Decreased Uninsurance Rate in 2021 Driven by Public Coverage Gains

January 20, 2023 - Around 8 million people gained health insurance coverage during the second year of the COVID-19 pandemic, primarily due to increased access to public coverage, a Health Affairs study found.

Temporary provisions tied to the COVID-19 public health emergency (PHE) have helped boost access to Medicaid, the Children’s Health Insurance Program (CHIP), and Affordable Care Act (ACA) marketplace plans.

Researchers used data from the Census Bureau’s Household Pulse Survey from January 10, 2021, to February 7, 2022, to assess changes in health insurance coverage during the second year of the pandemic. They also used Household Pulse Survey data from April 23, 2020, to February 7, 2022, to examine employment rates among Medicaid beneficiaries.

The study sample included nearly 900,000 adults ages 19 to 64.

The share of people with any health insurance coverage increased throughout the study period rising from 87.1 percent in January 2021 to 89.2 percent in February 2022. This translates to a 3.8 percentage point annualized increase and 8 million people gaining coverage during the 56 weeks.

The unemployment rate declined during the study period, but the rate of employer-sponsored coverage remained flat. Meanwhile, non-employer-sponsored coverage grew from 18.7 percent in January 2021 to 22.5 percent in February 2022.

The insurance growth was driven mainly by higher enrollment in public coverage. Over 3 million people gained Medicaid coverage, signaling a 1.5 percentage point increase. The share of people receiving other public coverage grew by 2.2 percentage points, translating to 4.7 million individuals gaining coverage.

At the same time, private coverage experienced a loss of 1.7 million people.

Public coverage gains were higher in states that had adopted Medicaid expansion, with these states seeing an average annual increase of 3.2 percentage points.

Coverage increases in expansion states were concentrated among adults between 27 and 50 years old and were driven by coverage sources outside employer-sponsored insurance. However, coverage gains among Hispanic people were driven by increases in employer-sponsored insurance, the study noted.

In non-expansion states, coverage gains among Black people were also due to employer-sponsored coverage increases.

In the employment analysis, researchers found that employment grew among Medicaid beneficiaries in expansion states but not expansion states. This suggests that those who lose Medicaid eligibility when the PHE expires may be able to receive employer-sponsored coverage.

“Although previous economic recessions have generally led to increases in the number of people without coverage, this recession and subsequent recovery have been different,” researchers wrote.

“Despite a severe drop in economic activity in 2020 due to the COVID-19 pandemic, as well as ongoing disruptions in the labor market and employment patterns through 2021, the number of uninsured people did not increase.”

These findings echo a recent report from the HHS Office of the Assistant Secretary for Planning and Evaluation (ASPE). Using data from the 2019 and 2021 American Community Survey, researchers found that the uninsurance rate dropped from 11.1 percent in 2019 to 10.5 percent in 2021.

In particular, uninsurance rates declined in states that adopted Medicaid expansion. Racial and ethnic minorities also experienced significant coverage gains. For example, the uninsurance rate decreased by 1 percentage point among the Latino community and 0.9 percentage points among the American Indian and Alaska Native community.

In addition, the report noted that Americans with low incomes saw a decrease in uninsurance. People with incomes of 100 to 138 percent of the federal poverty level (FPL) experienced a 1.4 percentage point drop in uninsurance. Those with incomes between 139 and 249 percent of FPL saw a 1 percentage point decrease.