Kentucky Eliminates Insurance Disparity

Starting in 2014, Kentucky saw one of the country’s most dramatic reductions in the number of uninsured adults due in large part to the state’s expansion of Medicaid. Prior to the expansions of coverage, Black Kentuckians made up a disproportionate number of the uninsured in the Commonwealth. Disparities in access to health care can often lead to disparities in health outcomes. Efforts to eliminate disparities in health outcomes can be facilitated through better access to coverage.

A recent article from the American Journal of Public Health explores whether Kentucky saw a decrease in insurance disparities. They find that starting in 2015 Blacks were no longer overrepresented as a share of the uninsured population. Effectively, the state eliminated the insurance disparity between Whites and Blacks. The authors found that in Kentucky there was an 11-point drop in the uninsured rate for Blacks and a nearly 10-point decrease for Kentucky’s Hispanic/Latino population. Kentucky still has a way to go to eliminate the disparity for Hispanic/Latino adults but the gains are a promising development and bring hope to the challenge of reducing health disparities in the future. 

One likely setback for Kentucky’s efforts to reduce disparities is the governor’s attempt to institute work requirements in the Medicaid program. The policy is currently suspended following the court decision that invalidated the waiver. Under Governor Bevin’s estimates, 100,000 Kentuckians would lose Medicaid coverage as a result of the work requirement, premium and additional cost sharing, lock-outs, and other restrictive policies. This rise in the uninsured will likely increase disparities because Kentucky’s Black population is disproportionally low-income and Medicaid has been a main driver behind the elimination of the insurance disparity.  

Michigan and Ohio received significant attention this year when their plans for work requirements included provisions to exempt rural predominately White counties and were criticized as trying to implement a blatantly race-based policy. Michigan ultimately withdrew this county level provision due to public pressure and Ohio’s plan is under review. However, the potential effect of renewing this disparity in Kentucky has largely been overlooked. Reducing health insurance coverage has far reaching effects; now is not the time to ignore the costs. 

Abstract

OBJECTIVES: To examine health insurance disparities since Kentucky’s implementation of the Affordable Care Act (ACA).

METHODS: Using the American Community Survey, we estimated coverage rates by race/ethnicity before and after implementation of the ACA (2013 and 2015), and we estimated whether groups were over- or underrepresented among the uninsured, compared with their share of the state population.

RESULTS: Kentucky’s uninsurance rate declined from 14.4% in 2013 to 6.1% in 2015 (P?<?.001). Uninsurance rates also declined for most racial/ethnic groups, including Blacks (16.7% to 5.5%; P?<?.001) and Whites (13.3% to 5.3%; P?<?.001). In 2015, Blacks were no longer overrepresented among Kentucky’s uninsured, with a significant decline in the ratio of Blacks among the state uninsured population compared with their share of the state population (1.16-0.91; P?=?.045).

CONCLUSIONS: In Kentucky, which mounted a robust implementation of the ACA-including Medicaid expansion, a state-based marketplace, and an extensive outreach and enrollment campaign-the state experienced not only a decline in the overall uninsurance rate but also an elimination in coverage disparities among Blacks, who historically were overrepresented among the uninsured.

PMID: 29771619

Blewett, LA, et al. Am J Public Health. 2018; 108 (7): 924-929.