center global policy solutions obamacare reduces racial disparities in health coverage.pdf

8/20/2019 Center Global Policy Solutions Obamacare Reduces Racial Disparities in Health Coverage.pdf

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T

he 2014 implementation o the Affordable Care Act (ACA), also known as Obamacare, has had a promisinstart in providing health insurance or all Americans. All racial groups have experienced substantialincreases in their health insurance coverage. Beore the ACA was enacted, people o color were much more

likely to be uninsured than Whites. Obamacare has reduced these disparities and has essentially eliminatedthe difference between the uninsured rates o Asian Americans and Whites and o Black and Whitechildren. Yet evidence rom Massachusetts’ health insurance reorm—a model or the Affordable Care Act—suggeststhat Obamacare is not going to completely eliminate racial and ethnic inequalities in health insurance coverage. Only more extensive expansion o government-sponsored health insurance is likely to achieve that goal.

Obamacare Reduces RacialDisparities in Health CoverageBy Algernon Austin

This issue brief finds:

Disparities in uninsured rates between Asian Americans and Whites and between Black and

White children were eliminated in 2014. Health insurance coverage for people of color

increased primarily due to increases in privateinsurance; for Whites, coverage increased primarilybecause of increases in government insurance.

Te growth in health insurance enrollment in 2014might have been 25 percent greater if all states hadexpanded Medicaid under Obamacare.

Te evidence from Massachusetts’ health insurance

reform—a model for Obamacare—suggests thatthe Affordable Care Act will lower uninsured rates for all, but racial and ethnic disparities in healthinsurance coverage between White and non-White populations will remain.

A significant expansion of Medicaid or Medicarecould eliminate all racial and ethnic disparities inhealth insurance coverage.

Health and WealthBenefits of HealthInsuranceAs one might imagine, or all people a lack o healthinsurance is associated with worse health outcomes.Te uninsured are less likely to receive needed careor preventable and chronic conditions. Tey arealso more likely to postpone care and to oregoneeded prescriptions due to cost. For these reasons,the uninsured are sicker and more likely to dieprematurely than the insured. 1

Te lack o health insurance also puts an individual’s

wealth at risk. Uninsured low- and moderate-incomeadults are twice as likely as the insured to use up theisavings or go into debt because o medical bills. TeKaiser Family Foundation reports:

In 2014, nearly a third (32 percent) of uninsuredadults said they were carrying medical debt. Medicdebts contribute to over half (52 percent) of debtcollections actions that appear on consumer credit



reports in the United States

and contribute to almosthalf of all bankruptciesin the United States.Uninsured people are moreat risk of falling into medicalbankruptcy than people withinsurance.2

Te stress o being unable to paymedical bills affects uninsuredadults’ job perormance, amily

relationships, and ability tosleep.3 Tis stress can lead tolower earnings and worse healthoutcomes, causing a downwardspiral.

Te high uninsured rateso Hispanics, Blacks, AsianAmericans and American Indians, are thereore acontributing actor in the health and wealth disparitiesbetween people o color and Whites. When peopleo color need medical treatment, they are less likelyto be able to afford it because they are less likely tohave medical insurance and more likely to be low- ormoderate-income.4 Reports rom Latinos and Blackssuggest that they are more likely than Whites to gowithout medical care because o the cost.5 I Latinosand Blacks do obtain treatment, they are more likely toall into debt because o their higher uninsured ratesand lower incomes. For example, research on wealthdisparities in Boston ound that Latinos and Blacks are

nearly twice as likely as Whites to have medical debt.6

Affordable CareAct Narrows HealthInsurance Disparities

2014 was a successul year or the Affordable CareAct. Te Census Bureau estimates that nearly 9

million individuals gained health insurance in 2014.7

Te Affordable Care Act has not only reduced thepercentage o all racial groups lacking health insurance

it has also reduced disparities in health-insurancecoverage between Whites and people o color.

Uninsured rates change in response to economicconditions, demographic shifs, and public policy.We cannot say precisely what portion o the declinein the uninsured rates is due to the policy change othe Affordable Care Act; however, the majority o thechange in these rates in 2014 is probably due to theACA because the drop, which occurred afer the Act’simplementation, was several times greater than any

other yearly reduction on record.8 Te unprecedentedpolicy change that is Obamacare is the most reasonabexplanation or this dramatic decline.

As Figure A illustrates, all major racial and ethnicgroups saw a reduction in their uninsured rate rom2013 to 2014. Te reduction or America’s racial andethnic minorities was almost double the reduction onon-Hispanic Whites, which narrowed the uninsured



rate disparity between peopleo color and Whites (able 1).

Most notably, the disparitybetween Asian Americans’higher uninsured rate andthe Whites’ lower one wasessentially eliminated in 2014,dropping rom a gap o morethan 3 percentage points in2013 to less than 1 percentagepoint in 2014. In this brie,uninsured rates within onepercentage point o each otherare considered to be equivalent.9

For Arican Americans, the gapbetween their higher uninsuredrate and that o Whites was5.5 percentage points in 2013,alling to 3.6 percentage pointsin 2014. For American Indians,10 the disparity withWhites dropped rom 10.9 percentage points in 2013to 8.7 points in 2014. For Hispanics, the uninsuredrate dropped considerably, but this group still has the

largest disparity with Whites, 11.8 percentage points.Tis large disparity is due, in part, to the relativelylarge share o the Hispanic population that is madeup o unauthorized immigrants, who are ineligible orMedicaid and ACA benefits.11

Tese changes, which are largely due to the AffordableCare Act, show that it is possible to create policiesthat benefit all Americans. No racial or ethnic groupwas excluded. Whites and all other groups increasedtheir health insurance coverage. People o color had

higher uninsured rates than Whites in 2013, and theyreceived a larger benefit rom the ACA; this has helpedto narrow the gaps between these groups. Tis policyapproaches the ideal or the nation in that it providesuniversal benefits to all and simultaneously reducesracial and ethnic disparities.

Obamacare EliminatesThree Racial DisparitiesIt is rare or a racial disparity to be eliminated, but

the Affordable Care Act has done so. Te ACA hassucceeded in eliminating the uninsured gap betweenAsian Americans and Whites, as discussed above. Ithas also eliminated the disparity in uninsured ratesbetween Black and White children, and between AsiaAmerican and White adult males.

Children’s Uninsured Rates

Since the late 1990s, the uninsured rate or childrenhas been declining because o Medicaid and the

Children’s Health Insurance Program (CHIP) whichwas established in 1997. CHIP provided states withederal assistance to create programs or childrenrom amilies with incomes that were too high toqualiy or Medicaid but too low to enable them toafford private health insurance. From 1997 to 2012,the uninsured rate or children was cut in hal.12 Evenin the immediate wake o the Great Recession, rom2008 to 2010, when the nonelderly adult uninsured



rate was increasing, the children’s

uninsured rate decreased.13

Tistrend produced a widening gapbetween the lower uninsuredrate or children and the higheruninsured rate or nonelderlyadults. However, the decline in thechildren’s uninsured rate stalledin 2013. Tere was no significantreduction in the children’suninsured rate rom 2012 to2013, even though there had been

significant reductions most o theprior years, including every yearrom 2008 to 2012.14

Because o the success oMedicaid and CHIP, healthpolicy analysts predicted thatthe Affordable Care Act wouldlead to urther reductions in theuninsured rate or children.15

Policies like the ACA that increasethe enrollment o adults in healthinsurance lead to increases inthe enrollment o their children.Additionally, many uninsuredchildren who were eligible orMedicaid or CHIP beore theACA gained coverage afer ACAimplementation because oincreased awareness, outreach,and enrollment efforts.16 Te

ACA also changed some policiesto increase the enrollment ochildren in Medicaid or CHIP. Notonly does the Act prevent statesrom lowering Medicaid and CHIP eligibility standardsor children, it requires a “children’s expansion” oMedicaid. All states must have a minimum Medicaideligibility level or children o up to 138 percent othe ederal poverty level. Because this eligibility level

was higher than the standard in several states, inthese states, children were moved rom CHIP intoMedicaid, which has lower costs and provides morecomprehensive services. Te ACA also increasedederal unding to states or CHIP.17



Probably due to the long push

to enroll low-income children,who are disproportionatelynon-White, in Medicaid andCHIP, the gaps in uninsured ratesbetween Whites and non-Whitesare smaller or children than ornonelderly adults. As with thegroups as a whole, children oall racial and ethnic groups sawdeclines in their uninsured rates,but non-White children saw

larger declines. Tese declinesreduced the gaps or all childreno color and totally eliminatedthe uninsured rate gap betweenBlack-and White children (FigureB).

In 2013, the uninsured rate orBlack children under 19 years old was 1.4 percentagepoints above the rate or White children (able2). Although both groups o children experiencedreductions in their uninsured rates, in 2014 the Blackrate declined aster, and the disparity was reduced tozero. Although the uninsured rates or White childrenand Black children both ell in 2014, the increase intheir health insurance coverage came rom differentsources. For white children, the increase in coveragewas mainly due to government insurance, while orBlack children it was mainly due to private insurance.(It is important to note that, in any year, individualsmay be covered by more than one type o insurance.)

From 2013 to 2014, the government insurance rateor White children increased by 2.4 percentage points,while their private insurance coverage declined by0.6 percentage points (Figure C and Appendix ableA-1). In contrast, Black children’s private insurancecoverage increased 3.6 percentage points, while theirgovernment insurance coverage increased only 0.4percentage points.

Te disparity in uninsured rates between AsianAmerican and White children was also nearlyeliminated (Figure B and able 2). Te disparity ellrom 2.7 percentage points in 2013 to 1.5 points in2014 (Figure B and able 2). As with Black children,the increase in health insurance coverage or AsianAmerican children was driven more by privateinsurance than by government insurance. Tepercentage point increase in private coverage or AsiaAmerican children rom 2013 to 2014 was more thanthree times as large as the increase in governmenthealth insurance coverage (Figure C and Appendixable A-1).

Te difference in uninsured rates between Hispanicand White children ell rom 6.1 percentage pointsto 4.7 points, and the inequality between AmericanIndian and White children ell rom 8.4 percentagepoints to 5.3 points (Figure B and able 2). For thesegroups also, growth in private coverage was greaterthan growth in government coverage. American Indichildren had the largest growth in private healthinsurance coverage—6.4 percentage points—and



were the only group other thanWhites to experience a decline

in government health insurancecoverage (Figure C and Appendixable A-1).

All children o color saw alarger increase in private healthinsurance than in governmentinsurance. Tere is reasonto be concerned about thisdevelopment since there are signsthat insurance purchased throughthe health insurance exchangesis still too expensive or manypeople to maintain or to useto ully access all o the healthcare that they need. Tis issue isdiscussed urther below.

Uninsured Rates for Menand Women

Obamacare has eliminated theuninsured-rate disparity betweenAsian American and White men,and it has nearly eliminatedthe disparity between AsianAmerican and White women.In 2013, the Asian Americanuninsured rate or men ages 19to 64 years was 2.7 percentagepoints higher than the White rate.In 2014, both rates declined, but

the Asian American rate was now0.2 percentage points below theWhite rate (Figure D and able 3).In 2013, the Asian American rateor women ages 19 to 64 years was3.7 percentage points higher thanthe White rate. In 2014, it wasreduced to 1.5 percentage points



(Figure E and able 3).

Tis narrowing o the disparitybetween Asian Americanand White adults was due touninsured rates alling morequickly or Asian Americanthan White adults. While Whiteadults saw similar increases inprivate and government insurancecoverage, Asian American adultssaw larger increases in private

insurance coverage (see Appendixable A-2).

Although Hispanic men andwomen had the biggest reductionin their uninsured rates (the mentied with Arican American men),their disparities with Whitesremain in the double digits and remain the largestdisparities o the racial and ethnic groups by gender.In 2014, Hispanic men (19 to 64 years old) had anuninsured rate 19 percentage points higher than Whitemen, and Hispanic women had a rate 14.7 percentagepoints above White women (able 3).

American Indian men and women also had a double-digit disparity with Whites in 2014 despite a narrowingo the uninsured gap. In 2014, American Indian men’suninsured rate was 13.3 percentage points higher thanthat o White men. For American Indian women, thegap with White women in 2014 was 10.2 percentage

points (able 3).

Te disparity in uninsured rates between Black andWhite men was 6.6 percentage points in 2014, havingdropped rom 10.1 percentage points in 2013. In 2014,the uninsured-rate disparity between Black and Whitewomen was 5 percentage points, having allen rom 6.7percentage points in 2013 (able 3).

Private Health InsuranceDominates Coverage

Gains for People of ColorGovernment InsuranceDominates CoverageGains for WhitesWhile all o the major racial and ethnic groupsexperienced increases in their rates o health insurancoverage rom 2013 to 2014, gains or people o colorunder 65 years old were primarily due to increases

in private insurance coverage. For Whites in this agegroup, the opposite was true: gains in coverage wereprimarily due to increases in government insurance.Latinos, Blacks, Asian Americans, and AmericanIndians all saw growth in their private insurancecoverage o more than 4 percentage points (FigureF and able 4). In contrast, or Whites, the increasein private insurance was only about a third o theincrease or the non-White groups.



It is not clear what is behindthis difference. Opposition to

Obamacare may be one actor.Whites express the strongestopposition to Obamacare,18 andconsequently, they may seekout its benefits on the healthinsurance exchanges less thanother groups.19 Alternatively,there could be a “ceiling effect.”Whites have the highest rateo health insurance coverage.20

When the rate is high, it may bedifficult to raise it even higher.Further research is necessary tounderstand this issue.

Whites experienced a gain o 2.1percentage points in governmentinsurance rom 2013 to 2014(Figure F and able 4). Tisincrease was squarely withinthe range o growth (rom 1.1

to 2.5 percentage points) o thenon-White groups. In contrast,whites had a 1.4 percentage-point increase in privateinsurance while all o the non-White groups had increases omore than 4 percentage points.Arican Americans had thesmallest gain in governmentinsurance—1.1 percentagepoints—and the biggest gain in

private insurance—4.9 percentagepoints. Te Hispanic increasein government insurance was2.2 percentage points, and theincrease in private insurance was 4.2 percentagepoints. American Indians had the biggest increase ingovernment insurance—2.5 percentage points—anda 4.3 percentage-point increase in private insurance.Asian Americans had a 1.3 percentage-point increase

in government insurance and a 4.4 percentage pointincrease in private insurance.

Tese findings suggest that Obamacare has beeneffective in reaching low-income Whites who areeligible or Medicaid in greater numbers due to the



“children’s expansion” o Medicaid and the generalexpansion o Medicaid among adopting states. White

children’s increase in government insurance coveragewas particularly strong relative to the other groups(Figure C).

In contrast, Blacks’ growth in government insurancecoverage is surprisingly low. Overall, Blacks had thelowest increase in government insurance o any group(Figure F). Given that this group is disproportionatelylow-income, this is not what one would expect. Te actthat many southeastern states, states with large Blackpopulation shares, did not have a general expansion oMedicaid may be responsible or this situation.21

Estimating the PossibleImpact of Full MedicaidExpansion in 2014Te Affordable Care Act expanded Medicaid to covermore low-income individuals, but the Supreme Courtmade the expansion optional or states. By January

1, 2014, 24 states and the District o Columbia hadagreed to expand Medicaid. Te Census Bureaureports that the uninsured rates or nonelderly adultsdeclined more in the states that expanded Medicaid.22

In those states that did not expand Medicaid, theharmul effect was not elt uniormly across racial andethnic groups. Blacks were more affected than othergroups because many o the non-expansion states arein the southeast, an area with a disproportionate shareo the Black population. Latinos and Asian Americans

were affected less because they are underrepresentedin the non-expansion states relative to their overallshare o the population. Whites and AmericanIndians are proportionally represented in the non-expansion states.23

As o September 2015, about 5.6 million adults livingin the states that did not expand Medicaid werecaught in a “coverage gap” or “assistance gap.”24 Tese

individuals were not poor enough to receive Medicaibut their income was not high enough or them to be

eligible or subsidies in the ACA’s health insurancemarketplaces. Whites make up 48 percent (2.7 millionpeople) o the adults in the coverage gap. Blacks makeup 27 percent (1.5 million people), and Hispanicsmake up 21 percent (1.2 million people).25

Estimates o the coverage gap described above arebased on the total number o adults potentiallyeligible or Medicaid i all states were to implementthe expansion, but not everyone who was requiredto obtain health insurance or who was eligible orMedicaid obtained health insurance in 2014.26

Tereore, it is also inormative to estimate how manyadults might not have obtained health insurance in2014 specifically because o the non-expansion oMedicaid in hal o the states. I one assumes thatthe size o the increase in health insurance coveragewould have been the same in non-expansion stateshad they expanded Medicaid as it was in the states thactually did expand it, then one can gain a sense o thmagnitude o the loss in health insurance coverage.

Had all states expanded Medicaid, an additional 2million Americans might have had health insurancein 2014, including about 1 million Whites, 400,000Latinos, 300,000 Blacks, 10,000 Asian Americans, and60,000 American Indians.27

Te growth in health insurance enrollment mighthave been 25 percent greater i all states had expandeMedicaid. White enrollment might have been 30percent greater; Hispanic enrollment, 15 percentgreater; Black enrollment, 15 percent greater; Asian

American enrollment, 1 percent greater; and AmericIndian enrollment, 20 percent greater.28 For nearly allgroups, these are not trivial figures. Even i potentialgrowth in enrollment due to Medicaid expansion washal the size o these estimates, it would still have beea significant addition to health insurance enrollmentin 2014. Hence, the ailure to expand Medicaid in allstates had significant costs or the health and wellbeino a large number o Americans.



Will the

AffordableCare Act Meetthe Needsof People ofColor?

While the Affordable Care Act haseliminated some racial disparitiesand reduced others, will it be ableto provide equally low uninsuredrates or all? Te AffordableCare Act was modelled onMassachusetts’ health insurancereorm, which was establishedin 2006.29 Tus, we can examinehealth insurance coverage in thatstate in recent years to predictwhat health insurance coveragemight be like when Obamacare

is a mature and well-establishedsystem. Te two programs, whilesimilar, are not the same however.Te Massachusetts reorm hasgreater potential to achieveuniversal coverage becauseObamacare has had to contendwith considerable politicalopposition and many states havereused to expand Medicaid, akey eature o the reorm. Te

Massachusetts case, thereore, islikely the best-case scenario orObamacare.

Te Kaiser Family Foundationreports that health insurance coverage has expandedsignificantly in Massachusetts since the healthinsurance reorm.30 In 2014, the state had the lowestuninsured rate in the country.31 Yet the Kaiser

Foundation ound that low-income individualsare still more likely to be uninsured and the costo health insurance still appears to be a burden orsome.32 Because people o color tend to have lowerthan average incomes, one would expect to see



higher uninsured rates among people o color inMassachusetts.

In this issue brie, pooled American CommunitySurvey (ACS) data or 2008 through 2012 is used todetermine i there are differences in uninsured ratesby race and ethnicity in Massachusetts. Additionally,the analysis o the data was divided by age becausechildren receive more government insurance coveragethrough Medicaid and CHIP (part o MassHealth inMassachusetts) and individuals 65 years old and overare eligible or Medicare.

Te ACS data shows that, by state (including theDistrict o Columbia), Massachusetts has the lowestuninsured rate overall.33 Moreover, Massachusettshas relatively low uninsured rates or people o colorgenerally. Yet the analysis also revealed some bad news:Tere continue to be racial and ethnic disparities inMassachusetts. Tere are smaller disparities, howeveramong children. Over the years 2008 to 2012, thereis no substantial difference among the uninsuredrates or White, Hispanic, Black, and Asian American

children (Figure G and able 5). White, Black, andAsian American children have uninsured rates o lessthan 2 percent, and the rate or Hispanic childrenis only a little above 2 percent. Te only substantialdifference is or American Indian children, whoseuninsured rate is 2.3 percentage points above theWhite rate. Tese findings suggest that Obamacarewill be able to lower uninsured rates or children andeliminate most o the racial and ethnic disparities ininsurance coverage or children.

Overall, nonelderly adults living in Massachusettshave the lowest uninsured rate (Appendix able A-3).By race, however, the rate is low or all groups butnot necessarily the lowest or each group by state.For Asian Americans, Massachusetts has the lowestrate. For Whites, the Massachusetts uninsured rateis statistically tied or the lowest with the Districto Columbia. For American Indians, the Districto Columbia is also the “state” with the lowest rate.

Whites and American Indians in the District oColumbia have the highest educational attainment

o their group by state,34 and they are employed at ahigh rate in jobs that provide health insurance.35 ForHispanics and Blacks, Hawaii has the lowest uninsurerate. Hawaii requires employers to provide healthinsurance or workers who work more than 20 hoursper week.36 While Massachusetts is not the lowest oreach group, it is at least the second lowest or eachgroup. Health insurance reorm appears to have set thstate o Massachusetts apart.

Even with this apparent success, significant inequalitin nonelderly adult uninsured rates remain inMassachusetts. Te smallest difference is betweenWhites and Asian Americans (Figure G and able5). Te Asian American uninsured rate is only 1percentage point above the White rate. Te Black rateis 5 percentage points higher than the White rate;the American Indian rate is 5.3 points higher; andthe Hispanic rate is 8.7 points higher. Tese findingssuggest that substantial racial disparities in healthinsurance coverage or nonelderly adults will remain

under Obamacare.

Individuals 65 years old and over are eligibleor Medicare. In this age group, all racial andethnic groups have very low uninsured rates inMassachusetts. Te highest uninsured rate is 2.2percent or Asian Americans (Figure G and able 5).Tis rate is 2 percentage points above the White rate.Hispanics and Arican Americans have a disparity wiWhites o less than 2 percentage points. Te AmericaIndian rate is essentially equal to that o the Whites.

Health insurance reorm in Massachusetts suggeststhat Obamacare will lower uninsured rates, but therates o White and non-White populations will notbe the same. Disparities will likely continue to belargest among nonelderly adults. In general, the loweuninsured rates and the smallest disparities are likelyto be among children and the elderly—the groups whreceive the highest levels o government assistance.



More Government

Insurance Would WorkBetter for People of ColorSo ar Obamacare has been a success, but it is not clearthat it will continue to be so. In particular, there arereasons to worry about whether the Act can delivertruly affordable health insurance to all who are eligible.Te White House has lowered its projections orhealth insurance enrollment in 2016.37 Many statesstill have not expanded Medicaid. Although the law

requires more employers to offer health insurance totheir employees, evidence suggests that the rate o newemployer-sponsored enrollment has been very low.For low-income workers, a health-insurance plan thatreduces income by nearly 10 percent and then has adeductible o thousands o dollars is not an affordableplan.38 Among those who look or insurance throughthe marketplaces, cost is also a major concern; manywho ail to choose a plan cite the price o coverageas the reason.39 Also, there are reports that some othose who have purchased health insurance throughthe marketplace may orgo care because o the highdeductibles.40 Even i Obamacare lowers the rate oincrease in health insurance costs, in the context ostagnating or declining household incomes41 anyincrease can be too big an increase or plans to remainaffordable. Given that America’s people o color aredisproportionately low- and moderate-income, theseaffordability challenges disproportionately affectminority groups.

Te evidence rom Massachusetts suggests that moregovernment assistance in providing health insuranceshould lower uninsured rates and reduce racial andethnic disparities. Te lowest uninsured rates andsmallest racial and ethnic disparities in this state wereor children, many o whom are covered by Medicaidor CHIP, and or the elderly, most o whom are coveredby Medicare. Tese programs present pathways orincreasing health insurance coverage and reducing

racial and ethnic disparities.

Te Affordable Care Act expanded Medicaid to138 percent o the poverty level or adults, while inMassachusetts, Medicaid- and CHIP-covered childrein amilies with incomes up to 300 percent o theederal poverty level.42 Expanding Medicaid or allup to 300 percent o the poverty level is probably abetter threshold or increasing coverage. Te payrollprocessing company ADP ound that there is very lowenrollment in employer-sponsored health insuranceamong employees earning less than $45,000 a year.43

A threshold o 300 percent o the poverty level wouldsubstantially reduce the number o employees earninless than $45,000 a year who need health insurancerom their employer.

Although means-tested benefits like Medicaid are lescostly than universal benefits, means-tested benefitstend to become stigmatized and get attacked. Anothealternative or achieving high insurance coverage andlow disparities between groups is to expand Medicareto cover all age groups. Tis would be a simple andpowerul way to bring about very low uninsured rateand very small racial and ethnic disparities.



Appendix



Appendix

(continued)



Table A-3. (Continued)

Average Adult Uninsured Rates by Stateand Race, 2008-2012 (19 to 64 years old)

Appendix

(continued)



Works Cited1. Kaiser Family Foundation, “Key Facts about the Uninsured Population,”Fact Sheet , (Menlo Park, CA: Te Henry J. Kaiser Family Foundation, Octob

5, 2015),http://kff.org/uninsured/act-sheet/key-acts-about-the-uninsured-population/; Randall R. Bovbjerg and Jack Hadley, “Why Health InsuranIs Important,” Health Policy Briefs (Washington, D.C.: Urban Institute, DC-SPG no.1, November 2007), http://www.urban.org/sites/deault/files/alresco/publication-pds/411569-Why-Health-Insurance-Is-Important.PDF; Stan Dorn, “Uninsured and Dying Because o It: Updating the Instituto Medicine Analysis on the Impact o Uninsurance on Mortality,” (Washington, D.C.: Urban Institute, January 2008), http://www.urban.org/sites/deault/files/alresco/publication-pds/411588-Uninsured-and-Dying-Because-o-It.PDF.

2. Kaiser Family Foundation, “Key Facts about the Uninsured Population.”

3. Ibid.

4. Jeff Larrimore, Mario Arthur-Bentil, Sam Dodini, and Logan Tomas, Report on the Economic Well-Being of U.S. Households in 2014 (Washington,DC: Board o Governors o the Federal Reserve System, 2015), Figure 9.

5. Susan L. Hayes, Pamela Riley, David C. Radley, and Douglas McCarthy, “Closing the Gap: Past Perormance o Health Insurance in Reducing Racialand Ethnic Disparities in Access to Care Could Be an Indication o Future Results,” Issue Brief (New York, NY: Te Commonwealth Fund, March

2015), Exhibit 2.

6. Ana Patricia Muñoz, Marlene Kim, Mariko Chang, Regine O. Jackson, Darrick Hamilton, and William A. Darity Jr.,Te Color of Wealth in Boston (Boston, MA: Federal Reserve Bank o Boston, 2015), able 4.

7. Jessica C. Smith and Carla Medalia, Health Insurance Coverage in the United States: 2014 (Washington, DC: U.S. Census Bureau, 2015), p. 3.

8. Matt Broaddus, “2014’s Historic Gain in Health Coverage,” Off the Charts [blog] (Washington, DC: Center on Budget and Policy Priorities, Septemb16, 2015), http://www.cbpp.org/blog/2014s-historic-gain-in-health-coverage.

9. Data on health insurance coverage or 2013 and 2014 was accessed through the CPS able Creator, which does not allow or the calculation oconfidence intervals.

10. Te data or American Indians is somewhat ambiguous. Tis analysis ollows the Census Bureau practice o counting individuals receiving coverageonly through the Indian Health Service (IHS) as uninsured. Te National Congress o American Indians states, “IHS is typically unded at just overhal the level o need, resulting in inadequate health care.” National Congress o American Indians, National Indian Child Welare Association,National Indian Education Association, and the National Indian Health Board,Native Children’s Policy Agenda: Putting Kids 1st (Washington, DC:National Congress o American Indians, 2015). Te Indian Health Service and the National Congress o American Indians encourage AmericanIndians to participate ully in the opportunities provided by the Affordable Care Act. National Congress o American Indians, “Te National Congro American Indians Resolution #SD-15-” (Washington, DC: National Congress o American Indians, 2015), http://www.ncai.org/SD-15-055_drafpd; Indian Health Service, “Affordable Care Act,” (Rockville, MD: Indian Health Service, 2015), https://www.ihs.gov/aca/.

11. Undocumented immigrants are ineligible or Medicaid, and they are barred rom receiving subsidies through the exchanges. Legal immigrantsare barred rom Medicaid in their first five years in the United States. Kaiser Family Foundation,Summary of the Affordable Care Act (Menlo Park,CA: Te Henry J. Kaiser Family Foundation, 2013), http://kff.org/health-reorm/act-sheet/summary-o-the-affordable-care-act/. Te CaliorniaEndowment is pushing or the Affordable Care Act to cover undocumented immigrants. Robert K. Ross, “Obamacare in Caliornia” [Letter to theeditor], New York imes, August 13, 2015, http://www.nytimes.com/2015/08/13/opinion/obamacare-in-caliornia.html?.

12. Robin Rudowitz, Samantha Artiga, and Rachel Arguello, “Children’s Health Coverage: Medicaid, CHIP and the ACA,” Issue Brief , (Menlo Park, CA:Te Henry J. Kaiser Family Foundation, March 26, 2014), http://kff.org/health-reorm/issue-brie/childrens-health-coverage-medicaid-chip-and-thaca/.

13. Ibid.14. Rudowitz, Artiga, and Arguello, “Children’s Health Coverage”; Joan Alker and Alisa Chester, Children’s Health Insurance Rates in 2014: ACA Results

Significant Improvements (Washington, DC: Georgetown University Health Policy Institute, 2015), http://cc.georgetown.edu/cc-resources/childrenuninsured-rate-2014-affordable-care-act/.

15. Rudowitz, Artiga, and Arguello, “Children’s Health Coverage.”

16. Phil Galewitz, “exas and Florida Expand Medicaid,” Kaiser Health News, September 29, 2014, http://khn.org/news/texas-florida-expand-kids-medicaid/; Alker and Chester, Children’s Health Insurance Rates in 2014.

17. Rudowitz, Artiga, and Arguello, “Children’s Health Coverage”; Galewitz, “exas and Florida Expand Medicaid.”

18. Pew Research Center, “Affordable Care Act Approval able,” Democrats Have More Positive Image, But GOP Runs Even or Ahead on Key Issues:Public Remains Split on ‘Who Should ake Lead’ on Problems (Washington, DC: Pew Research Center, 2015), p. 13, http://www.people-press.org/files/2015/02/2-26-15-Obama-and-Congress-release.pd.



19. For example, the New York imes reports, “And in a state [Kentucky] where approval o President Obama hovers around 34 percent, enthusiasm or health law is lacking even among some who stand to benefit rom it.” Abby Goodnough, “Kentucky, Beacon or Health Law, Now a Lab or Its Retrea

New York imes, November 27, 2015.20. Smith and Medalia, Health Insurance Coverage in the United States: 2014, able 5.

21. See Smith and Medalia, Health Insurance Coverage in the United States: 2014, able A-1 or the expansion states.

22. Smith and Medalia, Health Insurance Coverage in the United States: 2014, Figure 5.

23. Author’s analysis o 2013 American Community Survey data rom Steven Ruggles, Katie Genadek, Ronald Goeken, Josiah Grover, and Matthew SobIntegrated Public Use Microdata Series: Version 6.0 [Machine-readable database] (Minneapolis, MN: University o Minnesota, 2015), not shown.

24. Matthew Buettgens, “Medicaid Expansion Could Make Health Insurance Affordable or 5.6 Million,” Urban Wire [blog] (Washington, DC: UrbanInstitute, October 2, 2015), http://www.urban.org/urban-wire/medicaid-expansion-could-make-health-insurance-affordable-56-million.

25. Urban Institute, “Te ACA Coverage Gap: ables,” (Washington, DC: Urban Institute, 2015) and author’s calculations rom these tables, http://wwwurban.org/aca-coverage-gap-tables.

26. Te Kaiser Family Foundation estimates that, in 2015, more than a quarter o the uninsured are eligible or Medicaid. About a fifh o the uninsured

are eligible or marketplace subsidies. Rachel Garfield, Anthony Damico, Cynthia Cox, Gary Claxton, and Larry Levitt, “New Estimates o Eligibilityor ACA Coverage among the Uninsured,” Issue Brie (Menlo Park, CA: Te Henry J. Kaiser Family Foundation, October 13, 2015), http://kff.org/uninsured/issue-brie/new-estimates-o-eligibility-or-aca-coverage-among-the-uninsured/.

27. Tese estimates were derived by assuming that the decline in the uninsured rates would be the same in non-expansion states as in expansion statesi the non-expansion states had also expanded Medicaid. Te change in the uninsured rate rom 2013 to 2014 was calculated using the AmericanCommunity Survey. Changes were calculated by race or adults (19 to 64 years old) and children (0 to 18 years old) within three household incomecategories: 1 to 138 percent o the poverty level; 139 to 400 percent o the poverty level; and 401 percent o the poverty level and above. Te differencbetween the changes or the expansion and non-expansion states was then used to calculate the “missing” decline. I the decline by income categorylarger in the non-expansion states than in the expansion states, then it is assumed that there is no missing decline. Tis situation only arose with theanalysis or children.

Te difference in the size o the decline between expansion and non-expansion states extends beyond those eligible or Medicaid, suggesting that thare social and cultural actors (such as “welcome mat” actors) beyond the narrowly economic that affect the decision to enroll in health insurance.

Te American Community Survey data was accessed rom Steven Ruggles, et al., Integrated Public Use Microdata Series.

28. Te White (and American Indian) estimated increase in enrollment is larger than one might expect because the actual increase in non-expansionstates was relatively small. Conversely, the Black estimated increase is smaller than one might expect because the actual increase in non-expansionstates was relatively large.

29. Kaiser Family Foundation, “Massachusetts Health Care Reorm: Six Years Later,” (Menlo Park, CA: Te Henry J. Kaiser Family Foundation, May 1,2012), http://kff.org/health-costs/issue-brie/massachusetts-health-care-reorm-six-years-later/; Jesse Lee, “Early Affordable Care Act Enrollment& Te Massachusetts Experience,” White House blog (Washington, DC: Te White House, November 1, 2013), https://www.whitehouse.gov/blog/2013/11/01/early-affordable-care-act-enrollment-massachusetts-experience.

30. Kaiser Family Foundation, “Massachusetts Health Care Reorm: Six Years Later.”

31. Smith and Medalia, Health Insurance Coverage in the United States: 2014, able A-1.


33. Author’s analysis o Steven Ruggles, et al., Integrated Public Use Microdata Series, not shown. See also Smith and Medalia, Health Insurance Coverage

the United States: 2014, able A-1.34. Author’s analysis o the share o the population with a bachelor’s degree or higher with data rom Steven Ruggles, et al., Integrated Public Use Microd

Series, not shown.

35. Author’s analysis o data rom Steven Ruggles, et al., Integrated Public Use Microdata Series, not shown.

36. Mark Niesse, “In Hawaii, Employers Pay or Health Insurance,” USA oday , July 27, 2009, http://usatoday30.usatoday.com/news/health/2009-07-27-hawaii-insurance_N.htm.

37. Robert Pear, “Little Growth Predicted on Health Exchanges,” New York imes, October 15, 2015, http://www.nytimes.com/2015/10/16/us/politics/health-insurance-enrollment-expected-to-see-small-increase.html.

38. Stacy Cowley, “Many Low-Income Workers Say ‘No’ to Health Insurance,”New York imes, October 19, 2015, http://www.nytimes.com/2015/10/20/business/many-low-income-workers-say-no-to-health-insurance.html.


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39. Sara R. Collins, Munira Gunja, Michelle M. Doty, Sophie Beutel, “o Enroll or Not to Enroll? Why Many Americans Have Gained Insurance Underthe Affordable Care Act While Others Have Not,” Issue Brief (New York, NY: Te Commonwealth Fund, September 2015).

40. Abby Goodnough and Robert Pear, “Unable to Meet the Deductible or the Doctor,” New York imes, October 17, 2014, http://www.nytimes.com/2014/10/18/us/unable-to-meet-the-deductible-or-the-doctor.html.

41. Josh Bivens, Elise Gould, Lawrence Mishel, and Heidi Shierholz, Raising America’s Pay: Why It’s Our Central Economic Policy Challenge , EPI BriefinPaper #378 (Washington, DC: Economic Policy Institute, 2014), http://www.epi.org/publication/raising-americas-pay/.


43. Cowley, “Many Low-Income Workers Say ‘No’ to Health Insurance.”

center global policy solutions obamacare reduces racial disparities in health coverage.pdf

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