Disparities in Care: Beyond Insurance

Disparities in Care: Beyond Insurance 150 150 Dave Ghose

A Minnesota study suggests the ACA’s Medicaid expansion won’t be enough to reduce persistent health care disparities among minority groups.

The health care gap isn’t just about insurance. A variety of barriers — including transportation, inconvenient office hours, cultural biases and confusing information — prevent minorities from accessing health care. In a paper published in the August issue of the scientific journal Medical Care, a team of researchers in Minnesota showed that those barriers remain even after minority groups sign up for public insurance programs.

The findings have implications for the Affordable Care Act, which could add up to 16 million people to Medicaid in the coming years. The Medicaid expansion will benefit minorities, who are disproportionately represented among the uninsured, but the Minnesota study suggests it may not achieve truly equitable access without exploring issues beyond coverage.

“The Affordable Care Act is a first necessary step,” says Kathleen Thiede Call, PhD, the lead author of the study and a professor of public health at the University of Minnesota. “But it’s not sufficient.”

In 2008, Dr. Call’s team surveyed by mail and telephone about 4,600 people with public insurance in Minnesota, including federal and state programs. The study, funded by the Minnesota Department of Human Services, sought to identify reasons why some people — particularly minorities such as Latinos, African Americans, Somalis and Hmong — failed to take full advantage of the programs.

All enrollees reported barriers to care, with minorities more likely to experience problems than whites. Children experienced the same problems but to a lesser degree.

“What we heard in a lot of focus groups was that parents are willing to put up with certain things to get their children care, and they are less interested in doing that in getting care for themselves,” Dr. Call says.

Among all groups, cost-related barriers were the most common. Those include questions about the coverage of medication, preventative care and other services. Second most common were logistical concerns such as transportation, clinic hours and childcare. “Provider-related” barriers — often the result of cultural differences and biases — were the least prevalent overall, but significantly more common among minorities than whites.

Training health care providers about working with minorities and developing more welcoming health care settings could reduce some of those cultural barriers, Dr. Call says. But Dr. Call also suggests ingrained structural problems may be at the root of the issue. Overworked providers are more likely to rely on stereotypes and biases when they’re under pressure, she says.

“I think the health care system has to start thinking differently about how we structure these encounters,” she says. “Can you expect a doctor to get through 30 patients in a day and treat them all with respect, or do we need to change the way that we set up these situations?”



  1. Call KT, McAlpine DD, Garcia CM, Shippee N, Beebe T, Adeniyi TC, Shippee T.Barriers to care in an ethnically diverse publicly insured populationMedical Care. 2014 Aug, 52(8):720-727.
  2. DHS Disparities Project Management Team. Disparities and barriers to utilization among Minnesota Health Care Program enrollees. Minnesota Department of Human Services. 2009 Jun.