BEYOND THE NUMBERS
The uninsured rate fell to 8.6 percent in 2021, according to data released today in the Census Bureau’s American Community Survey (ACS). That’s down from 9.2 percent in 2019, prior to the COVID-19 pandemic, and matches 2016’s record low.
Driving much of the coverage gains were relief provisions enacted during the pandemic, most notably the prohibition on terminating Medicaid coverage for most enrollees during the official public health emergency, and enhanced premium tax credits to help people get covered through the Affordable Care Act (ACA) marketplaces. Administrative data show that Medicaid enrollment rose by over 15 million people between February 2020 and December 2021, while ACA marketplace enrollment also reached a record high.
The data are broadly consistent both with Tuesday’s release of Census’ Current Population Survey (CPS) and with earlier data from the Centers for Disease Control and Prevention’s National Health Interview Survey (NHIS). The 2021 ACS data provide important confirmation that the uninsured rate has declined substantially since 2019, before the pandemic. (The comparison of 2019 and 2021 ACS data largely avoids pandemic-related disruptions in data collection, which affected CPS estimates for 2019 and 2020 and led Census to cancel its standard release of ACS data for 2020.) The ACS also allows for more precise state-level estimates and clearer comparisons for examining longer trends because of its large sample size and consistent methodology over time.
Much of the Medicaid coverage gain can be attributed to the continuous coverage provision. Enacted in 2020 COVID relief legislation, it prohibits states from terminating Medicaid coverage for most enrollees during the official public health emergency in exchange for additional federal Medicaid funding. Also, seven states implemented ACA Medicaid expansions from 2019 to 2021, bolstering Medicaid enrollment. Today’s ACS data show that these states tended to see larger declines in uninsured rates, consistent with numerous studies showing that Medicaid expansion boosts overall coverage rates. The two states with the biggest uninsured rate declines from 2019 to 2021 — Maine and Idaho — both expanded Medicaid over this period.
In addition, administrative data show that enrollment in the ACA marketplaces reached record highs due in part to enhanced premium tax credits, along with a pandemic-related special enrollment period and substantially increased funding for outreach and enrollment assistance.
Consistent with the way these relief measures were targeted, low-income groups saw the largest declines in uninsured rates in the ACS data. The number of people who were uninsured dropped by about 6 percent — or roughly 1.5 million people — for people with incomes below 400 percent of the poverty threshold, while changing relatively little for people with incomes at or above 400 percent of the poverty threshold. The uninsured rate dropped to a record low for those with incomes under 138 percent of the poverty threshold.
Yet despite this progress on expanding coverage, today’s data show that 28.2 million people were without health insurance coverage in 2021, a time when the nation continued to contend with the pandemic. Large racial and ethnic disparities in uninsured rates also continued, due in large part to long-standing systemic racism resulting in fewer educational, economic, and other opportunities for people of color which limits their access to coverage.
American Indian and Alaska Natives and Latino people were the most likely to lack health coverage, with uninsured rates of 19.6 and 17.7 percent, respectively. In comparison, 5.7 and 5.9 percent of white and Asian people lacked coverage. Native Hawaiians and other Pacific Islanders were uninsured at a rate of 10.4 percent, and Black people had an uninsured rate of 9.6 percent.
Further progress is required to extend access to coverage and care. The Inflation Reduction Act was a good start, extending premium tax credit enhancements for those who buy marketplace coverage. The extensions staved off massive premium spikes and coverage losses that would have occurred otherwise and made coverage more affordable for an estimated 13 million people.
But policymakers must also close the Medicaid coverage gap. This gap renders 2.2 million uninsured people in non-expansion states — 60 percent of whom are people of color — ineligible for both Medicaid and financial assistance in the marketplace, despite having incomes below the poverty level. The 12 states that haven’t expanded Medicaid still have significant financial incentives to do so, to say nothing of the improvements expansion would have on the health and financial well-being of their residents. As in years past, today’s ACS data show that non-expansion states had much higher uninsured rates than expansion states, with states that had not expanded prior to 2021 comprising all of the top five states with the highest uninsured rates.
States must also act to make sure insured rates don’t regress. For 2022 at least, the uninsured rate has likely continued to decline, as the major policies that helped drive the reduction are still in effect and Medicaid and marketplace participation are still climbing. But more than 15 million people could lose coverage after the public emergency ends — widely expected to occur in January 2023 or later — and states resume their regular eligibility reviews of all Medicaid enrollees. States can take actions now to ensure that people who are still eligible remain on Medicaid and to help those who are no longer eligible to transition to other coverage.