Before the federal Affordable Care Act took effect, four in 10 Hispanic adults and greater than one in five African Americans in New Jersey lacked health insurance. By 2018, the uninsured rate had dropped to nearly 25% for Hispanics and was cut in half for black residents, to less than 11%.
The findings are from a study released today by the Commonwealth Fund, a national nonprofit dedicated to improving the U.S. health care system, particularly for underserved populations. Coverage also expanded among white individuals, but not as much as for minority residents.
While the Garden State was not alone in this trend, some populations here had coverage gains that bested the national averages, according to the study, which looked at data from 2013 through 2018. Across all states, uninsured rates fell from 40% to nearly 25% among Hispanic adults and from 24.4% to 14.4% for African Americans between the ages of 19 and 64. The rate for white adults dropped from 14.4% to 8.6% during this period.
This expansion in insurance coverage nationwide also made it easier for all populations to access care without worrying about the cost, with black and Hispanic residents showing the greatest bump, according to Commonwealth. And adults across the board were more likely to report they had a regular doctor, which experts consider an indicator of access.
Commonwealth researchers also found that states that embraced the Medicaid expansion permitted under the ACA — like New Jersey — saw greater gains in health equity, when compared with those states that did not choose to extend the public insurance program to cover more low-income residents.
More ACA reforms
The authors suggested during a teleconference Wednesday that additional ACA reforms now underway in New Jersey and other states could help continue these equity gains in years to come. This could become increasingly important, as Commonwealth found coverage growth has slowed significantly nationwide since 2016, which they attributed in part to Republican-led efforts to undermine the law.
“The Affordable Care Act’s coverage expansions have helped drive historic progress in reducing racial and ethnic gaps in health care, but we still have a long way to go,” said Commonwealth vice president Sara Collins, a co-author of the study. “Too many black and Hispanic adults are still unable to get health insurance or the health care they need, which contributes to inequitable health outcomes.”
“We know that coverage is the most important factor in people’s ability to access health care,” Collins said. “It is a necessary condition, but not the only condition when it comes to getting quality care,” she added, noting that black and Hispanic patients may still struggle to find a doctor who will accept Medicaid and face racial bias in their treatment, among other challenges.
Black and Hispanic residents have traditionally been insured at far lower rates than whites, according to Commonwealth, and are more likely to avoid getting medical treatment because of cost concerns and lack of a regular medical provider. Other research has shown minority populations are more likely to be born underweight, face higher rates of chronic disease and die prematurely, when compared to their white counterparts. In New Jersey, significant racial disparities in maternal health have attracted public attention recently.
Addressing these disparities was a major goal of the ACA, or Obamacare, which took full effect in 2014. The law enabled New Jersey to add 500,000 people to its Medicaid program and permitted another 300,000 residents to access commercial plans with federal subsidies to offset the cost. Millions more benefited from regulations designed to ensure quality coverage.
Some two dozen other states also grew Medicaid, and most saw positive results, according to Commonwealth. As of 2018, black adults in these expansion states were more likely to have insurance (with 10.1% uninsured) than white adults in states that didn’t enhance Medicaid (12.3%), the study notes. Hispanics saw coverage gains in both groups, but remain uninsured at significantly higher rates (19.1% in expansion states; 34.3% in states that didn’t expand Medicaid).
“This is wonderful, good news,” Linda Schwimmer, president and CEO of the New Jersey Health Care Quality Institute, said of the Garden State data. When it comes to certain diseases, she said, “the greatest predictor of (survivability) is insurance coverage.”
However, the coverage gains recorded after 2013 start to flatten out nationwide in 2016, in both expansion and nonexpansion states, Commonwealth found. Collins said this reflects the fact that fewer states expanded Medicaid after that point — a trend that could now be turning, as Nebraska and other states seek to build out their programs in coming years. She attributes the slowdown in Medicare expansion to political changes in Congress that led to efforts to undermine the law, and regulatory changes under the Trump administration that eliminated some of the federal supports, like much of the funding for enrollment outreach.
“This report confirms that improving health equity begins with access to affordable health coverage,” said Maura Collinsgru, who leads the health care program at New Jersey Citizen Action, a strong ACA advocate. “The ongoing resistance of Republicans to expand Medicaid and support the ACA in the face of such strong evidence of its benefits is unconscionable,” she said.
In New Jersey, Gov. Phil Murphy has sought to take greater control of the ACA, enhancing outreach efforts with state funds and taking back from the federal government operation of the commercial insurance exchange, or marketplace, which provides coverage for nearly 300,000 residents who earn too much to qualify for Medicaid but aren’t insured through their jobs. The state’s exchange system is scheduled to come online later this year.
“You would expect to see higher rates of coverage” for all groups in states that operate their own exchanges, Collins noted. New Jersey is one of a dozen states that have followed this state-run marketplace model.
Health care advocates in the Garden State are also encouraged by the prospect of a half dozen bills — lawmakers passed them at the end of the last legislative session, and they’re awaiting Murphy’s signature — to ensure patients here are protected if the federal government further erodes ACA benefits. The measures would require health plans to pay for specific benefits, provide certain preventive services at no out-of-pocket cost, cover those with preexisting conditions, and allow children to remain on their parents’ plans until age 26, among other requirements.
“We applaud New Jersey lawmakers for working to expand coverage and enshrine the ACA protections in New Jersey law, but we still have a lot of work to do,” Collinsgru said. “New Jersey is one of the most diverse states in the nation, and we need to do more to ensure all New Jerseyans can afford to access the quality health care they need, regardless of income, age, gender, ethnicity, immigration status or religion.”