Health insurance is an important factor that affects the access, quality, and cost of health care in the United States. However, not everyone has health insurance coverage, and the number and characteristics of the uninsured population vary across states and over time.
This article provides an overview of the key facts about the uninsured population in 2023, based on the most recent data available from various sources. It also discusses the impact of the COVID-19 pandemic on uninsured rates and the current enrollment trends and state estimates of health coverage under the Affordable Care Act (ACA).
Key Facts about the Uninsured Population
Number of Uninsured Americans in 2023
The Census Bureau’s American Community Survey (ACS) reported 27.5 million nonelderly uninsured in 2021, down roughly 1.5 million from 2019. The uninsured rate dropped from 10.9% in 2019 to 10.2% in 2021. Based on other sources, such as the National Health Interview Survey (NHIS) and the Health Reform Monitoring Survey (HRMS), the number of uninsured Americans in 2023 is estimated to be between 25 and 28 million, and the rate is between 9.5% and 10.5%.
Demographics of the Uninsured Population
Most uninsured persons come from working, low-income households. Adults are more likely to be uninsured than children in states with less public coverage. Asians have the lowest uninsured rate, while persons of color have a greater risk. 18–24-year-olds are the most uninsured.
Reasons for Being Uninsured
Many uninsured individuals blame the high cost of insurance, despite legislative attempts to lower it. Losing or moving employment, losing eligibility for public programs, not knowing coverage possibilities, or immigration status hurdles are further factors.
Healthcare access and expenses without coverage: Uninsurance may harm health and finances. Uninsured persons delay or forgo essential treatment, get less preventive and chronic care, and have poorer health outcomes. Medical costs may put uninsured persons in debt, insolvent, or limit their credit.
The Impact of the COVID-19 Pandemic on Uninsured Rates
Decrease in Uninsured Rate During the Pandemic
Unlike earlier downturns, the ACA’s coverage expansions helped those who lost employment and health coverage during the COVID-19 outbreak. The ACA extended Medicaid coverage to many low-income people and provided Marketplace subsidies for those below 400% of the federal poverty line (FPL) to close gaps in our healthcare system that left millions uninsured. The requirement that states maintain continuous enrollment for Medicaid enrollees and the enhanced Marketplace subsidies protected people from coverage losses and made private coverage more affordable, making it easier for low-income people most affected by the pandemic to gain and retain coverage. After growing for three years from 2017 to 2019, the number of nonelderly uninsured reduced by roughly 1.5 million from 28.9 million in 2019 to 27.5 million in 2021, and the uninsured rate dropped from 10.9% to 10.2%.
Factors Contributing to the Decrease
Various administrative data sources enable us to estimate pandemic health coverage rates. Employer-sponsored insurance falls significantly less than employment diminishes. From March to September 2020, employment dropped 6.2%, although participation in the fully-insured group market dipped 1.5%. If we generalize this result to the full group market, including self-insured employer plans, 2–3 million individuals may have lost job-based coverage between March and September 2020. Medicaid and marketplace participation may have offset employer-based coverage loss. Many who lost job-based health care qualified for Medicaid or a special enrollment opportunity to buy individual market health coverage (on- or off-exchange). Medicaid enrollment rose 4.3 million (6.1%) from February to July 2020, according to preliminary administrative statistics. From March to September 2020, managed care enrollment in 30 states climbed by 5 million, or 11.3%. MCOs cover two-thirds of Medicaid participants nationwide. States attribute these increases to rising unemployment (and loss of employer-sponsored insurance) and “maintenance of eligibility” (MOE) requirements tied to a 6.2 percentage point increase in the federal match rate (FMAP) authorized by the Families First Coronavirus Response Act (FFCRA)—which prevents states from disenrolling Medicaid beneficiaries if they accept the additional federal funding. According to the Department of Health and Human Services (HHS), nearly 16.4 million consumers selected plans in January 2023, and 15.6 million effectuated enrollment (paid a premium or otherwise completed enrollment) in February 2023 across all 50 states and the District of Columbia. This is up to 4.8 million plan choices and 4.3 million effectuated enrollments from 2021. The American Rescue Plan Act of 2021 (ARPA) increased and upgraded Marketplace premium tax credits, making coverage more affordable for millions of Americans and driving Marketplace membership.
Current Enrollment Trends and State Estimates
Enrollment in the Affordable Care Act
The ACA’s health insurance Marketplaces and Medicaid expansion in participating states began in 2014. According to the most current administrative statistics, 15.6 million customers were registered in Marketplace plans as of February 2023, while 18.8 million individuals were newly enrolled in Medicaid under the ACA’s extension of eligibility to adults as of September 2022. 1.2 million people were enrolled in the ACA’s Basic Health Program option in early 2023, and 4.6 million previously-eligible adults gained coverage under the Medicaid expansion by September 2022 due to enhanced outreach, streamlined applications, and increased federal funding under the ACA. According to 2022 and early 2023 enrollment figures, 40.2 million Americans were enrolled in ACA-related coverage across various coverage categories, the biggest number ever. This is a 30% rise from 2021 and a 219% increase from 2014.
State-specific Estimates of Uninsured Rates
Since 2013, the uninsured rate has dropped in all 50 states and the District of Columbia. In 2021, Massachusetts had 2.5% uninsured and Texas 18.0%. ACA Medicaid expansion may affect health insurance coverage rates. Thirty-six states and the District of Columbia increased Medicaid eligibility by January 1, 2021, while 14 did not. In 2021, expansion states had 6.6% uninsured and non-expansion states 12.7%. Five states with uninsured rates above 12%—Florida, Georgia, Oklahoma, Texas, and Wyoming—had not extended Medicaid eligibility. All states had a 0.5 percentage point drop in uninsured between 2019 and 2021. Idaho, Maine, Michigan, New Jersey, New York, Oregon, Pennsylvania, Rhode Island, Vermont, and Virginia had the biggest drops.
