Health Insurance Coverage in the United States
In the United States, health insurance coverage is provided by several public and private sources. Despite being among the world's top economic powers, the US remains the sole industrialized nation in the world without universal health care coverage. The United States healthcare system is ranked 29th compared to other nations, due to the lack of accessible care and resources. Prohibitively high cost is the primary reason Americans give for problems accessing health care.
Demographics and Coverage Distribution
During 2019, the U.S. population 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.
Trends in Uninsurance and Health Care Reform
At approximately 30 million in 2019, higher than the entire population of Australia, the number of people without health insurance coverage is one of the primary concerns raised by advocates of health care reform. Lack of health insurance is associated with increased mortality, estimated as 30–90 thousand excess deaths per year. Surveys indicate that 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, the historical data shows the following statistics regarding health insurance coverage:
| Year | Uninsured Persons (Millions) | Uninsured Rate (%) |
|---|---|---|
| 2012 | 45.6 | 14.8% |
| 2016 | 27.3 | 8.6% |
| 2019 | 29.6 | 9.2% |
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 2017 increase was the first increase in the number and rate of uninsured since 2010. The impact was greater among lower-income adults, who had a higher uninsured rate than higher-income adults.
Health Plan Options
Affordable Care Act (ACA)-Compliant Major Medical Coverage
Plans subject to the Affordable Care Act provide comprehensive major medical coverage. These plans are intended to serve as an individual’s primary medical coverage and are required to meet a variety of federal standards designed to help ensure both access to coverage and the quality of coverage. ACA plans must follow these guidelines:
- Essential Health Benefits: Must provide coverage for 10 categories of essential health benefits in the individual and small-group markets.
- Preventive Care: Must cover certain preventive care services without any cost to the individual (e.g., copayment or deductible).
- Benefit Limits: Cannot have any lifetime or annual dollar limits on essential health benefits.
- Pre-existing Conditions: Cannot exclude or limit coverage for pre-existing conditions.
- Premiums: Cannot charge individuals premiums that vary by health status (at enrollment or renewal).
- Guaranteed Issue: In the individual market, must be guaranteed issue, meaning that the insurer cannot deny coverage if the individual is enrolling during an open or special enrollment period.
Short-Term, Limited Duration Insurance (STLDI)
Short-term insurance plans are individual market products. As the name suggests, STLDI plans are designed for individuals who are transitioning from one type of primary medical coverage to another and have a temporary gap in coverage. Due to the short-term nature of these plans, they are not subject to ACA requirements. New federal regulations issued in August 2018, however, allow short-term plans to continue for a total coverage period (including any renewals) of 36 months.