The State of U.S. Health Insurance in 2022

The number and percentage of Americans lacking health insurance is falling to historic lows, thanks to policy changes aimed at helping people get and stay covered during the COVID-19 pandemic, as well as the recent decision by several states to expand Medicaid eligibility under the Affordable Care Act. Still, a large number of people in the United States remain uninsured or inadequately covered, a situation that will worsen when some temporary pandemic measures expire.

In this data brief, we present findings from the Commonwealth Fund Biennial Health Insurance Survey to describe the state of Americans’ health insurance coverage in 2022. We answer the following questions:

• How many people experience gaps in their coverage, and how long are those gaps?
• How many people have insurance but are underinsured?
• Are health care costs affecting people’s decision to get needed care?
• Are these costs leaving people with medical bills they cannot pay?

For the survey, SSRS interviewed a nationally representative sample of 8,022 adults age 19 and older between March 28 and July 4, 2022. This analysis focuses on 6,301 respondents under age 65. Note that because the 2022 edition of the Biennial Health Insurance Survey employed a new sampling method and was conducted mostly online rather than by telephone, as in the past, we are unable to present data on trends in responses over the years. To learn more about our survey, including the revised sampling method, see “How We Conducted This Survey.”

Survey Highlights

• Forty-three percent of working-age adults were inadequately insured in 2022. These individuals were uninsured (9%), had a gap in coverage over the past year (11%), or were insured all year but were underinsured, meaning that their coverage didn’t provide them with affordable access to health care (23%).
• Twenty-nine percent of people with employer coverage and 44 percent of those with coverage purchased through the individual market and marketplaces were underinsured.
• Forty-six percent of respondents said they had skipped or delayed care because of the cost, and 42 percent said they had problems paying medical bills or were paying off medical debt.
• Half (49%) said they would be unable to pay for an unexpected $1,000 medical bill within 30 days, including 68 percent of adults with low income, 69 percent of Black adults, and 63 percent of Latinx/Hispanic adults.
• Sixty-eight percent of Democrats, 55 percent of Independents, and 46 percent of Republicans said President Biden and Congress should make health care costs a top priority in the coming year.

Survey Findings

By mid-2022, 43 percent of adults ages 19 to 64 had inadequate insurance coverage, meaning they were uninsured at the time of the survey (9%), had coverage when surveyed but experienced a time without coverage in the past year (11%), or had continuous coverage over the past year but were underinsured (23%) (see the box, “Who Is Underinsured?”) (Table 1).

Our uninsured estimate is lower than the rate reported by the Centers for Disease Control and Prevention for this age group in the first quarter of 2022 (11.8%, with a confidence interval of 10.3% to 13.3%) and recently by the U.S. Census Bureau for all of 2021 (11.6%, with a confidence interval of 11.3% to 11.9%). (See “Estimates of U.S. Uninsured Rates” for detail.) U.S. uninsured rates have been declining as a result of historically high enrollment in Medicaid and in marketplace plans, driven primarily by pandemic-related policy changes.¹ Our survey estimate may indicate further gains through the first half of 2022. But while smaller surveys like ours can provide leading indications of the overall direction of U.S. uninsured rates, federal surveys, given their large sample sizes, will always provide the most reliable point estimates. It’s important to note that because our estimated uninsured rate has a margin of error of +/− .9 percent, the true estimate falls between 8 percent and 9.9 percent.

Among the world’s high-income countries, the U.S. stands alone for the complexity of its health insurance system. Americans are eligible for different types of coverage depending on whether their employer offers it, what their income level is, and what their age and health care needs are. There is no national autoenrollment mechanism for people who don’t have employer coverage; they must know which program they are eligible for and then sign up for coverage. Consequently, people can experience insurance gaps at different points in their lives, like when they lose a job.

In the survey, 20 percent of respondents either were uninsured at the time of the survey or were insured but reported a coverage gap in the prior year. The majority who were insured when surveyed but had had a coverage gap reported a gap of relatively short duration (data not shown). But the vast majority (79%) of people who were uninsured when surveyed had been without any coverage for a year or longer (Table 2). Across both groups, people who lacked coverage for a year or more were disproportionately poor, young, and Latinx/Hispanic; in fair or poor health or living with a chronic health problem; and/or living in the South.

The Affordable Care Act (ACA) plugged holes in the system through its insurance market reforms, including a ban on excluding people from coverage because of a preexisting health condition; its subsidies for marketplace plans; and its expansion of Medicaid eligibility. But because the law was built on the existing insurance system, people can still experience coverage gaps. In addition, many people experience chronic, structural uninsurance: these include people who fall into the Medicaid coverage gap in the 12 states that have yet to expand Medicaid as well as undocumented immigrants, who are not eligible for federally subsidized coverage. These individuals still have no access to affordable coverage.

To find out if they are eligible for one of the ACA’s subsidized marketplace plans or for Medicaid, at any time of year Americans can go to the federal website, HealthCare.gov, enter their income and address, and see what their coverage options are. But some people who are uninsured or have experienced a coverage gap do not sign up for either Medicaid or marketplace plan. In addition, some people who search for individual-market coverage or marketplace plan never end up enrolling in one.

According to our survey, not being able to afford plan premiums was the reason most often cited for not enrolling in individual market or marketplace coverage or losing such coverage.

Among uninsured people or those with a coverage gap who previously had Medicaid, loss of eligibility was the main reason most often cited (data not shown).

Open enrollment through the marketplaces lasts from November 1 through January 15, but people who lose their insurance, from any source, are generally eligible for a special enrollment period outside those dates. We asked people who had coverage through an employer whether they were aware they were eligible to enroll in a marketplace plan at any time if they lost their coverage. Fifty-six percent of people with employer coverage who had spent some time uninsured during the year were not aware of this enrollment flexibility (data not shown).

Among people who were insured all year in private health plans, 29 percent of those with coverage through an employer and 44 percent with individual market or marketplace coverage were underinsured. This means that their coverage wasn’t enough to enable affordable access to health care: either because their reported out-of-pocket costs, excluding premiums, and/or deductibles were high relative to their income (see the box, “Who Is Underinsured?”).

People with low income, whether covered by employer insurance or by an individual-market or marketplace plan, were underinsured at higher rates than people with higher income (Table 3). Enrollees with health problems also were at higher risk of being underinsured than healthier people, though differences were not significant for those covered in the individual market and marketplaces.

The high cost sharing people face in many employer, individual-market, and marketplace plans is primarily driven by the prices that providers, especially hospitals, charge to commercial insurers and employers. These prices are the highest in the world.² And consumers bear the burden, in the cost of their insurance, the size of their deductibles, their out-of-pocket maximums, and their copayments.

Lack of good health insurance is a barrier to people’s ability to get timely health care. Sixty-one percent of working-age adults who were underinsured and 71 percent of those who lacked continuous coverage said they had avoided getting needed health care because of the cost of that care. This included not going to the doctor when sick, skipping a recommended follow-up visit or test, not seeing a specialist when recommended, or not filling a prescription (Table 4).

While survey respondents reported delaying health care for treatment of new health conditions and for ongoing health problems — and sometimes both — somewhat more people said that the care they avoided was related to ongoing health problems (Table 4).

As much as a quarter of people with chronic health problems like diabetes said that out-of-pocket costs for prescription drugs to treat those problems had caused them to skip doses or not fill a prescription for the condition(s) they indicated.

Americans have amassed billions of dollars in medical debt as a consequence of inadequate insurance coverage. There is an estimated $88 billion of medical debt on consumer credit records, accounting for 58 percent of all debt-collection entries on credit reports — by far the largest single source of debt in collections.³ This estimate does not include debt people owe directly to providers.

In our survey, 30 percent of working-age adults reported that they had problems paying medical bills over the past year, and one-quarter said that they were paying off medical debt over time. The share of those with medical debt rose to more than one-third among people who were underinsured or lacked continuous coverage. Of people reporting medical debt, more than half (56%) said the amount was $2,000 or more (Table 5).

We also found out that more than 30 percent of adults who were underinsured or who lacked continuous coverage said they had been contacted by a collection agency about unpaid medical bills. While the majority of adults said that the bills in collection were those they could not afford to pay, one-quarter (24%) said the bills had been the result of a billing mistake.

About one-quarter of adults who were underinsured or lacked continuous coverage said they had to change their way of life to pay their medical bills.

Nearly half of adults with any medical bill problem or with medical debt said their issue was related to a surprise bill: they received care at an in-network hospital but were billed by a doctor there who was not in their plan’s network (Table 5). The No Surprises Act has outlawed surprise bills such as these, but the timeframe covered by the survey’s questions included the period before the law went into effect in January 2022.⁴

Problems with paying medical bills and debt stemmed most frequently from inpatient or outpatient hospital visits. The care people received that resulted in bill problems was split equally among treatment for new health conditions and for ongoing conditions (Table 5).

People experienced both short- and long-term financial consequences from medical bill problems or medical debt. About two of five adults who reported any medical bill problem or medical debt received a lower credit rating because of problems paying these bills, took on credit card debt to pay them, and/or used up all their savings to pay them.

The average insurance deductible for employer health plans with single coverage is more than $1,000 ($1,434 for all covered workers in 2021), and it’s more than $2,000 ($2,825) for HealthCare.gov marketplace plans.⁵ Out-of-pocket maximums average $4,272 for single coverage in employer plans and range up to $8,700 in marketplace plans.⁶ These plan features leave people with considerable cost exposure in case of a sudden illness or accident.

Half of survey respondents said that they would not have the money to cover an unexpected $1,000 medical bill within 30 days. Rates were even higher for specific groups: 68 percent for people with low income, 69 percent for Black adults, and 63 percent for Latinx/Hispanic adults.

When asked about their top health care policy priorities for the president and Congress, survey respondents were divided along partisan lines. The closest Democrats, Republicans, and Independents came to agreement was on the need to lower the cost of health care. Ensuring everyone has coverage, controlling COVID-19, and preparing for future pandemics were viewed as top priorities among a large majority of Democrats but fewer Independents and Republicans.

Conclusion and Policy Recommendations

The number of uninsured people in the U.S. has fallen by nearly half since the ACA was signed into law.⁷ Coverage gains over the past two years have been achieved through the American Rescue Plan Act’s enhanced marketplace subsidies and through the Families First Coronavirus Response Act’s requirement that states keep people enrolled in Medicaid until the end of the public health emergency in exchange for enhanced federal matching funds.⁸ Both provisions, coupled with increased outreach and advertising as well as state and federal extensions of open enrollment periods, drove enrollment in the marketplaces and Medicaid to record highs.

But the end of the public health emergency, expected in 2023, will trigger a massive effort by states to redetermine Medicaid enrollees’ eligibility, a process that could leave many uninsured. The findings of this survey point to two areas of policy change needed to protect and build on recent coverage gains and improve the quality of coverage. Below are some options for policymakers to consider.

Covering All Americans, and Keeping Them Covered

• The Inflation Reduction Act of 2022 extended the enhanced marketplace plan subsidies for three years. Congress can make them permanent. Our survey shows just how much consumers weigh the cost of premiums when deciding whether to enroll and stay enrolled in marketplace plans.
• Congress could require that states conduct Medicaid eligibility redeterminations gradually, and it could phase down enhanced Medicaid matching funds rather than eliminate them immediately at the end of the public health emergency. This would help states transition people to new coverage and prevent erroneous terminations of Medicaid coverage.
• Congress could provide a federal fallback option for Medicaid-eligible people in states that have yet to expand their program; this could reduce the number of uninsured people in those states by an estimated 1.9 million.⁹ The Urban Institute estimates that in those states, Black residents would see the biggest gains, with their uninsured rates falling by 27 percent.
• Congress could make it easier for adults to stay on Medicaid by allowing states to maintain continuous eligibility, without the need to apply for a federal waiver. States currently have this option for children enrolled in Medicaid and CHIP; those implementing it have lowered their child uninsured rates.¹⁰
• The Biden administration’s enhanced outreach and enrollment efforts during the pandemic could be maintained and expanded.¹¹
• Congress could allow people to autoenroll in comprehensive health coverage, a strategy that has the potential to move the nation to near-universal coverage.¹²

Improving Insurance Design and Protecting Consumers from Medical Debt

• The Biden administration or Congress could place limits on or ban short-term insurance plans and other coverage that doesn’t comply with ACA benefit requirements. Consumers who enroll in these skimpy policies are often exposed to catastrophic medical costs.¹³ By drawing healthier people out of the individual market and the marketplaces, these policies also have increased premiums for people who remain.¹⁴
• Congress could rein in deductibles and out-of-pocket costs in marketplace plans by enhancing cost-sharing reduction subsidies and changing the benchmark plan in the ACA marketplaces from silver to gold, which offers better financial protection.¹⁵ Not only would these policies reduce the number of Americans who are underinsured, but these improvements could lower the number of people without insurance by 1.5 million.¹⁶
• States, which regulate their fully insured employer markets, could use rate regulation to limit growth in premiums and cost sharing, as Rhode Island has.¹⁷ They could also explore other policy options to improve employer coverage, just as many states did prior to the ACA’s passage in requiring coverage of young adults on their parent’s plans.¹⁸
• The Biden administration recently launched new actions to protect consumers from being financially harmed by medical debt, including scrutinizing providers’ bill collection practices.¹⁹ Congress could reinforce those actions by requiring providers to allow debt repayment grace periods following illness or during appeals processes; banning egregious hospital practices such as suing patients, garnishing their wages, or placing liens on homes; and a ban or limits on charging interest.²⁰
• Federal and state policymakers could address the high health care prices driving up premiums and deductibles, such as by creating new public insurance options.²¹

The primary purpose of health insurance is to help people get health care in a timely fashion and protect them from catastrophic costs in the event of serious illness. Insurance fills these needs when coverage is continuous and comprehensive. While the ACA helped the U.S. make great strides toward better health coverage, the job is not done.