Latinos and Blacks Have Made Major Gains Under the Affordable Care Act, But Inequalities Remain
For decades, blacks and Latinos in the United States have been disproportionately uninsured and less likely than whites to receive the health care they need. But in the three years since the Affordable Care Act’s (ACA) health insurance marketplaces opened and states began to expand Medicaid eligibility, uninsured rates among Latinos and blacks have declined significantly, making it easier for people to access or afford needed care.
According to the most recent Commonwealth Fund Affordable Care Act tracking survey, conducted between February and April 2016, the uninsured rates for blacks dropped from 21 percent in 2013 to 13 percent in 2016 (Exhibit 1). The uninsured rates for Latinos also dropped—from a high of 36 percent pre-ACA to a low of 29 percent in the first quarter of 2016.
"Our study shows that most of the uninsured Latinos who remain unaware of the marketplaces were born outside of the United States (82%) and do not speak English very well (94%)."
Still, Latinos are significantly more likely than any other racial and ethnic group to be uninsured. One reason is that Latinos make up a disproportionate share (about 56 percent) of unauthorized immigrants, who are currently ineligible for Medicaid or participation in state and federal marketplaces.1 Our data show that foreign-born Latinos are more likely to be uninsured: 43 percent of foreign-born Latinos are uninsured compared with 14 percent of the U.S.-born. While our survey cannot determine citizenship status, we know from the American Community Survey that two-thirds of foreign-born Latinos (66%) are noncitizens and therefore not eligible for new coverage benefits.2
And yet, immigration status does not fully explain high uninsured rates among Latinos. According to an analysis of the American Community Survey, more than half of Latinos without health insurance in 2014 were citizens and thereby entitled to the full benefits of the health reform law.3
Medicaid Expansion Makes a Difference for Latino and Black Adults
States’ decisions about whether to expand Medicaid to low-income adults have also had an impact on uninsured rates among minorities. (See our map showing Medicaid expansion vs. nonexpansion states.) Among adults living in the 30 states and D.C. that had expanded Medicaid at the time of the survey, uninsured rates for blacks, whites, and U.S.-born Latinos are similar, ranging from 7 percent to 9 percent.4 In contrast, in states that had not expanded their Medicaid program, 16 percent of blacks and 24 percent of U.S.-born Latinos are uninsured, compared with 10 percent of whites (Exhibit 2). Uninsured rates do not differ significantly between white adults living in states that did or did not expand Medicaid.
Clearly, many more black and U.S.-born Latino adults would benefit if more states expanded Medicaid eligibility. Neither Texas nor Florida—both with large numbers of uninsured blacks and Latinos—have expanded Medicaid eligibility.5 A recent Rice University/Episcopal Health Foundation report finds that nearly half of uninsured Latinos in Texas—over 1 million people—could be eligible for Medicaid, subsidized coverage in ACA marketplace plans, or other private health insurance.6
New Health Insurance Coverage Is Helping People Get Care
Among adults who gained coverage under the ACA, more than half (57%) of blacks and U.S.-born Latinos said they had been uninsured before receiving marketplace or Medicaid coverage (data not shown). This new coverage is improving people’s ability to get care. Three-quarters (75%) of blacks and U.S.-born Latinos said they’ve used their coverage to visit a doctor, hospital, or other health care provider or to pay for prescription drugs. Six of 10 of these respondents said they would not have been able to access or afford this care before getting insurance.
Barriers to Insurance Remain for Immigrant Latino Adults
Our survey finds that three-quarters (78%) of uninsured Latinos are immigrants, and most in this group have low incomes and do not speak English well (Exhibit 3).
Some states are taking steps to help make health insurance affordable for immigrant families. California, Illinois, Massachusetts, New York, and Washington, D.C., already allow children from low-income families to access affordable health care through their Medicaid programs, regardless of their immigration status. And California may become the first state to extend insurance to unauthorized immigrant adults.7 In June, Governor Jerry Brown signed a bill that would allow as many as 390,000 unauthorized immigrants to purchase health insurance through the state’s marketplace, if the state is granted federal approval.
Gaps in Awareness Still Exist for Latinos and Blacks
Awareness about health insurance options under the ACA is a powerful predictor of whether a person actually applies for and obtains coverage. While levels of awareness of the health insurance marketplaces have increased among all adults since the beginning of the first open-enrollment period in October 2013, large numbers of blacks and Latinos still don’t know about them in 2016 (Exhibit 4). More than half of uninsured Latinos (55%) and 42 percent of uninsured blacks are unaware of the marketplaces, compared with 21 percent of uninsured white adults. Most of the uninsured Latinos and blacks who are unaware of the marketplaces are young (59%) and have low incomes (95%) and low levels of education (85%).8 Our study shows that most of the uninsured Latinos who remain unaware were born outside of the United States (82%) and do not speak English very well (94%).
Reaching the remaining uninsured Latinos and blacks will depend on states’ decisions on whether to expand Medicaid, innovation in public and private outreach efforts, and continued funding for outreach and enrollment assistance. Immigration reform and a loosening of the ACA’s restrictions on undocumented immigrants also would increase the number of people who are eligible for the coverage expansions.
Effective strategies to raise awareness of health insurance options under the ACA and facilitate enrollment among Latinos and blacks include:
- in-person or personal outreach and enrollment assistance (through a marketplace navigator or broker
- connections with community leaders, such as faith-based organizations, to publicize and host outreach and enrollment events9
- establish physical locations, such as retail storefronts located in urban areas, staffed by trained enrollment assisters, marketplace customer support workers, insurance agents, or brokers
- partnerships with well-regarded organizations (such as local hospitals, community health centers, or clinics) and individuals whose long-standing relationships within their communities make them trusted voices for outreach and education.
1 Pew Research Center tabulations of the 2014 American Community Survey. See R. Stepler and A. Brown, “Statistical Portrait of Hispanics in the United States” (Pew Research Center, April 19, 2016).
2 Foreign-born include individuals who may qualify for Medicaid or marketplace coverage under the ACA—such as naturalized citizens and permanent residents (green card holders)—as well as undocumented immigrant adults who do not qualify. According to the American Community Survey (2014), an estimated 33 percent of foreign-born Latinos are naturalized citizens and permanent residents while 66 percent are noncitizens. See R. Stepler and A. Brown, “Statistical Portrait of Hispanics in the United States” (Pew Research Center, April 19, 2016).
3 Based on 2014 American Community Survey estimates by the Pew Research Center, authors estimate that 46 percent of uninsured Latinos in 2014 were noncitizens. See J. M. Krogstad and M. H. Lopez, “Hispanic Immigrants More Likely to Lack Health Insurance Than U.S.-Born” (Pew Research Center, Sept. 26, 2014).
4 Louisiana expanded eligibility for Medicaid in 2016 and began enrollment in June.
5 Kaiser Family Foundation, “Uninsured Rates for the Nonelderly by Race/Ethnicity,” State Health Facts (Henry J. Kaiser Family Foundation, 2014).
6 E. Marks, V. Ho, and S.-C. Sim, The Impact of the Affordable Care Act on Adult Hispanics in Texas, Issue Brief #22 (Rice University Baker Institute and Episcopal Health Foundation, July 2016).
7“California Moves to Extend Health Insurance to Undocumented Immigrants,” Huffington Post, June 11, 2016.
8 We define “young” as those between the ages of 19 and 34, “lower education” as those who have completed high school or less, and “low income” as having income less than 250 percent of the federal poverty level.
9 State of Enrollment: Lessons Learned from Connecting America to Coverage, 2013–2014 (Enroll America, June 2014).