How the Affordable Care Act (ACA) Has Narrowed Racial and Ethnic Disparities in Insurance Coverage and Access to Health Care, 2013‐18

Abstract

Research ObjectiveThe insurance coverage expansions enacted through the Affordable Care Act have significantly increased access to health care since the main provisions went into effect in 2014. This study analyzes the degree to which the expansions have narrowed racial and ethnic disparities in insurance coverage and access to care between white adults and black and Hispanic adults. It also aims to examine differences between states that have expanded Medicaid eligibility and those that have not, while highlighting policy options that might further reduce differences between racial and ethnic groups.Study DesignData for this study come from the American Community Survey Public Use Microdata Sample (ACS PUMS) and the Behavioral Risk Factor Surveillance System (BRFSS), 2013‐2018. We specifically examine three coverage/access indicators: uninsured rates, going without care because of cost in the past 12 months, and having a usual source of care. We calculate national and state annual averages from 2013 to 2018 for each of the indicators listed above, stratified by race/ethnicity, as well as annual rates for individuals in both Medicaid expansion and nonexpansion states.Population StudiedThe ACS PUMS sample population consists of approximately 1.8 million adults ages 19‐64. The BRFSS sample population consists of approximately 270 000 adults ages 18‐64.Principal FindingsThe ACA coverage expansions have led to historic reductions in racial and ethnic health access disparities between 2013 and 2018, but progress has largely stopped since 2016. The black uninsured rate dropped almost 10 points during the period, and the coverage gap with whites narrowed by 4.1 points. Hispanic insurance coverage improved by 15.3 points, and the Hispanic white disparity decreased by 9.4 points. Racial differences have also narrowed for cost‐related access problems and having a usual source of care. Though progress was seen throughout the United States, individuals in expansion states generally experienced greater access to care and smaller racial disparities. Black adults in expansion states are now reporting access that is better than, or as good as, whites in nonexpansion states—including higher insurance coverage rates.ConclusionsThe ACA coverage expansions are associated with reduced racial and ethnic disparities, but these gains have stalled. Data show that Medicaid expansion disproportionately helps blacks and Hispanics, but 46 percent of black adults live in the 15 remaining nonexpansion states. Hispanics also continue to suffer from greater disparities.Implications for Policy or PracticeMedicaid expansion is a key tool for reducing racial disparities, but given the geographic concentration of black adults, further progress may be difficult if more states do not expand.Because black and Hispanic adults are more likely to have low incomes, current congressional reform bills and proposals that fix the Medicaid coverage gap could have a significant impact on disparities.The large remaining Hispanic white gap is likely impacted by the sizable undocumented immigrant population, which is not eligible to use the ACA Marketplaces, tax credits, or Medicaid. Progress may necessitate state‐specific strategies, such as California’s recent decision to fund Medicaid coverage for undocumented young adults.Primary Funding SourceThe Commonwealth Fund.