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The Persistently Uninsured
Private sector and public health care stakeholders, along with federal and state policymakers, have shaped enrollment policies and improved processes across health plans and programs over the last decade. At the same time, there remain millions of uninsured Americans who are not enrolled in health coverage. Even before the COVID-19 pandemic, roughly 30 million Americans lacked health coverage at any point in 2019.[1] The uninsured are also disproportionately likely to be Black or Latino.[2]

Some of the effects of a lack of health coverage for a meaningful portion of the population are well established: less access to and use of preventative care, barriers accessing high-quality health care, high out of pocket costs, delays in accessing care, and worse health outcomes, especially for older, less healthy patients.

Millions Eligible For Coverage, But Not Yet Enrolled
Despite these challenges stemming from lack of insurance, research indicates most such individuals are eligible for, but not enrolled in, a current health care plan or program. According to a 2022 analysis by the Congressional Budget Office, “10 percent of the population was without insurance in 2021 and 9 percent will be without insurance in 2022.” Of the individuals uninsured in CBO’s projection, 61 percent were eligible for subsidized coverage.


A previous report by CBO in 2020 found that 67 percent of uninsured individuals were eligible for subsidized coverage, with 36 percent of individuals being eligible for federally-subsidized health coverage (Medicaid, CHIP, or Marketplace coverage).[3] Roughly the same percentage – about a third of the overall persistently uninsured – were eligible for private coverage through an employer as well.

The 2020 CBO report also noted that “many uninsured people do not enroll in coverage because of the cost; others may not know that they are eligible for subsidized coverage or may be deterred by the complexity of enrolling.” As CBO suggested, the reasons for this gap in coverage are diverse and multi-faceted – ranging from affordability, to personal choice...from changes in jobs to changes in economic status…from linguistic or cultural barriers to missed opportunities to leverage data systems.

A Fresh Urgency
The resumption of Medicaid redeterminations has placed a renewed sense of urgency and focus on helping Americans find and enroll in health coverage for which they are eligible.

The COVID-19 pandemic has also focused needed attention on longstanding challenges millions of Americans face in health care –whether due to racial inequities, health disparities, socio-economic differences, or social determinants of health. Thus, coverage efforts also need to acknowledge and help address the real hurdles and challenges many face to receiving equitable access and care. New policies, strategies and tools to improve enrollment must be informed by and appropriately take into account these dynamics.

[1] Congressional Budget Office, Who Went Without Health Insurance in 2019, and Why? September 2020,

[2] ASPE Issue Brief: TRENDS IN THE U.S. UNINSURED POPULATION, 2010-2020, February 11, 2021,

[3] Congressional Budget Office: Who Went Without Health Insurance in 2019, and Why? September 30, 2020,

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