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).

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

 

This presentation 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.

 

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On Thursday, September 26th at 1:00 PM CST, SHADAC hosted 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 discussed 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 walked through how to access the data and examples of how to use it to answer research questions. We were also pleased to once again welcome a special guest from the Census Bureau, Sharon Stern, who joined the end of the webinar to participate in a Q&A, answering questions from attendees. 

Webinar attendees came away knowing more about:

• The new 2023 health insurance coverage estimates
• How to access the estimates via Census reports and the data.census.gov website
• How to access state-level estimates from the ACS using SHADAC’s State Health Compare web tool
• When and how to use 2023 Census data to understand health insurance coverage trends

Find a recording of this webinar, along with presentation slides and a transcript of webinar audio, below.

Find the slides from this presentation here. Find a transcript of this webinar here.

Speakers

Elizabeth Lukanen, Moderator
Deputy Director, SHADAC

Ms. Lukanen serves as the Deputy Director for SHADAC, overseeing center research and providing strategic direction and oversight. With 20 years of experience in the health policy arena, Ms. Lukanen specializes in managing complex projects and translating quantitative findings into actionable, policy-relevant information. Ms. Lukanen currently oversees SHADAC’s technical assistance to states in the areas of data use, analysis, and evaluation. Ms. Lukanen is vocal about the importance of collecting and reporting disaggregated data to explore issues related to health equity, while actively working with policymakers to improve data on race, ethnicity, sexual orientation, and gender identity.

 

Robert Hest, Speaker
Senior Research Fellow, SHADAC

Robert Hest joined SHADAC in 2017, providing expertise in survey data, quantitative data analysis, data visualization, and health coverage policy. Mr. Hest leads SHADAC’s work monitoring and investigating developments in the measurement of health insurance coverage and health care access, affordability and utilization in federal survey data. He also manages SHADAC’s State Health Compare website, coordinating data processing, quality assurance, dissemination, and documentation of data used on the site and leads SHADAC’s work in the Minnesota Research Data Center applying restricted-use data to analyze health care affordability, access, and utilization at the state level.

 

 

Andrea Stewart, Speaker
Research Fellow, SHADAC

Andrea Stewart joined SHADAC in 2018 as a Marketing and Communications Specialist, transitioning to a Research Fellow in 2022. Currently, Ms. Stewart leads SHADAC’s efforts to track and report health insurance coverage data from major federal surveys, and is involved in several other ongoing projects, including an effort to explore the potential for the creation of a Medicaid Equity Monitoring Tool. Portions of her other research work range in topic from health equity measurement to understanding the impacts of COVID-19 on federal survey data.

 

 

Sharon Stern, Speaker
Assistant Division Chief, U.S. Census Bureau

Sharon Stern is the Assistant Division Chief for employment characteristics in the U.S. Census Bureau’s Social, Economic and Housing Statistics Division. In her position, Ms. Stern oversees statistics on the labor force, health insurance and disability from several Census Bureau surveys. She has authored a wide variety of Census Bureau reports and papers on topics related to poverty, disability, and health insurance.

 

 

 

Stay up to date with our latest posts by joining our mailing list and following us on LinkedIn.

Walsh, Elliot
Research Dissemination Coordinator

e wals0421@umn.edu

Disability Health Care Data and Information: Resources from SHADAC

• Unfair treatment in health care settings, at work, or when applying for public benefits
• Adults with disabilities are more likely to live in poverty compared to adults with no disability
• People with a disability often have increased medical expenses, with a study from the National Disability Institute estimating that a U.S. household containing an adult with a disability must spend an estimated 28% more income to obtain the same standard of living as a household with no disability
• Those with disabilities have twice the risk of developing chronic health conditions like depression, diabetes, asthma, and poor oral health

Federal Survey Sample Size Analysis: Disability, Language, and Sexual Orientation and Gender Identity

• People who indicated sexual orientation or gender identity (SOGI)
• People with language access needs, and
• People with disabilities

Collection of Self-Reported Disability Data in Medicaid Applications: A Fifty-State Review of the Current Landscape (SHVS Brief)

States are likely undercounting the number of people with disabilities in their Medicaid programs. While some people with disabilities are covered by Medicaid as a result of disability- related eligibility, little is known about people with disabilities who are eligible on the basis of income or other factors. 

 

This State Health and Value Strategies (SHVS) Brief authored by SHADAC researchers Emily Zylla and Elizabeth Lukanen provides an overview of current disability data collection standards, including information on how states are collecting self-reported disability information on Medicaid applications. SHADAC researchers reviewed paper Medicaid applications for all 50 states and the District of Columbia alongside online applications for 36 states and the District of Columbia. 

 

Understanding and collecting better demographic data about the types of disabilities Medicaid enrollees experience can help us both identify any existing inequities and tailor possible solutions and resources appropriately. Read the brief in full here.

State Health Compare Disability Breakdowns

On SHADAC’s State Health Compare tool, users are able to examine a number of different measures related to health and health care at the state level. A number of these measures can be broken down by demographic categories, including by disability status, including:

• Health Insurance Coverage Type
• Broadband Internet Access
• Adult Unhealthy Days
• Unaffordable Rents

Data disaggregation such as this can help in identifying differences, trends, and similarities between different groups and demographics. See an example of what you can do with this data below, where we breakdown the measure ‘Adult Unhealthy Days’ by Disability Status.

Explore all of the measures including each of their available breakdowns at this link.

Housing Affordability Matters: Unaffordable Rents Infographics Updated with 2022 Data

Using data from the American Community Survey (ACS) in the ‘Unaffordable Rents’ measure on State Health Compare, we created a blog plus six accompanying infographics containing information on the connection between affordable housing and health. Within these publications, we included specific information on housing affordability for households with a person with a disability alongside all rental households to understand any differences in unaffordable rents between demographic groups.

 

For example, in the United States as a whole, 47.3% of rental households had unaffordable rents in 2022. In rental households that include a person that has a disability, that jumps to 54% had unaffordable rents in 2022. 

 

These resources also present data on other demographic groups including Medicaid enrollees, people of color, and household incomes less than 25,000 annually.

 

 

You can find each of the infographics created for the US and five individual states along with an explanatory blog on the topic here.

Minnesota Community and Uninsured Profile

This resource, originally funded by the Blue Cross Blue Shield of Minnesota Foundation, provides users with a tool that provides rates and counts of uninsured Minnesotans at various levels (ZIP code, county, MNSure rating area, state, etc.). The profile then can provide further breakdowns by a number of demographic factors, including by age, income, educational attainment, and disability status.  

 

Explore the profile here.

 

While this profile currently represents communities and uninsured populations from the single state of Minnesota, SHADAC researchers can provide additional technical assistance, profile customization, and analysis to other organizations and groups upon request.

 

If you or your organization is interested in working with this profile, or creating one relevant to you or your needs, don’t hesitate to reach out at shadac@umn.edu or on our contact page here.

Stay Informed on Disability Health Data Resources and Information

The resources and products above represent just some of the work SHADAC is doing that we hope can help advance health equity. Examining different demographic groups, identities, and experiences helps researchers, policymakers, and other stakeholders understand the challenges and barriers different people face – and, hopefully, use that information to tailor health equity work towards those differing needs in the future. 

 

You can stay up to date on our latest releases and updates by following us on LinkedIn, or by signing up for our newsletter.

 

Continue your journey to understand health disparities and health equity with the following products:

• Medicaid Equity Monitoring Tool Project
• LGBT Health Equity: Sexual Orientation and Gender Identity Data Resources from SHADAC
• Provider Discrimination by Sexual Orientation Among Cisgender and Transgender/Nonbinary Adults in Minnesota

Walsh, Elliot
Research Dissemination Coordinator

e wals0421@umn.edu

Telehealth Visit Data, ACEs Data, Opioid Sales, and More Updated on State Health Compare

National Survey of Children’s Health Data (NSCH)

Adverse Childhood Experiences

Adverse Childhood Experiences (ACEs) are traumatic events that occur during childhood, and include physical and emotional abuse, neglect, and household dysfunction, amongst others. These experiences can have long-term impacts on health and wellness long after childhood.

National Health Interview Survey Data (NHIS)

Made Changes to Medical Drugs (NHIS)

‘Made Changes to Medical Drugs’ is defined as the rate of individuals who made changes to medical drugs because of cost during the past twelve months by age for the civilian non-institutionalized population. Asking a medical provider to switch to a cheaper medication, taking less medication than prescribed, skipping dosages, using alternative therapies as a replacement, and delaying refills are all examples of how someone could make changes to medical drugs due to cost. Making changes such as these can have negative impacts on both short- and long-term health.

Trouble Paying Medical Bills (NHIS)

This measure tracks the percentage of people who had trouble paying off their medical bills in the last year. Like the ‘Made Changes to Medical Drugs’ measure, this can help understand and track health care affordability in the United States. This is especially relevant as the United States has some of the highest health care costs in the world.

Had Emergency Department Visit (NHIS)

Visits to the Emergency Department (ED) (also called the Emergency Room) are often costly and, in a surprisingly large number of cases, preventable. It’s estimated that between 13% and 27% of ED visits could be managed in primary care offices, clinics, and/or urgent care centers. 

Had Telehealth Visit (NHIS)

Telehealth, also called telemedicine, can expand access to care for many individuals and communities. Telehealth services conducted by phone or by video allow individuals to be connected with a health professional when they cannot get an in-person appointment, cannot safely leave their home, or lack transportation to get to an appointment, among a number of other reasons. Access to telehealth was expanded during the COVID-19 pandemic and has remained a popular way to access care.

Had Usual Source of Medical Care (NHIS)

When individuals do not have a usual source of medical care, health outcomes can be affected. For example, individuals may not seek care when they have a medical issue, which can result in delayed diagnosis of disease, worsening health conditions, etc. Lacking a usual source of care also means that people may miss out on preventative services and/or recommended screenings (like cancer screenings). They may also seek care in an Emergency Department, which we discussed earlier as being more costly and inefficient for both patients and health professionals.

Had General Doctor or Provider Visit (NHIS)

Utilization of health care services with a general doctor or provider is an important health-related behavior – seeing a general doctor allows individuals to obtain information about their health status, receive preventative services & screenings, maintain (or improve) their health and well-being, and respond to health problems with guidance from a professional health care provider. Seeing a provider can also form a relationship between patient and doctor/provider, where the doctor knows and monitors the patient over time.

Drug Enforcement Administration ARCOS Data

Sales of Opioid Painkillers

The Opioid Epidemic in the United States is widespread and destructive - since 2000, the annual number of overdose deaths from any kind of drug in the U.S. has multiplied nearly six times over, rising from 17,500 to over 106,000 people in 2021. Opioids caused a majority of these deaths, including both legal drugs and illicit drugs like heroin and fentanyl.

Data from the Bureau of Labor Statistics

Unemployment Rate

During the COVID-19 pandemic, the unemployment rate in the United States peaked at 14.8% in April 2020, which is the highest unemployment rate since 1948 (when unemployment data collection first began). 

Stay Up to Date with the Latest Data

Other Related Reading:

Comparing Federal Government Surveys That Count the Uninsured: 2023

How many Americans are uninsured? The exact answer is unclear, but general estimates can be obtained by comparing various federal government surveys that estimate uninsurance.

SHADAC has recently updated our annual “Comparing Federal Government Surveys that Count the Uninsured” brief following the release of new insurance coverage estimates from surveys conducted by the US Census Bureau, the Agency for Healthcare Research and Quality (AHRQ), and the Centers for Disease Control and Prevention (CDC).

Accurate estimates of the number of people that do not have insurance coverage (also referred to as uninsured or uninsurance) are important in understanding trends and the impacts of actions (policy changes), events (like public health emergencies), or shifts in the economic landscape (like periods of recession) that may affect health insurance coverage.

The brief provides an annual update to comparisons of uninsurance estimates from five federal surveys. As in prior years, we have included estimates from:

• The American Community Survey (ACS)
• The Current Population Survey (CPS)
• The Medical Expenditure Panel Survey - Household Component (MEPS-HC)
• The National Health Interview Survey (NHIS)

This year we have included data from an additional source:

• The Behavioral Risk Factor Surveillance System (BRFSS)

In this brief, SHADAC provides up-to-date and past national uninsurance estimates, as well as the latest state-level estimates from surveys (where feasible). 

 

We also analyze the primary factors contributing to variations in these estimates among surveys, along with potential reasons for their incomparability both within and across surveys.

View and download the Comparing Federal Government Surveys 2023 Brief to learn more about our findings and analysis.

Interested in insurance coverage trends? Learn more with the following SHADAC products:

• Comparing Federal Surveys That Count the Uninsured 2022 (last year’s version of this brief) 
• Tracking Health Insurance Coverage During the Unwinding: Monthly Data from the Household Pulse Survey
• Unemployment Rate Trends of the Past 5 Years: Pre-, Mid-, and Post-Pandemic