Health Policy$ense

The Affordable Care Act and Minority Health: Part II (Medicaid)

As the Affordable Care Act’s health insurance marketplaces begin their second year of open enrollment, LDI examines the current and potential impact of the ACA on the health of minority populations. This second post of a five-part series describes the benefits and shortfalls of the Medicaid expansion.

As originally passed, the ACA included a national expansion of Medicaid eligibility to 138% of poverty. However, the Supreme Court made expansion optional, and thus far, 28 states have decided to expand their programs. Although millions have gained coverage under the expansion, as many as four million uninsured people remain in the “coverage gap.” As shown below, they earn too little to be eligible for subsidies on the health insurance marketplaces, and they fall outside of their state’s present Medicaid eligibility limits.


People left in the gap are disproportionately racial and ethnic minorities. According to the Kaiser Family Foundation, 44% of uninsured adults in the coverage gap are White non-Hispanics, 24% are Hispanic, and 26% are Black. While some of this distribution reflects the level of uninsurance among minority groups, it also reflects the racial composition of the states that have not expanded Medicaid (Texas and Florida, for example).

The Urban Institute recently modeled the effects that the ACA would have in 2016 under conditions of partial and full Medicaid expansion. The results vividly illustrate the impact of both the ACA and the Supreme Court decision on minority coverage.

The authors explain:

Uninsurance rates are projected to fall for each racial/ethnic group with current Medicaid expansion decisions under the ACA. This narrows racial and ethnic coverage differences between whites and each minority group, except for blacks. This is because a disproportionately large share of blacks lives in nonexpansion states. If all states were to expand their Medicaid programs, uninsurance rates are projected to fall further for all racial and ethnic groups, with blacks experiencing a marked reduction in uninsurance rates and a narrowing of the difference between black and white uninsurance rates.

Just having a Medicaid card does not assure access to care. The ACA tried to address concerns that there would not be enough providers to see new Medicaid patients in two ways: by temporarily increasing primary care payment rates, and by increasing funding to community health centers. Provider participation in Medicaid has been limited, in part, by reimbursement rates that were 59% of Medicare rates. The ACA included a provision that “bumped” Medicaid fees for primary care up to Medicare levels for the first two years, with full federal funding. The increase expired on Jan. 1, 2015, and most states chose not to continue the bump with state funds. The effect of this two-year increase on provider participation rates and access to care is not yet known.

Community health centers have long been safety net providers for the uninsured and for Medicaid enrollees. According to the Kaiser Family Foundation, in 2011, 39% of patients seen in community health centers were covered by Medicaid, and 36% were uninsured. The ACA provided $11 billion over five years in funding to build new CHCs and expand the capacity of existing CHCs, who see a disproportionate percentage of racial and ethnic minorities. This funding will expire at the end of this fiscal year.

Tomorrow we will continue our series by reviewing new models of health care delivery funded or encouraged by the ACA and their potential impact on minority health.