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Identifying and Evaluating Equity Provisions in State Health Care Reform


Rapidly escalating health care costs, a rising number of people without health insurance, inconsistent health care quality, and a paucity of federal action to address these problems have prompted legislatures and governors in nearly two dozen states to consider significantly changing their approaches to health insurance coverage and health system regulation. Few of these reforms, however, have focused on inequality. Millions of people in the United States?principally racial and ethnic minorities, immigrants, and those who lack proficiency in English?face barriers to high-quality health care.

Such problems derive largely from the high rates of uninsurance among these groups, but it persists among them even when they are insured. They simply tend to receive a lower quality of health care. But by expanding health insurance coverage and addressing issues of access, quality, and cost, state-level health care reforms have the potential to address inequality?that is, to achieve equity.

The analysis in this report seeks to:

  1. Identify state-level policies that promote equitable health care access and quality for all populations (equity benchmarks).
  2. Evaluate existing laws, regulations, or reform proposals in five states?Massachusetts and Washington, which have already enacted sweeping health care reform legislation; and California, Illinois, and Pennsylvania, where legislators are considering similar programs?to determine whether they address health care disparities relative to these equity benchmarks.
  3. Several key findings emerge from this analysis:

  4. To promote health care equity, universal health insurance coverage is necessary but not sufficient. States can and should attend to health care access, quality, and infrastructure, particularly in underserved communities, and help patients become educated and empowered?able to advocate for their needs. But states should also find ways to improve state health care planning and address social and community-level determinants of health.
  5. Several states are addressing health care inequality through innovative means. All the states featured in this analysis have sought to make insurance and health care more affordable, and many are taking steps to improve health care quality?for example, by collecting data and monitoring for disparities.
  6. More must be done. None of the analyzed states are, for instance, implementing plans that would result in truly universal health insurance coverage or access. State policymakers should take advantage of the growing momentum for state health care reform to address such omissions.

Equity Benchmarks

Myriad factors contribute to health care inequality, and the lack of health insurance is one of the most important. Racial and ethnic minorities ("disparity populations") in particular are more likely to lack health insurance coverage or to be underinsured compared to non-Hispanic whites; while people of color make up just one-third of the U.S. population, they comprise over half of the nation?s 47 million uninsured individuals. But insurance coverage alone does not eliminate health care gaps. The health-services research literature suggests that states can make health care more equitable for disparity populations by:

Improving access to health care. States can expand opportunities for low- and moderate-income families to purchase private insurance or enroll in publicly subsidized programs, and they can establish mechanisms that make it easier for people to find affordable insurance. But even when insured, minority and low-income individuals are less likely to access health care as out-of-pocket costs rise and more likely than are native-born white Americans to face cultural and linguistic barriers to care. States can address these problems by establishing limits on copayments and other out-of-pocket costs in public insurance, by studying and responding to potential unintended effects of cost-sharing on utilization, by taking steps to increase diversity among the state's health care providers, and by providing incentives for health care systems to reduce cultural and linguistic barriers.

Improving the quality of care. States can provide incentives for strategies?such as pay-for-performance programs, performance measurement, and report cards?to reduce disparities in health care quality. In addition, states can promote the collection of data on health care access and quality by patients' race, ethnicity, income or education level, and primary language?and publicly report this information.

Empowering patients. Patients, particularly racial and ethnic minority and immigrant patients, should be able to make decisions about their health care and to demand that care consistent with their needs, preferences, and values be delivered. These goals can be pursued by developing and strengthening patient education and health literacy programs and by supporting training and reimbursement of community health workers, who can help patients navigate through the system.

Improving the state health care infrastructure. The relative lack of health insurance among racial and ethnic minorities is associated with lower levels of health care resources (e.g., practitioners, hospitals, and health care centers) in communities of color. Even if states achieved universal health insurance coverage, communities of color would still require investments to improve their health care infrastructure. States can address this situation by reducing the financial vulnerability of health care institutions serving poor and minority communities, by creating or broadening incentives for health care professionals to practice in underserved communities, and by requiring cultural-competency training for health care professional licensure.

Improving state program and policy infrastructure. States can better align health care resources with minority-community needs by gaining community input, by establishing or enhancing state offices of minority health (which increase the visibility and coordination of state health disparity-elimination programs), and by strengthening Certificate of Need (CON) policies as a tool for reducing geographic disparities.

Adopting or strengthening policies to address social and community-level determinants of health. State agencies that seek to reduce social and economic gaps are inherently engaging in health equity work. Almost all aspects of state policy in education, transportation, housing, commerce, and criminal justice influence the health of state residents and can have disproportionate impacts on marginalized communities. Thus states can address community-level and social determinants of health by coordinating the work of state agencies and by promoting the use of health impact-assessment tools, which evaluate the potential effects of government programs and initiatives both in and outside of the health care delivery sector.

Findings and Conclusions

Our analysis of five states' approaches to health insurance expansion finds that states are addressing disparities in several important ways. While no two of these states used the same approach, several policy strategies were common. These included:

  • Expanding access to health insurance products by reducing financial barriers to coverage
  • Improving and evaluating outreach and enrollment efforts
  • Collecting data (often while building upon federally mandated Medicaid data- collection programs) on health care access and quality measures by patient demographics
  • Supporting safety-net institutions
  • Improving health care provider diversity, distribution, and cultural competence.

Our analysis also revealed several missed opportunities for states? promotion of equity. None of the five states are implementing plans that would result in truly universal health-insurance coverage or access. Many groups, such as single and childless low-income adults, undocumented immigrants, and even some legal immigrants are not eligible for new state public-insurance expansions. Community-empowerment strategies are also uncommon. Only one of the states, Pennsylvania, has sought to strengthen local community input and direct resources (in this case, those of nonprofit hospitals) to meet community needs. And only one state, Washington, has sought to strengthen state CON programs as a tool for regulating health care resources; it has linked CON approval with a statewide health-resources strategy.


Based on these findings, we offer a number of recommendations that should be considered by a range of stakeholders?including state policymakers, health professionals, health consumer and advocacy groups, health plans, and businesses?in their efforts to achieve equitable health care for all. These recommendations include:

Make universal health care a core goal. Uninsurance is not just a problem for those who lack coverage; it also contributes to escalating health care costs and access problems, even for those who do have insurance. Only by covering everyone in the population can states eliminate uncompensated costs and strengthen the health care infrastructures of underserved communities.

Assess how policies to expand coverage affect currently underserved groups. The states analyzed here have employed different strategies?mandates to purchase insurance, for example?in order to expand coverage. States that are considering such strategies should monitor their impact and take steps to correct them should they have a disproportionately negative impact on marginalized populations.

Be an agent for change. State government can leverage the power of other stakeholders, both public and private, to help in the battle to eliminate health care disparities.

Reach for low-hanging fruit. Many of the policy strategies examined here can be implemented through regulatory strategies or contractual requirements rather than through legislation. For example, states are required by federal law to identify the race, ethnicity, and primary language of Medicaid beneficiaries and to provide this information to managed care contractors. This information can be used to generate reports on how plans are faring with respect to health care equity.

Actively monitor the implementation of new health care expansion laws. Almost all of the equity-related policies examined in this study require ongoing monitoring to ensure that they are actually addressing disparities.

Also see the Health Affairs article by Brian Smedley, "Moving Beyond Access: Achieving Equity in State Health Care Reform."

Publication Details



B. Smedley, B. Alvarez, R. Panares, C. Fish-Parcham, and S. Adland, Identifying and Evaluating Equity Provisions in State Health Care Reform, The Commonwealth Fund, April 2008.