Study: ACA reduced racial disparities in health coverage

Gap in insurance rates has dropped

The Affordable Care Act dramatically reduced racial disparities in health insurance coverage and access to care among black and Hispanic adults, especially in states that expanded Medicaid eligibility, according to a new report by the Commonwealth Fund.

Before the ACA, better known to many as “Obamacare,” was enacted in 2013, there was a 9.9 percentagepoint gap between the uninsured rate among white adults and the uninsured rate among black adults. The gap narrowed to 5.8 percentage points in 2018, according to the report, which analyzed census survey data.

The gap between white and Hispanic adults closed even more — from 25.7 percentage points to 16.3 percentage points.

In Pennsylvania, the uninsured rate gap between white and black adults now is under 4 percentage points.

Narrowing the race gap in insurance coverage is an important step toward a more equitable health system because having insurance is a gateway to getting health care, said Sara Collins, a vice president for the Commonwealth Fund.

“Coverage is the most important factor in people’s ability to access health care. ... It is a necessary condition, but it is not sufficient to people getting quality care,” Ms. Collins said. “Racial minorities, because of long-standing issues of bias in our delivery system, face an even greater hurdle to getting access to good care and good health outcomes.”

Though its provisions — such as covering pre-existing conditions — are popular among most Americans, the ACA has continued to be a political football, especially as the presidential election nears. President Donald Trump has attacked the program for years; some Democrats in the race want to replace it with a more universally available health care plan, while others want to improve the ACA.

Meanwhile, the cost of health care and insurance has continued to rise, driven partly by high-deductible health plans that grew under the ACA. For people who do not qualify for Medicaid or an income-based subsidy for insurance purchased through the ACA marketplace, insurance is expensive.

But a report released Thursday found that individual plan premiums declined for 2020 in 31 states — including Pennsylvania, where the cost of a benchmark plan covering a 40-year-old nonsmoker fell by 3%.

Black, Hispanic and white adults all gained insurance coverage under the ACA, which created an online insurance exchange with tax credits for people who buy individual insurance because they do not have employer-sponsored health insurance and provided financial backing for states to increase the income eligibility for Medicaid.

But in most states, minority adults saw a greater gain in insurance coverage compared with white adults, though they still are less likely to have insurance, Commonwealth Fund researchers found.

In Pennsylvania, the uninsured rate among black adults dropped 11.6 percentage points, between 2013 and 2018, to 10.2%. The uninsured rate among white adults declined 4.7 percentage points during that period, to 6.3% in 2018.

As more people gained insurance coverage that enabled them to see a doctor, racial gaps in access to care improved, too, the study found.

Black and Hispanic adults reported the greatest reduction in cost-related barriers to care. And the number of minority adults who said they had a “usual source of care,” such as a primary-care doctor or a health clinic, also increased.

The study did not look at other potential barriers to care and good health outcomes that disproportionately affect minority patients, such as unconscious bias among doctors. People with Medicaid coverage may also struggle to find a doctor who accepts their insurance or experience long wait times for an appointment.

In a statement, Ms. Collins said the ACA’s coverage expansion had helped drive “historic progress,” but there’s still much work to be done.

Hispanic adults, for example, still experience high uninsured rates compared to white and black adults. In Pennsylvania, the uninsured rate among Hispanic adults declined from 28.3% in 2013 to 16.8% in 2018.

In their report, researchers cautioned that the progress made since the ACA took effect has largely stalled since 2016. Uninsured rates have ticked upward slightly in the past two years as Mr. Trump and Republicans chipped away at the ACA.