Uninsured (As per America's Health Rankings)

U.S. Value: 9.2% (2020);  8.6% (2021)

Healthiest State: Massachusetts: 3.0% (2020); 2.5% (2021)

Least-healthy State: Texas: 18.4% (2020); 18.0% (2021)

Definition: Percentage of population not covered by private or public health insurance

Data Source & Year(s): U.S. Census Bureau, American Community Survey, 2019; 2020

Suggested Citation: America's Health Rankings analysis of U.S. Census Bureau, American Community Survey, United Health Foundation, AmericasHealthRankings.org, accessed 2022.

WHY DOES THIS MATTER?

Health insurance is critical in helping people receive the preventive and medical care they need to achieve and maintain good health. The nation’s uninsurance rate dropped significantly after the Affordable Care Act was enacted, yet nearly 28.2 million people a(2021) (as apposed to 29.6 million people during 2019) were still uninsured. In 2019, an analysis found that 73.7% of uninsured adults reported that they were uninsured because they could not afford health insurance.

Compared with insured adults, uninsured adults have more health disadvantages, including: 

• Worse health outcomes and higher rates of mortality and premature death.
• Higher rates of cancer mortality and greater risk of a late-stage cancer diagnosis. 
• Inadequate access to quality care, including preventive services. 
• Expensive medical bills due to undiagnosed or untreated chronic conditions and more emergency room visits. 

One study estimated that adults ages 20 to 64 in three Medicaid expansion states experienced a 6% decline in all-cause mortality compared with adults living in demographically and economically similar states that did not expand Medicaid. This decline was largely from medical conditions that respond well to medical management, such as HIV, heart disease and diabetes.

WHO IS AFFECTED?

Populations with higher uninsured rates include:

• Adults ages 26-34 compared with all other age groups. Older adults ages 55-64 had the lowest rates of being uninsured. 
• American Indian/Alaska Native and Hispanic adults as well as those who identify as other race compared with other racial and ethnic groups. White adults had the lowest rate.
• Adults with less than a high school education compared with those with higher education levels.
• Individuals living in non-Medicaid expansion states compared with those in Medicaid expansion states.
• Individuals with income levels below 100% of the federal poverty level compared with individuals with higher incomes.

GOALS

A Healthy People 2030 leading health indicator is to increase the proportion of people with health insurance from 89.0% to 92.1%.

https://www.americashealthrankings.org/explore/annual/measure/HealthInsurance/state/IN.  Last accessed June 2022

WHAT WORKS?

Medicaid expansion decreased uninsured rates among low-income individuals and vulnerable populations in states that expanded Medicaid. Currently, 45% of the uninsured population do not have access to health coverage provided by the Affordable Care Act because they live in a state that has not expanded Medicaid, they are not a U.S. citizen or their income is too high to be eligible for subsidies. Additional states adopting the Medicaid expansion or a policy change to make non-citizens eligible for health coverage under the Affordable Care Act could decrease the number of uninsured individuals. Increasing knowledge of government assistance programs may increase enrollment of eligible individuals. Policy changes can also help address the affordability issue

Increasing the number of people with health insurance is important to improve health outcomes and decrease health care spending. However, a combination of three strategies — expanding health insurance coverage, delivering better preventive and chronic care and focusing on community prevention — is more effective at saving lives and money than implementing any of these strategies alone.

https://www.americashealthrankings.org/explore/annual/measure/HealthInsurance/state/IN.  Last accessed Dec 2022 

The Affordable Care Act (ACA) brought sweeping change to the U.S. health care system, expanding comprehensive health insurance to millions of Americans and making it possible for anyone with health problems to get coverage by banning insurers from denying coverage or charging more because of preexisting conditions. In 2018 there were 18.2 million fewer uninsured people in the U.S. than when the ACA became law.¹ In addition, fewer people are forgoing health care because of cost or reporting high out-of-pocket costs relative to their income.² 

^{https://www.commonwealthfund.org/publications/issue-briefs/2019/aug/who-are-remaining-uninsured-and-why-do-they-lack-coverage}  Last accessed June 2022    

Rising health care costs, the economic downturn, an erosion of employer-based insurance, and public program cutbacks. Developing effective strategies for reducing uninsurance requires understanding why people lack insurance coverage. 

• In 2018, uninsured working-age adults in the United States were disproportionately low income, Latino, and under age 35.
• Following the ACA individual market subsidies and reforms, the share of adults who had tried to buy a plan in the individual market and reported difficulties finding an affordable plan fell from 60 percent to 34 percent. In 2018, 42 percent of adults reported difficulty finding affordable coverage. 

https://www.commonwealthfund.org/publications/issue-briefs/2019/aug/who-are-remaining-uninsured-and-why-do-they-lack-coverage  Last accessed 22 June 2022

Although cost is an important issue for all population subgroups studied, cost concerns were most prevalent among Hispanic individuals, noncitizens, and those likely to face the highest costs for coverage in the non-group market—the near-elderly and disabled adults. Over time, however, the importance of high insurance costs for adults and children in families with access to employer-sponsored insurance (ESI) coverage also has grown, likely reflecting the rising costs of ESI. 

https://www.urban.org/sites/default/files/publication/50831/411317-Why-Do-People-Lack-Health-Insurance-.PDF Last accessed 22 June 2022

https://www.cbpp.org/sites/default/files/archive/9-30-02health.htm Last accessed 06/15/2023

• Nearly half of uninsured adults may have been eligible for subsidized insurance through the marketplace or their state’s expanded Medicaid program.
• Two-thirds (67%) of uninsured adults had not gone to the marketplace to examine their coverage options. Of those, one-third (36%) said they didn’t think they could afford health insurance.

https://www.commonwealthfund.org/publications/issue-briefs/2019/aug/who-are-remaining-uninsured-and-why-do-they-lack-coverage   Last accessed 6/22/2022 

If policymakers want to increase insurance coverage they will need to address the fact that many of the uninsured view the cost of the coverage options available to them as “too high.” Lowering the cost of coverage (for example, by expanding eligibility for public insurance or providing subsidies for private insurance coverage) and/or raising the cost of being uninsured (for example, by imposing penalties for those who do not purchase coverage) could reduce the perceived high cost of coverage relative to being uninsured. 

https://www.urban.org/sites/default/files/publication/50831/411317-Why-Do-People-Lack-Health-Insurance-.PDF Last accessed 6/22/2022 

https://www.americashealthrankings.org/explore/annual/measure/HealthInsurance/state/IN.  Last accessed Dec 2022