Minority Enrollment in Health Insurance Marketplaces During the First Open Enrollment Period

The success of the Affordable Care Act’s first enrollment period is clear: More than 8 million people have signed up for health insurance coverage through the health insurance marketplaces since last October. Among different racial and ethnic groups, however, increases in health insurance coverage varied widely. African and Asian Americans enrolled at relatively high rates, while Hispanic enrollment was lower. The results from the first enrollment period tell us that minority enrollment is on the upswing, but there is more work to do. Learning more about who enrolled in health insurance coverage and who did not will help advocates, state marketplaces, and the U.S. Department of Health and Human Services (HHS) target their efforts more strategically for ongoing enrollment work.

High rates of health insurance enrollment among African American and Asian American consumers

A recent Gallup poll suggests significant improvement – a nearly 30 percent decline – in the rate of African Americans who lack health insurance nationally. Since the beginning of the open enrollment period, the rate of uninsurance among African Americans fell from 20.9 percent to just 14.7 percent. State-level data show remarkable success in enrolling African Americans in marketplace coverage. In Mississippi, for example, African Americans made up 50 percent of the uninsured population and nearly 60 percent of new enrollees. In Georgia, they made up 35 percent of the uninsured and 38 percent of enrollees.

Asian Americans also signed up for health coverage at high rates. In California, 13 percent of the uninsured population is Asian, yet Asians account for 21 percent of enrollees. In New Jersey, these numbers are 9 and 15 percent, respectively. These statistics are especially encouraging given the multiple obstacles to enrollment many Asian Americans faced, such as the lack of applications translated into Asian languages and limited access to bilingual assistance during the enrollment process.

Lower Hispanic enrollment due to various factors

Hispanic enrollment lagged significantly behind that of African and Asian Americans. According to the Gallup poll , the overall Hispanic uninsurance rate declined by about 15 percent during the first enrollment period. However, in no state did the rate of Hispanic enrollment come close to their percentage of the uninsured population. In Georgia, where black enrollment was strong, Hispanics made up 18 percent of the uninsured population but only 3.6 percent of enrollees. States from Arizona to New Jersey to Michigan also reported low Hispanic enrollment.

Latinos faced many of the same barriers to enrollment as Asian Americans. These barriers, combined with various factors specific to this population, may have contributed to lower enrollment. Some include:

• The dearth of Spanish-speaking navigators and assisters and culturally competent outreach materials in Spanish
• Fear of prosecution among mixed-status families: Citizens or legally present immigrants with undocumented family members may have hesitated to enroll for fear that their application information would be used to prosecute these family members, despite the fact the government is prohibited from such action
• Additionally the United States’ Hispanic population is younger on average than the rest of the country, which may have made them less likely to purchase coverage.

As more data becomes available about Hispanic enrollment, we will gain more insight into the main obstacles—and more importantly, to the strategies that hold promise for overcoming these obstacles.

American Indian and Alaska Native enrollment low but ongoing

Any assessment of American Indian and Alaska Native enrollment must consider the Indian Health Service’s unique role as the primary provider of health care to uninsured tribal members. Yet the fact that enrollment rates in many states were lower than the total share of the American Indian and Alaska Native population suggests a more concerted outreach effort is needed.

States with large American Indian populations, such as Alaska, North Dakota, and Oklahoma, all saw American Indians enroll at lower rates than their total share of the uninsured population. Fortunately, open enrollment never ends for members of federally recognized tribes, so there is still time to sign up.

How can we increase minority enrollment?

While the next open enrollment period does not begin until November, Medicaid enrollment remains open year round. And special enrollment periods provide some people who qualify with the opportunity to purchase private health insurance through the marketplace.

Still, there is much that can be done now to increase enrollment even among consumers who will not be eligible until November.

Following is a sample of the activities the government and nonprofit groups are pursuing or should be pursuing to increase minority enrollment:

• The federal government and states are continuing to improve their marketplace application processes to address problems encountered by many consumers in communities of color. The Office of Minority Health at HHS recently announced the Partnerships to Increase Coverage in Communities Initiative, designed to increase health insurance outreach and enrollment assistance for people in communities of color.
• Nonprofit organizations are crucial to raising awareness among communities of color about the availability of financial help and new health coverage options. Ongoing education to raise awareness about these options may occur through such grassroots campaigns as those sponsored by Covered California and Get Covered America last spring.
• Community-based, in-person, culturally effective outreach and enrollment assistance should continue to be a priority for funding and training.
• Ensuring that the applications and assistance are available in multiple languages will also be important, especially for minority groups that speak languages other than English or Spanish.

While this first round of enrollment under the Affordable Care Act was mostly positive for minorities, there is ample room for improvement, especially among Hispanics, American Indians, and Alaska Natives. We will gain a clearer picture of these trends once more of the state-based exchanges report the racial demographics of their enrollees. In the meantime, groups involved in enrollment should focus their efforts to help Americans of all backgrounds participate in the benefits of the Affordable Care Act.