Longstanding health policy concerns over the decades involve covering the uninsured, enhancing access to health care services, and improving the quality of those services. The Patient Protection and Affordable Care Act, also more commonly known as the Affordable Care Act, that became law in 2010 represented a major thrust in a comprehensive effort to address these important concerns. Although progress has been made during the past decade, the arrival of COVID-19 has presented several major challenges in the fulfillment of key policy aims.

Apart from health insurance provided by the public-sector Medicare and Medicaid programs, until recently approximately 180 millions workers relied on coverage obtained through employment in the private sector of the economy. The appearance of COVID-19 subsequently led to major job losses and unemployment that affected millions of workers, which in many cases was accompanied by a loss of coverage. As an important safety net program, the federal-state Medicaid program has made it possible for some unemployed workers to become eligible for participation in it.

The U.S. health domain consists of a complex web of interlocking components, both public and private. Important federal policymaking roles are played by the Centers for Disease Control & Prevention and the Center for Medicare & Medicaid Services, while agencies at state and lower government levels enjoy much autonomy regarding resource allocation. While all these entities may unite in trying to reduce health disparities affecting certain population sub-groups, practices beyond the health realm can pose significant obstacles. For example, a higher chance of mortgage application denial for black applicants tends to reduce black home ownership and increase the likelihood of renting, which lowers the accumulation of home equity. Less availability of that resource adds to the difficulty of meeting out-of-pocket health expenses. A related impediment is described in the following section.

Associations Between Historical Redlining And Birth Outcomes

An article in the journal PLOS ONE on August 7, 2020 describes a study of the association between historical redlining and preterm birth, low birth weight, small-for-gestational age, and perinatal mortality over a 10-year period in California. Although since repealed, historical segregation policies may perpetuate current health disparities by outliving their implementation period and continuing to contribute to the existence of this problem. Residential segregation can affect access to education, income, healthcare, and clean environments. Researchers examined the role of historical redlining, the practice of categorizing perceived neighborhood mortgage investment risk, on present birth outcomes. Historical redlining maps, also called Security Maps, were created more than 80 years ago for over 200 cities across the U.S. by the federal Home Owners’ Loan Corporation (HOLC), a government body founded in 1934 with the goal of rescuing homeowners from default by issuing replacement mortgages. These maps shaded neighborhoods one of four colors, corresponding to perceive investment risk, with red indicating the highest risk. The investigators hypothesized that the odds of adverse birth outcomes would increase as historical HOLC grade worsened. They indicate that achieving health equity across racial/ethnic and class lines requires a better understanding of how historically discriminatory policies, such as redlining, continue to shape current U.S. patterns of health disparities.

Obtaining Coverage Through Short-Term Health Insurance Plans

The Trump Administration has pursued several objectives since 2017 aimed at dismantling key elements of the Affordable Care Act, including an effort to enable individuals to purchase short-term health insurance plans. The U.S. Court of Appeals for the District of Columbia Circuit on July 17, 2020 upheld a decision allowing the sale of such plans that do not comply with the Affordable Care Act, making it possible to undermine the health law by expanding access to cheaper, less comprehensive insurance. The case stems from a rule the Administration released in August 2018 that expanded access to this form of coverage. Previously, the plans could be carried for only 90 days, but the rule allows for total coverage as long as 36 months. Generally lower priced, they can deny coverage based on pre-existing conditions. The Association for Community Affiliated Health Plans, which in 2018 sued to prevent the allowance of short-term plans, is expected to appeal the recent court decision.

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