Key Facts about the Uninsured Population

The pandemic-era coverage policies, including the Medicaid continuous enrollment provision and the enhanced Marketplace subsidies, continued to impact health coverage in the U.S. in 2023. During the pandemic, the coverage expansions put in place by the Affordable Care Act (ACA), including Medicaid expansion and subsidized Marketplace coverage, served as a safety net for people who experienced economic and coverage disruptions. Gains in Medicaid and Marketplace coverage contributed to significant declines in the uninsured rate through 2022. Although states began the process of unwinding continuous enrollment in Medicaid in April 2023 and resumed disenrolling people from Medicaid, the full effect of Medicaid disenrollments were not felt in 2023. In addition, the enhanced Marketplace subsidies, which were extended through 2025, remained in place. Both these factors contributed to maintaining most of the coverage gains experienced during the pandemic period in 2023.

This issue brief describes trends in health coverage in 2023, examines the characteristics of the uninsured population ages 0-64, and summarizes the access and financial implications of not having coverage. Using data from the American Community Survey (ACS), this analysis examines changes in health coverage from 2022 to 2023 and compares data for 2023 to data for 2019 to report on coverage trends during the pandemic and through the start of the unwinding of the Medicaid continuous enrollment provision. Because of disruptions in data collection during the pandemic, the Census Bureau did not release 1-year ACS estimates in 2020. The analysis focuses on coverage among people ages 0-64 since Medicare offers near universal coverage for people ages 65 and older, with just 457,000, or less than 1%, of people over age 65 uninsured.

Key Takeaways

• How many people are uninsured: Despite the unwinding of the Medicaid continuous enrollment provision that began in April 2023, the number of people ages 0-64 who were uninsured held steady at 25.3 million in 2023. However, the number of uninsured children increased from 3.8 million in 2022 to 4.0 million in 2023. Compared to 2019, the number of people who were uninsured declined by 3.6 million.
• Who is uninsured: Most uninsured people are in low-income families and have at least one worker in the family. Reflecting the more limited availability of public coverage in some states, adults ages 19-64 are more likely to be uninsured than children. Despite gains across groups over time, racial and ethnic disparities in coverage persist.
• Why are people uninsured: Many uninsured people cite the high cost of insurance as the main reason they lack coverage. In 2023, 63% of uninsured adults ages 18-64 said that they were uninsured because the cost of coverage was too high. Many uninsured people do not have access to coverage through a job, and some people, particularly poor adults in states that have not expanded Medicaid, remain ineligible for financial assistance for coverage. Although over half of people who are uninsured may be eligible for Medicaid or subsidized coverage in the Marketplaces, they may not be aware of these coverage options or may face barriers to enrolling. In some cases, even with subsidies, Marketplace coverage may not be affordable.
• How does not having coverage affect health care access: People without insurance coverage are less likely to access care and more likely to delay or forgo care because of costs. Although difficult to establish direct causality, research has linked Medicaid expansion to improved health outcomes, including lower mortality rates from cancer, cardiovascular disease, liver disease, and maternal mortality.
• What are the financial implications of being uninsured: Uninsured people often face unaffordable medical bills when they do seek care. Nearly half (49%) of uninsured adults say they have difficulty affording health care costs, more than double the share of those with private insurance (21%). These costs can quickly translate into medical debt since most people who are uninsured have low or moderate incomes and have little, if any, savings. More than six in ten (62%) uninsured adults report having health care debt compared to over four in ten (44%) insured adults.

Although coverage rates for the overall population ages 0-64 held steady in 2023, future changes to Medicaid and Marketplace coverage could have a significant impact on health coverage. Proposals that would alter how Medicaid is financed or that would impose work requirements on certain adults enrolled in the program would likely lead to a loss of Medicaid coverage. Moreover, the temporary enhanced Marketplace subsidies will expire after 2025 unless Congress acts. Without a permanent extension, the Congressional Budget Office estimates that the number of uninsured people will increase by 3.8 million, on average, in each year from 2026 to 2034. The combined Medicaid and Marketplace coverage losses could lead to a sizable increase in the number of people who are uninsured. In turn, the loss of coverage could have implications for access to care and financial stability associated with having health coverage and could lead to a worsening of disparities in health outcomes.

How many people are uninsured?

Among the population ages 0-64, both the number of uninsured (25.3 million) and the uninsured rate (9.5%) remained at historic lows in 2023. A continued decline in the number of uninsured adults ages 19-64 was offset by an increase in the number of uninsured children. Compared to 2019, prior to the start of the pandemic, the number of uninsured and the uninsured rate for the population ages 0-64 were both significantly lower in 2023. Nearly all groups experienced coverage gains, but American Indian or Alaska Native (AIAN) and Hispanic people had larger gains than their White counterparts and low-income individuals and those in working families had bigger gains than those at higher incomes and those without a worker in the family.

Key Details:

• In 2023, 25.3 million people ages 0 to 64 were uninsured, and the uninsured rate for this population was 9.5%, both statistically unchanged from 2022. While the uninsured rate held steady from 2022, it was lower than in 2019 (10.9%) prior to the start of the coronavirus pandemic (Figure 1).

• From 2019-2023, the uninsured rate declined by 1.4%, driven primarily by gains in Medicaid and Marketplace coverage because of pandemic-era coverage protections. The Medicaid continuous enrollment provision required states to keep people enrolled in Medicaid during the pandemic in exchange for enhanced federal funding and enhanced ACA Marketplace subsidies, first enacted in the American Rescue Plan Act (ARPA) and renewed through 2025 in the Inflation Reduction Act of 2022 (IRA). Although the enhanced Marketplace subsidies remained in effect in 2023, Medicaid continuous enrollment ended on March 31, 2023, and states resumed disenrolling people from Medicaid, though the full effects of the disenrollments were not felt in 2023. During this time period, employer coverage declined by 0.5% (Figure 2).
• While there was no change in the uninsured rate for the overall population ages 0 to 64 in 2023, the share of children 18 and younger without insurance increased from 5.1% in 2022 to 5.3% in 2023. At the same time, the uninsured rate for adults ages 19 to 64 decreased to 11.1% in 2023 from 11.3% the previous year (Figure 2). An increase in Medicaid coverage for adults 19-64 from 16.3% to 16.5% in 2023 drove the decline in the uninsured rate for this group. Despite the uptick in the uninsured rate for children in 2023, the share of children without health insurance coverage was still lower in 2023 compared to 2019.

• Although nearly all groups experienced coverage gains during the pandemic-period, they were largest for AIAN and Hispanic people and individuals in low-income families. From 2019 to 2023, the uninsured rate for AIAN people fell 3.0 percentage points (from 21.7% to 18.7%) and the uninsured rate for Hispanic people decreased by 2.1 percentage points (from 20.0% to 17.9%), although these groups remain more likely to be uninsured than their White counterparts. Native Hawaiian or Pacific Islander (NHPI) people did not experience a significant decline in the uninsured rate during this period, which may, in part, reflect the smaller sample size for NHPI people, which limits the power to detect statistically significant differences. While the uninsured rate dropped for people at all income levels, individuals in low-income families¹ experienced the largest declines. From 2019-2023, the uninsured rate for poor individuals dropped 2.2 percentage points (18.0% to 15.8%) and 2.7 percentage points for individuals with income 100-199% FPL (18.2% to 15.5%, Figure 3).

• From 2022 to 2023, the uninsured rate for the population ages 0 to 64 fell in six states (Florida, Hawaii, Illinois, Missouri, North Dakota, and Oregon) but increased in two states, Iowa and Idaho (Appendix Table A). At the same time, the uninsured rate for children increased in six states (Alabama, Idaho, New Mexico, South Carolina, Texas, and Washington). While these changes occurred in both expansion and non-expansion states, the uninsured rate was lower in expansion states (7.6%) compared to non-expansion states (14.1%) in 2023 (Figure 6).

Who is uninsured?

Most of the 25.3 million people ages 0-64 who are uninsured are adults, in working low-income families, and are people of color. Reflecting geographic variation in income and the availability of public coverage, most uninsured people live in the South or West. In addition, most who are uninsured have been without coverage for long periods of time. (See Appendix Table B for detailed data on characteristics of the uninsured population.)

Key Details:

• In 2023, of the total uninsured population ages 0 to 64, nearly three in four (73.7%) had at least one full-time worker in their family, and 11.2% had a part-time worker in their family (Figure 4). More than eight in ten (80.9%) uninsured people were in families with incomes below 400% of the federal poverty level, and nearly half (46.6%) had incomes below 200% FPL. White people made up 37.1% of the uninsured, and the remaining 62.9% included Hispanic (41.1%), Black (12.5%), and Asian (3.7%) people and people of other racial or ethnic backgrounds (Figure 4). Most uninsured individuals (74.2%) were U.S. citizens, while 25.8% were noncitizens. Almost three-quarters (73.9%) of uninsured people lived in the South or West.

• Adults ages 19 to 64 are more likely to be uninsured than children. In 2023, the uninsured rate for children was 5.3%, less than half the rate for adults at 11.1%.
• Uninsured rates in the U.S. still show clear racial and ethnic disparities. In 2023, 17.9% of Hispanic people and 18.7% of AIAN people ages 0 to 64 were uninsured—more than two and a half times the rate for White people (6.5%). Asian individuals had the lowest uninsured rate at 5.8%.

• Noncitizens are more likely than citizens to be uninsured. Nearly one-third of noncitizen immigrants were uninsured in 2023, while the uninsured rate for U.S.-born citizens was 7.5% and 8.9% for naturalized citizens. (Appendix Table B).
• Uninsured rates vary by state and by region; individuals living in non-expansion states are more likely to be uninsured (Figure 6). Six of the ten states with the highest uninsured rates in 2023 were non-expansion states (Figure 5 and Appendix Table A).

• Nearly two-thirds (64%) of people who were uninsured in 2023 have been without coverage for more than a year.² People who have been without coverage for long periods may be particularly hard to reach through outreach and enrollment efforts.

Why are people uninsured?

Lack of access to affordable health coverage is the main reason many people say they are uninsured. A majority of working age adults in the U.S. obtain health insurance through an employer; however, not all workers are offered employer-sponsored coverage or, if offered, can afford their share of the premiums. Medicaid covers many low-income individuals, especially children, but Medicaid eligibility for adults remains limited in most states that have not adopted the ACA expansion. Marketplace subsidies make coverage more affordable for many, but even subsidized Marketplace coverage can be unaffordable for some, and few people can afford to purchase private coverage without financial assistance.

Key Details:

• Cost is the most commonly cited reason for being uninsured. In 2023, 63.2% of uninsured adults ages 18-64 said they were uninsured because coverage is not affordable (Figure 7). Other reasons included not being eligible for coverage (27.0%), not needing or wanting coverage (26.6%), and signing up being too difficult (23.9%).

• Not all workers have access to coverage through their job. In 2023, 64.7% of uninsured workers worked for an employer that did not offer them health benefits.³ Among uninsured workers who are offered coverage by their employers, cost is often a barrier to taking up the offer. From 2014 to 2024, total premiums for family coverage increased by 52%, outpacing wage growth, and the worker’s share increased by 31%.⁴ Low-income families with employer-based coverage spend a significantly higher share of their income toward premiums and out-of-pocket medical expenses compared to those with income above 200% FPL.⁵ Particularly among people working for small employers , premium contributions for dependents can be unaffordable.
• Medicaid eligibility varies across states and eligibility for adults is limited in states that have not expanded Medicaid. As of December 2024, 41 states including DC had adopted the ACA Medicaid expansion. Two states implemented the expansion in 2023—South Dakota in July and North Carolina in December. In states that have not expanded Medicaid, the median eligibility level for parents is just 34% FPL and adults without dependent children are ineligible in most cases. Additionally, in non-expansion states, millions of poor uninsured adults fall into a “coverage gap” because they earn too much to qualify for Medicaid but not enough to qualify for Marketplace premium tax credits.
• Many lawfully present immigrants must meet a five-year waiting period after receiving qualified immigration status before they can qualify for Medicaid. States have the option to cover eligible children and pregnant people without a waiting period, and as of May 2024, 37 states have elected the option for children and 31 states have taken up the option for pregnant individuals. Lawfully present immigrants, including those who are not eligible for Medicaid because they have not met the five-year waiting period, are eligible for Marketplace tax credits. However, Some states have taken steps to provide fully state-funded coverage to some or all immigrants who are not eligible for federal coverage.
• Though financial assistance is available under the ACA to many of the remaining uninsured, not everyone who is uninsured is eligible for free or subsidized coverage. Nearly six in ten (14.5 million) uninsured individuals in 2023 were eligible for financial assistance either through Medicaid or through subsidized Marketplace coverage (Figure 8). However, over four in ten uninsured (10.9 million) are outside the reach of the ACA because their state did not expand Medicaid, they have an ineligible immigration status, or they were deemed to have access to an affordable Marketplace plan or offer of employer coverage.

How does not having coverage affect health care access?

Health insurance makes a difference in whether and when people get necessary medical care, where they get their care, and ultimately, how healthy they are. Uninsured adults are far more likely than those with insurance to postpone health care or forgo it altogether because of concerns over costs. The consequences can be severe, particularly when preventable conditions or chronic diseases go undetected.

Key Details:

• Uninsured adults are more likely to forgo needed care than their insured counterparts. In 2023, nearly half (46.6%) of uninsured adults ages 18 to 64 reported not seeing a doctor or health care professional in the past 12 months compared to 15.6% with private insurance and 14.2% with public coverage. Part of the reason for not accessing care among uninsured individuals is that many (42.8%) do not have a regular place to go when they are sick or need medical advice (Figure 9). But cost also plays a role. Over one in five (22.6%) adults without coverage said that they went without needed care in the past year because of cost compared to 5.1% of adults with private coverage and 7.7% of adults with public coverage. A KFF survey that asks about cost barriers for individuals and their family members reports higher percentages of both uninsured and insured people delaying or forgoing needed care due to cost.

• Uninsured children were also more likely than those with private insurance or public insurance to go without needed care due to cost in 2023 (9.5% compared to 0.7% and 1.0%, respectively). Furthermore, over a quarter (27.4%) of uninsured children had not seen a doctor in the past year, compared to 4.8% of children with public coverage and 3.7% of those with private coverage (Figure 9).
• Studies repeatedly demonstrate that uninsured individuals are less likely than those with insurance to receive preventive care and services for major health conditions and chronic diseases.^6,7,8,9 Because people without health coverage are less likely than those with insurance to have regular outpatient care, they are more likely to be hospitalized for avoidable health problems and to experience declines in their overall health. When they are hospitalized, uninsured people receive fewer diagnostic and therapeutic services and also have higher mortality rates than those with insurance.^{10,11,12,13,14}
• Research demonstrates that gaining health insurance improves access to health care considerably and diminishes the adverse effects of having been uninsured. A review of research on the effects of the ACA Medicaid expansion finds that expansion led to positive effects on access to care, utilization of services, the affordability of care, and financial security among the low-income population.
• More recent research generally shows Medicaid expansion is associated with improved health outcomes, although establishing direct causality between health insurance and health outcomes is complex. For example, Medicaid expansion is associated with increased early-stage diagnosis rates for cancer, lower rates of cardiovascular mortality, and increased odds of tobacco cessation.^15,16 Medicaid expansion has also been linked to lower mortality rates, including those from cancer, cardiovascular disease, liver disease, and maternal mortality.^17,18 Evidence suggests it also aids long-term recovery for substance use disorders and improves treatment management for conditions such as diabetes and HIV.
• Public hospitals, community clinics and health centers, and local providers that serve underserved communities provide an important health care safety net for uninsured people. However, safety net providers have limited resources and service capacity, and not all uninsured people have geographic access to a safety net provider.^19,20,21 High uninsured rates contribute to rural hospital closures and greater financial challenges for rural hospitals, leaving individuals living in rural areas at an even greater disadvantage to accessing care.^22,23 Research indicates that Medicaid expansion is associated with reductions in uncompensated care costs and improved financial performance for rural hospitals and other providers.

What are the financial implications of being uninsured?

Uninsured individuals often face unaffordable medical bills when they do seek care. These bills can quickly translate into medical debt since most people who are uninsured have low or moderate incomes and have little, if any, savings.

Key Details:

• Those without insurance for an entire calendar year pay for almost 40% of their care out-of-pocket.²⁴ In addition, hospitals frequently charge uninsured patients higher rates than those paid by private health insurers and public programs.^25,26,27,28
• Uninsured adults ages 18 to 64 are much more likely than their insured counterparts to lack confidence in their ability to afford usual medical costs. Nearly half (49%) of uninsured adults said they or a family member had problems paying for health care compared to 21% of insured adults, and over eight in ten (84%) uninsured adults said they worried that health care costs would put them in debt or increase their existing debt, compared to 71% of adults with insurance (Figure 10).

• Unaffordable medical bills can lead to medical debt, particularly for uninsured adults. More than six in ten (62%) uninsured adults report having health care debt compared to over four in ten (44%) insured adults. Uninsured adults are more likely to face negative consequences due to health care debt, such as using up savings, having difficulty paying other living expenses, or borrowing money.^29,30,31
• While federal and state laws require certain hospitals to provide some level of charity care, not all eligible patients benefit from these programs. Consequently, charity care costs represent a small share of operating expenses at many hospitals.
• Research suggests that gaining health coverage improves the affordability of care and financial security among the low-income population. Multiple studies of the ACA found declines in trouble paying medical bills and reductions in medical debt in expansion states relative to non-expansion states. More recent research found that Medicaid expansion decreased catastrophic health expenditures and was associated with greater increases in income among low-income individuals.