Black communities in the United States face many different barriers that have disproportionately affected their ability to achieve optimal health, including disparate impacts of various health conditions, inequitable access to affordable health care coverage, and difficulty affording care even when covered. Black patients are also more likely to report mistreatment by a health provider: around 18 percent of Black adults reported being treated unfairly by a health provider due to their race or ethnicity, compared to 11 percent of Hispanic adults and only 3 percent of white adults.1 Together, these barriers leave Black communities more likely to experience adverse health outcomes than other racial groups. A 2024 analysis by KFF found that, compared to white people, Black people have worse outcomes on approximately 70 percent of the metrics the analysis examined, including life expectancy and general health status.2

This report is the third in a series highlighting the importance of health insurance reform for marginalized populations; this report outlines policy solutions states can use to improve the affordability of care for and advance health equity for Black patients in the United States. Previous reports have examined how states can advance health equity for the LGBT community and for women.3 The report begins by describing the differences in coverage rates and sources for Black people in the United States, after which it describes how some health conditions disproportionately impact Black people’s health. It ends by providing five policy solutions that states could adopt to address these disparities: expand Medicaid, address insurance-based barriers to care, leverage a public option to promote affordability, build equity into anti-trust laws, and design insurance coverage to promote better maternal health outcomes.

Despite Some Improvement, Low Coverage Rates for Black Americans Persist

Black Americans experience disparities in health coverage rates compared to other racial and ethnic groups in the United States. The Affordable Care Act (ACA) drove meaningful improvements in insurance rates across the board; those improvements were higher for Black people, with the uninsured rate for nonelderly Black people dropping by about half between 2010 and 2024.4

Much of this drop in uninsured rates is due to Medicaid expansion under the ACA. While the law as passed required states to expand their Medicaid programs to all residents up to 138 percent of the federal poverty limit (FPL)—just under $36,800 for a family of three in 2025—a 2012 Supreme Court decision (National Federation of Independent Business v. Sebelius) later made this expansion optional.5 As of December 2024, forty states and the District of Columbia have adopted the expansion, and most states did so during 2014, the first year that states could expand their Medicaid programs.6 In 2023, the median income for Black households was about one-third lower than the median income for white households, and Black people were more than twice as likely to experience poverty than white people in 2023.7 As a result, Black people are about twice as likely to be enrolled in Medicaid as white adults in both expansion and non-expansion states, shown in Figure 1.8

Figure 1

In addition to Medicaid expansion, Health Insurance Marketplace coverage (also created by the ACA) played a role in improving coverage rates in the United States. However, this provision of the ACA was less impactful for Black Americans than Medicaid expansion; a recent brief by the U.S. Department of Health and Human Services (HHS) found that while each of the ACA’s coverage provisions drove increases in coverage rates for Black Americans, Medicaid coverage and employer-sponsored insurance (ESI) drove greater increases (5 percentage points and 4.3 percentage points, respectively) than did Marketplace coverage (1.6 percentage points).9

The enhanced financial assistance originally passed in the American Rescue Plan Act (ARPA) and extended under the Inflation Reduction Act (IRA) further improved Marketplace affordability. Under these laws’ changes versus the ACA, the financial assistance in the form of tax credits for Marketplace coverage is available to more people and is more generous. The enhanced tax credits are projected to have increased Marketplace enrollment among Black people more than any other racial or ethnic group.10 Recent research from HHS affirmed this estimate: from 2020 to 2023, Black enrollment increased by 95 percent, more than every group except Latino consumers.11 Importantly, the enhanced assistance has also led many consumers of all types to enroll in more generous plans than they had before, improving the value of this coverage even if the premiums people paid did not meaningfully change.12 This extra financial assistance expires in 2025; if the policy change is not extended, these coverage gains may be undone.

Despite these increases in coverage rates and affordability, significant racial disparities in coverage still exist: Black people were about 25 percent more likely to be uninsured than white people based on data released at the end of 2024.13 Figure 2 shows the difference in uninsured rates.

Figure 2

These differences in coverage rates are driven by a variety of factors. First, ten states still have not expanded Medicaid under the ACA, and despite these states only constituting about 28 percent of the U.S. population, about 37 percent of the U.S. Black population lives in one of these states, shown in Map 1.14 As a result of these policy choices, Black people are disproportionately likely to be in the Medicaid “coverage gap,” with incomes too high for their state’s Medicaid program, but too low for Marketplace premium tax credits. More than 11 percent of the uninsured Black population is in this coverage gap, significantly higher than any other racial group.15

Map 1

Similarly, systemic racism results in Black people disproportionately working lower-paying jobs that are less likely to offer employer-sponsored insurance (ESI) than white people.16 This lower average income also means that, even for Black workers who do receive health insurance as a benefit, premiums and out-of-pocket costs are often a greater burden on household finances than they are for white workers. In 2022, nearly two-thirds of uninsured adults cited cost as the primary reason for lacking health coverage, underscoring the impact of unaffordable coverage for the remaining uninsured population.17

These differences in coverage rates have a real impact on people’s health and ability to seek needed care. Nearly half of uninsured adults reported not seeing a health provider in the past year in a 2023 KFF survey, and, in the same survey, around one in five reported going without the care they needed due to cost.18 Another survey conducted this year found that 45 percent of uninsured Black adults skipped or postponed needed care due to cost.19

Even among insured adults, however, cost can still serve as a barrier to needed care. The 2023 KFF survey found that even those with private insurance went without care due to cost about 5 percent of the time, and more than 20 percent of insured Black adults reported skipping or postponing needed care due to cost.20

These affordability problems among the insured are due in part to “underinsurance”—facing out-of-pocket expenses that constitute a significant portion of income. The Commonwealth Fund estimates that around 16 percent of Black adults with health coverage are underinsured.21 This combination of higher uninsured rates and underinsurance among Black people results in more Black patients struggling to afford health care: around 60 percent of Black adults report difficulty affording care, while only 40 percent of white adults report the same.22

Many Severe and Chronic Health Conditions Disproportionately Harm Black People

In addition to facing barriers to affording health coverage and health care, Black people have unique health needs. Due to longstanding inequities in access to quality care, discrimination, social determinants of health (including environmental hazards), and other systemic barriers, many Black communities are disproportionately impacted by severe or chronic health conditions.

Two chronic health conditions that disproportionately impact Black people are high blood pressure and diabetes. More than half of all Black adults have high blood pressure, and rates of high blood pressure among men have been on the rise in recent years.23 Additionally, fewer Black adults diagnosed with high blood pressure report having their high blood pressure under control than white adults with the condition. 24 Similarly, Black adults are nearly twice as likely as white adults to have been diagnosed with diabetes.25

Black patients are more likely to be affected by severe adverse health outcomes, as well: systemic barriers to accessing diabetes care contribute to Black patients being nearly four times as likely to be hospitalized due to uncontrolled diabetes and more than three times as likely to have kidney failure due to diabetes in 2019.26 Other conditions have a worse impact on Black people despite lower incidence; for example, Black women were slightly less likely to have breast cancer than white women, but they are about 35 percent more likely to die of the condition.27

Another health issue that disproportionately harms Black people is maternal mortality. Black people are significantly more likely to die from pregnancy-related causes—that is, any death caused or aggravated by pregnancy during or up to forty-two days after the end of a pregnancy.28 Data released by the Centers for Disease Control and Prevention in May 2024 show that, in 2022, Black women were about 2.6 times more likely to die due to pregnancy-related causes, and these deaths are largely preventable.29 Figure 3 shows the disparities in maternal deaths.

Figure 3

It is important to note here that while not only women can become pregnant or give birth, the research on this topic does not sufficiently distinguish between cisgender women and other people assigned female at birth.

Concerningly, racial disparities in maternal mortality persist even when controlling for factors such as education or income, highlighting the impact of systemic discrimination on outcomes.30 Other health conditions that disproportionately impact Black women, such as high blood pressure and diabetes, also play a role.31 For example, a 2021 study published in the American Journal of Public Health found that Black women are more than five times more likely than white women to die due to preeclampsia and eclampsia, two blood-pressure-related conditions.32

Black women are also 63 percent more likely to develop gestational diabetes than white women, which contributes to the risk of maternal mortality.33

The lack of health coverage that many Black women face also contributes to racial disparities in maternal mortality rates: states that have expanded their Medicaid programs have seen declines in their maternal mortality rates, in part because Medicaid expansion allows low-income women to access needed care before they become pregnant.34 Access to care prior to pregnancy is shown to reduce maternal mortality rates, especially critical for Black women.35

Finally, anti-abortion laws across the country undermine efforts to improve maternal health. The Supreme Court eliminated the federal right to an abortion in Dobbs v. Jackson Women’s Health Organization, and forty-one states impose some level of restriction on abortion care, including thirteen states with total bans.36 These anti-abortion laws have resulted in OB-GYNs closing their practices, and they also have led to doctors waiting until pregnant patients are in worse health to provide necessary, life-saving care due to fear of legal repercussions.37

State Laws Can Advance Black Health Equity

States can address these barriers to optimal health for Black people, and doing so would likely help other residents as well. Many states with well-performing health systems overall also have lesser health disparities.38 To advance health equity and improve health care affordability for Black residents, states should:

  • expand Medicaid,
  • address insurance-based barriers to care,
  • leverage a public option to promote affordability,
  • build equity into anti-trust laws, and
  • design insurance coverage to promote better maternal health outcomes.

Expand Medicaid

To advance health equity for Black communities, states should begin by expanding health coverage through Medicaid alongside existing programs. For the ten states which have not yet expanded Medicaid under the ACA, this should be a first step. Expanding Medicaid is a relatively simple option for states to pursue, as it does not require a federal waiver or new program, but simply adjusting the eligibility for their existing Medicaid program to include all residents up to 138 percent of the federal poverty level (FPL). In particular, expanding Medicaid would benefit childless Black men, as childless men are otherwise not an eligibility category in Medicaid at any income except through waivers.39 While this will cost states some money, the federal government covers 90 percent of the costs of the expansion population, and research suggests that Medicaid expansion decreases uncompensated care and improves hospitals’ financial performance in addition to improving access to care.40

Medicaid expansion decreases uncompensated care and improves hospitals’ financial performance in addition to improving access to care.

States can also expand access to quality health coverage by extending postpartum Medicaid coverage under the American Rescue Plan Act (ARPA). Pregnant women can enroll in Medicaid at higher income levels than other women in every state but Idaho, and ARPA allowed states to extend this pregnancy-related Medicaid eligibility from sixty days postpartum to a full year, which is crucial to reducing postpartum maternal mortality.41 Most states have taken advantage of this provision, but two (Arkansas and Wisconsin) have not.42 Arkansas has not proposed any extension, and Wisconsin has proposed only extending coverage for ninety days, far short of the full year allowed by law.43 Two other states, Idaho and Iowa, are planning to implement an extension under ARPA but have not yet done so.44

Address insurance-based barriers to care

In addition to expanding Medicaid, states should also ensure that the private coverage options people have are affordable and valuable for patients and their families. This effort should include not just initiatives to reduce monthly premiums, but also initiatives to reduce out-of-pocket costs and utilization management techniques that can reduce access to care.

As a result of Black households’ lower average incomes, cost sharing that may seem reasonable in general can serve as a greater burden to Black people accessing needed care, as they constitute a greater percentage of household income. States can reduce the impact of cost sharing in a variety of ways.

First, policy change could target cost sharing for health conditions in statute where high-value care has already been identified. For example, just over half of all states have limited the cost sharing that patients may be charged for insulin, which can help prevent the harmful, expensive consequences of insulin rationing.45 Some states have gone further and eliminated cost sharing for a broader suite of diabetes care.46 Colorado, Washington, D.C., and Massachusetts all prohibit cost sharing for insulin for many marketplace plans, rather than simply limiting it, and Delaware prohibits cost-sharing for insulin pumps for all state-regulated health plans.47 Importantly, none of these reforms have had a meaningful impact on premiums while significantly improving patients’ ability to afford needed diabetes care services, medications, and supplies.48

States should also take efforts to look to the future on this topic. For example, Maryland’s Commission on Health Equity provides recommendations on how the state can address health disparities along racial, ethnic, cultural, and socioeconomic lines, and, in 2022, the commission recommended that Maryland require all plans on the state’s health insurance exchange offer preferred insulin and blood sugar monitors without cost-sharing, citing Washington, D.C.’s approach.49 While the commission’s recommendations are not binding, states can require their exchanges to adopt recommendations in laws creating similar commissions. Balancing known forms of high-value care with the ability to respond to new information in the future can ensure that patients are not held back by legislative gridlock.

Another approach states could take is supplementing cost-sharing reductions (CSRs) for marketplace enrollees. CSRs are federal financial assistance provided to marketplace enrollees under the ACA that reduces how much an enrollee must pay out of pocket for care.50 Marketplace enrollees can receive CSRs if they enroll in a silver-tier plan—a plan that covers 70 percent of average enrollee’s health expenses, known as actuarial value (AV).51 The generosity of CSRs scales with income: for enrollees with incomes up to 150 percent of the federal poverty line, they increase the AV up to 94 percent for the same silver plan.52

States have taken steps to supplement CSRs for marketplace enrollees. Massachusetts and California, for example, both subsidize premiums for lower-income enrollees to the point where a silver plan has a functional premium of $0.53 This approach promotes enrollment in CSR-eligible plans, avoiding lower-income enrollees choosing a less valuable plan because of concerns about affording a monthly premium. Patients are often sensitive to the monthly premium for insurance, so this approach would likely both increase enrollment overall and improve the value of that coverage to patients.54 Beginning in 2023, California has also directly subsidized the CSRs themselves, dramatically lowering patient cost-sharing and improving the value of these plans to patients.55

In addition to addressing out-of-pocket costs, states should also examine how utilization management by health insurers may undermine access to care. Utilization management is an umbrella term that refers to efforts to “deter overutilization or the receipt of unnecessary, unproven, or low-value care.”56 One form of utilization management is prior authorization, which requires patients to receive approval from an insurer before their insurer will pay for the care.57 Like other forms of utilization management, the goal with prior authorization is to avoid care that is unnecessary or for which a less expensive, equally effective alternative exists. For example, prior authorization is one method by which insurers have worked in recent years to prevent opioid abuse by requiring specified clinical criteria, such as a cancer diagnosis, before approving a prescription.58

If a patient does not receive prior authorization, patients have to choose between avoiding the care altogether or paying the entire bill out of pocket. Even for patients who do receive prior authorization, this can often represent a costly, time-consuming barrier to needed care. A 2023 KFF survey found that, among patients who reported problems with their insurance, patients whose care was subject to prior authorization were about three times as likely as patients whose care was not subject to prior authorization to either go without that care altogether or experience significant delays in accessing it.59 The same survey found that prior authorization patients were more than twice as likely to have experienced a decline in their health.60

States have a range of options available to address access problems stemming from prior authorization.61 One common policy adopted by states is requiring that insurance company employees making prior authorization determinations for diabetes care have medical expertise in the clinical standards for diabetes care. Researchers at Georgetown University have found that prior authorization requirements are often not aligned with the clinical standards for diabetes care, and this policy can help ensure that these determinations are based on the most up-to-date scientific information.62 Colorado and Illinois have built further on this approach, explicitly requiring insurers to use evidence-based treatment guidelines in their prior authorization determinations.63

Another approach that states have taken is extending the duration that a prior authorization approval is valid. Colorado, Illinois, Kentucky, and the District of Columbia all require that prior authorizations remain in place for a full year, and Colorado’s law extends this to three years for chronic conditions, including diabetes.64 This policy balances insurers’ interest in ensuring that care is medically necessary with patient access to clinically appropriate care without repeated administrative burdens. Regardless of approach, reforming prior authorization for diabetes care can improve the value of coverage for Black patients, promoting access to needed care for this chronic condition and closing disparities in access to treatments.65

Leverage a public option to promote affordability

In combination with efforts to ensure that patients can more easily afford insurance and health care, states should address the high root cost of health care. This high cost of care is what ultimately drives patient struggles to afford health care, health insurance premiums, and cost sharing. One way states can advance affordable coverage and address the root cost of care is through a public option. These programs can be especially useful in expanding coverage to patients with household incomes that are too high to be eligible for Medicaid, and they can help states advance equitable coverage in the commercial market, especially when implemented as a closely regulated marketplace plan, as two states have. These policy goals can include expanding coverage among targeted populations, but they can also include cost-containment efforts.

Three states—Washington, Colorado, and Nevada—have passed public option laws, and residents have been able to enroll in public option plans for at least two years in both Washington and Colorado. In particular, Colorado has seen significant success with its “Colorado Option” program, with around one-third of the state’s marketplace (more than 80,000 people) enrolling in a Colorado Option plan in 2024.66 Colorado’s law also includes an explicit goal of advancing health equity, and Nevada’s law names closing racial disparities as a goal.67 These goals have influenced how the laws have been implemented: Colorado’s network adequacy requirements for its public option embed health equity, and Nevada’s public engagement process for its plan has discussed how to equitably improve health coverage and affordability.68 While Washington’s public option law does not explicitly name equity as a goal, its requirements to offer more services before the deductible is met and to do so without cost sharing will disproportionately benefit lower-income, marginalized patients.69

In addition to representing a new coverage option, public options can also be used to lower the cost of care. For example, Colorado’s law requires carriers to lower premiums and limit premium growth.70 As a result, premium increases for Colorado Option plans for 2025 were only 4.6 percent, compared to 6.1 percent for other plans.71 Slower premium growth was driven by requirements that Colorado Option plans lower spending. Washington took a similar approach, requiring “Cascade Select” insurers to lower their average reimbursement rates to health providers to 160 percent of Medicare rates.72 As with Colorado, this approach appears to have been effective: Cascade Select plans were the cheapest option in twenty-six out of thirty-nine counties in Washington for the 2025 plan year.73

Colorado has also used the Colorado Option to build on its broader marketplace reforms around diabetes, prohibiting cost sharing for a variety of diabetes supplies as well as primary care visits.74 These improvements in affordability have helped improve coverage rates for Black patients in Colorado: the uninsured rate for Black Coloradans fell from 4.6 percent in 2021 to only 2 percent in 2023, the first year that Colorado Option plans were available.75

Build equity into anti-trust laws

In addition to using a public option to expand coverage, states should work to address hospital consolidation and its impacts on Black communities. Hospitals have become increasingly consolidated in recent years, and this consolidation has caused prices to dramatically increase without an associated increase in quality. Research has found that patients of color bear more of the financial burden of hospital consolidation increasing prices, and hospital consolidation can also harm health equity, even when prices do not increase.76 One significant way that this may impact Black patients is by reducing access to maternity care. Maternity wards are often less profitable, and hospital consolidation has led to these wards being closed post-merger.77

One way to address hospital consolidation is to expand the scope of merger review laws. By doing so, states can empower their attorneys general or other anti-trust officials to prevent the negative effects of hospital consolidation beyond price increases. For example, Connecticut law requires the state’s Office of Health Strategy to review proposed mergers for their impact on how they would “improve quality, accessibility and cost effectiveness of health care delivery.”78 New York’s certificate of need program operates similarly, requiring analysis of how any proposed merger would impact health equity.79

Another way states can address hospital consolidation is by requiring reviews for all transactions of a specific type. For example, New Jersey’s certificate of need law requires a full review of any transaction of a maternity hospital. Incorporating a similar requirement into other states’ merger review laws can help ensure that relatively low-cost mergers do not go unreviewed by the state when they reduce access to maternity care.80

Design insurance coverage to promote better maternal health outcomes

Finally, states should strengthen their efforts to address maternal mortality rates among Black women and other Black birthing people. Maternal mortality severely impacts health outcomes among Black women and birthing people and, therefore, warrants greater attention. There are two well-supported policies states should adopt to improve maternal health: covering doula care and implementing patient-centered models for prenatal care.

Cover doula care

Doulas are nonclinical workers who support pregnant people before, during, and after pregnancies, and research shows that doula care improves a variety of important clinical outcomes, increase patient satisfaction with their labor and delivery experiences, and lower overall clinical spending.81 Coverage for doula care should apply to both Medicaid and the commercial market to address the full spectrum of coverage Black women and birthing people may be enrolled in. Only around twenty states and the District of Columbia have enacted Medicaid coverage for doula care, and very few states require such coverage for private insurance. Many states have taken some action on doula coverage, typically adopting a pilot program for coverage. Map 2 shows state actions to cover doulas under Medicaid.

Map 2

In order to maximize the impact of this coverage, states should ensure that the rates paid for doula care are sustainable. In states that do not currently require coverage of doula care, some doulas vary their payments based on patient finances, which improves access can improve outcomes, but may also undermine the doula’s ability to remain in the profession.82 By working with doulas to develop sustainable reimbursement rates for Medicaid and private insurance coverage, states can ensure that doula care is a viable career, benefitting Black women and saving payers money. Researchers at Oregon Health and Science University estimated that doula care could save around $91 million per year, as well as avoiding nearly 220,000 unnecessary C-sections and reducing maternal deaths, uterine ruptures, and hysterectomies.83 Importantly, this study found savings at estimated reimbursement rates for doula care at $1,500, which advocates have proposed as a sustainable rate.84

States should also work to ensure that pregnant Medicaid beneficiaries are aware of Medicaid coverage for doula care. Multiple studies have found that Medicaid beneficiaries are often unaware of Medicaid-covered doula care services, undermining payment reform efforts and contributing to continued worse maternal health outcomes.85 New Jersey’s Medicaid program offers a model: managed care organizations in the state have incorporated doula care information into their beneficiary welcome packets.86

Implement effective, patient-centered models for prenatal care

In addition to requiring coverage doula care, states should implement effective, patient-centered models for prenatal care. One model that states should consider is group prenatal care. Under this approach, health care providers deliver the same prenatal services to groups of patients, rather than just individuals, and convene group discussions among patients.87

An example of a group prenatal care model is the CenteringPregnancy model.88 Under the model, around a dozen women at similar stages of their respective pregnancies receive individual medical assessments and prenatal care, followed by discussions and activities to inform care delivery.89 Some of these discussions and activities focus directly on perinatal care needs, such as the symptoms of postpartum depression, but others focus on creating a break from the stress of pregnancy with other patients in a similar moment in life.90

From 2013 to 2018, South Carolina ran a pilot project of the model in its Medicaid program, and a 2020 evaluation of the project found that the program meaningfully improved maternal and infant health outcomes for both low and high-risk pregnancies.91 Compared to patients who received individual care, patients who attended any CenteringPregnancy group sessions had lower rates of preterm birth (10.5 percent versus 8 percent, respectively), low birthweight (9.6 percent versus 8.1 percent), and neonatal intensive care unit admissions (7.7 percent versus 6.5 percent). 92 Patients who attended five or more sessions also had lower rates of C-section births 28.1 percent versus. 25 percent).93 For Black women, these outcomes generally showed even greater improvement: Black women who attended CenteringPregnancy sessions were about 15 percent less likely to deliver via C-section.94 The program also resulted in net savings to the state’s Medicaid program, lowering spending by an estimated $6 million over the five years it operated.95

Unfortunately, as with doula care, few states financially support this approach through their Medicaid programs.96 Researchers at Vanderbilt University have recommended enhanced reimbursement rates for group prenatal care to incentivize adoption by health care providers.97 Implementing this or another patient-centered approach to prenatal care can meaningfully improve health outcomes for Black women and children and avoid unnecessary and expensive care. An upfront investment in these programs will likely pay dividends, both to the state and to patients.

Conclusion: States Can Improve Black Patients’ Affordability and Health Outcomes

States can address the barriers that Black patients in the United States face to achieve optimal health that their white peers do not. These barriers stem from differences in health coverage rates and sources, different incidences and impacts of health conditions, as well as systemic racism. By working to expand health coverage, make health care services and health coverage more affordable, and adopt evidence-supported practices around pregnancy-related care, states can close gaps in access to care, reduce racial disparities in health outcomes, and improve affordability for their Black residents.

Notes

  1. Nambi Ndugga, Latoya Hill, and Samantha Artiga, “Key Data on Health and Health Care by Race and Ethnicity,” KFF, June 11, 2024, https://www.kff.org/key-data-on-health-and-health-care-by-race-and-ethnicity/.
  2. Ibid.
  3. Thomas Waldrop, “Equitable Insurance Coverage and Access Can Advance LGBT Health,” The Century Foundation, October 2, 2023, https://tcf.org/content/commentary/equitable-insurance-coverage-and-access-can-advance-lgbt-health/ and Lex Brierley, Anna Bernstein, and Thomas Waldrop “How States Can Relieve the Burden of Women’s High-Cost Private Health Coverage,” The Century Foundation, July 9, 2024, https://tcf.org/content/report/how-states-can-relieve-the-burden-of-womens-high-cost-private-health-coverage/.
  4.  Latoya Hill, Samantha Artiga, and Anthony Damico, “Health Coverage by Race and Ethnicity, 2010-2022,” KFF, January 11, 2024, https://www.kff.org/racial-equity-and-health-policy/issue-brief/health-coverage-by-race-and-ethnicity/; Elizabeth M. Briones and Robin A. Cohen, “Health Insurance Coverage: Early Release of Estimates From the National Health Interview Survey, January–June 2024,” National Center for Health Statistics, December 6, 2024, https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur202412.pdf.
  5. “Poverty Guidelines,” Office of the Assistant Secretary for Planning and Evaluation, January 17, 2025, https://aspe.hhs.gov/topics/poverty-economic-mobility/poverty-guidelines; National Federation of Independent Business v. Sebelius, 567 U.S. 519 (2012).
  6. “Status of State Medicaid Expansion Decisions,” KFF, November 12, 2024, https://www.kff.org/status-of-state-medicaid-expansion-decisions/.
  7. Gloria Guzman, “Median Income of Non-Hispanic White Households Increased While Asian, Black and Hispanic Median Household Income Did Not Change,” United States Census Bureau, September 10, 2024, https://www.census.gov/library/stories/2024/09/household-income-race-hispanic.html; “Poverty Rate by Race/Ethnicity,” KFF, accessed January 2, 2025, https://www.kff.org/other/state-indicator/poverty-rate-by-raceethnicity/.
  8. Latoya Hill, Samantha Artiga, and Anthony Damico, “Health Coverage by Race and Ethnicity, 2010–2022.”
  9. “Health Insurance Coverage and Access to Care Among Black Americans: Recent Trends and Key Challenges,” Office of the Assistant Secretary for Planning and Evaluation, June 7, 2024, https://aspe.hhs.gov/reports/health-insurance-coverage-access-care-black-americans.
  10. Jessica Banthin, Michael Simpson, and Mohammed Akel, “The Impact of Enhanced Premium Tax Credits on Coverage by Race and Ethnicity,” Urban Institute, August 12, 2024, https://www.urban.org/research/publication/impact-enhanced-premium-tax-credits-coverage-race-and-ethnicity.
  11. Anu Warrier et al., “HealthCare.Gov Enrollment by Race and Ethnicity, 2015–2023,” Office of the Assistant Secretary for Planning and Evaluation, March 22, 2024, https://aspe.hhs.gov/reports/marketplace-enrollment-race-ethnicity-2015-2023.
  12. Anupama Warrier et al., “HealthCare.Gov Plan Selections by Race and Ethnicity, 2015–2024,” Office of the Assistant Secretary for Planning and Evaluation, October 1, 2024, https://aspe.hhs.gov/reports/healthcaregov-plan-selections-race-ethnicity-2015-2024.
  13. Elizabeth M. Briones and Robin A. Cohen, “Health Insurance Coverage: Early Release of Estimates From the National Health Interview Survey.”
  14. “Status of State Medicaid Expansion Decisions,” KFF; author analysis of 2023 American Community Survey 1-year estimates.
  15. Nambi Ndugga, Latoya Hill, and Samantha Artiga, “Key Data on Health and Health Care by Race and Ethnicity.”
  16. Nambi Ndugga, Latoya Hill, and Samantha Artiga, “Key Data on Health and Health Care by Race and Ethnicity.
  17. Jennifer Tolbert et al., “Key Facts about the Uninsured Population,” KFF, December 18, 2024, https://www.kff.org/uninsured/issue-brief/key-facts-about-the-uninsured-population/.
  18. Ibid.
  19. Lunna Lopes et al., “Americans’ Challenges with Health Care Costs,” KFF, March 1, 2024, https://www.kff.org/health-costs/issue-brief/americans-challenges-with-health-care-costs/.
  20. Jennifer Tolbert et al., “Key Facts about the Uninsured Population.”
  21. Sara R. Collins, Lauren A. Haynes, and Relebohile Masitha, “The State of U.S. Health Insurance in 2022,” The Commonwealth Fund, September 29, 2022, https://www.commonwealthfund.org/publications/issue-briefs/2022/sep/state-us-health-insurance-2022-biennial-survey.
  22. Lunna Lopes et al., “Americans’ Challenges with Health Care Costs.”
  23. “Heart Disease and African Americans,” Office of Minority Health, September 22, 2023, https://minorityhealth.hhs.gov/heart-disease-and-african-americans.
  24. Ibid.
  25. “Diabetes and African Americans,” Office of Minority Health, September 22, 2023, https://minorityhealth.hhs.gov/diabetes-and-african-americans.
  26. Ibid.
  27. Ndugga, Hill, and Artiga, “Key Data on Health and Health Care by Race and Ethnicity.”
  28. Jenny Cresswell, “Maternal Deaths,” World Health Organization, accessed January 2, 2025, https://www.who.int/data/gho/indicator-metadata-registry/imr-details/4622.
  29. Donna L. Hoyert, “Maternal Mortality Rates in the United States, 2022,” National Center for Health Statistics, May 2, 2024, https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2022/maternal-mortality-rates-2022.htm; Susanna Trost et al., “Pregnancy-Related Deaths: Data From Maternal Mortality Review Committees in 36 U.S. States, 2017–2019,” Centers for Disease Control and Prevention, May 30, 2024, https://www.cdc.gov/maternal-mortality/php/data-research/mmrc-2017-2019.html.
  30. Emily E. Petersen et al., “Racial/Ethnic Disparities in Pregnancy-Related Deaths—United States, 2007–2016,” Morbidity and Mortality Weekly Report 68, no. 35 (September 6, 2019): 762–65, https://doi.org/10.15585/mmwr.mm6835a3; Kate Kennedy-Moulton et al., “Maternal and Infant Health Inequality: New Evidence from Linked Administrative Data,” National Bureau of Economic Research, September 2023, https://doi.org/10.3386/w30693.
  31. Nichele Washington, “Addressing Hypertension Is Critical for Lowering the Black Maternal Mortality Rate,” The Century Foundation, August 31, 2023, https://tcf.org/content/commentary/addressing-hypertension-is-critical-for-lowering-the-black-maternal-mortality-rate/.
  32. Marian F. MacDorman et al., “Racial and Ethnic Disparities in Maternal Mortality in the United States Using Enhanced Vital Records, 2016‒2017,” American Journal of Public Health 111, no. 9 (September 2021): 1673–81, https://doi.org/10.2105/ajph.2021.306375.
  33. Julie K. Bower et al., “Racial/Ethnic Differences in Diabetes Screening and Hyperglycemia among US Women after Gestational Diabetes,” Preventing Chronic Disease 16 (October 24, 2019), https://doi.org/10.5888/pcd16.190144; Katja Iversen, “Diabetes in Pregnancy: A Neglected Cause of Maternal Mortality,” Harvard T.H. Chan School of Public HealthMaternal Health Task Force, May 10, 2017, https://www.mhtf.org/2017/05/10/diabetes-in-pregnancy-a-neglected-cause-of-maternal-mortality/.
  34. Jamila Taylor and Anna Bernstein, “The Medicaid Coverage Gap and Maternal and Reproductive Health Equity,” The Century Foundation, August 10, 2021, https://tcf.org/content/commentary/medicaid-coverage-gap-maternal-reproductive-health-equity/.
  35. Annie M. Dude et al., “Preconception Care and Severe Maternal Morbidity in the United States,” American Journal of Obstetrics & Gynecology MFM 4, no. 2 (March 2022): 100549, https://doi.org/10.1016/j.ajogmf.2021.100549.
  36. Annie M. Dude et al., “Preconception Care and Severe Maternal Morbidity in the United States,” American Journal of Obstetrics & Gynecology MFM 4, no. 2 (March 2022): 100549, https://doi.org/10.1016/j.ajogmf.2021.100549.
  37. Sarah Varney, “After Idaho’s Strict Abortion Ban, OB-GYNs Stage a Quick Exodus,” KFF Health News, May 2, 2023, https://kffhealthnews.org/news/article/after-idahos-strict-abortion-ban-ob-gyns-stage-a-quick-exodus/; Black Maternal Health Federal Policy Collective, “Why Access to Abortion Care Matters for Black Maternal Health,” The Century Foundation, October 16, 2024, https://tcf.org/content/report/why-access-to-abortion-care-matters-for-black-maternal-health/.
  38. David C. Radley et al., “Advancing Racial Equity in U.S. Health Care,” The Commonwealth Fund, April 18, 2024, https://www.commonwealthfund.org/publications/fund-reports/2024/apr/advancing-racial-equity-us-health-care.
  39. Tricia Brooks et al., “A Look at Medicaid and CHIP Eligibility, Enrollment, and Renewal Policies During the Unwinding of Continuous Enrollment and Beyond,” KFF, June 20, 2024, https://www.kff.org/report-section/a-look-at-medicaid-and-chip-eligibility-enrollment-and-renewal-policies-during-the-unwinding-of-continuous-enrollment-and-beyond-report/.
  40. Meghana Ammula and Madeline Guth, “What Does the Recent Literature Say About Medicaid Expansion? Economic Impacts on Providers,” KFF, January 18, 2023, https://www.kff.org/medicaid/issue-brief/what-does-the-recent-literature-say-about-medicaid-expansion-economic-impacts-on-providers/.
  41.  “Medicaid and CHIP Income Eligibility Limits for Pregnant Women as a Percent of the Federal Poverty Level,” KFF, May 1, 2024, https://www.kff.org/affordable-care-act/state-indicator/medicaid-and-chip-income-eligibility-limits-for-pregnant-women-as-a-percent-of-the-federal-poverty-level/.
  42. “Medicaid Postpartum Coverage Extension Tracker,” KFF, December 2, 2024, https://www.kff.org/medicaid/issue-brief/medicaid-postpartum-coverage-extension-tracker/.
  43. Ibid.
  44. Ibid.
  45. “State Insulin Copay Caps,” American Diabetes Association, accessed January 2, 2025, https://diabetes.org/tools-resources/affordable-insulin/state-insulin-copay-caps; Adam Gaffney, David U. Himmelstein, and Steffie Woolhandler, “Prevalence and Correlates of Patient Rationing of Insulin in the United States: A National Survey,” Annals of Internal Medicine, October 18, 2022, https://doi.org/10.7326/m22-2477; Jane E. Brody, “The Costly, Life-Disrupting Consequences of Poor Diabetes Care,” New York Times, August 24, 2021, https://www.nytimes.com/2019/11/25/well/live/the-costly-life-disrupting-consequences-of-poor-diabetes-care.html.
  46. Christine Monahan and Jalisa Clark, “Using Health Insurance Reform to Reduce Disparities in Diabetes Care,” The Commonwealth Fund, August 18, 2022, https://www.commonwealthfund.org/blog/2022/using-health-insurance-reform-reduce-disparities-diabetes-care.
  47. Ibid.
  48. Ibid.
  49. Thomas Weaver, “Maryland Commission on Health Equity,” Maryland Department of Health, accessed January 2, 2025, https://health.maryland.gov/mche/pages/default.aspx; Becca Lane, “Health Equity Recommendations,” Maryland Health Benefit Exchange, July 20, 2022, https://health.maryland.gov/mche/Documents/Health%20Equity%20Recs%20-%20MCHE%207-20-22%20%282%29.pdf.
  50. Louise Norris, “What Is a Cost-Sharing Reduction?,” healthinsurance.org, accessed January 2, 2025, https://www.healthinsurance.org/glossary/cost-sharing-reduction/.
  51. “Cost-Sharing Reductions,” Center on Budget and Policy Priorities, October 2024, https://www.healthreformbeyondthebasics.org/cost-sharing-charges-in-marketplace-health-insurance-plans-part-2/.
  52. Ibid.
  53. Jason Levitis, “Supporting Insurance Affordability with State Marketplace Subsidies,” State Health and Value Strategies, March 11, 2021, https://www.shvs.org/supporting-insurance-affordability-with-state-marketplace-subsidies/.
  54. Amy Finkelstein, Nathaniel Hendren, and Mark Shepard, “Subsidizing Health Insurance for Low-Income Adults: Evidence from Massachusetts,” American Economic Review 109, no. 4 (April 1, 2019): 1530–67, https://doi.org/10.1257/aer.20171455.
  55. “Covered California to Launch State-Enhanced Cost-Sharing Reduction Program in 2024 to Improve Health Care Affordability for Enrollees,” Covered California, July 20, 2023, https://www.coveredca.com/newsroom/news-releases/2023/07/20/covered-california-to-launch-state-enhanced-cost-sharing-reduction-program/.
  56. Sabrina Corlette, Kennah Watts, and Rachel Schwab, “The Good, The Bad, The Costly: State Efforts to Reform Prior Authorization Practices,” Georgetown University Center on Health Insurance Reforms, July 2024, https://georgetown.app.box.com/s/ko751f98n3m42z2wmni3mk7280f5w6ta.
  57. Ibid.
  58. Chris Hamby, “Giant Companies Took Secret Payments to Allow Free Flow of Opioids,” New York Times, December 17, 2024, https://www.nytimes.com/2024/12/17/business/pharmacy-benefit-managers-opioids.html; “Our Response to the Deeply Flawed New York Times Article about Pharmacy Benefit Managers and Opioids,” Evernorth Health Services, December 17, 2024, https://www.evernorth.com/articles/our-response-deeply-flawed-new-york-times-article-about-pharmacy-benefit-managers.
  59. Karen Pollitz et al., “Consumer Problems with Prior Authorization: Evidence from KFF Survey,” KFF, September 29, 2023, https://www.kff.org/affordable-care-act/issue-brief/consumer-problems-with-prior-authorization-evidence-from-kff-survey/.
  60. Ibid.
  61. Amy Killelea, “Tackling Prior Authorization Barriers for Patients with Diabetes Webinar Slides,” Georgetown University Center on Health Insurance Reforms, December 6, 2024, https://www.dropbox.com/scl/fi/g9z4ylkjvwcqpa2a2vox9/Tackling-Prior-Authorization-Barriers-for-Patients-with-Diabetes-Webinar-Slides.pdf?rlkey=jo5vuiyh5yreibi5o3ib7ca2t&e=2&st=bxgg0pk6&dl=0.
  62. Ibid.
  63. Ibid.
  64. Ibid.
  65. Dong Ding and Sherry A. Glied, “Disparities in the Use of New Diabetes Medications: Widening Treatment Inequality by Race and Insurance Coverage,” The Commonwealth Fund, June 14, 2022, https://www.commonwealthfund.org/publications/issue-briefs/2022/jun/disparities-use-new-diabetes-medications-treatment-inequality.
  66. Vincent Plymell and Shelby Wieman, “80,655 Enroll in Colorado Option Plans for 2024, Polis Administration Continues Focus on Saving People Money on Health Care,” Colorado Division of Insurance, January 18, 2024, https://doi.colorado.gov/news-releases-consumer-advisories/80655-enroll-in-colorado-option-plans-for-2024-polis.
  67. Colorado General Assembly, “HB 21-1232,” June 16, 2021, https://leg.colorado.gov/sites/default/files/2021a_1232_signed.pdf; Nevada Legislature, “SB 240,” June 9, 2021, https://www.leg.state.nv.us/Session/81st2021/Bills/SB/SB420_EN.pdf.
  68. Jamila Taylor and Thomas Waldrop, “States Must Prioritize Health Equity as They Expand Coverage through Public Options,” The Century Foundation, September 8, 2022, https://tcf.org/content/report/states-must-prioritize-health-equity-as-they-expand-coverage-through-public-options/.
  69. Nicole Rapfogel and Maura Calsyn, “Public Options Will Improve Health Equity Across the Country,” Center for American Progress, May 5, 2021, https://www.americanprogress.org/article/public-options-will-improve-health-equity-across-country/.
  70. Colorado General Assembly, “HB 21-1232,” June 16, 2021, https://leg.colorado.gov/sites/default/files/2021a_1232_signed.pdf.
  71. John Ingold, “Health Insurance Prices for Some in Colorado Will Go up next Year. Here’s How Much.” Colorado Sun, October 18, 2024, https://coloradosun.com/2024/10/18/colorado-health-insurance-prices-2025/.
  72. “Cascade Select Public Option,” Washington State Health Care Authority, December 1, 2022, https://www.hca.wa.gov/assets/program/leg-report-cascade-select-20221216.pdf.
  73. Ilene Stohl, “Cascade Select Will Be Available across Washington in 2025,” Washington State Health Care Authority, October 15, 2024, https://www.hca.wa.gov/about-hca/news/news-release/cascade-select-will-be-available-across-washington-2025.
  74. “Covered Diabetic Supplies for Colorado Option Plans,” Covered Diabetic Supplies for Colorado Option Plans, accessed January 2, 2025, https://www.uhc.com/individuals-families/aca-marketplace/colorado-diabetes.
  75. 1. “2023 CHAS: Insurance Coverage,” Colorado Health Institute, November 11, 2024, https://www.coloradohealthinstitute.org/research/2023-chas-insurance-coverage.
  76. Robert J. Town et al., “Hospital Consolidation and Racial/Income Disparities in Health Insurance Coverage,” Health Affairs 26, no. 4 (July 2007): 1170–80, https://doi.org/10.1377/hlthaff.26.4.1170; Tara Oakman and Thomas Waldrop, “How States Can Advance Equity When Addressing Health Care Consolidation,” The Century Foundation, March 6, 2024, https://tcf.org/content/report/how-states-can-advance-equity-when-addressing-health-care-consolidation/.
  77. Rachel Mosher Henke et al., “Access to Obstetric, Behavioral Health, and Surgical Inpatient Services after Hospital Mergers in Rural Areas,” Health Affairs 40, no. 10 (October 1, 2021): 1627–36, https://doi.org/10.1377/hlthaff.2021.00160.
  78. General Statutes of Connecticut § 19a-638.
  79. “Health Equity Impact Assessment,” New York State Department of Health, September 2024, https://www.health.ny.gov/community/health_equity/impact_assessment.htm.
  80. “Certificate of Need Laws in New Jersey,” Institute for Justice, May 2020, https://ij.org/report/conning-the-competition/state-profile/new-jersey/.
  81. Alexis Robles-Fradet and Mara Greenwald, “Doula Care Improves Health Outcomes, Reduces Racial Disparities and Cuts Cost,” National Health Law Program, August 8, 2022, https://healthlaw.org/doula-care-improves-health-outcomes-reduces-racial-disparities-and-cuts-cost/
  82. Vina Smith-Ramakrishnan, “Solving the Black Maternal Health Crisis Will Require Advancing Access to Community-Based Doula Care,” The Century Foundation, April 7, 2022, https://tcf.org/content/commentary/solving-the-black-maternal-health-crisis-will-require-advancing-access-to-community-based-doula-care/.
  83. Karen Scrivner Greiner et al., “A Two-Delivery Model Utilizing Doula Care: A Cost-Effectiveness Analysis,” Obstetrics & Gynecology 131, no. 1 (May 2018): 36S–37S, https://doi.org/10.1097/01.aog.0000532965.56311.db.
  84. Ibid.; Asteir Bey et al., “Advancing Birth Justice: Community-Based Doula Models as a Standard of Care for Ending Racial Disparities,” Every Mother Counts, March 25, 2019, https://everymothercounts.org/wp-content/uploads/2019/03/Advancing-Birth-Justice-CBD-Models-as-Std-of-Care-3-25-19.pdf.
  85. Sashoy Patterson, Taylor Williams, and Angie Snyder, “Leveraging Medicaid Policy to Advance Doula Care,” Georgia Health Policy Center, December 13, 2023, https://maternalhealthlearning.org/resources/leveraging-medaid-policy-to-advance-doula-care/; “Doulas in Medicaid: Case Study Findings,” Medicaid and CHIP Payment and Access Commission, November 2023, https://www.macpac.gov/publication/doulas-in-medicaid-case-study-findings/.
  86. “Doulas in Medicaid: Case Study Findings,” Medicaid and CHIP Payment and Access Commission, November 2023, https://www.macpac.gov/publication/doulas-in-medicaid-case-study-findings/.
  87. Laurie C. Zephyrin et al., “Community-Based Models to Improve Maternal Health Outcomes and Promote Health Equity,” The Commonwealth Fund, March 4, 2021, https://www.commonwealthfund.org/publications/issue-briefs/2021/mar/community-models-improve-maternal-outcomes-equity.
  88. Sarah Kliff, “Sit in a Circle. Talk to Other Pregnant Women. Save Your Baby’s Life?” Vox, November 2, 2018, https://www.vox.com/future-perfect/2018/11/2/18040070/infant-mortality-south-carolina-amy-crockett.
  89. Ibid.
  90. Ibid.
  91. Emily C. Heberlein and Jessica C. Smith, “South Carolina CenteringPregnancy Expansion Project: Findings for Medicaid 2013–2018,” Georgia Health Policy Center, March 17, 2020, https://ghpc.gsu.edu/download/south-carolina-centeringpregnancy-expansion-project-findings-for-medicaid-2013-2018/.
  92. Ibid.
  93. Ibid.
  94. Ibid.
  95. Ibid.
  96. “Group Prenatal Care,” Prenatal-to-3 Policy Impact Center, accessed January 2, 2025, https://pn3policy.org/pn-3-state-policy-roadmap-2023/us/group-prenatal-care/.
  97. Ibid.

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