Racial Coverage Disparity Trends Have Persisted Through 2019

July 20, 2021 - The healthcare industry has changed substantially since the Affordable Care Act went into effect, but a recent Kaiser Family Foundation issue brief found that one fact remains the same: individuals in minority populations are more likely to be uninsured than their White peers, racial coverage disparities persist.

The brief traced trends in uninsurance rates by race and ethnicity spanning from 2010—before changes to Medicaid and the health insurance exchanges took effect—through 2019.

In 2010, nonelderly Hispanic and American Indian and Alaska Native individuals constituted the population with the highest uninsurance rates. At the time, around a third of these individuals were uninsured.

However, uninsurance dropped in minority populations from 2010 to 2016, exceeding the drop in uninsurance in the White population. Hispanic, nonelderly individuals saw the greatest improvements, declining from 32.6 percent uninsurance to 19.1 uninsurance during this six-year period.

Still, people of color faced a higher rate of uninsurance than White people.

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Then, in 2017 decreases in coverage disparities began to reverse. The uninsurance rate grew over the course of the next three years from 2016 to 2019 from 10.0 percent to 10.9 percent. The Hispanic population experienced the brunt of that increase, though White individuals and Black communities also saw a rise in uninsurance.

“These coverage losses likely reflected a range of policy changes made by the Trump administration after taking office in 2017 that reduced access to and enrollment in coverage,” the researchers explained. 

“These changes included decreased funds for outreach and enrollment assistance, introduction of plans to compete with ACA Marketplace plans, elimination of the penalty for not having coverage, guidance encouraging states to seek waivers to add new eligibility requirements for Medicaid coverage, and changes to immigration policy that are made some immigrant families more reluctant to participate in Medicaid and CHIP.”

Some studies show that families in the latter category remain unlikely to access healthcare due to the public charge rule.

Apart from regulatory changes, people of color may be less likely to access private coverage through employer-sponsored health plans. 

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In 2019, Asian Americans had the highest rate of private insurance coverage, with 78 percent of the community between the ages of 19 and 64 covered under private health insurance. Three-quarters of all nonelderly White adults were covered under private health insurance.

In contrast, less than half of the American Indians and Alaska Natives (AIAN) community (44 percent) had private healthcare coverage. In the Hispanic community, 54 percent had private healthcare coverage and 58 percent of the Black community had private coverage.

Among children, less than three in ten White children were on Medicaid or some form of public payer coverage. Nearly six in ten Black children, 54 percent of Hispanic children, and 54 percent of AIAN children were on public payer coverage in 2019.

Adult people of color who are not elderly are more likely to be uninsured than minority children, but some experts are calling for further expansion of Medicaid and the Children’s Health Insurance Program (CHIP).

In 2019, states that chose to embrace Medicaid expansion saw lower uninsured rates and higher Medicaid coverage with bigger gaps between the rate of uninsurance in White populations compared to minority populations.

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In both expansion and non-expansion states, around three-quarters of the nonelderly White population had private healthcare coverage. In expansion states, White adults saw an uninsurance rate of seven percent whereas in nonexpansion states the uninsurance rate was 13 percent.

In contrast, among Hispanic adults in expansion states, the uninsurance rate was 20 percent and in nonexpansion states, the rate was 35 percent. For Black adults in expansion states the uninsurance rate was 10 percent, while in nonexpansion states the rate was nearly double (19 percent).

“There are opportunities to increase coverage by enrolling eligible people in Medicaid or marketplace coverage, but Black, Hispanic, and Asian nonelderly uninsured people are less likely to be eligible compared to their White counterparts,” the brief explained.

Black individuals in states that have not adopted Medicaid expansion are more likely to fall into the coverage gap. Out of the twelve states plus the District of Columbia that have the highest shares of Black individuals, seven states have not adopted Medicaid expansion. 

Hispanic adults and Asian adults are more likely to be blocked from eligibility due to their immigration statuses. Nearly half of all Hispanic individuals are non-citizens and 74 percent of Asian adults are either naturalized citizens or non-citizens.

Researchers emphasized that the COVID-19 pandemic deepened coverage disparities. They recommended using Medicaid and the Affordable Care Act marketplace—particularly with the American Rescue Plan Act subsidies—to bolster coverage in minority populations.

“Beyond coverage, it also will be important to address inequities across the broad range of other social and economic factors that drive health and to address other inequities within the health care system that lead to poorer quality of care and health outcomes for people of color as part of efforts to advance health equity,” the brief concluded.