Racial and Ethnic Differences in Insurance Coverage and Health Care Access and Use

Assessing the New Federalism Discussion Paper No. 06-01

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Racial and ethnic minorities in the United States exhibit worse health outcomes on average than nonminority whites across a variety of health conditions. Despite an overall improvement in the U.S. population health status over the past several decades, the health status differences between minorities and whites have remained (Collins, Hall, and Neuhas 1999). While several factors contribute to the poorer health outcomes of minority communities, their diminished access to insurance, which contributes to poorer access to medical care, can play an important role in explaining these differences (Geiger 2003).

Several studies funded under the Urban Institute's Assessing the New Federalism (ANF) project document and seek to better understand racial and ethnic differences in insurance coverage, access to care, and use of care. This review emphasizes the new or unique contributions of ANF studies to the broad and growing literature, including the following:

• More recent trend data on racial and ethnic differences in insurance coverage
  The ANF project has produced studies and data based on its National Survey of America's Families (NSAF) that reflect trends in insurance and health care patterns across different racial and ethnic groups from 1997 to 2002.
• Insurance coverage differences among individuals eligible for public insurance
  While many studies have looked at insurance coverage differences among the low-income population, relatively few look at insurance coverage differences specifically among those who are the target of public coverage expansions.
• Geographic variation in racial and ethnic differences in insurance coverage
  NSAF data also gave researchers the ability to do state-specific analyses for 13 states. Understanding geographic variation of these differences is particularly useful as more health policy issues are decided at the state level.
• Studies that document insurance coverage and health care for American Indian/Alaska Native populations
  Two rounds of the NSAF data produced sufficient sample sizes (not often available in other surveys) to study insurance and health care access and use differences between the American Indian/Alaska Native and white populations.
• Analyses that estimate the relative importance of various factors in explaining differences
  Regression-based decompositions help determine which underlying factors are responsible for differences in insurance coverage and health care patterns. Better accounting for differences can help design better policies to reduce them.

We also discuss racial and ethnic differences in insurance coverage, and differences in health care access and use, that are similar to what has been reported frequently elsewhere. This illustrates how differences estimated with the NSAF resemble what is generally known about these differences.¹ We supplement our review of existing studies with additional results from our own analyses of the 2002 NSAF. Among our main findings are the following:

• The gap in insurance coverage between low-income Hispanic and white adults increased from 1997 to 2002.
• Low-income black and white children were equally likely to be uninsured, but black children were 24 percentage points more likely to have public coverage and 19 percentage points less likely to have employer-sponsored coverage.
• Coverage differences between Hispanics and whites are small for citizens who are proficient in English. Noncitizens and Hispanics who primarily speak Spanish are much less likely to have employer-sponsored insurance (ESI) coverage than whites.
• Black and Hispanic adults were less likely than white adults to have a usual source of health care or to have seen a physician in the past 12 months, even after controlling for demographic and socioeconomic characteristics, health insurance coverage, and other characteristics.
• Some racial and ethnic differences in access and use can be attributed to differences in health insurance coverage. Yet insurance coverage is at best a partial explanation for differences in access and use. Differences in income, education, and employment also matter and are even more important in some cases.

Notes from this section of the report

1 Recent reviews include Collins et al. (1999), Lillie-Blanton, Rushing, and Ruiz (2003), and Mayberry, Mili, and Ofili (2000).

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