Health Coverage by Race and Ethnicity, 2010-2023
Summary
Health coverage plays a major role in enabling people to access health care and protecting families from high medical costs. There have been longstanding racial and ethnic disparities in health coverage that contribute to disparities in health. This brief examines trends in health coverage by race and ethnicity from 2010 through 2023 and discusses the implications for health disparities. All noted differences between groups and years described in the text are statistically significant at the p<0.05 level. It is based on KFF analysis of American Community Survey (ACS) data for people under age 65. Key takeaways include:
There were gains in coverage across most racial and ethnic groups between 2019 and 2023 after several years of rising uninsured rates during the first Trump administration. The coverage gains between 2019 and 2023 were largely driven by increases in Medicaid coverage, reflecting policies to stabilize and expand access to affordable coverage that were implemented during the COVID-19 pandemic. These policies included enhanced subsidies to purchase Marketplace coverage and a requirement that states keep Medicaid enrollees continuously enrolled during the public health emergency (PHE), which led to record high Medicaid enrollment. While Medicaid enrollment fell as the pandemic era protections were unwound, it has remained higher than in 2019. These coverage gains helped narrow differences in uninsured rates for Hispanic, Black, and American Indian or Alaska Native (AIAN) people compared with White people, but the gains may be at risk due to potential Medicaid cuts and the expiration of the enhanced Marketplace subsidies.
Despite these coverage gains, disparities in coverage persisted as of 2023. AIAN and Hispanic people under age 65 had the highest uninsured rates at 18.7% and 17.9%, respectively. Uninsured rates for Native Hawaiian or Pacific Islander (NHPI) (12.8%) and Black people (9.7%) under age 65 also were higher than the rate for their White counterparts (6.5%). Coverage disparities have persisted over time, and in some cases widened despite recent gains and earlier large gains in coverage under the Affordable Care Act (ACA). For example, between 2010 and 2023, the uninsured rate for AIAN people grew from 2.4 to 2.9 times higher than the uninsured rate for White people, the Hispanic uninsured rate grew from 2.5 to 2.7 times higher than the rate for White people, and Black people remained 1.5 times more likely to be uninsured than White people.
Uninsured rates in states that have not expanded Medicaid are higher than rates in expansion states across most racial and ethnic groups as of 2023. Further, the differences in coverage rates between Hispanic, Black and NHPI people compared with White people are larger in non-expansion states compared with expansion states. However, the relative risk of being uninsured for Black and Hispanic people compared to White people is similar in expansion and non-expansion states.
Going forward, racial and ethnic disparities in coverage could widen due to potential Medicaid cuts, expiration of the enhanced subsidies for Marketplace coverage, and immigration policy changes. The incoming Trump administration and Republican controlled Congress are signaling plans to make significant changes to Medicaid and the ACA. House Republicans appear to be considering large cuts to Medicaid, which could help offset the cost of extending expiring tax cuts but would shift a substantial amount of Medicaid spending from the federal government to states, and likely lead states to make reductions in eligibility and/or benefits. Further, if Congress does not take action to extend the enhanced ACA Marketplace subsidies, which are set to expire in 2025, premiums will rise, likely leading to an increase in the number of uninsured people. Additionally, the Trump administration’s changes to immigration policy, including increased enforcement, the rescission of protections from enforcement activity in sensitive locations including health care facilities, and potential changes to public charge policy, will likely lead to reduced enrollment in health coverage of lawfully present immigrants and citizen children in immigrant families. Medicaid and Marketplace coverage losses would likely lead to widening racial disparities in coverage given that disproportionately large shares of Hispanic, Black, AIAN, and NHPI people are covered through these sources, which, in turn, would likely contribute to widening disparities in health.
Trends in Uninsured Rates by Race and Ethnicity, 2010-2023
Prior to the enactment of the ACA in 2010, Hispanic, Black, Asian, AIAN, and NHPI people under age 65 were more likely to be uninsured compared to their White counterparts, with Hispanic and AIAN people at the highest risk of lacking coverage (Figure 1). Their higher uninsured rates reflected more limited access to affordable health coverage options. Although the majority of individuals have at least one full-time worker in the family across racial and ethnic groups, there are ongoing racial disparities in employment and income that result in some groups having more limited access to coverage offered by an employer or having greater difficulty affording private coverage when it is available. While Medicaid helped fill some of these gaps in private coverage, prior to the ACA, Medicaid eligibility for parents in most states was limited to those with very low incomes (often below 50% of the poverty level), and adults without dependent children—regardless of how poor—were ineligible under federal rules.
Between 2010 and 2016, there were large gains in coverage across racial and ethnic groups under the ACA, but racial and ethnic disparities in coverage persisted. The ACA created new coverage options for low- and moderate-income individuals. These included provisions to extend dependent coverage in the private market up to age 26 and prevent insurers from denying people coverage or charging them more due to health status that went into place. Further, beginning in 2014, the ACA expanded Medicaid coverage to nearly all adults with incomes at or below 138% of poverty in states that adopted the expansion and made tax credits available to people with incomes up to 400% of poverty to purchase coverage through a health insurance Marketplace. Following the ACA’s enactment in 2010 through 2016, coverage increased across all racial and ethnic groups, with the largest increases occurring after implementation of the Medicaid and Marketplace coverage expansions in 2014. Hispanic people under age 65 had the largest percentage point increase in coverage, and their uninsured rate falling from 32.6% to 19.1%. Black, Asian, and AIAN people also had larger percentage point increases in coverage compared to White people over that period. Despite these larger gains, Hispanic, Black, AIAN, and NHPI people under age 65 remained more likely than their White counterparts to be uninsured as of 2016.
Beginning in 2017, coverage gains began reversing, and the number of uninsured increased for three consecutive years. The uninsured rate for the total population under age 65 increased from 10.0% in 2016 to 10.9% in 2019. Among this age group, Hispanic people had the largest statistically significant increase in their uninsured rate over this period (from 19.1% to 20.0%). There were also small but statistically significant increases in the uninsured rates among White and Black people under age 65, which rose from 7.1% to 7.8% and 10.7% to 11.4%, respectively, between 2016 and 2019. Rates for AIAN, NHPI, and Asian people under age 65 did not have a significant change. These coverage losses likely reflected policy changes made by the first Trump administration after taking office in 2017. These changes included decreased funds for outreach and enrollment assistance, guidance encouraging states to seek waivers to add new eligibility requirements for Medicaid coverage as well as to increase the frequency of eligibility verifications, and changes to public charge immigration policy that made some immigrant families more reluctant to participate in Medicaid and the Children’s Health Insurance Program (CHIP) (which were later reversed by the Biden administration).
After increasing for several years prior to the pandemic, uninsured rates declined between 2019 and 2023. The number of people under age 65 with insurance increased by 3.6 million between 2019 and 2023 as the uninsured rate dropped from 10.9% to 9.6%. (Because of disruptions in data collection during the first year of the pandemic, the Census Bureau did not release 1-year ACS estimates in 2020.) AIAN people had the largest percentage point increase in coverage, with their uninsured rate falling from 21.7% in 2019 to 18.7% in 2023. There were also smaller but statistically significant declines in uninsured rates among Hispanic (from 20.0% to 17.9%), Black (from 11.4% to 9.7%), Asian (from 7.2% to 5.8%), and White people (from 7.8% to 6.5%) during this period. These coverage gains were primarily driven by increases in Medicaid coverage, which offset declines in employer-sponsored coverage over the period. NHPI people did not have statistically significant changes in coverage over this period.
The coverage gains observed between 2019 and 2023 largely reflect policies adopted during the pandemic to stabilize coverage in Medicaid and enhance subsidies to purchase Marketplace coverage. Coverage gains reflected provisions in the Families First Coronavirus Response Act (FFCRA), enacted at the start of the pandemic that prohibited states from disenrolling people from Medicaid during the Public Health Emergency in exchange for enhanced federal funding. While Medicaid enrollment fell as the pandemic era protections were unwound, it has remained higher than in 2019. In addition, gains reflected enhanced ACA Marketplace subsidies made available by the American Rescue Plan Act (ARPA) and renewed in the Inflation Reduction Act of 2022 (IRA), boosted outreach and enrollment efforts, and low Marketplace attrition. Further, in 2019, the Biden administration reversed changes the Trump administration previously made to public charge immigration policies that had increased reluctance among some immigrant families to enroll in public programs, including health coverage.
Coverage disparities have persisted, and in some cases widened, over time even with recent gains and the large earlier gains in coverage under the ACA. For example, in 2010, the uninsured rate for AIAN people was 2.4 times higher than the uninsured rate for White people; however, in 2023, the uninsured rate for AIAN people had increased to 2.9 times higher than the rate for White people. Similarly, the Hispanic uninsured rate grew from 2.5 to 2.8 times higher than the rate for White people from 2010 to 2023, while Black people remained 1.5 times more likely to be uninsured than White people.
Coverage by Race and Ethnicity as of 2023
While there were minimal changes in overall uninsured rates between 2022 and 2023, Hispanic, Black, AIAN, and NHPI people under the age of 65 years old remained more likely than their White counterparts to be uninsured (Figure 2). AIAN and Hispanic people had the highest uninsured rates at 18.7% and 17.9%, respectively, as of 2023. Uninsured rates for NHPI (12.8%) and Black people (9.7%) also were higher than the rate for their White counterparts (6.5%). These differences in uninsured rates are driven by lower rates of private coverage among these groups. Medicaid coverage helps to narrow these differences but does not fully offset them.
Medicaid and CHIP coverage help fill gaps in private coverage and reduce coverage disparities for children, but some disparities in children’s coverage remain (Figure 2). Medicaid and CHIP cover larger shares of children than adults, reflecting more expansive eligibility levels for children. This coverage helps fill gaps in private coverage, with over half of Hispanic, Black, AIAN, and NHPI children covered by Medicaid and CHIP. However, there remain some disparities in children’s coverage. For example, AIAN children are about three times as likely as their White counterparts to lack coverage (12.7% vs. 4.0%). Moreover, Hispanic children are more than twice as likely as White children to be uninsured (8.5% vs. 4.0%).
Among people under the age of 65, uninsured rates in states that have not expanded Medicaid are higher than rates in expansion states across most racial and ethnic groups as of 2023 (Figure 3). The differences in coverage rates between Black and Hispanic people compared with White people are larger in non-expansion states compared with expansion states. However, the relative risk of being uninsured for Black, Hispanic, and Asian people compared with White people is similar in expansion and non-expansion states. For example, Hispanic people under the age of 65 years old are roughly 2.6 times as likely as their White counterparts to lack coverage in both expansion and non-expansion states. Uninsured rates for AIAN people are similar in expansion and non-expansion states. Overall, the differences in coverage by expansion status are primarily driven by differences in coverage rates among adults ages 18-64. However, White, Hispanic, Black, Asian, and NHPI children in non-expansion states also are more likely to be uninsured than those in expansion states. For example, 13.5% of Hispanic children in non-expansion states are uninsured compared to 6.1% of Hispanic children in expansion states.
Eligibility for Coverage among the Uninsured as of 2023
There are opportunities to increase coverage by enrolling eligible people in Medicaid or Marketplace coverage, but eligibility varies across racial and ethnic groups, and many remain ineligible for assistance. Overall, six in ten people who were uninsured in 2023 were eligible for financial assistance either through Medicaid or through subsidized Marketplace coverage, while the remaining four in ten were not eligible because they fell in the Medicaid coverage gap in states that have not expanded Medicaid, they were deemed to have access to an affordable Marketplace plan or offer of employer coverage, or they were ineligible due to their immigration status. However, the share of the remaining uninsured eligible for assistance varied by race and ethnicity. For example, uninsured Black people under age 65 were more likely than their White counterparts to fall in the coverage gap in states that have not expanded Medicaid, and uninsured Hispanic and Asian people under age 65 were less likely than White people to be eligible for coverage options, in part, reflecting higher shares of noncitizens who face immigrant eligibility restrictions among these groups (Figure 4).
Uninsured Black people under age 65 are more likely than their White counterparts to fall in the Medicaid “coverage gap” because a greater share live in states that have not implemented the Medicaid expansion. As of November 2024, 10 states have not adopted the ACA provision to expand Medicaid to adults with incomes through 138% of poverty. Most of these states are in the South, where a higher share of the Black population resides (Figure 5). In these states, 1.5 million uninsured people with incomes under poverty fall into the “coverage gap” and do not qualify for either Medicaid or premium subsidies in the ACA Marketplace.
Uninsured Asian, Black, Hispanic, and NHPI people under age 65 are less likely than their White counterparts to be eligible for coverage because they include larger shares of noncitizens who are subject to eligibility restrictions for Medicaid and Marketplace coverage (Figure 6). Lawfully present immigrants face eligibility restrictions for Medicaid coverage, with many having to wait five years after obtaining lawful status before they are eligible to enroll in Medicaid. Undocumented immigrants are not eligible to enroll in Medicaid and are prohibited from purchasing coverage through the Marketplaces.
Looking Ahead
Policies implemented amid the COVID-19 pandemic helped stabilize coverage and contributed to gains in coverage during this period. The coverage gains experienced during the COVID-19 pandemic were largely driven by an increase in Medicaid coverage, which offset declines in employer-sponsored coverage. As noted, temporary continuous enrollment provisions stabilized Medicaid coverage during the PHE, contributing to increases in enrollment. Additionally, the temporary enhanced subsidies for Marketplace coverage provided under ARPA, which were extended through 2025 under the IRA, also contributed to coverage gains. However, even with these gains, disparities in coverage remained.
Since the Medicaid continuous enrollment provision ended in March 2023, millions of people have been disenrolled. While there is limited data available on disenrollments by race and ethnicity, research suggests that Black and Hispanic people were two times more likely than White people to lose Medicaid due to being unable to complete the renewal process during the unwinding period. Many people who were disenrolled from Medicaid could find low-cost coverage on the ACA Marketplaces, including, in some cases, coverage with a zero (or near-zero) monthly premium requirement. However, others became uninsured. In focus groups, adults who were disenrolled from Medicaid reported losing coverage for a variety of reasons, including because they were no longer eligible; however, some believed they were still eligible and did not know why they were disenrolled. Many reported facing communication problems with their Medicaid agencies, and some who were disenrolled indicated that they faced gaps in coverage before reenrolling in Medicaid or became uninsured, which contributed to high out-of-pocket costs and difficulties accessing care that negatively impacted their health.
Going forward, racial and ethnic disparities in coverage could widen due to potential Medicaid cuts, expiration of the enhanced subsidies for Marketplace coverage, and immigration policy changes. The incoming Trump administration and Republican controlled Congress are signaling plans to make significant changes to Medicaid and the ACA. House Republicans appear to be considering large cuts to Medicaid, which could help offset the cost of extending expiring tax cuts but would shift a substantial amount of Medicaid spending from the federal government to states, and likely lead states to make reductions in eligibility and/or benefits. Further, if Congress does not take action to extend the enhanced ACA Marketplace subsidies, which are set to expire in 2025, premiums will rise, likely leading to an increase in the number of uninsured people. Additionally, the Trump administration’s changes to immigration policy, including increased enforcement, the rescission of protections from enforcement activity in sensitive locations including health care facilities, and potential changes to public charge policy, will likely lead to reduced enrollment in health coverage of lawfully present immigrants and citizen children in immigrant families. Medicaid and Marketplace coverage losses would likely lead to widening racial disparities in coverage given that disproportionately large shares of Hispanic, Black, AIAN, and NHPI people are covered through these sources, which, in turn, would likely contribute to widening disparities in health.