Lower-income Americans are less likely to have employer-sponsored insurance or be eligible for subsidized marketplace plans. People over 65 have the lowest uninsured rates, as Medicare, a governmental insurance program, mostly covers them. Nonelderly Americans without insurance dropped by 1.5 million between 2019 and 2021, reflecting improvements in Medicaid coverage and marketplace subsidies. However, some groups saw more modest reductions in their uninsured rates.
Factors Influencing Uninsured Rates
In 2020, household income accounted for about half of the variation in uninsured rates among America’s 85 largest metropolitan statistical areas (MSAs). People with higher wages are more likely to be offered employment-based insurance coverage or to afford private insurance independently. Low-income people may be eligible for public insurance through their state, such as Medicaid or SCHIP. Six out of ten Americans who are uninsured are members of working families. Generally, wage earners are more likely to be offered employment-based coverage if they work in larger firms or in manufacturing or sales (“wholesale and retail trade”) than in agriculture, forestry, fishing and mining, or construction. The uninsured rate is lower for family members with higher levels of education, notably those who have completed at least some postsecondary education. However, the uninsured rate is still higher for those with no college education or working in low-income occupations. Rates vary further by urban area, as the likelihood of having access to employment-based insurance varies according to the demographic makeup of each community.
The share of the population that is uninsured Americans varies by state. Demographic, socioeconomic, and geographic factors influence this variation. Among wage earners, the most important factor influencing coverage status is employment. Individuals with higher wages are more likely to have employment-based health insurance, and the likelihood of having that coverage increases as a family’s income level rises. Wage earners with fewer jobs are more likely to be uninsured, and those in small firms (less than 100 employees) have particularly low take-up rates. Marital status also influences the opportunity for individuals to obtain employment-based health insurance, with lower take-up rates among married women than men. The percentage of uninsured adults varies by age, race/ethnicity, and gender. In 2019, those identifying as uninsured reported that they had been so for reasons such as not needing or wanting coverage, the process of signing up was too difficult or confusing, they could not find a plan that met their needs, or they had signed up for coverage, but it had not yet started.
Many low-income people have insurance through employment-based plans or the individual marketplace. In 2021, the uninsured rate declined for these families. This drop was mostly due to increases in Medicaid and non-group coverage that offset declines in employer-sponsored coverage during the pandemic. In addition to declining employment-based coverage, many working-age adults cited cost concerns as the primary reason for their lack of insurance. These individuals are typically in a family that earns too much to qualify for public assistance but too little to receive premium tax credits, making private insurance in the marketplace affordable. In communities with high levels of joblessness and poverty, many working-age adults are not offered employment-based coverage and remain uninsured. However, in neighborhoods with more stable labor markets, workers are more likely to be offered coverage and take it up. For example, in families with a primary wage earner who is offered employment-based coverage but declines it, 83 percent of those family members remain insured through other means, such as buying their insurance or obtaining public coverage. Moreover, the uninsured rate tends to be lower in metropolitan areas with large immigrant populations, where many residents have public insurance through refugee status.
Families with a wage worker with employment-based coverage are likelier to have health insurance. However, not all families have such an option. Full-time, permanent employment offers the best chance of obtaining and maintaining family health insurance, as does an annual income at or above the poverty level. Families with children are also more likely to have insurance since they are usually eligible for and enrolled in Medicaid and SCHIP. Regional variations in uninsurance rates are largely driven by differences in the labor force and employer characteristics, especially firm size and employment sector. For example, workers in large firms are twice as likely to be offered employment-based insurance as workers in small firms. Similarly, Hispanic family members of wage earners with job-based coverage are less than half as likely to be provided such coverage as non-Hispanic whites; when they decline such coverage, they are about as likely to purchase individual or public insurance but remain about as likely to be uninsured. For these reasons, the uninsurance rate for people of color is higher than for whites.
Uninsured rates have dropped significantly since the COVID-19 pandemic, driven mainly by the expansion of Medicaid and private insurance options offered through marketplaces. The declines in the uninsured rate also reflect a counter-cyclical design of Medicaid that allows individuals to stay on their plans even when they lose employment or other income. Despite these gains, many adults need more coverage. Cost remains a major factor in deciding not to obtain health insurance, particularly for Hispanic individuals, noncitizens, and those likely to face high prices in the individual market—including near-elderly adults. Over time, the share of uninsured nonelderly adults who report concerns about cost has increased. Affordable health insurance determines whether people get needed care, where they receive it, and how healthy they are. Without it, they are more likely to postpone or skip healthcare needs and delay treatments for chronic diseases and conditions. When they finally seek care, they are more likely to experience medical bills they cannot afford. It can strain relationships, finances, and communities.