Dr. Howard Koh, former HHS assistant secretary for health during the Obama administration, said the ACA was never viewed as a completed work but rather as the foundation.
“We felt we had to lead by example,” said Koh, now a professor of the practice of public health leadership at Harvard University’s T.H. Chan School of Public Health. Koh played a key role in overseeing the ACA’s implementation. “If we were going to do it at the federal level, that would signal to states and cities we were supportive of such efforts at the local level and wanted to coordinate those efforts.”
Numerof is frustrated at the idea that access alone results in better outcomes.
“While expanding Medicaid may be better than nothing, it still doesn’t address the underlying issues of real access—that is meaningful primary care at a local level and community-based solutions that go beyond traditional physical healthcare,” she said.
Federal regulators did establish some broader health targets like reducing health inequities in access and outcomes. Racial and ethnic minority groups have traditionally had less access to healthcare services compared to white Americans and have disproportionately been at higher risk for a range of chronic health conditions.
Under the ACA, offices of minority health were established within six HHS agencies in 2010, including the CMS, the Centers for Disease Control and Prevention, the Food and Drug Administration, and the Substance Abuse and Mental Health Services Administration to coordinate disparity reduction activities.
The ACA also redesignated the National Institutes of Health’s National Center on Minority Health and Health Disparities into the National Institute on Minority Health and Health Disparities to integrate all of the NIH’s minority health and health disparities research.
HHS adopted new standards for collecting demographic data under the ACA to improve tracking of health differences among various populations to better target effective interventions.
In 2011, HHS developed its first national strategic action plan to address racial disparities. However, while individuals belonging to minority groups benefited from the ACA coverage expansions, more than half of the 28 million individuals who were still uninsured in 2018 were people of color, according to the Kaiser Family Foundation.
Federal and state initiatives have attempted to address disparities for certain health conditions that often disproportionately plague people of color. The ACA’s public health fund and the CDC’s $103 million Community Transformation Grants Program have supported evidence-based projects to reduce diabetes, heart disease and HIV, and to improve maternal and infant health among minority populations.
In spite of those programs, even supporters concede the ACA’s broader goal of achieving health equity among all Americans remains elusive.
“Coverage isn’t everything,” said Dr. Georges Benjamin, executive director of the American Public Health Association. “In many ways, expanding coverage has exposed a lot of the underlying problems that we’ve had in the healthcare system.”