Political and Economic Studies found that between 2003 and 2006, health and health care inequalities cost the nation $1.24 trillion in health care expenses as well as economic impacts, such as lost wages and productivity.

States have significant power under the federal health law to shape how health care is financed and delivered. For example, many states will set up health insurance exchanges, which, if done right, should help people purchase insurance in an open market; but also spread risk as broadly as possible, ensure adequate consumer input and oversight, and utilize culturally- and linguistically-fluent navigators to connect people to the insurance products they need.

State health agencies can also apply for flexible funding to support state and community efforts to fight obesity, increase HIV testing, reduce tobacco use, and expand mental health and substance abuse programs through the measure's Community Prevention and Public Health Fund. States may also receive Community Transformation Grants, which, if funded by congressional appropriators, can be used to improve neighborhood conditions to promote good health. Many public health experts believe that these provisions of the health law have the greatest potential to help eliminate health inequities because they target resources to strategies that promote good health for large populations, rather than individuals, and are effective in helping people to stay healthy in the first place.

But several states are clamoring for greater flexibility, including creating federal block grant funding for Medicaid, the nation's most important source of insurance for those with low incomes. Unfortunately, such a strategy is unlikely to help meet growing needs for insurance coverage. Medicaid block grants would force states to compete for increasingly limited federal resources and would solidify already stringent eligibility requirements in many states, such as Alabama, which covers working parents only up to 24 percent of the poverty line, or an annual income of $4,450 for a family of three.

Obama is correct to allow states to develop their own strategies for health care reform. But, unfortunately, some states are motivated to act more by budget-balancing pressures than by a desire to improve their residents' health and eliminate health inequities. As the joint center's research on the economic consequences of health inequalities demonstrates, however, there is a steep price to be paid for inaction in the face of need.

Given that the share of people of color in the U.S. population is expected to increase to at least half by 2042, it behooves states to take seriously the need to ensure that all Americans can enjoy the opportunity to achieve good health.