Hest, Robert
Theis, Lindsey
Stewart, Andrea

2021 ACS: Estimates Show Declining Uninsurance Rates Across 28 States, Driven by Rise in Public Coverage and Fall in Private Coverage

In a slight departure from their normal process, the U.S. Census Bureau released all 2021 estimates from the American Community Survey (ACS) today, which included state-level information about health insurance coverage by coverage 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 2019 to 2021.*

Overall, the data showed a decrease in the number of people who were uninsured at the time of the survey: 8.6% in 2021, down 0.5 percentage points (PP) from 9.2% of the population in 2019. This echoes the drops in uninsurance shown by the recently released Current Population Survey (CPS) estimates (8.3% in 2021 from 8.6% in 2020), as well as the NHIS (9.2% in 2021 from 9.7% in 2020, though this change was not statistically significant).

This blog post highlights some of the national and state-level changes in the broadest categories of insurance (uninsurance, public coverage, and private coverage), and takes a look at the changes in rates by two age groups, nonelderly adults (age 19-64) and children (age 0-18), across the states.

Key Findings from the 2021 ACS: Uninsurance, Public Coverage, and Private Coverage

Alongside the national decline in uninsurance, 28 states also experienced significant decreases in their rates of uninsured. Maine saw the largest decrease, falling 2.3 PP from 8.0% in 2019 to 5.7% in 2021. North Dakota was the only state to experience an increase in its uninsured rate, which rose by 1.0 PP from 6.9% in 2019 to 7.9% in 2021. Uninsured rates ranged from a low of 2.5% in Massachusetts to a high of 18.0% in Texas. Though we are unable to compare to estimates in 2020, these states continued a trend of having the lowest and highest rates of uninsurance from 2018 and 2019.

When looking at public coverage, rates increased to 36.8% in 2021 from 35.4% in 2019—a 1.4 PP increase. This trend was echoed by rising rates of public coverage across 36 states, and no states saw decreases in public coverage in 2021 as compared to 2019. Rates of public coverage ranged from a low of 22.3% in Utah to a high of 50.9% in New Mexico. Idaho saw the largest increase in public coverage from 2019 to 2021, rising 4.3 PP to 36.8% last year.

Conversely, rates of private coverage declined across the nation and among 18 states in 2021. The percentage of individuals with private coverage decreased 0.4 PP from 67.4% in 2019 to 67.0% last year. Private coverage rates ranged from a low of 53.3% in New Mexico to a high of 77.8% in Utah. Rhode Island experienced the largest drop in private coverage, falling 4.2 PP to 69.2% in 2021 from 73.3% in 2019. Florida was the only state to see an increase in private coverage, rising 0.7 PP to 63.1% in 2021 from 62.5% in 2019.

State-Level Uninsurance by Age

Uninsurance fell among nonelderly adults in 2021, declining by 0.7 PP to 12.2% from 12.9% in 2019. 26 states also saw decreases in their uninsured rates for nonelderly adults, and only North Dakota saw an increase, rising 1.9 PP to 10.1%. The largest decrease in uninsurance was seen in Idaho, whose rate of uninsured nonelderly adults dropped precipitously by 4.4 PP to 12.1% in 2021 from 16.5% in 2019.

Children also saw an overall decrease in uninsurance last year, falling 0.3 PP to just 5.4% in 2021. This was echoed by falling uninsured rates in ten states, with increases seen in just two—Idaho and Maryland. Oklahoma had the largest decrease in the rate of uninsured children, falling 1.2 PP from 8.6% in 2019 to 7.4% in 2021.

Changes in State-Level Uninsurance Rates by Age, 2019 vs. 2021

State-Level Public Coverage by Age

Examining rates of public coverage for nonelderly adults showed an overall increase of 1.4 PP from 2019 to 2021, rising from 17.7% to 19.1%. 35 states also saw public coverage increase among nonelderly adults, with no states reporting decreases. Once again, Idaho was the state to report the largest increase in public coverage for nonelderly adults, rising 7.1 PP to 19.4% in 2021.

Similarly, rates of public coverage rose by 1.4 PP for children from 2019 to 2021—an increase reflected across 23 states. Just one state, Montana, saw a decrease in public coverage among children from 2019 to 2021 (42.0% to 37.7%, a difference of 4.3 PP). Rhode Island saw the largest increase from 2019 to 2021, rising 7.1 PP to 40.3% of children covered by public insurance in the state.

Changes in State-Level Public Coverage by Age, 2019 vs. 2021

State-Level Private Coverage by Age

Overall, rates of private coverage remained unchanged for nonelderly adults in 2021, likely due to a mix of states reporting rate changes (7 increased and 11 decreased) in this type of coverage. Nonelderly adults in Maine saw the largest increase in public coverage, rising 1.9 PP to 75.9% in 2021. Rhode Island reported the largest decrease, dropping 3.3 PP to 74.4% in 2021.

Children also saw fewer changes in private coverage rates, both at the national level (rate of 60.5% coverage was statistically unchanged from 2019 to 2021) and across the states, with 5 reporting increases and 3 reporting significant decreases. Pennsylvania and Tennessee both reported the largest increase in private coverage for children, rising 1.9 PP to 65.4% and 60.6%, respectively. Rhode Island’s rate of private coverage among children saw a large drop from 2019 to 2021, falling 8.4 PP to 64.6%.

Changes in State-Level Private Coverage by Age, 2019 vs. 2021

Future Data Releases and Products

Supplemental tables for the 2021 ACS 1-Year Estimates will be released from the U.S. Census Bureau on October 20, 2021, and 2017-2021 ACS 5-Year Estimates will be available on December 8, 2021.

Stay tuned for more granular details about insurance coverage changes in the states from 2019 to 2021 via customized SHADAC tables examining coverage at the state and county level.

As this blog noted, changing rates of public and private coverage in 2021 drove overall declines in uninsured rates. Further analysis shows that these changes were, in turn, driven by shifts in Medicaid, employer-sponsored insurance (ESI), and direct-purchase coverage. A SHADAC blog post taking a deep dive into these trends will be published next week. In the meantime, to learn more about our latest research on ESI trends, check out our recent narrative report and 50-state comparison tables.

Related Materials
Recent Blog: CPS ASEC: 2021 National Health Insurance Coverage Estimates Show Falling Uninsured and Private Coverage Rates Across Population Demographics (Infographic)

Upcoming Webinar: SHADAC Hosting An Annual Conversation with the U.S. Census Bureau to talk Health Insurance Coverage Estimates from the 2021 ACS and CPS

On Thursday, September 29th at 1:00 PM Central Time (2:00 PM Eastern), SHADAC will host a webinar to examine the new 2021 coverage estimates from the ACS as well as from the Current Population Survey (CPS), with technical insight provided by researchers from SHADAC and special guests Sharon Stern and Laryssa Mykyta from the U.S. Census Bureau, which administers both surveys.

Speakers will discuss the new national and state-level estimates, and attendees will learn when to use which estimates from which survey, how to access the estimates via the data.census.gov site and the new ACS table formats, and there will be an opportunity to ask questions after the speaker presentations.

Register for the webinar here!

*Comparisons with 2020 ACS Data
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.

Notes
All changes described in this document are significant at the 90% level. Private coverage includes individually purchased and employer-sponsored coverage.

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).