Summary
Health coverage plays a major role in enabling people to access health care and protecting families from high medical costs. There have been longstanding racial and ethnic disparities in health coverage that contribute to disparities in health. This brief examines trends in health coverage by race and ethnicity from 2010 through 2022 and discusses the implications for health disparities. All noted differences between groups and years described in the text are statistically significant at the p<0>
There were gains in coverage across most racial and ethnic groups between 2019 and 2022 after several years of rising uninsured rates during the Trump Administration. The coverage gains between 2019 and 2022 were largely driven by increases in Medicaid coverage, reflecting policies to stabilize and expand access to affordable coverage that were implemented during the COVID-19 pandemic. These policies included enhanced subsidies to purchase Marketplace coverage and a requirement that states keep Medicaid enrollees continuously enrolled during the public health emergency (PHE), which led to a substantial increase in Medicaid enrollment. These coverage gains helped narrow differences in uninsured rates for Hispanic, Black, and American Indian and Alaska Native (AIAN) people compared with White people, but further progress may be at risk amid the unwinding of the Medicaid continuous enrollment requirement.
Despite these coverage gains, disparities in coverage persisted as of 2022. Nonelderly AIAN and Hispanic people had the highest uninsured rates at 19.1% and 18.0%, respectively as of 2022. Uninsured rates for nonelderly Native Hawaiian and Other Pacific Islander (NHOPI) (12.7%) and Black people (10.0%) also were higher than the rate for their White counterparts (6.6%). Coverage disparities have persisted over time, and in some cases widened, despite recent gains and earlier large gains in coverage under the Affordable Care Act (ACA). For example, between 2010 and 2022, the uninsured rate for AIAN people grew from 2.5 to 2.9 times higher than the uninsured rate for White people, the Hispanic uninsured rate grew from 2.5 to 2.7 times higher than the rate for White people, and Black people remained 1.5 times more likely to be uninsured than White people.
Uninsured rates in states that have not expanded Medicaid are higher than rates in expansion states across most racial and ethnic groups as of 2022. Further, the differences in coverage rates between Hispanic, Black and NHOPI people compared with White people are larger in non-expansion states compared with expansion states. However, the relative risk of being uninsured for Black and Hispanic people compared to White people is similar in expansion and non-expansion states.
The ongoing racial and ethnic disparities in coverage could further widen amid the unwinding of the Medicaid continuous enrollment provision. The Medicaid continuous enrollment provision, which had halted Medicaid disenrollments since March 2020, ended on March 31, 2023. As states unwind the continuous enrollment provision, they will redetermine eligibility for all Medicaid enrollees and will disenroll those who are no longer eligible or who may remain eligible but are unable to complete the renewal process. Since states began redeterminations, millions of people have been disenrolled from the program. While the limited data available on disenrollments by race and ethnicity do not point to racial and ethnic disparities in disenrollment rates, because Hispanic, Black, AIAN and NHOPI people are more likely than their White counterparts to be covered by Medicaid, they are likely disproportionately affected by the unwinding. Some individuals disenrolled from Medicaid will move to other sources of coverage, including Marketplace coverage. However, others will become uninsured. As such, the unwinding could potentially widen racial and ethnic disparities in coverage going forward.
Efforts to prevent coverage losses and further close coverage disparities are important for addressing longstanding racial disparities in health. Beyond coverage, it also will be important to address other inequities within the health care system and across the broad range of social and economic factors that drive health.
Trends in Uninsured Rates by Race and Ethnicity, 2010-2022
Prior to the enactment of the ACA in 2010, nonelderly Hispanic, Black, Asian, AIAN, and NHOPI people were more likely to be uninsured compared to their White counterparts, with Hispanic and AIAN people at the highest risk of lacking coverage (Figure 1). Their higher uninsured rates reflected more limited access to affordable health coverage options. Although the majority of individuals have at least one full-time worker in the family across racial and ethnic groups, there are ongoing disparities in employment and income that result in some individuals not having coverage offered by an employer or having difficulty affording private coverage when it is available. While Medicaid helped fill some of this gap in private coverage, prior to the ACA, Medicaid eligibility for parents in most states was limited to those with very low incomes (often below 50% of the poverty level), and adults without dependent children—regardless of how poor—were ineligible under federal rules.
Between 2010 and 2016, there were large gains in coverage across racial and ethnic groups under the ACA, but racial and ethnic disparities in coverage persisted. The ACA created new coverage options for low- and moderate-income individuals. These included provisions to extend dependent coverage in the private market up to age 26 and prevent insurers from denying people coverage or charging them more due to health status that went into place. Further, beginning in 2014, the ACA expanded Medicaid coverage to nearly all adults with incomes at or below 138% of poverty in states that adopted the expansion and made tax credits available to people with incomes up to 400% of poverty to purchase coverage through a health insurance Marketplace. Following the ACA’s enactment in 2010 through 2016, coverage increased across all racial and ethnic groups, with the largest increases occurring after implementation of the Medicaid and Marketplace coverage expansions in 2014. Nonelderly Hispanic people had the largest percentage point increase in coverage, with their uninsured rate falling from 32.6% to 19.1%. Nonelderly Black, Asian, and AIAN people also had larger percentage point increases in coverage compared to White people over that period. Despite these larger gains, nonelderly Hispanic, Black, AIAN, and NHOPI people remained more likely than their White counterparts to be uninsured as of 2016.
Beginning in 2017, coverage gains began reversing, and the number of uninsured increased for three consecutive years. The uninsured rate for the total nonelderly population increased from 10.0% in 2016 to 10.9% in 2019. Nonelderly Hispanic people had the largest statistically significant increase in their uninsured rate over this period (from 19.1% to 20.0%). There were also small but statistically significant increases in the uninsured rates among nonelderly White and Black people, which rose from 7.1% to 7.8% and 10.7% to 11.4%, respectively, between 2016 and 2019. Rates for nonelderly AIAN, NHOPI, and Asian people did not have a significant change. These coverage losses likely reflected policy changes made by the Trump Administration after taking office in 2017. These changes included decreased funds for outreach and enrollment assistance, guidance encouraging states to seek waivers to add new eligibility requirements for Medicaid coverage as well as to increase the frequency of eligibility verifications, and changes to public charge immigration policy that made some immigrant families more reluctant to participate in Medicaid and the Children’s Health Insurance Program (CHIP) (which have since been reversed by the Biden Administration).
After increasing for several years prior to the pandemic, uninsured rates declined between 2019 and 2022. Nearly 3.4 million nonelderly people gained coverage between 2019 and 2022 as the uninsured rate dropped from 10.9% to 9.6%. (Because of disruptions in data collection during the first year of the pandemic, the Census Bureau did not release 1-year ACS estimates in 2020.) AIAN people had the largest percentage point increase in coverage, with their uninsured rate falling from 21.7% in 2019 to 19.1% in 2022. There were also smaller but statistically significant declines in uninsured rates among Hispanic (from 20.0% to 18.0%), Black (from 11.4% to 10.0%), Asian (from 7.2% to 6.0%), and White people (from 7.8% to 6.6%) during this period. These coverage gains were primarily driven by increases in Medicaid coverage, which offset declines in employer-sponsored coverage over the period. NHOPI people did not have statistically significant changes in coverage over this period.
The coverage gains observed between 2019 and 2022 largely reflect policies adopted during the pandemic to stabilize coverage in Medicaid and enhance subsidies to purchase Marketplace coverage. Specifically, provisions in the Families First Coronavirus Response Act (FFCRA), enacted at the start of the pandemic, prohibited states from disenrolling people from Medicaid during the Public Health Emergency in exchange for enhanced federal funding. Coverage gains also likely reflected enhanced ACA Marketplace subsidies made available by the American Rescue Plan Act (ARPA) and renewed for another three years in the Inflation Reduction Act of 2022 (IRA), boosted outreach and enrollment efforts, a Special Enrollment Period for the Marketplaces provided in response to the pandemic, and low Marketplace attrition, Additionally, in 2019, the Biden Administration reversed changes the Trump Administration previously made to public charge immigration policies that had increased reluctance among some immigrant families to enroll in public programs, including health coverage.
Coverage disparities have persisted, and in some cases widened, over time even with recent gains and the large earlier gains in coverage under the ACA. For example, in 2010, the uninsured rate for AIAN people was 2.5 times higher than the uninsured rate for White people; however, in 2022, the uninsured rate for AIAN people had increased to 2.9 times higher than the rate for White people. Similarly, the Hispanic uninsured rate grew from 2.5 to 2.7 times higher than the rate for White people from 2010 to 2022, while Black people remained 1.5 times more likely to be uninsured than White people.
Coverage by Race and Ethnicity as of 2022
While overall uninsured rates continued to decline in 2022, nonelderly Hispanic, Black, AIAN, and NHOPI people remained more likely than their White counterparts to be uninsured (Figure 2). Nonelderly AIAN and Hispanic people had the highest uninsured rates at 19.1% and 18.0%, respectively, as of 2022. Uninsured rates for nonelderly NHOPI (12.7%) and Black people (10.0%) also were higher than the rate for their White counterparts (6.6%). These differences in uninsured rates are driven by lower rates of private coverage among these groups. Medicaid coverage helps to narrow these differences but does not fully offset them.
Medicaid and CHIP coverage help fill gaps in private coverage and reduce coverage disparities for children, but some disparities in children’s coverage remain (Figure 2). Medicaid and CHIP cover larger shares of children than adults, reflecting more expansive eligibility levels for children. This coverage helps fill gaps in private coverage, with over half of Hispanic, Black, AIAN, and NHOPI children covered by Medicaid and CHIP. However, there remain some disparities in children’s coverage. For example, AIAN children are three times as likely as their White counterparts to lack coverage (11.9% vs. 3.9%). Moreover, Hispanic children are twice as likely as White children to be uninsured (8.1% vs. 3.9%).
Among the total nonelderly population, uninsured rates in states that have not expanded Medicaid are higher than rates in expansion states across most racial and ethnic groups as of 2022 (Figure 3). The differences in coverage rates between Black and Hispanic people compared with White people are larger in non-expansion states compared with expansion states. However, the relative risk of being uninsured for Black, Hispanic, and Asian people compared with White people is similar in expansion and non-expansion states. For example, nonelderly Hispanic people are roughly 2.6 times as likely as nonelderly White people to lack coverage in both expansion and non-expansion states. Uninsured rates for AIAN people are similar in expansion and non-expansion states. Overall, the differences in coverage by expansion status are primarily driven by differences in coverage rates among nonelderly adults. However, White, Hispanic, Black, Asian, and NHOPI children in non-expansion states also are more likely to be uninsured than those in expansion states. For example, 23.8% of NHOPI children in non-expansion states are uninsured compared to 7.6% of NHOPI children in expansion states.
Eligibility for Coverage among the Uninsured as of 2022
There are opportunities to increase coverage by enrolling eligible people in Medicaid or Marketplace coverage, but eligibility varies across racial and ethnic groups, and many remain ineligible for assistance. Overall, six in ten people who were uninsured in 2022 were eligible for financial assistance either through Medicaid or through subsidized Marketplace coverage, while the remaining four in ten were not eligible because they fell in the Medicaid coverage gap in states that have not expanded Medicaid, they were deemed to have access to an affordable Marketplace plan or offer of employer coverage, or they were ineligible due to their immigration status. However, the share of the remaining uninsured eligible for assistance varied by race and ethnicity. For example, nonelderly uninsured Black were people more likely than their White counterparts to fall in the coverage gap in states that have not expanded Medicaid, and uninsured nonelderly Hispanic and Asian people were less likely than White people to be eligible for coverage options, in part, reflecting higher shares of noncitizens who face immigrant eligibility restrictions among these groups (Figure 4).
Uninsured nonelderly Black people are more likely than White people to fall in the Medicaid “coverage gap” because a greater share live in states that have not implemented the Medicaid expansion. As of December 2023, 10 states have not adopted the ACA provision to expand Medicaid to adults with incomes through 138% of poverty. Most of these states are in the South, where a higher share of the Black population resides (Figure 5). In these states, 1.5 million uninsured people with incomes under poverty fall into the “coverage gap” and do not qualify for either Medicaid or premium subsidies in the ACA Marketplace.
Uninsured nonelderly Hispanic, NHOPI, and Asian people are less likely than their White counterparts to be eligible for coverage because they include larger shares of noncitizens who are subject to eligibility restrictions for Medicaid and Marketplace coverage (Figure 6). Lawfully present immigrants face eligibility restrictions for Medicaid coverage, with many having to wait five years after obtaining lawful status before they are eligible to enroll in Medicaid. Undocumented immigrants are not eligible to enroll in Medicaid and are prohibited from purchasing coverage through the Marketplaces.
Looking Ahead
Policies implemented amid the COVID-19 pandemic helped stabilize coverage and contributed to gains in coverage during this period, but the unwinding of the Medicaid continuous enrollment provision could reverse these gains and widen disparities in coverage. The coverage gains experienced during the COVID-19 pandemic were largely driven by an increase in Medicaid coverage, which offset declines in employer-sponsored coverage. As noted, temporary continuous enrollment provisions stabilized Medicaid coverage during the PHE, contributing to increases in enrollment. Additionally, the temporary enhanced subsidies for Marketplace coverage provided under ARPA, which were extended through 2025 under the IRA, also contributed to coverage gains. However, even with these recent gains, disparities in coverage remain and could widen amid the unwinding of the Medicaid continuous enrollment requirement. Since the Medicaid continuous enrollment provision ended in March 2023, millions of people have been disenrolled. While the limited data available on disenrollments by race and ethnicity do not point to disparities in disenrollment rates, Hispanic, Black, AIAN and NHOPI people are likely disproportionately affected by the unwinding since they are more likely to be covered by Medicaid compared with their White counterparts. Many people who have been disenrolled from Medicaid could find low-cost coverage on the ACA Marketplaces, including, in some cases, coverage with a zero (or near-zero) monthly premium requirement. However, others may become uninsured. In focus groups, adults who were disenrolled from Medicaid reported losing coverage for a variety of reasons, including because they were no longer eligible; however, some believed they were still eligible and did not know why they were disenrolled. Many reported facing communication problems with their Medicaid agencies, and some who were disenrolled indicated that they faced gaps in coverage before reenrolling in Medicaid or became uninsured, which contributed to high out-of-pocket costs and difficulties accessing care that negatively impacted their health.
Mitigating coverage losses and closing disparities in coverage is important for addressing longstanding disparities in health. Beginning January 2024, states will be required to provide children with 12 months of continuous coverage in Medicaid and CHIP, enhancing their coverage stability and preventing gaps in coverage. Further, several states have implemented or proposed waivers to provide multi-year continuous Medicaid eligibility to children up to age six. Some states also obtained waivers to mitigate coverage losses amid the unwinding by increasing ex parte or automatic renewals, helping enrollees complete and submit renewal forms, and helping individuals re-enroll if they were disenrolled for procedural reasons. Continued efforts to improve renewal processes and reduce procedural disenrollments will be important beyond the unwinding period to prevent gaps in coverage. Moreover, opportunities remain to increase coverage and narrow disparities by enrolling eligible uninsured people in Medicaid or Marketplace coverage. These opportunities would increase if additional states adopted the Medicaid expansion. Two states implemented the Medicaid expansion in 2023, including South Dakota, as of July 1, 2023, and North Carolina, as of December 1, 2023. Ten states have not yet adopted the expansion. Research shows that Medicaid expansion is associated with reductions in racial/ethnic disparities in health coverage as well as narrowed disparities in health outcomes for Black and Hispanic individuals, particularly for measures of maternal and infant health.
Overall, research shows that having health insurance makes a key difference in whether, when, and where people get medical care and ultimately how healthy they are. KFF data show that more than half of adults (59%) have a favorable view of the ACA. Future trends in coverage will have a significant impact on disparities in health access and use as well as health outcomes over the long-term. Any potential changes to scale back coverage could result in widening disparities in the future. However, 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.
