A federal report finds “historic improvements” in the number of Black Americans who have health insurance since the adoption of the Affordable Care Act (the ACA, also known as Obamacare), which was signed into law in 2010. However, the advancements are not evenly shared across the nation, with the highest rates of uninsured Americans living in the Southern states that elected not to expand Medicaid under the ACA.

Published by the Office of the Assistant Secretary for Planning and Evaluation (ASPE), part of the Department of Health and Human Services, the report is one of a series of briefs that analyze changes and trends in health insurance coverage.

Among the top-level findings, the ASPE report highlights the following key points:

  • Since the implementation of the ACA’s coverage provisions, the uninsured rate among Black Americans under age 65 decreased by 8 percentage points, from 20% in 2011 to 12% in 2019. The uninsured rate for Black Americans, however, is still higher than that for white Americans: 12% compared to 9%.

  • The uninsured rate among Black Americans that report Latino ethnicity is similar to the uninsured rate among non-Latino Black Americans.

  • Southern states that have not expanded Medicaid have some of the nation’s highest uninsured rates for all population groups as well as large Black populations.

  • While access to care improved for Black Americans between 2011 and 2020, disparities in affordability of health care between Black and white Americans persist.

In 2020, about 46.9 million people in the United States, or 14.2% of the nation’s population,identified as Black or African American (including those who identify as such in combination with other races). Nearly 60% of Black Americans live in the South, according to the report.

What’s more, 37% of uninsured Black Americans live in Texas, Florida and Georgia, three states that have not expanded Medicaid. In contrast, Michigan and New York have the lowest rate of uninsured Black Americans; both of those states expanded Medicaid.

“We report historic improvements in coverage among Black Americans since implementation of the ACA,” write the report’s authors, adding that “despite that progress…disparities in health care access persist. A growing body of research shows that centuries of racism in the U.S. has had a profound and negative impact on communities of color, especially Black Americans.”

The report adds that the Biden-Harris administration has launched numerous efforts to increase the coverage and affordability of health insurance available through the ACA. For example, “76% of uninsured Black Americans can find a plan on Healthcare.gov for less than $50 a month and 66% can find a plan for $0 a month,” thanks in part to tax credits and subsidies through the American Rescue Plan (also known as the COVID-19 Economic Stimulus and Relief Package).

However, that doesn’t mean people with insurance through the ACA actually have affordable access to care. Gaps remain. As Michael W. Brooks, MD, an internist and president of Family Health Centers of Georgia, told The Washington Post, many of the marketplace insurance plans have high deductibles, which means that folks might skip visits to the doctor or pay out of pocket—which is especially concerning because many chronic illnesses like diabetes and high blood pressure are more common among Black Americans and require more frequent care. “Patients who bought health plans through ACA insurance marketplaces,” Brooks said, “often have such high deductibles that they end up paying out of pocket if they need to see a doctor about a chronic condition or an aching arm.”

Indeed, as the federal report points out, “differences in access to care for Black Americans are important to note given that Black Americans are more likely to live with or die prematurely from preventable health conditions and diseases compared to their White counterparts.”