Inequities in Health Insurance Coverage and Access for Black and Hispanic Adults

Introduction

Since its passage in 2010, the Affordable Care Act (ACA) has helped cut the U.S. uninsured rate nearly in half while significantly reducing racial and ethnic disparities in both insurance coverage and access to care — particularly in states that expanded their Medicaid programs.¹

While much of that progress occurred between 2013 and 2016, federal data show that more than 5 million people gained coverage between 2020 and early 2022, driving the uninsured rate down to a historic low of 8 percent.² This recent progress has been driven by federal and state policy actions that increased Medicaid and ACA marketplace coverage, primarily:

• a requirement in the Families First Coronavirus Response Act of 2020 that states keep people with Medicaid coverage continuously enrolled during the COVID-19 public health emergency,³ in exchange for greater federal funding
• additional states expanding eligibility for their Medicaid programs
• enhanced marketplace premium subsidies.⁴

In this brief, we update our 2020 and 2021 analyses of coverage and access inequities for Black and Hispanic adults in the U.S. using 2013–2021 data from the American Community Survey and the Behavioral Risk Factor Surveillance System. (For more detail, see “How We Conducted This Study.”) With a focus on the effects of Medicaid expansion and pandemic-era coverage policies, our update examines trends among and disparities between Black, Hispanic, and white adults across the following measures:

• 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.

Black and Hispanic adults had higher uninsured rates than white adults in 2013, before the ACA took full effect. The disparities reflected lower access to employer-sponsored insurance⁵ among people with low incomes, an unregulated and unsubsidized individual insurance market, and lack of Medicaid coverage for adults except for very low income parents in most states.

The ACA attempted to improve coverage rates in several ways, including: 1) by allowing states to expand Medicaid eligibility to everyone below 138 percent of the federal poverty level (in 2023, $20,120 for an individual and $41,400 for a family of four), funded nearly fully by the federal government; and 2) by subsidizing and regulating coverage purchased through the individual market.

Uninsured rates for adults in each of the three racial/ethnic groups fell after the coverage expansions went into effect in 2014, and Black and Hispanic residents reported the largest gains. Uninsured rates for Hispanic adults fell by 15.7 percentage points between 2013 and 2021. The Black adult uninsured rate dropped by 10.9 points, and the white uninsured rate declined by 6.3 points (Table 1).

These gains reduced coverage disparities considerably. The gap between white and Black adults has dropped from 9.9 percentage points to 5.3 points, and the gap for Hispanic adults has declined from 25.7 to 16.3 points (Table 6).

While the largest coverage gains occurred from 2013 to 2016, adult uninsured rates for these three groups, and for the nation overall, dropped again between 2019 and 2021, as new federal policies aimed at boosting coverage took effect. In fact, they reached historic lows, despite modest declines in employer-based coverage from pandemic-related job losses.

A wide range of states saw coverage gains for Black, Hispanic, and white adults between 2019 and 2021 during the first two years of the pandemic (Table 2).⁶ Uninsured rates for Black adults fell at least two percentage points in 14 states, with Nebraska (which expanded Medicaid in 2020) seeing an 11-point improvement. Large coverage gains occurred in several southern states with large Black populations such as Virginia, which expanded Medicaid in 2019, and nonexpansion North Carolina and Florida.

In 19 states, uninsured rates for Hispanic adults declined at least two points as well, with notable progress in Florida as well as California, an expansion state.

White adults experienced modest improvements in coverage in nearly all states.

Coverage improvements during the pandemic between 2019 and 2021 have been attributed to several factors:

• lower-than-expected declines in employer coverage
• the ACA’s coverage expansions, which acted as a safety-net for those who did lose employer coverage
• increased Medicaid coverage, as states implemented the Families First Coronavirus Response Act’s continuous enrollment requirement and more states expanded Medicaid⁷
• increased marketplace coverage resulting from the American Rescue Plan Act’s enhanced premium tax credits as well as federal and state outreach and enrollment efforts.⁸

We examined how these policies may have affected racial and ethnic groups differently during the 2019–21 period. We also looked for differences between adult residents of states that had expanded eligibility for their Medicaid program under the ACA as of January 1, 2021 (36 states plus the District of Columbia), and residents of the 14 states that had not.

We found that the percentage of adults in both expansion and nonexpansion states who reported having Medicaid or individual market coverage increased between 2019 and 2021, with Black and Hispanic adults seeing the largest coverage gains. Medicaid enrollment for each of the three groups increased the most in expansion states, while individual-market increases were larger in nonexpansion states. These coverage gains helped mitigate the loss of employer health benefits and lower uninsured rates overall in both expansion and nonexpansion states (Tables 1 and 3).⁹

Recent policies during the pandemic have improved coverage in states that have and have not expanded Medicaid. However, uninsured rates for Black, Hispanic, and white adults continue to be much lower in expansion states — nearly half those for nonexpansion states.

Residents of Medicaid expansion states also have made greater coverage gains since 2013, even though these states already had higher coverage rates than nonexpansion states prior to the ACA’s insurance reforms in 2014 (Table 1).

These lower uninsured rates are associated with greater Medicaid coverage. Within each of the three racial/ethnic groups, the percentage of adults enrolled in Medicaid is around two to three times higher in expansion states (Table 3).

Coverage disparities were also much lower in Medicaid expansion states, and they decreased more over the 2013–21 period. For example, the difference between Black and white adult uninsured rates was 3.3 percentage points in Medicaid expansion states but 5.7 points in nonexpansion states. The difference between Hispanic and white adults was 13.1 points in expansion states but 21.4 points in nonexpansion states (Table 6).

We also examined the effects of expanding Medicaid eligibility by looking at two neighboring states, Virginia and North Carolina. Neither state expanded Medicaid in 2014, when the ACA coverage expansions went into effect. But Virginia opted to expand its program in 2019, while North Carolina had not done so as of January 2021. However, the North Carolina legislature recently reached an agreement to expand, with a vote expected this summer.¹⁰

The uninsured rate for Black and white adults with incomes below 200 percent of the federal poverty level (in 2023, $29,160 for an individual and $60,000 for a family of four) declined in both states after 2013 but remained flat beginning in 2016.

After Virginia expanded Medicaid in 2019, uninsured rates for both Black and white lower-income adults dropped another 10 to 11 percentage points. By contrast, rates in North Carolina dipped modestly between 2019 and 2021 reflecting pandemic-related Medicaid and marketplace policy changes.

Because Black Virginians have lower incomes than white residents on average,¹¹ Medicaid expansion has helped narrow the state’s overall Black–white coverage disparity from 6.1 percentage points in 2018 to 2.9 points in 2021 (Table 4).

While Medicaid expansion has helped produce greater coverage gains and smaller disparities, the impact of the policy has been unevenly distributed because many states, including some of the most populated in the country, have yet to expand their programs.

Particularly concerning is the fact that a disproportionate share of low-income Black adults — 44 percent — live in the 12 states that had not yet expanded during the study period.¹² This includes four states that have among the highest number of Black residents: Texas, Florida, Georgia, and North Carolina. Thirty percent of low-income white adults live in those 12 states.

By expanding coverage options and lowering the risk for incurring high out-of-pocket costs, the ACA reduced the financial barriers that previously had prevented many Americans from getting needed health care at the right time.¹³

Black and Hispanic adults have experienced a greater reduction in cost-related access problems than white adults since 2013 (Table 5). Still, since Black and Hispanic adults had much higher rates of cost-related access problems than white adults did in 2013, those improvements have not fully eliminated disparities in access.

The percentage of Hispanic adults who said they avoided care because of cost dropped by 9.5 percentage points from 2013 to 2021. Cost-related access barriers for Black adults fell by 9.0 points and for white adults by 5.6 points.

While the initial reduction in cost-related access problems occurred between 2013 and 2016, adults within these three groups reported significantly fewer problems after 2019 — perhaps driven by pandemic-related restrictions that deterred people from seeking care altogether.¹⁴

The reduction in cost barriers has helped narrow disparities in access to care. The Black–white disparity in cost-related access problems dropped from 8.1 to 4.7 percentage points, while the Hispanic–white disparity declined from 12.7 to 8.9 points (Table 6).

Within each of the three racial/ethnic groups, proportionately fewer adults in Medicaid expansion states reported cost-related barriers to getting care, and differences between groups were smaller.

Black and Hispanic adults in Medicaid expansion states have seen cost barriers reduced more since 2013 compared to their counterparts in nonexpansion states, even though they were starting from a baseline of lower access problems (Tables 5 and 6).

Having a usual source of care, like a regular primary care doctor, is also considered a strong indicator of health care access. Being insured makes this more likely.¹⁵

The gap between Black and white adults who reported having a usual health care provider was fewer than 2 percentage points in 2021 (82.0% vs. 83.7%).¹⁶ In contrast, just 65.7 percent of Hispanic adults, who are uninsured at higher rates, reported having a usual care provider (Table 5).

Across each of these three groups, larger shares of adults living in Medicaid expansion states compared to nonexpansion states reported having a usual source of care (Table 5).

Policy Implications

The Affordable Care Act has been a powerful force for racial equity in health and health care over the past decade. The expansion in access to affordable coverage has served as the backbone for this progress, helping to remove financial barriers and increase access to primary care clinics and other providers where people can get the care they need to stay healthy.¹⁷ This access has become even more critical during the COVID-19 pandemic.

An important part of these improvements is the law’s Medicaid eligibility expansion. As we’ve shown here, Medicaid expansion continues to be associated with greater coverage gains, better access, and narrower racial/ethnic disparities across states. A growing body of research also points to a wide array of improved clinical outcomes, including mortality.¹⁸

Seven new states have expanded their Medicaid programs since 2019 (Idaho, Maine, Missouri, Nebraska, Oklahoma, Utah, and Virginia). South Dakota recently passed a ballot initiative to expand Medicaid, while several other states, including North Carolina, Wyoming, and Kansas, are considering legislative action or a ballot initiative.¹⁹

Medicaid, along with marketplace coverage, has helped maintain and improve coverage levels during the pandemic, in large part because of the continuous enrollment requirement of the Families First Coronavirus Response Act, which has increased enrollment by more than 21 million people.²⁰ In line with federal data, our analysis points to the critical role of Medicaid in recent coverage gains across both expansion and nonexpansion states, especially for Black and Hispanic adults.²¹

Along with enhanced premium subsidies in the ACA marketplaces (now extended through 2025) and increased federal funding for marketplace outreach and enrollment activities that lifted enrollment to a record 16 million this year, these policies have helped lower-income Americans, particularly people of color, get affordable health insurance and remain enrolled.²²

Despite this progress, key health outcomes such as life expectancy and maternal mortality have worsened during the pandemic, particularly for people of color.²³ Achieving full equity in insurance coverage is critical to reversing those trends, particularly since certain COVID-19 treatment and testing benefits are scheduled to sunset when the public health emergency ends in May.²⁴ Protecting progress made and avoiding further coverage gaps will require action on the part of state and federal legislators, including:

• Filling the Medicaid coverage gap. Despite increased financial incentives during the pandemic, 11 states have yet to expand Medicaid, including some of the most populous and racially/ethnically diverse states. Congress could create a federal fallback option for Medicaid-eligible people in these states.²⁵ The Urban Institute estimates that this reform would cover nearly half a million additional Black residents and shrink the Black–white coverage disparity among nonelderly people to a single percentage point.²⁶
• Minimizing coverage loss during Medicaid eligibility redeterminations. Black and Hispanic people are disproportionately enrolled in Medicaid and thus are especially at risk of losing coverage as states begin to redetermine eligibility on April 1, 2023.²⁷ The Biden administration has emphasized the need for states to do this slowly, allowing them 14 months to complete the process and requiring them to use up-to-date information to ensure against disenrolling people who remain eligible. While the federal omnibus bill phases down the federal matching funds and gives the federal government leverage to stop disenrollment in states that don’t follow federal guidelines, the phase-down is rapid, ending in nine months.²⁸ This gives states an incentive to move quickly.²⁹ As many as 15 million people are projected to be disenrolled, nearly half of whom will likely lose coverage because of administrative churn.³⁰
• Allowing longer continuous eligibility within Medicaid. Disruption in Medicaid coverage because of eligibility changes, administrative errors, and other factors can leave people uninsured and unable to get care. Congress could apply the lessons of the pandemic and give states the option to maintain continuous enrollment eligibility for 12 months without the need to apply for a waiver, just as they have for children in Medicaid and the Children’s Health Insurance Program.³¹
• Permanently extending enhanced marketplace premium subsidies beyond 2025. The primary reason people give for not enrolling in marketplace plans is the cost of the premium.³² A permanent extension of the enhanced marketplace subsidies is needed to keep people enrolled in plans and encourage new enrollment in the future.
• Creating an autoenrollment mechanism. Research shows that many uninsured people are eligible for Medicaid or subsidized marketplace coverage. Congress could allow people to autoenroll in comprehensive health coverage. The Urban Institute has shown that a comprehensive autoenrollment option has the potential to move the nation to near-universal coverage, and less-comprehensive reforms could still cover millions more.³³