Independent Insurance: Who Has It?

In 2022, 92.1% of people in the US, or 304 million, had health insurance at some point during the year. This represents an increase in the insured rate and number of insured people from 2021, when 91.7% or 300.9 million people were covered. The increase in the number of insured people is partly due to the coverage expansions put in place by the Affordable Care Act (ACA), which served as a safety net for those who lost their jobs or faced economic hardship during the coronavirus pandemic.

How many people are uninsured?

In 2022, 25.6 million nonelderly individuals were uninsured, a decrease of 3.3 million from 2019. The uninsured rate in 2022 was 9.6%, down from 10.2% in 2021 and 10.9% in 2019. This decrease is largely due to the 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 experienced other economic hardships during the coronavirus pandemic.

The number of nonelderly uninsured individuals dropped from 46.5 million in 2010 to fewer than 26.7 million in 2016 following the enactment of the ACA. However, this number climbed again during the Trump administration, prior to the pandemic. The uninsured rate among children was 5.1% in 2022, less than half the rate among nonelderly adults (11.3%). This is largely due to the broader availability of Medicaid and CHIP coverage for children compared to adults.

Among working-age Americans (those ages 18–64), 12.2% did not have health insurance in 2022, a decrease from 14.7% in 2019. The percentage of uninsured Americans of all ages decreased from 10.3% (33.2 million) in 2019 to 8.4% (27.6 million) in 2022. The number of uninsured children also decreased from 5.1% (3.7 million) in 2019 to 4.2% (3 million) in 2022.

The national uninsured rate reached an all-time low of 7.7% in early 2023, with approximately 6.3 million people gaining coverage since 2020. This is likely due to the Biden-Harris Administration's efforts to expand coverage and lower costs through various policies and plans such as the Inflation Reduction Act, the American Rescue Plan, and the Affordable Care Act (ACA).

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. Nonelderly adults are more likely to be uninsured than children, with the uninsured rate among children being 5.1% in 2022, less than half the rate among nonelderly adults (11.3%). This is 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 and American Indian and Alaska Native people are more than 2.5 times the uninsured rates for White people. However, Asian people have the lowest uninsured rate. Noncitizens are more likely than citizens to be uninsured. The uninsured rate for recent immigrants, those who have been in the U.S. 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%.

Most of the 25.6 million nonelderly people who are uninsured are in families with incomes below 400% FPL (80.8% in 2022) and nearly half (46.6%) had incomes below 200% FPL. People of colour make up a disproportionately large percentage of the uninsured population, with 45.7% of the nonelderly U.S. population accounting for 62.3% of the total nonelderly uninsured population.

Geographically, most uninsured people live in the South or West. Three-quarters of the uninsured population live in these regions.

Two-thirds of nonelderly people who were uninsured in 2022 have been without coverage for more than a year.

Why are people uninsured?

The main reason people are uninsured is the high cost of insurance. In 2022, 64% of uninsured non-elderly adults cited the cost of coverage as the main reason they lacked health insurance. This concern is especially prominent among low-income families, who make up two-thirds of the uninsured population. Despite policy efforts to improve the affordability of coverage, such as the Affordable Care Act (ACA), many people continue to struggle with the financial burden of insurance premiums.

Another factor contributing to people being uninsured is the lack of access to coverage through their jobs. Many individuals do not have the option of obtaining health insurance through their employer, and even when it is offered, the cost may still be prohibitive. From 2013 to 2022, total premiums for family coverage increased by 42%, outpacing wage growth, and the worker's share of these costs increased by 39%. This makes it challenging for low-income families to afford employer-based coverage.

Medicaid eligibility also plays a role in the uninsured rate. While Medicaid covers many low-income individuals, especially children, adult eligibility criteria vary across states. In states that have not expanded Medicaid, millions of adults fall into a "coverage gap," earning too much to qualify for Medicaid but not enough to qualify for Marketplace premium tax credits. Additionally, undocumented immigrants are generally ineligible for federally funded coverage, including Medicaid, further contributing to the uninsured population.

The complexity of the insurance system and a lack of knowledge about coverage options may also contribute to people remaining uninsured. Some individuals may not be aware of the availability of subsidized insurance plans or may find the enrollment process challenging. This is reflected in the Commonwealth Fund Biennial Health Insurance Survey from 2018, where two-thirds of uninsured adults had not visited the marketplace to explore their coverage options.

Finally, certain demographic factors increase the likelihood of being uninsured. In 2018, uninsured working-age adults were disproportionately from low-income households, Latino, and under the age of 35. Racial and ethnic disparities persist, with non-elderly Hispanic and American Indian/Alaska Native people having higher uninsured rates than their White counterparts.

How does not having insurance affect healthcare access?

Preventative Care and Screening Services

Uninsured people are far more likely to postpone healthcare or forgo it altogether. They are more likely to skip preventative services and report not having a regular source of healthcare. Uninsured adults are over three times more likely than insured adults to say they have not had a health-related visit in the past 12 months. They are also less likely to receive recommended screening tests such as blood pressure checks, blood sugar screening, and colon cancer screening. Part of the reason for poor access among the uninsured is that half do not have a regular place to go when they are sick or need medical advice, while the majority of insured people do have a regular source of care.

Problems Getting Needed Medical Care

One in five uninsured adults say that they went without needed care in the past year because of cost. Many uninsured people do not obtain the treatments their health care providers recommend for them. Uninsured people are more likely than those with insurance to report problems getting needed medical care.

Negative Health Consequences

Because uninsured people are less likely to have regular outpatient care, they are more likely to have negative health consequences. They are also less likely to receive necessary follow-up screenings than their insured counterparts, so they have an increased risk of being diagnosed at later stages of diseases, including cancer, and have higher mortality rates than those with insurance. When hospitalized, they receive fewer diagnostic and therapeutic services and have higher mortality rates than those with insurance.

Children's Access to Healthcare

Uninsured children are more likely to lack a usual source of care, to delay care, or to have unmet medical needs than children with insurance. They do not receive the same level of care as others and are at higher risk for preventable hospitalizations and for missed diagnoses of serious health conditions. Among children with special health care needs, those without health insurance have worse access to care than those with insurance.

Gaps in Health Insurance Coverage

Research has shown that adults who experience gaps in their health insurance coverage are less likely to have a regular source of care or to be up to date with blood pressure or cholesterol checks than those with continuous coverage. Similarly, adults who lack insurance for an entire year have poorer access to care than those who have coverage for at least part of the year, suggesting that even a short period of coverage can improve access to care.

What are the financial implications of being uninsured?

Being uninsured can have serious financial implications. Uninsured people often face unaffordable medical bills when they seek care, and these costs can quickly translate into medical debt. Providers absorb some of the costs of treating the uninsured, but not all of these costs are offset by funding. This results in billions of dollars in uncompensated care costs for providers.

Uninsured people are more likely to delay or forgo care due to costs, and when they do seek treatment, they are often charged the full price for that care. This is typically two to four times more expensive than what insurers or public programs pay. Uninsured people are also more likely to be asked to pay for the full cost of medical care upfront before they can see a doctor.

Uninsured people have lower medical expenditures overall than those with insurance, but they pay a much larger proportion of their medical costs out-of-pocket. This leaves them at an increased risk of financial strain and medical debt. Uninsured people are more likely to face negative consequences such as using up savings, having difficulty paying for basic necessities, or borrowing money.

The financial implications of being uninsured also extend beyond the individual. There are costs for businesses, whose employees may miss work or retire early due to health reasons, and for society, which misses out on the economic benefits of a healthy, productive population.

Frequently asked questions