The State of Health Insurance Coverage in the U.S.

Introduction

An estimated 26 million Americans, or 8 percent of the U.S. population, lacked health insurance in 2023.¹ While the United States still lags countries that have universal coverage, today’s uninsured rate represents a sea change from the years prior to the Affordable Care Act (ACA), when twice as many people — 49 million, or 16 percent of the population — lacked health coverage.² This was also a time when people with preexisting conditions were out of luck when they sought to buy insurance on their own, when millions of young adults became uninsured when they graduated from high school or college, and when insurance companies in the individual market charged young women much higher premiums than young men and rarely covered maternity care.

Congress and the Biden-Harris administration significantly strengthened the ACA with a temporary boost in premium subsidies for marketplace plans during the pandemic and then extended them in 2022. These subsidies, along with restored funding for outreach and enrollment following cutbacks during the Trump administration, led to a record 21 million people enrolling in marketplace plans in 2024.³ For households with low or moderate incomes, zero-premium or otherwise low-cost marketplace plans have been a source of affordable coverage for people who lost Medicaid when the pandemic-era continuous coverage protections ended. The extra subsidies also have allowed people in high-cost employer plans to access a more affordable coverage option.

Policymakers have more to do to protect the sweeping coverage gains of the past decade and build on these gains to bring comprehensive coverage to more people. The extended premium tax credits are set to expire at the end of 2025. If Congress fails to extend the enhanced tax credits, marketplace enrollees will experience an average premium increase of $705; 4 million more people are projected to become uninsured.⁴ Ten states still have not adopted the ACA’s Medicaid eligibility expansion, leaving 1.5 million of some of the poorest people in the country uninsured. And many Americans with insurance are still burdened by medical debt, medical billing errors, or denials of coverage.⁵

In the wake of an election that could fundamentally alter health care priorities, we present findings from the Commonwealth Fund Biennial Health Insurance Survey to describe the state of Americans’ health insurance coverage in 2024.⁶ We answer the following questions:

• How many people experience gaps in their coverage?
• How many people have insurance but are underinsured?
• Are health care costs affecting people’s decision to get needed care and is their health suffering as a result?
• How widespread is medical debt, and how much do people owe?

For the survey, SSRS interviewed a nationally representative sample of 8,201 adults age 19 and older between March 18 and June 24, 2024. This analysis focuses on 6,480 respondents ages 19–64; analysis of the 65-and-older population, most of whom have Medicare, will be published separately. Because of a new sampling method and online questionnaire introduced in 2022, in addition to changes to some key measures in 2024, we are unable to present data on trends in responses over the years. To learn more about our survey, including the revised sampling method, see “How We Conducted This Survey.”

Survey Findings

In 2024, a majority of American adults had the coverage necessary to enable access to timely and affordable care. But there remain clear areas for policy action. Nine percent of adults were uninsured at the time of the survey, 12 percent were insured but said they had been without coverage for a time during the year, and 23 percent had coverage all year but were underinsured.⁷

Among the insured working-age adults in the U.S. who had such high out-of-pocket costs or deductibles relative to their income in 2024 that they were effectively underinsured, the vast majority were in employer plans. About 14 percent had plans purchased in the individual market or the marketplaces, and 17 percent were enrolled in Medicaid or Medicare.

This distribution of underinsured adults reflects the predominance of employer coverage in the U.S. health insurance system and the growth of deductibles and cost sharing in those plans over time. It also shows that many people across the insurance system, both public and private, have plans that don't provide them with the cost protection needed to get timely care.

The high cost sharing in many employer, individual-market, and marketplace plans is primarily driven by growth in overall health care spending. One of the biggest drivers of this growth is the prices that health care providers charge commercial insurers and employers. These prices are the highest in the world.⁸ Bearing the burden of high costs are consumers, who end up paying more for their insurance and facing higher deductibles, out-of-pocket maximums, and copayments.

Being uninsured or underinsured are barriers to getting timely health care. Fifty-seven percent of working-age adults who were underinsured and 70 percent of those who lacked continuous coverage said they did not get needed care because of the cost. This included not going to the doctor when sick, skipping a recommended follow-up visit or test, not seeing a specialist when recommended, or not filling a prescription.

Forty-two percent of adults who didn’t get care because of cost said it was for an ongoing health condition, 29 percent said it was for a new health problem, and 28 percent said it was for both (data not shown).

As many as three in 10 people with a chronic health problem, such as diabetes, said that the costs for prescription drugs to treat the problem had caused them to skip doses or not fill the prescription at all. This includes about one-quarter of adults who had health insurance for the full year.

Many Americans lack comprehensive dental coverage. Many employers that offer dental coverage provide it as a supplemental benefit, which can be limited to routine preventive care. In our survey, 41 percent of adults reported delaying or not getting dental care because of the cost.

Three-quarters of insured adults said they had dental coverage (data not shown), and the survey’s findings show that it made a big difference in their ability to get care. Insured adults who did not have dental coverage reported cost-related delays in getting care at nearly the same rate as those who lacked any health insurance.

One in five respondents said they had delayed getting mental health care because of cost, with higher rates of delayed care reported by those with inadequate coverage. The ACA requires health plans offered in the individual and small-group markets and the marketplaces to cover behavioral health care, and most employers cover it.⁹ The Mental Health Parity and Addiction Equity Act requires health plans that include these services to cover them on par with their coverage of other health services. Enforcement, however, is uneven, and behavioral health provider shortages have made it difficult for many people to get timely access to care.

Fear of incurring expenses for care they can’t afford is endangering the health of many Americans, even those who have insurance. Two of five adults who reported they had delayed or skipped getting needed care because of costs said a health problem had gotten worse as a result. People in poor health or dealing with a chronic health condition reported at among the highest rates that a health problem had worsened because of delayed care.

Costs prevent many Americans from seeking health care, and those who do get care often leave the hospital or doctor’s office with bills they cannot pay. We asked people whether they had medical bills or debt of any kind that they were paying off over time, including dental, home health, or long-term care. Three in 10 reported they were paying off medical debt, with underinsured adults reporting this at the highest rate.

Of survey respondents with employer coverage, those with low and moderate income reported paying off medical debt at higher rates than those with higher income. People in employer plans and the individual market and marketplaces reported significantly higher rates of medical debt than people who had Medicaid.

Medical debt can harm the health and well-being of entire households. More than one-third of those reporting medical debt within their household said it had caused a member to delay or avoid getting needed health care or prescription medications. A similar share said they were forced to cut back on basic necessities like food, heat, or rent, while a quarter said they took on another job or worked more hours. More than three-quarters of people with medical debt said it made them anxious or worried.

Medical debt can have lasting financial consequences. Two of five adults reporting debt said they had used up all or part of their savings to pay it off, and 28 percent said they received a lower credit rating because of it.

Most people who have medical debt carry a lot of it: 83 percent reported total debt loads of $500 or more, and nearly half said they were paying off $2,000 or more. This means an estimated 24 percent of all U.S. working-age adults are carrying medical debt of more than $500, and 14 percent are saddled with $2,000 or more.

While media reports frequently highlight unexpected health care events and emergency room visits that leave people with lots of medical bills, our survey findings suggest that the source of much debt is simply care for chronic health problems. About half of adults with debt said it stemmed from treatment they received for an ongoing condition. Hospital care is the most frequently cited source of medical debt.

National estimates of the medical debt that Americans owe are based mainly on debt that goes to collection agencies who then report the debt to a consumer reporting agency. In 2023, an estimated 15 million people had $47 billion of medical debt on consumer credit reports.¹⁰ This is despite changes that the three largest nationwide credit reporting agencies implemented in July 2022, including the removal of initial medical debt balances of less than $500. Our survey shows these estimates understate the medical expenses people are paying off over time: three-quarters of respondents with medical or dental debt said that they were making some or all of their payments directly to health care providers.

More than a third of people with medical debt said the institutions they owe money to had reported their bill to a credit rating agency. Only small percentages of people said they had been threatened with a lawsuit, had their wages garnished, or had a lien placed on their property.

How to Bring Better Coverage to More Americans

The United States has made considerable gains in health insurance coverage since the Affordable Care Act’s passage, but more work is needed to cover the remaining uninsured, eliminate gaps in coverage, and ensure that all health insurance does what it’s supposed to: enable people to get health care when it’s needed, without fear of incurring debt.

The findings of this survey point to two areas of policy change needed to cover more people with good insurance. Below are some options for policymakers to consider.

Covering All Americans, and Keeping Them Covered

Permanently extend the enhanced marketplace premium tax credits set to expire in 2025. These larger tax credits, first passed by Congress in 2021 and then extended in 2022, have dramatically lowered household premiums and led to a record 21 million people enrolled in the marketplaces in 2024. If Congress fails to make these enhanced subsidies permanent, marketplace premiums will spike and enrollment will fall, increasing the number of uninsured. For example, the Urban Institute estimates that without the enhanced tax credits, annual premiums in 2025 would be $387 more for the lowest-income enrollees, who now pay nothing for their premiums, and nearly $3,000 more for individuals with incomes of $60,240 or more.¹¹ They estimate 4 million more people will become uninsured without these enhanced tax credits.¹²

Fill the Medicaid coverage gap. Congress could create a federal fallback option for Medicaid-eligible people in the 10 states that have yet to expand their program. One option is to expand marketplace eligibility to include people in the coverage gap coupled with an extension of the enhanced premium tax credits to ensure zero-premium plans and no cost sharing.¹³ Such an approach could cover the estimated 1.5 million uninsured people in the coverage gap in those states.¹⁴

Create a longer period of continuous Medicaid eligibility. Disruption in Medicaid coverage because of eligibility changes, administrative errors, and other factors can leave people uninsured and unable to get care. Congress could apply the lessons of the pandemic and give states the option to maintain continuous enrollment eligibility for adults for 12 months without the need to apply for a waiver — just as has been done for children in Medicaid and the Children’s Health Insurance Program.¹⁵

Create an autoenrollment mechanism. Research shows that many uninsured people are eligible for Medicaid or subsidized marketplace coverage. By allowing autoenrollment in comprehensive health coverage, Congress could move the nation closer to universal coverage.¹⁶

Improving Insurance Design and Protecting Consumers from Medical Debt

Lower deductibles and out-of-pocket costs in marketplace plans. Congress could extend cost-sharing reduction subsidies to middle-income people and change the benchmark plan in the ACA marketplaces from silver to gold, which offers better financial protection.¹⁷ These policies would save households $4.8 billion and decrease the number of uninsured by an estimated 1.5 million.¹⁸

Adjust premiums and cost sharing based on employee income. In 2022, just 10 percent of employers with 200 or more employees had programs to reduce premium contributions for lower-wage workers; only 5 percent had similar programs to reduce cost sharing.¹⁹

Protect consumers from being financially ruined by medical debt. In June 2024, the Biden-Harris administration released a new proposed rule to prohibit medical debt information from appearing on consumer credit reports. Earlier, it had taken steps to ensure greater scrutiny of providers’ bill collection tactics, among other actions. Many states have passed legislation to relieve medical debt, such as strengthening standards to ensure patients have access to hospital financial assistance programs, banning aggressive collection activities by hospitals, and prohibiting or capping interest on medical debt.²⁰ North Carolina has implemented an innovative debt relief program that provides enhanced Medicaid reimbursements to participating hospitals.²¹ All eligible hospitals in the state are participating and agree to relieve outstanding debt dating back to 2014 for Medicaid beneficiaries and other low-income patients, among other measures.

Lower health care cost growth. The relentless growth in the cost of health care, driven primarily by the prices that commercial insurers and employers pay to providers and for pharmaceuticals, is at the root of the nation’s medical debt and affordability crisis in commercial insurance. Ultimately, private payers will need to do a better job of leveraging their purchasing power to slow cost growth in commercial markets. Federal and state policymakers could help, for example, by creating new public plan options.²²