- Issue: Prior to the Affordable Care Act (ACA), blacks and Hispanics were more likely than whites to face barriers in access to health care.
- Goal: Assess the effect of the ACA’s major coverage expansions on disparities in access to care among adults.
- Methods: Analysis of nationally representative data from the American Community Survey and the Behavioral Risk Factor Surveillance System.
- Findings and Conclusions: Between 2013 and 2015, disparities with whites narrowed for blacks and Hispanics on three key access indicators: the percentage of uninsured working-age adults, the percentage who skipped care because of costs, and the percentage who lacked a usual care provider. Disparities were narrower, and the average rate on each of the three indicators for whites, blacks, and Hispanics was lower in both 2013 and 2015 in states that expanded Medicaid under the ACA than in states that did not expand. Among Hispanics, disparities tended to narrow more between 2013 and 2015 in expansion states than nonexpansion states. The ACA’s coverage expansions were associated with increased access to care and reduced racial and ethnic disparities in access to care, with generally greater improvements in Medicaid expansion states.
Historically, in the United States, there has been a wide gulf between whites and members of minority groups in terms of health insurance coverage and access. Proponents of the Affordable Care Act (ACA) hoped that law’s major insurance coverage expansions and reforms would begin to bridge those gaps.
Evidence suggests that uninsured rates have declined among blacks and Hispanics under the ACA,1 but have these coverage gains reduced disparities between whites and ethnic and racial minorities? This brief seeks to answer that question and to examine if disparities in access to coverage and care are different in states that expanded Medicaid and states that did not.
We compared national averages between 2013 and 2015 for white, black, and Hispanic adults on three key measures of health care access to determine the effect of the ACA’s major coverage expansions on disparities:
- the share of uninsured working-age adults ages 19 to 64
- the share of adults age 18 and older who went without care because of costs in the past year
- the share of adults age 18 and older without a usual source of care.
These measures align with those reported in the Commonwealth Fund Scorecard on State Health System Performance, 2017 Edition.
Additionally, we sought to determine if there were differences in disparities in states that chose to expand their Medicaid programs under the ACA and states that did not. For each indicator, we calculated the average rate for white, black, and Hispanic individuals in 2013 and in 2015 in two groups of states: the group of 27 states that, along with the District of Columbia, expanded their Medicaid programs under the ACA between January 1, 2014, and January 1, 2015, and the group of 23 states that had not expanded Medicaid as of that time.2
As the current administration and Congress weigh how to move forward after the recent failed attempt to repeal and replace the ACA, it is useful to examine how successful the law has been in making health care available to racial and ethnic groups that have historically been left out.
Unsurprisingly, given the Affordable Care Act’s widespread coverage expansions, the national averages on three indicators of health care access improved substantially across all three racial and ethnic groups we examined. The coverage expansions also appear to have played a role in narrowing long-standing disparities between white and minority populations. This shrinking occurred even as the uninsured rates for blacks and Hispanics started — and ended — higher than the rates for whites.
Uninsured Rates Decline, Disparities in Uninsured Rates Decrease
During the first two years of the ACA’s coverage expansions, the uninsured rate dropped 9 percentage points for black adults ages 19 to 64 and by 12 percentage points for Hispanic adults. The uninsured rate for white adults, which was already much lower, also declined by 5 percentage points (Exhibit 1, Appendix). These declines mean an estimated 2 million more black adults, 3.5 million more Hispanic adults, and 6.7 million more white adults had health insurance in 2015 compared to 2013.3 In looking at the number of people in each racial or ethnic group that benefitted from the coverage expansions, it’s important to note the overall U.S. population has a much larger share of white, non-Hispanics than black or Hispanic individuals.4 Because there are fewer minorities, a smaller numerical decrease may nonetheless still represent a greater proportional decline.
As a result of the greater reductions in uninsured rates among blacks and Hispanics as compared to whites, the disparity between uninsured working-age adults narrowed by 4 percentage points between blacks and whites, and by 7 percentage points between Hispanics and whites (Exhibit 1, Appendix).
Fewer Adults Skip Needed Care Because of Costs, Disparities Narrow
After the implementation of the ACA’s coverage expansions, minority populations experienced historic gains in their ability to access health care when needed. As uninsured rates declined, there also were reductions in the share of people who reported not getting needed medical care because the cost was too high.
Over the two-year period, the share of black adults that skipped doctor’s visits because of costs declined 4 percentage points, from 21 percent to 17 percent; the share of Hispanic adults that did so decreased by 5 percentage points, from 27 percent to 22 percent. These declines translated into an estimated 2.4 million fewer black and Hispanic adults age 18 and older in 2015 saying that cost prevented them from visiting a doctor when needed, compared to 2013.5 The share of white adults who went without care because of costs was much lower to start with, but it too declined: from 12 percent to 10 percent (Exhibit 2, Appendix). This means the number of white adults reporting they were unable to see a doctor because of cost decreased by nearly 3 million in the two years following the coverage expansions.6
This improvement narrowed the wide racial and ethnic disparities in forgone care because of costs, although black and Hispanic adults continued to face cost-related access barriers at higher rates than whites did (Exhibit 2, Appendix).
Fewer Adults Lack a Usual Source of Care
Having a usual source of care — that is, someone you consider a personal doctor or health care provider — is another strong predictor of health care access.7 Between 2013 and 2015, the share of black and of Hispanic adults age 18 and older without a usual source of care both decreased by 4 percentage points (Exhibit 3, Appendix). Although the proportion of minority adults without a personal health care provider is still high, particularly among Hispanics, an estimated 3.8 million more black adults and Hispanic adults had a usual source of care in 2015 than in 2013.8 White adults also saw their rate improve, from 18 percent to 17 percent (Exhibit 3, Appendix), a seemingly small difference that nonetheless translated to 3.7 million more white adults with a usual source of care in 2015 compared to 2013.9
As a result of these gains, by 2015, the black–white disparity in this measure was nearly cut in half, from 8 to 5 percentage points. The Hispanic–white disparity also narrowed, from 24 to 21 percentage points (Exhibit 3, Appendix).
Medicaid Expansion Associated with Less Disparity
The national averages mask notable differences in coverage and access to care between adults living in states that expanded Medicaid and those in states that did not.
Both in 2013 and in 2015, the average rate on each of the three indicators for all three racial and ethnic groups was lower in the group of states that expanded Medicaid under the ACA than the average rate in the group of states that did not expand. Racial and ethnic disparities were narrower in both years in expansion states, too (Exhibits 4–9, Appendix). The expansion states started with better rates and less disparity, perhaps at least in part because they tended to have more generous income eligibility criteria for Medicaid even before the ACA’s coverage expansions.10 In addition, some of these states had launched their own initiatives to expand coverage and access to residents in the years leading up to federal health reform.
Between 2013 and 2015, access to health care improved for each racial and ethnic group in both groups of states. Hispanics — notably, the group with the greatest barriers to access — tended to see greater improvements in expansion versus nonexpansion states. For blacks and whites, the improvements in expansion and nonexpansion states tracked one another more closely, with some exceptions.
The nonexpansion states likely owe their improvements at least partly to the ACA’s premium subsidies and insurance marketplaces, which were available in every state. This led to declines in uninsured rates among working-age adults in all states, even those without the Medicaid expansion.11 In addition, the “welcome mat” effect of the ACA contributed to gains in coverage in expansion and nonexpansion states alike.12 This phenomenon refers to uninsured people who were previously eligible for Medicaid — that is, even before the ACA coverage expansions — but not enrolled and then signed up after the ACA because of increased publicity about the Medicaid program.
Below we highlight some of the differences in coverage and access for minority adults before and after the ACA’s coverage expansions, and also compare these rates in states that expanded and did not expand Medicaid. In addition, we look at differences between minority adults and white adults in expansion and nonexpansion states.
Differences in Uninsured Rates for Adults
Between 2013 and 2015, the average uninsured rate for Hispanic adults fell by 14 percentage points in expansion states, from 36 percent to 22 percent. This compared to an 11 percentage-point decline in nonexpansion states, from 47 percent to 36 percent (Exhibit 4, Appendix). For black adults, the average uninsured rate fell by 9 percentage points in both groups of states. In expansion states, this decline nearly halved the average uninsured rate for black adults; in nonexpansion states, it reduced the share of uninsured black adults by about a third (Exhibit 5, Appendix).
As a result of these gains, the black–white disparity in uninsured rates narrowed from 7 to 4 percentage points in expansion states, and from 11 to 7 percentage points in nonexpansion states. The Hispanic–white disparity remained wide in both groups of states, but it was narrower and diminished more in expansion states compared to nonexpansion states.
Differences in the Share of Adults Who Went Without Care Because of Costs
The share of adults who went without needed care because of costs declined the most among Hispanics — a 5 percentage-point drop in both expansion and nonexpansion states (Exhibit 6, Appendix). Even with this improvement, one of five Hispanic adults went without care because of costs in expansion states in 2015. The rate was worse in nonexpansion states at nearly one of four forgoing care. Among black adults, the average rate of forgone care because of costs was lower to begin with and declined slightly more in expansion states compared to nonexpansion states (Exhibit 7, Appendix). This led to a slightly greater reduction in the black–white disparity on this indicator in expansion states compared to nonexpansion states. The Hispanic–white disparity, meanwhile, narrowed by the same amount in both groups of states.
Differences in the Share of Adults Without a Usual Source of Care
Across all three racial and ethnic groups, the share of adults age 18 and older without a usual source of care improved more in expansion states than in nonexpansion states (Exhibits 8 and 9, Appendix). The contrast was greatest among Hispanic adults, who saw a 5 percentage-point improvement on this indicator in expansion states compared to a 2 percentage-point improvement in nonexpansion states. The disparity between Hispanic and white adults also narrowed more in expansion states compared to nonexpansion states.
The Affordable Care Act’s coverage expansions have been successful in increasing access to health care among whites, blacks, and Hispanics and in reducing long-standing disparities based on race and ethnicity. Despite this progress, persistent gaps in access to care remain. This is true in states that expanded Medicaid as well as in those that did not expand, though the gaps remain larger in nonexpansion states. This is consistent with our previous research that found that in the years just prior to the ACA’s coverage expansions, racial and ethnic disparities in access to care were narrower among insured adults than uninsured adults, although they persisted in both groups.13
While insurance coverage may not eliminate disparities in health care access, it does help to reduce them. As of August 2017, 19 states have not expanded Medicaid under the ACA, including Florida, Georgia, North Carolina, and Texas, all of which are home to large black and/or Hispanic populations. A decision by these states to expand Medicaid would have positive effects for black and Hispanic residents in terms of access to care and reducing disparities.
After the recent failure of Congress to repeal and replace the ACA, bipartisan efforts are under way in both the House of Representatives and the Senate that could preserve the access gains achieved by Americans from all racial and ethnic backgrounds. One immediate priority is to strengthen and stabilize the marketplaces to ensure that the 17 million to 18 million people currently getting coverage through the marketplaces can reenroll in plans this fall.14 A key step is for Congress to set up permanent appropriations to reimburse insurance companies for the subsidies — also called cost-sharing reductions — that allow insurers to reduce out-of-pocket costs for low- and moderate-income people who purchase coverage in the marketplaces. Doing so will remove the ongoing uncertainty surrounding these payments that has led some insurers to propose higher premiums in 2018 than if payments were assured.15
Whatever the fate of the Affordable Care Act, these findings illustrate its successes — coverage expansion and improved access to health care for millions of blacks and Hispanics.
Indicators and Data Sources:
Percent of uninsured adults ages 19–64.
Percent of adults age 18 and older who went without care because of cost during past year and Percent of adults age 18 and older who did not have a usual source of care.
Our analysis stratifies survey respondents by their self-reported race or ethnicity: white (non-Hispanic), black (non-Hispanic), or Hispanic (any race).
We calculated national averages for each of the indicators listed above stratified by race/ethnicity. We also calculated the average rate for white, black, and Hispanic individuals in 2013 and in 2015 across two categories of states: the Medicaid expansion group included the 27 states that, along with the District of Columbia, expanded their Medicaid programs under the ACA between January 1, 2014, and January 1, 2015; the nonexpansion group comprised the 23 states that had not expanded Medicaid as of that time. Reported values are averages across survey respondents, not state averages. Subpopulation rates were suppressed if unweighted cell counts were less than 50.
1 M. M. Doty, M. Z Gunja, and S. R. Collins, and S. Beutel, “Coverage Gains Among Lower-Income Blacks and Latinos Highlight ACA’s Successes and Areas for Improvement,” To the Point, The Commonwealth Fund, Aug. 15, 2017. See also M. M. Doty, M. Z Gunja, S. R. Collins, and S. Beutel, “Latinos and Blacks Have Made Major Gains Under the Affordable Care Act, But Inequalities Remain,” To the Point, The Commonwealth Fund, Aug. 18, 2016.
2 Alaska, Indiana, Louisiana, and Montana expanded their Medicaid programs under the Affordable Care Act after January 1, 2015, and are therefore included in the group of nonexpansion states in this analysis.
3 Authors’ analysis of U.S. Census Bureau, 2013 and 2015 1-Year American Community Surveys, Public Use Microdata Sample (ACS PUMS).
4 In 2015, 12.3 percent of the total U.S. population was black, non-Hispanic; 17.6 percent was Hispanic (who may identify as any race); and 61.5 percent was white, non-Hispanic, according to the U.S. Census Bureau’s 2015 American Community Survey 1-year estimates. This translated into an estimated 39.6 million non-Hispanic black individuals and 56.5 million Hispanic individuals (who can be of any race), compared to 197.5 million white, non-Hispanic individuals in the U.S in 2015. See U.S. Census, American Fact Finder: 2015 ACS Demographic and Housing Estimates (U.S. Census, n.d.).
5 Authors’ analysis of 2013 and 2015 Behavioral Risk Factor Surveillance System (BRFSS).
6 Authors’ analysis of 2013 and 2015 Behavioral Risk Factor Surveillance System (BRFSS).
7 See https://www.healthypeople.gov/2020/topics-objectives/topic/Access-to-Health-Services.
8 Authors’ analysis of 2013 and 2015 Behavioral Risk Factor Surveillance System (BRFSS).
9 Authors’ analysis of 2013 and 2015 Behavioral Risk Factor Surveillance System (BRFSS).
10 C. Schoen, D. C. Radley, P. Riley, J. A. Lippa, J. Berenson, C. Dermody, and A. Shih, Health Care in the Two Americas: Findings from the Scorecard on State Health System Performance for Low-Income Populations, 2013 (The Commonwealth Fund, Sept. 2013), Exhibit 27, page 57. See also Kaiser Family Foundation, State Health Facts, Medicaid/CHIP Upper Income Eligibility Limits for Children, 2000–2017 (Henry J. Kaiser Family Foundation, 2017).
11 S. L. Hayes, S. R. Collins, D. C. Radley, D. McCarthy, and S. Beutel, A Long Way in a Short Time: States’ Progress on Health Care Coverage and Access, 2013–2015 (The Commonwealth Fund, Dec. 2016).
12 M. Frean, B. D. Sommers, and J. Gruber, “Understanding ACA’s Coverage Gains: Welcome Mat Effect & State Marketplaces Keys to Success,” Say Ahhh!, Georgetown University Health Policy Institute Center for Children & Families, May 18, 2016.
13 S. L. Hayes, P. Riley, D. C. Radley, D. McCarthy, Closing the Gap: Past Performance of Health Insurance in Reducing Racial and Ethnic Disparities in Access to Care Could Be an Indication of Future Results (The Commonwealth Fund, March 2015).
14 D. Blumenthal and S. R. Collins, “In the Aftermath,” To the Point, The Commonwealth Fund, July 28, 2017. See also T. S. Jost, “Fixing Our Most Pressing Health Insurance Problems: A Bipartisan Path Forward,” To the Point, The Commonwealth Fund, July 13, 2017.