Uninsured Americans: A Large Number

In early 2023, the national uninsured rate in the US reached an all-time low of 7.7%. This is a significant decrease from 2019, when the uninsured rate was 10.3%. Approximately 6.3 million people have gained health coverage since 2020, with 5.5 million of those being adults aged 18-64 and 0.7 million being children aged 0-17. The Biden-Harris Administration's efforts to increase healthcare access and lower costs, as well as the continuous enrollment condition in Medicaid, have been credited with this success.

The uninsured rate among children in the US

In 2019, the uninsured rate among children in the US was 5.1%. This rate decreased to 4.2% in 2021, with 3.9 million children under the age of 19 without health insurance, a decrease of 475,000 children from 2020. The decrease in the uninsured rate was driven by an increase in public coverage, particularly Medicaid and CHIP.

In 2022, the uninsured rate among children held steady at 5%, with nearly 4 million children under the age of 19 lacking insurance coverage. This rate was maintained from 2021, and 17 states saw their uninsured rates decline. However, the expiration of pandemic-relief measures in 2023 is expected to cause these numbers to climb.

The variation in uninsured rates among children across states is influenced by differences in state policies, practices, and local economic conditions. In 2022, the Northeast states of Massachusetts and Rhode Island had the lowest uninsured rates (2%), while Texas had the highest rate at 11%, with 854,000 children lacking insurance.

Overall, the uninsured rate among children in the US has been declining, with fluctuations, and public coverage programs like Medicaid and CHIP have played a significant role in reducing the number of uninsured children.

The number of uninsured nonelderly people

In 2022, the uninsured rate among children was 5.1%, less than half the rate among nonelderly adults (11.3%). This disparity is largely due to the broader availability of Medicaid and CHIP coverage for children compared to adults. Additionally, nonelderly adults are more likely to be uninsured than elderly individuals, as Medicare offers near-universal coverage for the elderly, with just 457,000 (less than 1%) of people over the age of 65 uninsured.

Racial and ethnic disparities in health coverage persist, with nonelderly Hispanic and American Indian and Alaska Native people more than 2.5 times more likely to be uninsured compared to White people. Undocumented immigrants are also disproportionately affected, as they are ineligible for federally funded coverage, including Medicaid and Marketplace coverage.

Most of the nonelderly uninsured population in the US are adults in working, low-income families, with at least one full-time worker in the family. In 2022, nearly three-quarters (73.3%) of nonelderly uninsured individuals had at least one full-time worker in their family, and more than eight in ten (80.8%) had incomes below 400% of the Federal Poverty Level (FPL). People of colour are overrepresented in the nonelderly uninsured population, accounting for 62.3% of the total, despite making up 45.7% of the nonelderly US population.

The high cost of insurance is the main reason cited by uninsured nonelderly adults for lacking coverage. In 2022, 64% of this population group stated that they were uninsured because the cost of coverage was too high. Many uninsured nonelderly individuals do not have access to coverage through their jobs, and some, especially those in states that have not expanded Medicaid, remain ineligible for financial assistance.

Racial disparities in insurance coverage

The number of uninsured Americans has been steadily decreasing since 2019, with the uninsured rate dropping by 18% during the pandemic. In 2022, 8.4% of Americans, or 27.6 million people, did not have health insurance, compared to 10.3% in 2019.

Despite these overall gains, racial and ethnic disparities in insurance coverage persist. Nonelderly American Indian and Alaska Native and Hispanic people experienced the largest gains in coverage between 2019 and 2022, with uninsured rates falling by 2.4 and 2.0 percentage points, respectively. However, as of 2022, nonelderly AIAN and Hispanic people still had the highest uninsured rates at 19.1% and 18.0%, respectively. Uninsured rates for nonelderly Native Hawaiian and Other Pacific Islander (12.7%) and Black (10.0%) individuals were also higher than the rate for their White counterparts (6.6%).

Hispanic, Black, AIAN, and NHOPI people are more likely to be uninsured compared to White people due to more limited access to affordable health coverage options. While most individuals have at least one full-time worker in the family across all racial and ethnic groups, there are ongoing disparities in employment and income that result in some individuals not having coverage offered by an employer or being unable to afford private coverage.

Prior to the Affordable Care Act (ACA), about 19% of the non-elderly US population was uninsured, with higher rates among racial and ethnic minorities. The ACA has helped to reduce these disparities by offering subsidies to lower-income working families, expanding Medicaid eligibility, and providing outreach in multiple languages to lower linguistic barriers. Despite these efforts, racial and ethnic disparities in insurance coverage remain, and in some cases have widened over time.

The dynamic nature of insurance coverage, with individuals gaining and losing coverage over time, also contributes to disparities. Minority groups have a greater propensity to lose insurance, and trigger events such as losing employment or changing jobs are connected to insurance loss. African Americans and Hispanics are more likely to lose existing health insurance coverage due to higher rates of unemployment and job loss. Additionally, language barriers and immigration rules that prevent undocumented immigrants from enrolling in public plans contribute to higher uninsured rates among Hispanics.

Addressing these racial and ethnic disparities in insurance coverage is crucial for improving access to healthcare and reducing health disparities. Efforts to stabilize and expand access to affordable coverage, such as the continuous enrollment provision in Medicaid and enhanced Marketplace subsidies during the COVID-19 pandemic, have helped to narrow differences in uninsured rates. However, further progress may be at risk as these temporary provisions are unwound.

The impact of the Affordable Care Act (ACA)

The Affordable Care Act (ACA) has had a significant impact on healthcare in the US, with three primary goals:

• Make affordable health insurance available to more people: The ACA provides subsidies ("premium tax credits") that lower costs for households, particularly those with incomes between 100% and 400% of the federal poverty level.
• Expand Medicaid coverage: The ACA aims to expand Medicaid to cover all adults with incomes below 138% of the federal poverty level. This expansion is optional for states, and as of 2020, 39 states, including the District of Columbia, had opted to expand Medicaid.
• Support innovative medical care delivery methods: The ACA supports the development of innovative approaches to lower the overall cost of healthcare.

The impact of the ACA has been far-reaching and has contributed to a decrease in the number of uninsured individuals in the US. Here are some key impacts of the ACA:

• Increased health insurance coverage: The ACA enabled millions of people to gain health insurance coverage, either through expanded Medicaid or the establishment of the Health Insurance Marketplace. An estimated 10.8 million low-income uninsured individuals enrolled in Medicaid in 2014, and this number grew to 12.2 million by 2015.
• Improved access to healthcare services: Gaining coverage through the ACA helped people improve their access to healthcare services. However, there are still limitations and gaps in the depth of covered services, especially in Medicaid and affordable private health insurance (PHI) plans.
• Reduced uninsured rate: The ACA contributed to a significant decline in the uninsured rate in the US. The National Health Interview Survey estimated that the rate of uninsured people dropped to 9% by 2015. The uninsured rate further decreased to an all-time low of 7.7% in early 2023, with approximately 6.3 million people gaining coverage since 2020.
• Addressing disparities: The ACA has helped reduce racial and ethnic disparities in healthcare coverage. However, disparities persist, and individuals in low-income families, people of color, and non-citizens are more likely to be uninsured.
• Improving financial security: The ACA has improved financial security for low-income individuals and families by making health insurance more affordable and reducing out-of-pocket expenses.
• Supporting safety net providers: The ACA has provided additional support to safety net providers, such as public hospitals, community clinics, and health centers, that serve uninsured and underserved communities.

While the ACA has had a positive impact on healthcare coverage and access, there are still challenges and limitations. For example, the availability of providers who accept Medicaid and the limited capacity of healthcare providers to meet the increased demand for services are ongoing issues. Additionally, the impact of the ACA varies across states, with inconsistent implementation of coverage expansions and differences between Medicaid-expanded and non-expanded states.

The financial implications of being uninsured

Being uninsured can have serious financial implications for individuals in the US. Uninsured people often face unaffordable medical bills, which can quickly lead to medical debt, especially since most uninsured people have low or moderate incomes and little to no savings. In 2017, non-elderly uninsured adults were twice as likely as those with insurance to have problems paying medical bills, with nearly two-thirds unable to pay their medical bills at all. Uninsured adults are more likely to face negative financial consequences such as using up their savings, struggling to pay for basic necessities, or borrowing money.

The cost of uncompensated care for the uninsured is substantial, amounting to about $85 billion in 2013. While funding from various sources, including the federal government, helps providers defray these costs, it does not fully offset them. Hospitals frequently charge uninsured patients two to four times what health insurers and public programs pay for the same services. As a result, people without insurance pay a much larger portion of their medical costs out-of-pocket compared to those with insurance.

Being uninsured can also impact an individual's ability to work and be productive. Lack of health coverage can lead to poorly managed chronic conditions, undetected or untreated illnesses, and a higher risk of avoidable deaths. This, in turn, can result in missed workdays or early retirement due to health reasons, affecting not only the individual but also their employer.

Furthermore, the financial implications of being uninsured extend beyond the individual to society as a whole. A healthy and productive population is beneficial to society, and when a significant portion of the population lacks health coverage, it can result in forgone economic benefits. Additionally, the health care system is burdened by bad debt and inefficient care for the uninsured, further exacerbating the issue.

Overall, the financial implications of being uninsured are far-reaching and have an impact on individuals, businesses, the health care system, and society at large.

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