What are the basic facts about the uninsured population?

Throughout the coronavirus pandemic, the Affordable Care Act's (ACA) coverage expansions, including Medicaid expansion and subsidized Marketplace coverage, served to protect people who lost their jobs or faced other economic and insurance challenges. Building on this foundation, pandemic-era policies, including continuous Medicaid enrollment and expanded Marketplace subsidies, further protected low-income people from losing coverage and increased the availability of private coverage. As a result, the number of uninsured nonelderly persons continued its downward trend in 2022, falling by nearly 1.9 million from 27.5 million in 2021 to 25.6 million in 2022, and the uninsured rate fell from 10.2 percent in 2021 to a record low of 9.6 percent in 2022.

This issue brief describes trends in health coverage in 2022, examines the characteristics of the uninsured elderly population, and summarizes the access and financial consequences of being uninsured. Using data from the American Community Survey (ACS), this analysis compares health insurance coverage data in 2022 with 2019 data to provide information on coverage and trends during the pandemic and to examine changes from 2021 to 2022; because of disruptions in data collection during the pandemic, the Census Bureau did not release ACS estimates for 1 year in 2020. The analysis focuses on nonelderly coverage because Medicare provides nearly universal coverage for the elderly: only 457,000, or less than 1 percent, of people over age 65 are uninsured.

How many people are uninsured?

In 2022, as the economy recovered and Medicaid protections and expanded Marketplace subsidies were implemented, the uninsured rate continued to decline, largely due to increases in coverage among nonelderly adults. The increases in coverage were larger among nonelderly American Indians and Alaska Natives and Hispanics compared to their white counterparts, and among low-income individuals and working families compared to higher-income individuals and those without a worker in the family.

In 2022, the number of uninsured nonelderly and the rate of uninsurance among the nonelderly population reached historic lows. After the ACA was passed, the number of uninsured seniors fell from more than 46.5 million in 2010 to less than 26.7 million in 2016, and then rose again before the pandemic began during the Trump administration. In 2022, the number of uninsured seniors will be 25.6 million, more than a million fewer than in 2016.

Key details:

The uninsured rate decreased in 2022, continuing the downward trend that began during the pandemic. The uninsured rate in 2022 decreases to 9.6% from 10.2% in 2021 and 10.9% in 2019, and the number of people without insurance decreases by 1.9 million from 2021 to 2022 and by 3.3 million from 2019 to 2022 (Figure 1).

• Protective measures put in place during the pandemic helped reduce the uninsured rate from 2019 through 2022. At the beginning of the pandemic, provisions of the Families First Coronavirus Response Act (FFCRA) required states to keep people enrolled in Medicaid until one month after the end of a COVID-19 public health emergency (PHE) in exchange for increased federal funding. Although the Consolidated Appropriations Act for 2023 ended continuous Medicaid enrollment in March 2023, coverage protections were in place throughout 2022. In addition, the expanded subsidies for ACA marketplace enrollees first enacted by the American Recovery and Reinvestment Act (ARPA) were extended for an additional three years in the Inflation Reduction Act of 2022 (IRA). As a result, compared to 2019, the percentage of nonelderly people with Medicaid coverage increased by 1.7 percentage points from 21.0% in 2019 to 22.6% in 2022, and the percentage of nonelderly people with non-group coverage increased by 0.5 percentage points from 6.9% in 2019 to 7.5% in 2022. Over the same period, employer coverage decreased 0.6 percentage points from 58.1% in 2019 to 57.5% in 2022 (Figure 2).
• Compared to 2021, the decrease in the number of people without health insurance in 2022 was driven by increases in coverage for nonelderly adults with employer-sponsored insurance, Medicaid, and non-group insurance. After declining in the first two years of the pandemic, the percentage of people with employer-based insurance increased from 57.0% in 2021 to 57.5% in 2022. While the level of Medicaid coverage did not change from 2021 to 2022, the share of people with non-group insurance increased from 7.3% in 2021 to 7.5% in 2022. (Figure 2).

• Administrative data indicate a larger increase in Medicaid coverage than the ACS assumes. According to the Centers for Medicare and Medicaid Services (CMS), Medicaid coverage in December 2022 is up nearly 30 percent from February 2020: 93 million people compared to 69 million covered by Medicaid in 2022, according to the ACS. Some of the discrepancy can be attributed to different ways of counting people, but some people may misreport the source of coverage in the survey because they don't know they are covered by Medicaid. In addition, national survey data tend to undercount lower-income people who are more likely to be covered by Medicaid. While these discrepancies have been around for a long time, they appear to have doubled during the pandemic.
• During the pandemic, coverage was widespread among the nonelderly population, but the largest increases were among American Indians and Alaska Natives, Hispanics, individuals from low-income families, and adults. From 2019 to 2022, the uninsured rate among American Indians and Alaska Natives decreased by 2.4 percentage points (from 21.7% to 19.1%), and the uninsured rate among Hispanics decreased by 2.0 percentage points (from 20.0% to 18.0%). Although the uninsured rate decreased for people at all income levels, people from low-income households saw the largest decrease in the uninsured rate, from 18.1% in 2019 to 15.7% in 2022. The uninsured rate for nonelderly adults decreased by 1.4 percentage points from 12.9% in 2019 to 11.3% in 2022, while the uninsured rate for children decreased by less than 0.6 percentage points from 5.6% to 5.1% (Figure 3).

• From 2019 to 2022, the uninsured rate decreased in 34 states, including 26 states with program expansions and 8 states without expansions; the remaining states did not experience significant decreases. For the entire 2019-2022 three-year period, no states saw an increase in the uninsured rate; however, one state, Maine, saw a statistically significant increase in the uninsured rate from 2021 to 2022. Although several non-expansion states experienced significant declines in uninsured rates during the pandemic, in 2022, the uninsured rate in the group of non-expansion states was nearly twice as high as in expansion states (14.1% vs. 7.5%) (Appendix Table A).

Who isn't insured?

Most of the 25.6 million uninsured nonelderly people are adults, low-income working families, and people of color. Consistent with geographic differences in income and availability of public insurance, most uninsured people live in the South or West. In addition, most of the uninsured have been uninsured for a long time. (See Appendix Table B for detailed data on the characteristics of the uninsured population.)

Key details:

Of the nonelderly uninsured in 2022, nearly three-quarters (73.3%) had at least one full-time worker in their family, and another 10.9% had a part-time worker in their family (Figure 4). More than eight in ten (80.8%) of the uninsured in 2022 lived in families with incomes below 400% FPL, and nearly half (46.6%) had incomes below 200% FPL. In addition, people of color made up 45.7% of the U.S. nonelderly population, but accounted for 62.3% of the total nonelderly uninsured population. Hispanics and whites made up the largest share of the nonelderly uninsured population at 40.0% and 37.7%, respectively (Figure 5). The majority of the uninsured (75.6%) were U.S. citizens and 24.4% were noncitizens in 2022. Nearly three-quarters of the population resides in the South and West.

• Nonelderly adults are more likely to be uninsured than children. In 2022, the uninsured rate among children is 5.1%, less than half that of nonelderly adults (11.3%), largely due to the greater availability of Medicaid and CHIP programs for children than for adults (Figure 5).
• Overall, racial and ethnic disparities in coverage persist. The uninsured rates for nonelderly Hispanics (18.0%) and American Indians and Alaska Natives (19.1%) are more than 2.5 times higher than the uninsured rate for whites (6.6%) (Figure 5). As in previous years, however, Asians have the lowest uninsured rate at 6.0%, although this masks differences in uninsured rates among the Asian population.

• Non-citizens are more likely than citizens to be uninsured. The uninsurance rate for recent immigrants who have lived in the U.S. for less than five years in 2022 was 30.3%, and for immigrants who have lived in the U.S. for more than five years it was 33.1%. In comparison, the uninsured rate for U.S.-born U.S. citizens was 7.7% and for naturalized citizens was 9.5% in 2022 (Appendix Table B).
• Rates of uninsurance vary by state and region; individuals living in states not covered by the program expansion are more likely to be uninsured (Figure 6). Ten of the fifteen states with the highest rates of uninsured in 2022 were states that did not participate in the program expansion (Figure 7 and Appendix Table A). Economic conditions, availability of employer-sponsored coverage, and demographics are other factors contributing to differences in uninsured rates across states.

• Two-thirds of nonelderly people who were uninsured in 2022 had been uninsured for more than a year. People who have been uninsured for a long time may find it particularly difficult to reach outreach and enroll.

Why aren't people insured?

Most non-elderly U.S. residents receive health insurance through their employer, but not all workers are offered employer-sponsored coverage or, if offered, can afford to pay their portion of the premiums. Medicaid covers many low-income people, especially children, and while Medicaid's continuous enrollment provision has increased Medicaid coverage in all states, Medicaid eligibility for adults remains limited in most states that have not enacted the ACA expansion. While subsidies for Marketplace coverage are available to many middle-income people, few can afford to purchase private coverage without financial assistance.

Key details:

• Cost continues to be a major barrier to obtaining coverage for people without insurance. In 2022, 64.2% of uninsured nonelderly adults said they were uninsured because they could not afford insurance, the most common reason for not having insurance (Figure 8). Other reasons included not being eligible for coverage (28.4%), not needing or wanting coverage (26.1%), and enrollment being too complicated (22.2%).

• Not all workers have access to coverage through their job. In 2022, 60.7% of uninsured non-elderly workers worked for an employer that did not offer health benefits. Among uninsured workers who are offered coverage by their employer, cost is often a barrier to accepting the offer. From 2013 to 2022, total family insurance premiums increased 42%, outpacing wage growth, and the employee share increased 39%. Low-income families with employer-sponsored coverage spend a much larger share of their income on premiums and medical expenses than those whose income exceeds 200% FPL. Especially among people working for small employers, premiums for dependent coverage can be prohibitive.
• Medicaid eligibility varies across states, and states that have not expanded Medicaid have limited eligibility for adults. As of December 2023, 41 states, including the District of Columbia, have adopted the ACA Medicaid expansion, although only 39 states implemented the expansion in 2022. In states that have not expanded Medicaid, the median eligibility level for parents is only 37% FPL, and adults without dependent children are mostly ineligible for the program. In addition, in states that have not expanded the program, millions of poor uninsured adults fall into the "coverage gap" because they earn too much to qualify for Medicaid but not enough to qualify for the Marketplace premium tax credits.
• Many legal immigrants must complete a five-year waiting period after obtaining qualified immigration status before they can qualify for Medicaid. States have the option to cover children and pregnant women without a waiting period, and as of January 2023, 35 states have chosen this option for children and 26 states have chosen this option for lawfully pregnant women. Lawfully residing immigrants are eligible for Marketplace tax credits, including those who are not eligible for Medicaid because they have not passed the five-year waiting period. However, undocumented immigrants are not eligible for federally funded insurance coverage, including Medicaid or Marketplace. Some states have taken steps to provide fully publicly funded coverage to some immigrant groups who are still eligible for federal coverage.
• While financial assistance is available to many of the remaining uninsured under the ACA, not all of the uninsured are eligible for free or subsidized coverage. Six in ten (15.3 million) of the uninsured in 2022 will be eligible for financial assistance through either Medicaid or subsidized Marketplace coverage (Figure 8). However, four in ten of the uninsured (10.3 million people) are outside the ACA because their state has not expanded Medicaid, their immigration status prevents them from qualifying for the program, or they are considered to have access to a low-cost Marketplace plan or an employer's offer of coverage. Some eligible uninsured may be unaware of insurance options or face barriers to enrollment, and even with expanded subsidies, Marketplace coverage may not be available to some uninsured individuals.

How does lack of insurance affect access to health care?

Health insurance determines whether and when people get the health care they need, where they get it, and ultimately how healthy they are. While the COVID-19 pandemic has impacted health care utilization in general, uninsured adults are much more likely than those with insurance to delay or forgo health care altogether due to concerns about cost. The consequences can be serious, especially if preventable conditions or chronic illnesses go undetected.

Key details:

• Studies have repeatedly demonstrated that uninsured individuals are less likely than those with insurance to receive preventive care and services for major health conditions and chronic diseases. Although overall health care utilization declined during the pandemic, in 2021, uninsured adults were more likely to cite cost-related barriers as a reason for delaying or refusing treatment than COVID-19 barriers. In 2022, nearly half (47.4%) of uninsured non-elderly adults reported not seeing a doctor or health care provider in the past 12 months, compared with 16.6% with private insurance and 14.0% with public insurance. Part of the reason for the lack of access to care among the uninsured is that many of them (43.1%) do not have a fixed place to go when they get sick or need medical advice (Figure 9). However, cost also plays a role. More than one in five (22.0%) nonelderly adults without insurance said they had declined needed care in the past year because of cost, compared to 4.7% of adults with private insurance and 7.4% of adults with public insurance.

• Many uninsured people do not get the treatment recommended to them by their health care providers because of cost. In 2022, uninsured non-elderly adults were twice as likely as adults with private insurance to say they had delayed or not gotten needed prescription drugs because of cost (12.3% vs. 5.4%). And while insured and uninsured people with an injury or newly diagnosed chronic disease receive similar follow-up care plans, people without health insurance are less likely than those with insurance to receive all recommended services.
• In 2022, uninsured children were more likely than children with private insurance to forgo needed treatment due to cost (8.6% vs. less than 1%). In addition, nearly a quarter (24.5%) of uninsured children had not seen a doctor in the past year, compared with 4.3% and 5.7% of children with public and private insurance, respectively (Figure 9).
• Because people without health insurance are less likely than those with insurance to use regular outpatient care, they are more likely to be hospitalized for avoidable health problems and experience a decline in their overall health. When hospitalized, uninsured people receive fewer diagnostic and therapeutic services and have a higher mortality rate than those with insurance.
• Research shows that obtaining health insurance significantly improves access to health care and reduces the negative consequences of being uninsured. A review of research on the impact of the ACA Medicaid expansion shows that the expansion led to positive effects on access to care, service utilization, affordability of care, and financial security among low-income populations. Medicaid expansion is associated with increased early cancer diagnoses, reduced cardiovascular disease mortality, and increased likelihood of tobacco cessation.
• Public hospitals, community clinics and health centers, and local providers serving low-income populations provide critical health insurance coverage for the uninsured. However, health network providers have limited resources and capacity, and not all uninsured people have geographic access to health network providers. High levels of uninsured contribute to rural hospitals closing and having major financial problems, leaving rural residents at an even greater disadvantage in accessing care. Studies show that Medicaid expansion is associated with reduced spending on uncompensated care and improved financial performance of rural hospitals and other providers.

What are the financial implications of not having insurance?

Uninsured individuals often face unaffordable medical bills when they seek care. These bills can quickly turn into medical debt because most people without insurance have low to moderate incomes and have few, if any, savings.

Key details:

• Those who are uninsured throughout the calendar year pay nearly 40% of their services out-of-pocket. In addition, hospitals often charge uninsured patients higher rates than those paid by private health insurance companies and government programs.
• Uninsured nonelderly adults are much more likely than their insured peers to lack confidence in their ability to pay for routine medical expenses. More than eight in ten (85%) uninsured nonelderly adults say they have difficulty paying for medical expenses, compared to 47% of adults with insurance (Figure 10).

• Unaffordable medical bills can lead to medical debt, especially for uninsured adults. More than six in ten (62%) uninsured adults report having medical debt compared to more than four in ten (44%) insured adults (Figure 10). Uninsured adults are more likely to experience negative consequences of medical debt, such as using up savings, having difficulty paying for other life expenses, or borrowing money. In addition to the significant financial consequences of having debt, two-thirds of uninsured adults with medical debt say they have had to make difficult sacrifices, such as eating out less, changing housing arrangements, or increasing their work hours, to pay off debt.
• Although federal and state laws require some hospitals to provide some level of charity care, not all eligible patients take advantage of these programs. Consequently, charity care costs are a small portion of many hospitals' operating expenses.
• Studies show that getting health insurance increases access to care and financial security for low-income people. Numerous ACA studies have found reduced problems paying medical bills and reduced medical debt in states covered by the program compared to states not covered. More recent studies have shown that Medicaid expansion reduced catastrophic health care costs and was associated with greater income gains among low-income people.

Conclusion

During the third year after the pandemic began, the number of people without health insurance continued to decline, reaching a record low in 2022. Thanks to the continuation of pandemic-related protections and an active labor market, the increase in coverage was driven by increases in employer, Medicaid, and non-group coverage for non-elderly adults. While the improvement in coverage was across the board, it was particularly large for American Indian and Alaska Native and Hispanic populations (although these groups remain more likely than whites to be uninsured), for low-income families, especially those living in poverty, and for working families, including those with only part-time family jobs.

Termination of Medicaid's continuous enrollment provision will likely reverse these recent gains in coverage. In April 2023, states resumed re-enrolling Medicaid enrollees and are weeding out those who are no longer eligible for the program or those who cannot complete the renewal process even though they are still eligible. Between March and July 2023, the net Medicaid enrollment dropped by nearly three million people. While some people who lose Medicaid get other insurance through an employer or the Marketplace, some undoubtedly become uninsured. Efforts by states, providers, health plans, and other organizations to increase outreach, as well as the availability of navigators and enrollment assisters to help people through the Medicaid renewal process, can increase the likelihood that people who are eligible for Medicaid will keep it and those who are no longer eligible will get other insurance. Extending extended Marketplace subsidies will make coverage more affordable for people excluded from Medicaid and may increase the proportion of people who successfully transition from Medicaid to the Marketplace. However, any significant increase in the number of uninsured people could undermine the improvements in health care access and financial stability associated with having health insurance, as well as exacerbate health disparities.