Medicaid Expansion Tied to Higher Coverage Gains, Fewer Disparities

While insurance coverage rates improved for Black, Hispanic, and White adults during the first two years of the COVID-19 pandemic, the gains were more significant in states that had implemented Medicaid expansion, according to an issue brief from the Commonwealth Fund.

The Commonwealth Fund used data from 2013 to 2021 from the American Community Survey and the Behavioral Risk Factor Surveillance System to update its previous analyses of coverage and access inequities for Black and Hispanic adults in the US.

The uninsured rate declined for Black (-15.7 percentage points), Hispanic (-10.9 percentage points), and White adults (-6.3 percentage points) between 2013 and 2021.

These changes helped reduce coverage disparities among the racial and ethnic groups. The coverage gap between White and Black adults fell from 9.9 percentage points to 5.3 points, and the gap between White and Hispanic adults went from 25.7 percentage points to 16.3 points.

The largest coverage gains occurred between 2013 and 2016. However, the uninsurance rate continued falling between 2019 and 2021 following pandemic-related federal policies, including the continuous Medicaid eligibility provision and the enhanced premium subsidies in the Affordable Care Act (ACA) marketplace.

The uninsurance rate for Black adults declined by at least two percentage points in 14 states. The rate fell by 11 points in Nebraska, which expanded Medicaid in 2020. Southern states with large Black populations, including Virginia, North Carolina, and Florida, also saw significant coverage gains.

The uninsurance rate for Hispanic adults fell by at least two percentage points in 19 states, with notable gains in Florida and California. White adults saw coverage improvements in nearly all states, the brief found.

Coverage gains among the three racial and ethnic groups were driven by increased enrollment in Medicaid and individual market plans. Medicaid coverage gains were highest in states that had expanded Medicaid, while individual market gains were highest in non-expansion states.

The overall uninsured rate was lower in Medicaid expansion states. In expansion states, 9.1 percent of adults were uninsured in 2021, compared to 18 percent in non-expansion states.

Coverage disparities were also lower in states that expanded Medicaid. For example, the difference between Black and White adult uninsured rates was 3.3 percentage points in Medicaid expansion states and 5.7 points in non-expansion states. Similarly, the difference in the uninsured rate between Hispanic and White adults was 13.1 percentage points in expansion states and 21.4 in non-expansion states.

Another impact of Medicaid expansion was seen when researchers compared Virginia, an expansion state, to North Carolina, a non-expansion state. After Virginia expanded Medicaid in 2019, the uninsured rate for Black and White lower-income adults dropped by 10 to 11 percentage points. Meanwhile, the uninsured rates in North Carolina only fell modestly due to pandemic-related policy changes.

Medicaid expansion helped narrow the Black-White coverage disparity in Virginia from 6.1 percentage points to 2.9 points in 2021.

Twelve states had yet to expand Medicaid during the study period, which may have furthered racial disparities in coverage. Forty-four percent of low-income Black adults live in non-expansion states, including four states with high numbers of Black residents: Texas, Florida, Georgia, and North Carolina. In comparison, 30 percent of low-income white adults live in non-expansion states.

Adults living in Medicaid expansion states had fewer cost-related access barriers and were more likely to have a usual care provider. In addition, the differences in care access barriers and having a usual care provider were smaller between Black and White adults and Hispanic and White adults in expansion states.

If the 11 states remaining states implement Medicaid expansion, around half a million additional Black adults would gain health insurance coverage, the brief projected. In addition, the Black-White coverage disparity would fall to one percentage point.

As the end of the COVID-19 public health emergency nears, between 15 and 18 million beneficiaries are expected to lose Medicaid coverage. Policymakers should act accordingly to help minimize coverage losses, allow longer continuous eligibility, and permanently extend the enhanced premium subsidies beyond 2025.