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This study was conducted jointly
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from the A-Mark Foundation.

Health Policy Fact Sheet

January 2020

 

Education Matters: Despite
Improvements Under the ACA,
Disparities in Coverage Based on
Educational Level Persist

Gerald Kominski, Petra W. Rasmussen, Chengcheng Zhang, Safia Hassan, and Deborah Freund

ince 2013, the Affordable Care Act

(ACA) has produced significant
reductions in the number of uninsured
individuals. Nevertheless, important
disparities persist among the remaining
uninsured. Such disparities are based on
a number of factors, including Medicaid
expansion status,' race and ethnicity,'
occupation,' and employment status.* One
overlooked disparity in coverage is the
association between educational attainment
and lack of insurance. Although the impact
of education on earnings is well documented,'
our findings suggest that education continues
to have an important impact on the likelihood
of being uninsured, regardless of income
level. We found substantial differences by
educational level within each category of
income. Specifically, lower levels of educational
attainment are associated with higher rates of
uninsurance in both the pre- and post-ACA
periods. Furthermore, differences in rates of
uninsurance by educational level have increased
in the post-ACA period, indicating greater
disparities based on educational attainment.

Using data from the American Community
Survey from 2013 and 2018, we calculated

the percentage of adults ages 18-64 years old
who were uninsured based on their educational
attainment. We also stratified the data by
three income categories: up to 100% of the
federal poverty level (FPL), 100-399% FPL,
and 400% + FPL.

Despite substantial reductions compared
to 2013, those with incomes less than
100% FPL continued to have the highest
rates of uninsurance in 2018 (Exhibit 1).
In 2013, those without a high school or
GED diploma had an uninsured rate that
was 20 percentage points higher than
the rate for those with a graduate degree.
Although all groups improved by 2018,
the percentage difference between those
without a high school or GED diploma
and those with a graduate degree actually
increased compared to the pre-ACA
period, indicating greater disparity. This
finding suggests that relative changes

in the rate of uninsurance, not just
absolute percentage-point changes, are
an important measure when examining
disparities.

Because significant differences have been
documented in the rate of uninsurance
among low-income people in Medicaid
expansion versus nonexpansion states,
we also examined the educational
differences for those with incomes less
than 100% FPL in expansion versus
nonexpansion states. We observed the
same pattern as that seen in Exhibit 1:
Although expansion states had lower rates
of uninsurance by educational level in
2013 compared to nonexpansion states,

 

 
 

 

UCLA CENTER FOR HEALTH POLICY RESEARCH

 

 

Exhibit 1 Uninsured Rate for 18-64-Year-Olds by Educational Attainment and Income
(as a Percentage of the Federal Poverty Level), 2013 and 2018

 

46.5%

<100% FPL

 

100-399% FPL

 

400%+ FPL

 

 

 

 

0% 10% 20% 30% 40% 50%

M Less than high school or GED diploma |_| High school or GED diploma Bisome college

Associate's degree Wi Bachelor's degree Wl Graduate degree

Note: Authors' analysis of the American Community Survey,
2013 and 2018. For 2018, 100% FPL was $12,060 for an
individual and $24,600 for a family of 4; 400% FPL was
$48,240 for an individual and $98,400 for a family of 4.

both expansion and nonexpansion states saw The educational differences observed among
greater relative improvement by 2018 among _ those whose incomes were 100-399% FPL
those with at least some college education, and who were subsidy eligible under the

indicating greater disparity. ACA were even greater than among those
£ parity. & g

 

 
 

 

UCLA CENTER FOR HEALTH POLICY RESEARCH

whose incomes were below the poverty level.
In 2013, those without a high school or GED
diploma were 3.7 times more likely to be
uninsured than those with a graduate degree.
This relative difference was greater in 2018,
despite improvements for every category of
educational attainment between 2013 and
2018. Those with at least some college saw
reductions of 38% to 40% in their rate of being
insured, while those with a high school or
GED diploma had a 34% reduction, and those
without a high school or GED diploma had a
28% reduction.

Perhaps most surprising is that, while absolute
levels of uninsurance were lowest among

those with the highest incomes, the relative
differences by educational level were greatest
in this income group. In 2013, those without
a high school or GED diploma were almost 10
times more likely to be uninsured compared to
those with a graduate degree, despite having
incomes of at least 400% FPL. In 2018, this
relative difference had not diminished, despite
absolute reductions among every category of
educational attainment.

Our findings suggest that educational
attainment plays an important role in health
insurance status independent of its impact

on household income. Further, although the
ACA has produced substantial reductions

in the percentage of uninsured across both
income categories and categories of educational
attainment, disparities by educational level
persist and have not diminished as a result of
the ACA. The reasons for these results are not
immediately obvious, but the findings certainly
merit attention and further investigation.
Educational attainment may be associated
with other factors that make it difficult

to obtain health insurance, even if health
insurance is seemingly more affordable. At a
minimum, our results certainly challenge the
notion that affordability alone is the major
determinant of being uninsured, especially
in light of our findings that educational

differences in rates of uninsurance are
large at the lowest income levels and even
greater at higher levels of income.

Data

Data for this fact sheet are from the 2013 and
2018 American Community Survey.

Author Information

Gerald FE. Kominski is a senior fellow at the
UCLA Center for Health Policy Research and a
professor at the UCLA Fielding School of Public
Health. Petra W. Rasmussen is a graduate student
researcher at the UCLA Center for Health Policy
Research and a PhD candidate at the UCLA
Fielding School of Public Health. Chengcheng
Zhang is a PhD candidate at Claremont Graduate
University. Safia Hassan is an undergraduate
student at Scripps College. Deborah Freund is

a university professor and president emerita at
Claremont Graduate University.

Suggested Citation

Kominski GF, Rasmussen PW, Zhang C, Hassan
S, Freund D. 2020. Education Matters: Despite
Improvements Under the ACA, Disparities in Coverage
Based on Educational Level Persist. Los Angeles,
CA: UCLA Center for Health Policy Research.

Endnotes

1 Courtemanche C, Marton J, Ukert B, Yelowitz A,
Zapata D. 2017. Early Impacts of the Affordable
Care Act on Health Insurance Coverage in Medicaid
Expansion and Nonexpansion States. Journal of Policy
Analysis and Management 36(1):178-210.

2 Artiga S, Orgera K, Damico A. February 2019.
Changes in Health Coverage by Race and Ethnicity Since
Implementation of the ACA, 2013-2017. San Francisco:
Kaiser Family Foundation. Issue Brief.

3 Agarwal SD, Goldman AL, Sommers BD. 2019.
Blue-Collar Workers Had Greatest Insurance
Gains After ACA Implementation. Health Affairs
38(7):1140-1144.

4 Berdahl TA, Moriya AS. 2018. Difference in
Uninsurance Rates Between Full- and Part-

Time Workers Declined in 2014. Health Affairs
37(10):1669-1672.

5 Vilorio D. March 2016. Career Outlook: Education
Matters. U.S. Bureau of Labor Statistics.

 

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