Healthcare Insurance: Who's Covered?

In 2022, 92.1% of people in the United States, or 304 million, had health insurance at some point during the year. This is an increase from 2021, when 300.9 million people, or 91.7% of the population, were covered. The number of uninsured people in the US has been decreasing since 2019, when 27.5 million people were uninsured. The decrease in the number of uninsured people is partly due to the coverage expansions put in place by the Affordable Care Act (ACA) and pandemic-era policies.

How many people are uninsured?

The number of people without health insurance in the US has been declining in recent years. In 2022, 8.4% or 27.6 million Americans of all ages did not have health insurance, compared to 10.3% or 33.2 million in 2019. This represents a decrease of 5.6 million people over the three-year period.

Among working-age Americans (those aged 18-64), 12.2% did not have health insurance in 2022, a decrease from 14.7% in 2019. The uninsured rate among adults aged 18-64 further declined to 11.0% in early 2023.

The decline in the uninsured rate is partly due to coverage expansions put in place by the Affordable Care Act (ACA), including Medicaid expansion and subsidized Marketplace coverage. These policies served as a safety net for people who lost their jobs or faced other economic disruptions during the coronavirus pandemic.

In 2022, the number of non-elderly uninsured individuals continued a downward trend, dropping by nearly 1.9 million from 27.5 million in 2021 to 25.6 million. The uninsured rate among the non-elderly population also reached an all-time low of 9.6% in 2022.

Most of the non-elderly uninsured individuals are adults in working low-income families, and people of colour. In 2022, nearly three-quarters (73.3%) of the non-elderly uninsured population had at least one full-time worker in their family, and over 80% had incomes below 400% of the Federal Poverty Level (FPL). People of colour made up 62.3% of the total non-elderly uninsured population, with Hispanic and White people comprising the largest shares at 40.0% and 37.7%, respectively.

Uninsured rates vary across states and regions, with individuals living in non-Medicaid expansion states being more likely to be uninsured. In 2022, adults in non-expansion states (19.2%) were twice as likely to be uninsured compared to those in Medicaid expansion states (9.1%).

Who is uninsured?

In 2022, 25.6 million nonelderly individuals were uninsured, a decrease of 3.3 million from 2019. Most of the nonelderly who are uninsured are adults, in working low-income families, and are people of colour.

Reflecting geographic variation in income and the availability of public coverage, most uninsured people live in the South or West. In addition, most who are uninsured have been without coverage for long periods of time.

Nearly three-quarters (73.3%) of the total nonelderly uninsured population in 2022 had at least one full-time worker in their family, and an additional 10.9% had a part-time worker in their family. More than eight in ten (80.8%) were in families with incomes below 400% of the Federal Poverty Level (FPL) in 2022, and nearly half (46.6%) had incomes below 200% of the FPL.

People of colour made up 45.7% of the nonelderly US population but accounted for 62.3% of the total nonelderly uninsured population. Hispanic and White people comprised the largest shares of the nonelderly uninsured population at 40.0% and 37.7%, respectively. Most uninsured individuals (75.6%) were US citizens, while 24.4% were noncitizens in 2022.

Nonelderly adults are more likely to be uninsured than children. The uninsured rate among children was 5.1% in 2022, less than half the rate among nonelderly adults (11.3%), largely due to the broader availability of Medicaid and CHIP coverage for children than for adults.

In general, racial and ethnic disparities in coverage persist. The uninsured rates for nonelderly Hispanic (18.0%) and American Indian and Alaska Native people (19.1%) are more than 2.5 times the uninsured rates for White people (6.6%). However, like in previous years, Asian people have the lowest uninsured rate at 6.0%, although this masks variation in the uninsured rate within the Asian population.

Noncitizens are more likely than citizens to be uninsured. The uninsured rate for recent immigrants, those who have been in the US for less than five years, was 30.3% in 2022, while the uninsured rate for immigrants who have lived in the US for more than five years was 33.1%. By comparison, the uninsured rate for US-born citizens was 7.7% and 9.5% for naturalized citizens in 2022.

Uninsured rates vary by state and by region; individuals living in non-expansion states are more likely to be uninsured. Ten of the fifteen states with the highest uninsured rates in 2022 were non-expansion states. Economic conditions, the availability of employer-sponsored coverage, and demographics are other factors contributing to variation in uninsured rates across states.

Why are people uninsured?

There are many reasons why people are uninsured. Here is an overview of the key factors:

Cost

The high cost of insurance is a significant factor in people being uninsured. In 2022, 64% of uninsured non-elderly adults cited the cost of coverage as the main reason for lacking insurance. This concern about affordability is not unfounded, as the average family premium for employer-based cover is $11,480 per year. Furthermore, total premiums for family coverage have increased by 42% since 2013, outpacing wage growth and contributing to the perception of insurance as unaffordable.

Eligibility

Eligibility criteria also play a role in people being uninsured. In 2022, 28.4% of uninsured non-elderly adults reported not being eligible for coverage. This issue is particularly prominent for undocumented immigrants, who are generally ineligible for federally funded coverage, including Medicaid and Marketplace plans. Additionally, lawfully present immigrants must typically meet a five-year waiting period before qualifying for Medicaid, contributing to coverage gaps.

Access and Awareness

Even when coverage is available, some people may not have access to it or be aware of their options. For example, in 2018, two-thirds of uninsured adults did not attempt to obtain health insurance through the marketplace, with over a third of them citing affordability concerns. Additionally, some people may be unaware of their eligibility for subsidized coverage or face barriers during the enrollment process.

Employment Status

Employment status also influences insurance coverage. Some employers may not offer health benefits to their workers, leaving them uninsured. Even when coverage is offered, the cost may still be a barrier for employees, especially if they have to cover dependents. This is particularly challenging for low-income families, where a significant portion of their income is spent on premiums and out-of-pocket medical expenses.

Political and Economic Factors

On a broader level, political and economic factors can impact insurance coverage. For instance, the federal budget deficit and low tax revenues may hinder the government's ability to prioritize healthcare and provide funding for universal coverage. Additionally, partisan divisions and a lack of organized advocacy for the uninsured can further complicate the legislative process and delay the implementation of comprehensive solutions.

How does not having insurance affect healthcare access?

Preventative Care and Screening Services

People without health insurance are less likely to receive preventative care and screening services. They are more likely to delay or forgo health care due to costs. Uninsured adults are over three times more likely than insured adults to say they have not had a health check-up in the past year. They are also less likely to receive recommended screening tests such as blood pressure checks, cholesterol checks, blood sugar screening, pap smear or mammogram (for women), and colon cancer screening. This is partly because half of uninsured people do not have a regular place to go when they are sick or need medical advice, while the majority of insured people do.

Cancer Care and Outcomes

Uninsured people are more likely to be diagnosed with cancer at a later stage and have a higher risk of dying than those with insurance. This is largely due to delayed diagnoses. Uninsured women are more likely to be diagnosed with breast cancer at a late stage and have a 30-50% greater risk of dying than women with private insurance. Uninsured patients with colorectal cancer have a greater risk of dying than those with private insurance, even when other factors such as the stage of cancer diagnosis and treatment methods are taken into account.

Chronic Disease Management and Patient Outcomes

Uninsured people with chronic diseases are less likely to receive appropriate care to manage their health conditions. They are less likely to receive routine screening services and to have frequent monitoring of their condition. For example, uninsured adults with hypertension are less likely to stay on drug therapy and more likely to experience worsening blood pressure control. Uninsured adults with diabetes are less likely to self-monitor blood glucose or receive recommended services such as foot examinations and eye exams.

Acute Care Services and Outcomes for Hospitalized Adults

Uninsured people are less likely to be admitted to hospital and receive fewer services when they are admitted. They are also more likely to experience higher rates of death in hospital and adverse medical events due to negligence. Uninsured people with acute cardiovascular disease are less likely to be admitted to a hospital that performs angiography or revascularization procedures and are more likely to die in the short term.

Overall Health Status and Mortality

Longitudinal studies have shown that uninsured adults are more likely to die prematurely than those with private insurance. Uninsured adults also experience greater declines in their self-reported health status over time.

What are the financial implications of being uninsured?

The financial implications of being uninsured can be significant, and often result in people forgoing necessary medical care. Uninsured individuals often face unaffordable medical bills, which can quickly lead to medical debt as most uninsured people have low or moderate incomes and limited savings. Uninsured people are also more likely to be charged higher rates for medical care than those with insurance, as hospitals frequently charge uninsured patients two to four times what health insurers or public programs pay for the same services.

In 2022, 85% of nonelderly uninsured adults in the US said they had difficulty affording health care costs, compared to 47% of adults with insurance. Over six in ten (62%) of uninsured adults reported having health care debt, compared to 44% of insured adults. Uninsured adults are more likely to face negative financial consequences due to health care debt, such as using up savings, having difficulty paying other living expenses, or borrowing money.

The financial implications of being uninsured can also lead to wider economic problems. Uninsured people are more likely to worry about paying for normal health care and medical bills, and over two-thirds (65%) of uninsured people with medical bill problems are unable to pay their medical bills at all. Uninsured adults are also more likely to face problems such as using up savings, having difficulty paying for necessities, borrowing money, or having medical bills sent to collection.

The financial implications of being uninsured can be particularly severe for those who do seek medical care. Uninsured people who use health care often have to pay the full cost of that care and frequently face difficulty paying medical bills. In 2015, a third (33%) of uninsured adults were asked to pay the full cost of medical care before they could see a doctor. Uninsured people are also more likely to pay a larger portion of their medical costs out-of-pocket, and in 2014, those without insurance who used medical services paid an average of $752 out of pocket, compared to $658 for those with private insurance and $236 for those with public coverage.

The financial implications of being uninsured can also have wider societal impacts. Providers incur billions in uncompensated care costs for the uninsured, and while funding is available to offset some of these costs, it does not fully cover them. In 2013, before the Affordable Care Act (ACA) was fully implemented, the uncompensated costs of care for the uninsured amounted to about $85 billion. While this amount is a small slice of total health care spending in the US, it can still place a significant burden on providers, particularly hospitals.

The financial implications of being uninsured can also be reduced through policy interventions. The ACA, which expanded coverage through Medicaid and subsidized Marketplace coverage, served as a safety net for people who lost jobs or faced economic and coverage disruptions during the coronavirus pandemic. As a result, the number of nonelderly uninsured individuals decreased by nearly 1.9 million from 2021 to 2022, and the uninsured rate decreased from 10.2% to a record low of 9.6%.

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