Prior to the enactment of the ACA in 2010, Hispanic, Black, Asian, AIAN, and NHPI people under age 65 were more likely to be uninsured compared to their White counterparts, with Hispanic and AIAN people at the highest risk of lacking coverage (Figure 1). Their higher uninsured rates reflected more limited access to affordable health coverage options. Although the majority of individuals have at least one full-time worker in the family across racial and ethnic groups, there are ongoing racial disparities in employment and income that result in some groups having more limited access to coverage offered by an employer or having greater difficulty affording private coverage when it is available. While Medicaid helps fill some of these gaps in private coverage, prior to the ACA, Medicaid eligibility for parents in most states was limited to those with very low incomes (often below 50% of the poverty level), and adults without dependent children—regardless of how poor—were ineligible under federal rules.
Between 2010 and 2016, there were large gains in coverage across racial and ethnic groups under the ACA, but racial and ethnic disparities in coverage persisted. The ACA created new coverage options for low- and moderate-income individuals. These included provisions to extend dependent coverage in the private market up to age 26 and prevent insurers from denying people coverage or charging them more due to health status. Further, beginning in 2014, the ACA expanded Medicaid coverage to nearly all adults with incomes at or below 138% of poverty in states that adopted the expansion and made tax credits available to people with incomes up to 400% of poverty to purchase coverage through a health insurance Marketplace. Following the ACA’s enactment in 2010 through 2016, coverage increased across all racial and ethnic groups, with the largest increases occurring after implementation of the Medicaid and Marketplace coverage expansions in 2014. Hispanic people under age 65 had the largest percentage point increase in coverage, with their uninsured rate falling from 24.8% to 19.1% between 2014 and 2016. Black, Asian, and AIAN people also had larger percentage point increases in coverage compared to White people over that period. Despite these larger gains, Hispanic, Black, AIAN, and NHPI people under age 65 remained more likely than their White counterparts to be uninsured as of 2016.
Beginning in 2017, coverage gains began reversing, and the number of uninsured increased for three consecutive years. The uninsured rate for the total population under age 65 increased from 10.0% in 2016 to 10.9% in 2019. Hispanic people had the largest statistically significant increase in their uninsured rate over this period (from 19.1% to 20.0%) although the absolute change was small. There were also small but statistically significant increases in the uninsured rates among White and Black people under age 65, which rose from 7.1% to 7.8% and 10.7% to 11.4%, respectively, between 2016 and 2019. Rates for AIAN, NHPI, and Asian people under age 65 did not have a significant change. These coverage losses likely reflected policy changes made by the first Trump administration after taking office in 2017. These changes included decreased funds for outreach and enrollment assistance, guidance encouraging states to seek waivers to add new eligibility requirements for Medicaid coverage as well as to increase the frequency of eligibility verifications, and changes to public charge immigration policy that made some immigrant families more reluctant to participate in Medicaid and the Children’s Health Insurance Program (CHIP) (which were later reversed by the Biden administration).
Pandemic-era policies drove broad coverage gains and reduced uninsured rates across most racial and ethnic groups between 2019 and 2023. After rising in the years before the pandemic, uninsured rates declined between 2019 and 2023, with 3.6 million more people under age 65 gaining coverage as the uninsured rate fell from 10.9% to 9.5%. Declines occurred across most racial and ethnic groups, with the largest drop among AIAN people (21.7% to 18.7%), alongside smaller but significant declines among Hispanic (20.0% to 17.9%), Black (11.4% to 9.7%), Asian (7.2% to 5.8%), and White people (7.8% to 6.5%), while changes for NHPI people were not statistically significant. These gains were driven largely by increased Medicaid coverage, which offset declines in employer-sponsored insurance, and reflected pandemic-era policies that stabilized and expanded coverage. These policies included the Families First Coronavirus Response Act’s continuous enrollment provision for Medicaid, which required states to pause disenrollments from Medicaid during the COVID pandemic in exchange for increased federal funding to states, enhanced ACA Marketplace subsidies under the American Rescue Plan Act and Inflation Reduction Act, increased outreach and enrollment efforts, and low Marketplace attrition.
After years of decline, the overall uninsured rate among people under age 65 increased in 2024, with significant increases among Hispanic, Black, and White people. The total number of people under age 65 without health coverage increased by more than 1.3 million to 26.7 million in 2024, and the uninsured rate for the population under age 65 increased from 9.5% to 9.8%.Hispanic people experienced the largest increase in uninsured rates between 2023 and 2024 (17.9% to 18.4%), followed by Black (9.7% to 10.1%) and White people (6.5% to 6.8%).Asian, AIAN andNHPI people did not have statistically significant changes in coverage over this period.
Coverage disparities have persisted, and in some cases widened, over time even with recent gains and the large earlier gains in coverage under the ACA. For example, in 2010, the uninsured rate for AIAN people was 2.4 times higher than the uninsured rate for White people; however, in 2024, the gap had increased to 2.9 times higher than the rate for White people. Similarly, the Hispanic uninsured rate grew from 2.5 to 2.8 times higher than the rate for White people from 2010 to 2024, while Black people remained 1.5 times more likely to be uninsured than White people.
