Hest, Robert
Stewart, Andrea

2023 ACS: After Two Years of Decline, Uninsured Rates Increased for Children; Public and Private Coverage Rates See Variations Across the States

This post is a part of our Survey Data Season series where we examine data from various surveys that are released annually from the summer through early fall. Find all of the Survey Data Season series posts on our Survey Data Season 2024 page here.

The U.S. Census Bureau released 2023 health insurance coverage estimates from the American Community Survey (ACS) yesterday, September 12, 2024. These estimates include both national- and state-level information about health insurance coverage by type, as well by certain demographic categories. 

Overall, 2023 ACS data and findings at the national level echoed those from the Current Population Survey (CPS ASEC), which was released this past Tuesday, September 10, 2024. According to new ACS data, among the total U.S. population, the 7.9% uninsured rate in 2023 remained statistically unchanged from the previous year (8.0%). 

Also like the 2023 CPS data, the newly released ACS data show a significant increase in the uninsured rate among children (age 0-18) in 2023, rising to 5.4% from 5.1% in 2022.

The rest of the blog will walk through state-level findings regarding different types of health insurance coverage (public, private, and uninsurance) in 2023. We will also discuss changes by age category for nonelderly adults (age 19-64) and children (age 0-18). 

Key Findings from the 2023 ACS by Health Insurance Coverage Types

Uninsurance

The stability of the national uninsurance rate from 2022 to 2023 was supported by little change among the states between these two years as well. 

The uninsured rate fell in 11 states, and increased in Iowa, New Jersey, and New Mexico. North Dakota saw the largest decrease in uninsurance at 1.9 percentage points (PP), moving from 6.4% in 2022 to 4.5% in 2023. New Mexico saw the largest percentage point increase in uninsurance at 0.9 PP, rising from 8.2% in 2022 to 9.1% in 2023. Across the states, Texas and Massachusetts continued their long-running trend as the states with the highest and lowest rates of uninsurance, at 16.4% and 2.6%, respectively. 

Private Coverage

2023 ACS data show that rates of private coverage fell slightly to 67.0% in 2023 from 67.2% in 2022. Rates of employer-sponsored insurance coverage (ESI) and direct purchase coverage were unchanged at 54.7% and 13.9%, respectively. 

Private insurance coverage rates decreased in nine states in 2023, and increased in four - Florida, North Dakota, Texas, and West Virginia. Delaware saw the largest decrease in private coverage with a 2.7PP decrease from 71.8% in 2022 to 69.1% in 2023. North Dakota saw the largest increase in private coverage, rising 2.4PP from 78.4% in 2022 to 80.8% in 2023. Rates of private coverage across the states ranged from a high of 80.8% in North Dakota to a low of 54.1% in New Mexico.

Public Coverage 

Nationally, the rate of public insurance coverage rose significantly in 2023, increasing to 37.4% from 37.2% the previous year. Surprisingly, the rate of Medicaid coverage was unchanged at 21.3% (21.2% in 2022), while the rate of Medicare coverage rose to 18.8% in 2023 from 18.5% the year prior. 

Public coverage saw the most change of all insurance types across the states in 2023, increasing in 13 and decreasing only in Arkansas, Idaho, Texas, and West Virginia. Arkansas saw the largest decrease in public coverage, falling by exactly 2.0PP from 45.0% in 2022 to 43.0% in 2023. Wyoming experienced the largest increase in public coverage, rising also by exactly 2.0PP from 31.2% in 2022 to 33.2% in 2023. Across the states, rates of public coverage ranged from a high of 52.2% in New Mexico to a low of 22.6% in Idaho in 2023.

Key State-Level Findings from the 2023 ACS by Age: Nonelderly Adults (19-64)

Uninsurance

The uninsured rate among nonelderly adults decreased 0.3PP from 11.3% in 2022 to 11.0% in 2023, representing the third year of falling uninsured rates for this group. Twelve states saw decreases in their uninsured rates while only Connecticut, Iowa, New Jersey, and Ohio saw increases in their uninsured rates. As with the overall population, North Dakota saw the largest decrease in uninsured rates among nonelderly adults, decreasing 2.2PP to 6.1% in 2023. Iowa saw the largest increase in uninsured rates, rising 1.0PP to 7.1% in 2023.

Private Coverage

The rate of private coverage among nonelderly adults was unchanged at 73.5% in 2023 (73.4% in 2022). Across the states, nearly the same number experienced increases (eight) in private coverage rates for nonelderly adults as experienced decreases (six). North Dakota had the largest increase at 3.3PP, with private coverage rates rising to 85.1% in 2023 from 81.8% in 2022. Delaware saw the largest decrease at 2.3PP, with private coverage rates falling to 74.0% in 2023 from 76.3% in 2022.

Public Coverage 

The rate of public coverage among nonelderly adults was also unchanged in 2023, holding steady at 19.5% (19.4% in 2022). Looking at the states, this rate stability was supported by a nearly equal number of states that experienced increases (six) as did those that experienced decreases (five). Delaware had the largest increase in public coverage, rising 2.1PP to 21.4% in 2023 from 19.3% in 2022. Arkansas had the largest decrease in public coverage, falling by 2.1PP to 24.1% in 2023 from 26.2% in 2022.

Key State-Level Findings from the 2023 ACS by Age: Children (0-18)

Uninsurance

The uninsured rate among children rose 0.3PP to 5.4% in 2023 from 5.1% in 2022. This change represents the first year of increased uninsurance among children after two years of falling rates. Five states saw an increase in their uninsured rate while three states — Colorado, Kentucky, and North Dakota — saw a decrease in their uninsured rate. As with nonelderly adults, North Dakota had the largest decrease in uninsured rates for children, falling 1.9PP from 5.5% in 2022 to 3.6% in 2023. New Mexico saw the largest increase in uninsurance, rising 2.1PP from 3.8% in 2022 to 5.9% in 2023. Rates of uninsurance among children ranged from a low of just 1.3% in the District of Columbia to a high of 11.9% in Texas.

Private Coverage

The rate of private coverage among children in 2023 was 60.6%, unchanged from the same recorded rate in 2022. Nearly as many states — Florida, Illinois, Maryland, and West Virginia — saw increases in rates of private coverage as those that saw decreases — New Mexico, Ohio, Pennsylvania, Tennessee, and Wyoming — from 2022 to 2023. West Virginia has the largest increase in private coverage, rising 4.8PP to 57.3% while Wyoming had the largest decrease in private coverage, falling 6.4PP to 65.2%.

Public Coverage 

The rate of public coverage among children in 2023 was 39.4%, statistically unchanged from the previous year at 39.6%. Five states — Iowa, Missouri, New Mexico, Tennessee, and Wyoming — saw an increase in public coverage while seven saw a decrease in public coverage. Wyoming had the largest increase in public coverage, rising 9.5PP to 33.6% while West Virginia had the largest decrease in public coverage, falling 5.0PP to 46.0% in 2023.

Future Data Releases and Products

Supplemental tables for the 2023 ACS 1-Year Estimates will be released from the U.S. Census Bureau on October 17, 2024, and 2019-2023 ACS 5-Year Estimates will be available on December 12, 2024. Stay up to date with the latest Survey Data Season releases and resources on the archive page here.

We will also soon be releasing more granular details about insurance coverage changes in the states from 2022 to 2023 via customized SHADAC tables examining coverage at the state and county level, along with an announcement of updated health insurance coverage measures available on State Health Compare.

Concluding the Continuous Coverage Requirement and the Medicaid Unwinding

The continuous coverage requirement that prevented states from terminating individuals’ Medicaid coverage during the COVID-19 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 has since ended on June 30, 2024. 

Each state was given a 14-month period to navigate returning to normal operations while also meeting reporting requirements set by the Centers for Medicare & Medicaid Services (CMS), such as submitting monthly “Unwinding Data Reports,” in order to publicly share coverage transitions and outcomes data during this time. Though the unwinding period has come to a close, a May 30, 2024, State Health Official (SHO) letter announced that CMS will extend these requirements for the foreseeable future. Beginning on July 1, 2024, all states are expected to continue to submit certain metrics contained in the Unwinding Data Report, now referred to as an “Eligibility Processing Report,” on an ongoing basis.

For more information on the post-unwinding period and reporting process, see a recent blog written by SHADAC researchers for State Health & Value Strategies:

Unwinding Ends, but States’ Reporting of Medicaid Renewal Data Continues (SHVS Cross-Post)

It is important to note that full-year 2023 estimates from all surveys, including the ACS and CPS, will not be fully reflective of a Medicaid unwinding process that began mid-year. However, provisional data from sources like the Census Bureau’s Household Pulse Survey, can give us an indicator of coverage trends during this time.

If you are interested in learning more, SHADAC researchers have compiled a clear, concise, and informative data resource that can be found here:

Tracking Health Insurance Coverage During the Unwinding: Monthly Data from the Household Pulse Survey

Related Releases and Materials

Recent Data Release: Current Population Survey ASEC: 2023 National Health Insurance Coverage Estimates Remain Steady for Adults but Rise for Children

We just released a new blog and accompanying infographic from SHADAC researchers covering the release of 2023 health insurance coverage data across the United States. Drawing from the Current Population Survey Annual Social and Economic Supplement (CPS ASEC), the blog looks at uninsured rates at the national level, as well as by select demographic categories.

Upcoming Webinar: U.S. Census Bureau Data Explained: Breaking Down 2023 Health Insurance Coverage Estimates from the ACS & CPS - featuring a Q&A with a Census Bureau Expert

On Thursday, September 26th at 1:00 PM CST, SHADAC will host a webinar covering the release of new Census data on health insurance coverage estimates for 2023. The estimates come from two key federal surveys conducted by the U.S. Census Bureau: The American Community Survey (ACS) and the Current Population Survey (CPS).

SHADAC researchers and presenters Robert Hest and Andrea Stewart will discuss the 2023 health insurance data at national and state levels, as well as by coverage type, and a range of other demographic categories (age, geography, poverty level, and more).

In addition, SHADAC will walk through how to access the data and examples of how to use it to answer research questions. We are also pleased to once again welcome a special guest from the Census Bureau, Sharon Stern, who will join us to answer questions from attendees after the presentation.

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).