The chances of obtaining employment-based health insurance are tied to many factors, including family structure and income levels. Full-time, full-year employment is associated with having the highest likelihood of coverage. In addition, families with two wage earners are more likely to have coverage than those with one. Firm size and employment sector are also important variables.

Men are More Likely Than Women to Be Uninsured

Several factors strongly influence whether or not a family member is insured. These include the type of employment sector, the likelihood that wage earners have access to insurance through an employer and the age of the primary wage earner. For example, members of families in the sales sector are more likely to be uninsured than those in other sectors. In addition, members of families whose primary wage earners are close to Medicare eligibility and do not have access to job-based coverage are also more likely to be uninsured. The gender of the primary wage earner also affects the likelihood that the family will be uninsured. For example, married women wage earners are less likely to be uninsured than single male wage earners because their husbands often meet the age requirements for Medicare coverage, and they do not. Conversely, nonworking married couples are more likely to be uninsured.

In 2021, the number of nonelderly uninsured Americans declined by 1.5 million over the previous year, reflecting large increases in Medicaid enrollment and declines in the number of people who lost their employer-sponsored coverage. The uninsured tended to be 19 to 64 years old, male and less educated than the US population. Moreover, they were disproportionately concentrated in the South and West.

Children are More Likely Than Adults to Be Uninsured

For generations, getting kids covered has been a top priority for the nation. Providing children with health coverage is important because it can prevent childhood medical problems that, left untreated, may have long-term consequences. The availability of health coverage also helps families meet their basic needs and reduces the strain on families due to high costs. However, the current national trend is that fewer children are becoming insured, and the percentage of uninsured children has increased in recent years.  Most uninsured children are US citizens and live in one- or two-parent family structures. Almost three-quarters of uninsured children are school-aged, and the remainder are infants or younger. Adults without children are more likely to be uninsured than adults with children. One group of adults whose uninsured rate has been increasing is young adults ages 18 through 24 years, and another is midlife adults ages 55 through 64 who have begun to experience declining incomes and are more likely than older adults to anticipate the need for healthcare services. Overall, working-age adults 19 through 64 are the largest group of uninsured people and are most concentrated in states that have not expanded their eligibility for Medicaid under the ACA. They are more likely than other groups to be male, have less than a high school education and have lower incomes.

Non-Hispanic Whites are More Likely Than Other Groups to be Uninsured

Among adults, non-Hispanic white people had the highest uninsured rate in 2021 at 19.0%, while Hispanic and black adults had lower rates of 19.4% and 10.2%, respectively. Hispanic and black people were also less likely than non-Hispanic white adults to have insurance coverage through an employer or the government. Adults in fair or poor health had a higher uninsured rate (24.3%) than those in excellent, very good, or good health (30.2%). Similarly, women had a higher uninsured rate than men (28.1%). Finally, immigrants were more likely to be uninsured than native citizens in 2021. The uninsured rate for immigrants in the country for fewer than five years was 28%, while the rate for native-born citizens was 10.2%.

Families with children are more likely to have insured members than families without children, reflecting the availability of needs-based public coverage for children, such as Medicaid and SCHIP. However, the overall level of coverage among working-age family members has mostly stayed the same since 1996. It may be partly due to a slow rate increase in premiums for employment-based family coverage. Moreover, access to private coverage depends on income levels, employment status, and other characteristics, including education. In general, families with children are more likely to have insured members, while households that do not have a wage earner are less likely to be covered by employment-based insurance.

The Likelihood of Being Uninsured is Higher For American Indians and Alaska Natives 

Despite the recent coverage gains seen across all people under 65, American Indians and Alaska Natives continue to experience persistently high rates of uninsurance. They are twice as likely to be uninsured as non-Hispanic Whites and less likely to have employment-based health insurance. This disparity may reflect longstanding barriers to accessing health care, including discrimination in providing services and cultural differences. Additionally, they face a disproportionate burden of chronic diseases resulting from economic adversity and a lack of health education. However, the ACA has expanded health insurance opportunities for American Indians and Alaska Natives through Medicaid. Although the expansion has not yet reached all eligible adults, nonelderly American Indian and Alaska Native people under 65 saw a significant decline in their uninsured rate between 2019 and 2021, largely due to increases in their Medicaid coverage.

In addition, studies show that low-income American Indians and Alaska Natives with IHS coverage perform as well or better than those without insurance on many healthcare access and utilization measures, including receiving routine preventive health services and diagnosing and treating diseases. These findings underscore the importance of expanding health insurance options for American Indians and Alaska Natives and improving health education and community-based support systems that promote healthy lifestyles. These efforts can help to reduce the significant gaps in health status and life expectancy experienced by this population group.