Alyssa Lane
The topic of Americans being over or under-insured is a critical issue that impacts the well-being and financial stability of individuals and families across the country. In recent years, the number of Americans without health insurance has decreased, with 8.4% or 27.6 million Americans uninsured in 2022. However, the issue of underinsurance remains prevalent, with many individuals facing unaffordable medical bills and accumulating medical debt. This situation disproportionately affects those with low or moderate incomes, who may struggle to access necessary healthcare services and face difficult choices between their health and financial stability. Understanding the dynamics of insurance coverage in the US is essential for policymakers and healthcare providers to ensure that individuals can access affordable and timely healthcare without compromising their financial well-being.
| Characteristics | Values |
|---|---|
| Number of uninsured people aged 0-64 in 2023 | 25.3 million |
| Number of uninsured children in 2023 | 4 million |
| Percentage of uninsured working-age Americans (18-64) in 2022 | 12.2% |
| Percentage of uninsured people of all ages in 2022 | 8.4% |
| Percentage of uninsured children of all ages in 2022 | 4.2% |
| Percentage of people with health insurance in 2022 | 92.1% |
| Percentage of people with private health insurance in 2022 | 65.6% |
| Percentage of people with public health insurance in 2022 | 36.1% |
| Percentage of uninsured adults facing difficulty affording health care costs | 49% |
| Percentage of insured adults facing difficulty affording health care costs | 21% |
| Percentage of uninsured adults with healthcare debt | 62% |
| Percentage of insured adults with healthcare debt | 44% |
| Percentage of underinsured adults avoiding healthcare due to cost | 57% |
| Percentage of underinsured adults with medical or dental debt | 44% |
| Percentage of adults with medical debt paying off $2000 or more | 48% |
| Number of people with medical debt in 2023 | 15 million |
| Amount of medical debt in billions in 2023 | $47 billion |
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What You'll Learn
Unaffordable medical bills
The high cost of healthcare in the US is a burden for many, with nearly half of US adults saying it is difficult to afford healthcare costs. This is a particular concern for lower-income families, with 49% of uninsured adults reporting difficulty in affording healthcare, compared to 21% of those with private insurance. Uninsured individuals often face unaffordable medical bills, which can quickly lead to medical debt, especially for those with low or moderate incomes and limited savings.
Even those with insurance can struggle with unaffordable medical bills and medical debt. In 2022, about four in ten adults (41%) reported having medical or dental debt, with this figure rising to 62% for uninsured adults. Medical debt is most common among those with poor health, financial insecurity, or both. People with complex health needs that require ongoing care can see medical bills accumulate over time, and those with worse health may also experience unemployment or income loss, making it even harder to afford medical bills.
High healthcare costs can lead people to delay or skip necessary medical care, with 57% of underinsured adults avoiding healthcare due to cost. This can have serious health consequences, with 41% of adults reporting that their health problems worsened due to delayed care. The high cost of prescription drugs is also an issue, with one in four adults opting for over-the-counter drugs instead of filling prescriptions due to cost concerns.
The complexity of the US healthcare system, with its various forms of insurance and associated rules, funding, and out-of-pocket costs, contributes to the challenge of affording healthcare. The lack of government intervention to control healthcare costs, as seen in other developed countries, drives up prices in the US. As a result, many Americans face the difficult choice between incurring unaffordable medical bills or forgoing necessary healthcare.
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Healthcare safety nets
The concept of a healthcare safety net in the United States conjures up the image of a tightly woven fabric of federal, state, and local programs stretched across the nation, ready to catch those who slip through the health insurance system. However, America's safety net is neither secure nor uniform, varying from state to state and community to community.
Public hospitals, community clinics and health centres, and local providers that serve underserved communities provide an important health care safety net for uninsured people. These safety net providers have limited resources and service capacity, and not all uninsured people have geographic access to them. Safety net hospitals are a type of medical centre that provides healthcare for individuals regardless of their insurance status or ability to pay. They are not defined by their ownership terms and can be either publicly or privately owned. Safety net hospitals tend to be located in areas with a lack of socioeconomic development and a shortage of healthcare providers. They often face financial instability and challenges in delivering care.
The financing and delivery of healthcare in the United States have undergone significant changes due to a more competitive healthcare marketplace, evolving federal policies, and the devolution of responsibilities to state and local governments. The introduction of managed care and the push for greater cost-effectiveness and efficiency have also played a role. Core safety net providers, such as hospitals, have struggled with the inability to shift costs for uncompensated care onto private insurance revenues, especially with restrictions on Medicaid revenues, their primary source of third-party financing.
To address the challenges faced by safety net providers, various strategies have been employed, including site visits, background papers, and funding from organisations like the California Healthcare Foundation and The Commonwealth Fund. Despite these efforts, America's healthcare safety net remains fragile, with safety net hospitals facing financial and operational difficulties.
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Uninsured rates by age
The percentage of uninsured Americans remained stable between 2022 and 2023, with an overall rate of uninsurance of 8.0% in 2023, a negligible change from 7.9% in 2022. However, rates of uninsurance vary across age groups, with adults aged 19-64 being more likely to be uninsured than children.
Among working-age adults (aged 19-64), the overall uninsured rate was 10.9% in 2023. However, this rate varied significantly across different demographic groups. For example, the uninsured rate among working-age Hispanic adults was 23.6%, roughly twice that of Black adults (11.1%) and more than twice that of non-Hispanic White and Asian adults (7% and 6.8%, respectively).
Texas has the highest uninsured rate in the nation for adults and children, with 21.7% of Texas adults aged 19-64 lacking health insurance in 2023, nearly double the national rate of 11.0%. The high uninsured rate in Texas has been attributed to the state's refusal to expand Medicaid, which has left millions of federal dollars untapped that could have been used to fund healthcare.
While Medicare offers near-universal coverage for those aged 65 and older, with less than 1% uninsured in this age group, the number of uninsured children increased from 3.8 million in 2022 to 4.0 million in 2023. The rate of uninsured children in 2023 was 4.6% in Medicaid expansion states and 8.3% in non-expansion states.
Uninsured rates also vary by income levels, with lower rates in Medicaid expansion states (8.9%) compared to non-expansion states (15.5%). Nearly six in ten uninsured individuals in 2023 were eligible for financial assistance through Medicaid or subsidized Marketplace coverage. However, over four in ten uninsured individuals were outside the reach of the Affordable Care Act (ACA) due to factors such as their state's non-expansion of Medicaid, ineligible immigration status, or access to affordable Marketplace plans.
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Healthcare costs and debt
Uninsured Americans and Healthcare Costs
Uninsured individuals in the US often face significant financial challenges when seeking healthcare. Nearly half of uninsured adults struggle with affording healthcare costs, and these costs can rapidly translate into medical debt. Uninsured adults are more likely to postpone or forgo healthcare due to financial concerns, and when they do seek care, they may encounter unaffordable medical bills. This situation disproportionately affects low-income families, with over ten million uninsured individuals facing limited access to financial assistance or safety net providers.
Underinsured Americans and Healthcare Costs
Underinsured Americans, those with insurance but inadequate coverage, also face challenges with healthcare costs. In 2024, 57% of underinsured adults avoided necessary healthcare due to financial concerns, and 44% reported having medical or dental debt. The fear of incurring expenses is not limited to the uninsured, as many insured Americans share this worry. This fear endangers the health of individuals with and without insurance, as delaying care can lead to worsening health problems.
Medical Debt in the US
Medical debt is a persistent issue in the US, impacting a significant portion of the population. In 2023, an estimated 15 million people had $47 billion in medical debt on consumer credit reports, with three in ten adults reporting they were paying off medical debt. The burden of medical debt falls disproportionately on lower-income adults, Black and Hispanic adults, women, and parents, and those with complex health needs or disabilities. People with cancer, for example, often face higher levels of debt due to the ongoing nature of their treatment. High deductibles, copays, and cost-sharing requirements can quickly accumulate to unmanageable financial obligations, even for those with insurance.
Impact of Healthcare Costs and Medical Debt
The impact of healthcare costs and medical debt goes beyond finances, affecting the health and well-being of individuals. Many Americans report cutting spending on essential items like food and clothing to pay for medical bills, and the stress of medical debt can take a toll on mental health. Additionally, skipping or delaying care due to financial concerns can have detrimental health consequences, with nearly two in ten adults reporting worsened health as a result.
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Insurance coverage trends
The number of Americans without health insurance has decreased in recent years. Between 2019 and 2022, the overall number of Americans without health insurance dropped by 5.6 million, with 8.4% (27.6 million) of Americans uninsured in 2022 compared to 10.3% (33.2 million) in 2019. This decrease in the uninsured rate continued into 2023, with 92.1% of people (304 million) having health insurance at some point during the year, an increase from 91.7% (300.9 million) in 2022.
Despite these gains, disparities persist, and certain groups remain more likely to be uninsured. For example, in 2023, the number of uninsured children increased to 4 million, up from 3.8 million in 2022. Adults ages 19-64 are also more likely to be uninsured than children, and racial and ethnic disparities in coverage persist.
Even among those with insurance, underinsurance is a significant issue. In 2024, 57% of underinsured adults reported avoiding necessary healthcare due to cost concerns, and 44% had medical or dental debt they were paying off over time. This problem is particularly acute for those with chronic health issues, with a quarter of those surveyed reporting that they had skipped doses or not filled prescriptions due to out-of-pocket costs.
The financial implications of being uninsured or underinsured can be severe. Uninsured and underinsured individuals often face unaffordable medical bills, leading to medical debt. In 2023, an estimated 15 million people had $47 billion of medical debt on consumer credit reports, with three in ten working-age adults reporting problems paying medical bills.
Overall, while insurance coverage rates have improved in recent years, issues of underinsurance and financial barriers to accessing healthcare persist, highlighting areas where policy interventions are needed to ensure timely and affordable care for all Americans.
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Frequently asked questions
As of 2024, a majority of American adults have the coverage necessary to enable access to timely and affordable healthcare. In 2022, 92.1% of people, or 304 million, had health insurance at some point during the year, representing an increase from 2021.
Uninsured individuals often face unaffordable medical bills, which can quickly lead to medical debt. They are also more likely to postpone or forgo healthcare due to financial concerns. High uninsured rates contribute to rural hospital closures, further limiting access to care.
Underinsured individuals may avoid seeking necessary healthcare due to cost concerns, leading to potential health deterioration. They are also more likely to incur medical debt, with nearly half of underinsured adults reporting medical or dental debt.
Several factors include income, state policies, immigration status, and the availability of public coverage. Most uninsured individuals are from low-income families, and adults ages 19-64 are more likely to be uninsured than children. State decisions on Medicaid expansion and eligibility criteria also play a significant role.
