Health insurance coverage in the United States

Health insurance coverage is provided by several public and private sources in the United States. Analyzing these statistics is more challenging due to multiple survey methods[12] and persons with multiple sources of insurance, such as those with coverage under both an employer plan and Medicaid.[1]

For the 273 million non-institutional persons under age 65 in 2019:[1]

• There were 159 million with employer-based coverage, 84 million with other coverage, and 30 million uninsured.[1]
• Of the 159 million with employer-based coverage, many are in self-funded health plans - about 60% in 2017[13]
• Of the 84 million with other coverage, 57 million were covered by Medicaid and Children's Health Insurance Program (CHIP), 12 million were covered by the ACA Medicaid expansion, 9 million were covered by the ACA/Obamacare exchanges, 5 million had other coverage such as private insurance purchased outside the ACA exchanges, and 1 million were covered by the ACA Basic Health Program.
• Of the 9 million on the ACA exchanges, 8 million received subsidies and 1 million did not.
• Of the 30 million uninsured, 24 million (80%) were lawfully present while 6 million (20%) were not lawfully present (i.e., undocumented immigrants).
• In 2018, 41% of the uninsured were white, 37% were Hispanic, and 14% were black.[10]
• Approximately 12 million institutional (military) personnel were covered by the Veteran's Administration in 2018.[2]
• The uninsured rate fell from a peak of 18.2% in 2010 to 10.5% by 2015, due primarily to ACA/Obamacare along with improvements in the economy.
• States that expanded Medicaid under Obamacare (37 as of 2019, including Washington D.C.) had lower uninsured rates than states that did not.
• Inability to afford insurance was the primary reason cited by persons without coverage (46%).[11]
• Lack of health insurance is associated with increased mortality, in the range 30-90 thousand deaths per year, depending on the study. This figure is calculated based on 1 additional death per 300-800 persons without health insurance, on a base of 27 million uninsured persons.[5]

The U.S. Centers for Disease Control and Prevention (CDC) reports the number and percentage of uninsured during each year. The following table includes those under age 65 who were uninsured at the time of interview.[14]

The 2010 figure represents the most recent peak, which was driven upward by the Great Recession. Most of the major provisions of the ACA took effect in 2014, so 2013 reflects the pre-ACA level. After reaching a record low in 2016 at the end of the Obama Administration, the number and percent of uninsured has risen during the first two years of the Trump Administration. The New York Times reported in January 2019 that the Trump Administration has taken a variety of steps to weaken the ACA, adversely affecting coverage.[15] The increases in the number of uninsured in the first 3 years of the Trump administration (2017-2019) reversed in 2020-2021, as Coronavirus relief measures expanded eligibility and reduced costs.[16]

U.S. uninsured number (millions) and rate (%), including historical data through 2016 and two CBO forecasts (2016/Obama policy and 2018/Trump policy) through 2026. Two key reasons for more uninsured under President Trump include: 1) Eliminating the individual mandate to have health insurance; and 2) Stopping cost sharing reduction payments.[17]

Several public and private sources report the number and percentage of the uninsured.[12] The Congressional Budget Office (CBO) reported the actual number of uninsured at 28.3 million in 2015, 27.5 million in 2016, 27.8 million in 2017, and 28.9 million in 2018.[18] The CBO May 2019 ten-year forecast reflected the policies of the Trump administration and estimated the number of uninsured would rise from 30 million in 2019, to 34 million by 2026, and to 35 million by 2029.[1] In a previous March 2016 ten-year forecast reflecting the policies of the Obama administration, CBO forecast 27 million uninsured in 2019 and 28 million in 2026.[19] The primary reason for the 6.5 million (24%) increase in uninsured from 2016 to 2029 is the repeal of the ACA individual mandate to have health insurance, enacted as part of the Trump tax cuts, with people not obtaining comprehensive insurance in the absence of a mandate or due to higher insurance costs.[9]

Gallup estimated in July 2014 that the uninsured rate for adults (persons 18 years of age and over) was 13.4% as of Q2 2014, down from 18.0% in Q3 2013 when the health insurance exchanges created under the Patient Protection and Affordable Care Act (PPACA or "Obamacare") first opened. The uninsured rate fell across nearly all demographic groups.[20]

The Commonwealth Fund reported that the uninsured rate among adults 19-64 declined from 20% in Q3 2013 to 15% in Q2 2014, meaning approximately 9.5 million more adults had health insurance.[21]

The United States Census Bureau annually reports statistics on the uninsured. The 2018 Census Bureau Health Insurance highlights summary report states that:

• "In 2018, 8.5 percent of people, or 27.5 million, did not have health insurance at any point during the year. The uninsured rate and number of uninsured increased from 2017 (7.9 percent or 25.6 million).
• The percentage of people with health insurance coverage for all or part of 2018 was 91.5 percent, lower than the rate in 2017 (92.1 percent). Between 2017 and 2018, the percentage of people with public coverage decreased 0.4 percentage points, and the percentage of people with private coverage did not statistically change.
• In 2018, private health insurance coverage continued to be more prevalent than public coverage, covering 67.3 percent of the population and 34.4 percent of the population, respectively. Of the subtypes of health insurance coverage, employer-based insurance remained the most common, covering 55.1 percent of the population for all or part of the calendar year.
• Between 2017 and 2018, the percentage of people covered by Medicaid decreased by 0.7 percentage points to 17.9 percent. The rate of Medicare coverage increased by 0.4 percentage points. The percentage of people with employment-based coverage, direct-purchase coverage, TRICARE, and VA or CHAMPVA health care did not statistically change between 2017 and 2018.
• The percentage of uninsured children under the age of 19 increased by 0.6 percentage points between 2017 and 2018, to 5.5 percent.
• Between 2017 and 2018, the percentage of people without health insurance coverage at the time of interview decreased in three states and increased in eight states."[2]

Gains in healthcare coverage under President Obama began to reverse under President Trump. The CDC reported that the number of uninsured rose from 28.2 million in 2016 (the last year of the Obama Administration) to 32.8 million in 2019, an increase of 4.6 million or 16%.[29]

The Commonwealth Fund estimated in May 2018 that the number of uninsured increased by 4 million from early 2016 to early 2018. The rate of those uninsured increased from 12.7% in 2016 to 15.5%. This was due to two factors: 1) Not addressing specific weaknesses in the ACA; and 2) Actions by the Trump administration that exacerbated those weaknesses. The impact was greater among lower-income adults, who had a higher uninsured rate than higher-income adults. Regionally, the South and West had higher uninsured rates than the North and East. Further, those 18 states that have not expanded Medicaid had a higher uninsured rate than those that did.[8]

Approximately 5.4 million Americans lost their health insurance from February to May 2020 after losing their jobs during the COVID-19 recession.[30][31] The Independent reported that Families USA report "found that the spike in uninsured Americans – adding to an estimated 84 million people who are already uninsured or underinsured – is 39 per cent higher than any previous annual increase, including the most recent surge at the height of the recession between 2008 and 2009 when nearly 4 million non-elderly Americans lost insurance."[32]

Number U.S. uninsured by reason in 2016 (non-elderly/under 65 years of age). An estimated 43% of the uninsured were eligible for financial assistance.[33]

Uninsured Americans in 2007, by income status

The Kaiser Family Foundation reported in October 2016 that there were 27.2 million uninsured under age 65, roughly 10% of the 272 million persons in that group. Kaiser reported that:

• 2.6 million were in the "coverage gap" due to the 19 states that chose not to expand the Medicaid program under the ACA/Obamacare, meaning their income was above the Medicaid eligibility limit but below the threshold for subsidies on the ACA exchanges (~44% to 100% of the federal poverty level or FPL);
• 5.4 million were undocumented immigrants;
• 4.5 million had an employer's insurance offer (making them ineligible for ACA/Obamacare coverage) but declined it;
• 3.0 million were ineligible for financial assistance under ACA/Obamacare due to sufficiently high income;
• 6.4 million were eligible for Medicaid or other public healthcare program but did not pursue it; and
• 5.3 million were eligible for ACA/Obamacare tax credits but did not enroll in the program.
• An estimated 46% cited costs as a barrier to getting insurance coverage.
• Nearly 12 million (43%) of persons were eligible for financial assistance (Medicaid or ACA subsidies) but did not enroll to obtain it.[34]

As of 2017, Texas had the highest number of uninsured at 17%, followed by Oklahoma, Alaska, and Georgia.[35]

A report by the Kaiser Family Foundation in April 2008 found that US economic downturns place a significant strain on state Medicaid and SCHIP programs. The authors estimated that a 1% increase in the unemployment rate increase Medicaid and SCHIP enrollment by 1 million, and increase the number uninsured by 1.1 million. State spending on Medicaid and SCHIP would increase by $1.4 billion (total spending on these programs would increase by $3.4 billion). This increased spending would occur while state government revenues were declining. During the last downturn, the Jobs and Growth Tax Relief Reconciliation Act of 2003 (JGTRRA) included federal assistance to states, which helped states avoid tightening their Medicaid and SCHIP eligibility rules. The authors conclude that Congress should consider similar relief for the current economic downturn.[41]

Prior to the Patient Protection and Affordable Care Act, medical underwriting was common, but after the law came into effect in 2014 it became effectively prohibited.

Medical underwriting made difficult for many consumers to purchase coverage on the individual market. Medical underwriting meant that insurance companies screen applicants for pre-existing conditions and reject those with serious conditions such as arthritis, cancer, and heart disease, but also such common ailments as acne, being 20 pounds over or under weight, and old sports injuries.[42] In 2008, an estimated 5 million of those without health insurance were considered "uninsurable" because of pre-existing conditions.[43]

Proponents of medical underwriting argue that it ensures that individual health insurance premiums are kept as low as possible.[44] Critics of medical underwriting believe that it unfairly prevents people with relatively minor and treatable pre-existing conditions from obtaining health insurance.[45]

One large industry survey found that 13% of applicants for individual health insurance who went through medical underwriting were denied coverage in 2004. Declination rates increased significantly with age, rising from 5% for those under 18 to just under one-third for those aged 60 to 64.[46] Among those who were offered coverage, the study found that 76% received offers at standard premium rates, and 22% were offered higher rates.[47] The frequency of increased premiums also increased with age, so for applicants over 40, roughly half were affected by medical underwriting, either in the form of denial or increased premiums. In contrast, almost 90% of applicants in their 20s were offered coverage, and three-quarters of those were offered standard rates. Seventy percent of applicants age 60–64 were offered coverage, but almost half the time (40%) it was at an increased premium. The study did not address how many applicants who were offered coverage at increased rates chose to decline the policy. A study conducted by the Commonwealth Fund in 2001 found that, among those aged 19 to 64 who sought individual health insurance during the previous three years, the majority found it unaffordable, and less than a third ended up purchasing insurance. This study did not distinguish between consumers who were quoted increased rates due to medical underwriting and those who qualified for standard or preferred premiums.[48] Some states have outlawed medical underwriting as a prerequisite for individually purchased health coverage.[49] These states tend to have the highest premiums for individual health insurance.[50]

The numbers of uninsured Americans and the uninsured rate from 1987 to 2008

The percent of people in US who reported not seeking medical care due to high cost.

Americans who are uninsured may be so because their job does not offer insurance; they are unemployed and cannot pay for insurance; or they may be financially able to buy insurance but consider the cost prohibitive.[51] During 2009 the continued low employment rate has negatively affected those who had previously been enrolled in employment-based insurance policies. Census Bureau states a 55 percent drop. Other uninsured Americans have chosen to join a health care sharing ministry as an alternative to insurance.[52]

Low-income workers are less likely than higher income individuals to be offered coverage by their employer (or by their spouse's employer) and less able to afford buying it on their own. Beginning with wage and price controls during World War II, and cemented by an income tax exemption ruling in 1954, most working Americans have received their health insurance from their employers.[53] However, recent trends have shown an ongoing decline in employer-sponsored health insurance benefits. In 2000, 68% of small companies with 3 to 199 workers offered health benefits. Since that time, that number has continued to drop to 2007, when 59% offered health benefits. For large firms with 200 or more workers, in 2000, 99% of employers offered health benefits; in 2007, that number stayed the same. On average, considering firms of all numbers of employees, in 2000, 69% offered health insurance, and that number has fallen nearly every year since, to 2007, when 60% of employers offered health insurance.[54]

One study published in 2008 found that people of average health are least likely to become uninsured if they have large group health coverage, more likely to become uninsured if they have small group coverage, and most likely to become uninsured if they have individual health insurance. But, "for people in poor or fair health, the chances of losing coverage are much greater for people who had small-group insurance than for those who had individual insurance." The authors attribute these results to the combination in the individual market of high costs and guaranteed renewability of coverage. Individual coverage costs more if it is purchased after a person becomes unhealthy but "provides better protection (compared to group insurance) against high premiums for already individually insured people who become high risk." Healthy individuals are more likely to drop individual coverage than less-expensive, subsidized employment-based coverage, but group coverage leaves them "more vulnerable to dropping or losing any and all coverage than does individual insurance" if they become seriously ill.[55]

Roughly a quarter of the uninsured are eligible for public coverage but are not enrolled.[56][57] Possible reasons include a lack of awareness of the programs or of how to enroll, reluctance due to a perceived stigma associated with public coverage, poor retention of enrollees, and burdensome administrative procedures. In addition, some state programs have enrollment caps.[57]

A study by the Kaiser Family Foundation published in June 2009 found that 45% of low-income adults under age 65 lack health insurance.[58] Almost a third of non-elderly adults are low income, with family incomes below 200% of the federal poverty level.[58] Low-income adults are generally younger, less well educated, and less likely to live in a household with a full-time worker than are higher income adults; these factors contribute to the likelihood of being uninsured.[58] In addition, the chances of being healthy decline with lower income; 19% of adults with incomes below the federal poverty level describe their health as fair or poor.[58]

The map illustrates the frequency of premature deaths (those under age 75) adjusted for the age of persons in the county.[59]

Insurance coverage helps save lives, by encouraging early detection and prevention of dangerous medical conditions. According to a 2014 study, the ACA likely prevented an estimated 50,000 preventable patient deaths from 2010 to 2013.[60] City University public health professors David Himmelstein and Steffie Woolhandler wrote in January 2017 that a rollback of the ACA's Medicaid expansion alone would cause an estimated 43,956 deaths annually.[61]

The Federal Reserve publishes data on premature death rates by county, defined as those dying below age 74.[59] According to the Kaiser Foundation, expanding Medicaid in the remaining 19 states would cover up to 4.5 million persons,[62] thus reducing mortality.[63] Texas, Oklahoma, Mississippi, Alabama, Georgia, Tennessee, Missouri and South Carolina, indicated on the Federal Reserve map (see graph at right) as having many counties with high premature mortality rates,[59] did not expand Medicaid.[62]

A study published in the American Journal of Public Health in 2009 found that lack of health insurance is associated with about 45,000 excess preventable deaths per year.[64] One of the authors characterized the results as "now one dies every 12 minutes."[65] Since then, as the number of uninsured has risen from about 46 million in 2009 to 48.6 million in 2012, the number of preventable deaths due to lack of insurance has grown to about 48,000 per year.[66]

A survey released in 2008 found that being uninsured impacts American consumers' health in the following ways:[67]

• More of the uninsured chose not to see a doctor when were sick or hurt (53%) vs 46% of the insured.
• Fewer of the uninsured (28%) report currently undergoing treatment or participating in a program to help them manage a chronic condition; 37% of the insured are receiving such treatment.
• 21% of the uninsured, vs. 16% of the insured, believe their overall health is below average for people in their age group.

EMTALA, enacted by the federal government in 1986, requires that hospital emergency departments treat emergency conditions of all patients regardless of their ability to pay and is considered a critical element in the "safety net" for the uninsured. However, the federal law established no direct payment mechanism for such care. Indirect payments and reimbursements through federal and state government programs have never fully compensated public and private hospitals for the full cost of care mandated by EMTALA. In fact, more than half of all emergency care in the U.S. now goes uncompensated.[88] According to some analyses, EMTALA is an unfunded mandate that has contributed to financial pressures on hospitals in the last 20 years, causing them to consolidate and close facilities, and contributing to emergency room overcrowding. According to the Institute of Medicine, between 1993 and 2003, emergency room visits in the U.S. grew by 26%, while in the same period, the number of emergency departments declined by 425.[89] Hospitals bill uninsured patients directly under the fee-for-service model, often charging much more than insurers would pay,[90] and patients may become bankrupt when hospitals file lawsuits to collect.

Mentally ill patients present a unique challenge for emergency departments and hospitals. In accordance with EMTALA, mentally ill patients who enter emergency rooms are evaluated for emergency medical conditions. Once mentally ill patients are medically stable, regional mental health agencies are contacted to evaluate them. Patients are evaluated as to whether they are a danger to themselves or others. Those meeting this criterion are admitted to a mental health facility to be further evaluated by a psychiatrist. Typically, mentally ill patients can be held for up to 72 hours, after which a court order is required.

Percent uninsured (under age 65) by state (2014)

  3.8% - 6%

  6% - 8%

  8% - 9.9%

  9.9% - 11.2%

  11.2% - 13.7%

  13.7% - 15.7%

  15.7% - 19%

  19% - 21.4%

The United States Census Bureau regularly conducts the Current Population Survey (CPS), which includes estimates on health insurance coverage in the United States. The data is published annually in the Annual Social and Economic Supplement (ASEC). The data from 1999 to 2014 are reproduced below.[n 1]As of 2012, the five states with the highest estimated percentage of uninsured are, in order, Texas, Nevada, New Mexico, Florida, and Alaska. The five states/territories with the lowest estimated percentage of uninsured for the same year are, in order, Massachusetts, Vermont, Hawaii, Washington, D.C., and Connecticut. These rankings for each year are highlighted below.[6][91]

People without health insurance in the United States may receive benefits from patient-assistance programs such as Partnership for Prescription Assistance.[92] Uninsured patients can also use a medical bill negotiation service, which can audit the medical bill for overcharges and errors.

On April 3, 2020, President Donald Trump announced that the federal government would use funds from the CARES Act to pay hospitals for treatment of uninsured patients infected with the virus that causes coronavirus disease 2019.[93]

• Health care reform in the United States
• Health insurance
• Health insurance in the United States
• List of healthcare reform advocacy groups in the United States
• Single-payer health care
• Universal health care
• Patient Protection and Affordable Care Act

• America's Uninsured Crisis: Consequences for Health and Health Care Institute of Medicine, National Academy of Sciences, 2009.
• FamiliesUSA contains links to numerous studies and literature about health care-related issues such as the uninsured.
• SHADAC's State Health Compare is a web-based tool that allows users to create customized tables and graphs showing health insurance coverage estimates using U.S. Census surveys between 2008 and 2017.
• Paul Fronstin, "Sources of Health Insurance and Characteristics of the Uninsured: Analysis of the March 2012 Current Population Survey." EBRI Issue Brief #376, September 2012, Employee Benefit Research Institute.