Summary

Health coverage plays a major role in enabling people to access health care and protecting families from high medical costs. People of color have faced longstanding disparities in health coverage that contribute to disparities in health. This brief examines trends in health coverage by race/ethnicity between 2010 through 2019, prior to the onset of the COVID-19, and discusses the implications for health disparities. It is based on KFF analysis of American Community Survey data for the nonelderly population. It finds:

Prior to the Affordable Care Act (ACA), people of color were more likely to be uninsured than their White counterparts. As of 2010, nonelderly Hispanic and American Indian and Alaska Native (AIAN) people had the highest uninsured rates, with nearly one in three lacking coverage, compared to 13.1% of nonelderly White people.

The ACA created new health coverage options that helped to narrow, but did not eliminate, these disparities in health coverage. Between 2010 and 2016, there were large gains in coverage across all racial/ethnic groups under the ACA. Hispanic people experienced the largest percentage point decline in their uninsured rate over the period, which fell 32.6% to 19.1%. Despite these gains in coverage, people of color remained more likely to be uninsured than their White counterparts as of 2016.

Beginning in 2017, coverage gains began reversing and the number of uninsured increased for three consecutive years. Uninsured rates increased for Hispanic, Black, and White people between 2016 and 2019, eroding some of the previous coverage gains realized under the ACA. These coverage losses likely reflected a range of policy changes made by the Trump administration that contributed to reduced access to and enrollment in coverage.

As of 2019, nonelderly AIAN, Hispanic, NHOPI, and Black people remained more likely to lack health insurance than their White counterparts. The higher uninsured rates among these groups largely reflects more limited rates of private coverage among these groups. While Medicaid and the Children’s Health Insurance Program (CHIP) help fill the gap in private coverage for people of color, they do not fully offset the difference, leaving them more likely to be uninsured. Across racial and ethnic groups, uninsured rates were higher and Medicaid coverage levels were lower in states that have not expanded Medicaid compared to those that have adopted the ACA Medicaid expansion.

Since 2019, job losses and decreases in income resulting from the COVID-19 pandemic, which have disproportionately affected people of color, may have contributed to disruptions in health coverage. The Biden administration and Congress have taken a range of actions to expand access to and enrollment in health coverage, which may help increase coverage and reduce disparities in coverage among people of color. Eliminating disparities in health coverage is an important component of addressing longstanding racial disparities in health. However, to advance health equity, it also will be important to address other inequities within the health care system as well as inequities across the broad range of social and economic factors that drive health.

Trends in Uninsured Rates by Race/Ethnicity, 2010-2019

Prior to the ACA, people of color were more likely to be uninsured compared to their White counterparts. In 2010, when the ACA was enacted, 46.5 million people or 17.8% of the total nonelderly population were uninsured. People of color were at much higher risk of being uninsured compared to White people, with Hispanic and AIAN people at the highest risk of lacking coverage (Figure 1). The higher uninsured rates among people of color reflected more limited access to affordable health coverage options. Although, the majority of individuals have at least one full-time worker in the family across racial and ethnic groups, people of color are more likely to live in low-income families that do not have coverage offered by an employer or to have difficulty affording private coverage when it is available. While Medicaid helped fill some of this gap in private coverage, prior to the ACA, Medicaid eligibility for parents was limited to those with very low incomes (often below 50% of the poverty level), and adults without dependent children—regardless of how poor—were ineligible under federal rules.

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Figure 1: Uninsured Rates for the Nonelderly Population by Race and Ethnicity, 2010-2019

Between 2010 and 2016, there were large gains in coverage across racial/ethnic groups under the ACA, but people of color remained more likely to be uninsured. The ACA created new coverage options for low- and moderate-income individuals. These 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, the ACA also required most people to have health insurance or be subject to a tax penalty. Beginning in 2014, the ACA expanded Medicaid coverage to nearly all adults with incomes at or below 138% of poverty in states that adopted the expansion and made tax credits available to people with incomes up to 400% of poverty to purchase coverage through a health insurance marketplace. Following the ACA’s enactment in 2010 through 2016, coverage increased across all racial/ethnic groups, with the largest increases occurring after implementation of the Medicaid and marketplace coverage expansions in 2014. Nonelderly Hispanics had the largest percentage point increase in coverage, with their uninsured rate falling from 32.6% to 19.1%. Nonelderly Black, Asian, and AIAN people also had larger percentage point increases in coverage compared to White people over that period. Despite these larger gains, nonelderly AIAN, Hispanic, Black, and NHOPI people remained more likely than their White counterparts to be uninsured as of 2016.

Beginning in 2017, coverage gains began reversing, and the number of uninsured increased for three consecutive years. The uninsured rate for the total nonelderly population increased from 10.0% in 2016 to 10.9% in 2019. Nonelderly Hispanic people had the largest significant increase in their uninsured rate over this period (from 19.1% to 20.0%). Further, Hispanic people accounted for over half of the 1.1 million increase in the total nonelderly uninsured between 2018 and 2019 alone. There were also small but statistically significant increases in the uninsured rates among nonelderly White and Black people, which rose from 7.1% to 7.8% and 10.7% to 11.4%, respectively, between 2016 and 2019. Rates for nonelderly AIAN, NHOPI, and Asian people did not have a significant change. These coverage losses likely reflected a range of policy changes made by the Trump administration after taking office in 2017 that reduced access to and enrollment in coverage. These changes included decreased funds for outreach and enrollment assistance, introduction of plans to compete with ACA Marketplace plans, elimination of the penalty for not having coverage, guidance encouraging states to seek waivers to add new eligibility requirements for Medicaid coverage, and changes to immigration policy that are made some immigrant families more reluctant to participate in Medicaid and CHIP.

Health Coverage by Race/Ethnicity as of 2019

As of 2019, nonelderly AIAN, Hispanic, NHOPI, and Black people remained more likely to lack health insurance than their White counterparts (Figure 2). The higher uninsured rates among these groups largely reflects more limited rates of private coverage among these groups. While Medicaid and the CHIP help fill the gap in private coverage for people of color, they do not fully offset the difference, leaving them more likely to be uninsured. Gaps in health coverage were larger among nonelderly adults compared to children, reflecting broader eligibility through Medicaid and CHIP for children compared to adults, even among states that have implemented the ACA Medicaid expansion. Over half of Hispanic, Black, and AIAN children and nearly half of NHOPI children were covered by Medicaid and CHIP in 2019, helping to narrow racial disparities in coverage among children. Even with this coverage, however, AIAN, NHOPI, and Hispanic children remained more likely to be uninsured than White children.

Across racial and ethnic groups, uninsured rates were higher and Medicaid coverage levels were lower in states that have not expanded Medicaid compared to those that have implemented the ACA Medicaid expansion.Among the total nonelderly population, across racial/ethnic groups uninsured rates in states that have not expanded Medicaid are nearly twice as high as rates in expansion states (Figure 3). These differences are primarily driven by differences in coverage rates among nonelderly adults by state expansion status. However, even among children, there are large differences in coverage rates by expansion status for some groups. For example, 15% of Hispanic children in non-expansion states are uninsured, compared to 6% of Hispanic children in expansion states. There is also are large difference in uninsured rates for NHOPI children, as over one in five (21%) lack coverage in non-expansion states compared to 5% in states that have expanded.

Eligibility for Coverage Among the Remaining Uninsured

There are opportunities to increase coverage by enrolling eligible people in Medicaid or marketplace coverage, but Black, Hispanic, and Asian nonelderly uninsured people are less likely to be eligible compared to their White counterparts. Prior to the pandemic, over half of the nonelderly uninsured were eligible for financial assistance through Medicaid or the ACA Marketplaces. The American Rescue Plan Act (ARPA) enacted in 2021 further increased access to health coverage through temporary increases and expansions in eligibility for subsidies to buy health insurance through the health insurance marketplaces. It also includes incentives to states that have not yet adopted the ACA Medicaid expansion to do so and provides a new option for states to extend the length of Medicaid coverage for postpartum women. With the temporary changes under ARPA, over six in ten (63%) nonelderly uninsured are eligible for financial assistance, while the remaining 37% are not eligible because their state did not expand Medicaid, their income was too high to qualify for marketplace subsidies, or they were ineligible due to their immigration status. Black, Hispanic, and Asian nonelderly uninsured people are less likely to be eligible for ACA coverage than their White counterparts. For example, nonelderly uninsured Black are people more likely than their White counterparts to fall in the coverage gap in states that have not expanded Medicaid, and uninsured nonelderly Hispanic and Asian people are more likely to be ineligible for coverage due to immigration status, reflecting higher shares of noncitizens among these groups (Figure 4).

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Figure 4: Eligibility for ACA Coverage Among Nonelderly Uninsured by Race/Ethnicity

Uninsured nonelderly Black people are more likely than White people to fall in the Medicaid “coverage gap” because a greater share live in states that have not implemented the Medicaid expansion. As of July 2021, 12 states have not adopted the ACA provision to expand Medicaid to adults with incomes through 138% of poverty. In these states, 2.2 million uninsured people with incomes under poverty fall in the “coverage gap” and do not qualify for either Medicaid or premium subsidies in the ACA marketplace.1 An additional 1.8 million uninsured adults in these states are currently eligible for marketplace coverage (because their incomes are between 100% and 138% of poverty level) but would be eligible for Medicaid if their state expanded. Most of these states are in the South, where a higher share of the Black population resides (Figure 5).

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Figure 5: Share of Total Nonelderly Population that is Black by State and Medicaid Expansion Status

Uninsured nonelderly Hispanic and Asian people are less likely than their White counterparts to be eligible for coverage because they include larger shares of noncitizens who are subject to eligibility restrictions (Figure 6). 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.

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Figure 6: Citizenship Status of Nonelderly Uninsured Population by Race/Ethnicity, 2019

Looking Ahead

The economic downturn associated with COVID-19, which has disproportionately affected people of color, may have contributed to disruptions in health coverage. Data suggest that low-income and Black and Hispanic adults have been particularly hard hit by the economic fallout of the pandemic, experiencing higher rates of job and income loss compared to their White counterparts. As many people lose jobs and income, many may face disruptions in their health coverage since most people get their insurance through their employer. While Medicaid and the ACA marketplaces have provided coverage options for people losing employer-sponsored coverage who might otherwise become uninsured, some of those losing employer-sponsored insurance may become uninsured.

There are opportunities to narrow disparities in coverage by enrolling eligible people in Medicaid or marketplace coverage. As noted, ARPA includes temporary increases and expansions in eligibility for subsidies to buy health insurance through the health insurance marketplaces as well as incentives to encourage states that have not yet adopted the ACA Medicaid expansion to do so. These provisions increase access to coverage for people of color, which may help to reduce disparities in coverage. For example, analysis finds uninsured people eligible for zero-premium plans under the ARPA are disproportionately Hispanic. Other analysis finds that nearly two in three (66%) Black nonelderly uninsured adults and 69% of Hispanic nonelderly uninsured adults can access a zero-premium plan. Data also show that, if all remaining states expanded Medicaid, six in ten uninsured adults who would become eligible would be people of color. Research further shows that Medicaid expansion is associated with reductions in racial/ethnic disparities in health coverage as well as narrowed disparities in health outcomes for Black and Hispanic individuals, particularly for measures of maternal and infant health.

The Biden administration has taken actions to facilitate enrollment of eligible people in health coverage. In January 2021, President Biden issued an Executive Order on Strengthening Medicaid and the Affordable Care Act, which established a special open enrollment period beginning February 15, 2021 for the federal health insurance marketplace, healthcare.gov, serving 36 states, which is intended to mitigate coverage losses due to the COVID-19 pandemic. During the period, people who are currently uninsured can enroll and people already enrolled in marketplace plans can change to different policies without any qualifying event. The administration also restored funding for navigators to help eligible people enroll in health coverage, which research shows can play a key role in helping eligible individuals enroll, and launched initiatives focused on boosting enrollment among Black and Latino individuals. In addition, the administration reversed changes to public charge policies made under the Trump Administration, which had made immigrant families more reluctant to enroll in health care and other programs even if they were eligible. It also reversed state waivers that had implemented work requirements for Medicaid coverage, which analysis has suggested can contribute to coverage losses among people who remain eligible for coverage.

Even with these recent actions, gaps in coverage remain. It remains unclear, which if any remaining states will implement the Medicaid expansion. Moreover, some uninsured individuals remain ineligible for assistance through Medicaid or the marketplace subsidies, including immigrants who face eligibility restrictions for coverage. Undocumented immigrants are not eligible to enroll in Medicaid or marketplace coverage and lawfully present immigrants face restrictions that limit Medicaid eligibility for many who have had lawful status for less than five years. There are a range of potential options that the administration and Congress may pursue to fill remaining gaps in coverage. It remains to be seen what additional action may be taken.

Closing remaining gaps in coverage would help to address longstanding disparities in health, which have been exacerbated by the COVID-19 pandemic. 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. Uninsured people are far more likely than those with insurance to postpone health care or forgo it altogether. Being uninsured can also have financial consequences, with many unable to pay their medical bills, resulting in medical debt. As such, 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. However, beyond coverage, it also will be important to address inequities across the broad range of other social and economic factors that drive health and to address other inequities within the health care system that lead to poorer quality of care and health outcomes for people of color as part of efforts to advance health equity.

Endnotes
  1. Though a successful 2020 state ballot measure in Missouri directed the Medicaid expansion to be in effect by July 1, 2021, the state legislature excluded expanded coverage from its fiscal year (FY) 2022 budget and June 23, 2021 circuit court held that the state was not required to implement expansion. If expansion dose not proceed, an additional nearly 127,000 uninsured nonelderly adults would fall into the coverage gap.

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