Persistent Disparities: Black Patients with Chronic Conditions Face Gaps in Alcohol Screening

By Lauren DeSouza- Master of Public Health, Simon Fraser Public Research University – Canada
https://sudrecoverycenters.com/our-team/
Staff Research and Content Writer

The Affordable Care Act (ACA) marked a significant step towards achieving greater and more equitable access to health care across the United States. The ACA expanded insurance coverage for preventive care such as screenings and vaccinations, expanding Medicaid eligibility and mandating private companies to provide these services at no additional cost to the patient. Primary preventive care is crucial to prevent downstream morbidity and mortality from preventable diseases.

But have the improvements in healthcare access and coverage from health reforms like ACA been experienced equally across the population?

A new study tested the efficacy of health reforms, particularly the ACA, by investigating patterns of alcohol screening in patients with chronic conditions that are exacerbated by alcohol use. Alcohol screening, a preventive care mechanism for which the ACA expanded coverage, is a simple, cost-effective health intervention that can contribute to better health outcomes for patients with chronic conditions. In this new study, researchers were interested in determining how health reforms such as the ACA affected the receipt of alcohol screenings for patients with different types of health insurance and between racial and ethnic groups.

Why is it important to screen for alcohol use?

Preventive health services, such as screening for excessive alcohol use, play a crucial role in reducing downstream health disparities. This is particularly true for patients with chronic conditions that can be worsened by excessive alcohol use.

Alcohol use affects many organs and body systems, including the brain, lungs, cardiovascular system, and immune system. Alcohol use can affect how quickly and to what extent some chronic conditions worsen. Additionally, excessive alcohol use can impair patients’ ability to self-manage their chronic conditions, whether adhering to specific diets or medication regimens. Early screening for excessive alcohol use can help patients access interventions to reduce alcohol consumption, thereby improving the management of their chronic condition.

Alcohol screening has direct and indirect impacts on morbidity and mortality. Disparities in receipt of screening, whether due to race, insurance status, or socioeconomic status, can exacerbate inequities in morbidity and mortality from alcohol-related diseases.

What did this study do?

The goal of this study was to examine patterns of alcohol screening in patients who have chronic conditions that are exacerbated by alcohol use. The study aimed to assess insurance-related and racial/ethnic disparities in receipt of alcohol screening, given the 2014 enactment of health care reforms under the Affordable Care Act (ACA). The authors were interested in determining how increased coverage for preventive behavioral health services under the ACA affected alcohol screenings for different insurance groups and between racial/ethnic groups.

Since the ACA’s reforms came into effect in 2014, the authors used data from the 2013 to 2019 National Surveys on Drug Use and Health to enable comparison of data points before and after the ACA reforms. This study specifically looked at patients who had at least one chronic condition that can be exacerbated by alcohol and who had visited a primary care facility in the past year. Chronic conditions included in this study, based on available data, included high blood pressure, heart diseases, diabetes, chronic bronchitis, chronic obstructive pulmonary disease, liver cirrhosis, hepatitis, asthma, and HIV/AIDS.

This study’s primary outcome of interest was the past-year receipt of primary care-based alcohol screening. This was a yes/no question indicated by the respondent’s self-report. The patient’s healthcare provider must have asked about whether, how often, or how much they drink in order for the patient to answer yes.

In their statistical analysis, the researchers adjusted for demographic factors and differences in the number of primary care visits and chronic conditions to avoid affecting the results.

Image via shkrabaanthony on Pexels

What were the main findings?

The final sample included over 46,000 patients across the US. Patients had an average of 1.4 chronic conditions, the most common being hypertension, diabetes, and asthma, and averaged 4.3 primary care visits per year. Most patients (73.6%) had private insurance, while 13.1% had Medicare, 5.3% had Medicaid, and 4.7% were uninsured.

There was an overall increase in the number of patients who received alcohol screening in primary care settings between 2013 and 2019. In 2013, 69% of patients had received alcohol screening in the past year; by 2019, that number had risen to 77%.

Insurance Status

Medicaid-insured patients experienced a significant increase in screening rates, especially between the 2013 and 2014-15 surveys, suggesting an immediate positive impact of healthcare reforms. During this time, the screening rate for Medicaid patients rose from 63% to 75%, equivalent to a 94% higher chance of being screened in 2014-15 versus in 2013. This increase was substantially higher than for those with private insurance (27%).

The researchers hypothesized that the more significant increase for Medicaid patients than privately insured patients was due to expanded coverage under the Affordable Care Act. This suggests a substantial positive impact of healthcare reform on access to preventable care services. However, those who were uninsured or insured under Medicare did not see increased odds of alcohol screening, indicating that gaps remain.

Racial/Ethnic Groups

There was an increase in alcohol screening across racial and ethnic groups. However, significant disparities remain between White patients and patients of color, especially for Black and Asian-American and Pacific Islander (AAPI) patients. Black patients had 12% lower odds of receiving screening for alcohol use compared to White patients. AAPI patients had 55% lower odds of being screened for alcohol use compared to White patients. These disparities persisted regardless of insurance type.

Researchers also investigated whether or not the significant increase in screening rates for Medicaid-insured patients in 2014-15 applied to all racial/ethnic groups. However, their analysis found that only Hispanic patients with Medicaid insurance experienced an increase in alcohol screenings.

There were also racial disparities for those with specific chronic conditions:

Black patients with heart disease had 41% lower odds of being screened for alcohol use compared to White patients with heart disease.
Black patients with hypertension had 13% lower odds for screening compared to White patients with hypertension.

Overall, there were no significant racial/ethnic differences in the number of alcohol screenings following healthcare reform (ACA). However, persistent disparities for Black and AAPI patients remained, raising concerns about the equitable distribution of preventive healthcare services. Of note, within each racial/ethnic group, older patients, those who were unemployed, and those with the lowest levels of education were the least likely to receive screening.

Why do racial disparities persist in alcohol screening?

Racialized groups often have more pressing healthcare needs than screening for alcohol, driven by longstanding racial disparities in primary care access and quality. Entrenched racial inequalities mean that patients of color, especially Black patients, frequently rely on under-resourced facilities, which receive lower funding and are often ill-equipped to address their complex health concerns. Black and other patients of color are often diagnosed at later stages of disease than their White counterparts and face more barriers to accessing care.

Historically entrenched racism and abuse against patients of color, particularly Black patients, have fostered deep-seated medical distrust. This distrust often leads to feelings of stigma and discomfort when discussing drinking behaviors with healthcare providers. Additionally, interpersonal racism can affect how providers ask questions or record information, sometimes rooted in implicit biases. For example, assumptions that Asian Americans and Pacific Islanders (AAPIs) drink less may dissuade providers from screening patients in this community. Such biases, coupled with systemic underfunding and barriers to access, compound the healthcare challenges faced by racialized groups in receiving preventive care.

Photo by Pavel Danilyuk on pexels

What are the implications of this research?

Alcohol screening for patients with chronic conditions increased significantly following the health reforms implemented nationwide in 2014. However, persistent disparities exist for patients with certain chronic conditions, in certain racial/ethnic groups, and those with specific insurance statuses.

Between 2013 and 2019, the number of patients receiving alcohol screenings rose significantly, but 23% of eligible Americans still miss this essential preventive service. These disparities are notably pronounced for individuals without insurance, for whom screening rates did not improve during the study period. This underscores how lack of coverage remains a barrier to healthcare access across the spectrum of care.

In addition, the study was limited to analyzing patients who had visited a primary care clinic, excluding the most disadvantaged who, due to various social determinants of health, cannot access a primary care provider. This limitation suggests that the reported 23% who did not receive screenings may underestimate the actual number of people missing out on this preventive measure.

Among Medicaid patients, screening increases were observed solely for Hispanic patients. Black, Asian American/Pacific Islander (AAPI), and American Indian/Alaska Native (AIAN) patients saw no improvements, pointing to persistent disparities that require further exploration. This finding highlights severe racial equity issues, as missing screenings can worsen chronic conditions and widen the health gaps in morbidity and mortality between racial and ethnic groups.

What action can be taken?

In their conclusion, the researchers emphasize the need for health systems and primary care providers to identify and address barriers to consistent alcohol screening. Interventions such as linking clinical reminders to chronic conditions and underrepresented racial/ethnic groups could improve screening rates. Investing in these screening systems and follow-up treatment for excessive alcohol use can provide substantial health benefits for patients with chronic conditions and help advance healthcare equity.

What are the key takeaways?

Alcohol screening is an effective preventive health service for patients with chronic conditions that can be exacerbated by excessive alcohol use.
Health reforms such as the Affordable Care Act successfully increased alcohol screenings across the population, in particular for patients covered by Medicaid.
Black and AAPI patients continue to receive alcohol screenings at lower rates than White patients, potentially widening disparities in chronic disease morbidity and mortality.
Screening rates remained stagnant for uninsured patients, highlighting additional barriers to accessing preventive healthcare.

References

Mulia, N., Zhu, Y., Phillips, A. Z., Ye, Y., Bensley, K. M. K., & Karriker-Jaffe, K. J. (2024). Inequities in alcohol screening of primary care patients with chronic conditions. American Journal of Preventive Medicine, In Press, Corrected Proof. https://doi.org/10.1016/j.amepre.2024.07.017