In 2020, as the coronavirus (COVID-19) pandemic took hold, 28 million people — or 8.6 percent of the population — were uninsured, according to a report from the Census Bureau. While this represents a significant portion of the population without coverage during a major public health crisis, overall the share of people without health insurance has been relatively stable over the past several years. Here’s a summary of the latest data to offer insights on why that happened, including how Americans currently get their coverage, how coverage differs across demographic and age lines, how the figures have changed over time, and how key federal programs like Medicaid factor in.
Uninsured Rates Before the Pandemic
In the decade before the enactment of the Affordable Care Act (ACA) in 2010, the uninsured rate averaged 15 percent. In 2014, provisions of the ACA went into effect, which enabled states to expand Medicaid eligibility and establish health insurance marketplaces. While outcomes varied by state, those policy changes contributed to a 3-percentage-point decrease in the share of uninsured people nationally in the initial year. As additional states adopted Medicaid expansion in the mid-2010s, the uninsured rate continued to drop, falling below 10 percent and remaining there since.
Uninsured Rates in 2020
Census data show that the uninsured rate in 2020 was not meaningfully different than the rate in 2018. Data for 2018 is compared to 2020 because the 2019 data were collected during the early months of the COVID-19 pandemic, which greatly reduced the survey response rate and led the Census Bureau to urge caution with regard to using that data. There are a couple of reasons why the number of uninsured Americans did not change significantly. The Census report finds that many of those who became unemployed during the pandemic were in low-income jobs and did not have employer-based health insurance to begin with. In addition, many people became eligible for Medicaid and CHIP due to lay-offs and provisions in the Families First Coronavirus Response Act that require states to ensure continuous enrollment. Enrollment in Medicaid and CHIP has grown by 20 percent since the pandemic began, reflecting its counter-cyclical design.
While the Census data related to the number of uninsured people for 2020 do not fully account for individuals who lost health insurance as a result of the pandemic due to survey structure, estimates from the National Health Interview Survey (NHIS) report similar numbers. The NHIS estimates that the highest quarterly uninsured rate of 2020 was 10.3 percent between October and December of that year. The NHIS data also show that the minor uptick in the uninsured rate during 2020 was reversed in 2021, with the rate falling to 8.9 percent, which is even lower than their measure of the uninsured rate in 2018 (9.4 percent).
Public and Private Health Insurance Coverage
The Census report also provides significant insights about the state of healthcare access in America during the midst of the pandemic. Health insurance is provided through various sources in both the private and public sectors. The Census Bureau defines the programs in each sector:
- Private Insurance includes employment-based insurance plans and plans purchased directly from a marketplace. It also includes TRICARE, which serves members of the military.
- Public Insurance includes Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), and veterans’ health programs.
In 2020, private insurance programs covered nearly twice as many Americans as did public programs. Of those with health insurance in 2020, 217 million people were enrolled in a private program and 113 million in a public program. Coverage estimates are not mutually exclusive because people can be covered by more than one type of health insurance during the year, so the sum of those numbers are greater than the U.S. population.
Employment-based plans accounted for more than half of the population with insurance; the next largest sources of coverage were Medicaid and Medicare. From 2018 to 2020, enrollment in employment-based plans declined from 178 million people to 177 million. In the same time period, enrollment in Medicare increased by about 2 million individuals, climbing to almost 60 million in 2020; that change was partly the result of growth in the number of people age 65 and over.
Uninsured rates differ across states and are largely dependent on whether a state expanded Medicaid eligibility. As part of the ACA, 32 states and the District of Columbia expanded Medicaid eligibility before January 2019. Since then, additional states have adopted a policy to expand eligibility, bringing the total to 39 states and jurisdictions. In 2020, nearly 58 million people were covered by Medicaid. Both Medicaid and CHIP provide health insurance coverage for vulnerable populations, including children. In 2020, the average uninsured rate for children in states that expanded eligibility was 4.0 percent, while states that did not expand Medicaid had an average uninsured rate of 8.5 percent. Similarly, a higher proportion of working-age adults were uninsured in states that did not expand Medicaid.
Health Coverage by Age
Every year since the enactment of the ACA, uninsured rates have been lower for all age groups than before implementation. The uninsured rate for Americans age 65 and older only increased 0.1 percent between 2018 and 2020; it remains the lowest of any age group, with 93.5 percent of such individuals covered by Medicare in 2020.
In the period from 2018 to 2020, the uninsured rate for working-age adults — those between ages 19 and 64 — increased from 11.7 to 11.9 percent. According to a Kaiser Family Foundation analysis, 74 percent of uninsured working-age adults in 2019 cited high costs as the reason why they lacked coverage. In states that did not expand Medicaid eligibility, many working-age adults fell into a “coverage gap,” earning too much to qualify for Medicaid, but not enough to qualify for premium tax credits that make purchasing private insurance in the marketplaces affordable.
For children under the age of 19, the uninsured rate did not significantly change between 2018 and 2020. Though the rate change was not significant, the number of children covered by a guardian’s employment-based plan decreased by about 521,000 between 2018 and 2020 and there was a decline of 805,000 children who were covered by Medicaid and CHIP. Nearly three-quarters of that amount stemmed from disenrollment in Medicaid and CHIP as states implemented barriers associated with maintaining coverage including periodic eligibility checks. For example, some states may disenroll individuals that cannot confirm their eligibility within 10 days of receiving a request for information. Increased coverage from TRICARE and other programs for veterans worked to offset some of the patches in coverage, but overall there was a slight increase in the number of uninsured children.
Health Coverage by Race
Heading into the pandemic, non-white Americans had the highest rates of being uninsured. This still holds true in the data from the pandemic, as those are also the groups that have been the most heavily affected by COVID in regards to employment and health. In 2020, 40 percent of the population were people of color, but they accounted for 63 percent of the uninsured population.
Though the number has improved significantly over the past decade, nearly 30 million Americans remain uninsured. During the pandemic, however, the number of uninsured Americans remained relatively stable, in part due to increased eligibility for Medicaid.
Looking ahead, policymakers should continue to work toward policies to improve the efficiency of the U.S. healthcare system, making it more accessible and affordable. Total healthcare spending in the United States is projected to account for nearly one-fifth of the economy by 2025. The federal share of that total is large and growing, which underscores the need to identify and implement solutions to improve healthcare performance in the United States, address a key driver of the federal debt, and better equip individuals to cope with serious threats to public health, like the coronavirus pandemic.
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