The study by KFF experts explores the characteristics of the uninsured population in 2021, the trends in health coverage throughout the pandemic’s second year, and the access and financial costs of not having insurance. This research compares health coverage statistics for 2021 to data for 2019 using data from the American Community Survey (ACS); due to disruptions in data collecting during the pandemic, the Census Bureau did not produce 1-year ACS estimates in 2020.
Who are the US’s uninsured?
Six in ten of the 27.5 million uninsured adults are persons of color, working families, non-elderly adults, and households with modest incomes. The majority of uninsured people reside in the South or West, which reflects regional differences in income and the accessibility of public insurance. Additionally, the majority of those without insurance have been uninsured for a protracted period of time.
In 2021, of the entire population of non-elderly people without insurance, slightly over seven in ten (70.2%) had at least one full-time worker in their family, and an additional 11.6% had a part-time worker.
In 2021, more than 80% of uninsured people (81.6%) lived in families with incomes below the FPL of 400%, and nearly half (48.2%) had incomes below the FPL of 200%.
In addition, although they made up 45.1% of the nonelderly population in the United States, people of color were responsible for 61.3% of the nonelderly uninsured. The non-elderly uninsured population was mostly made up of White and Hispanic persons, with 39.0% and 38.7% respectively.
In 2021, Americans made up the majority of the uninsured (77.1%), while foreigners made up 22.9% of the population, with approximately three-quarters residing in the South and West.
Children are less likely to be uninsured than non-elderly adults.
Children’s uninsured rates fell to 5.3% in 2021, less than half the rate for non-elderly adults (12.2%), in large part because Medicaid and CHIP coverage is more widely available for kids than it is for adults.
People of color are generally more likely than White people to be uninsured. More than 2.5 times as many Hispanics (19.0%) and American Indians and Alaska Natives (21.2%) lack health insurance as White individuals (7.2%). Asians, with a 6.4% uninsured percentage, continue to have the lowest rate, as in prior years.
Non-citizens are more likely to lack insurance than citizens.
In 2021, the percentage of new immigrants—those who have been in the country for less than five years—without health insurance was 28.9%, compared to 34.8% for those who have been in longer. In 2021, the uninsured rate for people of native countries was 8.4%, while it was 10.2% for citizens of other countries.
State and regional uninsured rates vary; those residing in non-expansion states are more likely to be uninsured. In 2021, non-expansion states made up ten of the top fifteen states with the highest uninsured rate. Other elements influencing the disparity in uninsured rates between states include demography, the state of the economy, and the availability of employer-sponsored insurance.
Why do people lack insurance?
The majority of Americans under 65 receive health insurance from their employers, but not all employees are provided with employer-sponsored coverage or, if they are, are able to pay their fair share of the costs. Many low-income people are covered by Medicaid, although adult Medicaid eligibility is still restricted in several states that have not approved the ACA expansion.
Medicaid coverage rose in many states as a result of the PHE’s Medicaid continuous enrollment mandate. Many people with moderate incomes can get financial aid for Marketplace coverage, but few people can afford to buy private insurance on their own.
The primary obstacle to coverage for the uninsured is still cost. The most often claimed reason for being uninsured in 2021 was that coverage was too expensive, which was given by 69.6% of uninsured non-elderly individuals. Ineligibility for coverage (26.2%), lack of need or desire for coverage (23.5%), and difficulty in enrolling (19.9%) were other justifications.
Not every employee has coverage through their employer. 64.4% of non-elderly uninsured workers in 2021 were employed by companies that did not provide health benefits. Cost is frequently a deterrent for uninsured workers who are offered coverage by their employers.
Family coverage’s overall premiums climbed by 43% between 2012 and 2022, while the worker’s portion increased by 41%, exceeding salary growth.
Compared to families with incomes above 200% FPL, low-income families with employer-based coverage devote a much larger proportion of their income to premiums and out-of-pocket medical costs.
Medicaid eligibility varies from state to state, and in those that have not expanded Medicaid, adult eligibility is constrained. Despite just 39 states having accepted the expansion in 2021, 40 states, including DC, have approved the ACA Medicaid expansion as of November 2022.
The median FPL qualifying level for parents in states without expanded Medicaid is merely 39%, and most adults without dependent children are not eligible.
Millions of uninsured adults who are poor and live in non-expansion states also have a “coverage gap” because of their income, which is too high to qualify for Medicaid but not high enough to qualify for Marketplace premium tax credits.
Many people who are in the country legally must wait five years after getting a qualifying immigration status in order to be eligible for Medicaid. Concerns over Trump’s revisions to the federal public charge immigration policy among immigrants who are eligible for Medicaid may prevent some from enrolling. Even though the Biden Administration undid the changes, uncertainty and dread can still exist.
Immigrants with legal status, including those who are ineligible for Medicaid due of the five-year waiting period, are eligible for Marketplace tax credits. However, Medicaid and Marketplace coverage are not available to unauthorized immigrants.
Even while the ACA makes financial aid available to many of the uninsured, not all uninsured people qualify for free or heavily discounted coverage. Many uninsured people qualified for financial aid through Medicaid or through Marketplace coverage that was subsidized.
However, this means that many people lack access to the ACA’s protections because their state did not expand Medicaid, they were determined to be ineligible due to their immigration status, or they had access to a reasonable Marketplace plan or employer-sponsored coverage option.
Even with increased subsidies, some uninsured people may not be aware of the coverage options available to them or may encounter enrollment obstacles, making Marketplace coverage costly for some uninsured people.