ACA is Reducing Disparities in Coverage

A recent study explores health insurance coverage changes for non-elderly Black, White, and Hispanic adults after implementation of the Affordable Care Act (ACA).

The study answered three different questions. First, were there changes in the source of coverage by race? There was an uptick in both public and private coverage for all races. However, Whites remained far more likely to be covered by private insurance (74.3%) compared to Blacks (52.9%) and Hispanics (48.2%). Blacks were more likely to have public insurance (26.4%) compared to Hispanics (18.4%) and Whites (13.9%).

Second, what changes in coverage occurred for the undocumented? Recall that undocumented immigrants generally do not qualify for Medicaid. There was a significant decline in the percentage of uninsured Hispanic noncitizens in every income category in both expansion and non-expansion states, but the decline was steeper in expansion states. Overall, 57.3% of Hispanic noncitizens were uninsured. The overall rate of non-coverage in this group soars above that of Whites (13.6%).

Third, to what extent are remaining racial disparities in coverage related to income and state Medicaid expansion status? For Hispanic citizens, remaining disparities are strongly linked to these two factors. Those living at <139% FPL in an expansion state enjoy rates of non-coverage only 3 percentage points higher than Whites; those living in non-expansion states have rates of non-coverage exceeding that of Whites by over 12 percentage points. Differences are similar but not as great for higher income groups. For Blacks, disparities in coverage are slightly less in expansion states and stay about the same across income levels.

The data show steeper uptake of insurance among minorities compared to Whites. The ACA is closing the gap in insurance coverage for minorities. But racial disparities in coverage still exist among the poor, even in Medicaid expansion states, and efforts to improve enrollment are still needed. The authors also recommend that Medicaid and ACA subsidies be expanded to the undocumented. Even better would be to see this group gain .  Finally, as I have mentioned previously, the ACA and Medicaid expansion will reduce the number of uninsured. It can’t not do this. The looming question is whether health disparities among the poor, Blacks, and Hispanics will decrease as a result of these policies.

commentary by Megan Doede

Abstract

OBJECTIVE: To document how health insurance coverage changed for White, Black, and Hispanic adults after the Affordable Care Act (ACA) went into effect.

METHODS: We used data from the American Community Survey from 2008 to 2014 to examine changes in the percentage of nonelderly adults who were uninsured, covered by Medicaid, or covered by private health insurance. In addition to presenting overall trends by race/ethnicity, we stratified the analysis by income group and state Medicaid expansion status.

RESULTS: In 2013, 40.5% of Hispanics and 25.8% of Blacks were uninsured, compared with 14.8% of Whites. We found a larger gap in private insurance, which was partially offset by higher rates of public coverage among Blacks and Hispanics. After the main ACA provisions went into effect in 2014, coverage disparities declined slightly as the percentage of adults who were uninsured decreased by 7.1 percentage points for Hispanics, 5.1 percentage points for Blacks, and 3 percentage points for Whites. Coverage gains were greater in states that expanded Medicaid programs.

CONCLUSIONS: The ACA has reduced racial/ethnic disparities in coverage, although substantial disparities remain. Further increases in coverage will require Medicaid expansion by more states and improved program take-up in states that have already done so.

PMID: 27196653 Buchmeuller, TC, et al. AJPH. 2016; 106(8):1416-21.