US uninsured rate was stable in 2023, even as states’ Medicaid purge began

KFF Health NewsSep 10 2024

The proportion of Americans without health insurance remained stable in 2023, the Census Bureau reported Tuesday, close to the record low the Biden administration achieved in 2022 through expansions of public programs, including the Affordable Care Act.

About 8% of Americans were uninsured, a statistically insignificant increase of just 0.1 percentage point from a year earlier. But because of the Census survey's methodology, the findings likely don't capture the experience of tens of millions of Americans purged from Medicaid rolls after pandemic-era protections expired in spring 2023.

Enrollment in Medicaid, the government health program for people with low incomes and disabilities, reached its highest level in April 2023. That was just before what's called the "unwinding," the process states have used to disenroll people from the program after the federal government lifted a prohibition on culling enrollment.

It isn't yet clear what effect the unwinding has had on insurance coverage, but the Census Bureau will release additional data on Thursday from a different survey that may refine the numbers.

"We are likely at a turning point," said Leighton Ku, director of the Center for Health Policy Research at George Washington University. "We are about to change to a new season where things will be a little worse off from Medicaid unwinding."

The Medicaid unwinding has been completed in most states, and more than 25 million people have been disenrolled, according to KFF, a health information nonprofit that includes KFF Health News. The Census report, based on surveys conducted early this year, counts people as uninsured only if they lacked insurance for all of 2023. So, for example, a person who was on Medicaid in April 2023 before the unwinding began then lost coverage and never regained it would nonetheless be counted as insured for the entire year.

Many people purged from Medicaid were successfully reenrolled in or obtained other insurance, such as Affordable Care Act marketplace or job-based coverage. Others remained uninsured.

Advocates have feared the unwinding would trigger a rise in the uninsured rate as people struggled to find alternative coverage.

But states, private health insurers, and advocates launched intense efforts to contact enrollees by phone, email, and social media to ensure they did not experience gaps in coverage.

Still, because of the way the Census Bureau reports the uninsured rate, the full impact of the unwinding won't be known until the 2026 report.

Beyond Medicaid, several other factors boosted the number of Americans with health insurance last year, including a strong economy and near-record-low unemployment. Most Americans obtain insurance through their jobs, according to the Census, meaning that higher employment typically results in broader health coverage.

Another key factor: enhanced federal subsidies that since 2021 helped lower the cost of private coverage through Obamacare. Sign-ups on Affordable Care Act marketplaces hit a record high of 20.8 million in 2024, according to a Treasury report released Tuesday.

But that extra financial assistance is slated to expire at the end of 2025, setting up a flashpoint for whichever party controls power in Washington after the November elections. Democrats want to extend the subsidies introduced during the pandemic, while many Republicans wish to let them end.

Before Congress passed the ACA in 2010, the uninsured rate had been in double digits for decades. The rate fell steadily under President Barack Obama but reversed under President Donald Trump, only to come down again under President Joe Biden.

In addition to expanding subsidies, the Biden administration increased advertising and the number of counselors who help people sign up for plans during the open enrollment season, which Trump greatly curtailed.

Also contributing to the reduction in the number of uninsured Americans are state efforts to expand coverage to mostly low-income residents. North Carolina, for example, expanded Medicaid eligibility in December 2023, resulting in more than 500,000 additional enrollees.

Decades of research shows that expanded health coverage helps people individually and the public overall. Health insurance pays for routine care and can protect people from financial calamity because of severe injuries or illness.

People who are uninsured are more likely to delay or avoid getting health care, which can lead to relatively minor problems becoming more severe and costly to treat. Having more people covered also means more patients can pay their bills, which can improve the financial condition of hospitals and other providers.

The health insurance data released annually by the Census Bureau is considered the most accurate picture of health coverage in the United States. The state-level uninsured data it plans to release Thursday, based on a larger survey, counts people as uninsured if they say they don't have coverage at the time they're contacted. Thus, it likely will provide more insight into the effects of the unwinding.