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Coverage Expansion
By Lisa Clemans-Cope, Genevieve M. Kenney, Matthew Buettgens, Caitlin Carroll, and Fredric Blavin
10.1377/hlthaff.2011.1086
HEALTH AFFAIRS 31,
NO. 5 (2012): 920930
2012 Project HOPE
The People-to-People Health
Foundation, Inc.
doi:
Lisa Clemans-Cope
(lclemans@urban.org) is a
senior research associate and
health economist at the Urban
Institutes Health Policy
Center, in Washington, D.C.
Genevieve M. Kenney is a
senior fellow at the Urban
Institutes Health Policy
Center.
Matthew Buettgens is a
senior research associate at
the Urban Institutes Health
Policy Center.
Caitlin Carroll is a research
assistant at the Urban
Institutes Health Policy
Center.
Fredric Blavin is a research
associate at the Urban
Institutes Health Policy
Center.
growing body of research has examined the likely effects of the Affordable Care Act of 2010 on health
insurance markets and coverage at
the national and state levels. According to estimates from the Congressional
Budget Office, under full implementation the
Affordable Care Act will reduce the number of
uninsured people by thirty-two million in 2019.1
Studies have examined how the laws effects
will be distributed by characteristics such as
geography, age, and income.2,3 However, no research has yet assessed its potential impact by
racial and ethnic group. This omission exists
even though some have advocated for coverage
expansions as a primary strategy for reducing
racial and ethnic differentials in health.4
920
H e a lt h A f fai r s
M AY 2 0 1 2
31 : 5
Large differentials in health insurance coverage by racial and ethnic group are a long-standing feature of coverage in the United States.5 In
2010, uninsurance rates among the nonelderly
were 2.6 and 1.8 times higher for Hispanics and
blacks, respectively, than for non-Hispanic
whites.6 Ample evidence demonstrates that uninsured people are more likely than their insured
counterparts to have unmet medical needs and
worse health outcomes.7,8 In addition, differential rates of health insurance coverage by race
and ethnicity are associated with differences in
access to health care related to factors such as
citizenship, income, and employers offers of
health insurance.4,5,9
Assuming that the US Supreme Court upholds
the constitutionality of the Affordable Care Act,
the law is expected to expand coverage substantially, but an estimated 2326 million people are
expected to remain uninsured.1,10 The extent to
which the Affordable Care Act might reduce
existing differentials in coverage is unknown.
A recent study of the Massachusetts 2006 reform initiative, upon which the Affordable Care
Act was modeled, underscores the complexity of
the issue.11 That studys authors found that the
state law greatly reduced the rate of uninsurance
among racial and ethnic minority groups but did
not reduce racial and ethnic differentials in coverage or access to care, in part because of comparable or larger improvements among nonminorities and the overall low baseline rate of
uninsurance in the state.
pay at least 2 percent of their incomes for premiums. That requirement may constitute a financial barrier to becoming insured, compared
with equivalently poor citizens or lawfully residing immigrants who have been in the country for
more than five years, who will be eligible for
Medicaid with low or no premium.
This analysis presents estimates of the effects
of the Affordable Care Act on coverage for the
nonelderly US population by race and ethnicity.
We address three key issues.
First, to what extent will coverage expansions
under the Affordable Care Act reduce racial and
ethnic differentials in coverage? Second, how do
patterns of coverage change under the Affordable Care Act across racial and ethnic groups?
Third, do the reasons for being uninsured after
implementation of the Affordable Care Act differ
by race and ethnicity?
Our analysis shows that the Affordable Care
Act has the potential to reduce racial and ethnic
coverage differentials substantially. However,
coverage gains will depend heavily on the intensity of efforts to enroll eligible people into Medicaid and CHIP and exchange coverage, and on
penalty and subsidy levels and exemptions. Policy decisions at the national, state, and local levels in the years leading up to full implementation
of the law will have an impact on coverage gains.
31:5
H e a lt h A f fai r s
921
Coverage Expansion
Care Act was implemented and then simulated
the acts main coverage provisions as if they had
been fully implemented in 2011. Our approach
differs from that of the Congressional Budget
Office, which provided ten-year estimates.
The model simulated the responses of individuals and employers to policy changes. It implicitly captured differential price responsiveness
across demographic characteristics such as race
and ethnicity. The underlying survey data captured differences across racial and ethnic groups
in baseline coverage decisions and in other factors that are key to behavioral responses under
reform, such as health care spending and employment.
Medicaid and CHIP participation ratesdefined as the ratio of eligible individuals enrolled
in the programs to that number of individuals
plus uninsured eligible individualswere also
calibrated by demographic characteristics and
observed patterns, and thus varied across racial
and ethnic groups.16 Participation rates after reform were notably higher for all racial and ethnic
groups compared to preAffordable Care Act
baseline rates.
The application of the individual mandate to
dependents has not been fully addressed in regulations. Because this could have a significant
effect on our estimates, we examined the sensitivity of the results to two alternative interpretations. (See the online Technical Appendix for
further details on the model, assumptions, and
differences between the estimates presented
here and previous studies.)17
Racial And Ethnic Groups Changes in coverage were examined for the following racial and
ethnic groups: white non-Hispanicreferred to
as white; black or African American nonHispanicreferred to as black; Hispanic; and
Asian, Native Hawaiian or other Pacific Islander,
American Indian or Alaskan Native, or other
racereferred to as Asian/other.
Hispanic ethnicity was identified using responses to the Current Population Survey question, Are you Spanish, Hispanic, or Latino?
Respondents designating multiple races were included in the Asian/other group. The distribution
of races within the Asian/other group category
was as follows: Asian/Pacific Islander (67.4 percent), multiracial (23.2 percent), and American
Indian/Aleutian/Eskimo (9.5 percent).
States For Analysis To identify states for
which our analyses were most relevant, we indicated the ten states with the largest nonelderly
black populations and the ten states with the
largest nonelderly Hispanic populations, using
estimates from the 2009 American Community
Survey.
Uninsured Groups Those predicted to be un922
H e a lt h A f fai r s
M AY 2 0 1 2
31 : 5
ethnicity. Although the existence of such benchmarks might lead to slightly different results, the
existing elasticities do vary by factors such as
income and current health coverage that are correlated with race and ethnicity. Also, the models
calibration process preserved differences in reported choices at baseline, such as take-up of
public coverage. Thus, our model implicitly included differential enrollment rates under the
Affordable Care Act across a broad range of demographic characteristics, including race and ethnicity.
Fifth, our results were also sensitive to the
modeling of the coverage requirement.16
Sixth, additional assumptions regarding specific aspects of the Affordable Care Act were
made to simulate the laws impact, as described
above.
Seventh and last, the model also assumed uniform implementation of the Affordable Care Act
in all states and, in particular, assumed that risk
adjustment between coverage inside and outside
of the exchanges was highly effective and that
markets were well regulated in all states. To the
extent that some states fall short, particularly in
states that include a disproportionately large
share of blacks and Hispanics, our estimates
may overstate coverage gains for blacks and Hispanics.
Exhibit 1
US Population Younger Than Age 65 Who Were Uninsured Before The Affordable Care Act And Will Be Uninsured After The
Acts Implementation, By Race And Ethnicity
Insurance status
Population below age 65 (millions)
Uninsured before the ACAc
Total
268.8
Whitea
166.4
Blacka
34.18
Hispanic
48.1
Asian/
other a,b
20.1
Number (millions)
Percent uninsured
Differential with whites
Uninsured under the ACA
50.3
18.7%
d
23.1
13.9%
d
7.4
21.6%
7.7%
16.0
33.3%
19.4%
3.7
18.5%
4.6%
Number (millions)
Percent uninsured
Differential with whites
26.4
9.8%
d
10.8
6.5%
d
3.4
9.8%
3.3%
10.1
21.1%
14.6%
2.1
10.4%
3.8%
23.8
8.9
47.4%
12.3
7.4
53.1%
4.0
11.8
54.6%
5.9
12.2
36.6%
1.6
8.2
44.1%
4.4
57.3%
4.8
24.7%
0.8
16.8%
Change in uninsurance
Number (millions)
Percentage-point change in uninsurance rate
Percent change in uninsurance rate
d
d
SOURCE Urban Institute analysis, Health Insurance Policy Simulation Model, 2011. aDoes not include those who indicate Hispanic
ethnicity. bThe Asian/other category is Asian/Pacific Islander (67.4 percent), multiracial (23.2 percent), and American Indian/
Aleutian/Eskimo (9.5 percent). cBaseline preAffordable Care Act (ACA) models coverage under current conditions. This
simulation estimates coverage under the key coverage-related components of HR 3590, the Patient Protection and Affordable
Care Act, and HR 4872, the Health Care and Education Reconciliation Act of 2010. Reforms were modeled as if they were fully
implemented in 2011, and estimates are for that single year. This exhibit shows coverage for nonelderly people only, including
some who are undocumented immigrants. dNot applicable.
M AY 2 0 1 2
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923
Coverage Expansion
Study Results
Baseline Uninsurance Rates In our preAffordable Care Act baseline estimates that modeled coverage under current conditions, US
black and Hispanic racial and ethnic groups
had much higher rates of uninsurance (21.6 percent and 33.3 percent, respectively) compared to
US whites (13.9 percent; Exhibit 1). After full
implementation of the Affordable Care Act,
blacks and Hispanics are projected to experience
large reductions in uninsurance but nevertheless
to remain more likely to be uninsured than
whites.
Absolute Reductions In Uninsurance
Blacks and Hispanics are projected to have the
largest absolute reductions in uninsurance rates
under the Affordable Care Act compared to other
racial and ethnic groups. The drop is 11.8 percentage points for blacks, corresponding to
4.0 million fewer people uninsured, and 12.2 percentage points for Hispanics, corresponding to
5.9 million fewer people uninsured (Exhibit 1).
In comparison, the uninsurance rate among
whites is expected to fall by 7.4 percentage
points, corresponding to 12.3 million fewer people uninsured, which is large relative to the baseline uninsurance rate for whites but much
smaller than the drops that are projected for
blacks and Hispanics.
Proportional Changes In Uninsurance The
preAffordable Care Act baseline uninsurance
rates varied greatly by race and ethnicity. Thus,
the largest percentage-point drops in uninsurance do not correspond to the largest relative
reductions in uninsurance levels. For example,
Hispanics are projected to have the largest percentage-point decrease in their uninsurance
rate, but they also had the highest rate of uninsurance at the baseline. As a result, the relative
reduction in uninsurance for Hispanics36.6
percentis projected to be smaller than for
whites and blacks53.1 percent and 54.6 percent, respectively. This result was driven in part
by the differential treatment of immigrants,
undocumented and legal, under the Affordable
Care Act, which disproportionately affects coverage gains for Hispanics, as discussed below.
The black-white differential in uninsurance
rates is predicted to shrink by 57.3 percent, from
7.7 percentage points to 3.3 percentage points.
The Hispanic-white differential is projected to be
more persistent, falling by 24.7 percent, from
19.4 percentage points to 14.6 percentage points.
These patterns, including the high uninsurance rate of 21.1 percent projected among Hispanics under the Affordable Care Act, can be
explained by several factors, which we examine
in turn below.
Sources Of Coverage The Affordable Care
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Health Affai rs
M AY 20 1 2
31 : 5
Act is projected to increase rates of health insurance coverage across all racial and ethnic groups
as a result of increased access to free or subsidized health insurance through Medicaid and
CHIP and the new subsidies available for coverage in the exchanges (Exhibit 2). Hispanicsthe
group with the lowest rate of coverage in the prebaseline periodhad the largest projected percentage increase in coverage rates under the Affordable Care Act (18.2 percent), compared to
blacks (15.1 percent) and whites (8.6 percent).
The largest coverage gains under the Affordable Care Act can be attributed to Medicaid and
CHIP coverage. Disproportionately large gains
in coverage through these programs are projected among blacks: The share of blacks covered
by the two programs is projected to increase by
8.4 percentage points to 36.5 percent, compared
to increases of 5.7 percentage points among
whites and 6.3 percentage points among Hispanics.
Under the Affordable Care Act, the most prevalent insurance type across all racial and ethnic
groups continues to be employer-sponsored coverage. Whites high rates of employer-based coverage are projected to increase only by 0.9 percentage point to 65.6 percent under the
Affordable Care Act.
The gains in the rate of employer-based coverage among blacks and Hispanics are projected to
be somewhat higher2.0 and 3.1 percentage
points, respectivelymainly because of increased access to employer plans offered
through the exchanges. However, the rates of
employer-based coverage among Hispanics
and blacks, at 45.4 and 38.1 percent respectively,
are still projected to be well below rates for
whites.
Additional small gains in the rate of nongroup
coverage are projected across the board but are
largest for Hispanics, 2.8 percentage points,
largely as a result of enrollment in the nongroup
exchanges.
Of the estimated 26.4 million individuals projected to be uninsured after the implementation
of the Affordable Care Act, those eligible for
Medicaid and CHIP, but who remain unenrolled,
constitute the single largest group, at 35.7 percent (Exhibit 3). This eligible-but-unenrolled
group includes 58.8 percent of the blacks who
we estimate will remain uninsured under the
Affordable Care Act, which is a higher proportion than found in the other racial and ethnic
groups examined.
Undocumented immigrants are projected to
constitute the second-largest group among the
uninsured. They account for 25.7 percent of the
total uninsured. Hispanics constitute the vast
majority82.2 percentof undocumented im-
Exhibit 2
Insurance Coverage Before The Affordable Care Act And Under The Affordable Care Act, And Changes In Coverage, By Race
And Ethnicity
Source of coverage
Baseline pre-ACAc
Insured
Medicaid and CHIPd
Medicare and other public coveragee
Employer-sponsored insurance
Nongroup insurance
Uninsured
Population
below
age 65
Whitea
81.3%
16.8
3.2
56.0
5.4
18.7
86.1%
11.3
3.5
64.7
6.6
13.9
93.5%
16.9
3.5
65.6
4.2
61.4
7.5
6.5
1.0
6.5
8.9
6.1
1.5
1.2
8.9
7.4
5.7
0.9
0.8
7.4
Increase in rate
10.9%
8.6%
Hispanic
Asian/
othera,b
78.4%
28.0
4.2
43.4
2.7
21.6
66.7%
27.3
1.6
35.0
2.8
33.3
81.5%
17.7
2.8
55.1
5.8
18.5
90.2%
36.5
4.2
45.4
2.2
43.2
4.1
3.6
0.5
9.8
78.9%
33.7
1.6
38.1
3.0
35.1
5.6
4.6
1.0
21.1
89.6%
23.3
2.8
57.0
3.3
53.8
6.5
5.3
1.2
10.4
Blacka
11.8
8.4
2.0
1.4
11.8
12.2
6.3
3.1
2.8
12.2
15.1%
8.2
5.6
1.9
0.7
8.2
18.2%
10.0%
SOURCE Urban Institute analysis, Health Insurance Policy Simulation Model, 2011. aDoes not include those who indicate Hispanic
ethnicity. bThe Asian/other category is Asian/Pacific Islander (67.4 percent), multiracial (23.2 percent), and American Indian/
Aleutian/Eskimo (9.5 percent). cBaseline preAffordable Care Act (ACA) models coverage under current conditions. For details
about the simulation, see Exhibit 1 notes. dThose with dual Medicaid/Medicare coverage are included in the Medicaid and CHIP
(Childrens Health Insurance Program) insurance type. eThose with Medicare and other public insurance at pre-ACA baseline are
assumed to remain in this coverage after the ACA.
Exhibit 3
Uninsured US Population Younger Than Age 65 Under The Affordable Care Act, By Eligibility Criteria And Race And Ethnicity
All nonelderly
Whitea
Millions
Millions
Percent
Blacka
Percent
Millions
Asian/otherb
Hispanic
Percent
Millions
Percent
Millions
Percent
9.4
35.7
4.2
38.4
2.0
58.8
2.6
25.3
0.7
35.0
6.8
25.7
0.4
3.3
0.3
7.4
5.6
55.0
0.6
29.0
2.2
8.5
1.4
12.8
0.2
6.0
0.4
4.4
0.2
9.6
4.2
3.8
26.4
15.8
14.4
100.0
2.5
2.5
10.8
22.6
22.9
100.0
0.5
0.4
3.4
16.1
11.7
100.0
0.9
0.7
10.1
9.0
6.4
100.0
0.3
0.3
2.1
13.6
12.9
100.0
SOURCE Urban Institute analysis, Health Insurance Policy Simulation Model, 2011. aDoes not include those who indicate Hispanic ethnicity. bThe Asian/other category is
Asian/Pacific Islander (67.4 percent), multiracial (23.2 percent), and American Indian/Aleutian/Eskimo (9.5 percent). cBaseline preAffordable Care Act (ACA) models
coverage under current conditions. For details about the simulation, see Exhibit 1 notes. People reporting multiple races are categorized as other race.
M AY 2 0 1 2
31:5
H e a lt h A f fai r s
925
Coverage Expansion
migrants projected to remain uninsured under
the Affordable Care Act.24 In fact, 55.0 percent of
Hispanics who remain uninsured under the Affordable Care Act are projected to be undocumented immigrantsa far higher share than
among the other racial and ethnic groups.
Exemptions From The Coverage Requirement Among all who are projected to remain
uninsured under the Affordable Care Act,
15.8 percentincluding a disproportionately
large share of whites, 22.6 percentwould not
be exempt from the coverage requirement and
would be obligated to pay penalties for being
uninsured, despite being eligible for subsidized
coverage in the exchanges (Exhibit 3).
Another 14.4 percent of the uninsuredagain,
a disproportionately large share of whites,
22.9 percentwould be bound by the coverage
requirement and would be subject to penalties
but not eligible for subsidized coverage in the
exchanges, largely because their incomes exceed
400 percent of the federal poverty level.
Only 8.5 percent of the uninsured would be
ineligible for public coverage and exempted
from the coverage requirement and penalty
payments.
Roles Of The States These estimates were
predicated on enrollment in Medicaid and CHIP,
subsidized exchange coverage, and other forms
of coverage under the Affordable Care Act as
modeled in the simulation. However, within
broad federal guidelines in the reform law, states
will have considerable latitude in how coveragerelated programs are structured and implemented, which will lead to variation in enrollment in different forms of coverage. Given that
Discussion
National Policy Implications Estimates from
our microsimulation model suggest that the Affordable Care Act will greatly expand health insurance coverage for all racial and ethnic groups,
largely because of increased access to free or
subsidized health insurance through Medicaid
and CHIP and the new exchanges. The largest
reductions in uninsurance rates are predicted
among blacks and Hispanics. Thus, the Affordable Care Act is poised to greatly reduce the coun-
Exhibit 4
Ten States With The Largest Black Populations And Hispanic Populations Younger Than Age 65 In 2009
Black population
Hispanic population
Percent
below
age 65
Cumulative
total percent
below age 65
State
Millions
State
Millions
Percent
below
age 65
Cumulative
total percent
below age 65
GA
NY
2.6
2.5
8.0
7.6
8.0
15.6
CA
TX
12.8
8.5
28.4
18.9
28.4
47.3
TX
FL
2.5
2.5
7.6
7.5
23.1
30.6
FL
NY
3.5
3.0
7.8
6.7
55.2
61.8
CA
NC
1.9
1.7
5.7
5.2
36.3
41.6
AZ
IL
1.9
1.9
4.2
4.2
66.1
70.2
IL
MD
VA
1.6
1.5
1.3
5.0
4.4
4.0
46.5
51.0
54.9
NJ
CO
NM
1.3
0.9
0.8
3.0
2.1
1.8
73.2
75.3
77.1
LA
Total
1.3
19.3
3.9
58.8
58.8
58.8
GA
Total
0.8
35.5
1.7
78.9
78.9
78.9
SOURCE 2009 American Community Survey (ACS). NOTES Black does not include people who indicate Hispanic ethnicity. Population is
restricted to noninstitutionalized civilians younger than age 65. Race/ethnicity is based on self-identified ACS response.
926
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MAY 2 012
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31 : 5
927
Coverage Expansion
vide care that goes beyond the requirement
under federal law to screen and stabilize all people with emergency medical conditions.32
The most important impact of the Affordable
Care Act on undocumented immigrants may be
to provide coverage for other family members
who are documented. Indeed, millions of families have mixed immigration status, including
many families with citizen children.33 However,
encouraging take-up of Medicaid and CHIP or of
exchange subsidies among eligible people in
families with mixed immigration status may require targeted outreach efforts to address fears
that the immigration status of a family member
could be adversely affected by program participation.34
Conclusion
The Affordable Care Act appears poised to shrink
the countrys long-standing racial and ethnic difThis research was funded in part by the
Annie E. Casey Foundation. Any opinions
and conclusions expressed herein are
those of the authors and do not
necessarily represent the views of the
NOTES
1 Congressional Budget Office. Selected CBO publications related to
health care legislation, 20092010
[Internet]. Washington (DC): CBO;
2010 Dec 22 [cited 2012 Feb 6].
Available from: http://www.cbo
.gov/publication/21993
2 Buettgens M, Garrett B, Holahan J.
America under the Affordable Care
Act. Washington (DC): Urban Institute; 2010.
3 Buettgens M, Holahan J, Carroll C.
Health reform across the states: increased insurance coverage and
federal spending on the exchanges
and Medicaid [Internet]. Washington (DC): Urban Institute; 2011 Mar
[cited 2012 Apr 3]. (Timely Analysis
of Immediate Policy Issues). Available from: http://www.urban.org/
uploadedpdf/412310-HealthReform-Across-the-States.pdf
4 Lillie-Blanton M, Hoffman C. The
role of health insurance coverage in
reducing racial/ethnic disparities in
health care. Health Aff (Millwood).
2005;24(2):398408.
5 Smedley BD, Stith AY, Nelson A,
editors. Unequal treatment: confronting racial and ethnic disparities
in health care. Washington (DC):
National Academies Press; 2003.
6 DeNavas-Walt C, Proctor BD, Smith
JC. Income, poverty, and health insurance coverage in the United
States: 2010. Washington (DC):
Census Bureau; 2011.
928
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15
16
17
18
19
20
21
HHS_Plan_complete.pdf
26 Koh HK, Graham G, Glied SA.
Reducing racial and ethnic disparities: the action plan from the Department of Health and Human
Services. Health Aff (Millwood).
2011;30(10):182229.
27 Zheng W, Schimmele CM. Racial/
ethnic variation in functional and
self-reported health. Am J Public
Health. 2005;95(4):7106.
28 Nazroo JY, Falaschetti E, Pierce M,
Primatesta P. Ethnic inequalities in
access to and outcomes of healthcare: analysis of the Health Survey
for England. Epidemiol Community
Health. 2009;63:102227.
29 National Immigration Law Center.
How are immigrants included in
health care reform? [Internet].
Washington (DC): NILC; 2010 Apr
[cited 2012 Mar 21]. Available from:
http://nilc.org/immigrantshcr.html
30 Centers for Medicare and Medicaid
Services. State Childrens Health Insurance Program; eligibility for prenatal care and other health services
for unborn children. Fed Regist.
2002 Oct 2;67(191):61956.
31 Although the Affordable Care Act
Lisa Clemans-Cope
is a senior research
associate and
health economist at
the Urban Institute.
Genevieve M.
Kenney is a senior
fellow at the Urban
Institute.
MAY 2 012
3 1:5
Health Affairs
929
Coverage Expansion
analysis of changes in health
insurance coverage. He holds a
doctorate in mathematics from the
University at Buffalo, State
University of New York.
Matthew Buettgens
is a senior research
associate at the
Urban Institute.
930
H e a lt h A f fai r s
M AY 2 0 1 2
Caitlin Carroll is a
research assistant
at the Urban
Institute.
31 : 5
Fredric Blavin is a
research associate
at the Urban
Institute.