Disparities in Health Measures By Race and Ethnicity Among Beneficiaries in Medicare Advantage: A Review of the Literature

Racial and Ethnic Health Equity in Medicare Advantage: Literature Review

Medicare Advantage is now the dominant form of Medicare coverage for Black, Hispanic, and Asian or Pacific Islander beneficiaries, while the share of American Indian or Alaska Native enrollees in these plans has more than doubled within the past decade (Figure 2). Medicare Advantage plans have several features that may attract enrollees, including people of color. These private plans are often available at little or no extra premium (other than the Part B premium), generally include an out-of-pocket limit (unlike traditional Medicare), and typically offer extra benefits such as dental, vision, and hearing services. Given relatively high Medicare Advantage enrollment rates among people of color, questions have emerged from policy makers, consumers, and others in the general community about whether there are racial and ethnic disparities in quality of care and beneficiary experience among Medicare Advantage enrollees.

To inform these questions, this brief summarizes findings from 20 studies published between January 1, 2018 and April 1, 2023 that compare quality of care and beneficiary experiences between people of color in Medicare Advantage and White enrollees, or the total Medicare Advantage population. These studies evaluated 46 different measures of quality of care and enrollee experience in Medicare Advantage. This report also discusses gaps in data and in the literature that contribute to challenges in understanding racial and ethnic disparities in quality of care and beneficiary experience in Medicare Advantage.

How do measures of quality of care and beneficiary experience compare between Black and White Medicare Advantage enrollees?

Nineteen studies examined 46 measures of quality of care and beneficiary experience among non-Hispanic Black enrollees (hereafter referred to as “Black enrollees”), including 17 studies that compared estimates for Black enrollees to White enrollees, and two studies that compared estimates for Black enrollees to the overall Medicare Advantage population, which is comprised of mostly White enrollees. These 19 studies examined hospital readmission rates (1 study), potentially avoidable hospitalizations for ambulatory care sensitive conditions (ACSCs) (2 studies), specific measures of disease management (8 studies), quality of plans (3 studies), measures related to experiences with care (8 studies), and utilization of preventive services (7 studies) (Appendix Table 1, Appendix Table 2). Most studies included multiple measures, and some measures were examined among enrollees with different conditions (e.g., receipt of statin therapy examined separately for enrollees with diabetes and cardiovascular conditions).

Among the 19 studies included in this review that compared measures for Black and White Medicare Advantage enrollees, results were less favorable for Black Medicare Advantage enrollees on more than half (24) of the measures examined for this group, more favorable on eight measures, similar on five measures, inconsistent across studies on two measures, and for seven measures, study authors described differences as not practically significant. A description of these results follows.

Hospital Readmissions and Potentially Avoidable Hospitalization

• Black Medicare Advantage enrollees had higher rates of hospitalization for ambulatory care sensitive conditions than White enrollees, based on two studies that controlled for differences in enrollees’ health status.¹, ² One of these studies also examined hospitalizations for ambulatory care sensitive conditions in different health care markets and found that differences persisted across geographic areas.³
• An additional study found that among enrollees in skilled nursing facilities, Black enrollees had higher rates of 30-day hospital readmissions than White enrollees after adjusting for differences in enrollee health status and other demographic characteristics.⁴ The differences were lower, but persisted when comparing Black and White enrollees who had stays at the same skilled nursing facility.

Disease management

• Mental health and substance use care: Compared to both White enrollees and the overall Medicare Advantage population, a lower share of Black enrollees with depression received antidepressant medication management (i.e., treated with antidepressant medication and remained on the medication for at least 12 weeks),^{5, 6, 7} and among those who were hospitalized or who had an emergency department visit for treatment of selected mental health conditions, a lower share of Black enrollees received follow-up care within 30 days of the hospital stay^{8, 9, 10} or emergency department visit.^{11, 12} However, among enrollees with a new episode of alcohol or other drug dependence, a higher share of Black enrollees than White enrollees and the overall Medicare Advantage population initiated treatment for alcohol or other drug dependence within 14 days of diagnosis.^{13, 14}
• Cardiovascular health: Compared to White enrollees and the overall Medicare Advantage population, a lower share of Black enrollees who were hospitalized and discharged with a diagnosis of acute myocardial infarction (i.e., a heart attack) received beta-blocker treatments;^{15, 16} a lower share of Black enrollees with cardiovascular disease adhered to statin therapy;^{17, 18} and a lower share of Black enrollees with hypertension had their blood pressure controlled.^{19, 20, 21} Additionally, among enrollees with a history of a cardiac event, a lower share of Black enrollees than White enrollees had their cholesterol adequately controlled.²²
• Diabetes care: Among enrollees with diabetes, a lower share of Black enrollees than White enrollees and the overall Medicare Advantage population had their blood sugar and blood pressure under control and adhered to statin therapy.^{23, 24} A lower share of Black enrollees than White enrollees used diabetes technology (e.g., insulin pump, continuous glucose monitoring).²⁵ Conversely, a higher share of Black enrollees with diabetes than White enrollees and the overall Medicare Advantage population received eye exams.^{26, 27}
• Multiple high-risk chronic conditions: Among enrollees with multiple high-risk chronic conditions, a lower share of Black enrollees than White enrollees and the overall Medicare Advantage population received follow-up care within seven days of an emergency department visit.^{28, 29}
• Other conditions: Among enrollees with chronic kidney disease, a lower share of Black enrollees than White enrollees were not dispensed a prescription for a potentially harmful medication,³⁰ and a higher share of Black enrollees than White enrollees had their kidney function decline at a faster rate over time.³¹ Conversely, among enrollees with dementia, a higher share of Black enrollees than White enrollees and the overall Medicare Advantage population were not dispensed a prescription for a potentially harmful medication for dementia.^{32, 33} A similar share of Black and White women ages 67 to 85 years who suffered a fracture had their osteoporosis adequately managed,³⁴ and a similar share of Black and White enrollees were dispensed a prescription for their rheumatoid arthritis.³⁵

Experiences with care

• A lower share of Black enrollees than White enrollees reported having a specialist visit in the past year, having a usual source of care, and having a primary care clinician as the source of regular care.³⁶
• A similar share of Black and White enrollees reported well-coordinated care and getting needed prescription drugs.³⁷ Findings related to getting needed care were mixed: one study found that a similar share of Black and White enrollees reported getting needed care,³⁸ while a second study, which did not control for differences in enrollee characteristics, found that a lower share of Black enrollees than White enrollees reported getting needed care.³⁹
• A similar share of Black enrollees and the overall Medicare Advantage population reported getting appointments and care quickly and that it was easy to get needed prescription drugs.⁴⁰
• A similar share of Black and White enrollees were enrolled in plans with narrow networks (i.e., less than 25% of available providers included in network) of primary care, psychiatry, and mental and behavioral health providers, based on a study that calculated the share of enrollees with various characteristics who were enrolled in plans with networks of different breadths.⁴¹ In a second study, a lower share of Black enrollees with end-stage renal disease were enrolled in plans with narrow networks of dialysis facilities than White enrollees.⁴²

Utilization of preventive services

• Vaccines: A lower share of Black enrollees than White enrollees and the overall Medicare Advantage population received flu vaccines^{43, 44, 45, 46} and pneumonia vaccines,⁴⁷ but a higher share of Black enrollees than White enrollees completed the full regimen of COVID-19 vaccines.⁴⁸
• Preventive cancer screenings: A lower share of Black enrollees than White enrollees and the overall Medicare Advantage population received prostate cancer screenings⁴⁹ but a higher share of Black enrollees received breast cancer screenings.^{50, 51, 52} A higher share of Black enrollees than White enrollees received colorectal cancer screenings⁵³ and pap smears.⁵⁴ However, a similar share of Black enrollees and the overall Medicare population received colorectal cancer screenings.⁵⁵
• Other preventive screenings: A lower share of Black enrollees than White enrollees had their cholesterol levels tested.⁵⁶ A similar share of Black and White enrollees without diabetes had their blood sugar tested to detect diabetes.⁵⁷

Quality Ratings of plans

• A lower share of Black enrollees than White enrollees were enrolled in higher-rated plans (i.e., 4-, 4.5- or 5-star plans), a result attributed to limited offerings of higher-rated Medicare plans in counties where Black enrollees reside.⁵⁸
• Black enrollees were more likely than White beneficiaries to be enrolled in lower-rated plans based on quality ratings calculated from the subset of measures included in the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey responses.⁵⁹
• A lower share of Black enrollees than White enrollees were in a vertically integrated plan (defined by the study authors as plans that were associated with a hospital health system that provides care), which the study found had higher overall star ratings.⁶⁰

How do measures of quality of care and beneficiary experience compare between Hispanic and White Medicare Advantage enrollees?

Seventeen studies examined 42 measures of quality of care and beneficiary experience among Hispanic enrollees, including 15 studies that compared estimates for Hispanic enrollees to White enrollees, and two studies that compared estimates for Hispanic enrollees to the overall Medicare Advantage population. These 17 studies examined hospital readmission rates (1 study), potentially avoidable hospitalizations for ACSCs (1 study), specific measures for disease management (8 studies), quality of plans (3 studies), and measures related to experiences with care (7 studies) (Appendix Table 1, Appendix Table 2). Most studies included multiple measures, and some measures were examined among enrollees with different conditions (e.g., receipt of statin therapy examined separately for enrollees with diabetes and cardiovascular conditions).

Among the 17 studies included in this review that compared measures for Hispanic and White Medicare Advantage enrollees, results were less favorable for Hispanic than White Medicare Advantage enrollees on more than a third (16) of measures examined for this group, more favorable on eight measures, similar on five measures, inconsistent across studies on three measures, and for 10 measures, study authors described differences as not practically significant. A description of these results follows.

Hospital Readmissions and Potentially Avoidable Hospitalization

• Hispanic and White enrollees had similar rates of hospitalization for ambulatory care sensitive conditions after controlling for differences in enrollees’ characteristics, including health status.⁶¹
• An additional study found that among enrollees in skilled nursing facilities, Hispanic and White enrollees had similar rates of 30-day hospital readmissions, after adjusting for differences in enrollee characteristics, such as health status.⁶²

Disease management

• Mental health and substance use care: Compared to White Medicare Advantage enrollees and the overall Medicare Advantage population, a lower share of Hispanic enrollees received antidepressant medication management (among those with depression),^{63, 64, 65} received follow-up care within 30 days of an emergency department visit for treatment of selected mental health conditions,^{66, 67} and initiated treatment within 14 days of a new episode of alcohol or other drug dependence.^{68, 69, 70} Among two studies that examined the share of enrollees receiving a follow-up visit within 30 days of hospitalization for treatment of select mental health conditions, one study found that a similar share of Hispanic and White enrollees received this follow-up care,⁷¹ while the other study found that a higher share of Hispanic enrollees than White enrollees received this follow-up care.⁷²
• Cardiovascular health: Compared to White enrollees and the overall Medicare Advantage population, a lower share of Hispanic enrollees who were hospitalized for a heart attack received beta-blocker treatments,^{73, 74} and a lower share of Hispanic enrollees with cardiovascular disease adhered to statin therapy.^{75, 76} A similar share of Hispanic and White enrollees with a history of a cardiac event had their cholesterol adequately controlled.⁷⁷ Findings on a measure related to blood pressure control were mixed: one study found that a higher share of Hispanic enrollees with hypertension had their blood pressure under control compared to White enrollees with hypertension,⁷⁸ while the second study found that the rates were similar between Hispanic and White enrollees.⁷⁹
• Diabetes care: Among Medicare Advantage enrollees with diabetes, a lower share of Hispanic enrollees than White enrollees and the overall Medicare Advantage population adhered to statin therapy⁸⁰ and used diabetes technology,⁸¹ but a higher share of Hispanic enrollees received eye exams^{82, 83} and statin therapy,^{84, 85} and had their blood pressure under control.⁸⁶ While a similar share of Hispanic and the overall Medicare Advantage population had their blood sugar controlled,⁸⁷ differences between Hispanic and White enrollees on this measure were mixed: one study found that a lower share of Hispanic enrollees than White enrollees had their blood sugar under control,⁸⁸ while the second study found that the rates were similar between Hispanic and White enrollees.⁸⁹
• Multiple high-risk chronic conditions: Among enrollees with multiple high-risk chronic conditions, a lower share of Hispanic enrollees than White enrollees and the overall Medicare Advantage population received follow-up care within seven days of an emergency department visit.^{90, 91}
• Other conditions: Among enrollees with chronic kidney disease, a lower share of Hispanic enrollees than White enrollees and the overall Medicare Advantage population were not dispensed a prescription for a potentially harmful medication,^{92, 93} and Hispanic enrollees had their kidney function decline at a faster rate over time than White enrollees.⁹⁴ Among enrollees with dementia, a lower share of Hispanic enrollees than White enrollees and the overall Medicare Advantage population were not dispensed a prescription for a potentially harmful medication.^{95, 96, 97} Conversely, among women ages 67 to 85 years in Medicare Advantage plans who suffered a fracture, a higher share of Hispanic enrollees than White enrollees and the overall Medicare Advantage population had their osteoporosis adequately managed.^{98, 99}

Experiences with care

• A lower share of Hispanic enrollees than White enrollees and the overall Medicare Advantage population reported getting appointments and care quickly.^{100, 101} Additionally, a lower share of Hispanic than White enrollees reported getting needed care,^{102, 103} including in one study that did not control for differences in enrollee characteristics.¹⁰⁴
• A similar share of Hispanic enrollees and the overall Medicare Advantage population reported that it was easy to get needed prescription drugs.¹⁰⁵
• Higher shares of Hispanic enrollees than White enrollees were enrolled in plans with narrow networks (i.e., less than 25% of available providers included in network) of primary care providers,¹⁰⁶ psychiatrists,¹⁰⁷ and dialysis facilities.¹⁰⁸ The study that looked at narrow networks of primary care and psychiatry providers presented bivariate comparisons of enrollees with various characteristics who were enrolled in plans with networks of different breadths,¹⁰⁹ while the study that focused on narrow networks of dialysis facilities presented both bivariate and multivariate comparisons.¹¹⁰

Utilization of preventive services

• Vaccines: A lower share of Hispanic enrollees than White enrollees received flu vaccines,^{111, 112} including a study that did not present multivariate comparisons.¹¹³ A higher share of Hispanic enrollees than White enrollees received COVID-19 vaccinations.¹¹⁴
• Preventive cancer screenings: A higher share of Hispanic enrollees than White enrollees and the overall Medicare population received appropriate screenings for breast cancer^{115, 116} and pap smears.¹¹⁷ A similar share of Hispanic and White enrollees were screened for prostate cancer.¹¹⁸
• Other preventive screenings: A higher share of Hispanic enrollees than White enrollees had their cholesterol levels tested¹¹⁹ and among enrollees without diabetes, a higher share of Hispanic enrollees than White enrollees had their blood sugar tested to detect diabetes.¹²⁰

Quality of plans

• A lower share of Hispanic enrollees than White enrollees were enrolled in 5-star rated plans, but a somewhat higher share of Hispanic than White enrollees were enrolled in 4-, 4.5, or lower (2- to 3.5) star rated plans, after adjusting for availability of plans at the county level.¹²¹
• A separate study found that Hispanic enrollees were more likely than White enrollees to be enrolled in lower-rated plans based on quality ratings calculated from the subset of measures included in the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey responses. ¹²²
• A third study found similar shares of Hispanic and White beneficiaries were enrolled in vertically integrated Medicare Advantage plans (i.e., plans associated with a hospital health system that provides care), which the study found had higher overall star ratings.¹²³

How do measures of quality of care and beneficiary experience compare between Asian and Pacific Islander and White Medicare Advantage enrollees?

Thirteen studies examined 36 measures of quality of care and beneficiary experience among Asian and Pacific Islander enrollees, including 11 studies that compared estimates for Asian and Pacific Islander enrollees to White enrollees and two studies that compared estimates for Asian and Pacific Islander enrollees to the overall Medicare Advantage population. Of the 13 studies, three studies presented estimates for Asian enrollees separately, seven studies presented findings for Asian and Pacific Islander enrollees as a single category, and three studies grouped Asian, Pacific Islander, and Native Hawaiians into a single category (See Appendix Table 1 for results for each group).

These 13 studies examined potentially avoidable hospitalizations for ACSCs (1 study), specific measures of disease management (8 studies), quality of plans (2 studies), measures related to experiences with care (6 studies), and utilization of preventive services (4 studies) (Appendix Table 1, Appendix Table 2). Most studies included multiple measures, and some measures were examined among enrollees with different conditions (e.g., receipt of statin therapy examined separately for enrollees with diabetes and cardiovascular conditions).

Among the 13 studies that compared measures for Asian and Pacific Islander and White Medicare Advantage enrollees, results were less favorable for Asian and Pacific Islander enrollees than White enrollees on nine of the measures examined for this group, more favorable on seven measures, similar on seven measures, inconsistent across studies on three measures, and for 10 measures, study authors described differences as not practically significant. A description of these results follows.

Potentially Avoidable Hospitalization

• Asian and Pacific Islander and White enrollees had similar rates of hospitalization for ambulatory care sensitive conditions, after controlling for differences in enrollee health status.¹²⁴

Disease management

• Mental health care: Among Medicare Advantage enrollees with depression, a lower share of Asian and Pacific Islander enrollees than White enrollees and the overall Medicare Advantage population received antidepressant medication management,^{125, 126, 127} and among enrollees with a new episode of alcohol or other drug dependence, a lower share of Asian and Pacific Islander enrollees than both groups initiated treatment for the condition.^{128, 129}Conversely, a higher share of Asian and Pacific Islander enrollees than White enrollees and the overall Medicare Advantage population were not prescribed opioids at a high dosage for more than 14 days.^{130, 131} A similar share of Asian and Pacific Islander enrollees and White enrollees received follow-up care within 30 days of an emergency department visit for select mental health conditions.¹³² Findings on receipt of follow-up care after hospital stays for mental illness were mixed: one study found that a higher share of Asian and Pacific Islander enrollees than White enrollees received this follow-up care,¹³³ while the second study found that a similar share of Asian and Pacific Islander and White enrollees received this follow-up care.¹³⁴

• Diabetes care: A lower share of Asian and Pacific Islander enrollees with diabetes than White enrollees used diabetes technology (either insulin pump or continuous glucose monitoring).¹³⁵ Conversely, among enrollees with diabetes, a higher share of Asian and Pacific Islander enrollees than White enrollees and the overall Medicare Advantage population received statin therapy and eye exams,^{136, 137} and a higher share of Asian and Pacific Islander than White enrollees with diabetes had their blood pressure under control.¹³⁸ Two studies that examined blood sugar control for Asian and Pacific Islander enrollees compared to White enrollees had mixed findings: one study found that a lower share of Asian and Pacific Islander enrollees than White enrollees had their blood sugar controlled,¹³⁹ while a second study found that a higher share of Asian and Pacific Islander enrollees than White enrollees had their blood sugar controlled.¹⁴⁰ An additional study found that a higher share of Asian and Pacific Islander enrollees than the share of Medicare Advantage enrollees overall had their blood sugar controlled.¹⁴¹ Among enrollees with diabetes, a similar share of Asian and Pacific Islander enrollees and the overall Medicare Advantage population had their blood pressure under control.¹⁴²
• Cardiovascular health: Compared to White enrollees and the overall Medicare Advantage population, a similar share of Asian and Pacific Islander enrollees who were hospitalized for a heart attack received beta-blocker treatments,¹⁴³ and a similar share of Asian and Pacific Islander enrollees with a history of a cardiac event had their cholesterol adequately controlled.¹⁴⁴ In the two studies that examined the share of enrollees with hypertension who had their blood pressure under control, differences in the shares of Asian and Pacific Islander and White enrollees on this measure were mixed.^{145, 146} An additional study comparing the share of Asian and Pacific Islander enrollees with hypertension to the overall Medicare Advantage population found that a higher share of Asian and Pacific Islander enrollees had their blood pressure controlled than the overall Medicare Advantage population.¹⁴⁷
• Other conditions: Compared to White enrollees and the overall Medicare Advantage population, a higher share of Asian and Pacific Islander enrollees with dementia were not dispensed a prescription for a potentially harmful medication,^{148, 149, 150} and a higher share of Asian and Pacific Islander women ages 67 to 85 years who suffered a fracture had their osteoporosis adequately managed.^{151, 152} Asian and Pacific Islander and White enrollees with chronic kidney failure experienced similar progression of the disease over time.¹⁵³
• Multiple high-risk chronic conditions: Among enrollees with multiple high-risk chronic conditions, a higher share of Asian and Pacific Islander enrollees than the overall Medicare Advantage population received follow-up care within seven days of an emergency department visit.¹⁵⁴

Experiences with care

• A lower share of Asian and Pacific Islander enrollees than White enrollees and the overall Medicare Advantage population reported getting needed care, getting appointments and care quickly, having their care well-coordinated, and getting needed prescription drugs.^{155, 156}
• A higher share of Asian and Pacific Islander enrollees than White enrollees were enrolled in plans with narrow networks (i.e., less than 25% of available providers included in network) of primary care providers,¹⁵⁷ psychiatrists,¹⁵⁸ mental and behavioral health providers,¹⁵⁹ and dialysis facilities.¹⁶⁰ One of these studies presented bivariate comparisons of enrollees with various characteristics who were enrolled in plans with networks of primary care, psychiatry, and mental health providers of different breadths,¹⁶¹ while the other study, focusing on networks of dialysis facilities, presented both bivariate and multivariate comparisons.¹⁶²

Utilization of preventive services

• Vaccines: A higher share of Asian and Pacific Islander than White enrollees and the overall Medicare Advantage population received a flu vaccine.^{163, 164}
  Preventive cancer screenings: The share of Asian and Pacific Islander enrollees receiving colorectal cancer screenings was similar to the share among White enrollees and the overall Medicare Advantage population.^{165, 166}

Quality of plans

• A lower share of Asian and Pacific Islander enrollees than White enrollees were enrolled in 4-, 4.5-, and 5-star rated plans and a higher share of Asian and Pacific Islander than White enrollees were enrolled in plans with ratings of 3.5 stars or below, after adjusting for availability of plans at the county level. ¹⁶⁷
• A similar share of Asian and Pacific Islander and White enrollees were enrolled in vertically integrated Medicare Advantage plans.¹⁶⁸

How do measures of quality of care and beneficiary experience compare between American Indian and Alaska Native Medicare Advantage enrollees and White enrollees?

Nine studies examined 25 measures of quality of care received by American Indian and Alaska Native enrollees, including seven studies that compared estimates for American Indian and Alaska Native enrollees to White enrollees, and two studies that compared estimates for American Indian and Alaska Native enrollees to the overall Medicare Advantage population. These nine studies examined measures for disease management (5 studies), quality of plans (1 study), experiences with care (7 studies), and utilization of preventive services (7 studies) (Appendix Table 1, Appendix Table 2). Most studies included multiple measures, and some measures were examined among enrollees with different conditions (e.g., receipt of statin therapy examined separately for enrollees with diabetes and cardiovascular conditions). These nine studies did not further disaggregate American Indian and Alaska Native enrollees living in tribal areas, likely due to sample size limitations.

Among the nine studies included in this review that compared American Indian and Alaska Native and White Medicare Advantage enrollees, findings were less favorable for American Indian and Alaska Native enrollees that White Medicare Advantage enrollees on seven measures, more favorable on four measures, similar on 12 measures, inconsistent across studies on one measure, and for one measure, study authors described differences as not practically significant.

Disease management

• Mental health care: A lower share of American Indian and Alaska Native enrollees than White enrollees initiated treatment for alcohol or other drug dependence within 14 days of diagnosis,¹⁶⁹ but a higher share of American Indian and Alaska Native enrollees was not prescribed opioids at a high dosage.¹⁷⁰ A similar share of American Indian and Alaska Native enrollees and White enrollees with depression received antidepressant medication management.¹⁷¹Compared to the overall Medicare Advantage population, a lower share of American Indian and Alaska Native enrollees received antidepressant medication management, but a higher share of American Indian and Alaska Native enrollees with a new episode of alcohol or other drug dependence initiated treatment for the condition.¹⁷²

• Cardiovascular health: A lower share of American Indian and Alaska Native enrollees with hypertension than White enrollees with hypertension had their blood pressure under control.¹⁷³ A similar share of American Indian and Alaska Native and White enrollees with cardiovascular disease received and adhered to statin therapy,¹⁷⁴ and a similar share of both groups of enrollees with a prior-year history of a cardiac event had their cholesterol under control.¹⁷⁵ However, compared to the overall Medicare Advantage population, a lower share of American Indian and Alaska Native enrollees with cardiovascular disease received and adhered to statin therapy.¹⁷⁶
• Diabetes care: Among enrollees with diabetes, a lower share of American Indian and Alaska Native enrollees than White enrollees and the overall Medicare Advantage population adhered to statin therapy^{177, 178} and had their blood sugar controlled.^{179, 180} Additionally, a lower share of American Indian and Alaska Native enrollees with diabetes than White enrollees had their blood pressure controlled.¹⁸¹ A similar share of American Indian and Alaska Native and White enrollees with diabetes received statin therapy and blood sugar testing.¹⁸² Compared to the overall population of Medicare Advantage enrollees with diabetes, a lower share of American Indian and Alaska Native enrollees received statin therapy, and a similar share received eye exams.¹⁸³
• Other conditions: Among enrollees with rheumatoid arthritis, a higher share of American Indian and Alaska Native enrollees than White enrollees received therapy for rheumatoid arthritis, and among enrollees with dementia, a higher share of American Indian and Alaska Native enrollees than White enrollees were not dispensed a prescription for a potentially harmful medication.¹⁸⁴ The share of American Indian and Alaska Native enrollees who were not dispensed a prescription for a potentially harmful medication for chronic renal failure was similar to the share among White enrollees¹⁸⁵ and the overall Medicare Advantage population.¹⁸⁶ Compared to the overall population of Medicare Advantage enrollees with dementia, a similar share of American Indian and Alaska Native enrollees with dementia were not dispensed a prescription for a potentially harmful medication.¹⁸⁷
• Multiple high-risk chronic conditions: Among enrollees with multiple high-risk chronic conditions, the share of American Indian and Alaska Native enrollees receiving follow-up care within seven days of an emergency department visit was similar to the share among White enrollees¹⁸⁸ and the overall Medicare Advantage population.¹⁸⁹

Experiences with care

• Compared to White enrollees and the overall Medicare Advantage population, a similar share of American Indian and Alaska Native enrollees reported getting needed care, getting appointments and care quickly, and having their care coordinated.^{190, 191} However, a lower share of American Indian and Alaska Native enrollees than White enrollees reported that it was easy to get needed prescription drugs.¹⁹²
• Among enrollees with end-stage renal disease, a higher share of American Indian and Alaska Native enrollees than White enrollees were enrolled in plans with narrow networks (e., less than 25% of available providers included in network) of dialysis facilities.¹⁹³ A similar share of American Indian and Alaska Native enrollees and White enrollees were enrolled in plans with narrow networks of primary care, psychiatry, and mental and behavioral health providers, based on a study that calculated the share of enrollees with various characteristics who were enrolled in plans with networks of different breadths.¹⁹⁴

Utilization of preventive services

• Vaccines: A similar share of American Indian and Alaska Native and White enrollees received a flu vaccine.¹⁹⁵ This review did not identify studies that compared utilization of other vaccines (e.g., pneumonia and COVID-19 vaccines) among American Indian and Alaska Native enrollees to White enrollees or to the total Medicare Advantage population.
• Preventive cancer screenings: A higher share of American Indian and Alaska Native women ages 50 to 74 in Medicare Advantage plans than White women of the same age in Medicare Advantage plans received breast cancer screening,¹⁹⁶ but a lower share of American Indian and Alaska Native women than women in the overall Medicare Advantage population received this screening.¹⁹⁷

Findings related to subgroups of people of color in Medicare Advantage plans

Gender. Only three studies in this review further stratified findings pertaining to Medicare Advantage enrollees by race and ethnicity and gender, with findings that generally mirrored the overall pattern for each racial or ethnic groups.^{198, 199, 200} For example, one study found that compared to White women and men enrolled in Medicare Advantage, a lower share of Asian and Pacific Islander women and men in Medicare Advantage, respectively, reported getting needed care, getting appointments and care quickly, having their care well-coordinated, and getting needed prescription drugs, and a higher share of Asian and Pacific Islander women and men than White women and men in Medicare Advantage reported getting an annual flu vaccine.²⁰¹

Rural residence. Just two studies examine measures of quality of care and beneficiary experience among enrollees in rural areas by race and ethnicity, with findings that mirrored the overall pattern in some, but not all measures.^{202, 203}For example, consistent with the overall pattern, a lower share of Black and Hispanic enrollees in rural areas than White enrollees in rural areas received beta-blocker treatments, but higher shares of Black and Hispanic enrollees in rural areas received breast cancer screenings.²⁰⁴ However, while a lower share of Hispanic enrollees than White enrollees overall reported getting appointments and care quickly, a similar share of Hispanic and White enrollees in rural areas reported getting appointments and care quickly. ²⁰⁵

Dual-eligible individuals. This review did not identify any studies that examined how measures of quality of care and beneficiary experience compare between dual-eligible people of color and dual-eligible White beneficiaries. Among dual-eligible individuals, higher shares of people of color are enrolled in Medicare Advantage plans than White beneficiaries: in 2020, a higher share of Black (54%), Hispanic (65%), and Asian/Pacific Islander (48%) dual-eligible individuals were enrolled in Medicare Advantage plans than White (41%) and American Indian or Alaska Native (25%) dual-eligible individuals. A better understanding of how these groups compare on measures of quality of care and beneficiary experiences could help inform an understanding of the extent to which Medicare Advantage plans are meeting the needs of dually-eligible individuals enrolled in these plans.

Discussion

With Medicare Advantage now covering more than half of all Black, Hispanic, and Asian and Pacific Islander Medicare beneficiaries, this review of the literature provides some insight into quality of care and beneficiary experiences for people of color enrolled in Medicare Advantage plans compared to White Medicare Advantage enrollees.

Overall, this review of these studies finds that while higher shares of Black Medicare Advantage enrollees than White enrollees received some preventive services, such as breast cancer screenings, findings were less favorable for Black enrollees than White enrollees on other preventive services, such as receipt of prostate cancer screenings, along with more than half of quality of care and beneficiary experience measures analyzed across the studies, such as higher rates of hospitalization for ambulatory care sensitive conditions. This review of the literature also finds that while higher shares of Hispanic enrollees than White enrollees received preventive services such as breast cancer screenings, findings were less favorable for Hispanic enrollees than White enrollees on more than a third of the measures, such as antidepressant medication management.

While a higher share of Asian and Pacific Islander enrollees than White enrollees received flu vaccines, few differences were found for Asian and Pacific Islander enrollees relative to White enrollees on other measures. Overall, fewer studies focused on American Indian and Alaska Native enrollees, making it difficult to assess the strength of the findings or how broadly they apply for this population. For instance, while a few studies examined receipt of breast cancer screenings among this population, this report did not identify studies that examined, or had sufficient sample size to examine, use of other preventive cancer screenings (e.g., colorectal, prostate, and cervical cancer screenings) among American Indian and Alaska Native enrollees compared with White enrollees or the overall Medicare Advantage population. None of the studies examined outcomes of care such as mortality rates or hospital-acquired infections by race and ethnicity, and very few studies focused on subgroups within each racial or ethnic group, such as gender and rural status. None of the identified studies examined the use of post-acute care or the total number or duration of hospital admissions among Medicare Advantage enrollees by race and ethnicity.

Substantial gaps in Medicare Advantage data hinder researchers’ ability to examine specific areas of interest in the context of Medicare Advantage, such as use of supplemental benefits offered by Medicare Advantage plans or the application of prior authorization and denials, by race and ethnicity. More concerted research efforts and more robust data to understand the experiences of people of color in Medicare Advantage plans would help inform policymakers and beneficiaries as enrollment in these plans continues to climb.

While the scope of this review is limited to Medicare Advantage enrollees, reflecting higher enrollment of Black, Hispanic, and Asian and Pacific Islander enrollees in these plans, the racial and ethnic disparities described in this report mirror disparities in health and health care in traditional Medicare, the overall Medicare population, and more broadly, the U.S adult population. Such disparities are influenced by a multitude of structural factors including systemic racism that accumulate over the course of a lifetime and may contribute to racial disparities in health experiences and outcomes in older ages.