The Uninsured Population and Health Coverage

The fragmented U.S. health coverage system leads to gaps in coverage. While employer-based insurance is the prevalent source of coverage for the nonelderly population, not all workers are offered coverage by their employer or, if offered, can afford their share of the premiums. Medicaid covers many low-income individuals, especially children, but eligibility for adults remains limited in most states that have not adopted the ACA Medicaid expansion. While subsidies for Marketplace coverage are available for many low and moderate-income people, few people can afford to purchase private coverage without financial assistance.

The cost of health coverage and care poses a challenge for the country broadly and is a significant barrier to coverage for people who are uninsured. In 2022, 64.2% of uninsured nonelderly adults said they were uninsured because coverage is not affordable, making it the most common reason cited for being uninsured (Figure 7). Other reasons included not being eligible for coverage (28.4%), not needing or wanting coverage (26.1%), and signing up being too difficult (22.2%).

Not all workers have access to coverage through their jobs. In 2022, 60.7% of nonelderly uninsured workers worked for an employer that did not offer them health benefits. Among uninsured workers who are offered coverage by their employers, cost is often a barrier to taking up the offer. 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.

A decade after the implementation of the ACA coverage options, 10 states have not adopted the Medicaid expansion, leaving 1.5 million uninsured people without an affordable coverage option. A coverage gap exists in states that have not adopted the expansion for poor adults who earn too much to qualify for Medicaid coverage but not enough to be eligible for subsidies in the Marketplace.

Lawfully present immigrants generally 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 January 2023, 35 states have elected the option for children and 26 states have taken up the option for lawfully present pregnant individuals. Lawfully present immigrants are eligible for Marketplace tax credits, including those who are not eligible for Medicaid because they have not met the five-year waiting period. However, the fear of the federal rules about “public charge,” which can deny an individual entry to the U.S. or adjustment to lawful permanent status (a green card) if it is determined the individual has a likelihood of becoming primarily dependent on the government for subsistence, can deter immigrants from seeking coverage. Undocumented immigrants are ineligible for federally-funded coverage, including Medicaid and Marketplace coverage.

Though financial assistance is available to many of the remaining uninsured under the ACA, not everyone who is uninsured is eligible for free or subsidized coverage. Six in 10 (15.3 million) uninsured individuals in 2022 were eligible for financial assistance through Medicaid or subsidized Marketplace coverage (Figure 8). However, 4 in 10 uninsured (10.3 million) were outside the reach of the ACA because their state did not expand Medicaid, their immigration status made them ineligible, or they were deemed to have access to an affordable Marketplace plan or offer of employer coverage (Figure 8).

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