Closing the Gap
If you draw ten people out of the hat of America, you can reasonably expect about one of them to be black, and one and a half of them to be Hispanic. Now remove from the hat everybody who has health insurance. Draw ten people out of the group of the uninsured, and about one and a half will be black. Three will be Hispanic.
The overrepresentation of black and Hispanic Americans among those who are uninsured is the result of large disparities in the percentages of each racial group who do not have insurance. While the percentage of white Americans of all ages who lack insurance has hovered around ten percent since 2002, the same rate has remained stubbornly close to fifteen percent for Asians, twenty percent for blacks, and thirty percent for Hispanics. The insurance gap is just one of a myriad of racial inequalities in healthcare whose causes have proven difficult to untangle. While higher rates of low-income households and lack of employer-sponsored coverage are major contributing factors, linguistic and cultural barriers can also present serious challenges to individuals seeking coverage.
As the Affordable Care Act begins to reshape the health insurance landscape, its effects on racial disparities in coverage will be closely watched. While more people of all races are expected to gain coverage at the national level, variations in policy and outreach efforts between states may cause racial gaps to widen in some areas, even as they may close in others.
Whether or not states chose to expand Medicaid has a marked effect on racial disparity in insurance coverage among residents of that state. Among the states that chose not to expand are several with the largest populations of uninsured black adults, including Florida, Texas, and Mississippi. A report from the Kaiser Family Foundation found that more than forty percent of low-income black adults nationally will fall into the “coverage gap” created by states opting against Medicaid expansion, compared to just twenty-nine percent of low-income white adults and twenty-four percent of low-income Hispanic adults. Political opposition to Medicaid expansion in states with some of the largest concentrations of uninsured, low-income blacks could prove devastating to hopes of shrinking racial disparities in coverage.
Even states that put their full weight behind implementation of the Affordable Care Act have not necessarily been successful in reaching uninsured minorities. California, for example, has a low rate of ACA enrollment among Hispanics, who make up make up thirty percent of the total population and nearly sixty percent of the state’s uninsured. By the end of the first open enrollment period, Hispanics accounted for just twenty-eight percent of enrollments through the California health insurance marketplace, Covered California. Critics point to problems with the state’s Spanish-language marketing efforts, including incorrect or clunky translations that rendered the media campaign largely ineffective. Others suggest that a cultural preference for in-person transactions makes one of the ACA’s biggest selling points – a website for buying insurance – less popular among Hispanics. Many argue that advertising directed at California’s Hispanic community should have emphasized the availability of Navigators to provide consumers in-person assistance with the enrollment process.
At the end of the first enrollment period, the outlook for reducing racial disparities in coverage is mixed. Changes in coverage between September 2013 and March 2014 showed some progress toward closing racial coverage gaps at the national level, but a detailed look at individual states complicates that picture.
A recent study from the Urban Institute showed that nationally, racial disparities in health insurance have slightly improved since the implementation of the Affordable Care Act. The gap in coverage between Hispanics and whites has shrunk from a difference of 24.7 percentage points prior to the start of open enrollment to one of 22.6 points near the end of it. Unfortunately, this study does not consider other racial groups individually. Instead it provides statistics on all “non-white non-Hispanic” adults, a group that is largely black but also includes Asians, Native Americans, and other racial and ethnic groups. The change in the gap for that cohort was similar to that for Hispanics, down to 6.2 points from 8.1 points. Whether this downward movement will persist remains to be seen, but at least for now the numbers are pointing in the right direction.
The picture of overall improvement at the national level obscures surprising variations in gains made among different racial groups and across different states. Of particular interest is how each racial group fared in states that did or did not choose to expand Medicaid. While both the percentage of uninsured in each racial group and the racial gaps in coverage were lower to begin with in Medicaid expansion states than they were in states that did not expand Medicaid, what is remarkable is how those gaps changed between the start and end of open enrollment. Minority groups were expected to experience much larger gains in coverage, relative to whites, in states that expanded Medicaid, while racial disparities were expected to grow in states that chose not to expand. Early results, however, have not cleanly matched those predictions, as different racial groups have seen differing patterns of change across expansion and non-expansion states.
For Hispanics, the greatest gains in coverage appeared where they were expected: in the set of states that expanded Medicaid. In those states, the rate of uninsured Hispanic adults dropped from over 34 percent in September 2013 to 27 percent by March 2014, closing the gap between Hispanics and whites by a full four points. Those gains stand in stark contrast to the minimal increase in coverage among Hispanics in the non-expansion states, where the rate of uninsured only decreased by two-tenths of a percentage point to 40.7 percent, and the racial gap in coverage actually increased by half a point.
The surprise comes in the pattern of gains seen by non-white non-Hispanic adults. In expansion states, the 3.3 percentage point increase in coverage for non-white non-Hispanics was only slightly larger than the 3.5 point increase for whites, so that the gap between the two groups shrank by just two-tenths of a point. Contrary to every expectation, the largest gains in coverage for non-white non-Hispanic adults actually came in the states that did not expand Medicaid: In those states, coverage increased by a full four points, closing the gap between non-white non-Hispanics and whites by 3.3 points.
The large gains seen by non-white non-Hispanics feels counterintuitive given the large number of low-income blacks who were left ineligible for Medicaid or subsidies on the Marketplace. Racial disparities in non-expansion states were expected to grow, not shrink. One possibility is that the change occurred in coverage among individuals who make slightly more than minimum income level needed to qualify for subsidies on the Marketplace, who therefore would have received significant financial support to buy private coverage. Because most analyses group people as having income above or below 138 percent of the Federal Poverty Limit – the maximum income level for Medicaid eligibility in states that expanded the program, but higher than the minimum to qualify for Marketplace subsidies in states that did not – that segment of the population could be difficult to assess. Yet another important factor to consider is a possible increase in employer-sponsored coverage, which a recent study from RAND found accounted for a large portion of the newly insured at the national level.
These numbers are not final – the authors of the Urban Institute study are careful to point out that because the survey they use closed on March 6, they did not capture the massive surge in enrollments that occurred right before the March 31 deadline. In California, the racial mix of enrollees changed significantly over the course of the final three weeks, and its possible that a similar pattern occurred in other states. However, all told, it seems unlikely that the first year of open enrollment under the Affordable Care Act has succeeded in closing the gap in insurance levels between black and Hispanic adults and their white counterparts.
Even as Americans across the board have seen gains in coverage, those gains have not been evenly distributed across racial groups, nor have they been felt equally in all states. In future years, the experience of states like California may help others in devising better ways to reach out to black and Hispanic communities. As more states consider expanding Medicaid, the potential for increasing coverage, particularly among black adults, is huge. While it may be impossible to fully eliminate racial disparities in health coverage until deeper socioeconomic equities are expunged, it is the responsibility of states to make use of every tool offered under the Affordable Care Act to improve access to coverage for Americans of all races.