Census: uninsured rates dropped significantly with ACA

With debate over the efficacy of the Affordable Care Act rising to the top of candidate priorities during this election year, new census data confirm that uninsured rates nationwide have been dropping significantly.

From 2013 to 2019, the uninsured rate for working-age adults (18-64) dropped across all 50 states and the District of Columbia, according to new data. Nationally, the uninsured rate fell by 7.6 percentage points, from 20.5% to 12.9%. This reduction was especially notable in states that expanded Medicaid under the Affordable Care Act (ACA). Of the 11 states that experienced the largest decreases in uninsured rates (10 percentage points or more), all were Medicaid expansion states.

Private insurance coverage also increased across most of the country. Between 2013 and 2019, 44 states and D.C. saw rises in private coverage, with Florida showing the most significant gain, up from 60.1% to 69.9%. No state reported a decline in private insurance coverage during this period.

Public health insurance coverage followed similar trends, with increases in 36 states. Medicaid expansion was a key factor in these shifts, as 29 of the states with rising public coverage expanded their Medicaid programs. Notably, New Mexico saw the largest jump in public coverage, from 19.1% to 32.5%. In contrast, Maine, Texas, and Utah, which did not expand Medicaid, experienced declines in public coverage.

The positive trend continued from 2019 to 2023, with the uninsured rate dropping further in 42 states. By 2023, the national uninsured rate for working-age adults had decreased to 11%. Once again, Medicaid expansion played a significant role in reducing uninsured rates, with states that expanded the program showing the largest declines. Public health insurance coverage grew in 36 states, with Oklahoma seeing the largest increase.

Impact on older adults

The uninsured rate for adults aged 65 and older has remained remarkably low since 2013, hovering between 0.1% and 2.1%. From 2013 to 2019, 14 states saw a decline in the uninsured rate for this group, with coverage shifts shaped by public and private insurance combinations like Medicare and Medigap plans. While these seniors primarily rely on public programs like Medicare, the period between 2013 and 2019 saw a notable decrease in private coverage for this age group, which fell in 48 states, ranging from 1.4 to 8.7 percentage points.

Public coverage for adults aged 65 and older slightly decreased in 23 states during this time, though public insurance for this group remained strong overall, covering between 90.6% and 98.4% of older adults across states in 2019.

From 2019 to 2023, this trend continued as the uninsured rate for adults aged 65 and older increased in seven states, while public and private coverage rates shifted downward. Private coverage dropped in 42 states, with the national rate for private insurance among older adults declining from 58% to 53.7%. Public coverage also saw declines in 35 states, though it remained high, with between 92.5% and 97.8% of adults in this age group covered by Medicare or other public options in 2023.

Despite these shifts, the uninsured rate for adults 65 and older has remained stable at the national level, driven largely by the widespread availability of Medicare. Public coverage has become the dominant form of insurance for this group, with fewer people relying on combinations of Medicare and private plans like Medigap. This reflects a broader trend toward public-only coverage for seniors in the U.S., especially as private coverage continues to decline across states.

The overall low uninsured rate for adults aged 65 and older, alongside changes in public and private coverage, highlights the ongoing evolution of healthcare coverage for America’s aging population.

Uninsured Rates: Children, Working-Age Adults

From 2019 to 2023, the uninsured rates for children and working-age adults saw notable declines in several major metropolitan areas. According to recent data, children under the age of 19 in large cities like Atlanta, Chicago, and Los Angeles experienced significant reductions in their uninsured rates during this period. This reflects broader national trends, particularly in states that expanded Medicaid under the Affordable Care Act (ACA).

For working-age adults (19 to 64), nearly every major metropolitan area saw decreases in uninsured rates. The Miami metro area had the most dramatic drop, with its uninsured rate falling from 21.9% in 2019 to 16.5% in 2023. This aligns with Florida's overall uninsured rate decrease, from 19.5% to 15.5% during the same period.

However, adults aged 65 and older experienced mixed results in some metropolitan areas. The uninsured rate in Detroit slightly increased from 0.4% to 0.7%, reflecting similar trends in Michigan. In contrast, the Washington, D.C., metro area saw a slight decline, from 1.6% to 1.2%.

Between 2013 and 2019, the ACA's implementation drove significant increases in health insurance coverage, with the largest gains seen in private and public coverage for working-age adults and children. Medicaid expansion and ACA-related policies such as marketplace coverage also contributed to the overall decrease in the uninsured rate across age groups. However, the pace of coverage growth slowed between 2019 and 2023, particularly for private insurance.
For older adults, the ACA made Medicare more affordable, leading to a drop in uninsured rates from 2013 to 2019. However, the trend stabilized from 2019 to 2023, with the uninsured rate for this group remaining low but facing slight fluctuations in some regions.

Overall, the data show the sustained impact of the ACA on reducing uninsured rates for children, working-age adults, and older Americans. However, the slower pace of private coverage growth since 2019 signals ongoing challenges in expanding healthcare access across the country.

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Doug Bailey is a journalist and freelance writer who lives outside of Boston. He can be reached at [email protected].