Decisions by payers such as what markets to participate in or how to design coverage plans in Affordable Care Act marketplaces may be contributing to fewer insurance options for racial and ethnic minorities, according to a study published April 27 in JAMA Network Open.
The findings suggest potential care access challenges for non-Hispanic Black individuals because counties with larger non-Hispanic Black populations tended to have fewer health plans available. Findings also indicated that payer network inclusion or exclusion may be an additional factor reducing care access for non-Hispanic Black patients and increasing care inequities. The results highlight a need for examination and enforcement of network adequacy standards within ACA marketplaces.
"An important link between historical redlining and health outcomes is likely related to health insurers' strategic considerations about what markets to participate within, how to design coverage plans and what physicians to include within their networks based on neighborhood characteristics. To the extent that these decisions are associated with the racial or ethnic makeup of these markets, we refer to this as insurance redlining," the study's authors wrote.
This study analyzed 34 state marketplaces, federal exchanges and physicians located within the 500 most populous U.S. cities in 2014. County-level data was sourced from individual market and issuer enrollment databases and county health rankings. Census tract data came from a national database of physician networks in 2014 marketplace plans, the U.S. Census Bureau and the CDC.
Six key takeaways:
- The first analysis looked at 2,270 counties to find the association of county-level prevalence of non-Hispanic Black residents with the number of payers that enter a certain market.
- If adjustments are made for population size, age, and race and ethnicity, a single standard deviation increase in the county non-Hispanic Black population was associated with a 14.1 percent reduction in the number of payers.
- If additional county-level risk selection controls and state fixed effects are considered, a single standard deviation increase in the non-Hispanic Black population was associated with a 2.3 percent reduction in available payers.
- If adjustments are made for population size, age, and race and ethnicity, a single standard deviation increase in the county non-Hispanic Black population was associated with a 14.1 percent reduction in the number of payers.
- For the second analysis, 16,006 to 25,096 census tracts were examined, depending on physician specialty, to find the association of census tract-level prevalence of non-Hispanic Black residents with insurance network breadth.
- For practitioners network breadth inclusion, a single standard deviation increase in the non-Hispanic Black population was associated with a 15.8 percent to 24.7 percent reduction in physicians' network participation.
- Once adjusted for additional state fixed effects, it yielded estimates of 6 percent to 13.5 percent reductions in practitioner network participation.
- For practitioners network breadth inclusion, a single standard deviation increase in the non-Hispanic Black population was associated with a 15.8 percent to 24.7 percent reduction in physicians' network participation.