health insurance coverage in the united states health insurance coverage in the united states in the united states, health insurance coverage is provided by several public and private sources. during 2019, the u.s. population overall was approximately 330 million, with 59 million people 65 years of age and over covered by the federal medicare program. the 273 million non-institutionalized persons under age 65 either obtained their coverage from employer-based (159 million) or non-employer based (84 million) sources, or were uninsured (30 million). during the year 2019, 89% of the non-institutionalized population had health insurance coverage. separately, approximately 12 million military personnel (considered part of the "institutional" population) received coverage through the veteran's administration and military health system. u.s. health insurance coverage estimate for 2019. cbo estimated aca/obamacare was responsible for 22 million persons covered via exchanges and medicaid expansion. this article is part of a series onhealthcare reform in theunited states history debate legislation preceding social security amendments of 1965 emtala (1986) hipaa (1996) medicare modernization act (2003) psqia (2005) superseded affordable health care for america (h.r. 3962) america's affordable health choices (h.r. 3200) baucus health bill (s. 1796) proposed american health care act (2017) medicare for all act (2021, h.r. 1976) healthy americans act (2007, 2009) health security act (h.r. 3600) latest enacted affordable care act (h.r. 3590) health care and education reconciliation act (h.r. 4872) reforms obama administration proposals public opinion reform advocacy groups rationing insurance coverage systems free market health insurance exchange nationalized insurance publicly-funded single-payer canadian vs. american two-tier universal third-party payment models all-payer rate setting capitation fee-for-service global payment united states portal health care portal despite being among the top world economic powers, the us remains the sole industrialized nation in the world without universal health care coverage. prohibitively high cost is the primary reason americans give for problems accessing health care. at approximately 30 million in 2019, higher than the entire population of australia, the number of people without health insurance coverage in the united states is one of the primary concerns raised by advocates of health care reform. lack of health insurance is associated with increased mortality, in the range 30-90 thousand deaths per year, depending on the study. multiple surveys indicate the number of uninsured fell between 2013 and 2016 due to expanded medicaid eligibility and health insurance exchanges established due to the patient protection and affordable care act, also known as the "aca" or "obamacare". according to the united states census bureau, in 2012 there were 45.6 million people in the us (14.8% of the under-65 population) who were without health insurance. following the implementation of major aca provisions in 2013, this figure fell by 18.3 million or 40%, to 27.3 million by 2016 or 8.6% of the under-65 population. however, the improvement in coverage began to reverse under president trump. the census bureau reported that the number of uninsured persons rose from 27.3 million in 2016 to 29.6 million in 2019, up 2.3 million or 8%. the uninsured rate rose from 8.6% in 2016 to 9.2% in 2019. the 2017 increase was the first increase in the number and rate of uninsured since 2010. further, the commonwealth fund estimated in may 2018 that the number of uninsured increased by 4 million from early 2016 to early 2018. the rate of those uninsured increased from 12.7% in 2016 to 15.5% under their methodology. the impact was greater among lower-income adults, who had a higher uninsured rate than higher-income adults. regionally, the south and west had higher uninsured rates than the north and east. cbo forecast in may 2019 that 6 million more would be without health insurance in 2021 under trump's policies (33 million), relative to continuation of obama policies (27 million). the causes of this rate of uninsurance remain a matter of political debate. in 2018, states that expanded medicaid under the aca had an uninsured rate that averaged 8%, about half the rate of those states that did not (15%). nearly half those without insurance cite its cost as the primary factor. rising insurance costs have contributed to a trend in which fewer employers are offering health insurance, and many employers are managing costs by requiring higher employee contributions. many of the uninsured are the working poor or are unemployed. overview health insurance coverage is provided by several public and private sources in the united states. analyzing these statistics is more challenging due to multiple survey methods and persons with multiple sources of insurance, such as those with coverage under both an employer plan and medicaid. for the 273 million non-institutional persons under age 65 in 2019: there were 159 million with employer-based coverage, 84 million with other coverage, and 30 million uninsured. of the 159 million with employer-based coverage, many are in self-funded health plans - about 60% in 2017 of the 84 million with other coverage, 57 million were covered by medicaid and children's health insurance program (chip), 12 million were covered by the aca medicaid expansion, 9 million were covered by the aca/obamacare exchanges, 5 million had other coverage such as private insurance purchased outside the aca exchanges, and 1 million were covered by the aca basic health program. of the 9 million on the aca exchanges, 8 million received subsidies and 1 million did not. of the 30 million uninsured, 24 million (80%) were lawfully present while 6 million (20%) were not lawfully present (i.e., undocumented immigrants). in 2018, 41% of the uninsured were white, 37% were hispanic, and 14% were black. approximately 12 million institutional (military) personnel were covered by the veteran's administration in 2018. the uninsured rate fell from a peak of 18.2% in 2010 to 10.5% by 2015, due primarily to aca/obamacare along with improvements in the economy. states that expanded medicaid under obamacare (37 as of 2019, including washington d.c.) had lower uninsured rates than states that did not. inability to afford insurance was the primary reason cited by persons without coverage (46%). lack of health insurance is associated with increased mortality, in the range 30-90 thousand deaths per year, depending on the study. this figure is calculated based on 1 additional death per 300-800 persons without health insurance, on a base of 27 million uninsured persons. the u.s. centers for disease control and prevention (cdc) reports the number and percentage of uninsured during each year. the following table includes those under age 65 who were uninsured at the time of interview. year number uninsured (mil) uninsured percent 2010 48.2 18.2% 2013 (pre-aca) 44.3 16.6% 2016 28.2 10.4% 2017 28.9 10.7% 2018 30.1 11.1% 2019 32.8 12.1% 2020 31.2 11.5% 2021 29.6 11.0% 2022h 27.0 9.9% the 2010 figure represents the most recent peak, which was driven upward by the great recession. most of the major provisions of the aca took effect in 2014, so 2013 reflects the pre-aca level. after reaching a record low in 2016 at the end of the obama administration, the number and percent of uninsured has risen during the first two years of the trump administration. the new york times reported in january 2019 that the trump administration has taken a variety of steps to weaken the aca, adversely affecting coverage. the increases in the number of uninsured in the first 3 years of the trump administration (2017-2019) reversed in 2020-2021, as coronavirus relief measures expanded eligibility and reduced costs. estimates of the number of uninsured u.s. uninsured under age 65, number (left axis in millions) and % (right axis) from 2010-2022 first half (h1). blue shows democratic party president, red a republican party president. u.s. uninsured number (millions) and rate (%), including historical data through 2016 and two cbo forecasts (2016/obama policy and 2018/trump policy) through 2026. two key reasons for more uninsured under president trump include: 1) eliminating the individual mandate to have health insurance; and 2) stopping cost sharing reduction payments. several public and private sources report the number and percentage of the uninsured. the congressional budget office (cbo) reported the actual number of uninsured at 28.3 million in 2015, 27.5 million in 2016, 27.8 million in 2017, and 28.9 million in 2018. the cbo may 2019 ten-year forecast reflected the policies of the trump administration and estimated the number of uninsured would rise from 30 million in 2019, to 34 million by 2026, and to 35 million by 2029. in a previous march 2016 ten-year forecast reflecting the policies of the obama administration, cbo forecast 27 million uninsured in 2019 and 28 million in 2026. the primary reason for the 6.5 million (24%) increase in uninsured from 2016 to 2029 is the repeal of the aca individual mandate to have health insurance, enacted as part of the trump tax cuts, with people not obtaining comprehensive insurance in the absence of a mandate or due to higher insurance costs. gallup estimated in july 2014 that the uninsured rate for adults (persons 18 years of age and over) was 13.4% as of q2 2014, down from 18.0% in q3 2013 when the health insurance exchanges created under the patient protection and affordable care act (ppaca or "obamacare") first opened. the uninsured rate fell across nearly all demographic groups. the commonwealth fund reported that the uninsured rate among adults 19-64 declined from 20% in q3 2013 to 15% in q2 2014, meaning approximately 9.5 million more adults had health insurance. the united states census bureau annually reports statistics on the uninsured. the 2018 census bureau health insurance highlights summary report states that: "in 2018, 8.5 percent of people, or 27.5 million, did not have health insurance at any point during the year. the uninsured rate and number of uninsured increased from 2017 (7.9 percent or 25.6 million). the percentage of people with health insurance coverage for all or part of 2018 was 91.5 percent, lower than the rate in 2017 (92.1 percent). between 2017 and 2018, the percentage of people with public coverage decreased 0.4 percentage points, and the percentage of people with private coverage did not statistically change. in 2018, private health insurance coverage continued to be more prevalent than public coverage, covering 67.3 percent of the population and 34.4 percent of the population, respectively. of the subtypes of health insurance coverage, employer-based insurance remained the most common, covering 55.1 percent of the population for all or part of the calendar year. between 2017 and 2018, the percentage of people covered by medicaid decreased by 0.7 percentage points to 17.9 percent. the rate of medicare coverage increased by 0.4 percentage points. the percentage of people with employment-based coverage, direct-purchase coverage, tricare, and va or champva health care did not statistically change between 2017 and 2018. the percentage of uninsured children under the age of 19 increased by 0.6 percentage points between 2017 and 2018, to 5.5 percent. between 2017 and 2018, the percentage of people without health insurance coverage at the time of interview decreased in three states and increased in eight states." underinsured those who are insured may be underinsured such that they cannot afford adequate medical care. a 2003 estimated that 16 million u.s. adults were underinsured in 2003, disproportionately affecting those with lower incomes – 73% of the underinsured in the study population had annual incomes below 200% of the federal poverty level. in 2019 gallup found that 25% of u.s. adults said they or a family member had delayed treatment for a serious medical condition during the year because of cost, up from 12% in 2003 and 19% in 2015. for any condition, 33% reported delaying treatment, up from 24% in 2003 and 31% in 2015. coverage gaps also occur among the insured population. johns hopkins university professor vicente navarro stated in 2003, "the problem does not end here, with the uninsured. an even larger problem is the underinsured" and "the most credible estimate of the number of people in the united states who have died because of lack of medical care was provided by a study carried out by harvard medical school professors himmelstein and woolhandler. they concluded that almost 100,000 people died in the u.s. yearly because of lack of needed care." another study focusing on the effect of being uninsured found that individuals with private insurance were less likely to be diagnosed with late-stage cancer than either the uninsured or medicaid beneficiaries. a study examining