In order to support state and local outreach efforts, ASPE has developed state, county, and local estimates of the number of U.S. residents without health insurance and their demographic characteristics, using the most recent Census data available from the 2021 American Community Survey (ACS). We analyzed the population of uninsured individuals ages 0-64 by family income.
We present results at three levels of geography:
- State-level – for all 50 states and Washington DC
- Public Use Microdata Areas (PUMA) level – PUMAs are the most granular level of geography available in the ACS public use file. PUMAs are geographic areas within each state that contain no fewer than 100,000 people; they can consist of part of a single densely populated county, or can combine parts or all of multiple counties that are less densely populated. Detailed maps of PUMAs for each state are available at: https://www.census.gov/geographies/reference-maps/2020/geo/2020-pumas.html
- County-level – to create county level estimates, we used a PUMA-to-county crosswalk from the Missouri Census Data Center. PUMAs spanning multiple counties had their estimates apportioned across those counties based on overall 2020 Census populations.
Our estimates are less precise at the PUMA and county levels than at the state level and thus are subject to greater sampling error; accordingly, they should be used with caution for purposes that require precise estimates. Counts of uninsured populations have been rounded to the nearest 100, resulting in slight differences between columns’ sums and the US total. Cells based on fewer than three underlying observations have been censored and marked with double asterisks (**).
We show these demographic estimates of the uninsured broken out by income, based on the health insurance unit (HIU), which consist of an adult, their spouse, and any dependent children.
We analyze the uninsured population in 3 distinct income groups, which vary based on state Medicaid expansion status. For states that have expanded Medicaid, we analyze those with HIU incomes at or below 138% of the federal poverty level (FPL), who are generally eligible for Medicaid; those with HIU incomes between 138% and 400% of FPL, who are generally eligible for Advance Payments of the Premium Tax Credit (APTC) for Marketplace coverage; and those with incomes above 400% of FPL. The Affordable Care Act (ACA) upper income for APTC eligibility of 400% FPL was removed with the implementation of the 2021 American Rescue Plan until 2022. The Inflation Reduction Act subsequently extended the removal of the upper income limit through 2025. We continue to separately present the demographics of the uninsured with HIU income greater than 400% FPL to monitor this group.
Note that these results are not a detailed program eligibility assessment. They are based solely on income and state of residence. They do not account for whether uninsured individuals have an affordable offer of employer coverage, which affects eligibility for APTCs, and they do not account for immigration status (unlike in previous ASPE data releases from 2019 data).
These estimates are meant to be reflective of the approximate size of the uninsured population, but they are not precise estimates. The approximations presented here may vary from other available estimates due to differences in data sources and methodology.
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