Racial and Ethnic Inequities in Health Care Coverage and Access, 2013–2019

Introduction

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.

Highlights

• 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.

Findings

Black and Latinx/Hispanic adults have historically reported much higher uninsured rates than white adults. This disparity reflects economic inequities, for these communities are less likely than white adults to receive coverage through their jobs,⁵ as well as immigration policies that can constrain coverage options for Latinx/Hispanic families in particular.⁶

The ACA promised to increase coverage equity by funding 100 percent of state Medicaid expansions in the first three years, phasing down to 90 percent over time, and by subsidizing individual marketplace plans.

Uninsured rates for all three groups fell after coverage expansions went into effect in 2014, and Black and Latinx/Hispanic adults made the largest gains. The Black adult uninsured rate dropped from 24.4 percent in 2013 to a low of 13.7 percent in 2016, before rising slightly to 14.2 percent in 2019. The Latinx/Hispanic uninsured rate decreased from 40.2 percent in 2013 to a low of 24.9 percent in 2018 but has since edged upward to 25.7 percent in 2019 (Table 1). These trends reduced coverage disparities in relation to white adults by 4.6 percentage points for Black adults and 9 points for Latinx/Hispanic adults (Table 6).

But progress stalled under the Trump administration, and coverage has eroded for all groups since 2016. The Latinx/Hispanic uninsured rate rose by nearly 1 percentage point between 2018 and 2019. This increase may reflect immigration policies initiated by the Trump administration that have led to reduced enrollment in public programs.

Between 2013 and 2019, Black adult uninsured rates dropped by at least 7 percentage points in 33 states,⁷ and the disparity in relation to white adults decreased by at least 4 points in 23 states (Table 2). Similar to the national trend, this progress occurred largely between 2013 and 2016.

The ACA allowed states to expand eligibility for Medicaid to everyone below 138 percent of FPL ($17,608 for an individual and $36,156 for a family of four), funded exclusively by the federal government in the first three years. Expanded Medicaid provided a comprehensive coverage option, at little or no cost, to eligible low-income people, who are disproportionately Black and Latinx/Hispanic.

States that had expanded Medicaid under the ACA by 2019 (left side of exhibit) typically reported lower uninsured rates among Black and white adults, larger improvements since 2013, and smaller disparities. Nonexpansion states like Georgia and Mississippi, home to large Black communities, reported some of the highest uninsured rates for both Black and white adults.

Latinx/Hispanic adults continue to face significant coverage barriers. These include ACA limits that do not allow undocumented immigrants to access Medicaid or the marketplaces, as well as other U.S. immigration policies.

Latinx/Hispanic uninsured rates in 2019 were at least 10 percentage points below 2013 rates in 33 states,⁸ and disparities with white adults were at least 7 percentage points smaller in 25 states (Table 2). States that had expanded Medicaid by 2019 (left side of exhibit) typically reported lower uninsured rates for Latinx/Hispanic and white adults and smaller disparities between the two. Nonexpansion states typically reported higher uninsured rates for Latinx/Hispanic and white adults; these included Texas and Florida, which are home to around 30 percent of the U.S. Latinx/Hispanic population.

But progress has largely stalled since 2016 — likely, at least in part, because of Trump administration actions that may have discouraged eligible Latinx/Hispanic families from seeking coverage. Those included the public-charge rule that allows the government to deny citizenship based on past Medicaid use,⁹ which the Biden administration has already stopped enforcing.¹⁰

We also analyzed pooled uninsured rates for individuals across two categories of states — the 33 states and the District of Columbia that had expanded their Medicaid program under the ACA as of January 1, 2019, and the 17 that had not.¹¹

Despite lower pre-ACA uninsured rates, Black, Latinx/Hispanic, and white adults living in expansion states all reported larger coverage gains between 2013 and 2019 than those in nonexpansion states. The uninsured rate among Black adults living in expansion states dropped 11.3 percentage points, while the uninsured rate for Latinx/Hispanic adults dropped by 16.3 points (Table 1). Those gains largely occurred between 2013 and 2016.

Coverage disparities between Black and Latinx/Hispanic and white adults also narrowed more in Medicaid expansion states (Table 6) — declining by 5.1 points for Black adults and 10.1 points for Latinx/Hispanic adults.

To further examine the effects of Medicaid expansion on coverage inequities, we look more closely at four states. Georgia, Louisiana, North Carolina, and Virginia did not expand their Medicaid programs immediately in 2014, when the ACA’s coverage expansions took effect. Louisiana and Virginia eventually expanded in 2016 and 2019, but Georgia and North Carolina have not.

The uninsured rate for Black adults with incomes below 200 percent of FPL ($25,760 for an individual and $53,000 for a family of four in 2021) dropped in all four states, but progress stalled after 2016 in Georgia and North Carolina (Table 3).

In contrast, in Louisiana the uninsured rate among low-income Black adults dropped by an additional 14.7 percentage points after expansion. Virginia expanded Medicaid in 2019 and reported a 6.2-point coverage improvement for the same group. Expansion in these two states also further narrowed the coverage gap between Black and white adults (Table 3).

The ACA’s coverage expansions have been a key tool for increasing coverage and improving racial and ethnic health care equity.

But even though Black and Latinx/Hispanic adults are disproportionately lower-income and more likely to be eligible for coverage under the law’s Medicaid expansion, they are also more likely to live in states that have chosen not to expand Medicaid eligibility.

Among those with income less than 138 percent of poverty, 46 percent of Black adults, 38 percent of Latinx/Hispanic adults, and 34 percent of white adults live in the 14 states that have not yet expanded Medicaid.

By expanding coverage options and reducing out-of-pocket cost exposure for lower-income people, the Affordable Care Act lowered financial barriers that can deter patients from getting timely health care.¹²

Black and Latinx/Hispanic adults were much more likely to be uninsured prior to the ACA’s coverage expansions and have seen the largest improvements since then. Greater coverage has been associated with improvements in access to health care.

The proportion of Black adults reporting they had avoided care because of cost dropped from 23.2 percent in 2013 to a low of 17.3 percent in 2019, with most of the gains concentrated between 2013 and 2016. Latinx/Hispanic adults reported a similar improvement trend: those with cost-related access problems fell from 27.8 percent in 2013 to a low of 21.2 percent in 2018, but rose to 22.8 percent in 2019 (Table 4). Gains for white adults also eroded slightly after 2016.

These improvements in access to care narrowed the disparity between Black and white adults by more than half, from 8.1 percentage points in 2013 to 3.8 points in 2019. The gap between Latinx/Hispanic and white adults fell from 12.7 points to a low of 8.3 points in 2018, but it has since increased (Table 6). Latinx/Hispanic adults reported an increase in cost-related access problems in 2019 that coincided with an uptick in their uninsured rate.¹³

Cost-related access problems declined for Black and Latinx/Hispanic adults in most states between 2013 and 2019, though changes were not statistically significant for all states (see Table 5).

Mirroring coverage, states that had expanded Medicaid by 2019 (left side of exhibits) typically reported lower rates of cost-related access problems for all three groups and larger improvements since 2013 — particularly among Black and Latinx/Hispanic adults.

In our pooled analysis, people living in expansion states also reported smaller disparities than those in nonexpansion states, and Black adults in expansion states had narrowed the gap with white adults to just 2.3 percentage points by the end of 2019 (Table 6).

Having a usual source of care — a personal doctor or other provider — is generally seen as a strong indicator of health care access.¹⁴

White adults were the most likely to have a usual source of care in 2013, at 77.6 percent, but after 2016 they reported a decline, down to 76.5 percent in 2019. Around 71 percent of Black adults reported a usual care provider in 2013. That improved to a high of 74.7 percent in 2016, though gains stalled after that point. This more than halved the disparity with white adults to 2.4 percentage points (Table 4 and Table 6).

Only around 55 percent of Latinx/Hispanic adults had a usual source of care in 2013. After improving to a high of 59.1 percent in 2015, this rate declined to 56.2 percent in 2019.¹⁵

People living in Medicaid expansion states are much more likely to have a usual source of care, and Black adults in those states are as likely as white adults to report a usual care provider (Table 4).

Policy Implications

New policies to expand health insurance coverage, and to help those who are eligible to enroll, will be necessary to cover more U.S. adults and further narrow racial and ethnic disparities.¹⁶ Since taking office, the Biden administration has taken several steps to improve coverage, through executive actions and legislative proposals. These include opening the ACA marketplaces for a special open enrollment period ending in August; funding new outreach and advertising efforts to increase Americans’ awareness of coverage options available to them; and issuing executive orders to reverse Trump administration rules that undermined insurance markets and make other improvements, such as fixing the “family glitch.”¹⁷ Biden also has issued executive orders on immigration policy and ended enforcement of the public-charge rule that has dissuaded even legal immigrants from seeking coverage for themselves and their children.¹⁸ And he has begun to unwind state efforts to impose work requirements in Medicaid and undermine insurance markets.¹⁹

On the legislative front, the American Rescue Plan includes a significant, though temporary, enhancement of marketplace premium subsidies.²⁰ It also provides temporary premium subsidies for people who sign up for COBRA coverage following job loss, as well as temporary access to zero-premium marketplace plans for people who file for unemployment this year. And the law incentivizes the 14 Medicaid nonexpansion states to move forward with a substantial, though temporary, increase in the federal Medicaid matching rate for their full Medicaid populations.

President Biden’s American Families Plan proposes to make the ARP subsidies permanent.²¹ The Urban Institute estimates this change would reduce the number of uninsured by 4.2 million in 2022 and lower household health care costs for people enrolled in the marketplaces and the individual market by nearly one-quarter.²² Recent estimates also indicate that the infusion of federal spending if all 14 states expanded could create more than 1 million new jobs nationwide.²³

The fraught politics over Medicaid expansion in states like Florida and Texas will continue to stall forward movement on expansion, despite new incentives in the ARP. In the meantime, 2 million people in the Medicaid coverage gap — too poor to qualify for marketplace subsidies and ineligible for their state Medicaid programs — will ride out the pandemic and beyond without access to affordable health insurance.²⁴ This group, among the poorest in the country, is disproportionately Black and Latinx/Hispanic. Allowing eligible people in these states to enroll in a plan offered through the marketplaces at $0 premium and $0 deductible and Medicaid equivalent benefits would provide health and economic security.²⁵

In the longer term, Congress may pursue additional reforms that build on these changes, such as adding a public insurance plan choice for everyone in the marketplaces²⁶ and creating a mechanism for automatically enrolling people in coverage.²⁷ Research shows that reforms like these could place the nation on a path toward universal, and more equitable, coverage and access to care.²⁸