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New Report: Affordable Care Act Has Narrowed Racial and Ethnic Gaps in Access to Health Care, But Progress Has Stalled

Blacks in States That Have Expanded Medicaid Are Now More Likely to Be Insured Than Whites in States That Have Not

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The Affordable Care Act (ACA) has led to historic improvements in access to health care for black and Hispanic adults in the United States while also reducing disparities with white adults. But progress has stalled since 2016 and eroded in some cases, according to a new Commonwealth Fund report.

The report, How the Affordable Care Act Has Narrowed Racial and Ethnic Disparities in Access to Health Care, looks at three key measures of health care access through the lens of race and ethnicity: not having insurance coverage, going without needed health care because of cost, and having a regular source of care. The researchers focused on the years 2013 to 2018.

In the years following the law’s major coverage expansions in 2014, the racial gap in access to health care narrowed across the country, especially in states that expanded Medicaid, according to the study. In these expansion states, the gap narrowed so much that rates of coverage and reports of access barriers among blacks were similar to, or even better than, those of white adults in nonexpansion states. Among the researchers’ other key findings:

Among the researchers’ other key findings:

  • Racial and ethnic gaps in uninsured rates narrowed significantly, but progress has stalled or eroded since 2016. The ACA has led to historic gains in health coverage in the U.S. — particularly for black and Hispanic adults. The uninsured rate for black adults dropped from 24.4 percent in 2013 to 14.4 percent in 2018, while the rate for Hispanic adults decreased from 40.2 percent to 24.9 percent. This reduced the disparity with white adults by 4.1 and 9.4 percentage points, respectively. Coverage gains for blacks and Hispanics, however, have stalled or even eroded since 2016, as they have for the U.S. population overall. Black adults have seen their uninsured rate tick up by 0.7 percentage points since 2016, while white adults have seen a half-point increase. This has largely halted the narrowing of racial coverage gaps.
Adult uninsured rates have decreased for all groups since 2013, and disparities have narrowed significantly among whites, blacks, and Hispanics.
  • Fewer black and Hispanic adults skip needed health care because of costs. Approximately 23 percent of black adults in 2013 said they avoided getting care because of the cost, compared to 17.6 percent in 2018. Costrelated access problems among Hispanic adults fell from 27.8 percent to 21.2 percent. This progress reduced differences with white adults. Most of this improvement also occurred between 2013 and 2016.
  • Medicaid helped reduce racial gaps in health care.
    • Insurance coverage disparities between white adults and the two minority groups shrank more in states that expanded Medicaid than in states that did not: The black–white coverage gap in Medicaid expansion states dropped from 8.4 percentage points to 3.7 points, while the gap between Hispanic and white uninsured rates shrank from 23.2 percentage points to 12.7 points. Because of this progress, black adults in expansion states are now more likely to be insured than white adults in nonexpansion states.
    • After expanding Medicaid in 2016, Louisiana’s black–white insurance coverage gap dropped rapidly in comparison to Georgia: To illustrate the potential impact of more states expanding Medicaid, the Commonwealth Fund researchers analyzed two Southern states with large black adult populations: Louisiana, which expanded Medicaid in 2016, and Georgia, which has yet to do so. In both states, adults with low incomes saw coverage gains from 2013 to 2015. After Louisiana expanded Medicaid in July 2016, uninsured rates for white and black adults with low incomes dropped an additional 12.2 and 16.0 percentage points, respectively. Georgia, however, stopped improving. Because an estimated 54 percent of black working-age adults in Louisiana have low incomes, Medicaid expansion helped drive the state’s overall black adult uninsured rate down to 11.3 percent in 2018. This was lower than ratesfor black adults (19.2%) and white adults (14.9%) in Georgia.

FROM THE EXPERTS:

Sara Collins, coauthor of the study and Commonwealth Fund Vice President for Health Care Coverage, Access, and Tracking

“The Affordable Care Act’s coverage expansions have helped drive historic progress in reducing racial and ethnic gaps in health care, but we still have a long way to go. Too many black and Hispanic adults are still unable to get health insurance or the health care they need, which contributes to inequitable health outcomes. Whether we can build on progress made since the ACA will depend on policies like expanding eligibility for Medicaid and enhancing subsidies, as well as addressing discrimination and related causes of our health system's long-standing racial inequities.”

 

David Blumenthal, M.D., Commonwealth Fund President

“It’s encouraging to see that the gaps in access to health care for black and Hispanic adults are narrowing over time, but we cannot let the progress we’ve made slip through our fingers. Improving upon the Affordable Care Act, and expanding Medicaid in all states, will be critical to ensuring that everyone can get the affordable, high-quality health care they deserve.”

Implications

The study authors note that state and federal policymakers could pursue a number of actions in the near term to further
reduce access differences for U.S. racial and ethnic minorities. These include:

  • Expanding Medicaid without restrictions in the 15 states that have not yet done so. Expansion under the ACA is a proven tool for narrowing racial gaps in access to care. Yet expanded Medicaid eligibility is not available to almost half of black adults and more than a third of Hispanics.
  • Filling the Medicaid coverage gap. With lower average incomes, black and Hispanic adults in nonexpansion states are at high risk of falling into a coverage gap in which their income is too high for Medicaid but not high enough to qualify for marketplace premium subsidies. Congress could help by making marketplace subsidies available to everyone with an income below 100 percent of the federal poverty level ($12,490 for an individual and $25,750 for a family of four).
  • Making premiums more affordable in the ACA marketplaces. Premium contributions for marketplace plans are capped at a certain percentage of income for people between 100 and 400 percent of the federal poverty level (the upper income cap is $49,960 for an individual and $103,000 for a family of four). Removing the upper income limit would expand eligibility for marketplace subsidies so more people could afford to buy plans.
  • Enacting targeted, state-specific Medicaid expansions beyond the ACA. California, for example, recently expanded Medicaid to cover undocumented young adults.
  • Allowing undocumented immigrants to shop for coverage in the marketplaces. This group is currently ineligible for coverage through the ACA insurance exchanges.

Additional Pertinent Research

Did the Affordable Care Act Reduce Racial and Ethnic Disparities in Health Insurance Coverage?

The New “Public Charge” Rule Affecting Immigrants Has Major Implications for Medicaid and Entire Communities

2019 Scorecard on State Health System Performance

Arkansas’s Medicaid Work Requirements Contributed to Higher Uninsured Rate and No Change in Employment

HOW WE CONDUCTED THIS STUDY

Indicators and Data Sources:

Percent of uninsured adults ages 19–64. Source: U.S. Census Bureau, American Community Survey Public Use Microdata Sample (ACS PUMS), 2013–2018.

Percent of adults ages 18–64 who went without care because of cost during past year and Percent of adults ages 18–64 who had a usual source of care. Source: Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System (BRFSS), 2013–2018.

Demographics, adults ages 19–64. Source: American Community Survey Public Use Microdata Sample (ACS PUMS), 2018.

The analysis stratifies survey respondents by their self-reported race or ethnicity: white (non-Hispanic), black (non-Hispanic), or Hispanic (any race). National annual averages were calculated from 2013 to 2018 for each of the three indicators listed above, stratified by race/ethnicity. The average annual rate also was calculated for white, black, and Hispanic individuals from 2013 to 2018 across two categories of states: the Medicaid expansion group, including the 31 states that, along with the District of Columbia, had expanded their Medicaid programs under the ACA as of January 1, 2018; and the nonexpansion group, comprising the 19 states that had not expanded Medicaid as of that time. (Maine and Virginia were considered nonexpansion states in this analysis because they both implemented their Medicaid expansions in 2019.) Reported values for expansion/nonexpansion categories are averages across survey respondents, not averages of state rates. Additionally, average annual state-specific uninsured rates from 2013 to 2018 were calculated for certain subpopulations in Louisiana and Georgia.

Publication Details

Publication Date: January 16, 2020
Contact: Bethanne Fox, Vice President, Outreach and Strategy, The Commonwealth Fund