The pandemic-era protection insurance policies, together with the Medicaid steady enrollment provision and the improved Market subsidies, continued to impression well being protection within the U.S. in 2023. Through the pandemic, the protection expansions put in place by the Inexpensive Care Act (ACA), together with Medicaid growth and sponsored Market protection, served as a security internet for individuals who skilled financial and protection disruptions. Good points in Medicaid and Market protection contributed to important declines within the uninsured price via 2022. Though states started the method of unwinding steady enrollment in Medicaid in April 2023 and resumed disenrolling folks from Medicaid, the complete impact of Medicaid disenrollments weren’t felt in 2023. As well as, the improved Market subsidies, which had been prolonged via 2025, remained in place. Each these elements contributed to sustaining many of the protection beneficial properties skilled through the pandemic interval in 2023.
This difficulty temporary describes developments in well being protection in 2023, examines the traits of the uninsured inhabitants ages 0-64, and summarizes the entry and monetary implications of not having protection. Utilizing knowledge from the American Group Survey (ACS), this evaluation examines adjustments in well being protection from 2022 to 2023 and compares knowledge for 2023 to knowledge for 2019 to report on protection developments through the pandemic and thru the beginning of the unwinding of the Medicaid steady enrollment provision. Due to disruptions in knowledge assortment through the pandemic, the Census Bureau didn’t launch 1-year ACS estimates in 2020. The evaluation focuses on protection amongst folks ages 0-64 since Medicare presents close to common protection for folks ages 65 and older, with simply 457,000, or lower than 1%, of individuals over age 65 uninsured.
Key Takeaways
How many individuals are uninsured: Regardless of the unwinding of the Medicaid steady enrollment provision that started in April 2023, the variety of folks ages 0-64 who had been uninsured held regular at 25.3 million in 2023. Nevertheless, the variety of uninsured youngsters elevated from 3.8 million in 2022 to 4.0 million in 2023. In comparison with 2019, the quantity of people that had been uninsured declined by 3.6 million.
Who’s uninsured: Most uninsured individuals are in low-income households and have at the least one employee within the household. Reflecting the extra restricted availability of public protection in some states, adults ages 19-64 usually tend to be uninsured than youngsters. Regardless of beneficial properties throughout teams over time, racial and ethnic disparities in protection persist.
Why are folks uninsured: Many uninsured folks cite the excessive price of insurance coverage as the primary motive they lack protection. In 2023, 63% of uninsured adults ages 18-64 mentioned that they had been uninsured as a result of the price of protection was too excessive. Many uninsured folks should not have entry to protection via a job, and a few folks, significantly poor adults in states that haven’t expanded Medicaid, stay ineligible for monetary help for protection. Though over half of people who find themselves uninsured could also be eligible for Medicaid or sponsored protection within the Marketplaces, they might not be conscious of those protection choices or could face limitations to enrolling. In some instances, even with subsidies, Market protection might not be reasonably priced.
How doesn’t having protection have an effect on well being care entry: Individuals with out insurance coverage protection are much less prone to entry care and extra prone to delay or forgo care due to prices. Though tough to ascertain direct causality, analysis has linked Medicaid growth to improved well being outcomes, together with decrease mortality charges from most cancers, heart problems, liver illness, and maternal mortality.
What are the monetary implications of being uninsured: Uninsured folks typically face unaffordable medical payments once they do search care. Almost half (49%) of uninsured adults say they’ve issue affording well being care prices, greater than double the share of these with personal insurance coverage (21%). These prices can rapidly translate into medical debt since most people who find themselves uninsured have low or reasonable incomes and have little, if any, financial savings. Greater than six in ten (62%) uninsured adults report having well being care debt in comparison with over 4 in ten (44%) insured adults.
Though protection charges for the general inhabitants ages 0-64 held regular in 2023, future adjustments to Medicaid and Market protection might have a major impression on well being protection. Proposals that will alter how Medicaid is financed or that will impose work necessities on sure adults enrolled in this system would doubtless result in a lack of Medicaid protection. Furthermore, the non permanent enhanced Market subsidies will expire after 2025 except Congress acts. With out a everlasting extension, the Congressional Finances Workplace estimates that the variety of uninsured folks will enhance by 3.8 million, on common, in annually from 2026 to 2034. The mixed Medicaid and Market protection losses might result in a large enhance within the variety of people who find themselves uninsured. In flip, the lack of protection might have implications for entry to care and monetary stability related to having well being protection and will result in a worsening of disparities in well being outcomes.
How many individuals are uninsured?
Among the many inhabitants ages 0-64, each the variety of uninsured (25.3 million) and the uninsured price (9.5%) remained at historic lows in 2023. A continued decline within the variety of uninsured adults ages 19-64 was offset by a rise within the variety of uninsured youngsters. In comparison with 2019, previous to the beginning of the pandemic, the variety of uninsured and the uninsured price for the inhabitants ages 0-64 had been each considerably decrease in 2023. Almost all teams skilled protection beneficial properties, however American Indian or Alaska Native (AIAN) and Hispanic folks had bigger beneficial properties than their White counterparts and low-income people and people in working households had greater beneficial properties than these at greater incomes and people with out a employee within the household.
Key Particulars:
In 2023, 25.3 million folks ages 0 to 64 had been uninsured, and the uninsured price for this inhabitants was 9.5%, each statistically unchanged from 2022. Whereas the uninsured price held regular from 2022, it was decrease than in 2019 (10.9%) previous to the beginning of the coronavirus pandemic (Determine 1).
From 2019-2023, the uninsured price declined by 1.4%, pushed primarily by beneficial properties in Medicaid and Market protection due to pandemic-era protection protections. The Medicaid steady enrollment provision required states to maintain folks enrolled in Medicaid through the pandemic in alternate for enhanced federal funding and enhanced ACA Market subsidies, first enacted within the American Rescue Plan Act (ARPA) and renewed via 2025 within the Inflation Discount Act of 2022 (IRA). Though the improved Market subsidies remained in impact in 2023, Medicaid steady enrollment ended on March 31, 2023, and states resumed disenrolling folks from Medicaid, although the complete results of the disenrollments weren’t felt in 2023. Throughout this time interval, employer protection declined by 0.5% (Determine 2).
Whereas there was no change within the uninsured price for the general inhabitants ages 0 to 64 in 2023, the share of youngsters 18 and youthful with out insurance coverage elevated from 5.1% in 2022 to five.3% in 2023. On the similar time, the uninsured price for adults ages 19 to 64 decreased to 11.1% in 2023 from 11.3% the earlier yr (Determine 2). A rise in Medicaid protection for adults 19-64 from 16.3% to 16.5% in 2023 drove the decline within the uninsured price for this group. Regardless of the uptick within the uninsured price for youngsters in 2023, the share of youngsters with out medical health insurance protection was nonetheless decrease in 2023 in comparison with 2019.
Though practically all teams skilled protection beneficial properties through the pandemic-period, they had been largest for AIAN and Hispanic folks and people in low-income households. From 2019 to 2023, the uninsured price for AIAN folks fell 3.0 proportion factors (from 21.7% to 18.7%) and the uninsured price for Hispanic folks decreased by 2.1 proportion factors (from 20.0% to 17.9%), though these teams stay extra prone to be uninsured than their White counterparts. Native Hawaiian or Pacific Islander (NHPI) folks didn’t expertise a major decline within the uninsured price throughout this era, which can, partially, mirror the smaller pattern dimension for NHPI folks, which limits the ability to detect statistically important variations. Whereas the uninsured price dropped for folks in any respect revenue ranges, people in low-income households skilled the most important declines. From 2019-2023, the uninsured price for poor people dropped 2.2 proportion factors (18.0% to fifteen.8%) and a pair of.7 proportion factors for people with revenue 100-199% FPL (18.2% to fifteen.5%, Determine 3).
From 2022 to 2023, the uninsured price for the inhabitants ages 0 to 64 fell in six states (Florida, Hawaii, Illinois, Missouri, North Dakota, and Oregon) however elevated in two states, Iowa and Idaho (Appendix Desk A). On the similar time, the uninsured price for youngsters elevated in six states (Alabama, Idaho, New Mexico, South Carolina, Texas, and Washington). Whereas these adjustments occurred in each growth and non-expansion states, the uninsured price was decrease in growth states (7.6%) in comparison with non-expansion states (14.1%) in 2023 (Determine 6).
Who’s uninsured?
A lot of the 25.3 million folks ages 0-64 who’re uninsured are adults, in working low-income households, and are folks of shade. Reflecting geographic variation in revenue and the supply of public protection, most uninsured folks dwell within the South or West. As well as, most who’re uninsured have been with out protection for lengthy intervals of time. (See Appendix Desk B for detailed knowledge on traits of the uninsured inhabitants.)
Key Particulars:
In 2023, of the entire uninsured inhabitants ages 0 to 64, practically three in 4 (73.7%) had at the least one full-time employee of their household, and 11.2% had a part-time employee of their household (Determine 4). Greater than eight in ten (80.9%) uninsured folks had been in households with incomes beneath 400% of the federal poverty stage, and practically half (46.6%) had incomes beneath 200% FPL. White folks made up 37.1% of the uninsured, and the remaining 62.9% included Hispanic (41.1%), Black (12.5%), and Asian (3.7%) folks and other people of different racial or ethnic backgrounds (Determine 4). Most uninsured people (74.2%) had been U.S. residents, whereas 25.8% had been noncitizens. Nearly three-quarters (73.9%) of uninsured folks lived within the South or West.
Adults ages 19 to 64 usually tend to be uninsured than youngsters. In 2023, the uninsured price for youngsters was 5.3%, lower than half the speed for adults at 11.1%.
Uninsured charges within the U.S. nonetheless present clear racial and ethnic disparities. In 2023, 17.9% of Hispanic folks and 18.7% of AIAN folks ages 0 to 64 had been uninsured—greater than two and a half occasions the speed for White folks (6.5%). Asian people had the bottom uninsured price at 5.8%.
Noncitizens are extra doubtless than residents to be uninsured. Almost one-third of noncitizen immigrants had been uninsured in 2023, whereas the uninsured price for U.S.-born residents was 7.5% and eight.9% for naturalized residents. (Appendix Desk B).
Uninsured charges fluctuate by state and by area; people dwelling in non-expansion states usually tend to be uninsured (Determine 6). Six of the ten states with the very best uninsured charges in 2023 had been non-expansion states (Determine 5 and Appendix Desk A).
Almost two-thirds (64%) of people that had been uninsured in 2023 have been with out protection for greater than a yr. Individuals who have been with out protection for lengthy intervals could also be significantly onerous to achieve via outreach and enrollment efforts.
Why are folks uninsured?
Lack of entry to reasonably priced well being protection is the primary motive many individuals say they’re uninsured. A majority of working age adults within the U.S. get hold of medical health insurance via an employer; nevertheless, not all employees are supplied employer-sponsored protection or, if supplied, can afford their share of the premiums. Medicaid covers many low-income people, particularly youngsters, however Medicaid eligibility for adults stays restricted in most states that haven’t adopted the ACA growth. Market subsidies make protection extra reasonably priced for a lot of, however even sponsored Market protection could be unaffordable for some, and few folks can afford to buy personal protection with out monetary help.
Key Particulars:
Value is probably the most generally cited motive for being uninsured. In 2023, 63.2% of uninsured adults ages 18-64 mentioned they had been uninsured as a result of protection shouldn’t be reasonably priced (Determine 7). Different causes included not being eligible for protection (27.0%), not needing or wanting protection (26.6%), and signing up being too tough (23.9%).
Not all employees have entry to protection via their job. In 2023, 64.7% of uninsured employees labored for an employer that didn’t provide them well being advantages. Amongst uninsured employees who’re supplied protection by their employers, price is commonly a barrier to taking over the provide. From 2014 to 2024, whole premiums for household protection elevated by 52%, outpacing wage development, and the employee’s share elevated by 31%. Low-income households with employer-based protection spend a considerably greater share of their revenue towards premiums and out-of-pocket medical bills in comparison with these with revenue above 200% FPL. Notably amongst folks working for small employers , premium contributions for dependents could be unaffordable.
Medicaid eligibility varies throughout states and eligibility for adults is restricted in states that haven’t expanded Medicaid. As of December 2024, 41 states together with DC had adopted the ACA Medicaid growth. Two states applied the growth in 2023—South Dakota in July and North Carolina in December. In states that haven’t expanded Medicaid, the median eligibility stage for folks is simply 34% FPL and adults with out dependent youngsters are ineligible generally. Moreover, in non-expansion states, tens of millions of poor uninsured adults fall right into a “protection hole” as a result of they earn an excessive amount of to qualify for Medicaid however not sufficient to qualify for Market premium tax credit.
Many lawfully current immigrants should meet a five-year ready interval after receiving certified immigration standing earlier than they’ll qualify for Medicaid. States have the choice to cowl eligible youngsters and pregnant folks with out a ready interval, and as of Might 2024, 37 states have elected the choice for youngsters and 31 states have taken up the choice for pregnant people. Lawfully current immigrants, together with those that usually are not eligible for Medicaid as a result of they haven’t met the five-year ready interval, are eligible for Market tax credit. Nevertheless, Some states have taken steps to offer absolutely state-funded protection to some or all immigrants who usually are not eligible for federal protection.
Although monetary help is obtainable below the ACA to lots of the remaining uninsured, not everybody who’s uninsured is eligible free of charge or sponsored protection. Almost six in ten (14.5 million) uninsured people in 2023 had been eligible for monetary help both via Medicaid or via sponsored Market protection (Determine 8). Nevertheless, over 4 in ten uninsured (10.9 million) are exterior the attain of the ACA as a result of their state didn’t broaden Medicaid, they’ve an ineligible immigration standing, or they had been deemed to have entry to an reasonably priced Market plan or provide of employer protection.
How doesn’t having protection have an effect on well being care entry?
Medical insurance makes a distinction in whether or not and when folks get crucial medical care, the place they get their care, and in the end, how wholesome they’re. Uninsured adults are way more doubtless than these with insurance coverage to postpone well being care or forgo it altogether due to issues over prices. The results could be extreme, significantly when preventable situations or persistent ailments go undetected.
Key Particulars:
Uninsured adults usually tend to forgo wanted care than their insured counterparts. In 2023, practically half (46.6%) of uninsured adults ages 18 to 64 reported not seeing a health care provider or well being care skilled prior to now 12 months in comparison with 15.6% with personal insurance coverage and 14.2% with public protection. A part of the explanation for not accessing care amongst uninsured people is that many (42.8%) should not have a daily place to go when they’re sick or want medical recommendation (Determine 9). However price additionally performs a task. Over one in 5 (22.6%) adults with out protection mentioned that they went with out wanted care prior to now yr due to price in comparison with 5.1% of adults with personal protection and seven.7% of adults with public protection. A KFF survey that asks about price limitations for people and their relations experiences greater percentages of each uninsured and insured folks delaying or forgoing wanted care because of price.
Uninsured youngsters had been additionally extra doubtless than these with personal insurance coverage or public insurance coverage to go with out wanted care because of price in 2023 (9.5% in comparison with 0.7% and 1.0%, respectively). Moreover, over 1 / 4 (27.4%) of uninsured youngsters had not seen a health care provider prior to now yr, in comparison with 4.8% of youngsters with public protection and three.7% of these with personal protection (Determine 9).
Research repeatedly reveal that uninsured people are much less doubtless than these with insurance coverage to obtain preventive care and providers for main well being situations and persistent ailments.,,, As a result of folks with out well being protection are much less doubtless than these with insurance coverage to have common outpatient care, they’re extra prone to be hospitalized for avoidable well being issues and to expertise declines of their total well being. When they’re hospitalized, uninsured folks obtain fewer diagnostic and therapeutic providers and now have greater mortality charges than these with insurance coverage.,,,,
Analysis demonstrates that gaining medical health insurance improves entry to well being care significantly and diminishes the adversarial results of getting been uninsured. A evaluation of analysis on the results of the ACA Medicaid growth finds that growth led to constructive results on entry to care, utilization of providers, the affordability of care, and monetary safety among the many low-income inhabitants.
More moderen analysis usually exhibits Medicaid growth is related to improved well being outcomes, though establishing direct causality between medical health insurance and well being outcomes is complicated. For instance, Medicaid growth is related to elevated early-stage analysis charges for most cancers, decrease charges of cardiovascular mortality, and elevated odds of tobacco cessation., Medicaid growth has additionally been linked to decrease mortality charges, together with these from most cancers, heart problems, liver illness, and maternal mortality., Proof suggests it additionally aids long-term restoration for substance use issues and improves remedy administration for situations resembling diabetes and HIV.
Public hospitals, group clinics and well being facilities, and native suppliers that serve underserved communities present an vital well being care security internet for uninsured folks. Nevertheless, security internet suppliers have restricted sources and repair capability, and never all uninsured folks have geographic entry to a security internet supplier.,, Excessive uninsured charges contribute to rural hospital closures and larger monetary challenges for rural hospitals, leaving people dwelling in rural areas at a good larger drawback to accessing care., Analysis signifies that Medicaid growth is related to reductions in uncompensated care prices and improved monetary efficiency for rural hospitals and different suppliers.
What are the monetary implications of being uninsured?
Uninsured people typically face unaffordable medical payments once they do search care. These payments can rapidly translate into medical debt since most people who find themselves uninsured have low or reasonable incomes and have little, if any, financial savings.
Key Particulars:
These with out insurance coverage for a complete calendar yr pay for nearly 40% of their care out-of-pocket. As well as, hospitals incessantly cost uninsured sufferers greater charges than these paid by personal well being insurers and public packages.,,,
Uninsured adults ages 18 to 64 are more likely than their insured counterparts to lack confidence of their skill to afford normal medical prices. Almost half (49%) of uninsured adults mentioned they or a member of the family had issues paying for well being care in comparison with 21% of insured adults, and over eight in ten (84%) uninsured adults mentioned they frightened that well being care prices would put them in debt or enhance their current debt, in comparison with 71% of adults with insurance coverage (Determine 10).
Unaffordable medical payments can result in medical debt, significantly for uninsured adults. Greater than six in ten (62%) uninsured adults report having well being care debt in comparison with over 4 in ten (44%) insured adults. Uninsured adults usually tend to face damaging penalties because of well being care debt, resembling utilizing up financial savings, having issue paying different dwelling bills, or borrowing cash.,,
Whereas federal and state legal guidelines require sure hospitals to offer some stage of charity care, not all eligible sufferers profit from these packages. Consequently, charity care prices signify a small share of working bills at many hospitals.
Analysis means that gaining well being protection improves the affordability of care and monetary safety among the many low-income inhabitants. A number of research of the ACA discovered declines in hassle paying medical payments and reductions in medical debt in growth states relative to non-expansion states. More moderen analysis discovered that Medicaid growth decreased catastrophic well being expenditures and was related to larger will increase in revenue amongst low-income people.
