Cultural Collisions and the Limits of the Affordable Care Act
Harris, Jasmine E., The American University Journal of Gender, Social Policy & the Law
National Federation of Independent Business v. Sebelius ("NFIB") settled the central constitutional questions impeding the rollout of the Patient Protection and Affordable Care Act ("Affordable Care Act" or "ACA"): whether the federal government's "individual mandate" to purchase or hold health insurance and the federal government's authority to retract existing federal dollars if states fail to expand Medicaid eligibility violate the Constitution.1 However, a number of residual questions persist in its wake. While most of the focus this year has been on related constitutional issues-such as religious exemptions from offering contraceptive coverage to employees2-NFIB also clears the path for a discussion of the merits of the ACA's policy goals and the extent to which the ACA succeeds on its own terms.
Undeniably, the ACA will narrow the qualitative divide between the scope of coverage in private and public insurance markets. The ACA is the first comprehensive federal health care legislation to reorganize financing and delivery of health care based on three guiding principles: quality, access, and equitable outcomes. For example, the ACA expands public health insurance by offering financial incentives3 for states to expand Medicaid eligibility to residents with incomes up to 138%4 of the federal poverty level, and, in the private market, offers federal subsidies to individuals with incomes up to 400% of the federal poverty level to purchase private insurance through newly established insurance exchanges. Even discounting the handful of states opting out of Medicaid expansion,5 millions of newly insured people will enter the formal health care system in 2014-a tremendous achievement.6
Post-NFIB, discussions of the ACA tend to focus on these policy outcomes-most visibly on access, and on the ACA, more generally-as an unmistakably good thing. However, meaningful access to quality health care is not a simple question of coverage affordability as a legal or policy matter. Insurance may be a gateway to accessing care but if the health delivery system lacks competence and capacity to build sustainable relationships, and recognize and respond to cultural differences in illness perception, health outcomes will not improve.7
Perhaps the most egregious examples of inaccessible health care can be found in the mental health arena, where demand is high, providers are in short supply,8 and people in need of support services are most often silenced and presumed to lack decision-making capacity on account of their mental and psychosocial disabilities.9 Racially and ethnically diverse communities "bear a greater burden from unmet mental health needs [than do whites] and thus experience a greater loss to their overall health and productivity."10 They have less access to mental health services than do whites because of restrictive health plans, the absence of providers, and normative differences in beliefs about health and illness. Furthermore, when they do access mental health care, it is more likely poorer in quality.11
The ACA demonstrates the same monochromatic approach that current U.S. health care policy takes to ensuring meaningful access across cultural divides. This Article focuses on the Affordable Care Act and mental health promotion among Latinos as one of the clearest examples of the overly simplistic approach denying meaningful access to racially and ethnically diverse communities. Specifically, this Article demonstrates that the ACA is limited in its ability to improve mental health outcomes among racially and ethnically diverse communities because it does not reach or, at best, narrowly addresses the ways in which health care has been historically defined, delivered, regulated, and experienced in the United States. The cornerstone of mental health care delivery continues to be highly specialized and concentrated among "culturally incompetent"12 medical doctors, in a paternalistic doctor-patient relationship, and regulated at the state level. …