Racial and Ethnic Characteristics of Individuals with Substance Use Disorders in the Medicaid Expansion “Coverage Gap”
While approximately one million Americans with substance abuse disorders (SUDs) are projected to gain Medicaid coverage under the Affordable Care Act (ACA), it remains unclear which demographic groups will benefit the most. Estimates suggest that some racial groups will be underrepresented in the Medicaid expansion population—however, these estimates are not specific to individuals with SUDs. Consequently, it is unknown how Medicaid’s expansion will influence racial and ethnic disparities in insurance coverage for substance abuse treatment (SAT). Developing this knowledge is critically important for developing effective interventions and policy advocacy strategies to address such disparities. To address this gap, we examine racial and ethnic characteristics of individuals with SUDs who meet new federal eligibility criteria for Medicaid, comparing those who live in states that expanded Medicaid (expansion states) with those who live in states did not (non-expansion states).
METHODS
This study is a secondary analysis of data from the 2010-2011 waves of the National Survey on Drug Use and Health. The weighted sample included 16,617 respondents and was restricted to childless, uninsured adults with reported income less than 138% of the federal poverty line who met new federal eligibility criteria for Medicaid, as well as criteria for alcohol use disorders (AUDs) and drug use disorders (DUDs). Chi square tests with Rao-Scott adjustment (to account for complex sample design) assessed differences in the number of individuals with AUDs alcohol and DUDs meeting new federal criteria for Medicaid eligibility—across expansion and non-expansion states, and by racial and ethnic group (Whites, African-Americans, Native Americans, Asians, Latinos, mixed race).
FINDINGS
Overall, few differences were found in rates of SUDs across Medicaid expansion and non-expansion states. Yet, there were large, statistically significant differences in the racial and ethnic composition of newly-Medicaid eligible individuals with SUDs in expansion and non-expansion states. In total, 39.2% of African-Americans, and 26.2% of Native Americans with AUDs have become Medicaid-eligible, as opposed to 80.9% of Asian Americans, 56.0% of mixed-race individuals 49.8% of Latinos, and 46.3% of Whites. Our findings indicate similar disparities for individuals with DUDs: 39.3% of African-Americans, and 39.3% of Native Americans with DUDs have become Medicaid-eligible, compared with 81.2% of Asian Americans, 56.7% of Latinos, 54.2% of mixed-race individuals, and 47.0% of Whites.
CONCLUSIONS
Due to differential distribution of racial and ethnic groups across expansion and non-expansion states, our findings suggest major racial and ethnic differences in coverage access among individuals meeting new federal criteria for Medicaid eligibility. Specifically, African Americans and Native Americans will be significantly overrepresented in the coverage gap. Prior to Medicaid’s expansion this year, African Americans and Native Americans already had lower rates of insurance coverage compared to Whites. The uneven expansion of Medicaid across the nation may serve to widen that gap and potentially increase health disparities for racial and ethnic minorities, counter to the goals of the ACA. A likely consequence of the Supreme Court’s decision to allow states to “opt in” to Medicaid may be the widening of racial and ethnicity disparities in insurance coverage for SAT.