ARTICLE REVIEW 4
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REFLECTION
Health Care Reform and Equity: Promise, Pitfalls, and Prescriptions
ABSTRACT The United States has made little progress during the past decade in addressing health care disparities. Recent health care reforms offer an historic opportunity to create a more equitable health care system. Key elements of health care reform relevant to promoting equity include access, support for primary care, enhanced health information technology, new payment models, a national quality strategy informed by research, and federal requirements for health care disparity moni- toring. With effective implementation, improved alignment of resources with patient needs, and most importantly, revitalization of primary care, these reforms could measurably improve equity.
Ann Fam Med 2011;9:78-84. doi:10.1370/afm.1213.
INTRODUCTION
T he United States has made little progress toward greater equity in
health care quality according to the annual National Health Care Dis-
parities Reports.1 Recent health care reforms offer an historic oppor-
tunity to make inroads. In this commentary, I review key provisions of these
reforms, particularly those in the Patient Protection and Affordable Care
Act, often shortened to Affordable Care Act (ACA) of 2010,2 and discuss
their potential promise, pitfalls, and steps (prescriptions) needed to jump-
start progress toward more equitable health care (Table 1). I begin by briefl y
reviewing causes of health care disparities and then discuss selected, key
health care reform provisions within 6 interlocking domains: access related to
insurance coverage and costs, strengthening primary care, improvements in
health information technology, changes in physician payment, adoption of a
national quality, and improved disparity monitoring and accountability.
CAUSES OF HEALTH CARE DISPARITIES Health care disparities related to race, ethnicity, socioeconomic status
(SES), and markers of social disadvantage result from a complex confl u-
ence of patient, clinician, and system levels factors.3 These disparities
often refl ect reciprocal infl uences between social stratifi cation and ensuing
social disadvantage and worse health4; unconscious clinician bias toward
socially disadvantaged persons5,6; separate and often unequal care7-10; and a
health care system, including primary care,11 that is ill-equipped to address
the often complex needs of socially disadvantaged patients, who often
become underserved patients.12
Equitable health care means more than elimination of bias, it also means
creation of patient-centered systems of care that support healing and caring
relationships that are responsive to patients’ needs, wishes, and context.13
Improving equity requires aligning health care resources and capability with
patient needs, particularly patients who have been historically underserved.12
Kevin Fiscella, MD, MPH Departments of Family Medicine and Com-
munity & Preventive Medicine, University
of Rochester, Rochester, NY
Confl ict of interest: Dr Fiscella served on the Insti- tute of Medicine Committee on Future Directions for the National Health Care Quality and Disparities Report and has consulted for the Health Resources Services Administration.
CORRESPONDING AUTHOR
Kevin Fiscella, MD, MPH
1381 South Ave
Rochester, NY 14620
H E A LT H C A R E R E F O R M A N D E Q U I T Y
Table 1. Promise, Pitfalls, and Prescriptions for Improved Equity Under Health Reform
Health Reform Provision Promise Pitfall Prescription
Access (insurance and costs)
Expanded coverage Coverage for up to 32 mil- lion uninsured
Need for robust primary care system
Remaining 23 million uninsured
Absence of “public option” undermines cost control for care for previously uninsured
Revitalize primary care
Universal coverage
Expansion of Medicare eligibility and other public options
Behavioral health parity Reduced cost barriers Does not address barriers related to stigma related to mental health care
Integrate behavioral health services into primary care
Elimination of co-pay- ments for evidence- based preventive care
Reduce cost barriers May accelerate trends toward cost shifting to patients for medical and behavioral care, worsening disparities
Restrict cost sharing based on percent family income
Revitalization of primary care including the safety net Improved physician
payments Modest improvement in
resources Not suffi cient to generate practice
adaptive reserve for transformation Major payment reform
Elimination in Medicare- Medicaid payment differences
Potential to minimize sepa- rate and unequal systems
Does not address gap between Medi- care and private insurance payments.
Eliminate differences in payment by insurance type.
Prohibit segregation of care based on payment type within health care sys- tems that receive federal funds.
Bonus for work in short- age areas
Modest impact on physician maldistribution
Too small to have signifi cant effect Comprehensive strategy to primary care and workforce issues
National Health Care Work Force Commission
Potential to infl uence work force maldistribution
Depends on authority of commission to affect key issues
Address student selection, training, payments, and quality of practice in shortage areas
Improvement in federal load repayment
Improved recruitment to shortage areas
Does not address retention following fulfi llment of commitment
Enhance quality of practice and payment
Collaborative Care Network
Improvement in care coordi- nation for underserved
Need for vibrant primary care safety net to coordinate care
Strengthen adaptive reserve of safety net
Piloting of new care models
Spark innovation Modest investments may not be suffi cient
Practice change is a continuous process
Support innovation in all practices
Greater funding for practice-based research for underserved
Funding for primary care extension programs
State-operated health insurance exchanges
Opportunity to promote new care delivery models
Not all states will opt for innovation
Health information technology Incentives for physicians
and hospitals Acceleration of diffusion
nearing tipping point Does not ensure improvement in
quality
Digital divide by practice and patient
Support for quality improvement collab- oratives that leverage health informa- tion technology
Subsidies for safety-net practices and training and support for patients in use of health information technology
Payment model reform Payment Advisory Board Potential move from volume
to value payment
Potential for changes in pri- mary care payment
Success dependent on members of board
Major changes in needed in quantity and type of fi nancing for primary care
National Pilot Medicare Payment Program
Piloting of bundled payments
Relatively small change
Unknown impact of bundled payments on primary care
Potential adverse impact on underserved
Build in monitoring of effects on care for underserved patients
National quality strategy Formal national quality
improvement strategy Potential to integrate multiple
elements of health reform Potential for neglect of the physician-
patient relationship Need to keep patient and relationships
at fore Reporting of perfor-
mance by federal programs
Improved accountability for programs for underserved
Inadequate funding for implementa- tion and PBRN research, particularly in safety-net practices
Improved funding for practice-based research, particularly safety-net practices
Monitoring disparities Enhance collection of
disparity data within health care
Improved detection of disparities
Assessing disparities does not assure they are addressed
Build in continuous loops between reporting, policy/intervention and follow-up
Analyze disparities trends
Identifi cation of key dispari- ties for targeted action
Monitoring alone is not suffi cient DHHS should hold federally sponsored programs accountable for progress in addressing disparities
DHHS = Department of Health and Human Services; PBRN = practice-based research network.
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H E A LT H C A R E R E F O R M A N D E Q U I T Y
ACCESS Improving equity begins with improving health care
system access. System access is strongly affected by
insurance coverage and cost. Minority and low-SES
patients are more often uninsured than their counter-
parts.1 Lack of health insurance is a major contributor
to health care disparities14; health care disparities are
smaller in such health systems as the Veterans Affairs,
where access is more uniform.15 ACA provisions will
eventually expand insurance coverage to an estimated
32 million uninsured persons, but the Congressional
Budget Offi ce estimates that health care reform may
still leave 23 million persons, including undocumented
immigrants, without any coverage.16
Recent reforms also offer potential for improv-
ing access to behavioral care for poor and minority
patients and for addressing disparities in behavioral
health utilization.1 Cost represents a key barrier. Parity
provisions in the Mental Health Parity and Addiction
Equity (MHPAE) Act of 2008 (https://www.cms.gov/
healthinsreformforconsume/04_thementalhealthparity-
act.asp) and ACA minimize cost differences between
behavioral and medical care. Specifi cally, MHPAE pro-
hibits health plans from imposing deductibles, co-pay-
ments, and out-of-pocket limits on mental health and
substance abuse coverage that are higher than those
imposed for medical-surgical coverage. It also prohibits
restrictions on days of hospital coverage and dura-
tion and scope of behavioral treatment beyond limits
that health plans impose for medical-surgical cover-
age. Access to behavioral health care for underserved
groups could be further enhanced through creation of
integrated primary and behavioral health care similar
to the Veterans Affairs health system.17
Health care costs contribute to disparities, even
among the insured.18 Insurance deductibles and co-pay-
ments discourage appropriate health care use,19 affecting
those with the least income. ACA will eliminate patient
cost sharing for evidence-based preventive services
covered by Medicare and Medicaid. It also authorizes
Medicare coverage for annual health assessments and
eventually eliminates the so-called donut hole in Medi-
care part D prescription coverage. Prohibitions against
exclusions for preexisting conditions and lifetime limits
on spending by health plans may provide greater benefi t
to low-SES patients who are more often affected by
chronic conditions.20 These changes may also reduce
physician decision-making time devoted to patients’ abil-
ity to pay21 and may incrementally move the country
toward improved health care equity. Potential benefi ts of
these changes, however, may be undermined by trends
toward increased patient cost sharing.22 Cost sharing
disproportionately affects low-income patients.23 Pre-
miums for obtaining insurance though health insurance
exchanges for the uninsured will be based on household
income, but many low-income workers may continue to
pay high premiums for employer-based coverage.
PRIMARY CARE Access to primary care is associated with fewer dispari-
ties in outcomes.24 A robust primary care system is the
cornerstone for a more equitable health care system.
Longitudinal, caring relationships with patients provide
the opportunity to minimize stereotypes and foster
patient enablement and capability, potentially yielding
more equitable care.25,26
Revitalization of primary care is critical to health
reform success.27 ACA takes important, although mod-
est steps, in addressing critical primary care needs:
payment reform, enhancing the training pipeline,
transforming practice, and buttressing the primary
care safety net. ACA provisions include establishment
of a National Health Care Workforce Commission,
increased support for workforce training (Title VII
and the Prevention and Public Health Fund), cultural
competency training, enhanced payments, expansion of
health centers, and piloting of new care models. ACA
also provides bonus payments to primary care physi-
cians under Medicare and eliminates differences in
payments between Medicaid and Medicare for primary
care. It further provides Medicare bonuses to primary
care physicians who work in shortage areas, helping
to minimize geographically related disparities. These
reforms may begin to minimize disparities in resources
between primary care practices whose patient popula-
tions differ by social disadvantage. These reforms could
also conceivably reduce de facto segregation in health
care by insurance type (eg, faculty practices vs clinics),
although federal regulations prohibiting intra-insti-
tutional segregation of care by insurance type within
systems receiving federal funding may be needed. To
be sure, modest increases in payments alone will not be
suffi cient to address the maldistribution of primary care
physicians, much less avert a primary care shortage.28
Poor and minority patients are at greater risk for
lacking primary care; those with access are more often
seen within resource-strapped safety-net practices,
such as federally qualifi ed community health centers
(FQHCs), hospital clinics, and a small portion of com-
munity physicians.7,29 Strengthening the primary care
safety net is critical to ensuring access after expansion
of insurance coverage.
FQHCs are the most important source of primary
care for underserved patients, currently serving 20
million patients who are largely minority and of low
income.30 FQHCs will likely remain the key source for
primary care to underserved groups under health care
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reform.30 ACA invests heavily ($11 billion) in FQHC
expansion, potentially doubling the number of patients
served. Annual federal loan repayment for physicians
working in underserved areas increases to $50,000
(from $35,000), part-time practice is now permitted,
and teaching time within FQHC is now counted for
repayment. Furthermore, ACA supports establishing
new teaching health centers and provides new systems
of payment for this teaching.
These investments alone are not suffi cient to ensure
transformation of care within FQHCs. Enhancement
in health center fi nancing will be needed to generate
an adaptive reserve (ie, capability of practices to imple-
ment and sustain change)31 to facilitate FQHC practice
redesign.32 Federal support is needed to sustain and
advance quality improvements previously initiated
through the Health Disparities Collaboratives.33 Inno-
vative training programs are also needed to develop
future medical home leaders for the underserved.34
ACA also supports establishment of the commu-
nity-based Collaborative Care Network Program
to support local consortia of health care providers
(including health centers) to coordinate and inte-
grate health care services for low-income uninsured
and underinsured patients. Potentially, this provision
could foster innovative, community-wide solutions
for care for underserved patients, including promo-
tion of patient capability.35 Success will depend on the
strength of local partnerships and creation of sustain-
able models of primary care delivery that effectively
coordinate use of community resources.
ACA aims to transform health care quality (including
primary care) through a series of small but potentially
synergistic steps.27 It promotes piloting of new care
models, including medical homes, chronic disease man-
agement teams, and integration of medical and behav-
ioral health care. State-run health insurance exchanges
provide states with the opportunity to establish new
primary care models. If successful, these models could
reinvigorate primary care while creating systems of care
that provide the time, resources, and capability needed
to respond to the needs of underserved patients.11,36
The path to transformation will not be easy. As
the Patient-Centered Medical Home National Dem-
onstration Project has shown, transformation is a
slow, challenging process, requiring high motivation
and often external support.31 Toward this end, ACA
authorizes the creation, but no corresponding fund-
ing, for primary care extension programs designed to
assist primary care practices in quality improvement.37
Funding for this program is critical if primary care is
take full advantage of reforms. Without buttressing
key resources in primary care and addressing adaptive
reserve within practices,38 the combined stress of care
for more (newly insured) patients coupled with pres-
sure to transform practice, could undermine patients’
care, demoralize primary care clinicians, and hinder
progress toward a more equitable system.
HEALTH INFORMATION TECHNOLOGY Adequate health information technology, including
availability of electronic health records (EHRs), is one of
the pillars for transforming primary care and improving
health care quality and equality.39 Adoption has been
relatively slow, but a tipping point may be near. By 2009,
44% of offi ce physicians in the United States reported
use of some type of EHRs.40 With funding through the
American Recovery Reinvestment Act (ARRA) of 2009
(http://www.recovery.gov/About/Pages/The_Act.aspx),
physicians and hospitals will receive fi nancial incentives
through Medicaid or Medicare for acquiring and engag-
ing in federally defi ned meaningful use of EHRs. Federal
certifi cation of EHR vendors for meaningful use should
spur improvements in EHRs.41 Features, if suffi ciently
user-friendly, such as patient registries, reminders, deci-
sion support, computerized order entry, and electronic
prescribing, offer the potential for improving equity
through improved tracking, population management,
standardization of care, and possibly reduced decision-
making bias.42 Establishment of regional Health Infor-
mation Technology Extension programs and Beacon
Community Cooperative Agreement programs may fur-
ther facilitate technology diffusion, infrastructure, and
exchange capabilities within regions across the country.
Slower diffusion of this technology to practices
serving minority patients, however, could have the
unintended consequence of worsening health care dis-
parities by further widening inequalities in resources
between providers.43 In addition, powerful incentives
may be needed to promote effective information
exchange between systems and between patients and
providers. Last, in the absence of targeted initiatives,
the digital divide in knowledge and access to technol-
ogy could worsen disparities when practices begin
to implement online scheduling, patient portals, and
patient health records.44
PAYMENT MODELS New payment models may potentially promote equity
by fostering quality improvement, including the devel-
opment of new care models, such as the patient home,
potentially better suited to meet the needs of poor and
minority patients.11 Payment systems that reward pay-
ment for health care value (ie, better quality relative to
cost) rather than volume might produce better align-
ment between patient needs and resources.
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ACA innovations designed to enhance value include
allowing providers who are organized as accountable
care organizations to share in cost savings, creation
of an innovation center within Centers for Medicare
and Medicaid Services (CMS), establishment of an
independent payment advisory board, reduction in
hospital payments for hospital-acquired conditions,
and establishment of a national Medicare pilot program
to develop and evaluate bundled payments (a type of
limited capitation). Provided that bundled payments
take into account the greater health care needs of
underserved patients and do not penalize safety-net
providers,45 they offer the potential for promoting
equity by redirecting resources to health care value and
population health. As with any major reform, however,
unintended consequences are possible. Implementation
of bundled payments could discourage accountable
care organizations from enrolling underserved patients
because these organizations may fear potentially higher
costs, unless payments take into account patients’ social
disadvantage in addition to case-mix.46 Bundled pay-
ments could also undermine the sustainability of small
private practices that often provide care to underserved
patients in many rural communities.
A NATIONAL HEALTH CARE QUALITY STRATEGY Equity represents a core dimension of health care
quality.47 Efforts to promote health care quality offer
potential for promoting equity, particularly if efforts
include explicit focus on addressing disparities48 or pro-
duce “zero defects.”49 ACA directs the Secretary of the
Department of Health and Human Services (DHHS) to
develop a national quality improvement strategy includ-
ing selecting and reporting on uniform quality measures
by federally sponsored programs. The secretary has
charged the Agency for Healthcare Research and Qual-
ity (AHRQ) with leading this effort. The appointment
of quality improvement maven, Donald Berwick, to
lead CMS may further energize health care reforms.
ACA calls for equity to be one of the considerations in
the development and selection of quality of measures.
Improved measurement of quality and equity could
focus more attention and resources on addressing health
care disparities and aligning resources with needs.
A shift in federal research funding priorities is nec-
essary, however, to fully enable a national strategy to
improve health care quality and reduce disparities.50 In
2007, the United States spent 4.5% of total health care
expenditures on biomedical research, but only 0.1%
on health services research.51 The National Institute
of Health (NIH) director, Francis Collins has made
research relevant to health reform an NIH priority,52
but this new NIH priority presumably refers mainly to
comparative effectiveness research rather than research
designed to optimize health care delivery. The ACA
has also upgraded the National Center on Minority
Health to an NIH institute. Although this change bodes
well for improved community-based health disparities
research, it is not clear whether it will shift funding
toward health care disparities research. A center of inno-
vation will be established within CMS. Even so, devel-
oping and implementing a national quality and disparity
strategy will require adequate and stable PBRN funding
(eg, to support practice facilitators who can boost prac-
tices’ adaptive reserve), particularly implementation of
new care models within safety-net practices.53 Given the
growing federal investment in FQHCs and their pivotal
role in addressing disparities, research funding is needed
to inform optimal care delivery models in these sites.
MONITORING HEALTH CARE DISPARITIES ACA directs DHHS to evaluate health and health care
systems to enhance collection and reporting of health
care data by race, ethnicity, sex, primary language,
disability, and rural residence. Similar directives are
included in EHR meaningful use requirements. Avail-
ability of these data will facilitate better assessment and
implementation of interventions to address disparities by
health plans and hospitals.54 ACA directs DHHS to ana-
lyze data to detect and monitor trends in health dispari-
ties for each federally conducted or supported health
care or public health program or activity. These require-
ments may facilitate greater accountability for assessing
and addressing health care disparities within federally
sponsored programs. With suffi cient commitment from
DHHS leadership, this requirement could potentially
result in a systematic effort by federally sponsored
programs to publicly report on and address health care
disparities within their programs. These efforts could
be aided by changes in the National Healthcare Qual-
ity Report and National Healthcare Disparity reports
recommended by the Institute of Medicine.55 Included
are national priorities in areas of quality and disparities,
improved actionability including accountability, and an
expanded quality framework that includes the domains
of health care access and health care infrastructure
required to improve quality and equity. Closing the
feedback loop between quality and equity reporting and
corrective federal, state, and local policies will be critical
given the enormous complexity of reforms.
CONCLUDING THOUGHTS Health care reforms, many not slated for enactment
until 2014, offer an unprecedented opportunity to cre-
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ate a more equitable patient-responsive health care
system. ACA targets access by expanding insurance
coverage and the FQHC safety net. Further legislation
will be required to address access for the remaining 23
million uninsured. Other provisions related to costs
may improve equity, but trends toward greater patient
cost sharing may offset gains unless ways are found to
mitigate their impact on low-income persons.
Health reform also offers promise in a number of
areas besides system access, including primary care,
health information technology, payment reform, a
national quality strategy, and disparity monitoring.
Two fundamental challenges lie in the way. The fi rst
challenge is aligning health care resources with patients
needs. At the level of the patient visit,11 practice,7 and
hospital,9 resources are misaligned.12 Health care reform
takes small steps toward addressing this problem, but
trends toward pay for performance and bundled pay-
ment could worsen this mismatch if they fail to account
for the needs of underserved patients and practices
serving them.56,57 Ultimately, systems of payments must
account for patient morbidity as well as patient com-
plexity,58 including contextual capability related to lan-
guage, culture, health literacy, and disempowerment.
The second challenge relates to revitalization of
primary care, particularly for underserved patients.
Whether health reform promotes equity may depend
partly on how health reforms affect key relationships,
not only between clinicians and patients, but also
between clinicians and other team members. This
means creating systems that provide the time, space,
and interpersonal relationships necessary to ensure
high quality primary care. It also means creating pri-
mary care teams in which all members’ experience and
training are optimally utilized.59 With the diffusion of
health information technology and emerging changes
in payment, transformation to team-based care may
prove to be primary care’s greatest challenge. Emerg-
ing data suggest that teams improve patients’ health
status.60 Transformation to team care, however, is
enormously challenging. Transforming primary care
requires not only major changes in medical training61
but also supportive infrastructure, such as primary care
extension programs and learning collaboratives. Fed-
eral agencies charged with implementing health reform
should take notice.
Assuming health care reforms survive the loom-
ing political and legal land mines during the next four
years, primary care will likely confront a period of
extraordinary change. Success in creating a more equi-
table and patient-responsive health care system may
depend in part on our ability as primary care clinicians
to seize these opportunities and champion systems of
care responsive to the needs of all patients.
To read or post commentaries in response to this article, see it online at http://www.annfammed.org/cgi/content/full/9/1/78.
Key words: Healthcare disparities; health care reform; primary care; health policy
Submitted July 20, 2010; submitted, revised, October 18, 2010; accepted November 7, 2010.
Acknowledgement: Adjuah van Keken assisted with the preparation of this manuscript.
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