DATA BRIEF JANUARY 2020 How the The insurance coverage expansion ushered in by the Affordable Care Act (ACA) has significantly increased Americans’ ability to get the health care they need since the law’s main provisions went into effect in 2014. Research also indicates that the ACA narrowed Affordable Care racial and ethnic disparities in insurance coverage1 — a key objective of the law, and one that enjoys substantial public support.2 Act Has Narrowed In this brief, we examine how much the ACA also has reduced disparities in access to health care among black, Hispanic, and white adults. Using data from the federal American Racial and Ethnic Community Survey (ACS) and the Behavioral Risk Factor Surveillance System (BRFSS) for the years 2013 to 2018, we review: Disparities in • differences in the share of black, Hispanic, and white adults who are uninsured (ages 19 to 64) Access to Health • differences in the share who went without care because of cost in the past 12 months (ages 18 to 64) Care • differences in the share with a usual source of care (ages 18 to 64). We examine the degree to which racial and ethnic differences have narrowed since the ACA went into effect, what differences exist between states that have expanded Medicaid and those that have not, and which policy options might further reduce disparities. Jesse C. Baumgartner We hope these findings will help guide policymakers as they consider options for moving Research Associate the nation closer to a more equitable, higher-performing health care system. The Commonwealth Fund Sara R. Collins KEY HIGHLIGHTS Vice President The Commonwealth Fund ACA’s coverage expansions have led to historic reductions in racial disparities in The access to health care since 2013, but progress has stalled and, in some cases, eroded David C. Radley since 2016. Senior Scientist The Commonwealth Fund gap between black and white adult uninsured rates dropped by 4.1 percentage The points, while the difference between Hispanic and white Susan L. Hayes uninsured rates fell 9.4 points. Former Senior Researcher The Commonwealth Fund How the Affordable Care Act Has Narrowed Racial and Ethnic Disparities in Access to Health Care 2 Disparities narrowed in both states that expanded Medicaid years after the ACA’s implementation, black adults living in Five eligibility and in those that did not. In expansion states, all states that expanded Medicaid report coverage rates and access three groups had better overall access to care than they did in to care measures as good as or better than what white adults in nonexpansion states, and there were generally smaller differences nonexpansion states report. between whites and the two minority groups. While black working-age adults have benefited significantly from Medicaid expansion, they disproportionately (46%) reside in the 15 states that haven’t yet expanded their programs. HOW WE CONDUCTED THIS STUDY Analytical Approach We stratified survey respondents by their self-reported race or ethnicity: Indicators and Data Sources white (non-Hispanic), black (non-Hispanic), or Hispanic (any race). We • Percent of uninsured adults ages 19–64: U.S. Census Bureau, American Community Survey Public Use Microdata Sample (ACS PUMS), 2013– calculated national annual averages from 2013 to 2018 for each of the 2018. indicators listed above, stratified by race/ethnicity. We also calculated the average annual rate for white, black, and Hispanic individuals from 2013 to • Percent of adults ages 18–64 who went without care because of cost 2018 across two categories of states: the Medicaid expansion group included during past year and Percent of adults ages 18–64 who had a usual source of care: Centers for Disease Control and Prevention, Behavioral the 31 states that, along with the District of Columbia, had expanded their Risk Factor Surveillance System (BRFSS), 2013–2018. Medicaid programs under the ACA as of January 1, 2018; the nonexpansion group comprised the 19 states that had not expanded Medicaid as of that • Demographics, adults ages 19–64: American Community Survey Public time (Maine and Virginia are considered nonexpansion states in this analysis Use Microdata Sample (ACS PUMS), 2018. because they both implemented their Medicaid expansions in 2019). The ACS PUMS and BRFSS are large federal surveys used to track Reported values for expansion/nonexpansion categories are averages across demographic and health characteristics of the U.S. population. The ACS survey respondents, not averages of state rates. samples approximately 3.5 million individuals each year, with annual response rates over 90 percent.3 The Census Bureau makes approximately In addition, for certain subpopulations in Louisiana and Georgia we two-thirds of ACS response records available to researchers in the Public calculated average annual state-specific uninsured rates from 2013 to 2018. Use Microdata Sample. The Centers for Disease Control and Prevention Subpopulation rates based on small samples were suppressed. Estimates conduct the BRFSS each year in partnership with implementing agencies in derived from ACS PUMS were suppressed if unweighted cell counts were less each state. The 2018 BRFSS had a response rate just under 50 percent, with than 50; estimates derived from BRFSS were suppressed if the measures’ approximately 437,500 completed responses; similar response rates were unweighted cell count was less than 50 or the relative standard error seen in previous years.4 (standard error divided by the estimate) was under 30 percent. commonwealthfund.org Data Brief, January 2020 How the Affordable Care Act Has Narrowed Racial and Ethnic Disparities in Access to Health Care 3 Adult uninsured rates have decreased for all groups since 2013, and disparities have FINDINGS narrowed significantly among whites, blacks, and Hispanics. Black, Hispanic, and white adults have all made Exhibit 1. Adult uninsured rates have decreased for all groups since 2013, and disparities have narrowed significantly among whites, blacks, and Hispanics. historic insurance coverage gains under the 5 ACA (Table 2). According to the U.S. Census Bureau’s American Community Survey, the Percentage of uninsured adults ages 19 to 64, by race and ethnicity U.S. working-age adult uninsured rate fell from 20.4 percent in 2013, just before the law’s main 50 All Black Hispanic White provisions took effect, to 12.4 percent in 2018.6 This improvement occurred between 2013 and 40.2 2016; since then, the rate has risen slightly. 40 Blacks and Hispanics had the highest uninsured 33.0 rates prior to the law’s passage and have made 30 the largest gains. The uninsured rate for black 25.5 24.9 adults dropped from 24.4 percent in 2013 to 14.4 24.4 percent in 2018, while the rate for Hispanic adults 19.2 decreased from 40.2 percent to 24.9 percent. 20 20.4 13.7 14.4 This progress reduced the difference between 16.3 the two groups and white adults (Table 3). The 14.5 10 12.1 12.4 black–white disparity in coverage dropped 11.4 from 9.9 percentage points in 2013 to 5.8 points 8.2 8.6 in 2018. The gap between uninsured Hispanics and whites, meanwhile, declined from 25.7 0 2013 2014 2015 2016 2017 2018 points to 16.3 points. Data: American Community Survey Public Use Microdata Sample (ACS PUMS), 2013–2018. But the insurance gains made by blacks and Hispanics have stalled, and even eroded, since Source: Jesse C. Baumgartner et al., How the Affordable Care Act Has Narrowed Racial and Ethnic Disparities in Access to Health Care (Commonwealth Fund, Jan. 2020). 2016 — much as they have for the overall population. Black adults have seen their uninsured rate tick up by 0.7 percentage points since 2016, while white adults have seen a half-percentage-point increase. This has largely halted the improvement in coverage disparities. Hispanic adults continue to report significantly higher uninsured rates than either white or Data: American Community Survey Public Use Microdata Sample (ACS PUMS), 2013–2018. black adults. commonwealthfund.org Data Brief, January 2020 How the Affordable Care Act Has Narrowed Racial and Ethnic Disparities in Access to Health Care 4 All groups are experiencing fewer financial barriers to accessing care, with black and The coverage gains under the ACA made it Hispanic adults showing the largest reduction. easier for people to get health care.7 Adults Exhibit 2. All groups are experiencing fewer financial barriers to accessing care, with black and Hispanic adults showing the largest reduction. with low income have benefited the most from the law’s insurance subsidies, out-of-pocket cost protections, and expansion in Medicaid Percentage of adults ages 18 to 64 who avoided care because of cost in the past 12 months, by race and ethnicity eligibility.8 50 All Black Hispanic White Black and Hispanic adults are almost twice as likely as white adults to have low income (less than 200% of the federal poverty level, or 40 FPL) (Table 1) and, prior to 2013, they reported significantly higher rates of cost-related problems getting care. After the ACA’s major 30 27.8 coverage expansions in 2014, they experienced 24.9 23.2 the largest overall improvements in access 21.9 20.9 21.2 (Table 4). Twenty-three percent of black adults 20 18.5 16.6 17.9 17.6 reported avoiding care because of cost in 2013, 15.1 15.1 compared to 17.6 percent in 2018. Cost-related 15.1 access problems among Hispanic adults fell 13.7 12.9 10 12.7 from 27.8 percent to 21.2 percent, while those reported by whites dropped from 15.1 percent to 12.9 percent. 0 2013 2014 2015 2016 2017 2018 As a result, differences narrowed between Data: Behavioral Risk Factor Surveillance System (BRFSS), 2013–2018. white adults and black and Hispanic adults in cost-related access problems. The black– Source: Jesse C. Baumgartner et al., How the Affordable Care Act Has Narrowed Racial and Ethnic Disparities in Access to Health Care (Commonwealth Fund, Jan. 2020). white disparity shrank from 8.1 percentage points in 2013 to 4.7 points in 2018, while the Hispanic–white difference fell from 12.7 points to 8.3 points (Table 3). Again, most of that improvement occurred between 2013 and 2016. Data: Behavioral Risk Factor Surveillance System (BRFSS), 2013–2018. commonwealthfund.org Data Brief, January 2020 How the Affordable Care Act Has Narrowed Racial and Ethnic Disparities in Access to Health Care 5 Adults with a usual source of care have modestly increased for black and Hispanic Having a usual source of care — defined as a groups since 2013. personal doctor or other health care provider Exhibit 3. Adults with a usual source of care have modestly increased for black and Hispanic groups since 2013. like a health clinic where someone would usually go if they were sick — is generally seen as a strong indicator of health care access.9 Percentage of adults ages 18 to 64 who reported a usual source of care, by race and ethnicity The share of black and Hispanic adults with 90 All Black Hispanic White a usual source of care climbed by about three percentage points between 2013 and 2018 (Table 4). This modestly reduced disparities 80 77.6 78.1 78.6 with white adults, who continue to be the most 77.0 74.7 likely to have a usual source of care among the 74.1 72.0 73.4 three groups (Table 3). 73.0 73.8 70 72.6 71.1 The black–white disparity for reporting a usual source of care decreased from 6.5 percentage points in 2013 to 2.8 points in 2018, and the 60 difference between Hispanics and whites 58.2 58.2 dropped from 22.4 points to 18.7 points. The 56.2 55.3 improvement on this measure stalled for blacks 50 and Hispanics after 2015. 40 2013 2014 2015 2016 2017 2018 Data: Behavioral Risk Factor Surveillance System (BRFSS), 2013–2018. Source: Jesse C. Baumgartner et al., How the Affordable Care Act Has Narrowed Racial and Ethnic Disparities in Access to Health Care (Commonwealth Fund, Jan. 2020). Data: Behavioral Risk Factor Surveillance System (BRFSS), 2013–2018. commonwealthfund.org Data Brief, January 2020 How the Affordable Care Act Has Narrowed Racial and Ethnic Disparities in Access to Health Care 6 Black adults living in expansion states are now lessnow less likely to be uninsured than Exhibit 4. Black adults living in expansion states are likely to be uninsured than white The ACA offered states the opportunity to expand white adults in nonexpansion states. eligibility for Medicaid, with the federal government adults in nonexpansion states. picking up most of the additional cost. We examined Percentage of uninsured adults ages 19 to 64, race and ethnicity by Medicaid expansion status all three of our health insurance and access measures 50 for individuals across two categories of states — those Black (expansion) Black (nonexpansion) White (expansion) White (nonexpansion) that had expanded their Medicaid program under the 40 ACA as of January 1, 2018, and those that had not. The 31 states that, along with the District of Columbia, 30 27.3 had expanded their programs typically started from 22.7 a stronger baseline and had smaller initial racial and 21.5 20 17.5 18.7 ethnic disparities. This was likely because of state- 15.8 16.9 specific factors, such as more generous pre-ACA 14.4 11.6 12.3 10 13.1 Medicaid eligibility standards.10 9.9 10.1 9.7 6.1 6.4 Uninsured rates for blacks, Hispanics, and whites 0 2013 2014 2015 2016 2017 2018 declined in both expansion and nonexpansion states between 2013 and 2018. In addition, disparities in coverage between whites and blacks and Hispanics Although Although Hispanic adults in bothof states reported lower uninsured rates and Exhibit 5. Hispanic adults in both groups groups of states reported lower uninsured also narrowed over that time period in both sets reduced disparities, the gainsthe gains were larger in Medicaid expansion states. rates and reduced disparities, were larger in Medicaid expansion states. of states. But progress has stalled and even slightly Note: Expansion states are those that expanded Medicaid by January 1, 2018. As ofand ethnicity by Medicaidnot yet expanded Medicaid. Maine and Virginia implemented Medicaid Percentage of uninsured adults ages 19 to 64, race that date, there were 19 states that had expansion status eroded (Table 2, Table 3). expansion in 2019 and are considered nonexpansion for this analysis. Data: American Community Survey Public Use Microdata Sample (ACS PUMS), 2013–2018. 50 46.9 Hispanic (expansion) Hispanic (nonexpansion) People living in Medicaid expansion states benefited Source: Jesse C. Baumgartner et al., How the Affordable Care Act Has Narrowed Racial and Ethnic Disparities in(nonexpansion) White (expansion) White Access to Health Care the most in terms of coverage gains. All three groups 40.6 (Commonwealth Fund, Jan. 2020). 40 36.3 reported lower uninsured rates in expansion states 34.7 34.3 compared to nonexpansion states, and larger 30 28.6 coverage improvements between 2013 and 2018. 20.0 19.1 Coverage disparities in expansion states narrowed the 20 16.9 14.4 most over the period, even though the disparities were 11.6 12.3 smaller to begin with. The black–white coverage gap in 10 13.1 9.7 those states dropped from 8.4 percentage points to 3.7 6.1 6.4 points, while the difference between Hispanic and white 0 2013 2014 2015 2016 2017 2018 uninsured rates fell from 23.2 points to 12.7 points. Because of this progress, blacks in expansion states Note: Expansion states are those that expanded Medicaid by January 1, 2018. As of that date, there were 19 states that had not yet expanded Medicaid. Maine and Virginia implemented Medicaid expansion in 2019 and are considered nonexpansion for this analysis. are now more likely to be insured than whites in Data: American Community Survey Public Use Microdata Sample (ACS PUMS), 2013–2018. nonexpansion states. commonwealthfund.org expanded Medicaid by January 1, 2018. As of that date, there were 19 states that had not yet expanded Medicaid. Maine and Virginia implemented Medicaid Note: Expansion states are those that Data Brief, January 2020 expansion in 2019 and are considered nonexpansion for this analysis. Data: American Community Survey Public Use Microdata Sample (ACS PUMS), 2013–2018. How the Affordable Care Act Has Narrowed Racial and Ethnic Disparities in Access to Health Care 7 Black–white differences in cost-related access problems have narrowed in bothin both Exhibit 6. Black–white differences in cost-related access problems have narrowed Since 2013, Hispanics, blacks, and whites in expansion and nonexpansion states. expansion and nonexpansion states. both expansion and nonexpansion states have Percentage of adults ages 18 to 64 who avoided care because of cost in the past 12 months, race and ethnicity by become increasingly less likely to report that Medicaid expansion status they went without health care because of cost 50 Black (expansion) Black (nonexpansion) in the past 12 months (Table 4). Disparities also White (expansion) White (nonexpansion) have narrowed, resulting in more equitable 40 access to care (Table 3). 30 Black adults in Medicaid expansion states 25.5 22.6 experienced a larger reduction in cost-related 20.8 21.0 20.8 20 19.2 access problems (6.6 percentage points) than 16.9 15.5 15.1 15.7 those in nonexpansion states (4.7 points). Blacks 14.8 14.3 10 14.0 12.6 in expansion states now report cost-related 11.2 11.1 access problems at about the same rates as 0 2013 2014 2015 2016 2017 2018 whites in nonexpansion states (Table 4).11 The gap between Hispanic and white adults The Hispanic–white disparitydisparity for avoiding care because of cost has dropped Exhibit 7. The Hispanic–white for avoiding care because of cost has dropped reporting cost-related access problems significantlyin both expansion and nonexpansion states. significantly in both expansion and nonexpansion states. narrowed in both expansion states (from Percentage of adults ages 18 to 64 who avoided care because of cost in the past 12 months, race and ethnicity by 12.1 percentage points to 8.3 points) and Note: Expansion states are those that expanded Medicaid by January 1, 2018. As of that date, there were 19 states that had not yet expanded Medicaid. Maine and Virginia implemented Medicaid Medicaid expansion status expansion in 2019 and are considered nonexpansion for this analysis. nonexpansion states (from 13.8 points to 8.3 Data: Behavioral Risk Factor Surveillance System (BRFSS), 2013–2018. 50 Hispanic (expansion) Hispanic (nonexpansion) points). The larger decline in disparities in White (expansion) White (nonexpansion) Source: Jesse C. Baumgartner et al., How the Affordable Care Act Has Narrowed Racial and Ethnic Disparities in Access to Health Care (Commonwealth Fund, Jan. 2020). nonexpansion states was mainly because of a 40 smaller improvement for whites in those states. 30.7 30 27.9 26.2 25.7 23.9 23.1 19.6 19.5 20 16.9 15.5 15.1 15.7 10 14.0 12.6 11.2 11.1 0 2013 2014 2015 2016 2017 2018 Note: Expansion states are those that expanded Medicaid by January 1, 2018. As of that date, there were 19 states that had not yet expanded Medicaid. Maine and Virginia implemented Medicaid expansion in 2019 and are considered nonexpansion for this analysis. Data: Behavioral Risk Factor Surveillance System (BRFSS), 2013–2018. commonwealthfund.org expanded Medicaid by January 1, 2018. As of that date, there were 19 states that had not yet expanded Medicaid. Maine and Virginia implemented Medicaid Note: Expansion states are those that Data Brief, January 2020 expansion in 2019 and are considered nonexpansion for this analysis. Data: Behavioral Risk Factor Surveillance System (BRFSS), 2013–2018. How the Affordable Care Act Has Narrowed Racial and Ethnic Disparities in Access to Health Care 8 Black adults in expansion states are now almost as likelyas likely as whitein those Exhibit 8. Black adults in expansion states are now almost as white adults adults in Regardless of whether they lived in a Medicaid same statesstates to a usualusual source of care. those same to have have a source of care. expansion state or not, white adults did not report improvement in having a usual source of Percentage of adults ages 18 to 64 who reported a usual source of care, race and ethnicity by Medicaid expansion status care between 2013 and 2018. Whites began the 90 Black (expansion) Black (nonexpansion) period at a comparatively higher baseline than White (expansion) 80.6 White (nonexpansion) blacks and Hispanics. 79.1 79.8 79.1 80 75.0 76.7 78.1 77.2 In contrast, blacks and Hispanics reported 75.3 75.4 70 73.5 73.4 modest improvement in having a usual source 71.4 71.2 68.7 70.2 of care, in both expansion and nonexpansion 60 states (Table 4).12 Black adults in expansion states improved the most, with 73.5 percent 50 reporting a usual care provider in 2013 versus 77.2 percent in 2018. They are now more likely 40 2013 2014 2015 2016 2017 2018 than white adults in nonexpansion states to have a usual source of care, and almost as likely as white adults in expansion states. HispanicsHispanics in both expansion and nonexpansion states reported modestly higher Exhibit 9. in both expansion and nonexpansion states reported modestly higher rates for a usualusual source of care, while white adults largely maintained their higher rates. rates for a source of care, while white adults largely maintained their higher rates. The gap between blacks and whites in having a usual source of care decreased in Medicaid Note: Expansion states are those that expanded Medicaid by January 1, 2018. As of that date, there were 19care,that had not yetethnicity by Medicaid expansion status Percentage of adults ages 18 to 64 who reported a usual source of states race and expanded Medicaid. Maine and Virginia implemented Medicaid expansion in 2019 and are considered nonexpansion for this analysis. expansion states (to 1.9 percentage points) Data: Behavioral Risk Factor Surveillance System (BRFSS), 2013–2018. 90 Hispanic (expansion) Hispanic (nonexpansion) and nonexpansion states (to 2.3 points). The White (expansion) White (nonexpansion) Source: Jesse C. Baumgartner et al., How the Affordable Care Act Has Narrowed Racial and Ethnic Disparities in Access to Health Care 80.6 difference between Hispanics and whites in 79.1 79.8 (Commonwealth Fund, Jan. 2020). 79.1 80 expansion states dropped to 17.8 points, while in nonexpansion states it decreased to 20.2 75.0 75.3 75.4 70 73.4 points. Disparities actually decreased more in 63.0 60.1 61.3 nonexpansion states, mainly because white 60 58.2 adults in those states became slightly less likely to have a usual source of care during the 50 53.2 50.2 49.7 50.6 2013–2018 period (Table 3). 40 2013 2014 2015 2016 2017 2018 Note: Expansion states are those that expanded Medicaid by January 1, 2018. As of that date, there were 19 states that had not yet expanded Medicaid. Maine and Virginia implemented Medicaid expansion in 2019 and are considered nonexpansion for this analysis. Data: Behavioral Risk Factor Surveillance System (BRFSS), 2013–2018. commonwealthfund.org Data Brief, January 2020 Note: Expansion states are those that expanded Medicaid by January 1, 2018. As of that date, there were 19 states that had not yet expanded Medicaid. Maine and Virginia implemented Medicaid expansion in 2019 and are considered nonexpansion for this analysis. Data: Behavioral Risk Factor Surveillance System (BRFSS), 2013–2018. How the Affordable Care Act Has Narrowed Racial and Ethnic Disparities in Access to Health Care 9 After expanding Medicaid, Louisiana’s black–white insurance coverage disparity Expanded Medicaid eligibility has been an dropped rapidly in comparison to Georgia — driven largely by lower-income adults. important tool for improving racial equity in Exhibit 10. After expanding Medicaid, Louisiana’s black–white insurance coverage disparity coverage and access to care. This is because blacks dropped rapidly in comparison to Georgia — driven largely by lower-income adults. and Hispanics are disproportionately lower income.13 But an estimated 46 percent of black Percentage of uninsured adults ages 19 to 64, Louisiana and Georgia, 0–199% FPL, by race and ethnicity working-age adults live in the 15 states that have 50 not expanded Medicaid — a much larger share of Black (Louisiana) Black (Georgia) people than the national average — along with 36 White (Louisiana) White (Georgia) 42.0 percent of Hispanics.14 The majority of Medicaid 40 41.4 nonexpansion states are in the South. 40.9 37.7 33.2 31.8 32.3 33.1 To illustrate the potential effects of further Medicaid expansion, we analyzed two Southern 30 30.1 29.4 30.4 states with large black adult populations. 28.7 24.3 Louisiana chose to expand Medicaid in 2016, while 22.8 Georgia has yet to do so. As the exhibit shows, 20 16.5 white and black adults with incomes under 200 percent of the federal poverty level (which is 10 14.0 $24,980 for an individual and $51,500 for a family of four in 2020) experienced coverage gains from 2013 to 2015 in both states. But after Louisiana 0 expanded Medicaid in July 2016, uninsured 2013 2014 2015 2016 2017 2018 rates for both groups dropped an additional 12.2 Note: FPL = federal poverty level. points to 16.0 points. Georgia’s uninsured rates, Data: American Community Survey Public Use Microdata Sample (ACS PUMS), 2013–2018. meanwhile, did not improve after 2016 (Table 5). Source: Jesse C. Baumgartner et al., How the Affordable Care Act Has Narrowed Racial and Ethnic Disparities in Access to Health Care (Commonwealth Fund, Jan. 2020). Because an estimated 54 percent of black working-age adults in Louisiana have low incomes (Table 1), Medicaid expansion helped drive the state’s overall black adult uninsured rate down to 11.3 percent in 2018 (Table 5). This was lower than the rate for black adults (19.2%) and white adults (14.9%) in Georgia. Note: FPL = federal poverty level. Data: American Community Survey Public Use Microdata Sample (ACS PUMS), 2013–2018. commonwealthfund.org Data Brief, January 2020 How the Affordable Care Act Has Narrowed Racial and Ethnic Disparities in Access to Health Care 10 CONCLUSION expanded Medicaid eligibility is not available to nearly half of black The ACA’s coverage expansions have led to nationwide improvements adults and more than a third of Hispanics, causing an inordinately in coverage and access to care. As our analysis and other recent studies negative impact on these communities of color. If more states don’t show, the law also has led to historic reductions in racial disparities choose to expand Medicaid, further reductions in racial disparities in coverage and access since 2014. This is true across most states, and may be difficult to attain. especially those that have expanded Medicaid. Our findings on the positive effects of expanding Medicaid also Still, nearly 10 years after the law’s passage, notable gaps between offer a window into the potential impact that current congressional people of color and whites remain across all regions and income levels. reform bills and proposals could have on disparities. That includes not only “Medicare for all” approaches, but also reforms that seek to Progress has also stalled for all three groups since 2016, and insurance eliminate the Medicaid expansion gap and realize the ACA’s original coverage has slightly eroded for both black and white adults. That can intent.17 Alternatively, Republican proposals to end Medicaid be linked in part to congressional inaction: there has been no federal expansion altogether would likely reverse the ACA’s historic legislation since 2010 to enhance or reinforce the ACA. At the same improvements in racial disparities in health care access.18 time, recent legislation and executive actions have negatively affected Americans’ coverage and access to care, including: the repeal of the • Make marketplace subsidies available to people with incomes individual mandate penalty for not having health insurance; substantial under 100 percent of the poverty level or otherwise fill the reductions in funding for outreach and enrollment assistance for people Medicaid coverage gap. With significantly lower incomes, black and who may be eligible for marketplace or Medicaid coverage; and the Hispanic adults in nonexpansion states are at high risk of falling loosening of restrictions on health plans that don’t comply with the into a coverage gap in which their income is too high for existing ACA’s rules. Medicaid but not high enough to qualify for marketplace premium subsidies (100%–400% of poverty).19 Hispanic adults also experience much larger disparities, in part because undocumented immigrants can’t qualify for marketplace coverage, • Remove the income cap on marketplace subsidy eligibility. receive subsidies, or enroll in Medicaid.15 These disparities could be Premium contributions for marketplace plans are capped at a exacerbated by the Trump administration’s new “public charge” rule.16 certain percentage of income for people between 100 percent and 400 percent of poverty, with a maximum of 9.78 percent of income. Nevertheless, state and federal policymakers can take actions in the Removing the upper income limit would provide relief to people near term to further reduce the racial differences in health care access who are currently spending more than this maximum share of their that persist: earnings on health insurance.20 • Expand Medicaid without restriction in the remaining 15 states. • Enact targeted, state-specific Medicaid expansions beyond the Medicaid expansion is a proven tool for reducing racial disparities, ACA. For example, California recently expanded its Medicaid one that our data show benefits blacks and Hispanics the most. Yet program to cover undocumented young adults.21 commonwealthfund.org Data Brief, January 2020 How the Affordable Care Act Has Narrowed Racial and Ethnic Disparities in Access to Health Care 11 • Allow undocumented immigrants to shop for coverage in the marketplaces. This group is currently ineligible for coverage through the ACA insurance exchanges. All the policies presented here can help make the U.S. health care system more equitable. But they will need to be accompanied by efforts to address drivers of racial inequities in health that extend beyond access to health insurance. Those include inequities in educational opportunity and income22 and the fact that people of color are often perceived and treated differently by health care providers.23 A recent survey of Americans’ values with regard to health care shows that a majority do not believe that everyone in the U.S. receives equal treatment within the health system.24 And an overwhelming majority believe that everyone should. commonwealthfund.org Data Brief, January 2020 How the Affordable Care Act Has Narrowed Racial and Ethnic Disparities in Access to Health Care 12 Table 1. U.S. Demographic Estimates, 2018 (base: adults ages 19–64) United States Expansion states Nonexpansion states Louisiana Georgia Total Total Total Total Total % % % % % (millions) (millions) (millions) (thousands) (thousands) Total 193 100.0% 119 100.0% 74 100.0% 2,695 100.0% 6,245 100.0% Race/Ethnicity White 116 60.1% 72 60.6% 44 59.1% 1,599 59.3% 3,257 52.2% Black 24 12.5% 12 10.1% 12 16.3% 854 31.7% 1,993 31.9% Hispanic 35 18.1% 22 18.2% 13 18.0% 134 5.0% 573 9.2% Income 0–199% FPL 53 27.5% 31 26.2% 22 29.6% 981 36.6% 1,823 29.5% 200%–399% FPL 56 29.2% 33 27.9% 23 31.2% 737 27.5% 1,855 30.0% 400%+ FPL 83 43.3% 54 45.9% 29 39.2% 959 35.8% 2,498 40.4% Race/Ethnicity, by income White 0–199% FPL 25 21.7% 15 20.8% 10 23.3% 423 26.6% 743 23.0% 200%–399% FPL 32 27.5% 19 26.2% 13 29.7% 445 28.0% 903 28.0% 400%+ FPL 58 50.8% 38 53.1% 20 47.0% 721 45.4% 1,581 49.0% NOTES Black Expansion states are those 0–199% FPL 9 39.5% 5 38.7% 5 40.3% 454 53.6% 716 36.4% that expanded Medicaid by January 1, 2018. As of that 200%–399% FPL 8 31.6% 4 29.7% 4 33.5% 223 26.4% 644 32.8% date, there were 19 states that had not yet expanded 400%+ FPL 7 28.9% 4 31.6% 3 26.1% 170 20.1% 607 30.9% Medicaid. Maine and Virginia implemented Medicaid Hispanic expansion in 2019 and are considered nonexpansion for 0–199% FPL 14 38.9% 8 37.8% 5 40.6% 61 46.3% 249 43.8% this analysis. FPL = federal poverty level. 200%–399% FPL 12 34.7% 7 34.5% 5 35.0% 38 28.4% 194 34.2% 400%+ FPL 9 26.4% 6 27.7% 3 24.4% 33 25.2% 125 22.1% DATA American Community Survey Public Use Microdata Sample (ACS PUMS), 2018. commonwealthfund.org Data Brief, January 2020 How the Affordable Care Act Has Narrowed Racial and Ethnic Disparities in Access to Health Care 13 Table 2. Uninsured Rates by Demographics, 2013–2018 (base: adults ages 19–64) United States Expansion states Nonexpansion states Net change Net change Net change 2013 2016 2017 2018 2013 2016 2017 2018 2013 2016 2017 2018 (% points) (% points) (% points) Total 20.4 12.1 12.2 12.4 –8.0 18.4 9.2 9.1 9.2 –9.1 23.9 16.8 17.3 17.6 –6.3 Race/Ethnicity White 14.5 8.2 8.4 8.6 –5.9 13.1 6.1 6.2 6.4 –6.7 16.9 11.6 12.1 12.3 –4.5 Black 24.4 13.7 13.9 14.4 –9.9 21.5 9.9 9.5 10.1 –11.4 27.3 17.5 18.3 18.7 –8.6 Hispanic 40.2 25.5 25.1 24.9 –15.3 36.3 20.0 19.3 19.1 –17.2 46.9 34.7 34.5 34.3 –12.6 Income 0–199% FPL 37.9 23.1 23.1 23.2 –14.7 34.6 17.1 16.6 16.6 –18.0 42.8 31.8 32.2 32.4 –10.4 200%–399% FPL 20.0 12.9 13.4 13.9 –6.1 18.9 10.8 10.9 11.3 –7.7 21.7 15.9 16.9 17.7 –4.0 400%+ FPL 6.7 4.1 4.5 4.8 –1.9 6.3 3.4 3.6 3.9 –2.4 7.7 5.4 6.1 6.6 –1.1 Race/Ethnicity, by income 0–199% FPL White 31.2 17.5 17.8 18.0 –13.2 28.7 12.4 12.3 12.5 –16.1 35.0 25.1 25.8 25.9 –9.0 Black 34.4 20.3 20.5 20.8 –13.6 30.1 13.7 13.1 13.6 –16.5 38.5 26.7 27.5 27.7 –10.8 NOTES Expansion states are those Hispanic 54.0 36.7 36.1 36.0 –18.0 48.5 28.1 27.3 26.9 –21.6 63.0 50.2 49.6 49.6 –13.4 that expanded Medicaid by January 1, 2018. As of that 200%–399% FPL date, there were 19 states that had not yet expanded White 15.3 9.6 10.2 10.6 –4.7 14.5 8.0 8.3 8.5 –6.0 16.5 12.0 12.9 13.5 –3.0 Medicaid. Maine and Virginia implemented Medicaid Black 20.5 11.9 12.3 13.3 –7.2 19.3 10.0 9.6 10.3 –9.0 21.6 13.7 14.7 15.9 –5.7 expansion in 2019 and are considered nonexpansion for Hispanic 35.5 23.2 23.1 23.7 –11.8 32.7 19.1 18.6 19.1 –13.6 40.4 30.0 30.5 31.0 –9.3 this analysis. 400%+ FPL Net change is percentage- point change between 2013 White 5.2 3.1 3.4 3.7 –1.5 4.8 2.6 2.8 3.0 –1.9 6.0 4.2 4.6 5.0 –1.0 and 2018. FPL = federal poverty level. Black 10.2 5.6 6.1 7.1 –3.2 9.8 4.7 4.9 5.6 –4.2 10.8 6.8 7.6 8.9 –2.0 Hispanic 15.0 9.5 10.4 10.7 –4.3 13.9 8.0 8.4 8.7 –5.1 17.0 12.1 14.1 14.1 –2.9 DATA American Community Survey Public Use Microdata Sample (ACS PUMS), 2013–2018. commonwealthfund.org Data Brief, January 2020 How the Affordable Care Act Has Narrowed Racial and Ethnic Disparities in Access to Health Care 14 Table 3. Trends in Black–White and Hispanic–White Disparities in Insurance Coverage and Access, 2013–2018 Black–White disparity Hispanic–White disparity (percentage points) (percentage points) Net change Net change 2013 2018 2013 2018 (% points) (% points) Uninsured rates (base: adults ages 19–64)* U.S. average 9.9 5.8 –4.1 25.7 16.3 –9.4 Expansion states 8.4 3.7 –4.7 23.2 12.7 –10.5 Nonexpansion states 10.4 6.4 –4.0 30.0 22.0 –8.0 Care avoided because of cost (base: adults ages 18–64)** U.S. average 8.1 4.7 –3.4 12.7 8.3 –4.4 Expansion states 6.8 3.1 –3.7 12.1 8.3 –3.8 Nonexpansion states 8.6 5.2 –3.5 13.8 8.3 –5.5 Usual source of care (base: adults ages 18–64)** U.S. average 6.5 2.8 –3.7 22.4 18.7 –3.6 Expansion states 5.6 1.9 –3.7 20.9 17.8 –3.1 Nonexpansion states 6.3 2.3 –4.1 24.8 20.2 –4.6 NOTES Expansion states are those that expanded Medicaid by January 1, 2018. As of that date, there were 19 states that had not yet expanded Medicaid. Maine and Virginia implemented Medicaid expansion in 2019 and are considered nonexpansion for this analysis. DATA * American Community Survey Public Use Microdata Sample (ACS PUMS), 2013–2018. ** Behavioral Risk Factor Surveillance System (BRFSS), 2013–2018. commonwealthfund.org Data Brief, January 2020 How the Affordable Care Act Has Narrowed Racial and Ethnic Disparities in Access to Health Care 15 Table 4. Rates for Access Indicators by Race/Ethnicity, 2013–2018 (base: adults ages 18–64) United States Expansion states Nonexpansion states Net change Net change Net change 2013 2016 2017 2018 2013 2016 2017 2018 2013 2016 2017 2018 (% points) (% points) (% points) Care Avoided Because of Cost in Previous 12 Months Total 18.5 15.1 15.7 15.1 –3.4 17.0 13.3 13.7 13.2 –3.9 21.0 18.1 18.9 18.2 –2.8 Race/Ethnicity White 15.1 12.7 13.3 12.9 –2.2 14.0 11.2 11.6 11.1 –2.9 16.9 15.1 16.0 15.7 –1.3 Black 23.2 17.9 18.8 17.6 –5.6 20.8 14.8 15.9 14.3 –6.6 25.5 21.0 21.7 20.8 –4.7 Hispanic 27.8 21.9 21.9 21.2 –6.7 26.2 19.6 19.7 19.5 –6.7 30.7 25.7 25.3 23.9 –6.7 Usual Source of Care Total 72.0 73.8 73.1 72.6 0.6 73.9 76.4 75.7 75.0 1.0 68.9 69.6 68.9 68.8 0.0 Race/Ethnicity White 77.6 78.6 77.5 77.0 –0.6 79.1 80.6 79.6 79.1 0.0 75.0 75.4 74.1 73.4 –1.6 Black 71.1 74.7 74.4 74.1 3.0 73.5 78.1 78.6 77.2 3.7 68.7 71.4 70.3 71.2 2.5 Hispanic 55.3 58.2 58.1 58.2 3.0 58.2 63.0 62.4 61.3 3.1 50.2 50.6 51.3 53.2 3.0 NOTES Expansion states are those that expanded Medicaid by January 1, 2018. As of that date, there were 19 states that had not yet expanded Medicaid. Maine and Virginia implemented Medicaid expansion in 2019 and are considered nonexpansion for this analysis. Net change is percentage- point change between 2013 and 2018. DATA Behavioral Risk Factor Surveillance System (BRFSS), 2013–2018. commonwealthfund.org Data Brief, January 2020 How the Affordable Care Act Has Narrowed Racial and Ethnic Disparities in Access to Health Care 16 Table 5. Louisiana/Georgia Uninsured Rates by Demographics, 2013–2018 (base: adults ages 19–64) Louisiana Georgia Net change Net change 2013 2016 2017 2018 2013 2016 2017 2018 (% points) (% points) Total 24.7 15.4 12.5 11.8 –12.9 26.0 18.1 18.7 19.1 –6.9 Race/Ethnicity White 18.9 11.8 9.7 9.5 –9.4 19.1 13.9 14.1 14.9 –4.2 Black 31.3 17.3 13.0 11.3 –19.9 28.4 18.0 19.0 19.2 –9.2 Hispanic 52.7 43.8 38.0 39.6 –13.2 60.1 46.8 45.3 45.5 –14.6 Income 0–199% FPL 41.8 25.9 19.7 17.8 –24.0 46.3 35.0 35.5 35.9 –10.4 200%–399% FPL 21.3 14.4 11.9 11.6 –9.7 21.9 16.4 17.6 18.8 –3.1 400%+ FPL 9.7 5.5 5.5 5.9 –3.8 8.1 5.6 6.5 7.3 –0.8 Race/Ethnicity, by income 0–199% FPL White 37.7 24.3 18.0 16.5 –21.2 40.9 32.3 32.2 33.1 –7.9 Black 42.0 22.8 16.6 14.0 –27.9 41.4 29.4 30.1 30.4 –11.0 Hispanic 70.7 58.5 51.8 54.0 –16.7 75.5 62.6 62.7 63.4 –12.1 200%–399% FPL White 19.0 12.0 10.6 10.9 –8.1 17.9 13.7 14.9 16.4 –1.5 Black 22.5 14.3 10.3 8.7 –13.8 21.0 14.1 14.9 16.4 –4.6 Hispanic 45.3 38.4 33.6 34.8 –10.5 50.0 40.4 38.9 40.7 –9.3 NOTES 400%+ FPL Net change is percentage- point change between 2013 White 7.4 4.5 4.2 4.6 –2.7 5.9 4.5 5.1 5.7 –0.3 and 2018. FPL = federal poverty level. Black 14.6 6.4 7.5 8.0 –6.6 12.4 6.5 7.9 9.3 –3.0 Hispanic 31.4 20.0 20.3 20.4 –11.0 21.3 16.2 17.1 18.6 –2.6 DATA American Community Survey Public Use Microdata Sample (ACS PUMS), 2013–2018. commonwealthfund.org Data Brief, January 2020 How the Affordable Care Act Has Narrowed Racial and Ethnic Disparities in Access to Health Care 17 NOTES 12. Improvement for Hispanics and blacks in nonexpansion states was 1. Ajay Chaudry, Adlan Jackson, and Sherry A. Glied, Did the Affordable not statistically significant. Care Act Reduce Racial and Ethnic Disparities in Health Insurance 13. Radley, Collins, and Hayes, 2019 Scorecard on State, 2019. Coverage? (Commonwealth Fund, Aug. 2019). 14. Based on Medicaid expansion status as of publication date, with 2. Eric C. Schneider et al., Health Care in America: The Values and Virginia, Maine, Idaho, and Utah included as expansion states; authors’ Experiences That Could Shape Health Reform (Commonwealth Fund, analysis of U.S. Census Bureau, 2018 1-Year American Community Dec. 2019). Survey, Public Use Microdata Sample (ACS PUMS). 3. See U.S. Census Bureau, “American Community Survey — Response 15. As of 2016, there were an estimated 8.4 million undocumented Rates,” n.d. immigrants from Latin America living in the United States. Jeffrey S. 4. See Centers for Disease Control and Prevention, “BRFSS Combined Passel and D’Vera Cohn, U.S. Unauthorized Immigrant Total Dips to Landline and Cell Phone Weighted Response Rates by State, 2018,” n.d. Lowest Level in a Decade (Pew Research Center, Nov. 2018). 5. Chaudry, Jackson, and Glied, Did the Affordable Care Act, 2019. 16. Sara Rosenbaum, “The New ‘Public Charge’ Rule Affecting Immigrants Has Major Implications for Medicaid and Entire 6. Estimates of the rate vary slightly across federal surveys, depending on Communities,” To the Point (blog), Commonwealth Fund, Aug. 15, 2019. the age group, question, and methodology. 17. Senator Bernie Sanders, “The Medicare for All Act of 2019” (S. 1129); 7. Munira Z. Gunja, Sara R. Collins, and Herman K. Bhupal, Is the and Senator Elizabeth Warren, “Ending the Stranglehold of Health Care Affordable Care Act Helping Consumers Get Health Care? (Commonwealth Costs on American Families,” Nov. 1, 2019; and Vice President Joe Biden, Fund, Dec. 2017). “The Biden Plan to Protect and Build on the Affordable Care Act,” n.d.; and Mayor Pete Buttigieg, “Medicare for All Who Want It: Putting Every 8. David C. Radley, Sara R. Collins, and Susan L. Hayes, 2019 Scorecard on American in Charge of Their Health Care with Affordable Choice for State Health System Performance (Commonwealth Fund, June 2019). All,” n.d. 9. See “Access to Health Services,” Healthy People 2020, healthypeople.gov. 18. Republican Study Committee, A Framework for Personalized, 10. Cathy Schoen et al., Health Care in the Two Americas: Findings from Affordable Care, n.d. the Scorecard on State Health System Performance for Low-Income 19. Rachel Garfield, Kendal Orgera, and Anthony Damico, The Coverage Populations (Commonwealth Fund, Sept. 2013), Exhibit 27, p. 57. Gap: Uninsured Poor Adults in States That Do Not Expand Medicaid 11. Difference is not statistically significant. (Henry J. Kaiser Family Foundation, Jan. 2020). commonwealthfund.org Data Brief, January 2020 How the Affordable Care Act Has Narrowed Racial and Ethnic Disparities in Access to Health Care 18 20. Jodi Liu and Christine Eibner, Expanding Enrollment Without the Individual Mandate: Options to Bring More People into the Individual Market (Commonwealth Fund, Aug. 2018). 21. Alexei Koseff, “California Will Give Health Coverage to Undocumented Young Adults,” San Francisco Chronicle, June 10, 2019. 22. Sandro Galea et al, “Estimated Deaths Attributable to Social Factors in the United States,” American Journal of Public Health 101, no. 8 (Aug. 2011): 1456–65. 23. Laurie Zephyrin, “Pregnancy-Related Deaths Reflect How Implicit Bias Harms Women. We Need to Fix That.,” STAT, July 10, 2019; Kevin A. Schulman et al., “The Effect of Race and Sex on Physicians’ Recommendations for Cardiac Catheterization,” New England Journal of Medicine 340, no. 8 (Feb. 1999): 618–26; and William L. Schpero et al., “For Selected Services, Blacks and Hispanics More Likely to Receive Low-Value Care Than Whites,” Health Affairs 36, no. 6 (June 2017): 1065–69. 24. Schneider et al., Health Care in America, 2019. commonwealthfund.org Data Brief, January 2020 How the Affordable Care Act Has Narrowed Racial and Ethnic Disparities in Access to Health Care 19 ABOUT THE AUTHORS Jesse C. Baumgartner is a research associate in the Health Care project. Previously, he was associate in domestic health policy for Abt Coverage, Access, and Tracking program at the Commonwewalth Fund. Associates, with responsibility for a number of projects related to Before joining the Fund, he worked as a technology development/ measuring long-term care quality and evaluating health information licensing manager at Memorial Sloan Kettering Cancer Center, a life technology initiatives. Dr. Radley received his Ph.D. in health policy from sciences consultant at Stern Investor Relations, and earlier in his career the Dartmouth Institute for Health Policy and Clinical Practice, and holds as a reporter for the Lewiston Tribune in Idaho. Mr. Baumgartner earned a B.A. from Syracuse University and an M.P.H. from Yale University. his B.A. in journalism and history from the University of North Carolina Susan L. Hayes, M.P.A., is a Ph.D. candidate in Health Services at Chapel Hill, where he was elected Phi Beta Kappa, and is currently Research at Brown University. She is a former senior researcher for the pursuing his M.P.H. at the CUNY Graduate School of Public Health and Commonwealth Fund’s Health Care Coverage, Access, and Tracking Health Policy. He is also a CFA® charterholder. program. Ms. Hayes holds an M.P.A. from New York University’s Wagner Sara R. Collins, Ph.D., is vice president for Health Care Coverage, Access, School of Public Service and an A.B. in English from Dartmouth College. and Tracking at the Commonwealth Fund. An economist, Dr. Collins She has been a journalist, a freelance health writer, a contributing editor to joined the Fund in 2002 and has led the Fund’s national program on health Parent & Child magazine, and cowrote a book on raising bilingual children insurance since 2005. Since joining the Fund, she has led several national with a pediatrician at Tufts Medical Center. surveys on health insurance and authored numerous reports, issue briefs, and journal articles on health insurance coverage and policy. She has ACKNOWLEDGMENTS provided invited testimony before several Congressional committees At the Commonwealth Fund, the authors thank David Blumenthal, and subcommittees. Prior to joining the Fund, Dr. Collins was associate Elizabeth Fowler, Eric Schneider, and Barry Scholl for helpful director/senior research associate at the New York Academy of Medicine. comments; Chris Hollander, Deborah Lorber, Paul Frame, and Jen Earlier in her career, she was an associate editor at U.S. News & World Wilson for editing and design; and Munira Gunja and Gabriella Report, a senior economist at Health Economics Research, and a senior Aboulafia for research support. health policy analyst in the New York City Office of the Public Advocate. Dr. Collins holds a Ph.D. in economics from George Washington University. Editorial support was provided by Christopher Hollander. David C. Radley, Ph.D., M.P.H., is senior scientist for the Commonwealth Fund’s Health Care Coverage, Access, and Tracking program, working on For more information about this brief, please contact: the Scorecard project. Dr. Radley develops national, state, and substate Jesse C. Baumgartner regional analyses on health care system performance and related Research Associate, Health Care Coverage, Access, and Tracking insurance and care system market structure analyses. He is also a senior The Commonwealth Fund study director at Westat, a research firm that supports the Scorecard jbcmwf.org commonwealthfund.org Data Brief, January 2020 About the Commonwealth Fund The mission of the Commonwealth Fund is to promote a high-performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society’s most vulnerable, including low-income people, the uninsured, and people of color. Support for this research was provided by the Commonwealth Fund. The views presented here are those of the authors and not necessarily those of the Commonwealth Fund or its directors, officers, or staff.