The voices of Urban Institute's researchers and staff
December 16, 2014

Racial/ethnic differences in uninsurance rates under the ACA: Where you live matters

Initial estimates suggest that the Affordable Care Act (ACA) has already reduced uninsured rates across all racial/ethnic groups, likely reducing longstanding racial/ethnic differences in health insurance coverage between whites and minorities.

However, for poor and near-poor adults living in nonexpansion states—states that have elected not to expand their Medicaid programs under the ACA by January 2015—a substantial share have no affordable coverage option and are likely to remain uncovered. For low-income individuals without health insurance coverage, where you live matters.

A new report from the Urban Institute’s Health Policy Center projects uninsured rates in 2016 for five major racial/ethnic groups—whites, Latinos, blacks, Asians, and American Indian/Alaska Natives—under three scenarios: without the ACA, under the ACA with current Medicaid expansion decisions, and under the ACA with all states expanding Medicaid. (See map below.)

Using data from the American Community Survey, Urban’s Health Insurance Policy Simulation Model projects large reductions in uninsured rates for all racial/ethnic groups under current Medicaid expansion decisions (as of December 2014), and even larger reductions under the ACA with full Medicaid expansion. This narrows racial/ethnic coverage differences between whites and each minority group except, however, for blacks. This is because a disproportionately large share of blacks live in nonexpansion states.

To illustrate, the graphic to the right shows the three difference coverage scenarios in the St. Louis area including parts of Missouri and Illinois. Missouri decided not to expand Medicaid under the ACA, while neighboring Illinois expanded its Medicaid program in January 2014.

Just over 20 percent of black residents in the St. Louis, Missouri area are projected to be uninsured without the ACA; this falls to 14.8 percent under the ACA with current expansion decisions and to 7.5 percent if Missouri were to expand Medicaid.

In Illinois, just 5.3 percent of black St. Louis-area Illinois residents are projected to remain uninsured under the state’s Medicaid expansion.

Similarly, DC and Maryland expanded Medicaid, while neighboring Virginia decided not to expand its program. Urban’s projections show that the uninsured rate for blacks without the ACA is 9.3 percent in DC, 14.7 percent in Maryland’s DC suburbs, and 15.3 percent in Virginia’s DC suburbs.

Under the current Medicaid expansion decisions, uninsured rates for blacks are projected to fall to 3.9 percent in DC, 6.4 percent in nearby Maryland areas, and 10.4 percent in nearby Virginia areas. If Virginia expands Medicaid, the uninsured rate for blacks in that state’s DC suburbs would drop to 6.2 percent.

The report also shows state- and national-level examinations of all racial/ethnic groups. By race/ethnicity, compared with projections without the ACA:

ACA with current Medicaid expansion decisions

  • White: 11.1 million would gain coverage, a 51.6 percent reduction in the number of uninsured
  • Latino: 6.6 million would gain coverage, a 39.2 percent reduction in the number of uninsured
  • Black: 2.9 million would gain coverage, a 42.3 percent reduction in the number of uninsured
  • Asian/Pacific Islander: 1.3 million would gain coverage, a 48.2 percent reduction in the number of uninsured
  • American Indian/Alaska Native: 633,000 would gain coverage, a 49.5 percent reduction in the number of uninsured

ACA with all states expanding Medicaid

  • White: 13.9 million would gain coverage, a 64.5 percent reduction in the number of uninsured
  • Latino: 7.8 million would gain coverage, a 46.7 percent reduction in the number of uninsured
  • Black: 4.3 million would gain coverage, a 63.2 percent reduction in the number of uninsured
  • Asian/Pacific Islander: 1.4 million would gain coverage, a 53.6 percent reduction in the number of uninsured
  • American Indian/Alaska Native: 787,000 would gain coverage, a 61.6 percent reduction in the number of uninsured

For uninsured individuals, where you live matters. The ACA, through Medicaid expansion, is likely to reduce longstanding racial/ethnic differences in health insurance coverage between whites and minorities. But for those living in nonexpansion states, health insurance coverage remains out of reach.

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