US Uninsurance Dropped to 10.5% in 2021, Greater Equity in Coverage Gains

The US non-senior uninsurance rate declined from 11.1 percent in 2019 to 10.5 percent in 2021, with low-income and historically underserved demographics seeing the highest growth in health insurance coverage, according to a report from the Assistant Secretary for Planning and Evaluation (ASPE) Office of Health Policy under the US Department of Health and Human Services (HHS).

“The Biden-Harris Administration has worked tirelessly to expand access to health insurance and lower costs for America’s families,” HHS Secretary Xavier Becerra said in the press release.

“We know that access to quality, affordable health care is key to healthier lives, economic security, and peace of mind. As we move forward, the Department of Health and Human Services will continue to do everything we can to protect, expand, and strengthen the programs that provide the quality, affordable health care Americans rely on and deserve.”

The researchers relied on data from the 2019 and 2021 American Community Survey

The results highlighted three characteristics of populations that saw significant increases in healthcare coverage in 2021: Medicaid expansion status, race and ethnicity, and income.

First, states that decided to adopt Medicaid expansion saw their uninsurance rates decrease. In particular, states that expanded their Medicaid programs during the study timeframe saw big shifts in their uninsurance rates.

Maine, which expanded its Medicaid program in 2019, had the highest drop in uninsurance. The state saw its uninsurance rate drop 3.2 percent between 2019 and 2021. Around 32,000 residents gained coverage.

In addition to Maine, the states of Idaho, Oklahoma, Virginia, and Nebraska expanded their Medicaid programs to include more of the low-income community during the study timeframe. These states were among the top ten states with the highest coverage gains between 2019 and 2021.

In contrast, some states that have not adopted Medicaid expansion saw a growth in uninsurance rates.

One out of the top ten states that had the highest coverage losses between 2019 and 2021 was a nonexpansion state (Alabama). But at the more granular level, all of the Public Use Microdata Areas (PUMAs)—or regions with no less than 100,000 residents—with the highest coverage losses except for two were found in nonexpansion states. Six out of the top ten PUMAs with the highest uninsurance growth were found in Texas.

Florida was the only state that had not adopted Medicaid expansion that was in the top ten states with the highest increase in health insurance coverage. It ranked in tenth place with a 1.2 percentage point drop in uninsurance and an uninsurance rate of 15.6 percent in 2021. Only Oklahoma, which adopted Medicaid expansion in 2021, had a higher uninsurance rate in 2021.

Second, racial and ethnic demographics that have been historically underserved saw progress toward widespread coverage.

The Latino community—which has an uninsurance rate that is twice the US uninsurance rate—saw a 1.0 percentage point decline in uninsurance. The improvement was particularly strong among Dominican Americans who saw uninsurance rates decline by 2.4 percentage points. Around 343,000 Mexican Americans gained coverage.

The American Indian and Alaska Native community experienced a 0.9 percentage point drop.

Within the Asian American and Native Hawaiian/Pacific Islander demographic, the Samoan community saw a 4.2 percentage point drop and Chamorro Americans saw a 5.9 percentage point decrease in uninsurance. Around 30,000 Korean Americans and 46,000 Chinese Americans became uninsured.

Although Japanese Americans saw an increase in uninsurance, this demographic continued to demonstrate the strongest coverage rate.

The improvements bridged language barriers as well. Households without any English-speaking adults saw a 1.5 percentage point drop in uninsurance.

Finally, the report highlighted a drop in uninsurance among Americans with incomes between 100 and 250 percent of the federal poverty level (FPL).

Individuals with incomes of 100 to 138 percent of the federal poverty level saw uninsurance decline by 1.4 percentage points. Those with household incomes of 139 to 249 percent of the federal poverty level saw a 1.0 percentage point decrease in uninsurance. All other income categories saw uninsurance drop less than one percentage point, except for the highest income bracket which experienced no change.

“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,” the report concluded. “Policy efforts are ongoing to address disparities in coverage and mitigate potential coverage loss in the future.”

The researchers attributed these results to policy changes and health equity efforts under the Biden administration, including the continuous enrollment policy and implementation of more granular racial categories. Experts have expressed concerns that when the public health emergency ends many of these coverage gains will be lost.