Racial and Ethnic Disparities in Health Insurance Coverage

Health insurance coverage varies substantially between racial and ethnic groups in the United States. Compared to non-Hispanic whites, African Americans and people of Hispanic origin had persistently lower insurance coverage rates at all ages. This article describes age- and group-specific dynamics of insurance gain and loss that contribute to inequalities found in traditional cross-sectional studies. It uses the longitudinal 2008 Panel of the Survey of Income and Program Participation (N=114,345) to describe age-specific patterns of disparity prior to the Affordable Care Act (ACA). A formal decomposition on increment-decrement life-tables of insurance gain and loss shows that coverage disparities are predominately driven by minority groups’ greater propensity to lose the insurance that they already have. Uninsured African Americans were faster to gain insurance than non-Hispanic whites but their high rates of insurance loss more than negated this advantage. Disparities from greater rates of loss among minority groups emerge rapidly at the end of childhood and persist throughout adulthood. This is especially true for African Americans and Hispanics and their relative disadvantages again heighten in their 40s and 50s.

Racial and ethnic disparities in health insurance coverage rates account for a sizable share of the difference in access to health care (Lillie-Blanton and Hoffman 2005). African American and Hispanic individuals in the United States are more likely to be uninsured throughout adulthood than non-Hispanic individuals (Kirby and Kaneda 2010). Without insurance, people face considerable barriers in receiving health services. Many health care providers require insurance coverage from their patients or charge a prohibitively high fee (Himmelstein et al. 2005; Institute of Medicine 2002; Kasper et al. 2000; Nelson et al. 1999; Zuekas & Weinick 1999). Inconsistent or unstable insurance coverage also have negative consequences. Patients who frequently change health care providers due to insurance loss or change experience more interruptions in their care and are less likely to establish ongoing relationships with their physicians.

Efforts to decrease health disparities between racial and ethnic groups must identify and reduce factors that cause African Americans, Hispanics, and Asians to have greater uninsurance rates relative to non-Hispanic whites. Prior literature has identified socioeconomic characteristics—income, employment, citizenship, and language—associated with uninsurance that are more prevalent in minority populations. The literature focuses on these factors as barriers to acquiring health insurance. Few studies acknowledge that high ununinsurance rates can occur in populations from high rates of insurance loss. Even fewer studies, if any, account for how the changing dynamics of gaining and losing insurance across the life-course contributes to overall disparities in insurance coverage rates.

Identifying the factors that are creating disparities at various ages is especially important with policy changes that affect people differently by age. For example, the recent Dependent Coverage Mandate of the Affordable Care Act (ACA) now allows parents to cover their children until age 26 regardless of their marriage, residential, and employment statuses. This has improved coverage among 19 to 25 year olds (Simon et al. 2015) and more so for children of parents who already had private coverage.

This paper examines how differences in rates of insurance loss and gain contribute to coverage inequalities between Non-Hispanic whites, African Americans, Hispanics, and Asians. The analysis adapts a multiple increment-decrement life table approach to demonstrate how age-specific probabilities of gaining and losing insurance leads to disparities across the life course. From life-tables, I construct synthetic cohorts and compare their insurance coverage. I decompose between-group coverage differences into rates of insurance gains and losses controlling for differential mortality to identify whether lower rates of gain or excess rates of loss leads to coverage inequality at each age. Specifically, I address the following research questions.

1. How much of between-race/ethnic disparities are explained by differences in rates of insurance gain? How much of it is explained insurance loss?
2. How do the dynamics of losing and gaining insurance contribute to the disparity across the life-course? At which ages do gains or losses exacerbate disparities?

Prior to the ACA, about 19 percent of the non-elderly US population was uninsured (Clemens-Cope et al. 2012) but the prevalence of uninsurance differed substantially by race or ethnic group. About twenty-percent of African Americans were uninsured. In comparison non-Hispanic whites had an uninsurance rate of about thirteen percent (KFF 2013). About 18 percent of Asians were not insured. Hispanics had the highest prevalence of uninsurance; about a third of Hispanics living in the United States were without health insurance. Researchers cite low income and propensity to work in jobs with no health benefits as the primary causes for high uninsurance rates among African Americans (Institute of Medicine 2003). Studies say that these low-income jobs pay too much to qualify for public assistance but pay too little to be able to afford private insurance policies leaving individuals and families to live without coverage (Edin and Kefalas 2011). Lack of job-based insurance is also a reason why Hispanics have high uninsurance rates. In addition, language barriers and immigration rules that prevent undocumented and recent immigrants from enrolling in public plans prevent Hispanics from getting insurance (DeNavas-Walt et al. 2013; Goldman, Smith, and Sood 2005). Low take-up of public insurance has been cited along with employment in jobs without health benefits as the cause of higher uninsurance rates among Asians (Institute of Medicine 2003).

The ACA attempts to address these issues. It is offering subsidies to help lower-income working families without employer benefits afford private insurance plans. Medicaid aims to expand eligibility beyond children and the medically needy to reduce uninsurance rates among low-income, healthy adults. Outreach in multiple languages aims to lower linguistic barriers to enrolling in both public and private insurance among Hispanics and Asians. The ACA has also expanded the age of eligibility of a dependent to 26 regardless of student, employment, and marital status to reduce uninsurance as young people transition into adulthood. It has also barred insurers from denying coverage based on preexisting conditions. These changes are expected to increase enrollment among racial and ethnic minorities (Clemans-Cope et al. 2012; Holahan and McGrath 2013). Recent studies indeed show greater declines in coverage inequality between non-Hispanic white and minority groups (CDC 2015). Cross-sectional evaluations of the reform’s impact are informative but can obscure differences in how fast people gain or lose their insurance plans. The life-table models in this paper shows that the predominant factor—quicker to lose insurance or slower to gain coverage—that leads to racial and ethnic disparities differ widely by age and group. The findings demonstrate a need for a more dynamic approach in examining coverage inequality.