Recent changes to Medicaid programs, aimed at closing a health coverage gap in the U.S., have left behind some Americans — particularly people of color.

Among the non-elderly population in the U.S. — those under age 65 — insured rates rose during the Covid pandemic, with 3.4 million Americans enrolling in health coverage between 2019 and 2022, according to a report by KFF. That shift was due in part to the Medicaid and health care marketplace provisions put in place as a result of the Affordable Care Act, the report said.

But as the global health crisis waned and Medicaid coverage expansions faced delays in some states, insured rates fell and Black Americans remained disproportionately uninsured compared with white Americans, according to KFF, formerly known as Kaiser Permanente.

In 2022, 10% of Black Americans were uninsured, compared with 6.6% of white Americans. Black people were 1.5 times more likely to be uninsured than their white peers in 2022, the report said. People who identified as American Indian or Alaskan Native were 2.9 times more likely than their white counterparts to be uninsured, while Hispanic Americans were 2.7 times more likely to be uninsured.

“The biggest driver of the racial coverage gap is the states that have not expanded Medicaid under the Affordable Care Act,” said Jenn Wagner, a director at the Center on Budget and Policy Priorities. “Those states have a higher population of Black individuals who are unable to access Medicaid coverage because they don’t fit into one of the eligibility categories within that state.”

Medicaid, a joint program between the federal government and states, offers health insurance to low-income adults and children. The Affordable Care Act passed in 2010, included a provision to expand Medicaid coverage to people at lower income levels who may not be covered by private insurers. But not all states have expanded the coverage requirements, according to KFF.

In those states that haven’t expanded Medicaid, uninsured adults who don’t meet the requirements for coverage but still fall under the poverty line are left with little option.

In 2022, about half of Black Americans younger than 65 were insured through an employer or a private insurer, according to KFF, while nearly 40% were insured through Medicaid or another public option.

Black unemployment rates are consistently higher than the national average and higher than other groups, according to U.S. Bureau of Labor Statistics data, meaning fewer Black people have access to health insurance through employers. In January, Black unemployment ticked up slightly to 5.3%, according to the bureau, compared with a national average of 3.7% and a white unemployment rate of 3.4%.

“Most Black people are in a family with a full-time worker, but less likely than their white counterparts to have private coverage, which reflects that they’re more likely to be in low-income jobs that may not offer health coverage,” said Samantha Artiga, a director at KFF.

In states that don’t offer Medicaid expansion, 13.3% of non-elderly Black Americans are uninsured, according to KFF, compared with 7.3% of that population in states that have already adopted the expansion.

Adding to the disparity in uninsured rates, a separate provision of Medicaid that automatically reenrolled participants for coverage ended in March 2023, leaving millions of Americans to proactively reenroll themselves. Many, unaware of the changes, saw their coverage lapse.

“We’re seeing a lot of administrative barriers with the renewal process that are coming very clear,” Wagner said. “People are losing coverage, not because they’re determined ineligible or fall into the coverage gap, but because they didn’t get the form or the state didn’t process the timeline.”

Since March, at least 17.4 million people were disenrolled from Medicaid or the related Children’s Health Insurance Program coverage. More than 35 million people had their coverage renewed, while 41 million renewals are either pending or not yet due, according to KFF.

Community health centers such as West Oakland Health, founded by four Black women in 1967, are working to address the coverage gap. Robert Phillips, the chief executive officer of WOH, said the center noticed a downtick in patients immediately following the end of continuous enrollment.

“The drop in Medicaid patients was precipitous,” Phillips said.

Phillips and his staff began reaching out to their Medicaid patients, and he said patients have been returning as the centers alert them to the need to renew their coverage.

“It’s making us work extra hard,” Phillips said. “We want folks to know they’re still eligible for coverage and for those who just didn’t know because they got a notice saying that their coverage ended.”

WOH’s five locations in the East Bay Area of California serve minorities and low-income households seeking affordable health care. Most of the patients at WOH are Black and are covered under Medicaid, according to the company.