Alyssa Lane
In 2023, an estimated 8% of the US population, or 26 million people, were without health insurance. This is a significant number of people, but it is also one of the lowest rates in history. The number of uninsured people varies by age and poverty level, with nearly one in four US adults having health coverage all year but facing high out-of-pocket costs. The high cost of insurance is the main reason many people lack coverage, and nearly half of uninsured adults say they struggle to afford healthcare costs. The US has made gains in health insurance coverage since the Affordable Care Act's passage, but more work is needed to cover the remaining uninsured.
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What You'll Learn
The percentage of people without health insurance in 2023
The percentage of people without health insurance in the United States has been steadily declining over the years, reaching one of its lowest levels in history in 2023. According to a September 2024 report by the Census Bureau, around 8% of the population, or about 26 million people, were uninsured in 2023. This is a significant improvement from the years before the Affordable Care Act (ACA) was enacted in 2010, when the uninsured rate averaged 15%.
The decline in the uninsured rate from 2019 to 2023 was primarily driven by gains in Medicaid and Marketplace coverage due to pandemic-era coverage protections. The number of people with Medicaid coverage increased, and the continuous enrollment provision enacted during the pandemic played a role in this increase. However, this provision ended on March 31, 2023, and the full effects of disenrollments were not felt until after 2023. Despite this, the overall number of people with health insurance in 2023 increased compared to pre-pandemic levels, with 9 million more insured individuals than in 2018.
The uninsured rate varies across different demographic groups. In 2023, the share of children without health insurance increased, with 4 million children uninsured, up from 3.8 million in 2022. The uninsured rate for children under the age of 19 increased by 0.5 percentage points to 5.8% between 2022 and 2023. However, the share of children without insurance in 2023 was still lower compared to 2019. Additionally, adults aged 19-64 are more likely to be uninsured than children, with an uninsured rate of 11.1% in 2023, down from 11.3% in 2022.
Racial and ethnic disparities in coverage persist, with AIAN and Hispanic people more likely to be uninsured than their White counterparts. From 2019 to 2023, the uninsured rate for AIAN people decreased from 21.7% to 18.7%, while the rate for Hispanic people decreased from 20.0% to 17.9%. In 2022, more than one in four Hispanic adults aged 18-64 (27.6%) lacked health insurance, a higher percentage than Black, non-Hispanic adults (13.3%), White, non-Hispanic adults (7.4%), and Asian, non-Hispanic adults (7.1%).
The high cost of insurance is a significant factor contributing to the lack of coverage for many individuals. In 2023, 63% of uninsured adults aged 18-64 cited the cost of coverage as the main reason for not having insurance. Uninsured individuals often face unaffordable medical bills and are more likely to incur medical debt. Nearly half (49%) of uninsured adults report difficulty affording healthcare costs, and more than six in ten (62%) have medical debt.
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The reasons why people are uninsured
In 2023, 92% of people in the US, or approximately 305.2 million people, had health insurance for some or all of the year. This means that around 8% of people, or 25.3 million, were uninsured. The number of uninsured children increased from 3.8 million in 2022 to 4.0 million in 2023.
The main reason why people are uninsured is the high cost of insurance. In 2023, 63% of uninsured adults aged 18-64 said that they were uninsured because the cost of coverage was too high. Many uninsured people do not have access to coverage through their jobs, and some, particularly in states that have not expanded Medicaid, are ineligible for financial assistance. While over half of uninsured people may be eligible for Medicaid or subsidised coverage, they may not be aware of these options or may face barriers to enrolling. Even with subsidies, Marketplace coverage may not be affordable.
Unaffordable medical bills can quickly translate into medical debt, especially for those with low or moderate incomes. Uninsured people are less likely to access care and more likely to delay or forgo it due to concerns over costs. This can have severe consequences, particularly when preventable conditions or chronic diseases go undetected.
Other reasons for people being uninsured include a lack of knowledge about their coverage options, and the loosening of regulations on short-term plans that don't comply with the ACA, which may expose people to high costs and insurance fraud.
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The financial implications of being uninsured
In the first quarter of 2023, 7.7% of US adults, or 25.3 million people, were uninsured. This figure represents a slight decrease from the previous quarter, but it is still a significant number. The percentage of people without health insurance in the US remained around 8% in 2023, with rates varying by age and poverty level. Most uninsured people are in low-income families, and the main reason cited for lacking insurance coverage is the high cost of insurance.
The cost of insurance is a significant factor in why some people are uninsured. Insurance premiums can be expensive, and for those on low incomes, affording coverage can be challenging. The premium rate for a life insurance policy, for example, depends on mortality and interest rates, as well as operating costs. As insurance costs continue to rise, many companies are no longer able to offer it as an employee benefit. Shopping for insurance in the private market often results in expensive policies and high-deductible plans.
Government initiatives like the Affordable Care Act (ACA) and the expansion of Medicaid have helped make insurance more accessible. The ACA allows millions to access subsidised healthcare plans, and the continuous enrollment provision during the pandemic ensured that people remained enrolled in Medicaid. However, many consumers are ineligible for these subsidies, and even with subsidies, Marketplace coverage may not be affordable. Additionally, undocumented immigrants are ineligible for federally funded coverage, including Medicaid and Medicare.
The impact of being uninsured goes beyond financial penalties. Lack of health insurance leads to reduced access to medical services and poorer health outcomes. Uninsured individuals may also face challenges in receiving compensation for injuries and losses in the event of an accident. However, it is important to note that hospitals that accept federal money are required to provide a certain amount of free or reduced-fee care, and federal and state laws mandate that certain hospitals offer some level of charity care.
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Racial and ethnic disparities in coverage
In 2023, 92% of people in the USA, or approximately 305.2 million, had health insurance for some or all of the year. This figure represents a slight decrease from 2022, when 92.1% of people, or 304 million, were insured. Despite this high overall rate of insurance coverage, racial and ethnic disparities persist.
Racial and ethnic disparities in health and healthcare are pervasive in the USA. Black and AIAN (American Indian or Alaska Native) individuals experience lower life expectancies and higher rates of premature mortality compared with White and Hispanic populations. These disparities are particularly pronounced in states with high concentrations of these minority communities. According to the Commonwealth Fund 2024 State Health Disparities Report, unequal access to high-quality care fuels these disparities.
Hispanic individuals, in particular, face the highest uninsured rates and encounter significant barriers to accessing high-quality care. Disparities in the quality of care and utilization of health care services are also evident, with White populations generally receiving better quality care compared with Black, Hispanic, AIAN, and AANHPI (Native Hawaiian or Other Pacific Islander) communities.
The Institute of Medicine (IOM) defines disparities in healthcare as "racial or ethnic differences in the quality of health care that are not due to access-related factors or clinical needs, preferences, and appropriateness of intervention." The IOM report on unequal treatment concluded that "racial and ethnic disparities in healthcare exist and, because they are associated with worse outcomes in many cases, are unacceptable."
Several factors contribute to racial and ethnic disparities in health and healthcare. Policy decisions at the federal, state, and local levels have perpetuated economic suppression, educational disparities, and housing segregation, which contribute to unequal access to high-quality care. While initiatives like the Affordable Care Act (ACA) have narrowed these gaps to some extent, significant disparities remain, particularly in states that have not expanded Medicaid eligibility.
To address these disparities, the Commonwealth Fund report outlined several policy recommendations, including:
- Extending enhanced marketplace premium subsidies permanently
- Encouraging states to expand Medicaid or allow Medicaid-eligible individuals to enroll in zero-premium marketplace plans
- Reducing deductibles and out-of-pocket costs for marketplace insurance plans
- Lowering immigration-related barriers to coverage for certain groups of undocumented, low-income immigrant adults and children
- Requiring insurers to collect and report information on race and ethnicity to promote equitable treatment of enrollees in commercial insurance plans
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The impact of the COVID-19 pandemic on insurance coverage
The COVID-19 pandemic has had a significant impact on insurance coverage in the United States. While the overall rate of insurance coverage remained relatively stable during the pandemic, with 92.0% of people insured in 2023, the pandemic has exposed and exacerbated existing disparities in access to healthcare.
One of the most significant impacts of the pandemic has been the loss of employment-based insurance coverage for millions of Americans. As unemployment rates rose during the pandemic, many people lost their health insurance along with their jobs. This was particularly pronounced among communities of colour, who were disproportionately impacted by job losses. According to Families USA, the spike in uninsured Americans during the pandemic was 39% higher than any previous annual increase.
The pandemic also highlighted the vulnerability of certain racial and ethnic groups in the United States, who experienced higher rates of infection and mortality due to underlying social and economic inequalities. African Americans, for example, were more likely to be essential workers, live in dense urban environments, and have pre-existing health conditions, all of which increased their risk of exposure to the virus. Additionally, Hispanic and Filipino Americans were heavily impacted by the pandemic, with many working in essential jobs and facing language barriers that hindered their access to health information. The pandemic also led to increased "othering" and xenophobia towards Asian Americans, resulting in lower testing rates and higher excess mortality.
Indigenous communities in the United States, such as the Navajo Nation, were also particularly hard hit by the pandemic, experiencing infection rates that surpassed those in densely populated states. Additionally, undocumented immigrants within these communities faced additional challenges in accessing healthcare due to fears of deportation under the Trump administration's hardline immigration policies.
While the expansion of Medicaid and Marketplace coverage during the pandemic helped to offset some of the losses in employment-based insurance, the unwinding of these provisions began in April 2023. As a result, the number of uninsured children increased from 3.8 million in 2022 to 4.0 million in 2023, indicating a potential reversal of the gains made during the pandemic.
The pandemic has also had broader implications for the insurance industry, with insurers facing complex issues such as coverage for pandemic-induced business interruptions and increased liability risks. The pandemic's impact on the economy has also led some individuals to reduce their insurance spending or seek less expensive coverage, further exacerbating the impact on insurance coverage.
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Frequently asked questions
In 2023, 26 million people, or 8% of the population, were without health insurance.
The percentage of people without health insurance has been declining since 2019. In 2022, 8.4% of Americans, or 27.6 million people, did not have health insurance, down from 10.3% in 2019.
In 2023, the uninsured rate for children under the age of 19 was 5.8%, up from 5.3% in 2022. Among working-age Americans (those ages 18-64), 12.2% did not have health insurance in 2022.
Uninsured people often face unaffordable medical bills and are more likely to delay or forgo care because of costs. They are also more likely to have health care debt.
