Health Policy Fact Sheet January 2020
Education Matters: Despite Improvements Under the ACA, Disparities in Coverage Based on Educational Level Persist Gerald Kominski, Petra W. Rasmussen, Chengcheng Zhang, Safia Hassan, and Deborah Freund
Since 2013, the Affordable Care Act (ACA) has produced significant reductions in the number of uninsured individuals. Nevertheless, important disparities persist among the remaining uninsured. Such disparities are based on a number of factors, including Medicaid expansion status,1 race and ethnicity,2 occupation,3 and employment status.4 One overlooked disparity in coverage is the association between educational attainment and lack of insurance. Although the impact of education on earnings is well documented,5 our findings suggest that education continues to have an important impact on the likelihood of being uninsured, regardless of income level. We found substantial differences by educational level within each category of income. Specifically, lower levels of educational attainment are associated with higher rates of uninsurance in both the pre- and post-ACA periods. Furthermore, differences in rates of uninsurance by educational level have increased in the post-ACA period, indicating greater disparities based on educational attainment.
Using data from the American Community Survey from 2013 and 2018, we calculated the percentage of adults ages 18-64 years old who were uninsured based on their educational attainment. We also stratified the data by three income categories: up to 100% of the federal poverty level (FPL), 100-399% FPL, and 400%+ FPL.
Despite substantial reductions compared to 2013, those with incomes less than 100% FPL continued to have the highest rates of uninsurance in 2018 (Exhibit 1). In 2013, those without a high school or GED diploma had an uninsured rate that was 20 percentage points higher than the rate for those with a graduate degree. Although all groups improved by 2018, the percentage difference between those without a high school or GED diploma and those with a graduate degree actually increased compared to the pre-ACA period, indicating greater disparity. This finding suggests that relative changes in the rate of uninsurance, not just absolute percentage-point changes, are an important measure when examining disparities.
Because significant differences have been documented in the rate of uninsurance among low-income people in Medicaid expansion versus nonexpansion states, we also examined the educational differences for those with incomes less than 100% FPL in expansion versus nonexpansion states. We observed the same pattern as that seen in Exhibit 1: Although expansion states had lower rates of uninsurance by educational level in 2013 compared to nonexpansion states,
This study was conducted jointly by the UCLA Center for Health
Policy Research and the Claremont Graduate University with support
from the A-Mark Foundation.
UCLA CENTER FOR HEALTH POLICY RESEARCH
Uninsured Rate for 18-64-Year-Olds by Educational Attainment and Income (as a Percentage of the Federal Poverty Level), 2013 and 2018
Exhibit 1
0% 10% 20% 30% 40% 50%
46.5% 41.8%
32.4% 33.9%
29.2% 26.8%
42.6% 28.9%
23.5% 18.9%
15.4% 11.6%
31.5% 25.4%
18.2% 18.9%
16.7% 15.3%
30.6% 19.1%
14.6% 11.3%
9.3% 7.2%
21.1% 11.0%
7.9% 6.0%
4.0% 2.2%
15.8% 8.4%
5.6% 4.2%
2.7% 1.6%
2013
2018
2013
2018
2013
2018
< 10
0% F
P L
10 0–
39 9%
F P
L 40
0% +
F P
L
Less than high school or GED diploma High school or GED diploma Some college
Associate’s degree Bachelor’s degree Graduate degree
Note: Authors’ analysis of the American Community Survey, 2013 and 2018. For 2018, 100% FPL was $12,060 for an individual and $24,600 for a family of 4; 400% FPL was $48,240 for an individual and $98,400 for a family of 4.
both expansion and nonexpansion states saw greater relative improvement by 2018 among those with at least some college education, indicating greater disparity.
The educational differences observed among those whose incomes were 100-399% FPL and who were subsidy eligible under the ACA were even greater than among those
UCLA CENTER FOR HEALTH POLICY RESEARCH
whose incomes were below the poverty level. In 2013, those without a high school or GED diploma were 3.7 times more likely to be uninsured than those with a graduate degree. This relative difference was greater in 2018, despite improvements for every category of educational attainment between 2013 and 2018. Those with at least some college saw reductions of 38% to 40% in their rate of being insured, while those with a high school or GED diploma had a 34% reduction, and those without a high school or GED diploma had a 28% reduction.
Perhaps most surprising is that, while absolute levels of uninsurance were lowest among those with the highest incomes, the relative differences by educational level were greatest in this income group. In 2013, those without a high school or GED diploma were almost 10 times more likely to be uninsured compared to those with a graduate degree, despite having incomes of at least 400% FPL. In 2018, this relative difference had not diminished, despite absolute reductions among every category of educational attainment.
Our findings suggest that educational attainment plays an important role in health insurance status independent of its impact on household income. Further, although the ACA has produced substantial reductions in the percentage of uninsured across both income categories and categories of educational attainment, disparities by educational level persist and have not diminished as a result of the ACA. The reasons for these results are not immediately obvious, but the findings certainly merit attention and further investigation. Educational attainment may be associated with other factors that make it difficult to obtain health insurance, even if health insurance is seemingly more affordable. At a minimum, our results certainly challenge the notion that affordability alone is the major determinant of being uninsured, especially in light of our findings that educational
differences in rates of uninsurance are large at the lowest income levels and even greater at higher levels of income.
Data Data for this fact sheet are from the 2013 and 2018 American Community Survey.
Author Information Gerald F. Kominski is a senior fellow at the UCLA Center for Health Policy Research and a professor at the UCLA Fielding School of Public Health. Petra W. Rasmussen is a graduate student researcher at the UCLA Center for Health Policy Research and a PhD candidate at the UCLA Fielding School of Public Health. Chengcheng Zhang is a PhD candidate at Claremont Graduate University. Safia Hassan is an undergraduate student at Scripps College. Deborah Freund is a university professor and president emerita at Claremont Graduate University.
Suggested Citation Kominski GF, Rasmussen PW, Zhang C, Hassan S, Freund D. 2020. Education Matters: Despite Improvements Under the ACA, Disparities in Coverage Based on Educational Level Persist. Los Angeles, CA: UCLA Center for Health Policy Research.
Endnotes 1 Courtemanche C, Marton J, Ukert B, Yelowitz A,
Zapata D. 2017. Early Impacts of the Affordable Care Act on Health Insurance Coverage in Medicaid Expansion and Nonexpansion States. Journal of Policy Analysis and Management 36(1):178-210.
2 Artiga S, Orgera K, Damico A. February 2019. Changes in Health Coverage by Race and Ethnicity Since Implementation of the ACA, 2013-2017. San Francisco: Kaiser Family Foundation. Issue Brief.
3 Agarwal SD, Goldman AL, Sommers BD. 2019. Blue-Collar Workers Had Greatest Insurance Gains After ACA Implementation. Health Affairs 38(7):1140-1144.
4 Berdahl TA, Moriya AS. 2018. Difference in Uninsurance Rates Between Full- and Part- Time Workers Declined in 2014. Health Affairs 37(10):1669-1672.
5 Vilorio D. March 2016. Career Outlook: Education Matters. U.S. Bureau of Labor Statistics.
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