In a recent piece for Health Affairs, Renee Landers et al. write about the role Medicare has played and can continue to play in reducing racial disparities. In a separate piece for the International Journal for Health Services, Gracie Himmelstein and Kathryn Himmelstein expose the disparities in health care literally rooted in the hospitals Americans use, disparities that Medicare in its current form cannot address. In combination, these pieces reveal the value of expanding and improving Medicare and the value of Medicare for all in addressing racial inequities.
When Medicare was enacted in 1965, it played a major role in addressing racial and ethnic disparities in health care coverage and access to care. Hospitals were required to desegregate in order to benefit from Medicare payments. But, even though virtually everyone over 65 has health care coverage, people with Medicare still experience disparities in access to care and health outcomes.
Black and Hispanic people under 65 are far more likely to be uninsured than White people. Expanding Medicare coverage to everyone, or to people five to 15 years younger than 65, or allowing people to buy-in to Medicare, could all affect health and racial equity to different degrees. Medicare for all would help most in reducing disparities in affordability and access to care. Other options could help, but far less.
Even with the same insurance coverage, both people of color over 65 and people of color with disabilities on Medicare have been found to have lower quality of care and worse health outcomes than White people. Out-of-pocket costs in Medicare create financial barriers to care. Many people do not know about Medicare Savings Programs and other programs that fill gaps in coverage.
And, Medicare does not cover dental, vision or hearing care. These benefit gaps need to be addressed to further reduce disparities. So do social determinants of health, such as housing, food and education.
We also need better data. Federally funded health plans are required to collect data on race and ethnicity for their enrollees. Privately funded health plans are not. The data collected needs to include quality measures. Then, equity outcomes could be tracked, including inequitable treatment.
On top of guaranteed health care for all with full coverage and improved benefits, we need to address the inequitable distribution of health care resources in the US, which the Medicare for All bills in Congress are designed to do. Gracie Himmelstein and Kathryn Himmelstein, MD show in a recent study that US hospitals serving people of color have poorer resources, including fewer capital assets, than other hospitals. Fewer resources are likely to mean poorer quality care.
Hospitals with poorer resources do not tend to offer capital-intensive services as frequently as other hospitals. It might be possible to correct these inequities through an equalization of resources to hospitals.
Himmelstein and Himmelstein also found that hospital segregation continues and big differences in quality are evident. In 2010-11, three in four Black babies were born in one-fourth of US hospitals. Hospitals serving people of color have fewer nurses relative to patients, lower patient safety and higher hospital readmission rates, along with higher mortality rates for a number of conditions.
In addition to improving and expanding Medicare, Medicare for all is designed to ensure an equitable distribution of resources among hospitals.
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