Key Facts on Health and Health Care by Race and Ethnicity

November 2019 | Chart Pack

Samantha Artiga and Kendal Orgera Executive Summary This chart pack provides data on demographics; health coverage, access, and utilization; and health status by race and ethnicity to provide greater insight into the status of health disparities and changes in disparities since implementation of the Affordable Care Act (ACA) coverage expansions in 2014. It finds:

As of 2017, more than four in ten (42%) nonelderly individuals living in the United States were people of color, slightly higher than the share who were people of color in 2013 (40%). Some areas of the country, particularly the South, were more diverse than others. Between 2013 and 2017, the share of the nonelderly population who are people of color increased in all states, except for DC. Over the 2013 to 2017 period, the share of families with a full-time worker and family income increased and disparities in work status and income narrowed, but gaps between groups of color and Whites remained. As of 2017, people of color were younger, included higher shares of noncitizens, and were more likely to be poor compared to Whites.

All racial and ethnic groups experienced improvements in health coverage, access, and utilization compared to prior to the ACA (Figure 1). Hispanics and Blacks experienced improvements in the largest number of the examined measures related to coverage, access, and use. (See Appendix 1 for an overview of indicators examined.) Data gaps limited the analysis for AIANs and NHOPIs.

Figure 1 Changes in Health Coverage, Access, and Use Since Implementation of the Affordable Care Act NUMBER OF MEASURES THAT IMPROVED, DID NOT CHANGE, OR GOT WORSE COMPARED TO BEFORE IMPLEMENTATION OF THE AFFORDABLE CARE ACT:

3 3 5 6 7 2 8 Data Limitation Improved No Change 8 Got Worse 6 4 7 1 4 3 2 1 1 1 White Black Hispanic Asian AIAN NHOPI

Note: Most measures compare data between 2013 and 2017; some use different years due to data availability. “Improved” or “Got Worse” indicates a statistically significant difference between years at the p<0.05 level. “No change” indicates no statistically significant difference. “Data limitation” indicates no separate data for a racial/ethnic group, insufficient data for a reliable estimate, or comparisons not possible due to overlapping samples. AIAN refers to American Indians and Alaska Natives. NHOPI refers to Native Hawaiians and Other Pacific Islanders. Persons of Hispanic origin may be of any race but are categorized as Hispanic for this analysis; other groups are non-Hispanic. These improvements helped narrow some disparities in health coverage, access, and utilization, but nonelderly Blacks and Hispanics continued to fare worse than Whites across most examined measures post-ACA (Figure 2). Nonelderly Asians generally fared similar to Whites across measures. However, the data may mask underlying differences and disparities among subgroups of Asians. Gaps in the data limit the ability to assess access and utilization of care for NHOPIs.

Figure 2 Post-ACA Coverage, Access, and Use of Care among Groups of Color Compared to Whites NUMBER OF MEASURES FOR WHICH GROUP FARED BETTER, THE SAME, OR WORSE COMPARED TO WHITES:

1 1 2 3 3 3 7 Data Limitation 8 Better 5 No Difference Worse 8 7 3 4 3 2

Black Hispanic Asian AIAN NHOPI

Note: Measures are for 2018 or the most recent year for which data are available. “Better” or “Worse” indicates a statistically significant difference from Whites at the p<0.05 level. No difference indicates no statistically significant difference. “Data limitation” indicates data are no separate data for a racial/ethnic group, insufficient data for a reliable estimate, or comparisons not possible due to overlapping samples. AIAN refers to American Indians and Alaska Natives. NHOPI refers to Native Hawaiians and Other Pacific Islanders. Persons of Hispanic origin may be of any race but are categorized as Hispanic for this analysis; other groups are non-Hispanic.

Across racial and ethnic groups, most measures of health status remained stable or improved compared to prior to the ACA (Figure 3). (See Appendix Table 2 for an overview of indicators examined.) Compared to prior to the ACA, AIDS diagnosis rates, heart disease and cancer death rates, and smoking rates decreased for most groups. Most other measures remained stable or could not be assessed over time due to data limitations. The smaller number of improvements in measures of health status and outcomes compared to measures of coverage, access, and use may reflect that a broad array of factors, including social and environmental factors outside the health care system, affect health and that it may take additional time for measureable changes in health to occur in response to improvements in coverage, access, and use.

Figure 3 Changes in Measures of Health Status Since Implementation

of the Affordable Care Act NUMBER OF MEASURES THAT IMPROVED, DID NOT CHANGE, OR GOT WORSE COMPARED TO BEFORE IMPLEMENTATION OF THE AFFORDABLE CARE ACT:

6 6 6 6 7

17 Data Limitation 8 5 10 12 11 Improved No Change Got Worse 10 14 4 7 10 9 5 3 3 1 1 1 White Black Hispanic Asian AIAN NHOPI

Key Facts on Health and Health Care by Race and Ethnicity 2

Blacks and AIANs continued to fare worse than Whites across most examined health status indicators post-ACA (Figure 4). Findings for Hispanics were mixed, but they continued to face large disparities for certain measures. Disparities in teen birth rates, infant mortality rates, and HIV or AIDS diagnosis and death rates were particularly striking for Blacks, Hispanics, and AIANs. Asians fared better than Whites on the majority of examined indicators, but, as discussed earlier, the data may mask disparities among subgroups of Asians. Large data gaps limit examination of health status for NHOPIs.

Figure 4 Post-ACA Health Status among Groups of Color Compared to Whites NUMBER OF MEASURES FOR WHICH GROUP FARED BETTER, THE SAME, OR WORSE COMPARED TO WHITES:

1 3 7 5 11 10 2 Data Limitation 21 2 3 Better No Difference 6 19 Worse 17 14 3 8 3 Black Hispanic Asian AIAN NHOPI

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Introduction Racial and ethnic disparities in health and health care remain a persistent challenge in the United States. Disparities not only result in inequities but also limit continued improvement in quality of care and population health and result in unnecessary health care costs. Many initiatives are underway to address disparities, and the Affordable Care Act (ACA) included provisions that advance efforts to reduce disparities. One key step to addressing disparities is identifying and documenting them. This information is necessary to develop and target interventions and to track progress over time. Data available to measure disparities is improving. Notably, the ACA requires all federal data collection efforts to obtain information on race, ethnicity, sex, primary language, and disability status. However, significant gaps in data persist, particularly for smaller population groups and racial and ethnic subgroups. These data gaps limit the ability to assess and address disparities and mask disparities among underlying subgroups.

This chart pack provides data on demographics; health coverage, access, and utilization; and health status by race and ethnicity to provide greater insight into the status of disparities. It examines changes in these measures by racial/ethnic group since the ACA coverage expansions were implemented in 2014, how these changes have affected disparities between groups of color and Whites, and how groups of color compare to Whites based on the most recent data available.1 Throughout the text, changes over time or differences between groups are only identified if they are statistically significant. Where data are available, this analysis examines measures by six racial/ethnic groups: White, Asian, Hispanic, Black, American Indian and Alaska Native (AIAN), and Native Hawaiian and Other Pacific Islander (NHOPI). Due to data limitations noted above, measures are not always available for all groups. The majority of measures are for the nonelderly population, but some measures include the total population or a specific subpopulation. Data are examined for 2013 (the year prior to implementation of the ACA coverage expansion) or the closest pre-ACA year available, and the most recent year available, which is generally 2017 or 2018. Years vary by measure and dataset (see Methods).

Key Facts on Health and Health Care by Race and Ethnicity 4

Demographics As of 2017, more than four in ten (42%) nonelderly individuals living in the United States were people of color, slightly higher than the share who were people of color in 2013 (40%) (Figure 5).

Figure 5 Nonelderly Population by Race/Ethnicity, 2013 and 2017

2013 2017

Black Black 13% 13%

People Hispanic People Hispanic White of Color: 20% of Color: 19% 60% 40% White 42% 58%

Asian Asian 5% 6% AIAN AIAN 0.7% 0.7%

NHOPI NHOPI Other 3% Other 3% 0.2% 0.2% Total Nonelderly Population: 264.2 M 267.5 M

Notes: AIAN refers to American Indians and Alaska Natives. NHOPI refers to Native Hawaiians and Other Pacific Islanders. Other includes people of mixed race. Persons of Hispanic origin may be of any race but are categorized as Hispanic for this analysis; other groups are non-Hispanic. Includes nonelderly individuals 0-64 years of age. Total may not sum to 100% due to rounding. Source: Kaiser Family Foundation analysis of 2013 & 2017 American Community Survey (ACS), 1-Year Estimates.

Some areas of the country, particularly the South, were more diverse than others (Figure 6).

Figure 6 Share of Nonelderly Population that is a Person of Color by

State, 2017

WA VT ME ND MT NH MN OR WI NY MA ID SD MI RI CT WY PA IA NJ NE OH DE NV IL IN MD UT WV VA DC CO KS CA MO KY NC TN OK SC Less than 20% (9 States) AZ NM AR MS AL GA 20% to Less than 40% (23 States) LA TX 40%+ (19 States including DC) AK FL

Note: Includes nonelderly individuals 0-64 years of age. Source: Kaiser Family Foundation analysis of 2017 American Community Survey (ACS), 1-Year Estimates.

Key Facts on Health and Health Care by Race and Ethnicity 5

Between 2013 and 2017, the share of the nonelderly population who are people of color increased in all states, except for DC (Figure 7). The largest percentage point increases in the share of the nonelderly population who are people of color occurred in: Nevada (3.8 percentage points), Massachusetts (3.7 percentage points), North Dakota (3.5 percentage points), Connecticut (3.4 percentage points), and Rhode Island (3.0 percentage points).

Figure 7 Percentage Point Change in Share of Nonelderly Population that is a Person of Color by State from 2013 to 2017

WA VT ME ND MT NH MN OR WI NY MA ID SD MI RI CT WY PA IA NJ NE OH DE NV IL IN MD UT WV VA DC CO KS CA MO KY NC TN OK SC AZ NM AR No Statistically Significant Change (DC) MS AL GA Increase of < 1.5 Percentage Point (18 States) LA TX Increase of 1.5 to < 3 Percentage Points (27 States) AK FL Increase of 3+ Percentage Points (5 States)

Note: Includes nonelderly individuals 0-64 years of age. Source: Kaiser Family Foundation analysis of 2013 & 2017 American Community Survey (ACS), 1-Year Estimates.

People of color generally were younger compared to Whites (Figure 8). During both 2013 and 2017, the share of the population below age 35 was higher for all groups of color compared to Whites. Between 2013 and 2017, the nonelderly population became older, with the share below age 35 decreasing across all racial and ethnic groups, except Whites.

Figure 8 Percent of Nonelderly Population Who is Below Age 35 by Race/Ethnicity, 2013 and 2017

2013 2017

64.7^ 62.9*^ 57.2^ 56.6*^ 58.5^ 56.8*^ 59.9^ 57.2*^ 48.7% 48.9* 52.4^ 51.9*^

White Black Hispanic Asian AIAN NHOPI

* Indicates statistically significant difference from 2013 at the p<0.05 level. ^ Indicates statistically significant difference from Whites in the respective year at the p<0.05 level. Note: AIAN refers to American Indians and Alaska Natives. NHOPI refers to Native Hawaiians and Other Pacific Islanders. Persons of Hispanic origin may be of any race but are categorized as Hispanic for this analysis; other groups are non-Hispanic. Includes nonelderly individuals 0-64 years of age. N/A: Point estimates do not meet minimum standards for statistical reliability. Source: Kaiser Family Foundation analysis of 2013 & 2017 American Community Survey (ACS), 1-Year Estimates.

Key Facts on Health and Health Care by Race and Ethnicity 6

People of color included higher shares of noncitizens relative to Whites, with the highest rates among Hispanics (21%) and Asians (29%) (Figure 9). Between 2013 and 2017, the share who are noncitizens decreased from 24% to 21% among Hispanics, while it increased slightly among Asians, from 28% to 29%. There was also a small increase in the share of Blacks who are noncitizens from 2013 to 2017.

Figure 9 Percent of Nonelderly Population Who is a Noncitizen by Race/Ethnicity, 2013 and 2017

2013 2017

28%^ 29%*^ 24%^ 21%*^ 14%^ 14%^ 2% 2% 4%^ 4%*^ <1%^ <1%^ White Black Hispanic Asian AIAN NHOPI

Across all racial and ethnic groups, most individuals lived in a family with a full-time worker (Figure 10). Reflecting an improving economy, the share of nonelderly individuals living in a family with a full-time worker increased across all racial and ethnic groups between 2013 and 2017, and disparities between groups of color and Whites narrowed. Despite these increases, Blacks and AIANs remained less likely to have a full-time worker in the family compared to Whites as of 2017.

Figure 10 Percent of the Nonelderly Population with a Full-Time Worker in the Family by Race/Ethnicity, 2013 and 2017

2013 2017

86%^ 87%*^ 82% 84%* 84%* 83%* 80%^ 78%^ 73%*^ 68%^ 67%^ 70%*^

White Black Hispanic Asian AIAN NHOPI

Key Facts on Health and Health Care by Race and Ethnicity 7

Although the majority of individuals lived in a family with a full-time worker across racial and ethnic groups, groups of color were more likely to have family income below poverty compared to Whites (Figure 11). Between 2013 and 2017, the share of individuals with family income below poverty decreased for all groups except NHOPIs. Larger decreases for groups of color compared to Whites helped to narrow income disparity, but, as of 2017, all groups of color remained more likely to be poor than Whites.

Figure 11 Percent of Nonelderly Population with Income Below Poverty by Race/Ethnicity, 2013 and 2017

2013 2017

29^ 30^ 24*^ 25^ 27*^ 19*^ 21^ 19^ 12% 10%* 13^ 11*^

White Black Hispanic Asian AIAN NHOPI

Key Facts on Health and Health Care by Race and Ethnicity 8

Coverage, Access to, and Use of Care All racial and ethnic groups experienced improvements in coverage, access to care, and use of care compared to prior to the ACA (Figure 12), and some disparities between groups of color and Whites narrowed. Hispanics and Blacks experienced improvements in the largest number of the examined measures related to coverage, access, and use. Despite these improvements, nonelderly Blacks and Hispanics continued to fare worse than Whites across most examined indicators of coverage, access, and use (Figure 13). Nonelderly Asians generally fared similar to Whites across measures. However, the data may mask underlying differences and disparities among subgroups of Asians. Gaps in the data limit the ability to assess access and utilization of care for NHOPIs.

Figure 12 Changes in Health Coverage, Access, and Use Since Implementation of the Affordable Care Act NUMBER OF MEASURES THAT IMPROVED, DID NOT CHANGE, OR GOT WORSE COMPARED TO BEFORE IMPLEMENTATION OF THE AFFORDABLE CARE ACT:

3 3 5 6 7 2 8 Data Limitation Improved No Change 8 Got Worse 6 4 7 1 4 3 2 1 1 1 White Black Hispanic Asian AIAN NHOPI

Figure 13 Post-ACA Coverage, Access, and Use of Care among Groups of Color Compared to Whites NUMBER OF MEASURES FOR WHICH GROUP FARED BETTER, THE SAME, OR WORSE COMPARED TO WHITES:

1 1 2 3 3 3 7 Data Limitation 8 Better 5 No Difference Worse 8 7 3 4 3 2

Black Hispanic Asian AIAN NHOPI

Key Facts on Health and Health Care by Race and Ethnicity 9

Uninsured Rate All groups experienced large decreases in their uninsured rate since implementation of the ACA, but disparities in coverage persisted as of 2017 (Figure 14). All groups of color had larger percentage-point decreases in their uninsured rate compared to Whites, which narrowed coverage disparities. Hispanics experienced the largest absolute decrease, with their uninsured rate falling from 30% to 19%. Despite these larger gains in coverage, most groups of color remained more likely to be uninsured relative to Whites as of 2017. In particular, nonelderly Hispanics were nearly three times as likely as Whites to lack coverage (19% vs. 7%) and nonelderly AIANs were over three times as likely as Whites to be uninsured (22% vs. 7%) as of 2017.

Figure 14 Uninsured Rate for the Nonelderly Population by Race/Ethnicity, 2013 and 2017

2013 2017

30%^ 30%^ 22%*^ 19%^ 19%*^ 16%^ 18%^ 12% 11%*^ 11%*^ 7%* 7%*

White Black Hispanic Asian AIAN NHOPI

Key Facts on Health and Health Care by Race and Ethnicity 10

Access to Care Nearly all groups had decreases in the share of nonelderly adults reporting going without seeing a doctor due to cost between 2013 and 2018 (Figure 15). Relatively larger decreases for Blacks, Hispanics, and AIANs narrowed their disparity compared to Whites over this period. However, as of 2018, Blacks, Hispanics, AIANs, and NHOPIs were more likely than Whites to report going without needed care due to cost.

Figure 15 Percent of Nonelderly Adults Who did not See a Doctor Due to Cost in the Past 12 Months by Race/Ethnicity

2013 2018

27%^ 23%^ 25%^ 21%*^ 19%*^ 19% 19%^ 15% 17%*^ 13%* 12%^ 10%*^

White Black Hispanic Asian AIAN NHOPI

There were also decreases in the share of nonelderly adult Blacks and Hispanics who reported delaying care for reasons other than cost between 2013 and 2018 (Figure 16). Despite the decrease, as of 2018, Blacks and Hispanics were more likely to report delaying care for reasons other than cost compared to Whites. In addition, AIANs were nearly twice more likely than Whites to delay care due to other reasons than cost in 2018 (36% vs. 19%).

Figure 16 Percent of Nonelderly Adults Who Delayed Care Due to Other Reasons in the Past 12 Months by Race/Ethnicity

2013 2018

35%^ 36%^ 30%^ 27%^ 24%*^ 25%*^ 26% 19% 19% 21% 19% 22%

White Black Hispanic Asian AIAN NHOPI

Key Facts on Health and Health Care by Race and Ethnicity 11

Between 2013 and 2018, the share of nonelderly adults with no usual source of care when sick decreased among Hispanics (Figure 17). However, Blacks and Hispanics were more likely than Whites to lack a usual source of care as of 2018. Across groups, small shares of children lacked a usual source of care, but the share of Black children with no usual source of care increased from 4% to 8% between 2013 and 2018. As of 2018, Black and Hispanic children were more likely than White children to not have a usual source of care. Data gaps limit the ability to measure the likelihood of having a usual source of care among NHOPIs and AIAN children.

Figure 17 Percent of Nonelderly Population without a Usual Source of Care When Sick Other than the Emergency Room by Race/Ethnicity, 2013 and 2018 Adults (Age 18-64) (%) Children (Age 0-17) (%) 2013 2018 2013 2018

31^ 26*^ 21^ 20^ 18^ 16% 14* 15 16 10 8*^ 7^ 7^ 5 6 N/A 3% 3 4 N/A N/A

White Black Hispanic Asian AIAN NHOPI White Black Hispanic Asian AIAN NHOPI

* Indicates statistically significant difference from 2013 at the p<0.05 level. ^ Indicates statistically significant difference from Whites in the respective year at the p<0.05 level. Note: AIAN refers to American Indians and Alaska Natives. NHOPI refers to Native Hawaiians and Other Pacific Islanders. Persons of Hispanic origin may be of any race but are categorized as Hispanic for this analysis; other groups are non-Hispanic. N/A: Data are included in an “other” racial category and cannot be separately identified or point estimates do not meet minimum standards for statistical reliability. Source: Kaiser Family Foundation analysis of 2013 & 2018 National Health Interview Survey.

Key Facts on Health and Health Care by Race and Ethnicity 12

Use of Care The share of nonelderly adults going without health and dental care in the last year decreased for White, Black, and Hispanic nonelderly adults between 2013 and 2018 (Figure 18). There were no changes in the share of nonelderly adult Asians or AIANs using health or dental care between 2013 and 2018, and data are insufficient to assess use for NHOPIs. The increases in use of health and dental care narrowed disparities between groups of color and Whites. However, as of 2018, most groups of color were more likely to go without a health care or dental visit compared to Whites.

Figure 18 Percent of Nonelderly Adults without a Health Care or Dental Visit in the Last 12 Months by Race/Ethnicity

No Health Care Visit (%) No Dental Visit (%) 2013 2018 2013 2018

50^ 44^ 43^ 41*^ 39 34% 37*^ 36 33^ 31* 32 28*^ 24^ 24^ 21 17% 20^ 17* 15* 13

N/A N/A White Black Hispanic Asian AIAN NHOPI White Black Hispanic Asian AIAN NHOPI

* Indicates statistically significant difference from 2013 at the p<0.05 level. ^ Indicates statistically significant difference from Whites in the respective year at the p<0.05 level. Note: AIAN refers to American Indians and Alaska Natives. NHOPI refers to Native Hawaiians and Other Pacific Islanders. Persons of Hispanic origin may be of any race but are categorized as Hispanic for this analysis; other groups are non-Hispanic. Includes nonelderly individuals 18-64 years of age. N/A: Data are included in an “other” racial category and cannot be separately identified. Source: Kaiser Family Foundation analysis of 2013 & 2018 National Health Interview Survey.

Across groups, a small share of children reported going without a health care visit in the past year, and there were no changes in health care use among children between 2013 and 2018. As of 2018, Hispanic and Asian children were more likely than White children to go without a health care visit in the past year (Figure 19). The share of Black, Hispanic, and Asian children going without dental care decreased over the period. Data gaps limited assessment of use of care for AIAN and NHOPI children.

Figure 19 Percent of Children without a Health Care or Dental Visit in the Last 12 Months by Race/Ethnicity

No Health Care Visit (%) No Dental Visit (%) 2013 2018 2013 2018

23^ 19% 22^ 22^ 18 15* 17* 17* 18 10^ 10^ 7% 6 7 5 8^ 7 N/A N/A N/A N/A White Black Hispanic Asian AIAN NHOPI White Black Hispanic Asian AIAN NHOPI

* Indicates statistically significant difference from 2013 at the p<0.05 level. ^ Indicates statistically significant difference from Whites in the respective year at the p<0.05 level. Note: AIAN refers to American Indians and Alaska Natives. NHOPI refers to Native Hawaiians and Other Pacific Islanders. Persons of Hispanic origin may be of any race but are categorized as Hispanic for this analysis; other groups are non-Hispanic. N/A: Data are included in an “other” racial category and cannot be separately identified or point estimates do not meet minimum standards for statistical reliability. Sources: Kaiser Family Foundation analysis of 2013 & 2018 National Health Interview Survey.

Key Facts on Health and Health Care by Race and Ethnicity 13

There were no changes in rates of young children who did not receive all recommended immunizations across groups between 2013 and 2017 (Figure 20). As of 2017, Black children were more likely than White children to not have received all recommended immunizations (33% vs. 28%). Data were not available for NHOPI children.

Figure 20 Percent of Children (19-35 Months) Who Have Not Received All Recommended Immunizations by Race/Ethnicity

2013 2017

35%^ 34% 33%^ 31% 30% 30% 28% 28% 27% 28%

N/A White Black Hispanic Asian AIAN NHOPI

* Indicates statistically significant difference from 2013 at the p<0.05 level. ^ Indicates statistically significant difference from Whites in the respective year at the p<0.05 level. Note: AIAN refers to American Indians and Alaska Natives. NHOPI refers to Native Hawaiians and Other Pacific Islanders. Persons of Hispanic origin may be of any race but are categorized as Hispanic for this analysis; other groups are non-Hispanic. N/A: Data are included in an “other” racial category and cannot be separately identified. See source for more information on immunizations included. Sources: Hill, et. al, National, State, and Selected Local Area Vaccination Coverage Among Children Aged 19-35 Months - United States, 2013 & 2017, Morbidity and Mortality Weekly Report, CDC. Retrieved from: https://stacks.cdc.gov/view/cdc/53336 and https://stacks.cdc.gov/view/cdc/59414.

In both 2012 and 2018, a smaller share of Black women did not receive a mammogram in the past two years compared to White women (Figure 21). Changes in the share of women receiving a Pap smear were mixed. From 2012 to 2018, the share who did not receive a Pap smear increased among White, Black, Hispanic, and Asian women. As of 2018, Asian women were more likely than White women to go without a Pap smear, while Black and Hispanic women were less likely to go without a Pap smear compared to Whites.

Figure 21 Percent of Women Who Have Not Received Selected Health Screenings by Race/Ethnicity

Did Not Receive a Mammogram in Did Not Receive a Pap Smear in Past 2 Years (Women Aged 50-74) (%) Past 3 Years (Women Aged 21-65) (%) 2012 2018 2012 2018

30^ 32*^ 29 23 25 25* 25^ 26^ 21% 22 21 21 20% 21*^ 20 23 17^ 16^ 17^ 16 15^ 18*^ 18^

N/A White Black Hispanic Asian AIAN NHOPI White Black Hispanic Asian AIAN NHOPI

* Indicates statistically significant difference from 2012 at the p<0.05 level. ^ Indicates statistically significant difference from Whites in the respective year at the p<0.05 level. Note: AIAN refers to American Indians and Alaska Natives. NHOPI refers to Native Hawaiians and Other Pacific Islanders. Persons of Hispanic origin may be of any race but are categorized as Hispanic for this analysis; other groups are non-Hispanic. N/A: Point estimates do not meet minimum standards for statistical reliability. Source: Kaiser Family Foundation analysis of 2012 & 2018 Behavioral Risk Factor Surveillance System.

Key Facts on Health and Health Care by Race and Ethnicity 14

Health Status Across racial and ethnic groups, most measures of health status were stable or improved compared to prior to the ACA (Figure 22), but most groups of color continued to fare worse than Whites across indicators of health status post-ACA (Figure 23). Compared to prior to the ACA, AIDS diagnosis rates, heart disease and cancer death rates, and smoking rates decreased for most groups. Most other measures remained stable or could not be assessed over time due to data limitations. The smaller number of improvements in measures of health status and outcomes compared to measures of coverage, access, and use, may reflect that a broad array of factors, including social and environmental factors outside the health care system, affect health and that it may take additional time for measureable changes in health to occur in response to improvements in coverage, access, and use. Blacks and AIANs continued to fare worse than Whites across most examined health status indicators post-ACA. Findings for Hispanics were mixed, but they continued to face large disparities for certain measures. Disparities in teen birth rates, infant mortality rates, and HIV or AIDS diagnosis and death rates were particularly striking for Blacks, Hispanics, and AIANs. Asians fared better than Whites on the majority of examined indicators, but, as discussed earlier, the data may mask disparities among subgroups of Asians. Large data gaps limit examination of health status for NHOPIs.

Figure 22 Changes in Measures of Health Status Since Implementation of the Affordable Care Act NUMBER OF MEASURES THAT IMPROVED, DID NOT CHANGE, OR GOT WORSE COMPARED TO BEFORE IMPLEMENTATION OF THE AFFORDABLE CARE ACT:

6 6 6 6 7

17 Data Limitation 8 5 10 12 11 Improved No Change Got Worse 10 14 4 7 10 9 5 3 3 1 1 1 White Black Hispanic Asian AIAN NHOPI Note: Most measures compare data between 2013 and 2017; some use different years due to data availability. “Improved” or “Got Worse” indicates a statistically significant difference between years at the p<0.05 level. “No change” indicates no statistically significant difference. “Data limitation” indicates no separate data for a racial/ethnic group, insufficient data for a reliable estimate, or comparisons not possible due to changes in measures or overlapping samples. AIAN refers to American Indians and Alaska Natives. NHOPI refers to Native Hawaiians and Other Pacific Islanders. Persons of Hispanic origin may be of any race but are categorized as Hispanic for this analysis; other groups are non-Hispanic.

Figure 23

Post-ACA Health Status among Groups of Color Compared to Whites NUMBER OF MEASURES FOR WHICH GROUP FARED BETTER, THE SAME, OR WORSE COMPARED TO WHITES:

1 3 7 5 11 10 2 Data Limitation 21 2 3 Better No Difference 6 19 Worse 17 14 3 8 3 Black Hispanic Asian AIAN NHOPI

Key Facts on Health and Health Care by Race and Ethnicity 15

Self-Reported Health Status Between 2013 and 2018, there were no changes in the share of nonelderly adults reporting fair or poor health status across groups of color (Figure 24). As of 2018, Blacks, Hispanics, and AIANs were more likely than Whites to report fair or poor health status, while Asians were less likely to indicate fair or poor health. The share of nonelderly adults reporting a physical limitation increased for Whites, Hispanics, and Asians over the period, but there were no changes for other groups. As of 2018, Black, Hispanic, and Asian nonelderly adults were less likely than Whites to report a physical limitation, while AIANs were more likely to report a physical limitation.

Figure 24 Percent of Nonelderly Adults Reporting Fair/Poor Health Status and a Physical Limitation by Race/Ethnicity, 2013 and 2018

Fair or Poor Health Status (%) Physical Limitation (%) 2013 2018 2013 2018

42^ 43^ 30% 33* 30 30^ 20^ 20^23*^ 15^ 18^ 17*^ 14^ 12^ 11^ 14^ 10% 9* 7^ 7^ N/A N/A

White Black Hispanic Asian AIAN NHOPI White Black Hispanic Asian AIAN NHOPI

* Indicates statistically significant difference from 2013 at the p<0.05 level. ^ Indicates statistically significant difference from Whites in the respective year at the p<0.05 level. Note: AIAN refers to American Indians and Alaska Natives. NHOPI refers to Native Hawaiians and Other Pacific Islanders. Persons of Hispanic origin may be of any race but are categorized as Hispanic for this analysis; other groups are non-Hispanic. Includes nonelderly individuals 18-64 years of age. N/A: Data are included in an “other” racial category and cannot be separately identified. Source: Kaiser Family Foundation analysis of 2013 & 2018 National Health Interview Survey.

There were limited changes in the share of nonelderly adults reporting 14 or more physically or mentally unhealthy days within the past 30 days between 2013 and 2018 (Figure 25). Rates of both measures increased for nonelderly adult Whites. Asians were less likely than Whites to report frequent physically and mentally unhealthy days as of 2018, while AIANs had higher rates compared to Whites.

Figure 25 Percent of Nonelderly Adults with 14 or More Physically or Mentally

Unhealthy Days in the Past 30 Days by Race/Ethnicity, 2013 and 2018

≥ 14 Physically Unhealthy Days (%) ≥ 14 Mentally Unhealthy Days (%) 2013 2018 2013 2018

17^ 20^ 20^ 19^ 15* 14^ 15 13 11% 11* 12^ 12^ 12^ 12 9 9 12% 12^ 11 12 5^ 5^ 7^ 7^

White Black Hispanic Asian AIAN NHOPI White Black Hispanic Asian AIAN NHOPI

Key Facts on Health and Health Care by Race and Ethnicity 16

Birth Risks and Outcomes Groups of color were at higher risk for certain birth risks and outcomes compared to Whites as of 2017 (Figure 26). Specifically, among Blacks, Hispanics, AIANs, and NHOPIs, a higher share of births were preterm, low-birthweight, or among mothers that received late or no prenatal care compared to Whites. Asians were also more likely than Whites to have low-birthweight births and births that received late or no prenatal care, but less likely than Whites to have a preterm birth. Due to changes in methodology, 2017 data could not be compared to data prior to the ACA.

Figure 26 Percent of Births with Selected Risk Factors by Race/Ethnicity, 2017

White Black Hispanic Asian AIAN NHOPI

20%^ 14%^ 14%^ 13%^ 10%^ 12%^ 11%^ 10%^ 9% 9%^ 7% 7%^ 9%^ 8%^ 8%^ 8%^ 4% 5%^

Preterm Births Low Birthweight Late or No Prenatal Care

^ Indicates statistically significant difference from Whites in the respective year at the p<0.05 level. Note: AIAN refers to American Indians and Alaska Natives. Persons of Hispanic origin may be of any race but are categorized as Hispanic for this analysis; other groups are non-Hispanic. Source: Kaiser Family Foundation analysis of Centers for Disease Control and Prevention, National Center for Health Statistics, Natality Public Use File, 2017.

As of 2017, Blacks, Hispanics, AIANs, and NHOPIs had a higher teen birth rate than Whites (Figure 27). In contrast, the teen birth rate among Asians was lower than the rate for Whites. Preliminary 2018 data shows that the teen birth rates continued to decrease from 2017 to 2018 for Whites, Blacks, and Hispanics. Due to changes in methodology, 2017 data could not be compared to data prior to the ACA.

Figure 27

Birth Rate (per 1,000) for Teen Girls Ages 15-19 by Race/Ethnicity, 2017

32.9^ 27.5^ 28.9^ 25.5^ 13.2 3.3^

White Black Hispanic Asian AIAN NHOPI

Key Facts on Health and Health Care by Race and Ethnicity 17

As of 2017, Blacks, Hispanics, AIANs, and NHOPIs had higher infant mortality rates relative to Whites (Figure 28). These disparities were particularly large for Blacks and AIANs whose infant mortality rates were roughly two times higher than Whites. Due to changes in methodology, 2017 data could not be compared to data prior to the ACA.

Figure 28 Infant Mortality Rate (per 1,000) by Race/Ethnicity, 2017

11.0^ 9.2^ 7.6^ 4.7 5.1^ 3.8^

White Black Hispanic Asian AIAN NHOPI

^ Indicates statistically significant difference from Whites in the respective year at the p<0.05 level. Note: AIAN refers to American Indians and Alaska Natives. Persons of Hispanic origin may be of any race but are categorized as Hispanic for this analysis; other groups are non-Hispanic. Source: Centers for Disease Control and Prevention, National Center for Health Statistics, Division of Vital Statistics, Linked Birth/Infant Death Records, 2013 & 2017, WONDER Online Database.

Key Facts on Health and Health Care by Race and Ethnicity 18

HIV and AIDS Diagnosis and Death Rates Despite small declines in HIV and AIDS diagnosis rates among Black and Hispanic teens and adults, these groups continued to face major disparities in 2017 (Figure 29). Compared to Whites, Blacks had an over eight times higher HIV diagnosis rate and a nearly ten times higher AIDS diagnosis rate, and the HIV and AIDS diagnosis rates for Hispanics were more than three times the rates for Whites. In contrast to the decreases experienced by Blacks and Hispanics, the HIV diagnosis rate for AIANs increased between 2013 and 2017, and their HIV diagnosis rate was nearly twice as high as the rate for Whites as of 2017. HIV and AIDS diagnosis rates for NHOPIs also were higher than those for Whites in 2017.

Figure 29

HIV or AIDS Diagnosis per 100,000 Among Teens and Adults by Race/Ethnicity, 2013 and 2017

HIV Diagnosis Rate AIDS Diagnosis Rate

White 6.2 3.4 5.9 2.5 Black 53.9 35.0 49.8 24.9

Hispanic 21.9 12.2 20.8 8.5 2013 2017 Asian 5.6 2.5 6.0 2.1

AIAN 7.8 4.5 10.8 3.6 4.9 NHOPI 10.9 11.9 5.5

Note: Data based on surveillance data reported by states to the CDC. AIAN refers to American Indians and Alaska Natives. NHOPI refers to Native Hawaiians and Other Pacific Islanders. Persons categorized by race were not Hispanic or Latino. Individuals in each race category may, however, include persons whose ethnicity was not reported. Includes individuals age 13 and older. Data for HIV and AIDS diagnoses are as of 2017. Source: Centers for Disease Control and Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2013-2017.

Similar to diagnosis rates, death rates for individuals with HIV decreased for Black and Hispanic teens and adults between 2013 and 2016, but their death rates remained higher than Whites (Figure 30). Blacks had a more than seven times higher death rate for individuals with an HIV diagnosis and the death rate for Hispanics was nearly double the rate for Whites as of 2016. Death rates for individuals with HIV are deaths due to any cause, not only from HIV-related illness.

Figure 30 Death Rate for Individuals with HIV Diagnosis per 100,000 by Race/Ethnicity, 2013 and 2016

2013 2016

23.3 20.6

6.2 5.6 2.9 2.9 3.4 0.5 0.6 2.4 2.3 2.6

White Black Hispanic Asian AIAN NHOPI

Note: Data based on surveillance data reported by states to the CDC. AIAN refers to American Indians and Alaska Natives. NHOPI refers to Native Hawaiians and Other Pacific Islanders. Persons categorized by race were not Hispanic or Latino. Individuals in each race category may, however, include persons whose ethnicity was not reported. Includes individuals age 13 and older. Death rate data are as of 2016. Death rates for individuals with HIV are deaths due to any cause, not only from HIV- related illness. Source: Centers for Disease Control and Prevention, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, 2014-2016.

Key Facts on Health and Health Care by Race and Ethnicity 19

Health Conditions There were limited changes in rates of asthma, diabetes, and heart attacks or heart disease among nonelderly adults between 2013 and 2018 (data not shown; see Appendix Table 2). As of 2018, groups of color varied in the likelihood of having these conditions compared to Whites. AIANs were more likely than Whites to have asthma, diabetes, and a heart attack or heart disease (Figure 31). Blacks, Hispanics, and NHOPIs also were more likely to have diabetes than Whites. In contrast, Asians were less likely to have asthma and less likely to have a heart attack or heart disease compared to Whites.

Figure 31

Percent of Nonelderly Adults with Selected Health Conditions by Race/Ethnicity, 2018 Told By Doctor They Have Report Currently Told By Doctor Had a Heart Attack or Have Asthma They Have Diabetes Have Heart Disease

White 10% 7% 4%

Black 12%^ 11%^ 4%

Hispanic 7%^ 9%^ 4%

Asian/Pacific 5%^ 6% 2%^ Islander

AIAN 17%^ 14%^ 7%^

NHOPI 7%^ 10%^ 5%

^ Indicates statistically significant difference from Whites in the respective year at the p<0.05 level. Note: AIAN refers to American Indians and Alaska Natives. NHOPI refers to Native Hawaiians and Other Pacific Islanders. Persons of Hispanic origin may be of any race but are categorized as Hispanic for this analysis; other groups are non-Hispanic. Includes nonelderly adults 18-64 years of age. Source: Kaiser Family Foundation analysis of 2018 Behavioral Risk Factor Surveillance System.

The share of White children with asthma decreased between 2013 and 2018 (Figure 32). As of 2018, asthma rates were higher for Black and Hispanic children compared to White children, while Asian children were less likely than White children to have asthma. Data do not allow for separate measures of Asians and NHOPIs; there were insufficient data for AIAN children.

Figure 32 Percent of Children Ages 0-17 Who Have Asthma by Race/Ethnicity

2013 2018

13%^ 14%^ 8% 7% 8%^ 6%* 5%^ 4%^ N/A N/A

White Black Hispanic Asian AIAN NHOPI

* Indicates statistically significant difference from 2013 at the p<0.05 level. ^ Indicates statistically significant difference from Whites in the respective year at the p<0.05 level. Note: AIAN refers to American Indians and Alaska Natives. NHOPI refers to Native Hawaiians and Other Pacific Islanders. Persons of Hispanic origin may be of any race but are categorized as Hispanic for this analysis; other groups are non-Hispanic. Data are included in an “other” racial category and cannot be separately identified or point estimates do not meet minimum standards for statistical reliability. Source: Kaiser Family Foundation analysis of 2013 & 2018 National Health Interview Survey.

Key Facts on Health and Health Care by Race and Ethnicity 20

Groups of color generally had lower cancer rates than Whites as of 2016 (Figure 33). Across the examined indicators, cancer rates were generally lowest for AIANs and Asians and Pacific Islanders. Data do not allow for separate measures of Asians and NHOPIs. Statistically significant differences between Hispanics and Whites cannot be identified due to overlapping samples between these groups.

Figure 33 Age-Adjusted Rate of Cancer Incidence Per 100,000 by Race/Ethnicity, 2016

White Black Hispanic Asian/Pacific Islander AIAN

437 433^

335 277^ 275^

125 123^ 94 92^ 72^ 57 57 37 42^ 33 29^ 30^ 29 33^ 38^

New Cancer Rate Breast Cancer Rate Colon and Rectum Lung and Bronchus (Female Only) Cancer Rate Cancer Rate ^ Indicates statistically significant difference from Whites at the p<0.05 level. Note: AIAN refers to American Indians and Alaska Natives. Data for Native Hawaiians and Other Pacific Islanders could not be separated from Asians. Persons of Hispanic origin may be of any race; other groups may include individuals reporting Hispanic ethnicity. Significance testing between White and Hispanic not indicated due to overlapping samples between these groups. Data for groups other than White and Black should be interpreted with caution; see source technical notes for more information. Includes individuals of all ages. Source: U.S. Cancer Statistics Working Group. U.S. Cancer Statistics Data Visualizations Tool, based on November 2018 submission data (1999-2016): U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute; https://www.cdc.gov/cancer/uscs/USCS-1999-2016-ASCII.zip, June 2019.

Death rates associated with heart disease and cancer decreased for nearly all groups between 2013 and 2017, but only Hispanics saw a decrease in diabetes-related death rates (data not shown; see Appendix 2). Blacks had a higher risk of death for all three diseases compared to Whites as of 2017 (Figure 34). Hispanics and AIANs also had higher diabetes death rates than Whites, but lower rates of heart disease and cancer deaths. Asians and Pacific Islanders had the lowest death rates for these conditions. Data do not allow for separate measures of Asians and NHOPIs.

Figure 34 Age-Adjusted Death Rates per 100,000 for Selected Diseases by Race/Ethnicity, 2017

Diabetes Heart Disease Cancer

White 18.8 167.3 157.9

Black 38.7^ 204.2^ 178.0^

Hispanic 25.5^ 112.5^ 108.1^

Asian/Pacific 16.5^ 84.3^ 95.2^ Islander

AIAN 46.1^ 149.4^ 130.0^

^ Indicates statistically significant difference from Whites at the p<0.05 level. Note: AIAN refers to American Indians and Alaska Natives. Persons of Hispanic origin may be of any race but are categorized as Hispanic for this analysis; other groups are non-Hispanic. Includes individuals of all ages. Data for Native Hawaiians and Other Pacific Islanders were not separated from Asians. Data for some groups should be interpreted with caution; see http://wonder.cdc.gov/wonder/help/ucd.html#Racial. Source: Centers for Disease Control and Prevention, National Center for Health Statistics, WONDER Online Database, Underlying Cause of Death, 2017. Accessed at http://wonder.cdc.gov/ucd-icd10.html.

Key Facts on Health and Health Care by Race and Ethnicity 21

Smoking, Obesity, and Substance Use Between 2013 and 2018, smoking rates declined for White, Black, Hispanic, and Asian nonelderly adults, while obesity rates increased among White, Black, Hispanic, and Asian adults (Figure 35). Hispanics and Asians had lower smoking rates than Whites as of 2018, while AIANs were more likely than Whites to smoke. Blacks, Hispanics, AIANs, and NHOPIs had higher obesity rates than Whites, while Asians were less likely than Whites to be obese.

Figure 35 Smoking and Obesity Rates Among Nonelderly Adults by Race/Ethnicity, 2013 and 2018

Percent Who Smoke (%) Percent Who are Obese (%) 2013 2018 2013 2018

40*^ 38^ 39^ 36^ 35^ 32^ 34*^ 35^ 28% 31* 31^ 31 22% 22 24 23 19* 18* 14^13*^ 12*^ 10^ 8*^ 10^

White Black Hispanic Asian AIAN NHOPI White Black Hispanic Asian AIAN NHOPI

* Indicates statistically significant difference from 2013 at the p<0.05 level. ^ Indicates statistically significant difference from Whites in the respective year at the p<0.05 level. Note: AIAN refers to American Indians and Alaska Natives. NHOPI refers to Native Hawaiians and Other Pacific Islanders. Persons of Hispanic origin may be of any race but are categorized as Hispanic for this analysis; other groups are non-Hispanic. Includes nonelderly individuals 18-64 years of age. Share of adults who are obese is the share with a BMI of 30 or greater. Source: Kaiser Family Foundation analysis of 2013 & 2018 Behavioral Risk Factor Surveillance System.

Obesity rates for children remained stable across groups between 2011-2012 and 2015-2016. As of 2015-2016 rates were higher among Black and Hispanic children compared to White children (Figure 36). There were insufficient data for AIAN and NHOPI children.

Figure 36 Percent of Children Ages 2-19 Who are Obese by

Race/Ethnicity

2011-2012 2015-2016

26%^ 20%^ 22%^ 22%^ 14% 14% 9%^ 11% N/A N/A White Black Hispanic Asian AIAN NHOPI

* Indicates statistically significant difference from 2013-2014 at the p<0.05 level. ^ Indicates statistically significant difference from Whites in the respective year at the p<0.05 level. Note: AIAN refers to American Indians and Alaska Natives. NHOPI refers to Native Hawaiians and Other Pacific Islanders. Persons of Hispanic origin may be of any race but are categorized as Hispanic for this analysis; other groups are non-Hispanic. N/A: Data are included in an “other” racial category and cannot be separately identified. Source: Kaiser Family Foundation analysis of 2011-2012 National Health and Nutrition Examination Survey and Data Brief 288: Prevalence of Obesity Among Adults and Youth: United States, 2015–2016, available: https://www.cdc.gov/nchs/data/databriefs/db288_table.pdf#4.

Key Facts on Health and Health Care by Race and Ethnicity 22

As of 2018, there were few differences across groups in alcohol or illicit drug dependence or abuse (Figure 37). Asians were less likely than Whites to report alcohol or illicit drug dependence or abuse. Due to changes in methodology, 2018 data could not be compared to data prior to the ACA.

Figure 37 Alcohol and/or Illicit Drug Dependence or Abuse in the Past Year Among Teens and Adults Age 12 and Older by Race/Ethnicity, 2018

8% 10% 9% 7% 7% 5%^

White Black Hispanic Asian AIAN NHOPI

^ Indicates statistically significant difference from the White population at the p<0.05 level. Note: AIAN refers to American Indians and Alaska Natives. NHOPI refers to Native Hawaiians and Other Pacific Islanders. Persons of Hispanic origin may be of any race but are categorized as Hispanic for this analysis; other groups are non-Hispanic. See source for classifications of illicit drugs and dependence or abuse. Source: Substance Abuse and Mental Health Services Administration. (2019). Results from the 2018 National Survey on Drug Use and Health: Detailed tables. Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration. Retrieved from https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHDetailedTabs2018R2/NSDUHDetailedTabs2018.pdf, Table 5.5B.

Conclusion In sum, disparities in health and health care remain a persistent challenge in the United States. The data presented here show that despite improvements in some measures since implementation of the ACA coverage expansions, people of color continue to face significant disparities in coverage, access to, and utilization of care, and health status and outcomes. The scope and types of disparities vary across racial and ethnic groups. These disparities are driven by a wide range of factors both inside and outside the health care system. Moreover, although the ACA included provisions designed to increase data available to identify and monitor disparities, there remain key gaps in data, particularly for some racial and ethnic subgroups.

Key Facts on Health and Health Care by Race and Ethnicity 23

Methods Data for this chart pack come from a variety of nationally-representative datasets, including the 2013 and 2017 American Community Survey, the 2012, 2013, and 2018 Behavioral Risk Factor Surveillance System, the 2013 and 2018 National Health Interview Survey, the 2011-2016 National Health and Nutrition Examination Survey, and the 2018 National Survey on Drug Use and Health, as well as from several online reports and databases, including the 2017 Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report (MMWR) on vaccination coverage, the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (NCHHSTP) Atlas, the United States Cancer Statistics Incidence and Mortality Web-based Report, the 2017 CDC Natality Public Use File, and the CDC WONDER online database.

Unless otherwise noted, race/ethnicity was categorized by non-Hispanic White (White), non-Hispanic Black (Black), Hispanic, non-Hispanic American Indian and Alaska Native (AIAN), non-Hispanic Asian (Asian), and non-Hispanic Native Hawaiian or Other Pacific Islander (NHOPI). Asian and NHOPI race categories were combined when they could not be separately identified. “N/A” indicates that data for a racial/ethnic group could not be separated from an “other” category in that data source or cases in which point estimates have relative standard errors greater than 30% and do not meet minimum standards for statistical reliability. Non-Hispanic Whites were the reference group for all significance testing. All noted differences were statistically significant differences at the p<0.05 level.

Endnote

1 This analysis measures disparities in absolute terms—i.e., the simple difference between groups of color and Whites for each measure. Disparities may also be measured in relative terms by examining the percentage difference between measures for groups. Absolute and relative measures of disparities can provide differing results regarding changes in disparities over time. For more information see: Keppel, K., et al., (2005). Methodological issues in measuring health disparities. Vital and health statistics. Series 2, Data evaluation and methods research, (141), 1–16, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3681823/.

Key Facts on Health and Health Care by Race and Ethnicity 24

Appendix Table 1: Differences Compared to Whites and Between Pre-ACA to Recent Data for Selected Access and Utilization Measures White Black Hispanic Asian AIAN NHOPI Pre- % Point Pre- % Point Pre- % Point Pre- % Point Pre- % Point Pre- % Point Recent Recent Recent Recent Recent Recent ACA Change ACA Change ACA Change ACA Change ACA Change ACA Change COVERAGE AND ACCESS Uninsured Rate 12% 7% -5.0% 19% 11% -7.7% 30% 19% -11.1% 16% 7% -8.6% 30% 22% -8.4% 18% 11% -7.5% Overall Did Not See a Doctor 15% 13% -2.2% 23% 17% -5.6% 27% 21% -6.3% 12% 10% -2.7% 25% 19% -6.2% 19% 19% 0.8% Due to Cost Delayed Needed Care for Reasons Other 19% 19% 0.3% 27% 24% -3.7% 30% 25% -4.1% 21% 19% -1.9% 35% 36% 1.6% 22% 26% 4.0% than Cost Nonelderly Adults with No Usual Source of 16% 14% -1.2% 21% 20% -1.1% 31% 26% -4.9% 18% 15% -3.2% 16% 10% -6.3% Care Other than ER N/A Children with No Usual Source of Care 3% 3% 0.1% 4% 8% 3.8% 7% 7% -0.2% 5% 6% 1.3% N/A Other than ER UTILIZATION OF CARE Nonelderly Adults with No Health Care Visit 17% 15% -2.2% 20% 17% -2.8% 33% 28% -4.8% 24% 24% -0.4% 13% 21% 8.1% in Past 12 Months Nonelderly Adults with No Dental Visit in Past 34% 31% -3.0% 44% 37% -6.9% 50% 41% -8.3% 36% 32% -3.5% 39% 43% 3.8% 12 Months Children with No Health Care Visit in 7% 6% -1.1% 7% 5% -1.7% 10% 8% -1.8% 7% 10% 2.8% N/A Past 12 Months N/A Children with No Dental Visit In Past 12 19% 18% -1.0% 22% 15% -7.4% 22% 17% -4.8% 23% 17% -6.1% 18% N/A N/A Months Children (19-35 Months) Who Have Not Received All 28% 28% 0.6% 35% 33% -1.5% 31% 30% -1.1% 27% 28% 0.3% 30% 34% 4.2% Recommended Immunizations Women (50-74) that Did Not Receive a 21% 22% 0.5% 17% 16% -1.3% 23% 21% -2.4% 17% 21% 4.0% 30% 25% -4.8% N/A 16% N/A Mammogram in the Past 2 Years Women (21-65) that Did Not Receive a 20% 25% 5.0% 15% 18% 3.1% 18% 21% 2.9% 25% 32% 6.6% 26% 29% 3.3% 20% 23% 3.4% Pap Smear in the Past 3 Years SUMMARY Worse - - 1 8 7 2 9 8 1 5 3 1 5 4 0 1 2 0 No Difference/ - - 6 2 3 4 2 3 4 5 8 8 5 5 7 3 3 3 No Change Better - - 5 2 2 6 1 1 7 2 1 3 0 0 2 0 0 1 Missing - - 0 0 0 0 0 0 0 0 0 0 2 3 3 8 7 8 Note: Blue means group fares significantly better than Whites for the period OR statistically significant improvement between pre-ACA and Recent period, while orange means group fares significantly worse than Whites for the period OR statistically significant decline between pre-ACA and Recent period. N/A indicates no separate data for a racial/ethnic group, insufficient data for a reliable estimate, or comparisons not possible due to overlapping samples. AIAN refers to American Indians and Alaska Natives. NHOPI refers to Native Hawaiians and Other Pacific Islanders. Persons of Hispanic origin may be of any race but are categorized as Hispanic for this analysis; other groups are non-Hispanic. See Methods for sources.

Key Facts on Health and Health Care by Race and Ethnicity 25

Appendix Table 2: Differences Compared to Whites and Between Pre-ACA to Recent Data for Selected Health Status Measures White Black Hispanic Asian AIAN NHOPI Pre- % Point Pre- % Point Pre- % Point Pre- % Point Pre- % Point Pre- % Point Recent Recent Recent Recent Recent Recent ACA Change ACA Change ACA Change ACA Change ACA Change ACA Change HEALTH STATUS Fair or Poor Health Status 10% 9% -0.7% 15% 14% -0.8% 12% 11% -1.0% 7% 7% -0.3% 18% 20% 2.2% N/A Physical Limitation 30% 33% 2.6% 30% 30% -0.5% 20% 23% 3.1% 14% 17% 3.8% 42% 43% 0.7% ≥14 Physically Unhealthy 11% 11% 0.3% 12% 12% -0.2% 12% 12% -0.1% 5% 5% 0.3% 17% 20% 3.0% 9% 9% 0.0% Days ≥14 Mentally Unhealthy Days 12% 15% 2.4% 14% 15% 0.5% 13% 12% -0.3% 7% 7% 0.6% 20% 19% -0.5% 11% 12% 1.1% BIRTH RISKS AND OUTCOMES Pre-Term Births N/A 9% N/A N/A 14% N/A N/A 10% N/A N/A 9% N/A N/A 12% N/A N/A 11% N/A Low Birthweight N/A 7% N/A N/A 14% N/A N/A 7% N/A N/A 9% N/A N/A 8% N/A N/A 8% N/A Late/No Prenatal Care N/A 4% N/A N/A 10% N/A N/A 8% N/A N/A 5% N/A N/A 13% N/A N/A 20% N/A Teen Birth Rate/1,000 N/A 13.2 N/A N/A 27.5 N/A N/A 28.9 N/A N/A 3.3 N/A N/A 32.9 N/A N/A 25.5 N/A Infant Mortality Rate/1,000 N/A 4.7 N/A N/A 11.0 N/A N/A 5.1 N/A N/A 3.8 N/A N/A 9.2 N/A N/A 7.6 N/A HIV/AIDS DIAGNOSIS AND DEATH RATES HIV Diagnosis 13+ 6.2 5.9 -0.3 53.9 49.8 -4.1 21.9 20.8 -1.1 5.6 6.0 0.4 7.8 10.8 3.0 10.9 11.9 1.0 AIDS Diagnosis 13+ 3.4 2.5 -0.9 35.0 24.9 -10.1 12.2 8.5 -3.7 2.5 2.1 -0.4 4.5 3.6 -0.9 4.9 5.5 0.6 Death Rate for Individuals 2.9 2.9 0.0 23.3 20.6 -2.7 6.2 5.6 -0.6 0.5 0.6 0.1 3.4 2.4 -1.0 2.3 2.6 0.3 with a HIV Diagnosis 13+ HEALTH CONDITIONS Asthma Rate among Adults 9% 10% 0.2% 11% 12% 0.9% 7% 7% 0.1% 4% 5% 0.3% 14% 17% 2.9% 10% 7% -2.5% Diabetes Rate among Adults 7% 7% 0.7% 11% 11% 0.1% 9% 9% 0.1% 6% 6% 0.5% 12% 14% 1.4% 10% 10% 0.5% Heart Attack/Heart Disease 4% 4% 0.2% 5% 4% -0.6% 4% 4% 0.3% 2% 2% 0.4% 6% 7% 1.5% N/A 5% N/A among Adults Children's Asthma Rate 8% 6% -1.9% 13% 14% 0.9% 7% 8% 0.6% 5% 4% -1.1% N/A N/A New Cancers Rate/100,000 455 437 -18.5 460 433 -26.3 356 335 -21.6 295 277 -18.0 301 275 -26.3 Breast Cancer Rate/100,000 127 125 -1.6 125 123 -2.5 95 94 -1.1 94 92 -1.5 76 72 -4.2 (Female Only) Colon/Rectum Cancer 38 37 -1.6 46 42 -3.8 35 33 -1.5 31 29 -1.6 32 30 -2.0 Rate/100,000 Lung/Bronchus Cancer N/A: Combined with 62 57 -4.6 63 57 -5.6 32 29 -3.0 36 33 -3.7 45 38 -7.8 Rate/100,000 Asian Group Diabetes Death Rate/100,000 18.6 18.8 0.2 39.5 38.7 -0.8 26.3 25.5 -0.9 15.9 16.5 0.6 44.7 46.1 1.4 Heart Disease Death 170.9 167.3 -3.7 212.6 204.2 -8.4 120.1 112.5 -7.5 92.1 84.3 -7.8 154.5 149.4 -5.2 Rate/100,000 Cancer Death Rate/100,000 167.7 157.9 -9.9 194.4 178.0 -16.4 114.5 108.1 -6.4 101.3 95.2 -6.1 141.7 130.0 -11.8 SMOKING, OBESITY, AND SUBSTANCE USE Smoking Rate 22% 19% -3.1% 22% 18% -3.6% 14% 13% -1.4% 10% 8% -2.2% 35% 32% -3.3% 24% 23% -1.9% Obesity Rate 28% 31% 2.9% 38% 40% 2.3% 31% 34% 3.0% 10% 12% 2.1% 35% 39% 3.7% 31% 36% 5.0% Children's Obesity Rate 14% 14% 0.0% 20% 22% 1.8% 22% 26% 3.4% 9% 11% 2.4% N/A N/A Alcohol/Drug Dependence or N/A 8% N/A N/A 7% N/A N/A 7% N/A N/A 5% N/A N/A 10% N/A N/A 9% N/A Abuse SUMMARY Worse - - 5 17 19 1 9 14 1 1 3 3 13 17 1 2 8 3 No Difference/No Change - - 4 4 5 10 3 2 9 1 3 10 0 2 14 6 6 7 Better - - 12 0 3 10 9 11 11 19 21 8 6 7 5 1 3 0 Missing - - 6 6 0 6 6 0 6 6 0 6 8 1 7 18 10 17 Note: Blue means group fares significantly better than Whites for the period OR statistically significant improvement between pre-ACA and Recent period, while orange means group fares significantly worse than Whites for the period OR statistically significant decline between pre-ACA and Recent period. N/A indicates no separate data for a racial/ethnic group, insufficient data for a reliable estimate, or comparisons not possible due to overlapping samples. Changes may not match due to rounding. AIAN refers to American Indians and Alaska Natives. NHOPI refers to Native Hawaiians and Other Pacific Islanders. Persons of Hispanic origin may be of any race but are categorized as Hispanic for this analysis; other groups are non-Hispanic. HIV diagnosis, AIDS diagnosis, and death rate for individuals with a HIV diagnosis are all from surveillance data, therefore changes did not need to be statistically tested. See Methods for sources.

Key Facts on Health and Health Care by Race and Ethnicity 26