The ACA: Adding Coverage for All

Given the Supreme Court’s decision in June to uphold the individual mandate, it certainly is an exciting time for coverage expansion and the concomitant reduction in the number of uninsured. However, researchers remain uncertain about the degree to which the Affordable Care Act (ACA) will differentially impact uninsurance rates among racial and ethnic groups. In their article in Health Affairs, Lisa Clemans-Cope and her colleagues used the Urban Institute’s Health Insurance Policy Simulation Model to estimate the impact of the ACA on uninsurance rates among minority groups.

Clemans-Cope et al. focused on changes in coverage among white non-Hispanics, Hispanics, and blacks, in the ten states with the largest non-elderly black and Hispanic populations. Based on the simulation model, blacks and Hispanics will experience the largest reductions in uninsurance rates. However, their likelihood of being uninsured after full implementation of the ACA will still remain much higher than that of whites.

According to Clemans-Cope et al., the uninsurance rate among blacks will drop by 11.8 percentage points, meaning that 4 million fewer blacks will be uninsured. For Hispanics, the drop will be 12.2 percentage points, meaning 5.9 million fewer Hispanics will be uninsured. Finally, for whites, the drop will be 7.4 percentage points, meaning 12.3 million fewer whites will be uninsured.

Another way to understand these findings is in terms of increases in coverage rates. The ACA will increase coverage through:

“increased access to free or subsidized health insurance through Medicaid and CHIP [Children’s Health Insurance Program], and the new subsidies available for coverage in the exchanges.”

Estimated at 18.2 percent, Hispanics are projected to have the highest percentage increase in coverage rates under full implementation of the ACA. For blacks, the increase is estimated at 15.1 percent; whites, 8.6 percent. If increases in coverage are considered based on receipt of both Medicaid and CHIP, blacks are projected, among the three groups, to fare the best. That is, the coverage rate among blacks who benefit from both Medicaid and CHIP will increase by 8.4 percentage points; Hispanics, 6.3 percentage points; whites, 5.7 percentage points.

Although Hispanics are projected to experience gains in coverage, Clemans-Cope et al. suggest that the aforementioned estimates for Hispanics are complicated by several considerations. First, Hispanics constitute 27.5 percent of the total uninsured population. Second, they account for 82.2 percent of undocumented immigrants, to whom coverage will not be expanded. Finally, 55 percent of Hispanics who remain uninsured under the ACA will be undocumented immigrants and will rely on the generosity of private physicians and hospitals to provide care beyond the demands of federal law. It is unclear, then, whether Hispanics will fare better than either blacks or whites in any of the preceding comparisons, i.e., in terms of percentage gains in coverage and drops in uninsurance rates.

Furthermore, health and related policy choices in California and Texas, wherein more than half of non-elderly Hispanics reside, will be crucial to determining the effects of the ACA on uninsurance (or coverage rates) among Hispanics. On the whole, however, the ACA, under full implementation, is expected to lower disparities in coverage rates between whites and blacks as well as between whites and Hispanics.

Feature Photo: cc/David Boyle in DC