OFFICE OF ISSUE BRIEF

HEALTH POLICY

ASSISTANT SECRETARY FOR
PLANNING AND EVALUATION

LL
Changes in Health Insurance Coverage, 2019-2021:

- ASPE

 

Geographic and Demographic Patterns in the
Uninsured Rate

The U.S. experienced significant gains in health insurance coverage from 2019 to
2021, reaching an all-time low uninsured rate in early 2022. However, changes in
health coverage varied substantially by state and demographic characteristics.

Aiden Lee, Joel Ruhter, Arielle Bosworth, Christie Peters, Nancy De Lew, Benjamin D. Sommers

 

KEY POINTS

e Nationally, the uninsured rate for the U.S. population under age 65 fell from 11.1 percent in 2019
to 10.5 percent in 2021. Gains in coverage were largest in several states with recent Medicaid
expansions, including Maine (-3.2 percentage points, representing 32,000 additional people
covered) and Idaho (-2.1 percentage points, or 23,000 additional people covered).

e Larger gains in coverage occurred for demographic groups with higher historical uninsured rates,
including adults ages 19-34 and 35-49 (both declined by 1.0 percentage point), Latino individuals
(-1.0 percentage point), American Indian/Alaska Native individuals (-0.9 percentage points), and
non-English speaking adults (-1.5 percentage points).

e By household income, the decline in the uninsured rate was largest for those with incomes
between 100 and 250 percent of the Federal Poverty Level (FPL).

® Coverage gains varied widely across Asian American and Native Hawaiian/Pacific Islander
(AANHPI) and Latino communities; disaggregating data for these groups reveals important
differences in coverage patterns.

e Federal policies - such as an extended Marketplace Special Enrollment Period in 2021, expanded
and enhanced premium tax credits under the American Rescue Plan, enhanced funding for
Marketplace outreach and enrollment assistance, and the Medicaid continuous enrollment
provision during the COVID-19 public health emergency - likely contributed to gains in health
coverage since 2019, particularly among low-income populations and communities of color.

 

BACKGROUND

The initial economic impact of the COVID-19 pandemic affected access to health insurance coverage for many
Americans. Sharp increases in unemployment in early 2020 and subsequent ongoing impacts of the pandemic
led to losses in employer sponsored coverage (ESI), the largest source of health coverage in the country. While

 

January 2023 ISSUE BRIEF 1
there is no single definitive administrative data source for ESI, estimates of group coverage decreases in 2020
ranged from 1.6 million to 3.3 million.t_ Due in part to the federal response to the Public Health Emergency
(PHE), public coverage such as Medicaid and CHIP absorbed much of the loss from private coverage. Medicaid
and CHIP enrollment increased by 20.2 million enrollees from February 2020 to September 2022, or an
increase of 28.6 percent; most of this coverage increase occurred in Medicaid.? Medicaid's role as a safety net
was bolstered by the continuous enrollment requirement under the Families First Coronavirus Response Act of
2020 (FFCRA), which prevented states from disenrolling most Medicaid enrollees during the PHE as a condition
for receiving a temporary 6.2 percentage point increase in the federal Medicaid match rate.? This, along with
recent Medicaid expansions in states including Maine, Virginia, Idaho, Oklahoma, and Missouri, contributed to
more individuals gaining coverage during the PHE.

Other federal policy actions - most notably enhanced premium tax credits through the American Rescue Plan
(ARP), an extended Special Enrollment Period (SEP) during 2021, and increased investment in outreach efforts
- helped expand coverage via the Marketplace. These efforts have also contributed to increasing Marketplace
coverage across all racial and ethnic groups and closing coverage disparities; in states using the federal
HealthCare.gov platform, Latino and Black Americans experienced the greatest relative gains in Marketplace
enrollment between 2020 and 2022, at 53 percent and 49 percent, respectively.* Overall, data from the
National Health Interview Survey (NHIS) indicate that the national uninsured rate reached an all-time low of
8.0 percent in early 2022 (8.0 percent for all ages, 9.6 percent for those under age 65), but with a slight
increase in the second quarter of 2022 (8.6 percent for all ages, 10.3 percent for those under age 65).>°

This Issue Brief examines the composition of the population that is uninsured and highlights changes in
uninsured rates by geography and demographic factors from 2019 to 2021, which reflect the COVID-19
pandemic and subsequent federal policy actions. It follows a recent ASPE release of a state- and local-level
dataset on the uninsured population in the U.S. that uses the newly released 2021 American Community
Survey (ACS)."? While the NHIS provides timely estimates of overall coverage rates, the ACS has a much larger
sample size, which enables more detailed analyses of who had coverage and who remained uninsured in 2021.

METHODS

We examined data from the 2019 and newly released 2021 ACS to provide state and local estimates of the
number of U.S. residents without health insurance and their demographic characteristics." The ACS,
conducted by the U.S. Census Bureau, is the largest nationwide survey of households. Over 3.5 million
households are contacted annually to participate in the ACS, which collects information on social, economic,
housing, and demographic characteristics.®

We analyze the ACS at two levels of geography - at the state and the Public Use Microdata Areas (PUMA)
levels. PUMAs are geographic areas within each state that contain no fewer than 100,000 people and are the
most granular level of geography available in the ACS public use file. PUMAs can consist of part of a single
densely population county (such as a city neighborhood) or can combine parts or all of multiple counties that
are less densely populated.

 

"The Census Bureau discourages comparisons of 2020 ACS data to other years, given issues with non-response bias created by the
COVID-19 pandemic. For this reason, our analysis only includes 2019 and 2021 data.

 

January 2023 ISSUE BRIEF 2
In addition to geography, we analyze patterns of coverage changes by income, race, and ethnicity. For race
and ethnicity, we analyze patterns of coverage for White non-Latino, Black non-Latino, American Indian/Alaska
Native (AI/AN), Latino, and Asian American and Native Hawaiian/Pacific Islander (AANHPI) populations.
AANHPIs are one of the fastest growing racial groups in the United States, increasing from 16.5 million
individuals in 2013 to 19.8 million in 2021. This was an increase of 19.5 percent, compared to the 5.0 percent
population growth for the country as a whole.®"° Latinos are the largest racial or ethnic group in the U.S. and
are projected to grow from 18.8 percent to 25.0 percent of the population by 2045." Previous research
indicates that wide variation in coverage rates within different Latino and AANHPI communities may be
obscured in aggregate statistics for those groups; we follow previous research in identifying multiple Latino
and AANHPI subgroups using the ACS to further examine coverage patterns in these populations.*2?

Income categorization is based on the "health insurance unit" (HIU), which includes adults, their spouses, and
their dependent children (ages 0-18, plus full-time students under age 23)."* All analyses were limited to
individuals between the ages of 0 and 64, since nearly all adults 65 and older are enrolled in Medicare.

RESULTS

Figure 1 shows health coverage gains and losses by PUMA from 2019 to 2021. Areas in green show gains in
health coverage (a decrease in uninsured rates), and areas in red show losses in health coverage (an increase
in uninsured rates).

Figure 1. Changes in Health Coverage by PUMA, From 2019 to 2021 (Ages 0-64)

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Percentage Point Change in Uninsured Rate from 2019 to 2021
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Note: Public Use Microdata Areas (PUMAs) are geographic areas within each state that contain no fewer than 100,000
people and are the most granular level of geography available in the ACS public use file. They can consist of part of a
single densely population county (such as a city neighborhood) or can combine parts or all of multiple counties that are
less densely populated.

 

January 2023 ISSUE BRIEF 3
Table 1 shows the states and PUMAs with the greatest decrease in uninsured rates from 2019 to 2021. Maine
had the greatest state decrease in uninsured rates from 2019 to 2021, with a 3.2 percentage point reduction.
This is equivalent to 32,000 individuals in the state gaining health coverage. Notably, Maine expanded
Medicaid in 2019 and shifted to a State-based Marketplace in 2021, which took effect for the 2022 plan year.

At the PUMA level, Arizona's Pinal County (Central) PUMA had the greatest coverage gains from 2019 to 2021
(11.0 percentage points), which is equivalent to 15,000 individuals gaining coverage. Approximately 61.5
percent of the individuals who were uninsured in this PUMA had household incomes below poverty (100%
FPL), and 36.8 percent were ages 19-34. Latinos made up the greatest proportion of the PUMA's population
without insurance at 40.0 percent, while White non-Latinos made up 33.9 percent.'

Many of the PUMAs with large coverage gains between 2019 and 2021 still have uninsured rates above the
national average in 2021. For example, Texas's East Texas COG (Southwest) PUMA experienced a 9.6
percentage point decrease in its uninsured rate since 2019, but its 2021 uninsured rate of 22.3 percent is still
more than double the national average (10.5 percent).

Out of the 10 states that had the greatest coverage gains in Table 2, five of them (Maine, Idaho, Oklahoma,
Virginia, and Nebraska) expanded Medicaid to low-income uninsured adults between 2019 and 2021. This
expanded eligibility, along with the continuous coverage provisions of the FFCRA, likely helped more
individuals gain coverage during the COVID-19 pandemic. If the remaining 11 non-expansion states were to
expand Medicaid eligibility to adults up to 138% FPL, a previous ASPE report estimated approximately 3.8
million uninsured adults would be eligible to gain health coverage.**

Appendix Table 1 presents changes in uninsured rates for all 50 states between 2019 and 2021.

 

* All demographic information in this report at the PUMA level comes from: State and Local Estimates of the Uninsured Population in
the U.S. Using the Census Bureau's 2021 American Community Survey. Office of the Assistant Secretary for Planning and Evaluation,
U.S. Department of Health and Human Services. November 2022. Accessed at: https://aspe.hhs.gov/reports/state-county-local-
estimates-uninsured-population

* South Dakota has planned its implementation of Medicaid expansion for July 2023. Once implemented, an estimated 23,000 non-
elderly adults would be eligible for health coverage in the state.

 

January 2023 ISSUE BRIEF 4
Table 1. States and PUMAs with Largest Coverage Gains Between 2019 and 2021 (Ages 0-64)

       
     
     
 

yt 1K Uninsured Rate Uninsured Rate Percentage Point Change
2019 2021 from 2019 to 2021

  

U.S. Total
New Hampshire
Oklahoma

Florida

  

AUT PANS Uninsured Rate Uninsured Rate

2019 2021

Pinal County (Central) -Florence Town, 31.9% 21.0%
Eloy (Northeast) & Coolidge Cities (AZ)

Greene County-Springfield City (North) 24.4% 13.5% -10.8
(MO)

Buncombe County (Northwest) (NC) 22.0% 11.2% -10.8
Kennebec County (ME) 17.1% 6.7% -10.4

East Texas COG (Southwest) -Henderson 31.9% 22.3% -9.6
& Anderson Counties (TX)

St. Lucie County (North) (FL) 27.3% 18.0% -9.4

Northwest New Mexico-Navajo Nation 26.0% 16.8% -9.3
Oh)

Milwaukee City (South Central) (WI) 26.0% 16.7% -9.3
Marion County (North) (FL) 29.9% 20.7% -9.2

Miami-Dade County (Northeast) - 22.3% 13.4% -8.8
Hialeah City (North Central) (FL)

Note: Some percentage point changes between 2019 and 2021 do not sum precisely due to rounding.

Percentage Point Change
from 2019 to 2021
-11.0

 
   
 

     

   

Table 2 shows states and PUMAs with the largest increases in their uninsured rates from 2019 to 2021.
Alabama had the largest state increase (0.4 percentage points), indicating that approximately 31,000
additional Alabamians became uninsured from 2019 to 2021. Alabama is one of 11 states that has not
expanded Medicaid to date. ASPE estimates an additional 240,000 uninsured adults would be newly eligible for
Medicaid if Alabama expanded eligibility for low-income adults up to 138% FPL."

At the PUMA level, Texas's Houston City (West) PUMA had the greatest increase in its uninsured rate from
2019 to 2021. In 2021, almost 60,000 people, or 56.3 percent of the population residing in the PUMA, were
uninsured. Almost half of the population without insurance had household incomes of 139-249% FPL.
Individuals ages 19-34 made up the greatest proportion of those who were uninsured at 47.9 percent,
followed by those ages 35-49, who made up 30.4 percent. Notably, 93.0 percent of the uninsured individuals
were Latino, while 77.7 percent of those who were uninsured reported there were no English-speaking adults

 

January 2023 ISSUE BRIEF 5
in the household, and 81.1 percent of those without insurance reported that Spanish was spoken in the
household.

Six of the 10 PUMAs with the greatest increases in uninsured rates since 2019 are in Texas. Despite almost
43,000 Texans gaining health coverage from 2019 to 2021, the state's uninsured rate of 20.9 percent remains
almost twice that of the nation's average (10.5 percent). Texas also has not expanded Medicaid and has the
largest number of low-income adults that are potentially eligible for Medicaid coverage. If the state expanded
Medicaid to adults with incomes up to 138% FPL, ASPE estimates an additional 1,378,000 uninsured adults
would be eligible for Medicaid coverage."®

Table 2. States and PUMAs with Largest Coverage Losses Between 2019 and 2021 (Ages 0-64)

 

     

Uninsured Rate Uninsured Rate Percentage Point Change
2019 yl from 2019 to 2021

       

U.S. Total

Maryland
North Dakota
District of Columbia

Rhode Island

    
 

AUT PANS Uninsured Rate Uninsured Rate Percentage Point Change
2019 2021 from 2019 to 2021

Houston City (West) -Westpark Tollway, 44.8% 56.3% 11.5
Between Loop I-610 & Beltway TX-8 (TX)
Dallas County (West) -Irving (South) & 29.8% 38.6% 8.8
Grand Prairie (North) Cities (TX)
Houston City (North) & Aldine-Between 39.6% 48.2% 8.7
Loop I-610 & Beltway TX-8 (TX)
Concho Valley COG-Tom Green 13.9% 22.5% 8.6
County-San Angelo City (TX)

5.4% 13.8% 8.4
Albuquerque City (Southeast Heights) 11.2% 19.6% 8.3
OY)

Whitman, Asotin, Adams, Lincoln, 5.3% 13.3% 8.0
Columbia & Garfield Counties (WA)

16.3% 24.3% 8.0
Pinellas County (Central) -Clearwater 12.6% 20.6% 8.0
City (South & Central) (FL)
Tarrant County (Southeast)- Mansfield 7.7% 15.5% 7.8
(North) & Arlington (Southwest) Cities
(TX)

Note: Some percentage point changes between 2019 and 2021 do not sum precisely due to rounding.

 
      

 

January 2023 ISSUE BRIEF 6
Table 3 shows uninsured rates by demographic group from 2019 to 2021. Nationally, the uninsured rate
declined from 11.1 percent to 10.5 percent, a 0.7 percentage point change that represents more than 1.6
million people gaining coverage. Larger gains in coverage occurred for demographic groups with higher
historical uninsured rates, including adults ages 19-34 and 35-49 (both declined by 1.0 percentage point),
Latino individuals (-1.0 percentage point), American Indian/Alaska Native individuals (-0.9 percentage points),
and households without any English speaking adults (-1.5 percentage points). Individuals ages 19-34 were
most likely to be uninsured in 2021 at 15.0 percent, followed by those ages 35-49 years at 13.0 percent.
Individuals with incomes between 100-138% FPL had the greatest reduction in uninsured rates, decreasing 1.4
percentage points from 17.7 percent to 16.3 percent, while those between 139-249% FPL had a decrease of
1.0 percentage points.

Table 3. Changes in the Uninsured Rate for the U.S. Population From 2019 to 2021 (Ages 0-64)

      

Characteristics UT ela re} Uninsured Percentage Point
Rate 2019 Rate 2021 Change from
2019 to 2021

      
   
 
 

Overall Uninsured Rate

 

0-18
19-34 16.0% 15.0% -1.0
35-49 14.0% 13.0% -1.0
50-64 9.5% 9.1% -0.4
EETA-VA Saal ayy Latino 20.2% 19.1% -1.0
White, Non-Latino 8.0% 7.4% -0.6
Black, Non-Latino 12.4% 11.9% -0.5
Asian American and Native 7.4% 6.5% -0.9
Hawaiian/Pacific Islander

American Indian/Alaska Native 22.4% 21.5% -0.9
Multi-racial or Other 8.5% 8.5% 0.0
Male 12.5% 11.8% -0.6
Female 9.8% 9.1% -0.7
HIU Income < 100% FPL 19.2% 18.4% -0.8
HIU Income 100-138% FPL 17.7% 16.3% -1.4
HIU Income 139-249% FPL 16.3% 15.3% -1.0
HIU Income 250-400% FPL 10.2% 10.1% -0.1
HIU Income 400% FPL 3.9% 4.0% 0.0
Language Spoken No English-Speaking Adults in 28.8% 27.3% -1.5
Household

English Spoken in Household 9.5% 8.9% -0.6
Note: Some percentage point changes between 2019 and 2021 do not sum precisely due to rounding.

*The health insurance unit (HIU) consists of an adult, their spouse, and any dependent children.

Table 4 shows the changes in uninsured rates for AANHPI individuals, who have a lower overall uninsured rate
than the nation as a whole. However, the overall uninsured rate masks considerable variation across AANHPI
subgroups. The results show that several groups experienced large gains in coverage, while others -
particularly those with low uninsured rates to begin with - had more modest changes or even slight increases
in their uninsured rates. Samoan and Chamorro Americans had large decreases in uninsured rates, at 4.2 and

 

January 2023 ISSUE BRIEF 7
5.9 percentage points, respectively. Korean Americans also experienced a large decrease in uninsured rates,
with a 2.2 percentage-point decrease from 2019 to 2021, equivalent to more than 30,000 people gaining
coverage. Chinese Americans had the greatest number of people gain insurance, with 46,000 people
becoming insured. Japanese Americans had a 0.9 percentage point increase in uninsured rates from 2019 to
2021; despite this increase, they continue to have low uninsured rates relative to other AANHP! subgroups and
the national average.

Table 4, Changes in the Uninsured Rate by AANHPI Subgroup, From 2019 to 2021 (Ages 0-64)

       
 
      
 
  

AANHPI Subgroups Teese CLK) Uninsured Rate ee Til elm elit)
2019 PA ipa Change from 2019
to 2021

           

ORF te) 11.1% 10.5% -0.7
All AANHPI 74% 6.5% -0.9

7.2% 6.4% -0.8

Asian Indian alone 5.4% 4.4% -1.0

3.7% 4.7% 0.9
6.7% 5.6% -1.0
6.2% 5.7% -0.5
9.0% 7.8% 1.3
11.4% 9.1% -2.2
10.1% 9.6% 0.5
12.9% 10.7% 2.2
10.2% 4.3% 5.9
11.7% 7.4% 4.2
9.0% 9.6% 0.6

ila Native Hawaiian and Other 16.8% 14.8% 20
Pacific Islander**
Note: Some percentage point changes between 2019 and 2021 do not sum precisely due to rounding.
Population estimates combine the total number of Asians alone without another race. Subgroups within the Asian and
NHPI categories are listed in order of increasing 2021 uninsured rate.
*Includes the "Other Asian Alone" category from the ACS as well as other smaller subgroups but excludes "All
combinations of Asian races only" subgroup.
**Includes the "Other Native Hawaiian and Other Pacific Islander" category from the ACS as well as other smaller
subgroups.

Table 5 shows the changes in uninsured rates for Latino individuals, who are twice as likely to be uninsured as
the population as a whole and show considerable variation in uninsured rates across subgroups. Dominican
Americans had the greatest percentage point decrease in uninsured rates at 2.4 percentage points, which was
equivalent to more than 12,000 additional individuals gaining coverage. Mexican Americans had the greatest
number of individuals gain coverage from 2019 to 2021, at 343,000 people. Despite these gains, uninsured
rates among Latinos are still much higher than their non-Latino White counterparts and the U.S. average.

 

§ The Consolidated Appropriations Act, 2021, required states and the District of Columbia to provide Medicaid coverage for individuals
considered Compact of Free Association (COFA) migrants, which may have impacted the overall decrease in uninsured rates among
NHPIs.

 

January 2023 ISSUE BRIEF 8
Table 5. Changes in the Uninsured Rate by Latino Origin, From 2019 to 2021 (Ages 0-64)

Latino Origin OTT eela ste Math ks OTe =e Mathes Percentage Point

2019 2021 Change from 2019
to 2021

-0.7

   

     

U.S. Total 11.1%

 

10.5%

 

Ci 202% 19.1% 10
es 75: 17% 03
9.9% 9.1% oA

13.0% 10.6% -2.4

16.9% 14.6% 22

16.5% 14.8% 47
15.9% 15.2% 08
29.9% 29.5% 05

Note: Some percentage point changes between 2019 and 2021 do not sum precisely due to rounding.

*includes the South American countries included in the ACS variable "HISP" and "Other South American" origin.
*includes the Central American countries included in the ACS variable "HISP" and "Other Central American" origin.

Tables 4 and 5 show the significant heterogeneity in coverage rates among Latinos and AANHPI subgroups that
are obscured when aggregating these subgroups together into larger estimates. For instance, there is a 21.8
percentage point difference in uninsured rates between Central Americans and Spanish Americans, and a 6.3
percentage point difference between NHPIs and Asian Indians; these differences across subgroups are larger
than the overall coverage differences between Latino (19.1 percent) and White (7.4 percent) individuals, or
AANHPI (6.5 percent) and White (7.4 percent) individuals.

DISCUSSION

Despite the public health and economic distress of the COVID-19 pandemic, the U.S. experienced a decline in
the uninsured rate in 2020 and 2021, likely due in part to changes in federal and state coverage policies for
Medicaid and the Marketplace. This new report provides granular details on who experienced changes in
health coverage - and where - since 2019.

While overall gains in health coverage occurred nationally, coverage changes varied by geography and
demographic groups. Many of the areas with the greatest coverage gains since 2019 had higher than average
uninsured rates in 2021, suggesting progress in narrowing geographic disparities but still with substantial gaps
remaining; the lack of Medicaid expansion in 11 states plays a key ongoing role in coverage disparities across
states. Likewise, most demographic groups saw decreases in uninsured rates across age, income, or race and
ethnicity, while certain populations including Latino individuals, young adults, and low-income families
experienced some of the largest gains in coverage.

Research studies shed light on the reasons people lack health coverage and what policy approaches may have
helped reduce the uninsured rate in recent years. The most common barrier cited by people without
insurance is cost, with more than 70 percent of uninsured people reporting that health coverage was
unaffordable. In addition, many people are not aware of the coverage they may be eligible for, with nearly 2 in
3 individuals being unfamiliar with financial assistance for Marketplace coverage." This barrier is particularly
prevalent among individuals with limited English proficiency. A 2016 study of AAPI adults found new enrollees
and immigrants with limited English proficiency faced disproportionate challenges with the enrollment

 

January 2023 ISSUE BRIEF 9
process, and another study of Latino adults seeking urgent care at a public hospital found that they

experienced challenges with gaining awareness of health insurance benefits and completing the enrollment
20,21

process."

To address these two primary barriers to coverage - affordability and awareness - the Biden-Harris
Administration implemented the ARP's expanded premium tax credits for Marketplace coverage and increased
grants awarded to Navigators in Federally-Facilitated Marketplaces to train and certify over 1,500 Navigators."
During the first full year of the Biden-Harris Administration, nearly 6 million new consumers signed up for
coverage through the Marketplaces nationwide during the 2021 SEP and the 2022 Open Enrollment Period
(OEP).22 This includes 2.8 million people who newly enrolled during the 2021 SEP, and more than 3 million
who newly enrolled during the 2022 OEP. A record-breaking 14.5 million individuals signed up for health
coverage during the 2022 OEP, 10.3 million of which were plan selections in states using the HealthCare.gov
platform." As of January 11, 2023, nearly 15.9 million Americans - including 11.9 million people in states
using HealthCare.gov - had selected a health plan for the 2023 OEP."

One key policy that has been in place for the past two years - the Medicaid continuous enrollment provision -
will end starting in April 2023, under the recently passed Consolidated Appropriations Act, 2023.76 More than
15 million Medicaid and CHIP enrollees may be at risk for losing coverage, though efforts to assist them in
obtaining alternative insurance such as Marketplace coverage and the Inflation Reduction Act's extension of
the ARP's enhanced tax credits through 2025 can mitigate the risk of becoming uninsured."" The gains in
coverage detected in this report were largest for those in the income range (between 100% and 250% FPL)
frequently eligible for new zero- or low-cost Marketplace coverage under the ARP, and for groups that may
particularly benefit from enhanced outreach, such as non-English speaking families.

Our analysis also explored coverage for Latino and AANHPI subgroups. President Biden's Executive Order on
advancing racial equity acknowledges that many federal datasets are not disaggregated by race, ethnicity, and
other key demographic variables." Presenting data at a more granular level can show more nuanced trends
within demographic groups and assist with focused outreach and enrollment efforts. This report shows that
uninsured rates within subgroups differ more than between these groups and their White counterparts.

An important limitation of this analysis is that the ACS is currently only available through the end of 2021.
Early release data from the NHIS showed that the uninsured rate reached an all-time low in the first quarter of
2022, but with a slight increase in the second quarter of 2022.7? These 2022 changes are not yet reflected in
the detailed demographic and local estimates of coverage that are only possible with the ACS's larger sample
size (but is only currently available through 2021). An additional limitation is that the ACS does not include
sexual orientation or gender identity data, preventing evaluation of coverage changes among LGBTQI+
individuals.

CONCLUSION

The extension of enhanced Marketplace premium tax credits under the ARP, increased enrollment outreach,
recent states' adoption of the ACA's Medicaid expansion option for low-income adults, and the Medicaid
continuous enrollment provision were associated with expanded health coverage rates since 2019. Policy
efforts are ongoing to address disparities in coverage and mitigate potential coverage loss in the future.

 

January 2023 ISSUE BRIEF 10
APPENDIX

Appendix Table 1. Uninsured Rates by State, From 2019 to 2021 (Ages 0-64)

 

 

SEE E liars) Uninsured Rate 2019 Uninsured Rate 2021 Percentage Point
Change from 2019 to
2021
12.1% 12.5% 0.4
ES ce 12.9% 11.8% "1.1
er 14.1% 13.2% -0.9
ee 11.5% 11.6% 0.1
9.1% 8.3% 0.9
9.4% 9.5% 0.1
7.0% 6.1% 0.9
8.8% 7.5% 1.3
4.0% 4.2% 0.1
Florida = sid 16.8% 15.6% -1.2
16.2% 15.3% -0.8
[CEN re 5.1% 4.4% 0.7
WF 12.4% 10.2% -2.1
ae 8.7% 8.3% 0.4
rer 10.6% 9.0% -1.6
ee 5.8% 6.1% 0.3
ee 11.2% 11.0% -0.2
8.0% 6.9% 1.1
ec 11.2% 9.7% -1.4
EC 10.2% 7.1% -3.2
7.0% 7.3% 0.2
3.6% 2.9% 0.7
se 7.2% 6.4% 0.8
VC 5.8% 5.2% 0.6
Wee) 16.2% 15.2% -1.0
ie 12.5% 11.4% "1.1
rr 10.3% 9.8% -0.5
9.7% 8.5% 1.3
13.9% 13.6% -0.3
7.9% 6.1% -1.8
9.5% 8.5% 0.9
BYE 12.2% 12.1% 0.0
6.3% 6.2% 0.1
13.6% 12.4% -1.2
8.5% 8.8% 0.2
ee 8.2% 8.1% 0.2
18.0% 16.6% "1.4
8.8% 7.6% 1.2
7.4% 6.9% 0.4
5.0% 5.1% 0.1
13.3% 12.5% -0.8
January 2023 ISSUE BRIEF 11
 

 

11.7% 11.6% -0.1
12.6% 12.5% -0.1
21.4% 20.9% -0.5
ee 11.0% 10.4% -0.5
5.4% 4.2% 1.2
9.5% 8.1% "1.4
7.7% 7.6% 0.1
8.8% 8.3% 0.5
er 7.2% 6.8% 0.4
14.9% 14.4% -0.5
11.1% 10.5% -0.7
Note: Some percentage point changes between 2019 and 2021 do not sum precisely due to rounding.
ISSUE BRIEF 12

January 2023
REFERENCES

 

1 Ruhter J, Conmy AB, Chu RC, Peters C, De Lew, N., and Sommers, BD. Tracking Health Insurance Coverage in 2020-2021
(Issue Brief No. HP-2021-24). Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and
Human Services. October 2021. Accessed at: https://aspe.hhs.gov/reports/tracking-health-insurance-coverage

2 Centers for Medicare and Medicaid Services. September 2022 Medicaid and CHIP Enrollment Trends Snapshot. Accessed
at: https://www.medicaid.gov/sites/default/files/2023-01/september-2022-medicaid-chip-enrollment-trend-
snapshot.pdf

3 Medicaid CMS-64 FFCRA Increased FMAP Expenditure Data Collected through MBES. Medicaid.gov. Accessed at:
https://www.medicaid.gov/medicaid/financial-management/state-budget-expenditure-reporting-for-medicaid-and-
chip/expenditure-reports-mbescbes/medicaid-cms-64-ffcra-increased-fmap-expenditure-data-collected-through-
mbes/index.html

4 Chen L, Lee A, Branham DK, Finegold K, Peters C, Sorbero ME, Elliott MN, Euller R, and Sommers BD. HealthCare.gov
Enrollment by Race and Ethnicity, 2015-2022. (Data Point No. HP-2022-25). Office of the Assistant Secretary for Planning
and Evaluation, U.S. Department of Health and Human Services. October 25, 2022. Accessed at:
https://aspe.hhs.gov/index.php/reports/healthcaregov-enrollment-race-ethnicity-2015-2022

5 Lee A, Ruhter J, Peters C, De Lew N, Sommers BD. National Uninsured Rate Reaches All-Time Low in Early 2022. (Issue
Brief No. HP-2022-23). Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and
Human Services. August 2022. Accessed at: https://aspe.hhs.gov/reports/2022-uninsurance-at-all-time-low

§ Cohen RA, Cha AE. Health Insurance Coverage: Early Release of Quarterly Estimates From the National Health Interview
Survey, April 2021-June 2022. Centers for Disease Control and Prevention. National Health Interview Survey. Accessed at:
https://www.cdc.gov/nchs/data/nhis/earlyrelease/Quarterly Estimates 2022 Q12.pdf

7 State and Local Estimates of the Uninsured Population in the U.S. Using the Census Bureau's 2021 American Community
Survey. Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services.
November 2022. Accessed at: https://aspe.hhs.gov/reports/state-county-local-estimates-uninsured-population

® American Community Survey Information Guide. (October 2017). Census.gov. Accessed at:
https://www.census.gov/programs-surveys/acs/library/information-guide.html

° Chu, RC and Sommers, BD. Health Insurance Coverage Changes Since Implementation of the Affordable Care Act: Asian
Americans and Pacific Islanders (Issue Brief No. HP-2021-11). Washington, DC: Office of the Assistant Secretary for
Planning and Evaluation, U.S. Department of Health and Human Services. May 24, 2021. Accessed at:
https://aspe.hhs.gov/reports/health-insurance-coverage-changes-asian-americans-pacific-islanders

10 Estimates are from the 2013 and 2021 American Community Survey (ACS) using the U.S. Census Bureau's Advanced
search tool, which can be accessed at https://data.census.gov/cedsci/advanced

11 Health Insurance Coverage and Access to Care Among Latinos: Recent Trends and Key Challenges (Issue Brief No. HP-
2021-2). Washington, DC: Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and
Human Services. October 2021. Accessed at: https://aspe.hhs.gov/reports/health-insurance-coverage-access-care-among-
latinos

22 Gonzales S, Sommers BD. Intra-Ethnic Coverage Disparities among Latinos and the Effects of Health Reform. Health Serv
Res. 2018;53(3):1373-1386. doi:10.1111/1475-6773.12733

13 Chu, RC and Sommers, BD. Health Insurance Coverage Changes Since Implementation of the Affordable Care Act: Asian
Americans and Pacific Islanders (Issue Brief No. HP-2021-11). Washington, DC: Office of the Assistant Secretary for
Planning and Evaluation, U.S. Department of Health and Human Services. May 24, 2021. Accessed at:
https://aspe.hhs.gov/reports/health-insurance-coverage-changes-asian-americans-pacific-islanders

14 State and Local Estimates of the Uninsured Population in the U.S. Using the Census Bureau's 2021 American Community
Survey. Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services.
November 2022. Accessed at: https://aspe.hhs.gov/reports/state-county-local-estimates-uninsured-population

15 New Federal Report Shows Maine Has Third Largest Decline in Uninsured Rate Among Maine People Eligible for
Medicaid Expansion. (August 3, 2022). State of Maine Office of Governor Janet T. Mills. Accessed at:
https://www.maine.gov/governor/mills/index.php/news/new-federal-report-shows-maine-has-third-largest-decline-
uninsured-rate-among-maine-people

16 Rudich J, Branham DK, Peters C, and Sommers BD. Estimates of Uninsured Adults Newly Eligible for Medicaid If
Remaining 12 Non-Expansion States Expand Medicaid: 2022 Update (Data Point No. HP-2022-06). Office of the Assistant

 

 

 

 

 

 

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Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. February 2022. Accessed at:
https://www.aspe.hhs.gov/reports/updated-estimates-medicaid-eligibility-non-expansion-states

17 Rudich J, Branham DK, Peters C, and Sommers BD. Estimates of Uninsured Adults Newly Eligible for Medicaid If
Remaining 12 Non-Expansion States Expand Medicaid: 2022 Update (Data Point No. HP-2022-06). Office of the Assistant
Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. February 2022. Accessed at:
https://www.aspe.hhs.gov/reports/updated-estimates-medicaid-eligibility-non-expansion-states

18 Rudich J, Branham DK, Peters C, and Sommers BD. Estimates of Uninsured Adults Newly Eligible for Medicaid If
Remaining 12 Non-Expansion States Expand Medicaid: 2022 Update (Data Point No. HP-2022-06). Office of the Assistant
Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. February 2022. Accessed at:
https://www.aspe.hhs.gov/reports/updated-estimates-medicaid-eligibility-non-expansion-states

19 Reaching the Remaining Uninsured: An Evidence Review on Outreach & Enrollment Strategies. (Issue Brief No. HP-2021-
21). Washington, DC: Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human
Services. October 2021. Accessed at: https://aspe.hhs.gov/reports/reaching-remaining-uninsured-outreach-enrollment

20 Cook, K W, John, |, Chung, C, Tseng, W and Lee, J. (2016, Sept.) Medicaid Expansion and Healthcare Access: Lessons
from Asian American and Pacific Islander Experiences in California. Accessed at:
https://link.springer.com/article/10,1007/s10903-016-0496-x#citeas

21 Guerrero, E G, Legnick-Hall, R and Andrews, C. (2017, Nov.) Underlying Challenges of Public Health Insurance
Enrollment and Utilization among Latino Adults: Insights from the Largest Safety-Net Institution in Los Angeles. Accessed
at: https://www.ncbi.nim.nih.gov/pmc/articles/PMC5657251/

22 Reaching the Remaining Uninsured: An Evidence Review on Outreach & Enrollment Strategies. (Issue Brief No. HP-2021-
21). Washington, DC: Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human
Services. October 2021. Accessed at: https://aspe.hhs.gov/reports/reaching-remaining-uninsured-outreach-enrollment

23 On 12-Year Anniversary of the Affordable Care Act, New HHS Report Shows Ways the Biden-Harris Administration's
American Rescue Plan Investments Are Lowering Health Care Costs and Expanding Coverage. CMS. Accessed at:
https://www.cms.gov/newsroom/press-releases/12-year-anniversary-affordable-care-act-new-hhs-report-shows-ways-
biden-harris-administrations

24 Marketplace 2022 Open Enrollment Period Report: Final National Snapshot. (January 27, 2022). CMS. Accessed at:
https://www.cms.gov/newsroom/fact-sheets/marketplace-2022-open-enrollment-period-report-final-national-snapshot
25 Marketplace 2023 Open Enrollment Period Report: National Snapshot #3. (January 11, 2023). CMS. Accessed at:
https://www.cms.gov/newsroom/fact-sheets/marketplace-2023-open-enrollment-period-report-national-snapshot-3

26 Kay Dates Related to the Medicaid Continuous Enrollment Condition Provisions in the Consolidated Appropriations Act,
2023. (January 5, 2023). CMCS. Accessed at: https://www.medicaid.gov/sites/default/files/2023-01/cib010523 1.pdf

27 Unwinding the Medicaid Continuous Enrollment Provision: Projected Enrollment Effects and Policy Approaches (Issue
Brief HP-2022-20) Washington, DC: Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of
Health and Human Services. August 19, 2022. Accessed at: https://aspe.hhs.gov/reports/unwinding-medicaid-continuous-
enrollment-provision

28 Executive Order On Advancing Racial Equity and Support for Underserved Communities Through the Federal
Government. (January 20, 2021). The White House. Accessed at: https://www.whitehouse.gov/briefing-
room/presidential-actions/2021/01/20/executive-order-advancing-racial-equity-and-support-for-underserved-
communities-through-the-federal-government/

2° Cohen RA, Cha AE. Health Insurance Coverage: Early Release of Quarterly Estimates From the National Health Interview
Survey, April 2021-June 2022. Centers for Disease Control and Prevention. National Health Interview Survey. Accessed at:
https://www.cdc.gov/nchs/data/nhis/earlyrelease/Quarterly Estimates 2022 Q12.pdf

 

January 2023 ISSUE BRIEF 14
 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Office of the Assistant Secretary for Planning and Evaluation

200 Independence Avenue SW, Mailstop 447D
Washington, D. C. 20201

For more ASPE briefs and other publications, visit:
aspe.hhs.gov/reports

else Te]
=]

ABOUT THE AUTHORS

Aiden Lee is a Public Health Analyst in the Office of Health Policy
in ASPE.

Joel Ruhter is an Analyst in the Office of Health Policy in ASPE.
Arielle Bosworth is an Economist in the Office of Health Policy in
ASPE.

Christie Peters is the Director of the Division of Health Care
Access and Coverage for the Office of Health Policy in ASPE.
Nancy De Lew is the Associate Deputy Assistant Secretary for
Health Policy in ASPE

Benjamin D. Sommers is the Senior Official Performing the
Duties of the Assistant Secretary for Planning and Evaluation.

SUGGESTED CITATION

Lee A, Ruhter J, Bosworth A, Peters C, De Lew N, Sommers BD.
Changes in Health Insurance Coverage from 2019 to 2021:
Geographic and Demographic Patterns in the Uninsured Rate
(Issue Brief No. HP-2023-01). Office of the Assistant Secretary for
Planning and Evaluation, U.S. Department of Health and Human
Services. January 2023.

COPYRIGHT INFORMATION

All material appearing in this report is in the public domain and
may be reproduced or copied without permission; citation as to
source, however, is appreciated.

DISCLOSURE
This communication was printed, published, or produced and
disseminated at U.S. taxpayer expense.

 

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January 2023

ISSUE BRIEF

15