Summary

The Affordable Care Act (ACA) coverage expansions provided an opportunity to increase coverage and address longstanding racial and ethnic disparities in health coverage.¹ This brief examines changes in health coverage by race and ethnicity between 2013 and 2017, providing insight into how coverage has changed since implementation of the ACA. It is based on Kaiser Family Foundation analysis of the nonelderly population using American Community Survey data. (See methods for more details). It shows:

• People of color experienced large gains in coverage under the ACA that narrowed longstanding disparities in coverage. Research suggests these gains will likely lead to reductions in disparities in access to and use of health care as well as health outcomes over the long-term.
• Between 2016 and 2017, coverage gains stalled or began reversing for some groups. The uninsured rate increased for the first time since implementation of the ACA, with small but statistically significant increases in the uninsured rates for Whites and Blacks.
• Despite the large coverage gains for people of color under the ACA, significant disparities in coverage persist. Recent federal and state policies, including several changes the Trump administration has made to ACA implementation and Medicaid waivers that add eligibility restrictions, may further erode coverage gains and progress reducing disparities. These disparities leave people of color at greater risk of difficulty accessing care and financial instability from health care costs.

  People of color saw big gains in coverage under the ACA that narrowed longstanding disparities. But from 2016 to 2017 coverage gains stalled or began reversing for some groups, including small but significant uninsured rate increases for whites and blacks

The ACA Health Coverage Expansions

The ACA created new coverage options for low- and moderate-income individuals that went into effect in 2014. Under the ACA, as of 2014, Medicaid coverage has been expanded to nearly all adults with incomes at or below 138% of poverty in states that have adopted the expansion, and tax credits are available for people with incomes up to 400% of poverty who purchase coverage through a health insurance marketplace. These new coverage options have increased access to health insurance and health care for millions. In addition, the ACA included provisions to promote employer-based coverage, extend dependent coverage in the private market up to age 26, and prevent insurers from denying people coverage or charging them more due to health status. As enacted, it also required most people to have health insurance coverage or be subject to a tax penalty.

Since taking office, the Trump administration has made several changes to ACA implementation that have altered the availability of coverage or likelihood that people will sign up for coverage. These changes include decreased funds for outreach and enrollment assistance, introduction of plans to compete with ACA marketplace plans, negation of the requirement to have coverage, guidance encouraging states to seek waivers to add new eligibility requirements for Medicaid coverage, and changes to immigration policy. These could erode the coverage gains and progress reducing disparities.

Coverage by Race/Ethnicity Prior to the ACA

Prior to the ACA, people of color were significantly more likely to be uninsured than Whites. In 2013, just before the major ACA coverage expansions went into effect, 44 million people or 16.8% of the total nonelderly population were uninsured. People of color were at much higher risk of being uninsured compared to Whites, with Hispanics and American Indians and Alaska Natives (AIANs) at the highest risk of lacking coverage (Figure 1). These higher uninsured rates reflected limited access to affordable health coverage options among groups of color. Although, across racial and ethnic groups, the majority of individuals had at least one-time full time worker in the family, most groups of color were significantly more likely to be low-income compared to Whites (data not shown). These findings reflect that people of color are more likely to be employed in low-wage jobs and industries that are less likely to offer health coverage. Further, given their lower incomes, they face increased difficulty affording employer-based coverage or private coverage through the individual market.

Figure 1: Health Coverage of Nonelderly Individuals by Race/Ethnicity, 2013

Changes in Coverage by Race/Ethnicity under the ACA

Since implementation of the major ACA health coverage expansions in 2014, people of color have experienced large coverage gains that helped narrow the longstanding racial and ethnic disparities in coverage. These gains reflected increases in both Medicaid and private coverage. Hispanics experienced the largest coverage gain (Figure 2). Asians, AIANs, and Blacks also experienced larger coverage gains compared to Whites. These coverage gains helped to narrow racial and ethnic disparities in coverage. However, people of color remained more likely to be uninsured, with AIANs and Hispanics at the highest risk of lacking coverage.

Figure 2: Uninsured Rates Among Nonelderly Individuals by Race/Ethnicity, 2013-2017

Most racial and ethnic groups had larger coverage gains in states that implemented the Medicaid expansion compared to those that have not. Except for Asians, all racial and ethnic groups experienced larger percentage point declines in their uninsured rate in states that implemented the expansion compared to states that did not (Figure 3).

Figure 3: Percentage Point Change in Uninsured Rates by Race/Ethnicity and State Medicaid Expansion Status, 2013-2017

Between 2016 and 2017, coverage gains stalled or began to reverse for some groups, with the uninsured rate increasing for the first time since implementation of the ACA. The uninsured rate among the total nonelderly population increased from 10.0% to 10.2%. Whites and Blacks had small but statistically significant increases in their uninsured rates, which rose from by 0.2 percentage points from 7.1% to 7.3% and by 0.5 percentage points from 10.7% to 11.1%, respectively (Figure 4). Other racial and ethnic groups did not have statistically significant changes in their uninsured rates.

Figure 4: Percentage Point Change in Uninsured Rates Among Nonelderly Individuals by Race/Ethnicity, 2016-2017

The Remaining Uninsured as of 2017

As of 2017, most groups of color remained significantly more likely to be uninsured than Whites. AIANs and Hispanics were at the highest risk of being uninsured, with over one in five (22%) AIANs and 19% of Hispanics lacking coverage compared to 7% of Whites (Figure 5). Uninsured rates for children were lower than rates for adults, but AIAN children were over three times as likely as White children to be uninsured and Hispanic children were twice as likely as White children to lack coverage.

Figure 5: Uninsured Rates Among Nonelderly Individuals by Race/Ethnicity, 2017

As of 2017, uninsured rates for all racial and ethnic groups were higher in states that have not implemented the Medicaid expansion compared to those that have expanded (Figure 6). This pattern reflects the fact that, prior to the ACA, most groups had higher uninsured rates in non-expansion states, and most groups experienced smaller coverage gains in non-expansion states compared to states that expanded.

Figure 6: Uninsured Rate Among Nonelderly Individuals by Race/Ethnicity and State Medicaid Expansion Status, 2017

There are opportunities to increase coverage among the remaining uninsured through enrollment of eligible individuals in Medicaid or Marketplace coverage, but eligibility varies across racial and ethnic groups and many remain ineligible for assistance. In 2017, 27.4 million nonelderly people lacked health insurance. An estimated 55% of this population is eligible for financial assistance for coverage through Medicaid (25%) or the Marketplaces (30%).² However, eligibility varies across racial and ethnic groups and many remain ineligible. For example, uninsured Blacks are more likely than Whites to fall in the coverage gap in states that have not expanded Medicaid, and uninsured Hispanics and Asians are less likely than Whites to be eligible for coverage options (Figure 7).

Figure 7: Current Eligibility for ACA Coverage Among the Nonelderly Uninsured by Race/Ethnicity

Uninsured nonelderly Blacks are more likely than Whites to fall in the coverage gap because a greater share live in states that have not implemented the Medicaid expansion. Nationwide, 2.5 million poor adults fall into a coverage gap in the 14 states that had not adopted the ACA Medicaid expansion to adults as of January 2019. Blacks make up a greater share of the population in the South, where most states have not expanded Medicaid (Figure 8).

Figure 8: Share of Total Population that is Black by State and Current Medicaid Expansion Status

Uninsured nonelderly Asians and Hispanics are less likely than Whites to be eligible for financial assistance for coverage, because they include larger shares of noncitizens who are subject to eligibility restrictions (Figure 9). Under the ACA, lawfully present immigrants continue to face eligibility restrictions for coverage, with many having to wait five years after obtaining lawful status before they may enroll in Medicaid coverage. Undocumented immigrants are not eligible to enroll in Medicaid and are prohibited from purchasing coverage through the Marketplaces.

Figure 9: Citizenship Status of Nonelderly Uninsured Population by Race/Ethnicity, 2017

Looking Ahead

There remain opportunities to increase coverage by enrolling eligible uninsured individuals into ACA coverage options, and coverage opportunities will increase if additional states adopt the Medicaid expansion. Following the 2018 elections, several states are poised to implement the Medicaid expansion in 2019³, and additional states may consider expansion moving forward. Implementation of the Medicaid expansion in additional states would increase opportunities to reduce disparities in coverage, particularly among Blacks, who currently are more likely to fall in the Medicaid coverage gap since a large share of the population lives in the South, where few states have adopted the Medicaid expansion.

However, recent federal and state policy changes could erode the coverage gains and progress achieved in reducing disparities in coverage under the ACA. The ACA contributed to large coverage gains among people of color that helped narrow disparities in coverage between 2013 and 2016. This began to reverse for some groups between 2016 and 2017, and significant disparities persisted as of 2017. Recent federal and state policies may further reverse coverage gains and erode the progress reducing disparities. Since taking office, the Trump administration has made several changes to ACA implementation that have altered the availability of coverage or likelihood that people will sign up for coverage. These changes include decreased funding for outreach and enrollment assistance, introduction of plans to compete with ACA marketplace plans, negation of the requirement to have coverage, and changes to immigration policy. In addition, in response to new guidance from the administration, several states have obtained waivers to add Medicaid eligibility restrictions to their programs, including work requirements and premiums, which result in additional barriers to coverage and coverage losses.

The outcomes of current debate over health coverage policy will have implications for people’s coverage, access, and overall health and well-being. Research shows that having health insurance makes a key difference in whether, when, and where people get medical care and ultimately how healthy they are.⁴ Uninsured people are far more likely than those with insurance to postpone health care or forgo it altogether. The consequences can be severe, particularly when preventable conditions or chronic diseases go undetected. Being uninsured can also have serious financial consequences, with many unable to pay their medical bills, resulting in medical debt. Given the significant impacts of coverage, future trends in coverage will have a significant impact on disparities in health access and use as well as health outcomes over the long-term.

Data and Methods