Hest, Robert
Theis, Lindsey
Stewart, Andrea

2022 ACS: Declining Uninsured Rates for the U.S. and States are Supported by Private and Public Coverage Increases

The U.S. Census Bureau released 2022 health insurance coverage estimates from the American Community Survey (ACS) today, which included state-level information about health insurance coverage by type as well by certain demographic categories. The Census Bureau also released an accompanying report and blog post highlighting many of the changes seen from 2021 to 2022.

Overall, the data showed a drop in uninsured rates, with an 8.0% rate of uninsurance in 2022 as compared to 8.6% in 2021. This echoes similar year-over-year decreases in uninsurance shown in data from the Current Population Survey (CPS), for which estimates were released on Tuesday, and in recent survey data from the National Health Interview Survey (NHIS). Eight percent represents the lowest-ever national rate of uninsurance measured in the ACS.

The national decline in uninsurance was supported by decreases in 27 states, with Maine the only state to see an increase in its uninsured rate, from 5.7% in 2021 to 6.6% in 2022, reversing the previous trend from 2019 to 2021.* Overall, uninsured rates ranged across states from a low of 2.4% in Massachusetts to a high of 16.6% in Texas, a continuing trend from past years. The largest drop in uninsured rates was found in Oklahoma, which fell by 2.1 percentage points (PP) to 11.7% in 2022 from 13.8% in 2021.

The drop in uninsured rates coincided with small yet significant increases in 2022 for both private coverage — 67.2% from 67.0% in 2021 — and public coverage — 37.2% from 36.8%. Alaska saw the largest increase in private coverage, rising 2.2 PP to 66.4%. Nine states saw increases in private coverage, while nine states saw decreases in private coverage. And unsurprisingly, Oklahoma saw the largest increase in public coverage, rising 2.3 PP to 39.6%: Oklahoma was one of two states, along with Missouri to have expanded Medicaid in 2022.

The rest of this blog post highlights some of the national and state-level changes that took place between 2021 and 2022 in the broadest categories of insurance (uninsurance, public coverage, and private coverage) for two key age groups, nonelderly adults (age 19-64) and children (age 0-18). Accompanying interactive maps allow readers to view and sort the different coverage types for each age group.

Key Findings from the 2022 ACS: Nonelderly Adults (19-64)

Figure 1. Changes in state-level coverage rates among nonelderly adults, 2021-2022

State-Level Uninsurance
Nonelderly adults also saw falling uninsurance rates, dropping by 0.9 PP from 12.2% in 2021 to 11.3% in 2022. Additionally, 31 states saw decreases in their uninsured rates for nonelderly adults while only Maine saw an increase, rising 1.4 PP to 9.6%. The largest decline in uninsurance was seen in Oklahoma, whose rate of uninsured nonelderly adults dropped a notable 3.4 PP to 16.8% in 2022.

State-Level Private Coverage
Private coverage increased significantly for nonelderly adults, rising 0.7 PP to 73.4% in 2022 from 72.7% in 2021. This increase was echoed across 21 states, with Mississippi seeing the largest increase at 2.2 PP, rising to 69.7% in 2022. Private coverage levels fell across just three states — Maine, Minnesota, and Virginia — with Maine seeing the most significant drop, falling 1.8 PP to 74.1% in 2022.

State-Level Public Coverage
Overall, nonelderly adults also experienced a significant increase in public coverage from 2021 to 2022. Rates of public coverage rose to 19.4% from 19.1% in 2021, driven by similar increases across 14 states. Individually, Oklahoma once again saw the largest increase — 19.9%, up from 16.3% in 2021. Of the eight states that saw decreases in 2022, public coverage for nonelderly adults declined the most in Rhode Island, dropping 2.1 PP to 21.7

Key Findings from the 2022 ACS: Children (0-18)

Figure 2. Changes in state-level coverage rates among children, 2021-2022

State-Level Uninsurance
For children, uninsured rates fell to 5.1% in 2022 from 5.4% in 2021. Fourteen states also saw drops in children’s uninsurance, Wyoming being the largest - falling 3.5 PP to 7.9%, followed by New Mexico, which saw a 2.6 PP decrease from 6.4% in 2021 to 3.8% in 2022. Three states (Connecticut, Pennsylvania, and Wisconsin) saw increased children’s uninsured rates for 2022.

State-Level Private Coverage
Unlike nonelderly adults, children did not experience an overall increase in private coverage for 2022. Private coverage remained statistically unchanged for children nationally at 60.6%. However, 13 states did see rising private coverage rates, with Rhode Island leading the way, jumping 4.8 PP to 69.4% in 2022. Six states saw declines in private coverage, led by a drop of 2.3 PP in Missouri, whose rate of private coverage for children in 2022 was 63.2%.

State-Level Public Coverage
Like private coverage rates, public coverage remained statistically unchanged for children from 2021 to 2022, sitting at 39.6%. Just eight states saw increased public coverage for kids in 2022, led by a 2.6 PP jump in North Dakota, from 21.3% in 2021 to 23.9% in 2022. And seven states saw declining public coverage rates, with children in Rhode Island experiencing a precipitous fall of 5.9 PP to 34.4% in 2022.

Future Data Releases and Products

Supplemental tables for the 2022 ACS 1-Year Estimates will be released from the U.S. Census Bureau on October 19, 2023, and 2018-2022 ACS 5-Year Estimates will be available on December 7, 2023.

Stay tuned for more granular details about insurance coverage changes in the states from 2021 to 2022 via customized SHADAC tables examining coverage at the state and county level, and for an announcement of updated health insurance coverage measures available on State Health Compare.

Notes

All changes described in this document are significant at the 90% level. Private coverage includes individually purchased, employer-sponsored coverage, and TRICARE military health coverage Public coverage includes Medicare, Medicaid/CHIP, and VA health care. Public and private coverage types are not exclusive and include individuals with those types of coverage alone or in combination with other coverage. Estimates represent the civilian noninstitutionalized population.

Overarching estimates of uninsurance and public and private coverage are for all ages, except where noted for children (age 0-18) and nonelderly adults (19-64).

COVID-19 Public Health Emergency Impacts

Continuous Coverage Requirement

The continuous coverage requirement that prevented states from terminating individuals’ Medicaid coverage during the pandemic ended on March 31, 2023. The resumption of Medicaid eligibility redeterminations and renewals (and potential disenrollments), a process commonly referred to as the “unwinding,” began on April 1, 2023, and each state has a year to navigate a return to normal operations while also meeting reporting requirements set by CMS for publicly sharing coverage transitions and outcomes data during this time. While the health insurance estimates released by the US Census Bureau for 2022 precede the beginning of the unwinding process, the data provide an essential baseline for understanding how health insurance coverage is distributed across the U.S. and among the states prior to the unwinding, as well as marker to measure the impacts of this seismic coverage transition as potentially millions of individuals, both adults and children, are poised to lose Medicaid and must either find another form of coverage (e.g., state-based marketplace or employer-sponsored insurance [ESI]), or risk becoming uninsured.

Several resources have been compiled by SHADAC to track the unwinding process in a variety of avenues, falling under several broader categories:

Guidance for States

• Using Surveys to Monitor Coverage Transitions During the Unwinding of the Medicaid Continuous Coverage Requirement
• Best Practices for Publicly Reporting State Unwinding Data

Health Insurance Coverage Data Tracking

• State-Based Marketplace Transition Data During the Unwinding
• State Dashboards to Monitor the Unwinding of the Medicaid Continuous Coverage Requirement
• Tracking Health Insurance Coverage During the Unwinding: Monthly Data from the Household Pulse Survey

*Data Collection and Dissemination
As has been extensively documented by both SHADAC and the Census Bureau, disruptions to data collection and dissemination efforts—as well as the presence of significant nonresponse bias—due to the COVID-19 pandemic heavily impacted estimates for 2020. As such, the Census Bureau released 2020 ACS 1-year data in an “experimental-only” format and cautioned against their use. Similarly, the Census Bureau recommends that data users do not compare 2020 ACS 1-year experimental estimates with any other data. Researchers therefore have compared 2019 to 2021 data.