Bjp Policies Since 2014

[Clara Zellinger]

Healthcoverage plays a major role in enabling people to access health care and protecting families from high medical costs. There have been longstanding racial and ethnic disparities in health coverage that contribute to disparities in health. This brief examines trends in health coverage by race and ethnicity from 2010 through 2022 and discusses the implications for health disparities. All noted differences between groups and years described in the text are statistically significant at the p

There were gains in coverage across most racial and ethnic groups between 2019 and 2022 after several years of rising uninsured rates during the Trump Administration. The coverage gains between 2019 and 2022 were largely driven by increases in Medicaid coverage, reflecting policies to stabilize and expand access to affordable coverage that were implemented during the COVID-19 pandemic. These policies included enhanced subsidies to purchase Marketplace coverage and a requirement that states keep Medicaid enrollees continuously enrolled during the public health emergency (PHE), which led to a substantial increase in Medicaid enrollment. These coverage gains helped narrow differences in uninsured rates for Hispanic, Black, and American Indian and Alaska Native (AIAN) people compared with White people, but further progress may be at risk amid the unwinding of the Medicaid continuous enrollment requirement.

Despite these coverage gains, disparities in coverage persisted as of 2022. Nonelderly AIAN and Hispanic people had the highest uninsured rates at 19.1% and 18.0%, respectively as of 2022. Uninsured rates for nonelderly Native Hawaiian and Other Pacific Islander (NHOPI) (12.7%) and Black people (10.0%) also were higher than the rate for their White counterparts (6.6%). Coverage disparities have persisted over time, and in some cases widened, despite recent gains and earlier large gains in coverage under the Affordable Care Act (ACA). For example, between 2010 and 2022, the uninsured rate for AIAN people grew from 2.5 to 2.9 times higher than the uninsured rate for White people, the Hispanic uninsured rate grew from 2.5 to 2.7 times higher than the rate for White people, and Black people remained 1.5 times more likely to be uninsured than White people.

Uninsured rates in states that have not expanded Medicaid are higher than rates in expansion states across most racial and ethnic groups as of 2022. Further, the differences in coverage rates between Hispanic, Black and NHOPI people compared with White people are larger in non-expansion states compared with expansion states. However, the relative risk of being uninsured for Black and Hispanic people compared to White people is similar in expansion and non-expansion states.

The ongoing racial and ethnic disparities in coverage could further widen amid the unwinding of the Medicaid continuous enrollment provision. The Medicaid continuous enrollment provision, which had halted Medicaid disenrollments since March 2020, ended on March 31, 2023. As states unwind the continuous enrollment provision, they will redetermine eligibility for all Medicaid enrollees and will disenroll those who are no longer eligible or who may remain eligible but are unable to complete the renewal process. Since states began redeterminations, millions of people have been disenrolled from the program. While the limited data available on disenrollments by race and ethnicity do not point to racial and ethnic disparities in disenrollment rates, because Hispanic, Black, AIAN and NHOPI people are more likely than their White counterparts to be covered by Medicaid, they are likely disproportionately affected by the unwinding. Some individuals disenrolled from Medicaid will move to other sources of coverage, including Marketplace coverage. However, others will become uninsured. As such, the unwinding could potentially widen racial and ethnic disparities in coverage going forward.

Efforts to prevent coverage losses and further close coverage disparities are important for addressing longstanding racial disparities in health. Beyond coverage, it also will be important to address other inequities within the health care system and across the broad range of social and economic factors that drive health.

The coverage gains observed between 2019 and 2022 largely reflect policies adopted during the pandemic to stabilize coverage in Medicaid and enhance subsidies to purchase Marketplace coverage. Specifically, provisions in the Families First Coronavirus Response Act (FFCRA), enacted at the start of the pandemic, prohibited states from disenrolling people from Medicaid during the Public Health Emergency in exchange for enhanced federal funding. Coverage gains also likely reflected enhanced ACA Marketplace subsidies made available by the American Rescue Plan Act (ARPA) and renewed for another three years in the Inflation Reduction Act of 2022 (IRA), boosted outreach and enrollment efforts, a Special Enrollment Period for the Marketplaces provided in response to the pandemic, and low Marketplace attrition, Additionally, in 2019, the Biden Administration reversed changes the Trump Administration previously made to public charge immigration policies that had increased reluctance among some immigrant families to enroll in public programs, including health coverage.

Coverage disparities have persisted, and in some cases widened, over time even with recent gains and the large earlier gains in coverage under the ACA. For example, in 2010, the uninsured rate for AIAN people was 2.5 times higher than the uninsured rate for White people; however, in 2022, the uninsured rate for AIAN people had increased to 2.9 times higher than the rate for White people. Similarly, the Hispanic uninsured rate grew from 2.5 to 2.7 times higher than the rate for White people from 2010 to 2022, while Black people remained 1.5 times more likely to be uninsured than White people.

Among the total nonelderly population, uninsured rates in states that have not expanded Medicaid are higher than rates in expansion states across most racial and ethnic groups as of 2022 (Figure 3). The differences in coverage rates between Black and Hispanic people compared with White people are larger in non-expansion states compared with expansion states. However, the relative risk of being uninsured for Black, Hispanic, and Asian people compared with White people is similar in expansion and non-expansion states. For example, nonelderly Hispanic people are roughly 2.6 times as likely as nonelderly White people to lack coverage in both expansion and non-expansion states. Uninsured rates for AIAN people are similar in expansion and non-expansion states. Overall, the differences in coverage by expansion status are primarily driven by differences in coverage rates among nonelderly adults. However, White, Hispanic, Black, Asian, and NHOPI children in non-expansion states also are more likely to be uninsured than those in expansion states. For example, 23.8% of NHOPI children in non-expansion states are uninsured compared to 7.6% of NHOPI children in expansion states.

There are opportunities to increase coverage by enrolling eligible people in Medicaid or Marketplace coverage, but eligibility varies across racial and ethnic groups, and many remain ineligible for assistance. Overall, six in ten people who were uninsured in 2022 were eligible for financial assistance either through Medicaid or through subsidized Marketplace coverage, while the remaining four in ten were not eligible because they fell in the Medicaid coverage gap in states that have not expanded Medicaid, they were deemed to have access to an affordable Marketplace plan or offer of employer coverage, or they were ineligible due to their immigration status. However, the share of the remaining uninsured eligible for assistance varied by race and ethnicity. For example, nonelderly uninsured Black were people more likely than their White counterparts to fall in the coverage gap in states that have not expanded Medicaid, and uninsured nonelderly Hispanic and Asian people were less likely than White people to be eligible for coverage options, in part, reflecting higher shares of noncitizens who face immigrant eligibility restrictions among these groups (Figure 4).

Uninsured nonelderly Hispanic, NHOPI, and Asian people are less likely than their White counterparts to be eligible for coverage because they include larger shares of noncitizens who are subject to eligibility restrictions for Medicaid and Marketplace coverage (Figure 6). Lawfully present immigrants face eligibility restrictions for Medicaid coverage, with many having to wait five years after obtaining lawful status before they are eligible to enroll in Medicaid. Undocumented immigrants are not eligible to enroll in Medicaid and are prohibited from purchasing coverage through the Marketplaces.

Policies implemented amid the COVID-19 pandemic helped stabilize coverage and contributed to gains in coverage during this period, but the unwinding of the Medicaid continuous enrollment provision could reverse these gains and widen disparities in coverage. The coverage gains experienced during the COVID-19 pandemic were largely driven by an increase in Medicaid coverage, which offset declines in employer-sponsored coverage. As noted, temporary continuous enrollment provisions stabilized Medicaid coverage during the PHE, contributing to increases in enrollment. Additionally, the temporary enhanced subsidies for Marketplace coverage provided under ARPA, which were extended through 2025 under the IRA, also contributed to coverage gains. However, even with these recent gains, disparities in coverage remain and could widen amid the unwinding of the Medicaid continuous enrollment requirement. Since the Medicaid continuous enrollment provision ended in March 2023, millions of people have been disenrolled. While the limited data available on disenrollments by race and ethnicity do not point to disparities in disenrollment rates, Hispanic, Black, AIAN and NHOPI people are likely disproportionately affected by the unwinding since they are more likely to be covered by Medicaid compared with their White counterparts. Many people who have been disenrolled from Medicaid could find low-cost coverage on the ACA Marketplaces, including, in some cases, coverage with a zero (or near-zero) monthly premium requirement. However, others may become uninsured. In focus groups, adults who were disenrolled from Medicaid reported losing coverage for a variety of reasons, including because they were no longer eligible; however, some believed they were still eligible and did not know why they were disenrolled. Many reported facing communication problems with their Medicaid agencies, and some who were disenrolled indicated that they faced gaps in coverage before reenrolling in Medicaid or became uninsured, which contributed to high out-of-pocket costs and difficulties accessing care that negatively impacted their health.

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