Uninsured in United States

United States

Health insurance is critical in helping people get the preventive and acute medical care they need to achieve and maintain good health. The nation’s uninsured rate dropped significantly after the Affordable Care Act was enacted, yet over 26.3 million people were still uninsured in 2022. In 2021, an analysis found that 69.6% 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.
• Higher rates of mortality and premature death.
• Higher rates of cancer mortality and greater risk of late-stage cancer diagnosis. 
• Inadequate access to quality care, including preventive services. 
• Expensive medical bills due to undiagnosed or untreated chronic conditions.
• More complex and expensive emergency room visits. 

Individuals who are uninsured or experience inconsistent health care coverage encounter more interruptions in accessing care and difficulties in covering medical expenses compared to individuals with continuous insurance coverage. 

One study estimated that adults ages 20-64 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.

According to America’s Health Rankings data, the uninsured rate is higher among: 

• Adults ages 26-34 compared with all other age groups. Adults ages 55-64 have the lowest rate. 
• 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 have the lowest rate.
• Adults with less than a high school education compared with those with higher levels of education.
• 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. 
• Noncitizen (lawfully present and undocumented immigrants) adults compared with the general U.S. population.

Medicaid expansion has decreased uninsured rates among low-income individuals and vulnerable populations in states that have enacted it. In 2019, 45% of the uninsured population did not have access to health coverage provided by the Affordable Care Act because they lived in a state that had not expanded Medicaid, they were not U.S. citizens or their income was too high to be eligible. Increasing Medicaid expansion could further reduce the number of uninsured individuals. Increasing knowledge of government assistance programs may increase enrollment of eligible individuals. Policy changes can also help address issues with affordability.

Increasing the number of people with health insurance is important to improve health outcomes and decrease health care spending. However, a combination of three core 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.

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

Buettgens, Matthew, and Urmi Ramchandani. “The Health Coverage of Noncitizens in the United States, 2024,” 2024. https://www.urban.org/sites/default/files/2023-05/The%20Health%20Coverage%20of%20Noncitizens%20in%20the%20United%20States%202024.pdf.

Freeman, Joseph D., Srikanth Kadiyala, Janice F. Bell, and Diane P. Martin. “The Causal Effect of Health Insurance on Utilization and Outcomes in Adults: A Systematic Review of US Studies.” Medical Care 46, no. 10 (2008). https://doi.org/10.1097/MLR.0b013e318185c913.

Garfield, Rachel, and Kendal Orgera. “The Uninsured and the ACA: A Primer — Key Facts about Health Insurance and the Uninsured amidst Changes to the Affordable Care Act.” KFF, January 2019. https://files.kff.org/attachment/The-Uninsured-and-the-ACA-A-Primer-Key-Facts-about-Health-Insurance-and-the-Uninsured-amidst-Changes-to-the-Affordable-Care-Act.

Guth, Madeline, Rachel Garfield, and Robin Rudowitz Published. “The Effects of Medicaid Expansion under the ACA: Studies from January 2014 to January 2020,” March 17, 2020. https://www.kff.org/medicaid/report/the-effects-of-medicaid-expansion-under-the-aca-updated-findings-from-a-literature-review/.

Keisler-Starkey, Katherine, and Lisa N Bunch. “Health Insurance Coverage in the United States: 2019,” September 2020. https://www.census.gov/content/dam/Census/library/publications/2020/demo/p60-271.pdf.

Michael E. Chernew, David M. Cutler, and Shivani A. Shah. “Reducing Health Care Spending: What Tools Can States Leverage?,” August 18, 2021. https://doi.org/10.26099/dyp4-2t03.

Newton, Manya F., Carla C. Keirns, Rebecca Cunningham, Rodney A. Hayward, and Rachel Stanley. “Uninsured Adults Presenting to US Emergency Departments: Assumptions vs Data.” JAMA 300, no. 16 (October 22, 2008): 1914–24. https://doi.org/10.1001/jama.300.16.1914.

Rudowitz, Robin, Patrick Drake, Jennifer Tolbert, and Anthony Damico Published. “How Many Uninsured Are in the Coverage Gap and How Many Could Be Eligible If All States Adopted the Medicaid Expansion?,” March 31, 2023. https://www.kff.org/medicaid/issue-brief/how-many-uninsured-are-in-the-coverage-gap-and-how-many-could-be-eligible-if-all-states-adopted-the-medicaid-expansion/.

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Sommers, Benjamin D. “State Medicaid Expansions and Mortality, Revisited: A Cost-Benefit Analysis.” American Journal of Health Economics 3, no. 3 (May 11, 2017): 392–421. https://doi.org/10.1162/ajhe_a_00080.

Tolbert, Jennifer, Patrick Drake, and Anthony Damico Published. “Key Facts about the Uninsured Population,” December 19, 2022. https://www.kff.org/uninsured/issue-brief/key-facts-about-the-uninsured-population/.

Ward, Elizabeth, Michael Halpern, Nicole Schrag, Vilma Cokkinides, Carol DeSantis, Priti Bandi, Rebecca Siegel, Andrew Stewart, and Ahmedin Jemal. “Association of Insurance with Cancer Care Utilization and Outcomes.” CA Cancer J Clin 58, no. 1 (February 2008): 9–31. https://doi.org/10.3322/CA.2007.0011.

Wilper, Andrew P., Steffie Woolhandler, Karen E. Lasser, Danny McCormick, David H. Bor, and David U. Himmelstein. “Health Insurance and Mortality in US Adults.” American Journal of Public Health 99, no. 12 (December 1, 2009): 2289–95. https://doi.org/10.2105/AJPH.2008.157685.

Woolhandler, Steffie, and David U. Himmelstein. “The Relationship of Health Insurance and Mortality: Is Lack of Insurance Deadly?” Annals of Internal Medicine 167, no. 6 (June 27, 2017): 424–31. https://doi.org/10.7326/M17-1403.