9.3.4: Uninsured and Underinsured

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Page ID: 237555

Fabiane Morales
Coastline College

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Until 2010, roughly 22.5% of Americans were either uninsured (15%) or underinsured (7.5%). For these individuals, the lack of adequate protection meant that a significant medical emergency was often a direct path to bankruptcy. Under the Affordable Care Act of 2010, the number of people without insurance dropped to about 10%. The reform addressed the underinsured crisis by mandating that plans cover a standardized set of 'Essential Health Benefits', ensuring that insurance provides meaningful financial protection (Rielgelman & Kirkwood, 2025 p242).

The majority of the uninsured population consists of low-income working families. Because public coverage (like Medicaid) is often more restrictive for adults than for children, those aged 19–64 face higher rates of being uninsured. Furthermore, while the Affordable Care Act has expanded coverage broadly, significant racial and ethnic disparities in insurance access continue to characterize the U.S. healthcare landscape. High costs remain the number one reason Americans go without health insurance, affecting 63% of the uninsured population. This is driven by a lack of employer-sponsored options and the 'Medicaid gap' in non-expansion states. Despite the availability of subsidies, a combination of outreach failures, enrollment barriers, and the high cost of 'affordable' premiums prevents millions from utilizing the coverage they are legally entitled (Tolbert et al, 2024).

It is important to note that according to data, this trend of uninsured is set to shift to an upward trend for 2026 due to two main factors:

Subsidy expiration. The Affordable Care Act Subsidy has expired on December 31, 2025. Without the subsidy, premiums are increasing by an average of 114%, and experts estimate this will cause about 4 million people to drop coverage because they will no longer be able to afford it (Paulus, 2025).
Removal of automatic renewal. Medicaid is stopping automatic renewal of coverage and, with it, removing those deemed ineligible under the current status requirement, resulting in coverage being declined for 25 million people. The states hit hardest are those without Medicaid expansion (Hest, 2025).
The underinsured are those who have insurance but whose out-of-pocket costs are too high relative to their income. This makes it impossible for them to afford care. The trend of inadequate insurance, according to experts, is also expected to shift upward for 2026 due to the following reasons:
Premium increases. Marketplace premiums are rising by an average of 20-26%, while employer-sponsored insurance (the source for 164 million Americans) is rising by 6-9%, nearly triple the inflation rate (Heimall, 2025).
High deductible. Deductibles for health plans have increased dramatically; for example, an individual plan is expected to rise from $7,476 to $10,600. This may mean that many people will need to pay for coverage out of pocket (Long, Lo, Wallace, & Pestaina, 2026).

As this book is being written, we are at the beginning of 2026, and it seems we, as a nation and in public health, will face some challenges ahead.

Reference

Heimall, M. (2025). How federal spending cuts will increase health care costs in 2026. Health Well Foundation www.healthwellfoundation.org

Hest, R. (2025). 15 years of the Affordable Care Act: more Americans than evern have health insurance coverage. SHADAC www.shadac.org

Long, M., Lo, J., Wallace, R., & Pestaina, K. (2026). Policy changes brind renewed focus on high-deductable health plans. Kaiser Family Foundation www.kff.org

Paulus, N. (2025). Uninsured Americans in 2026: 27 million without coverage as ADA subsidies face expiration. MoneyGeek www.moneygeek.com

Riegelman, R. & Kirkwood, B. (2025). Public health 101: Improving community health (4th ed). Jones & Bartlett Learning, LLC.

Tolbert, J. Cervantes, S. & Bell, C. (2024). Key facts about the uninsured population. Kaiser Family Foundation www.kff.org

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