Census Bureau: 'Health Insurance Coverage Status & Type by Geography – 2021 & 2022'

WASHINGTON, Sept. 16 (TNSrep) -- The U.S. Census Bureau issued the following report (No. ACSBR-015) by Douglas Conway and Breauna Branch entitled "Health Insurance Coverage Status and Type by Geography: 2021 and 2022."

Here are excerpts:

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INTRODUCTION

Demographic shifts as well as economic and government policy changes can affect people's access to health coverage. For example, between 2021 and 2022, the labor market continued to improve, which may have affected private coverage in the United States during that time./1

Public policy changes included the renewal of the Public Health Emergency, which allowed Medicaid enrollees to remain covered under the Continuous Enrollment Provision./2

The American Rescue Plan (ARP) enhanced Marketplace premium subsidies for those with incomes above 400 percent of the poverty level as well as for unemployed people./3

In addition to national policies, individual states and the District of Columbia can affect health insurance coverage by making Marketplace or Medicaid more accessible and affordable. This variation may be more or less pronounced across states. Missouri and Oklahoma expanded Medicaid eligibility under the Patient Protection and Affordable Care Act (ACA) in 2022, leaving only twelve states without expanded Medicaid eligibility, primarily in the South and parts of the Midwest./4,5

Kentucky, Maine, and New Mexico created state-based health insurance marketplaces on November 1, 2021, to replace their previously federally run exchanges./6

State and federal policies designed to increase public coverage may also affect the supply and demand for private coverage. As a result, a variety of changes in coverage rates are possible.

This brief uses the 2021 and 2022 American Community Survey (ACS) 1-year estimates to examine differences in health insurance coverage status and select subtypes (Medicaid, direct purchase, and employer-based) for the 50 states, the District of Columbia, and the 25 most populous metropolitan areas (refer to the "What Is Health Insurance Coverage?" text box)./7

It also examines year-to-year changes (2021 to 2022) across these geographies.

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1 The Bureau of Labor Statistics reported increases in national employment from 2021 to 2022. More information is available at <www.bls.gov/opub/mlr/2023/article/unemployment-rate-returnedto-its-prepandemic-level-in-2022.htm>.

2 Juliette Cubanski et al., "What Happens When COVID-19 Emergency Declarations End? Implications for Coverage, Costs, and Access?," Kaiser Family Foundation, 2023, <www.kff.org/coronaviruscovid-19/issue-brief/what-happens-when-covid-19-emergencydeclarations-end-implications-for-coverage-costs-and-access/>.

3 For more information, refer to the American Rescue Plan Act, P.L. 117-2, March 11, 2021, <www.congress.gov/bill/117th-congress/house-bill/1319/text>.

4 Note that for the purposes of this brief, we consider a state to have expanded Medicaid eligibility if it expanded eligibility on or before January 1st of that expansion year. For a state to have expanded Medicaid eligibility in 2022, it would have had to expand eligibility after January 1, 2021, but before January 1, 2022. For more information, refer to the Patient Protection and Affordable Care Act, P.L. 111-148, March 23, 2010, available at <www.congress.gov/bill/111th-congress/house-bill/3590>.

5 For more information on the U.S. Census Bureau's geographic levels, refer to Geographic Levels at <www.census.gov/programssurveys/economic-census/guidance-geographies/levels.html>.

6 "Kentucky, Maine, and New Mexico Launch State Marketplaces for 2022 Coverage," Centers for Medicare & Medicaid Services press release, 2023, <www.cms.gov/newsroom/press-releases/kentuckymaine-and-new-mexico-launch-state-marketplaces-2022-coverage>.

7 The Census Bureau has reviewed this data product to ensure appropriate access, use, and disclosure avoidance protection of the confidential source data used to produce this product (Disclosure Review Board (DRB) approval number: CBDRB-FY23SEHSD003-049). For information on confidentiality protection, sampling error, nonsampling error, and definitions in the American Community Survey, refer to <https://www2.census.gov/programssurveys/acs/tech_docs/accuracy/ACS_Accuracy_of_Data_2022.pdf>.

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WHAT IS HEALTH INSURANCE COVERAGE?

This brief presents state-level estimates of health insurance coverage using data from the American Community Survey (ACS). The U.S. Census Bureau conducts the ACS throughout the year; the survey asks respondents to report their coverage at the time of interview. The resulting measure of health insurance coverage, therefore, reflects an annual average of current comprehensive health insurance coverage status.* This uninsured rate measures a different concept than the measure based on the Current Population Survey Annual Social and Economic Supplement (CPS ASEC).

For reporting purposes, the ACS broadly classifies health insurance coverage as private insurance or public insurance. The ACS defines private health insurance as a plan provided through an employer or a union, coverage purchased directly by an individual from an insurance company or through an exchange (such as healthcare.gov), or coverage through TRICARE. Public insurance coverage includes federal programs (such as Medicare, Medicaid, and the Children's Health Insurance Program or CHIP), individual state health plans, and CHAMPVA (Civilian Health and Medical Program at the Department of Veterans Affairs), as well as care provided by the Department of Veterans Affairs. In the ACS, people are considered insured if they were covered by any of these types of health insurance at time of interview. People are considered uninsured if they were not covered by any of these types of health insurance at time of interview or if they only had coverage through the Indian Health Service (IHS), as IHS coverage is not considered comprehensive.

* Comprehensive health insurance covers basic health care needs. This definition excludes single-service plans, such as accident, disability, dental, vision, or prescription medicine plans.

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The large sample size of the ACS allows for an examination of the uninsured rate and coverage by type for subnational geographies./8

Key Findings

* In 2022, the uninsured rate varied from 2.4 percent in Massachusetts to 16.6 percent in Texas (Figure 1 and Figure 2). The District of Columbia was among the lowest with an uninsured rate of 2.9 percent, not statistically different from Massachusetts.

* Utah and North Dakota reported the highest rate of private coverage (78.4 percent) in 2022, while New Mexico had the lowest private coverage rate (54.4 percent) (Figure 3)./9

* Utah had the lowest rate of public coverage in 2022 (22.2 percent), and New Mexico had the highest (Figure 4).

* Twenty-seven states had lower uninsured rates in 2022 compared with 2021. Maine was the only state whose uninsured rate increased (6.6 percent in 2022, up from 5.7 percent in 2021) (Figure 1 and Appendix Table B-1).

* From 2021 to 2022, 13 states reported increases in public coverage, with only Rhode Island reporting a decrease of 2.2 percentage points (Appendix Table B-3).

* From 2021 to 2022, nine states reported increases in private coverage, while seven reported decreases (Appendix Table B-2).

DIFFERENCES IN THE UNINSURED RATE BY STATE IN 2022

In 2022, uninsured rates at the time of interview ranged across states from a low of 2.4 percent in Massachusetts to a high of 16.6 percent in Texas, compared to the national rate of 8.0 percent./10

Ten of the 15 states with uninsured rates above the national average were states that have not expanded Medicaid eligibility, and two of those 15 states, Oklahoma (11.7 percent) and Missouri (8.6 percent), had recently expanded Medicaid eligibility in 2022./11

Twenty-nine states and the District of Columbia had an uninsured rate below the national average.

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8 The Current Population Survey Annual Social and Economic Supplement (CPS ASEC) is the leading source of national level estimates of health insurance coverage. For a comparison of ACS and CPS ASEC measures of health insurance coverage, refer to <www.census.gov/topics/health/health-insurance/guidance.html>.

9 Respondents may have more than one health insurance coverage type at the time of interview. As a result, adding the total number of people with private coverage and the total number with public coverage will sum to more than the total number with any coverage.

10 The uninsured rates in the District of Columbia and Massachusetts were not statistically different.

11 Between January 1, 2014, and January 1, 2022, 38 states and the District of Columbia elected to expand Medicaid eligibility under the ACA. The 12 states that had not expanded Medicaid eligibility under the ACA on or before January 1, 2021, included Alabama, Florida, Georgia, Kansas, Mississippi, North Carolina, South Carolina, South Dakota, Tennessee, Texas, Wisconsin, and Wyoming. For more information on expansion states, refer to Appendix Table A-1.

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Figure 1. Percentage of People Without Health Insurance Coverage by State and State Medicaid Expansion Status: 2021 and 2022 (Civilian, noninstitutionalized population)

Note: State Medicaid expansion status in 2022 is used to estimate change between 2021 and 2022. For information on expansion status, refer to Appendix Table A-1. For information on confidentiality protection, sampling error, nonsampling error, and definitions in the American Community Survey, refer to <https://www2.census.gov/programs-surveys/acs/tech_docs/accuracy/ACS_Accuracy_of_Data_2022.pdf>.

Source: U.S. Census Bureau, 2021 and 2022 American Community Survey, 1-year estimates.

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Among that group, only Wisconsin had not expanded Medicaid eligibility. As a group, the states that expanded Medicaid eligibility had a lower uninsured rate (6.3 percent) compared with nonexpansion states (11.8 percent)./12

States in the South had some of the highest uninsured rates, while states in the Northeast had some of the lowest uninsured rates. Of the 15 states that had uninsured rates above the national average, nine were in the South, ranging from 8.8 percent to 16.6 percent. All states in the Northeast - Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont - had uninsured rates below the national average./13

PRIVATE HEALTH INSURANCE COVERAGE BY STATE IN 2022

Private coverage may be held through an individual's or family member's employer, by buying it directly on the Marketplace Exchange or through a broker (direct purchase), or through TRICARE for current or retired members of the military or their dependents.

Private health insurance coverage at the time of interview ranged from a low of 54.4 percent in New Mexico to a high of 78.4 percent in Utah and North Dakota./14

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12 Nonexpansion states are states that did not expand Medicaid eligibility.

13 For more information on states by region, refer to <www.census.gov/programssurveys/economic-census/guidancegeographies/levels.html#par_textimage_34>.

14 In 2022, the private coverage rates were not statistically different in North Dakota and Utah.

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Figure 2. Uninsured Rate by State: 2022

Note: For information on confidentiality protection, sampling error, nonsampling error, and definitions in the American Community Survey, visit <https://www2.census.gov/programs-surveys/acs/tech-docs/accuracy/ACS-Accuracy_of_Data_2022.pdf>.

Source: U.S. Census Bureau, 2022 American Community Survey, 1-year estimates.

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Louisiana had the second-lowest rate of private coverage (58.1 percent) followed by Arkansas (60.0 percent). Hawaii (75.0 percent), Minnesota (74.7 percent), and New Hampshire (75.6 percent) had among the highest rates of private coverage (Figure 3 and Appendix Table B-2)./15

States that had high rates of private health coverage at the time of interview were also among the states with the highest employer-sponsored coverage rates: Hawaii (61.3 percent), Minnesota (61.0 percent), New Hampshire (62.0 percent), North Dakota (60.9 percent), and Utah (64.4 percent)./16

A high rate of employer-sponsored coverage may be related to a low unemployment rate in a state. Unemployment rates in Minnesota (2.7 percent), New Hampshire (2.5 percent), North Dakota (2.1 percent), and Utah (2.3 percent) were lower than the national average of 3.6 percent./17

Four of the five states with the highest private coverage rates had higher direct-purchase coverage rates than the national average of 13.9 percent in 2022. Direct-purchase coverage rates in those states were: Minnesota (16.2 percent), New Hampshire (15.3 percent), North Dakota (19.2 percent), and Utah (15.4 percent)./18

This may be related to the cost of direct purchase plans. Two of these states, Minnesota and New Hampshire, had the lowest average benchmark ACA Marketplace premiums of any state./19

North Dakota had one of the highest direct-purchase coverage rates at 19.2 percent, which likely contributed to its high private coverage rate.

Although it is possible for states that expand Medicaid eligibility to have lower private coverage rates triggered by an increase in public coverage, it is also possible that Medicaid and private coverage complement each other, and, thus, private coverage may go up with Medicaid eligibility expansion due to competitive pricing. For example, a report from the Department of Health and Human Services indicated that states that expand Medicaid eligibility have, on average, 7 percent lower ACA Marketplace premiums./20 In 2022, the private coverage rate for the group of states that expanded Medicaid eligibility was 67.9 percent, while the group of nonexpansion states had a private coverage rate of 65.6 percent (Appendix Table B-5).

PUBLIC HEALTH INSURANCE COVERAGE BY STATE IN 2022

Public health insurance coverage may be obtained through Medicare (coverage for most people aged 65 or older or people with certain disabilities), Medicaid (coverage for those with low incomes or a disability), or the Department of Veterans Affairs (coverage for eligible veterans: VA Care or CHAMPVA).

As in 2021, New Mexico had the highest rate of public health insurance coverage at 51.2 percent, while Utah had the lowest rate at 22.2 percent (Figure 4 and Appendix Table B-3)./21 While the public coverage was high in New Mexico, it had the lowest rate of private coverage rate in 2022, leaving it with an uninsured rate near the national average. Similarly, Utah's low public coverage rate was offset by its relatively high private coverage, also resulting in an uninsured rate close to the national average.

If a state expanded its Medicaid eligibility as part of the ACA, that may affect its public coverage rate. Examining expansion states as a group, the prevalence of public coverage in 2022 was 38.5 percent, 4.2 percentage points higher than nonexpansion states, at 34.3 percent (Appendix Table B-5). Medicaid coverage accounted for a portion of that difference. Medicaid coverage was 22.7 percent in the group of states that expanded Medicaid eligibility and 18.0 percent in the group of nonexpansion states.

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15 In 2022, the private coverage rates in Hawaii, Minnesota, and New Hampshire were not statistically different.

16 In 2022, the rates of employer-sponsored health coverage in Hawaii, Minnesota, New Hampshire, and North Dakota were not statistically different from one another.

17 U.S. Department of Labor, Bureau of Labor Statistics, Local Area Unemployment Statistics, Table A, <www.bls.gov/news.release/pdf/srgune.pdf>.

18 In 2022, the direct-purchase coverage rates were not statistically different in New Hampshire and Utah.

19 The Kaiser Family Foundation analyzed monthly premium data for all tiers (bronze, silver, and gold) for a 40-year-old in each state and county, weighted by county plan selections. Refer to <www.kff.org/healthreform/state-indicator/average-marketplacepremiums-by-metal-tier/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Average%20Benchmark%20Premium%22,%2 2sort%22:%22asc%22%7D>.

20 Aditi Sen and Thomas DeLeire, "The Effect of Medicaid Expansion on Marketplace Premiums," 2016, <https://aspe.hhs.gov/sites/default/files/migrated_legacy_files//153561/McaidExpMktplPrem.pdf>. The Urban Institute also found lower premiums among Medicaid expansion states. Refer to <www.urban.org/sites/default/files/2023-03/Changes%20in%20Marketplace%20Premiums%20and%20Insurer%20Participation%2C%202022-2023.pdf>.

21 Douglas Conway and Breauna Branch, "Health Insurance Coverage Status and Type by Geography: 2019 and 2021," 2022, <www.census.gov/content/dam/Census/library/publications/2022/acs/acsbr-013.pdf>.

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Figure 3. Percentage of People With Private Coverage by State and State Medicaid Expansion Status: 2021 and 2022

Note: State Medicaid expansion status in 2022 is used to compare change between 2021 and 2022. For more information on expansion states, refer to Appendix Table A-1. For information on confidentiality protection, sampling error, nonsampling error, and definitions in the American Community Survey, refer to <https://www2.census.gov/programs-surveys/acs/tech_docs/accuracy/ACS_Accuracy_of_Data_2022.pdf>.

Source: U.S. Census Bureau, 2021 and 2022 American Community Survey, 1-year estimates.

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Figure 4. Percentage of People With Public Coverage by State and State Medicaid Expansion Status: 2021 and 2022

Note: State Medicaid expansion status in 2022 is used to compare change between 2021 and 2022. For more information on expansion states, refer to Appendix Table A-1. For information on confidentiality protection, sampling error, nonsampling error, and definitions in the American Community Survey, refer to <https://www2.census.gov/programs-surveys/acs/tech_docs/accuracy/ACS_Accuracy_of_Data_2022.pdf>.

Source: U.S. Census Bureau, 2021 and 2022 American Community Survey, 1-year estimates.

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CHANGES IN THE UNINSURED RATE BY STATE FROM 2021 TO 2022

From 2021 to 2022, uninsured rates decreased across 27 states, while only Maine had an increase. The uninsured rate in Maine increased from 5.7 percent to 6.6 percent, although it remained below the national average. Maine's uninsured rate was still below 8.0 percent, which was the state's uninsured rate in 2019, the year before it expanded Medicaid eligibility./22 Declines in the uninsured rate in the majority of these states were related to changes in their public and private coverage rates. For seven of the states with lower uninsured rates in 2022, the difference was driven by increases in private coverage. These states were Florida, Kansas, Mississippi, North Carolina, Ohio, South Carolina, and Texas.

For seven states, the uninsured rate decrease was related to increases in public coverage with no corresponding change in the level of private coverage. These states were Alabama, California, Georgia, Illinois, Indiana, Michigan, and Oklahoma. In three states (Missouri, New York, and Virginia), it was shifts in coverage from private to public that contributed to the decline in their uninsured rates.

The uninsured rate in expansion states as a group decreased from 6.8 percent to 6.3 percent; nonexpansion states experienced a decrease in the uninsured rate from 12.8 percent to 11.8 percent, which was driven by an increase in private coverage.

CHANGES IN PRIVATE HEALTH INSURANCE COVERAGE BY STATE FROM 2021 TO 2022

Changes in private insurance subtypes in a state can affect the overall distribution of changes in private coverage. Sixteen states had changes to private health insurance coverage; nine had increases and seven had decreases.

Of the nine states in which private coverage rose, three reported combined increases in employer-sponsored and direct-purchase coverage (Iowa, North Carolina, and Texas); three reported increases in direct-purchase coverage only (Florida, Kansas, and Mississippi); and two reported increases in employer-based coverage only (Alaska and South Carolina) (Appendix Table B-4). The Centers for Medicare and Medicaid Services (CMS) reported that Marketplace enrollment in the U.S. increased from 12.0 to 14.5 million people between 2021 to 2022./23 Many states with increases in direct-purchase coverage also showed increases in Marketplace enrollment of 22 percent or greater (based on CMS data), and many states with increases in employer-based coverage had decreases in unemployment rates./24

For the seven states with declines in private coverage rates, two experienced decreases in employer-sponsored coverage (Appendix Table B-2). Decreases in direct-purchase coverage were also seen in Minnesota (0.5 percentage points) and Missouri (0.8 percentage points)./25

While states that expanded Medicaid eligibility as a group did not experience a change to the private coverage rate, nonexpansion states as a group had an increase of 0.8 percentage points.

CHANGES IN PUBLIC COVERAGE BY STATE FROM 2021 TO 2022

In 2022, 13 states saw increases in public health insurance coverage while only one state, Rhode Island, had a decrease. This led to an increased public coverage rate for the nation overall at 37.2 percent in 2022. As with private coverage, changes in the distribution of public coverage subtypes (e.g., Medicaid) may affect the overall public coverage rate. Rhode Island reported a decrease in public coverage of 2.2 percentage points, which was driven by a decrease in people reporting Medicaid (2.3 percentage points) (Figure 4 and Appendix Table B-3)./26 Increases in public health insurance coverage ranged from 0.6 percentage points to 2.3 percentage points across states.

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22 Douglas Conway and Laryssa Mykyta, "Decline in Share of People Without Health Insurance Driven by Increase in Public Coverage in 36 States," 2022, <www.census.gov/library/stories/2022/09/uninsured-ratedeclined-in-28-states.html>.

23 In January 2021, an executive order extended a special enrollment period to sign up for Marketplace coverage, continued and expanded through 2022. Kaiser Family Foundation, "Marketplace Enrollment 2014-2023," based on analysis of Centers for and Medicare Marketplace Open Enrollment Period Public Use Files. Refer to <www.cms.gov/files/document/health-insuranceexchanges-2022-open-enrollment-reportfinal.pdf>, <www.kff.org/health-reform/state-indicator/marketplace-enrollment/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%2 2%7D>, and <www.healthaffairs.org/content/forefront/new-biden-executive-order-aimsbuild-coverage-gains>.

24 U.S. Department of Labor, Bureau of Labor Statistics, Local Area Unemployment Statistics, Unemployment Rates for States, 2022 Annual Averages, <www.bls.gov/lau/ lastrk22.htm>, and Unemployment Rates for States, 2021 Annual Averages, <www.bls.gov/lau/lastrk21.htm>. For estimates of direct purchase health insurance coverage by state, refer to Appendix Table B-4 in this brief https://www.cms.gov/files/document/healthinsurance-exchanges-2022-open-enrollmentreport-final.pdf.

25 There was no statistical difference in the decrease in the direct-purchase rate in in Minnesota and Missouri between 2021 and 2022.

26 Per CMS, Rhode Island reported a decline in Child Medicaid and CHIP (Children's Health Insurance Program) enrollment from December 2021 to January 2022. Refer to <www.medicaid.gov/medicaid/national-medicaid-chip-programinformation/downloads/dec-2021-jan-2022medicaid-chip-enrollment-trend-snapshot.pdf>.

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At the time of interview, 21.2 percent of people were covered through Medicaid in 2022. In general, people in states that expanded Medicaid eligibility may report higher rates of public coverage than those in nonexpansion states, and with potentially larger increases in states that more recently expanded Medicaid eligibility. Eleven of the 38 expansion states reported increases in public coverage from 2021 to 2022. Oklahoma, which expanded Medicaid eligibility in 2022, reported one of the largest increases (2.3 percentage points)./27 Among other states that had expanded Medicaid eligibility recently, Missouri (on/after January 1, 2022), Nebraska (on/after January 1, 2020), and Virginia (on/after January 1, 2018) all reported increases of 1.0 percentage point or greater from 2021. Only two nonexpansion states experienced increases in public coverage in 2022 (Alabama and Georgia).

As a group, states that expanded Medicaid eligibility may have increased Medicaid rates over time, but rates may also decrease in some years due to economic conditions./28 Between 2021 and 2022, the group of states that had expanded Medicaid eligibility saw an increase of 0.2 percentage points in Medicaid coverage, to 22.7 percent; however, there was no increase for the group of nonexpansion states./29 The increase in public coverage, and by extension Medicaid, was consistent with Medicaid enrollment, which has increased since 2020, as reported by CMS./30

METROPOLITAN AREAS

Differences in the Uninsured Rate in the 25 Most Populous Metropolitan Areas in 2022 The uninsured rates in the 25 most populous metropolitan areas of the United States followed a similar pattern to the states, with uninsured rates ranging from 2.4 percent in Boston-Cambridge-Newton, MA-NH, to 18.0 percent in Houston-The Woodlands-Sugar Land, TX. The Boston-Cambridge-Newton, MA-NH, metropolitan area has a competitive ACA Marketplace, both states expanded Medicaid eligibility, and Massachusetts has an individual health insurance mandate, all of which may have contributed to the low rate./31 Among the most populous metropolitan areas, the San Francisco-Oakland-Berkeley, CA, metropolitan area had the second-lowest uninsured rate, and has expanded its healthcare, both in the private and public markets, via its Medi-Cal system and Healthy San Francisco program for the uninsured./32 In May 2022, California expanded Medi-Cal to all adults 50 years or older, which also may contribute to the higher insured rates in this metropolitan area./33 By contrast, the three metropolitan areas with the highest uninsured rates - two of which accounted for about half of the state population (Dallas-Fort Worth-Arlington and Houston-The Woodlands-Sugar Land) - were in Texas, a nonexpansion state with the highest uninsured rate for a second year in a row./34

Changes in the Uninsured Rate by 25 Most Populous Metropolitan Areas from 2021 to 2022

Between 2021 and 2022, 11 out of the 25 most populous metropolitan areas in the United States saw declines in the uninsured rate; and none experienced an increase in uninsured rates./35 Charlotte-Concord-Gastonia, NC-SC, experienced one of the largest decreases (1.8 percentage points) in the uninsured rate from 2021 to 2022, which is consistent with the decrease in the uninsured rates in both South Carolina and North Carolina./36 The uninsured rate in 14 metropolitan areas did not statistically change between 2021 and 2022.

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27 There was no statistical difference in the increase in the public coverage rate in Nebraska and Oklahoma between 2021 and 2022.

28 State Medicaid eligibility expansion status in 2022 is used to compare change between 2021 and 2022.

29 There was no statistically significant change among nonexpansion states from 2021 to 2022.

30 Data from the CMS showed that Medicaid enrollment continued to increase in 2022, following increases in 2020 and 2021. At the end of 2021, 44.2 million adults were enrolled in Medicaid, while 40.0 million children were enrolled in Medicaid/CHIP. At the end of 2022, Medicaid enrollment in adults increased by about 4.2 million and 1.7 million in children. Refer to Appendix B of the December 2022 Medicaid and CHIP Enrollment Trends Snapshot at <www.medicaid.gov/medicaid/national-medicaidchip-program-information/downloads/December-2022-medicaid-chip-enrollmenttrend-snapshot.pdf>.

31 John Holahan, Erik Wengle, and Claire O'Brien, "Marketplace Competition and Premiums, 2019-2022," Urban Institute, April 2022, <www.urban.org/sites/default/files/2022-04/Marketplace%20Premiums%20and%20Competition%202019-22.pdf>; ACA Marketplace Participation Tracker 2015- 2023, Robert Wood Johnson Foundation, <www.rwjf.org/en/insights/our-research/interactives/aca-marketplace-participationtracker.html>. Massachusetts implemented a state individual health insurance mandate starting in 2006.

32 Caroline Davis, "San Francisco Bay Area: Regional Health Systems Vie for Market Share," California Health Care Almanac, California Health Care Foundation, April 2021, <www.chcf.org/wp-content/uploads/2021/04/RegionalMarketAlmanac2020BayArea.pdf>.

33 For more information, refer to Older Care Expansion at California Department of Health Care Services at <www.dhcs.ca.gov/services/medi-cal/eligibility/Pages/OlderAdultExpansion.aspx>.

34 These most populous metropolitan areas had the highest uninsured rates in 2022 and 2021. Refer to <www.census.gov/content/dam/Census/library/publications/2022/acs/acsbr-013.pdf>.

35 When comparing metropolitan areas from 2021 to 2022, we used the 25 most populous metropolitan areas in 2022 as the basis for comparison. However, none of the 25 most populous metropolitan areas changed from 2021 to 2022; only the order of their population ranking within the 25 metro areas did.

36 The changes in the uninsured rates from 2021 to 2022 in Dallas-Fort Worth-Arlington, TX (1.0 percentage points); Denver-Aurora-Lakewood, CO (1.4 percentage points); Houston-The Woodlands-Sugar Land, TX (1.3 percentage points); and Orlando-Kissimmee-Sanford, FL (1.4 percentage points), were not statistically different from the change in Charlotte-Concord-Gastonia, NC-SC.

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SUMMARY

The uninsured rate fell in 27 states (mainly states that had expanded Medicaid eligibility), while only Maine had an increase of 0.8 percentage points. Only one state saw a decrease in public coverage (Rhode Island), while seven states experienced decreases in private coverage. As groups, states that expanded Medicaid eligibility saw an increase in public coverage, while states that did not expand Medicaid eligibility saw an increase in private coverage from 2021 to 2022, although expansion states had both higher private and public coverage rates than nonexpansion states to start with in both 2021 and 2022. Massachusetts had the lowest uninsured rate and Texas had the highest in 2022./37 In 2022, Utah had the highest private coverage and lowest public coverage rate, while New Mexico had the highest public coverage and the lowest private coverage rate, consistent with the pattern in 2021./38,39 Across the 25 most populous metropolitan areas, Boston-Cambridge-Newton, MA-NH, had the lowest uninsured rate in 2022, while three metropolitan areas in Texas had the highest uninsured rates, consistent with the state's uninsured state ranking.

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37 The uninsured rates in the District of Columbia and Massachusetts were not statistically different from one another.

38 Douglas Conway and Breauna Branch, "Health Insurance Coverage Status and Type by Geography: 2019 and 2021," American Community Survey Briefs, ACSBR-013, U.S. Census Bureau, Washington, DC, 2022, <www.census.gov/content/dam/Census/library/publications/2022/acs/acsbr-013.pdf>. 39 In 2022, the private coverage rates were not statistically different in North Dakota and Utah.

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Figure 5. Percentage of Uninsured People for the 25 Most Populous Metropolitan Areas: 2021 and 2022

Note: For information on confidentiality protection, sampling error, nonsampling error, and definitions in the American Community Survey, refer to <https://www2.census.gov/programs-surveys/acs/tech_docs/accuracy/ACS_Accuracy_of_Data_2022.pdf>.

Source: U.S. Census Bureau, 2021 and 2022 American Community Survey, 1-year estimates.

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SOURCE AND ACCURACY

The data presented in this brief are based on the ACS sample interviewed from January 2021 through December 2021 (2021 ACS) and the ACS sample interviewed from January 2022 through December 2022 (2022 ACS). The estimates based on these samples describe the average values of person, household, and housing unit characteristics over the period of collection. Data presented in this brief are subject to sampling and nonsampling error. Sampling error is the uncertainty between an estimate based on a sample and the corresponding value that would be obtained if the estimates were based on the entire population (as from a census).

Measures of sampling error are provided in the form of margins of error for all estimates included in this brief. All comparative statements in this brief have undergone statistical testing, and comparisons are significant at the 90 percent confidence level, unless otherwise noted. In addition to sampling error, nonsampling error may be introduced during any of the operations used to collect and process survey data such as editing, reviewing, or keying data from questionnaires. For more information on sampling and estimation methods, confidentiality protection, and sampling and nonsampling errors, refer to the 2022 ACS Accuracy of the Data document at <https://www2.census.gov/programs-surveys/acs/tech_docs/accuracy/ACS_ Accuracy_of_Data_2022.pdf>.

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The report is posted at: https://www.census.gov/content/dam/Census/library/publications/2023/acs/acsbr-015.pdf