The following section describes the race and ethnicity of those who have selected a plan in the Federally-facilitated Marketplace (FFM) through during the period October 1, 2013–March 31, 2014 (including Special Enrollment Period (SEP) activity through April 19, 2014). States with State-based Marketplaces are not required to report race and ethnicity to CMS.
Race and Ethnicity Data Obtained from the FFM Application
The application for coverage through the FFM contains questions on race and on ethnicity, both marked as optional (See Figure C1 below).29 For ethnicity, applicants can choose one or more options describing Latino and Hispanic origin or “Other” ethnicity. The question on race contains several detailed race categories, plus an option for “Other” race.30
Questions on Race and Ethnicity on the Application for Coverage through the FFM.
For our analysis of the characteristics of individuals who selected a Marketplace plan through the FFM by race/ethnicity, we have combined the detailed categories on the Marketplace application into eight basic categories for race/ethnicity: American Indian/Alaska Native, African-American, Asian, Latino, Native Hawaiian/Pacific Islander, White, Multiracial, and Unknown/Other.31 For example, the detailed categories Japanese and Chinese are grouped with other detailed races into the broader “Asian” category.
Our first step in creating mutually exclusive classifications for race/ethnicity was classifying as Latino those who reported any Latino/Hispanic ethnicity. Next, non-Latinos were classified as multiracial if they reported two or more major race categories. The remaining non-Latinos were classified as American Indian/Alaska Native alone, African-American alone, Asian alone, Native Hawaiian/Pacific Islander alone, and White alone. Using these combined racial/ethnic categories, 31.1 percent of persons who selected Marketplace plans through the FFM were classified in the category Unknown/Other.
For the race question alone, 34.8 percent of the total 5.45 million who selected a Marketplace plan through the FFM either did not respond or selected “Other,” which is not distinguishable from nonresponse (“unknown”) in the data available for analysis. For the ethnicity question, 92.6 percent either did not respond or selected “Other.” Overall, we have information on neither race nor ethnicity for 31.1 percent of those who selected a Marketplace plan through the FFM.
Rates of Unknown Race/Ethnicity in Other Data
At 31.1 percent, the share of unknown race/ethnicity in FFM Marketplace plan selection data is higher than in survey data. Federal surveys have lower non-response rates to questions on race and ethnicity: the main Census surveys have missing data on 3 to 5 percent of respondents, and the National Health Interview Survey has missing information for about 5 percent of respondents. The federal statistical agencies generally impute race and ethnicity to fill in these gaps in survey data.32
However, the proportion of missing race/ethnicity data among those who have selected a Marketplace plan through the FFM is lower than that reported in administrative data sources in the healthcare industry. One study found that one-third to one-half of commercial plans report challenges in collecting data from enrollees due to concerns for privacy, as well as inadequate IT resources, and a lack of race/ethnicity fields on forms.33 As of 2008, commercial plans that collected race and ethnicity data only had information for about 40 percent of their members.34 The health insurance company Aetna, which began collecting data on race and ethnicity for all its members in 2002 via enrollment forms, currently has information on race/ethnicity for about 35 percent of its membership.35 A study of administrative data from the Department of Veterans Affairs found that race/ethnicity information was missing from files for 36 percent of patients.36 Research shows that administrative data may not accurately reflect applicants’ race and ethnicity, and minority groups may be particularly under-reported. Studies examining sources of administrative data have found that race and ethnicity data does not match self-reported data, or other analyses that reclassify race/ethnicity data. For example, numerous studies demonstrate that the Medicare Enrollment Database under-identifies Hispanics, Asians, Pacific Islanders, and American Indians, compared to White and African-American beneficiaries.37,38,39,40 Researchers who compared self-reported race against information in the Medicare Enrollment Database found that race information in the database was correct for only 29.5 percent of people who self-reported as Hispanic, 35.7 percent of those who self-reported as of American Indians/Alaska Natives, and 54.7 percent of those who self-reported as of Asians/Pacific Islanders.41,42
Moreover, the racial/ethnic makeup of 31 percent of persons with unknown race and ethnicity who selected a Marketplace plan through the FFM may differ substantially from that among those who reported race and ethnicity. For example, if racial and ethnic minorities are more likely to skip the optional questions, they would be disproportionately under-reported in the overall totals. Moreover, the percentage unknown varies greatly by state. In four states (Arkansas, Montana, North Dakota, and South Dakota), the percentage with unknown race/ethnicity is less than 20 percent, while the rate of unknown race/ethnicity is over 35 percent in Michigan, Louisiana, and Florida. See Appendix Table C2 below for state level numbers of individuals who did and did not report their race and ethnicity.
Research shows that minorities may be concerned, skeptical, or confused about why their race/ethnicity data is being collected, and fear that this data may be used to target them for charging higher premiums or denying care.43 Some people believe that they would receive disparate services based on their answers to questions about race and ethnicity.44 Consumers want assurances that their race and ethnicity data will be confidential, and used for purposes of improving quality.45
Race/Ethnicity among Persons Who Selected a Marketplace Plan through the FFM
Unknown/Other included: According to self-reported information on race/ethnicity on Marketplace applications, including those who chose not to report information, Whites (43.3 percent) account for the largest proportion of Marketplace plan selections through the FFM. The next largest race/ethnicity categories are African-Americans (11.5 percent), Latinos (7.4 percent), and Asians (5.5 percent). Nearly one-third (31.1 percent) of the total 5.4 million individuals who have selected a Marketplace plan through the FFM selected either no choice or “Other” for both ethnicity and race on their application for Marketplace coverage. (See Table C1, column A for details.)
Unknown/Other excluded: Among those individuals who selected a Marketplace plan through the FFM and reported their race/ethnicity, Whites represent the largest proportion (62.9 percent), followed by African-Americans (16.7 percent), Latinos (10.7 percent), and Asians (7.9 percent) (see Column B of Table C1 and Figure C3 below for details).
Appendix Table C1.
Distribution of FFM Marketplace Plan Selections by Race and Ethnicity46
10-1-2013 to 3-31-2014, Including Additional SEP Activity through 4-19-14
Comparison to the QHP Eligible Population
Racial and ethnic minorities make up a disproportionately large share of the nation’s uninsured nonelderly U.S. citizens and others lawfully present (“eligible uninsured”).47 The private plans in the Marketplaces serve eligible individuals who are uninsured, as well as those who may have previously sought coverage through the individual market. For this reason we compare the FFM Marketplace plan selections to the estimated QHP eligible population—individuals potentially eligible for Marketplace coverage but not for Medicaid/CHIP. For purposes of this analysis, our estimate of the “QHP eligible” includes U.S. citizens and others lawfully present who are uninsured or have nongroup health insurance (coverage through the individual market) and who have family incomes that are too high to qualify either for Medicaid or an exemption from the coverage mandate on the basis of financial hardship. Specifically, the QHP eligible include uninsured and nongroup-covered adults in Medicaid expansion states with family incomes above 138 percent of the FPL, adults with incomes above 100 percent of the FPL in non-expansion states, and children (age 0-18) with family incomes above 250 percent of the FPL in both types of states.48
Overall, the distribution of FFM Marketplace plan selections by race/ethnicity looks similar to the distribution of the QHP eligible population. However, the proportion of Whites and of Latinos is lower among FFM Marketplace plan selections than among the QHP eligible, while the proportion of Asians and African-Americans is higher among FFM Marketplace plan selections than the QHP eligible (see Figure C2).
Distribution by Race/Ethnicity of Marketplace Plan Selections and the QHP Eligible Population in the 36 FFM States, Where Race/Ethnicity Is Reported (Unknown/Other Category Is Excluded), 10-1-2013 to 3-31-2014, including Additional SEP Activity through 4-19-14
(1) AI/AN represents American Indian/Alaska Native; NH/PI represents Native Hawaiian/Pacific Islander.
(2) Native Hawaiians/Pacific Islanders account for 0.1 percent of FFM Marketplace plan selections and of the QHP eligible.
(3) This table shows the proportion of each race/ethnicity within the two different populations specified. For example, 62.9 percent of all individuals who have selected a Marketplace plan through the FFM are White, while 66.5 percent of all QHP eligible are White. The two percentages are based on different denominators.
Distribution of Marketplace Plan Selections in the FFM by Race/Ethnicity Where Race/Ethnicity Is Reported, (Excluding Unknown/Other), 10-1-2013 to 3-31-14, Including Additional SEP Activity through 4-19-14
Notes: Percentages are out of the total 3.8 million persons who selected a plan through the FFM and reported race/ethnicity. Of the total 5.4 million who selected a plan through the FFM, 31.1 percent did not report race or ethnicity.
Special Provisions for American Indians and Alaska Natives
The Affordable Care Act contains special provisions for American Indians and Alaska Natives relating to cost-sharing reductions, a special monthly enrollment period, and cost and eligibility rules for Medicaid/CHIP.49 The Marketplace application includes a separate question related to eligibility for these special protections provided to American Indians and Alaska Natives that is asked as part of the financial assistance application process. In response to this question, which is specific to American Indian/Alaska Native status, more than 48,103 persons who have selected a Marketplace plan through the FFM have indicated that they were American Indian or Alaska Native.50
Data from the optional race/ethnicity question on the Marketplace application provide an incomplete picture of American Indian and Alaska Native Marketplace plan selections because answering the question is voluntary.51 The optional race question on the Marketplace application is not used for determining whether American Indians and Alaska Natives qualify for benefits such as cost-sharing reductions and other protections.
In addition to special protections in the Marketplace, American Indians and Alaska Natives may be eligible for services through the Indian Health Service, which provides comprehensive primary health care and disease prevention services through a network of hospitals, clinics, and health stations on or near reservations. Indian Health Service facilities are predominately located in rural primary care settings and are managed by Indian Health Service, Tribes and Urban Indian programs. Initial American Indian and Alaska Native enrollment data may be low because of the statutory special monthly enrollment period and potential eligibility for Indian Health Service.
Variation by State
The racial/ethnic distribution of the persons who have selected a Marketplace plan through the FFM differs by state, reflecting variation in underlying state-level demographics.52 The following analysis is based on data for Marketplace plan selections where race/ethnicity is known (unknown/other is excluded); see Appendix Table C3 for additional details:
- Whites: In nearly all FFM states, Whites represent the largest share of Marketplace plan selections, though their proportion of enrollment ranges from 95.9 percent in Maine to 33.3 percent in Mississippi.
- Latinos: Border states have the highest shares of Latinos among Marketplace plan selections, with Texas at 33.6 percent, New Mexico at 31.1 percent, Arizona at 24.2 percent, followed by Florida at 19.2 percent.
- African-Americans: The highest concentration of African-American Marketplace plan selections is in Southern states, with Mississippi at 59.5 percent, Georgia at 38.6 percent, Louisiana at 37.9 percent, and Alabama at 29.9 percent.
- Asians: The highest concentration of Asians Marketplace plan selections is in Virginia at 17.7 percent, New Jersey at 16.3 percent, and Georgia at 14.8 percent.
- American Indians and Alaska Natives: The highest concentration of American Indians and Alaska Natives is in two states: Wyoming at 3.5 percent and Oklahoma at 3.1 percent.
- Native Hawaiians and Pacific Islanders: The highest concentration of Native Hawaiians and Pacific Islanders is in Alaska at 0.6 percent and Utah at 0.6 percent.
While this report does not include race and ethnicity data from most of the 15 State-based Marketplace states, California, Washington, and Nevada have publicly reported information on the racial and ethnic makeup of individuals who have selected Marketplace plans during the initial open enrollment period.
- California: For Covered California, 35 percent of the persons who have selected a Marketplace plan are White; 28 percent are Latino; 21 percent are Asian; 6 percent are of mixed race; 4 percent are of unknown race (non-Latino); 3 percent are African-American; 3 percent are of Other races; and less than 1 percent each are American Indian and Alaska Native, and Native Hawaiian and other Pacific Islander.53 The share of Latino Marketplace plan selections in California increased over the course of the initial open enrollment period: Latinos represented 18 percent of enrollees through December,54 and 26 percent of cumulative enrollment through February.55
- Washington: The state of Washington reported that among the 152,753 individuals who selected a Marketplace plan through March 31, 2014, 6.8 percent were of Latino ethnicity, 27.1 percent were non-Latino, and 66 percent did not declare their ethnicity. Race was reported separately from ethnicity, and 21.3 percent of enrollees did not provide their race. The reported race categories were: American Indian (0.6 percent of total), Asian (10.3 percent), African-American (2.4 percent), Other race (3.4 percent), Pacific Islander (1.7 percent), White (60.0 percent), Alaska Native (0.1 percent), and Hawaiian (0.1 percent). 56
- Nevada: In Nevada's Health Link, 17.8 percent of private plan enrollees have reported their ethnicity as Hispanic, according to a media report.57
Growth in the FFM
Data on race and ethnicity available from mid-February to the end of open enrollment show that enrollment among racial and ethnic minorities grew faster than those who reported themselves as White (see Figure C4).
Growth in Marketplace Plan Selections in the FFM by Race/Ethnicity, 2-22-2014 to 3-29-2014
Notes: Represents the weekly growth rate (percentage increase) in the number of unique individuals who have been determined eligible to enroll in a plan through the FFM, and have selected a plan (with or without the first premium payment having been received by the issuer) by race/ethnicity.
Source: Centers for Medicare & Medicaid Services, as of 4-29-2014
The Department will continue to develop outreach strategies to reach the eligible uninsured and encourage coverage through the Health Insurance Marketplace, including racial and ethnic minorities who are more likely to be uninsured. As we continue to assess the initial open enrollment period for the Marketplace, we will evaluate the lessons learned to work to improve outreach efforts and coverage rates in the 2014-2015 open enrollment period.
Based on experience with the Children’s Health Insurance Program (CHIP), we expect participation in the Marketplace to increase steadily over time across all racial and ethnic groups. The rate of participation among low-income children in CHIP, which was launched in 1997, has steadily increased among eligible children of all racial and ethnic groups over the past 15 years. We expect that concerted outreach efforts and a growing awareness of coverage options will increase the rate of insurance coverage across all populations for the Marketplace as well.
Appendix Table C2. Number of Individuals Who Selected a Marketplace Plan through the FFM, by State and by Race/Ethnicity (Unknown/Other included)
10-1-2013 to 3-31-14, Including Additional SEP Activity through 4-19-14
* Asterisks denote less than 0.1% or 10 or fewer Marketplace plan selections; however, the data for these states are included in the FFM total. Racial/ethnic categories are mutually exclusive. All individuals reporting Latino or Hispanic ethnicity are counted in the “Latino” column.
(1) Idaho and New Mexico are Federally supported SBMs for 2014; they are using the FFM platform for 2014.
Appendix Table C3. Distribution of Individuals Who Selected a Marketplace Plan through the FFM, by State and by Race/Ethnicity (Unknown/Other excluded)
10-1-2013 to 3-31-14, Including Additional SEP Activity through 4-19-14
* Asterisks denote less than 0.1% or 10 or fewer Marketplace plan selections. Racial/ethnic categories are mutually exclusive. All individuals reporting Latino or Hispanic ethnicity are counted in the “Latino” column.
(1) Idaho and New Mexico are Federally supported SBMs for 2014; they are using the FFM platform for 2014.
29 Answer options under the race/ethnicity questions on the Marketplace application are based on collection standards under Section 4302 of the Affordable Care Act. For more information, see: http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlid=208
30 The optional race question on the Marketplace application is not used for determining eligibility for special health insurance benefits and protections for American Indians and Alaska Natives.
31 The race/ethnicity categories used in this analysis correspond to the six minimum categories for the combined format of race/ethnicity reporting according to standards maintained by the U.S. Office of Management and Budget, plus categories for Multiracial and Unknown/Other. For more information, see: http://www.whitehouse.gov/omb/fedreg_1997standards
32 ASPE correspondence with U.S. Census and the National Center for Health Statistics regarding the American Community Survey, the Current Population Survey, and the National Health Interview Survey; February 2014.
33 José J. Escarce, Rita Carreón, German Veselovskiy, and Elisa H. Lawson, “Collection of race and ethnicity data by health plans has grown substantially, but opportunities remain to expand efforts,” Health Affairs, vol. 30, no. 10 (2011).
35 Aetna, “Aetna’s Commitment,” accessed April 25, 2014. Available at: http://www.aetna.com/about-aetna-insurance/initiatives/racial-ethnic-equ...
36 Nancy R. Kressin, Bei-Hung Chang, Ann Hendricks, and Lewis E. Kazis, “Agreement between administrative data and patients’ self-reports of race/ethnicity,” American Journal of Public Health, vol. 93, no. 10 (2003), p. 1734-1739.
37 Susan L. Arday, David R. Arday, Stephanie Monroe, and Jianyi Zhang, “HCFA's racial and
ethnic data: current accuracy and recent improvements,” Healthcare Financing Review, vol. 21, no. 4 (2000).
38 P.W. Eggers, and L. G. Greenberg, “Racial Differences in Hospitalization Rates among Aged Medicare Beneficiaries,” Health Care Financing Review, vol. 21, no. 4 (1998), p. 1-15.
39 DR. Waldo, “Accuracy and Bias of Race/Ethnicity Codes in the Medicare Enrollment Database,” Health Care Financing Review, Winter 2004-2005/Volume 26, Number 2.
40 Alan M. Zaslavsky, John Z. Ayanian, and Lawrence B. Zaborski, “The validity of race and ethnicity in enrollment data for Medicare beneficiaries." Health services research 47, no. 3 (2012), p. 1300-1321.
41 Celia Eicheldinger, and Arthur Bonito, “More accurate racial and ethnic codes for Medicare administrative data,” Health care financing review 29, no. 3 (2008).
42 Arthur Meltzer, Arthur J. Bonito, Celia R. Eicheldinger, and Christian Evensen, “Health Disparities: Measuring Health Care Use and Access for Racial/Ethnic Populations,” Centers for Medicare and Medicaid Services and RTI International, 2005.
43 Wynia R. Hasnain, Clark K. Taylor, and Ayodola Anise, “Collecting race, ethnicity, and language data to identify and reduce health disparities: perceptions of health plan enrollees,” Medical Care Research and Review 68, no. 3 (2011): 367-381.
44 “National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care: A Blueprint for Advancing and Sustaining CLAS Policy and Practice,” Office of Minority Health, U.S. Department of Health and Human Services, April 2013.
45 Wynia R. Hasnain, Clark K. Taylor, and Ayodola Anise, “Collecting race, ethnicity, and language data to identify and reduce health disparities: perceptions of health plan enrollees,” Medical Care Research and Review 68, no. 3 (2011): 367-381.
46 Column A is based on total Marketplace plan selections through the FFM, including those for whom race/ethnicity is unknown. Column B is based on total FFM Marketplace plan selections with known data on race/ethnicity (i.e., excluding those for whom race/ethnicity is unknown).
47 We use the term “eligible uninsured” to refer to those who are potentially eligible for coverage through the Marketplace and Medicaid/CHIP. For more information about eligibility to purchase coverage in the Marketplace, see https://www.healthcare.gov/immigration-status-and-the-marketplace/. The estimates contained in this brief do not take into account certain Marketplace coverage and Medicaid/CHIP eligibility requirements, such as those relating to other minimum essential coverage or tax filing requirements, and thus the populations described in this brief should be construed as “potentially” eligible, subject to these other requirements.
48 We make the simplifying assumption in this analysis that all children with incomes below 250 percent of the FPL would be eligible for Medicaid/CHIP rather than the Marketplace. Actual CHIP income thresholds vary by state.
49 Section 1402(d) of the Affordable Care Act.
50 This number is for the number of persons who selected Marketplace plans through the FFM for the period October 1, 2013 to April 21, 2014.
51 Of the total 5.4 million people who selected a plan through the FFM, 34.8 percent did not report race, and 31.1 percent reported neither race nor ethnicity.
52 This discussion does not include data from the 15 State-Based Marketplaces: California, Colorado, Connecticut, District of Columbia, Hawaii, Kentucky, Massachusetts, Maryland, Minnesota, Nevada, New York, Oregon, Rhode Island, Vermont, and Washington.
53 Covered California, “Covered California Enrollment Statistics, April 17, 2014, http://3.bp.blogspot.com/-Ir_3Vrs61_o/U1BpfBRhu2I/AAAAAAAAAZM/QqRUOE0rng...
54 Chad Terhune and Soumya Karlamangla, “More Latinos enrolling in Covered California health plans,” Los Angeles Times, February 19, 2014. Available at: http://www.latimes.com/business/la-fi-exchange-enrollment-20140220,0,507....
55 “Covered California Begins Countdown to Final Days to Enroll in Health Plans,” March 13, 2014. Available at: http://news.coveredca.com/2014/03/covered-california-begins-countdown-to....
56 Washington Health Benefit Exchange, “Health Coverage Enrollment Report: October 1, 2013 – March 31, 2014,” April 23, 2014. Available at: http://wahbexchange.org/files/4513/9821/1124/WAHBE_End_of_Open_Enrollmen...
57 Jennifer Robison, "Hispanic enrollment in state health insurance exchange proves disappointing," Las Vegas Review-Journal, April 26, 2014. Available at: http://www.reviewjournal.com/business/hispanic-enrollment-state-health-i....