“The latest uninsured figures show that expanding subsidies and public programs is not enough,” writes health policy expert Sally Pipes. “If policymakers want more Americans to obtain coverage, they need to make insurance better and cheaper—not merely more heavily subsidized.”
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The number of uninsured Americans ticked upward to 26.7 million in 2024, according to an analysis published this month by KFF.
The report’s authors attribute that trend to the “high cost of private insurance and limited availability of public coverage.”
Unpack the numbers, though, and the situation becomes more complicated. The number of uninsured is simply not a useful heuristic for evaluating the U.S. healthcare system.
First, consider just how big the United States is. The number of people without insurance is a tiny fraction of the overall population—about 7.8%.
“Just over half (52.9% or 14.1 million) of uninsured individuals in 2024 were estimated to be eligible for financial assistance either through Medicaid or through subsidized [Obamacare] Marketplace coverage,” the analysis notes.
That fact alone complicates the narrative that coverage is out of reach for most of the uninsured. Most of them could obtain heavily subsidized or fully subsidized coverage under programs that already exist. If they did, the share of Americans without insurance would fall to less than 4%.
The remaining 12.6 million uninsured are largely people who live in states that did not expand Medicaid, are ineligible for federal assistance because of their immigration status or have access to an exchange or employer plan that the law considers affordable.
Some would buy insurance if they felt they could afford it. But other research shows that many Americans are uninsured by choice.
A report from the Centers for Disease Control and Prevention published earlier this year found that one-third of uninsured adults in 2024 did not cite cost as a reason for lacking coverage. Within that group, 44.1% said they did not need or want insurance. Another 21.3% said the enrollment process was too difficult or confusing. Others said they could not find a plan that met their needs.
Those responses suggest that many Americans are uninsured because they do not view the available coverage as worth the cost or hassle.
Obamacare’s insurance market regulations are a major reason why. The law requires insurers to cover a federally prescribed set of “essential” health benefits, regardless of whether patients want or need them. It also bars insurers from charging people based on their expected health costs and caps premiums for older enrollees at three times those for younger ones.
By restricting insurers’ ability to price coverage according to risk, Obamacare pushed insurers to control costs in other ways—including higher premiums and deductibles and narrow provider networks.
The federal government has also limited the availability of more affordable short-term health plans, which need not follow Obamacare’s cost-inflating regulations. The maximum term for a short-term plan is just three months, with an insurer option for a one-month renewal. Some states have banned these plans altogether.
Medicaid, meanwhile, is hardly the gold standard of access. The program often pays doctors far less than private insurance does, which can make it difficult for beneficiaries to find physicians willing to see them.
That is the hidden lesson of the KFF report. America’s healthcare challenge is not that too few people have insurance. It is that the coverage available to many people is too expensive, too restrictive or too unattractive to justify signing up—even when taxpayers pick up much of the bill.
Policymakers should instead focus on improving access to affordable coverage that is worth having. Rolling back Obamacare’s most burdensome mandates would allow insurers to offer more affordable and tailored coverage options. Expanding access to short-term health plans would provide lower-cost alternatives for Americans who do not want or need comprehensive exchange coverage.
For more than a decade, Washington has measured success by how many people it can enroll in government-approved coverage. But insurance cards are not the same thing as affordable, attractive coverage.
The latest uninsured figures show that expanding subsidies and public programs is not enough. If policymakers want more Americans to obtain coverage, they need to make insurance better and cheaper—not merely more heavily subsidized.