January 17, 2020

The United States made notable progress in addressing racial disparities in uninsured rates and access to care after the Affordable Care Act's (ACAs) coverage expansions took effect—but that progress appears to have stalled since 2016, according to a Commonwealth Fund report released Thursday.

Just updated: Where the states stand on Medicaid expansion, mapped

For the report, researchers examined federal survey data from 2013 to 2018 to assess the ACA's effect on racial and ethnic disparities in health care access and coverage. During that time period, the researchers looked at the percentage of adults ages 19 to 64 years old who were uninsured, avoided care because of cost concerns, and those who has a regular source of care, such as a primary care provider.  

Coverage gaps in racial disparities narrow after ACA

The researchers found that after the ACA's main coverage expansions took effect, racial gaps in uninsured rates narrowed from 2013 to 2015, after which those gains leveled off:

Sara Collins, VP of health care coverage and access at the Commonwealth Fund, said, "Historically, black and Hispanics in the U.S. have been far less likely to have health insurance," but insured rates improved after the ACA took effect and made it easier for low-income U.S. residents to get health coverage.

In addition, the researchers found that the percentages of black, Hispanic, and white adults who reported avoiding care because of costs declined from 2013 and 2015. Though those trends began to reverse after 2015:

The researchers also found more adults reported having a regular health care provider from 2013 to 2015, but that metric also began to decline after 2015:

The researchers said the biggest gains were seen in states that expanded their Medicaid programs. The researchers found that the uninsured rate gap narrowed to such an extent from 2013 to 2015 that rates coverage and access to care barriers among blacks in expansion states were in line with—or in some cases even better than—those of white adults in nonexpansion states. And while progress there has slowed, the researchers found it has not yet reversed, meaning the gains in disparity reduction are largely holding steady. 

Reasons for the disparities—and the slowed progress

The researchers highlighted reasons for the continuing racial disparities in health coverage and access, as well as the country's slowed progress in narrowing the disparities.

Jesse Baumgartner, the study's lead author and a research associate at The Commonwealth Fund, said, "Despite the positive effect of Medicaid expansion on coverage and access inequities, almost half of black working-age adults are living in the 15 states that have still not implemented Medicaid expansion" and more than one-third of working-age Hispanic adults live in nonexpansion states. She said, "This means that the failure to expand Medicaid in the remaining 15 states has a larger negative impact on black and Hispanic communities." 

The researchers partly attributed the lack of progress in narrowing the racial disparities since 2016 to Congressional inaction, saying federal lawmakers have not passed legislation to enhance the ACA. The researchers also cited Republican efforts to dismantle the health care law, such as zeroing out the individual mandate's tax penalty and loosening restrictions on non-ACA-compliant health plans, as reasons for the stalled progress (Baumgartner et al., Commonwealth Fund, 1/16; Commonwealth Fund release, 1/16; Owens, "Vitals," Axios, 1/16; Galvin, U.S. News & World Report, 1/16; Schumaker, ABC News, 1/16; Ross Johnson, Modern Healthcare, 1/16).

Just updated: Where the states stand on Medicaid expansion, mapped

The Daily Briefing editorial teams have been tracking where each state stands on the issue since the ruling, combing through lawmakers' statements, press releases, and media coverage. In this latest iteration of our Medicaid map, we've determined each state's position based on legislative or executive actions to expand coverage to low-income residents using ACA funding.

Get the Map
Download Now

Topics