What Post-ACA Healthcare Utilization Rates Say About Race and Healthcare

Since it became law in 2010, the Affordable Care Act, or ACA, has substantially increased Americans’ access to healthcare. In doing so, the policy has helped address social and economic barriers to medical care that have disproportionately affected low-income households and members of racial and ethnic minority groups.

The passage of the law has had a significant impact on how patients from these communities select and engage with care providers. Many patients, both white and non-white, choose to be treated by a doctor whose racial and cultural background is the same as (or similar to) their own. Researchers refer to this type of dynamic as a race-concordant medical relationship. 

Dr. Alyson Ma and Dr. Alison Sanchez of the University of San Diego Knauss School of Business recently conducted research on the nature of these relationships and what they mean to the healthcare system as a whole. Their insights illuminate broader issues related to race and healthcare utilization, including how diversity in the health workforce could increase the likelihood that members of minority groups will seek out the care that they need. 

Methodology Behind the Research

Ma and Sanchez reported their findings on the relationships between minority patients and healthcare providers in a 2019 paper titled “The Impact of Patient-Provider Race/Ethnicity Concordance on Provider Visits: Updated Evidence from the Medical Expenditure Panel Survey.” 

The researchers analyzed data from the 2014–2015 Medical Expenditure Panel Survey, which tracks a variety of metrics within the U.S. healthcare system, such as patient demographics, healthcare access and usage rates, treatment costs and insurance coverage. From these data sets, Ma and Sanchez derived a sample of more than 25,000 individuals from various racial and ethnic backgrounds, including those who self-identified as white, African American, Hispanic and Asian American.

The researchers then established five standard measures to quantify healthcare utilization, which refers to how often patients see doctors and use other types of medical services. Three of them focused on the probability that a patient would seek preventive care, obtain care for new health problems and seek continuing care for an ongoing health problem. The other two were numerical measures: the number of emergency room visits and the number of total physician visits.

Ma and Sanchez also defined several control variables for the study: race/ethnicity concordance, non-health-related socioeconomic and demographic factors, health-related characteristics, provider communication characteristics and provider location characteristics. Within these categories, the researchers explored factors such as self-reported physical condition, family income and insurance status.

Through their analysis of this expansive data set, the researchers uncovered new insights into how race and ethnicity can influence patients’ health decisions, including whether to seek medical treatment. They note that while the ACA may have eased part of the financial burden in preventing access to healthcare, a number of social obstacles continue to deter some individuals from using various types of health services.

“It's not just about throwing insurance access at people,” Sanchez says. “There are a lot of other structural inequalities within the system that need to be addressed.”

Results of the Research

The study’s key finding was that patients in several minority groups who were in race-concordant relationships with their doctors were more likely to seek and receive healthcare, compared with patients who self-identified as white.

This connection was especially strong among Hispanic and Asian patients. People in these groups who saw doctors of the same race had a higher probability of receiving treatment for preventive care, ongoing health issues and new medical conditions.

“Race concordance is a statistically significant factor that increases the likelihood of patients’ visiting their provider,” the authors note in the report. “Our results demonstrate that racial disparities in healthcare utilization can be partially explained by race concordance.”

One likely reason for this finding is that the language and cultural barriers that might otherwise discourage individuals from seeking treatment tend to be less of an issue when doctors and patients share a common racial or ethnic background. The researchers also found that patients are more likely to visit doctors when they find it easy to contact them by phone and when travel time to their offices is less than 30 minutes. The study also indicates that “relative to those born in the U.S., foreign-born patients are less likely to seek medical attention."

The researchers did not observe statistically significant links for some of the other variables they tracked, including family income, education levels and the amount of time a patient has lived in the U.S. However, Ma and Sanchez explain that while this particular study did not yield clear evidence that these factors play a role in patients’ health decisions, there could still be a connection.

What These Findings Mean

By providing access to a larger pool of health practitioners and treatment options, the ACA made it easier for many people of color to seek care from doctors who share their racial and ethnic backgrounds. Building on this premise, Ma and Sanchez’s research suggests that, in turn, the law has contributed to higher rates of healthcare utilization among Asian and Hispanic Americans who share a common cultural bond with their medical providers.

Ma and Sanchez’s work provides important context for the future of health policy, particularly with regard to how changes to the law could affect minority communities. For example, reductions in the services offered through the ACA would likely decrease access to health care services overall while also creating unique challenges for minority patients in race/ethnic concordance with their doctors whom they may perceive a greater level of trust and can easily communicate with.

“There are other social factors that are going on within the system that are affecting whether people feel comfortable going in and speaking to their provider,” Sanchez says, adding that minority patients’ preference for race-concordant relationships may be “a symptom of larger disparities within our health care system.”

Because minorities have historically experienced discrimination within this system, they may feel a lingering sense of distrust for providers of different races and ethnicities. 

“The ACA has, in a slight way, alleviated some of the financial constraints,” Sanchez says. “However, what it hasn't addressed is the deeper societal factor of trust within the patient-provider relationship, as well as communication issues and things of that nature.”

“People are passing concerns along to their doctor, and their doctor is not believing them,” she adds. “So you can give people access to a doctor, but there are other factors that can discourage patients from going in and trying to establish a relationship with a provider. They might have to convince them, ‘Yes, I really am in pain,’ or ‘I need this medication,’ or ‘I'm experiencing these problems.’ Will they be believed?”

What’s Next?

Ma and Sanchez are dedicated to exploring the ways that race, ethnicity and other social factors shape the U.S. healthcare system. Their research could help address long-standing challenges, ranging from communication barriers to concerns about racial and cultural discrimination in health care. 

Looking ahead to their next endeavors, Ma and Sanchez plan to dive deeper into these issues and further explore the nuances of the relationships between patients and care providers before and after the implementation of the ACA. They have proposed additional research on the experiences of more narrowly defined racial and ethnic subgroups of patients, and they also intend to examine whether race-concordant relationships have a measurable impact on prescription adherence and other health outcomes.

To prevent this type of systemic discrimination, the researchers suggest that future health care policies should focus on improving the patient-provider experience across cultures as part of a larger effort to promote better access to care.

Alyson Ma is a professor of economics at the University of San Diego's Knauss School of Business. Her teaching philosophy is evidence-based and innovative pedagogy that engages students. Her course delivery and assessment vary depending on the topic and course level.

Alison Sanchez is an assistant professor of economics and business analytics at the University of San Diego's Knauss School of Business. Her interdisciplinary research combines behavioral economics with techniques and insights from neuroscience, psychology, information theory and machine learning with a focus on consumer behavior.