Emerging Threats to Health Equity

By Cynthia Miller, MD, MPH, FACP, Vice President, Medical Director, Access Experience Team, PRECISIONvalue
and Maureen Hennessey, PHD, CPCC, CPHQ , Senior Vice President, Director of Value Transformation, PRECISIONvalue

The Biden administration has made health equity a priority, from The Center for Medicare & Medicaid Innovation’s (CMMI)’s new strategy to Biden’s appointment of health disparities advisor, Marcella Nunez-Smith. The “Ever-Evolving Pandemic,” while exposing the nation’s enormous health disparities, has also led to significant policies increasing the number of insured Americans. The Public Health Emergency (PHE) declaration and the American Rescue Plan Act enabled policy changes that expanded enrollment in Medicaid and Health Exchange plans. However, these advancements are at risk. If the PHE declaration is discontinued this year, it could result in the largest Medicaid disenrollment in history, with up to 15 million people potentially losing coverage. Additionally, other pandemic-related changes that provided more flexibility in covered benefits may soon be terminated, further limiting low-income individuals from receiving necessary treatment.  

Pandemic Policies Improved Health Equity

The Families First Coronavirus Response Act (FFCRA), enacted under the Trump administration, required states to allow for continuous enrollment of Medicaid beneficiaries in exchange for increased funding.  As a result, Medicaid enrollment increased as states did not automatically disenroll beneficiaries, which historically led to a churn and interrupted coverage. Causes for disenrollment occur because of income changes, address and contact information changes, or other circumstances. If states do not phase out disenrollment slowly and do not enact other measures that promote continuous coverage, such as mechanisms to address seasonal employment, states may disenroll beneficiaries unexpectedly. Rapid disenrollment will increase the amount of churn to levels potentially more significant than past levels. Disrupted coverage is associated with adverse health outcomes, such as care delays and less frequent medication refills; thus, interrupted coverage may exacerbate health disparities.   

The American Rescue Plan Act of 2021 (ARPA), enacted under the Biden administration, increased premium tax credits (PTCs) for Exchange plans and expanded eligibility for these credits for individuals with incomes above 400% of the federal poverty level (FPL). As a result, enrollment increased significantly, and the potential expiration of these allowances may lead to 3.1 million uninsured people in 2023. Non-Hispanic Black individuals, young adults, and people with incomes between 138 and 400% of the FPL are among those who will bear the burden of the loss in insurance. Ten percent of non-Hispanic Black individuals will be uninsured compared to the ARPA rate of 8.1%. The Centers for Medicare & Medicaid (CMS)’s administrator, Chiquita Brooks LaSure, has called for an extension of these benefits, and HHS is projecting a significant rise in the number of uninsured Americans and skyrocketing premiums without extension. Given that uninsured individuals are less likely to receive preventive care and treatment for major health and chronic conditions, health disparity gaps will likely widen without extending the PTCs into 2023.  

Post-Pandemic or Endemic Threats

Cessation of Medicaid continuous enrollment and premium tax credits for Exchange will contribute to health inequities in myriad ways. Payers will likely see a drop or interruption in Medicaid, CHIP, and Exchange plan enrollment. Insurance churn can result in worsening adherence and overall health, increased emergency department use, and interruptions in physician care. Safety net hospitals may see a larger population of uninsured and sicker patients due to terminated insurance, which may worsen the already financially stressed system. Hospitals that struggle financially may lay off personnel to compensate, further exacerbating care access, particularly among those with more limited means.

Enhanced subsidies for ACA plans allowed low-income members to obtain coverage with zero or near-zero-dollar premium plans. ARPA subsidies opened coverage for those not eligible for Medicaid in non-expansion states. Ending these subsidies will likely exacerbate racial and urban-rural inequities. Additionally, if more people lose financial support, we may see more disparities in behavioral health and substance abuse due to financial distress and worsening access to care. Pharmaceutical companies may see decreased utilization of chronic disease medications due to loss of insurance. Finally, price hikes due to hospital labor shortages and ensuing traveling nurse costs may lead to higher charges and premiums. Patients may see a reduction in additional benefits such as transportation as payers reduce them to manage costs. Finally, given assertions that inconsistent health insurance coverage worsened the pandemic and COVID-19 mortality rates, there is concern that disruption or termination of insurance coverage could lead to COVID surges, further exacerbating health disparities. 

A recent KFF article reported that “Black people fared worse than other racial and ethnic groups in all maternal health indicators measured,” which is linked to systemic and overt discrimination. The NIH has noted that late maternal deaths occurring 6 weeks to 1 year after childbirth were 3.5 times more likely among Black women than White women. Recent legislative decisions may further exacerbate disparities among women and children. States that have not expanded Medicaid have historically poor maternal and child outcomes. If non-expansion states restrict reproductive services, outcomes for low-income and people of color may worsen. These alarming rates have prompted some legislative steps to decrease maternal deaths. For example, states can now provide Medicaid insurance coverage for up to 12 months post-pregnancy, and some states are beginning to implement expanded coverage. Maternal health advocates have noted that the issue has bipartisan support and remain hopeful that additional Congressional maternal care funding will be forthcoming for vulnerable populations. 

Pharmaceutical Companies Can Support Vulnerable Populations

Insurance coverage is a critical social determinant of health, and its disruption will undoubtedly lead to the discontinuation of care for many vulnerable people with serious conditions. The results of untreated illness will be expanded health disparities, large numbers of emergency department visits and hospitalizations, and higher associated costs. While action among multiple facets of the healthcare industry will be needed to mitigate these impacts, pharmaceutical companies can serve an essential role by ensuring continued access and adherence to therapeutics by:

  • Focusing on health equity to prevent further declines in access to chronic disease medications due to loss of insurance or high out-of-pocket costs
  • Partnering with states, payers, and pharmacies to increase access to medication outside of insurance as a stopgap measure
  • Reaching out to medically underserved people and expanding access to critical medications for chronic diseases such as COPD and diabetes and conditions such as high-risk pregnancies

All stakeholders must maintain vigilance during and beyond an ever-evolving pandemic to safeguard against further health inequities. Pharmaceutical companies can be an integral component of partnerships in the future.