Health Coverage by Race and Ethnicity: Examining Changes Under the ACA and the Remaining Uninsured
Despite improvements in population health and continued efforts to reduce disparities in health and health care, people of color remain more likely to be uninsured and to face increased barriers accessing care compared to Whites.1 People of color also are less likely than Whites to utilize care and fare worse than Whites on many measures of health status and health outcomes.2 As the United States population becomes more racially and ethnically diverse, with people of color projected to constitute over half of the population in 2045,3 addressing these disparities is increasingly important. The Affordable Care Act (ACA) coverage expansions offer an opportunity to increase coverage among people of color, which could help reduce longstanding racial and ethnic disparities in health coverage. This brief examines changes in health coverage by race and ethnicity under the ACA and their impact on disparities in coverage. It also provides information on the remaining uninsured by race and ethnicity and estimates of eligibility for ACA coverage among the uninsured, which may help inform continued outreach and enrollment efforts moving forward.
This brief is based on Kaiser Family Foundation analysis of Current Population Survey data for the nonelderly population, which includes individuals between ages 0-64. See, “Estimates of Eligibility for ACA Coverage among the Uninsured in 2016,” for more information on methods used to estimate eligibility for coverage among the uninsured. Throughout the brief, AIAN is used to refer to American Indians and Alaska Natives and NHOPI is used to refer to Native Hawaiian or Other Pacific Islander. Individuals of Hispanic origin may be any race but are classified as Hispanic for this analysis; all other groups are limited to non-Hispanic individuals.
The ACA Health Coverage Expansions
One of the goals of the ACA is to increase health coverage by establishing new coverage options for low- and moderate-income individuals. The ACA includes an expansion of Medicaid to low-income adults with incomes up to 138% of the federal poverty level (FPL) ($27,821 for a family of three in 2016).4 The ACA also established health insurance Marketplaces through which individuals can purchase insurance coverage and provides tax credits to individuals with incomes between 100% and 400% FPL ($80,640 for a family of three in 2016).5
Under the ACA, these expansions became effective as of January 2014. As enacted, the Medicaid expansion to low-income adults was to be implemented nationwide; however, it was effectively made a state option by the 2012 Supreme Court ruling on the ACA. As of October 2016, 32 states, including the District of Columbia, had implemented the expansion.6 In the 19 states that have not expanded, an estimated 2.6 million poor adults fall into a coverage gap.7 These adults did not gain access to an affordable coverage option because they earn too much to qualify for Medicaid but not enough to receive tax credits for Marketplace coverage, which become available at 100% FPL.
Changes in Health Coverage by Race/Ethnicity, 2013-2015
Prior to the ACA, people of color were more likely to be uninsured than Whites. As of 2013, a total of 41.1 million nonelderly individuals were uninsured. Hispanics and AIANs were at the highest risk of being uninsured with roughly one in four lacking coverage (Figure 1). Blacks and Asians also were more likely than Whites to lack coverage. Overall, the uninsured in 2013 included 18.7 million Whites, 13.1 million Hispanics, 5.8 million Blacks, 2.2 million Asians, 0.5 million AIANs, and 0.1 million NHOPIs.
People of color have experienced larger gains in coverage compared to Whites since implementation of the ACA. Between 2013 and 2015, the total number of nonelderly uninsured fell from 41.1 million to 28.5 million, reducing the uninsured rate from 15% to 10% over the period. All racial and ethnic groups experienced reductions in their uninsured rate over this period (Figure 2). Declines were larger among communities of color compared to Whites, with particularly large decreases among Hispanics (Figure 3).
Even with larger coverage gains between 2013 and 2015, nonelderly Hispanics, Blacks, and AIANs were still more likely than nonelderly Whites to be uninsured as of 2015. AIANs and Hispanics remained at the highest risk of being uninsured (Figure 4, and Appendix Table 1). This pattern held true among nonelderly adults. Uninsured rates for children were lower than rates for adults with no significant differences in uninsured rates between Black and White children. However, Hispanic children were nearly twice as likely as White children to be uninsured, and the uninsured rate for AIAN children was nearly five times higher than the rate for White children.
Changes in racial and ethnic disparities in coverage varied across groups and by different measures of disparities. One measure of disparities is the percentage point difference between uninsured rates for groups, referred to as an absolute disparity. Between 2013 and 2015, the percentage point difference in uninsured rates between Whites and other racial and ethnic groups narrowed for all groups, except AIANs and NHOPIs (Figure 5 and Appendix Table 2). Hispanics had the sharpest decline in this difference, which fell from 14 percentage points in 2013 to 9 percentage points in 2015.
Disparities also can be assessed by examining the ratio of uninsured rates between one group and another, referred to as a relative disparity. Between 2013 and 2015, relative disparities compared to Whites decreased for Asians, Hispanics, and NHOPIs. As a result of this decrease, the relative disparity between Asians and Whites was eliminated and NHOPIs fared better compared to Whites as of 2015. However, relative disparities remained for Hispanics in 2015. The relative disparity for AIANs increased over the period, and there was no significant change in the relative disparity for Blacks.
Characteristics of nonelderly Uninsured by Race/Ethnicity as of 2015
People of color accounted for over half of the 28.5 million individuals who remained uninsured in 2015 (Figure 6). This share included 32% or 9.1 million who were Hispanic, 15% or 4.3 million who were Black, and 4% or 1.3 million who were Asian, with AIANs, NHOPIs, and mixed race individuals accounting for the roughly 1 million remaining uninsured people of color.
Key characteristics of the remaining nonelderly uninsured, such as work status, income, family status, and citizenship status, vary by race and ethnicity:
Across racial and ethnic groups, most nonelderly uninsured individuals have a full-time worker in the family, but uninsured Blacks, Hispanics, Asians, and AIANs are more likely than uninsured Whites to have family income below poverty (Figure 7).
Nonelderly uninsured Hispanics, Blacks, and AIANs are younger compared to uninsured Whites (Figure 8). In particular, children make up a higher share of uninsured Hispanics and AIANs compared to uninsured Whites.
A larger share of nonelderly uninsured Hispanics, Blacks, and AIANs are in families with children compared to uninsured Whites (Figure 9). For uninsured Hispanics and AIANs, single adults comprise a smaller share of the uninsured compared to Whites. However, among Blacks, single adults account for a higher share, making up over half of the uninsured.
A significantly larger share of nonelderly uninsured Asians, Hispanics, NHOPIs, and Blacks are immigrants compared to uninsured Whites (Figure 10). Uninsured Asians have the largest share of immigrants with over seven in ten naturalized citizens and non-citizens. Immigrants account for six in ten uninsured Hispanics, and nearly half of uninsured NHOPIs are non-citizens.
Estimates of Eligibility for ACA Coverage as of 2016
As of 2016, an estimated 27 million nonelderly people lacked health insurance nationwide. Overall, an estimated 43% of this population is eligible for financial assistance to gain coverage.8 This includes nearly a quarter (24%) who are eligible for Medicaid and 19% who are eligible for premium tax credits to purchase coverage through the Marketplace.9
Patterns of eligibility for coverage among the remaining uninsured differ across racial and ethnic groups (Figure 11). AIANs have the highest share of uninsured nonelderly individuals who are eligible for coverage, with over two in three eligible, including over half who are eligible for Medicaid. Nearly half of uninsured nonelderly Blacks are eligible for coverage, but they are twice as likely as uninsured nonelderly Whites (20% vs. 10%) to fall into the coverage gap in states that did not expand Medicaid. Smaller shares of nonelderly uninsured Asians (34%) and Hispanics (33%) are eligible for coverage compared to uninsured Whites (49%), reflecting that these groups include larger shares of non-citizens who do not qualify due to immigration status.
People of color account for a substantial share of the nonelderly uninsured who are eligible for coverage but not enrolled. Overall, people of color account for over half of the total nonelderly uninsured population that is eligible for Medicaid and 42% of those eligible for tax credits (Figure 12). Reflecting their large overall population sizes, Hispanics and Blacks account for the largest portions of these shares.
Although people of color have had larger gains in coverage compared to Whites since implementation of the ACA, racial and ethnic disparities in coverage remain. Prior to the ACA, people of color were more likely than Whites to be uninsured. Although these groups, particularly Hispanics, experienced larger gains in coverage compared to Whites since the ACA, Blacks, Hispanics, and AIANs remain more likely to be uninsured than Whites as of 2015. Uninsured rates are lower for children than adults, but disparities in coverage persist for Hispanic and AIAN children. Notably, AIAN children remain the only group of children with a double-digit uninsured rate, which is nearly five times higher than the rate for White children. Increasing coverage among these groups will be key for achieving further reductions in disparities in coverage.
Targeted outreach and enrollment efforts could contribute to increased coverage gains. Such efforts may be particularly effective at increasing coverage among AIANs and Blacks since large shares of uninsured individuals in these groups are eligible for coverage assistance. However, targeted efforts to reach all people of color will be key for continued nationwide progress increasing coverage since they account for a substantial share of the remaining uninsured who are eligible for Medicaid or tax credit subsidies. Understanding how characteristics of the remaining uninsured vary by race and ethnicity may help inform outreach and enrollment efforts.
Although enrollment efforts may continue progress increasing coverage, potential coverage gains are limited by state Medicaid expansion decisions and immigrant eligibility restrictions. The impact of these restrictions vary across racial and ethnic groups. For example, because a high share of the Black population resides in the South, where many states have not expanded Medicaid, uninsured Blacks are twice as likely as uninsured Whites to fall into the Medicaid coverage gap. Eligibility among uninsured Asians and Hispanics is more limited than other groups, reflecting that these groups include higher shares of non-citizens who are ineligible due to immigrant eligibility restrictions.
Together these findings show that there remain opportunities to increase coverage and further reduce coverage disparities by reaching those who are eligible for coverage but not yet enrolled. Understanding which groups remain at higher risk of being uninsured, their characteristics, and how eligibility for coverage varies by race and ethnicity can help inform these efforts and provide increased understanding of remaining coverage gains that can be achieved. The data also show that some uninsured individuals remain ineligible for coverage assistance. As such, safety-net resources will remain particularly important for serving these populations.
Samantha Artiga, Petry Ubri, and Julia Foutz are with the Kaiser Family Foundation. Anthony Damico is an independent consultant to the Kaiser Family Foundation.