The Affordable Care Act (ACA) helped to significantly reduce U.S. racial and ethnic disparities in health insurance coverage and to improve access to care, especially in states that expanded eligibility for their Medicaid programs.1 But, after 2016, coverage gains stalled and slightly eroded. Combined with job and income losses stemming from COVID-19, this interruption in progress has left many people vulnerable to the health and economic risk of lacking comprehensive and affordable insurance during a public health crisis, particularly lower-income residents of the 14 states that have not expanded Medicaid.2
However, the American Rescue Plan Act (ARP) provides nonexpansion states with even greater incentives to expand their Medicaid programs to include all low-income adults. States that pursue expansion will receive a temporary increase in the federal matching rate for their existing Medicaid population and will still pay only 10 percent of the cost for the new enrollees.3 In addition, the ARP temporarily enhances premium subsidies for plans purchased through the marketplaces, including $0 premium plans for individuals with incomes up to $19,140 and for families of four earning up to $39,300. President Biden’s American Families Plan proposes to make these subsidies permanent.
In this brief, we update our 2020 report on coverage and access inequities using 2013–2019 data from the American Community Survey Public Use Microdata Sample (ACS PUMS) and the Behavioral Risk Factor Surveillance System (BRFSS).4 We examine trends in Black and Latinx/Hispanic disparities across the following measures, with a particular focus on the effects of Medicaid expansion on equity at the state level:
- adults ages 19 to 64 who are uninsured
- adults ages 18 to 64 who went without care in the past 12 months because of cost
- adults ages 18 to 64 who report having a usual health care provider.
- Adult uninsured rates and racial and ethnic coverage inequities declined in almost every state from 2013 to 2019, leading to both increased and more equitable health care access. But progress stalled nationally after 2016, and all groups have reported recent drops in coverage or access.
- The coverage gap between Black and white adults dropped by 4.6 percentage points between 2013 and 2019 to 5.3 points, with the gains largely concentrated between 2013 and 2016. The difference between the Latinx/Hispanic and white uninsured rates fell by 9 percentage points to 16.7 points between 2013 and 2019, reaching a low of 16.3 points in 2018. But the uninsured rates among Black and Latinx/Hispanic adults remain significantly higher than that of white adults.
- Adults in Medicaid expansion states reported better coverage and access rates, narrower disparities between groups, and greater improvements across nearly every measure between 2013 and 2019.
- After Louisiana and Virginia expanded Medicaid in 2016 and 2019, respectively, their uninsured rates for lower-income Black adults dropped significantly in comparison to Georgia and North Carolina, which have not yet expanded.
- Medicaid expansion is associated with increased coverage equity, but adults with income below 138 percent of the federal poverty level (FPL) in the remaining nonexpansion states are disproportionately Black and Latinx/Hispanic.