How Many Uninsured Are in the Coverage Gap and How Many Could be Eligible if All States Adopted the Medicaid Expansion? (2023)

The end of the Medicaid continuous enrollment provision in March 2023 and the resumption of Medicaid disenrollments after a three-year pause during the pandemic are likely to refocus attention on gaps in Medicaid coverage in the ten states that have not adopted the Affordable Care Act’s (ACA) Medicaid expansion as of March 2023. During the pandemic, Medicaid enrollment increased and the uninsured rate dropped largely due to continuous enrollment. Once Medicaid disenrollments resume, the number of people who are uninsured is expected to increase and could rise more steeply in non-expansion states. In expansion states, because all adults with incomes up to 138% of the federal poverty level (FPL) are eligible for Medicaid, many current enrollees will remain eligible even if their incomes have risen. However, in non-expansion states, with eligibility thresholds often quite low and largely limited to parents, many of those with incomes below poverty who are no longer eligible for Medicaid will not have access to an affordable coverage option and will likely become uninsured.

Notably, two states have taken recent action to adopt the Medicaid expansion. In November 2022, voters in South Dakota approved Medicaid expansion through a ballot measure and in March 2023, legislation adopting the Medicaid expansion in North Carolina was signed into law, although expansion is contingent on passage of a state budget later in the year. If expansion proceeds as expected in North Carolina, it will become the 41st expansion state (including the District of Columbia), leaving ten states that have not adopted the expansion. This brief presents estimates of the number and characteristics of uninsured people in the ten non-expansion states who could be reached by Medicaid if their states adopted the Medicaid expansion using data from 2021, the most recent year available. It should be noted that this analysis focuses on the number of uninsured people who would be newly eligible if non-expansion states adopted the expansion; the total number of people who would become eligible for Medicaid is larger because it includes people with incomes 100%-138% FPL who are currently enrolled in Marketplace coverage as well as some who may have other coverage. An overview of the methodology underlying the analysis can be found in theData and Methods, and more detail is available in theTechnical Appendices.

What is the coverage gap?

The coverage gap exists in states that have not adopted the ACA Medicaid expansion for adults who are not eligible for Medicaid coverage or subsidies in the Marketplace. The ACA expanded Medicaid to nonelderly adults with income up to 138% FPL ($14,580 annually for an individualin 2023) with enhanced federal matching funds (now at 90%). This expanded eligibility for low-income parents and newly established Medicaid coverage for adults without dependent children; however, the expansion is effectively optional for states as a result of a 2012 Supreme Court ruling. As of March 2023, 41 states including DC have expanded Medicaid (Figure 1). As noted above, North Carolina has adopted the Medicaid expansion contingent on passage of a state budget later this spring.

In the remainingten states that have not adopted the Medicaid expansion an estimated 1.9 million individualsfall into the coverage gap. Adults who fall into the coverage gap have incomes above their state’s eligibility for Medicaid but below poverty, making them ineligible for subsidies in the ACA Marketplaces (Figure 2). When enacted, the ACA did not anticipate that states would be permitted to forgo Medicaid expansion; as such, subsidies in the Marketplaces are not available for people with incomes below poverty.

Figure 2: Gap in Coverage for Adults in States that Do Not Expand Medicaid Under the ACA

Medicaid eligibilityfor adults in states that have not expanded their programs is very low. In these states, the median income limit for parents is just 38% FPL, or an annual income of $9,447 for a family of three in 2023, and in nearly all states not expanding (except Wisconsin through a waiver), childless adults remain ineligible regardless of their income(Figure 3). In Texas, the state with the lowest eligibility threshold, parents in a family of three with incomes above $3,977 annually, or just $331 per month, are not eligible for Medicaid. Because there is no pathway for coverage for childless adults, except in Wisconsin, more than three-quarters (76%) of people in the coverage gap fall into this group.

States that have not implemented the expansion have uninsured rates that are nearly double the rate of expansion states (15.4% compared to 8.1%). People without insurance coverage have worse access to care than people who are insured. One in five uninsured adults in 2021 went without needed medical care due to cost and uninsured people are less likely than those with insurance to receive preventive care and services for major health conditions and chronic diseases.

What are the characteristics of people in the coverage gap?

Adults left in the coverage gap are concentrated in three states in the South. Four in ten people in the coverage gap reside in Texas, which has very limited Medicaid eligibility, and consequently, a large uninsured population (Figure 4). One in five people in the coverage gap live in Florida, and 13% in Georgia. In total, 97% of those in the coverage gap live in the South. Seven of the 16 states in the South have not adopted the Medicaid expansion, and the region has more poor, uninsured adults and higher uninsured rates compared to other regions.

People in the coverage gap are disproportionately people of color.Nationally, over six in ten (61%) people in the coverage gap are people of color, a share that is higher than for non-elderly adults generally in non-expansion states (47%) and for non-elderly adults nationwide (40%) (Figure 5). These differences in part explain persistingdisparities in health insurance coverage by race/ethnicity.

Despite having low income, nearly six in ten people in the coverage gap are in a family with a worker, and nearly half are working themselves (Figure 6).Adults who work may still have incomes below poverty because they work low-wage jobs.People with incomes below poverty often do not have access to employer based health insurance or if available, it is often unaffordable. The most common jobs among adults in the coverage gap are cashier, cook, waiter/waitress, construction laborer, maid/housecleaner, retail salesperson, and janitor. For parents in non-expansion states, even part-time work may make them ineligible for Medicaid.

Some people in the coverage gap have significant current health care needs.KFF analysis of the 2021 American Community Survey shows that more than one in six (15%) people in the coverage gap have a functional disability, meaning they have serious difficulty with hearing, vision, cognitive functioning, mobility, self-care, or independent living. Even with functional disabilities, many are not able to qualify for Medicaid through a disability pathway leaving them uninsured. Older adults, age 55-64, an age of increasing health needs, make up 17% of people in the coverage gap.Researchhas demonstrated that uninsured people in this age range may leave health needsuntreateduntil they become eligible for Medicare at age 65.

How many uninsured could gain coverage if all states adopted the expansion?

If all states adopted the Medicaid expansion, approximately 3.5 million uninsured adults would become newly eligible for Medicaid. This number includes the 1.9 million adults in the coverage gap and an additional 1.6 million uninsured adults with incomes between 100% and 138% FPL, most of whom are currently eligible for Marketplace coverage but not enrolled (Figure 7 and Table 1). Most of the adults who are currently eligible for coverage in the Marketplace qualify for plans with zero premiums; however, even with no premiums, Medicaid could provide more comprehensive benefits and lower cost-sharing compared to Marketplace coverage. The potential number of people who could be reached by Medicaid expansion varies by state.

While not counted in the numbers above, there are an estimated 173,000 people in the coverage gap and 154,000 uninsured adults with incomes 100%-138% FPL who will become eligible for Medicaid if Medicaid expansion proceeds in North Carolina with the passage of a budget (Table 2). There are an additional 281,000 people in North Carolina who are currently insured in the ACA marketplace with incomes 100%-138% of FPL who will become newly eligible for Medicaid with expansion.

What is the outlook ahead?

Almost ten years after implementation of the Medicaid expansion in January 2014, a substantial body of research points to largely positive effects. KFF reports published in2020and2021reviewed more than 600 studies and concluded that expansion is linked to gains in coverage, improvement in access and health, and economic benefits for states and providers. More recent studies generally find positive effects related to more specific outcomes such as improved access to care, treatment and outcomes for cancer, chronic conditions, sexual and reproductive health and behavioral health. Studies also point to evidence of reduced racial disparities in coverage and access, reduced mortality and improvements in economic impacts for providers (particularly rural hospitals) and economic stability for individuals.

While attempts to pass federal legislation to address the coverage gap nationally failed, states that newly implement Medicaid expansion will receive atemporary fiscal incentiveunder theAmerican Rescue Plan Act(ARPA). Under ARPA, states that newly adopt expansion are eligible for an additional 5 percentage point increase in the state’s traditional match rate (FMAP) for two years. This incentive does not apply to the expansion population; states are required to cover 10% of the cost of Medicaid expansion, with the federal government covering 90%.The traditional FMAP applies to most spending for all non-expansion groups (children, parents and people eligible based on age 65 plus or disability); Medicaid spending for non-expansion groups is much larger than spending for the expansion group. KFF analysisshows that all non-expansion states could see a net fiscal benefit over a two-year period if they adopted the expansion. For the two states that recently adopted the expansion, South Dakota and North Carolina, the estimated fiscal benefit is $60 million and $1.2 billion, respectively.

Seven of the last eight states to adopt expansion did so through a ballot measure; however, that is not an option in most other non-expansion states. Every state, except North Carolina, that hasadoptedexpansion since 2019 has done so not through legislative or executiveprocesses, but as a result of a successful ballot initiative. Most recently,in South Dakotavoters approved a ballot question in November 2022. Although expansion ballot initiatives have been successful in all seven states where they have gone to voters (Idaho, Maine, Missouri, Nebraska, Oklahoma, and Utah), most of the remainingnon-expansion statesdo not haveballot initiative processes.North Carolina is the first state to adopt expansion through a legislative process since Virginia adopted in 2019.

Expansion could help stem increases in the number of people who are uninsured as the Medicaid continuous enrollment provision ends and states resume disenrollments after a three year pause during the pandemic. All states have experienced significant Medicaid enrollment growth as a result of legislation enacted early in the pandemic that prohibited states from disenrolling people from Medicaid in exchange for enhanced federal matching funds. The increase in Medicaid coverage has been a key factor contributing to the decline in the uninsured rate. When the continuous enrollment provision expires on March 31, 2023 and states resume regular Medicaid disenrollments, millions are expected to lose Medicaid if they are no longer eligible or if they face barriers completing their renewals. While most people who are determined to no longer be eligible in expansion states will qualify for other coverage, either through the Marketplace or through an employer, in non-expansion states, poor parents who are no longer eligible for Medicaid will likely fall into the coverage gap and become uninsured.



How Many Uninsured Are in the Coverage Gap and How Many Could be Eligible if All States Adopted the Medicaid Expansion? ›

How many uninsured could gain coverage if all states adopted the expansion? If all states adopted the Medicaid expansion, approximately 3.5 million uninsured adults would become newly eligible for Medicaid.

How many people are in the coverage gap? ›

Over 2.1 million uninsured adults with low incomes are in the Medicaid coverage gap – too poor to qualify for Affordable Care Act (ACA) marketplace assistance because they have incomes below the poverty line, yet ineligible for Medicaid because their state hasn't enacted ACA Medicaid expansion.

How many people in the US are not covered by insurance? ›

Roughly 30 million Americans of all ages had no health insurance in 2021. That's roughly 9.2% of the population.

How many Americans are uninsured in 2023? ›

The Congressional Budget Office estimates that in 2023, 248 million people in the US who are younger than age sixty-five have health insurance coverage (mostly through employment-based plans), and twenty-three million people, or 8.3 percent of that age group, are uninsured—with significant variations in coverage by ...

What is coverage gap in health insurance? ›

This means there's a temporary limit on what the drug plan will cover for drugs. Not everyone will enter the coverage gap. The coverage gap begins after you and your drug plan have spent a certain amount for covered drugs. Once you and your plan have spent $4,660 on covered drugs in 2023, you're in the coverage gap.

What states did not expand Medicaid? ›

Wyoming, Kansas, Texas, Wisconsin, Tennessee, Mississippi, Alabama, Georgia, South Carolina and Florida have yet to adopt the expansion of Medicaid, leaving over 2.1 million people in the “coverage gap” — meaning they fall into the income level that would make them eligible for Medicaid but cannot access it because ...

How big is the Medicare gap? ›

The Medicare Part D donut hole or coverage gap is the phase of Part D coverage after your initial coverage period. You enter the donut hole when your total drug costs—including what you and your plan have paid for your drugs—reaches a certain limit. In 2023, that limit is $4,660.

How many people are uninsured in the US CDC? ›

8.4% or 27.6 million Americans of all ages did not have health insurance in 2022 compared to 10.3% or 33.2 million in 2019. In the same time period, 4.2% or 3 million children did not have health insurance compared with 5.1% or 3.7 million in 2019.

How many Americans are covered by Medicaid? ›

93,876,834 individuals were enrolled in Medicaid and CHIP in the 50 states and the District of Columbia that reported enrollment data for March 2023. 86,714,574 individuals were enrolled in Medicaid.

Which state has the highest number of uninsured people in the US? ›

Texas was the state with the highest percentage of uninsured among its population, while Massachusetts reported the lowest share of uninsured This statistic presents the percentage of the total population in the United States without health insurance in 2021, by state.

How many immigrants are uninsured in the US? ›

Uninsured Rates by Immigration Status

As of 2021, more than three-quarters (77%) of the 27.5 million nonelderly uninsured were U.S.-born and naturalized citizens, while the remaining 23% were noncitizens (Figure 2).

What percentage of US citizens have health insurance? ›

The number of people with health insurance in the U.S. was over 300 million in 2021, about 92 percent of the population. The health system in the country is a mix of both public and private insurers, but private is the main form of health insurance coverage among the U.S. population.

What happens if you can't afford healthcare in America? ›

By federal law, nonprofit hospitals must offer financial assistance to those who cannot pay their bills. Some states also have other laws about uncompensated care, such as Washington, where all hospitals must tell patients about financial assistance programs when they receive care.

How do you avoid coverage gap? ›

Here are some ideas:
  1. Buy Generic Prescriptions. ...
  2. Order your Medications by Mail and in Advance. ...
  3. Ask for Drug Manufacturer's Discounts. ...
  4. Consider Extra Help or State Assistance Programs. ...
  5. Shop Around for a New Prescription Drug Plan.
Sep 10, 2022

How is gap insurance calculated? ›

How to calculate gap insurance. The amount of gap insurance you'll want on your financed or leased car is your remaining auto loan balance minus your car's current actual cash value. The actual cash value, or "ACV," of your car is what it is worth minus depreciation.

Is Gap considered full coverage? ›

No, gap insurance is not the same as full coverage, but it can be part of full coverage. Full coverage is commonly defined as the combination of a state's minimum required insurance, comprehensive insurance, and collision insurance, though gap coverage is included if required by a lender or lessor.

What would happen if all states expanded Medicaid? ›

How many uninsured could gain coverage if all states adopted the expansion? If all states adopted the Medicaid expansion, approximately 3.5 million uninsured adults would become newly eligible for Medicaid.

What state has the highest Medicaid enrollment? ›


Which state has the most generous Medicaid? ›

Top 10 States for Medicaid Spending
  • California: $82 billion.
  • New York: $62.9 billion.
  • Texas: $40.3 billion.
  • Pennsylvania: $27.6 billion.
  • Florida: $21.8 billion.
  • Ohio: $21.7 billion.
  • Illinois: $19.3 billion.
  • Massachusetts: $17.1 billion.

What changes are coming to Medicare in 2023? ›

Everyone pays a Part B monthly premium, even people with Medicare Advantage plans. In 2023, the Part B standard premium is $164.90 per month, down from $170.10 per month in 2022. If you have a higher income, you may pay more. The Part B deductible dropped to $226 in 2023, down from $233 in 2022.

What is the greatest permissible gap for Medicare? ›

Greatest Permissible Gap (GPG)

The GPG is defined in Section 10(3) of the national Health Insurance Act 1973 and requires that the difference between the MBS fee for an item and the 85% Medicare benefit must not be greater than a specified amount.

What changes are coming to Medicare in 2024? ›

How Is the Medicare Part D Benefit Changing in 2024? In 2024, costs in the catastrophic phase will change: the 5% coinsurance requirement for Part D enrollees will be eliminated and Part D plans will pay 20% of total drug costs in this phase instead of 15%.

Who has the highest percentage of uninsured? ›

About Uninsured
  • US Value: 8.6%
  • Top State(s): Massachusetts: 2.5%
  • Bottom State(s): Texas: 18.0%
  • Definition: Percentage of population not covered by private or public health insurance.
  • Data Source and Years: U.S. Census Bureau, American Community Survey, 2021.

Which group has the highest rates of uninsured population? ›

Despite these coverage gains, disparities in coverage persisted as of 2021. Nonelderly American Indian and Alaska Native (AIAN) and Hispanic people had the highest uninsured rates at 21.2% and 19.0%, respectively as of 2021.

What percentage of Americans age 25 to 34 have no health insurance? ›

In 2019, 15.6 percent of young adults aged 19 to 34 were uninsured, higher than the uninsured rate for children under the age of 19 (5.7 percent), other working-age adults 35 to 64 years (11.3 percent), and adults 65 and older (0.8 percent) (Figure 1).

What percent of Americans are eligible for Medicaid? ›

The percentage of Americans covered by the Medicaid public health insurance plan increased from 17.8 percent in 2020 to around 18.9 percent in 2021. However the percentage of those insured through Medicaid remains lower than the peak of 19.6 percent in 2015.

How many US consumers are eligible for both Medicare and Medicaid? ›

The 12.5 million people who are jointly enrolled in Medicare and Medicaid, Medicare-Medicaid enrollees (also referred to as dually-eligible beneficiaries or dual eligibles), receive their primary health insurance coverage through Medicare and some assistance from their state Medicaid program.

How many US citizens are on Medicaid and Medicare? ›

In 2020, 12.5 Million People Were Enrolled in Both Medicare and Medicaid. Medicare-Medicaid enrollees comprised 20% of the total Medicare population (including beneficiaries in both traditional Medicare and Medicare Advantage) and 14% of the total Medicaid population, but the shares varied widely across states.

Who is the least likely to be uninsured in the United States? ›

In general, people of color are at higher risk of being uninsured than White people. The uninsured rates for Hispanic people (19.0%) and American Indians and Alaska Natives (21.2%) are more than 2.5 times the uninsured rates for White people (7.2%) (Figure 5).

What race is more likely to be uninsured? ›

The U.S. uninsured rate in 2021 across race and Hispanic origin groups ranged from 5.7% for White, non-Hispanic people to 18.8% for those identifying as American Indian and Alaska Native, non-Hispanic. Hispanic or Latino people had among the highest uninsured rate in the nation at 17.7%.

What is the least insured state? ›

In 2021, Utah had the lowest rate of public coverage (22.3%) and New Mexico's public coverage rate (50.9%) was the highest across states and the District of Columbia (Figure 3).

Do immigrants get Social Security if they never paid into it? ›

Noncitizens who live and work in the U.S. legally do pay into Social Security and qualify for benefits under the same terms as citizens. Undocumented people who work may contribute to Social Security via payroll taxes, but they cannot claim benefits.

Which age group in America is most likely to be uninsured? ›

Young Adults (Ages 18 Through 24 Years)

Almost three out of every ten young adults do not have health insurance. Members of this age group are nearly twice as likely to be uninsured compared to members of the general population under age 65.

What percent of immigrants to the U.S. are poor? ›

Immigrant households in 2021 had a median income of $69,622, compared to $69,734 for native-born households. Fourteen percent of immigrants were poor (that is, with family incomes below the official poverty threshold of $27,500 for a family of four with two children in 2021), compared to 13 percent of the U.S. born.

How much of the population is white in the US? ›

As of July 1, 2022, United States Census Bureau estimates that 75.8% of the US population were white alone, while Non-Hispanic whites were 59.3% of the population.

What percentage of population is covered by life insurance in USA? ›

The percentage of Americans with life insurance is about 52%, including individual and workplace life insurance, according to LIMRA.

Is everyone in the US covered by health insurance? ›

The goal of health care reform is to make health insurance affordable and available to all Americans. And the law requires nearly all Americans to have health coverage. Most coverage satisfies this requirement, including: Insurance you get from an employer.

Do poor people get free healthcare USA? ›

Medicaid and the Children's Health Insurance Program (CHIP) provide free or low-cost health coverage to some low-income people, families and children, pregnant women, the elderly, and people with disabilities.

Can you live without health insurance in the US? ›

If you don't have health insurance, you could end up paying a penalty for no health insurance. Therefore, you should make an effort to find health insurance that works for your needs. Check to see if your state still has a state-level individual mandate that could affect you if you're uninsured.

Is healthcare free for poor people in the US? ›

There is no universal healthcare.

The U.S. government does not provide health benefits to citizens or visitors. Any time you get medical care, someone has to pay for it.

When did the coverage gap close? ›

Beginning in 2011, the Affordable Care Act (ACA) took measures to close the donut hole, known as the Coverage Gap. Then, in 2012, the ACA implemented discounts for the Coverage Gap.

What is the impact of the coverage gap? ›

People in the coverage gap are ineligible for Medicaid because their states haven't adopted the expansion and they have incomes too low to qualify for ACA marketplace subsidies.

Is the donut hole going away? ›

When did the donut hole close? The donut hole finally closed for good in 2020, having been phased out in 2019 for brand-name drugs and then in 2020 for generic drugs. The Affordable Care Act enacted in March 2010 gradually reduced the share of costs people had to pay in the donut hole starting in 2011.

Does the donut hole reset each year? ›

You will remain in the Catastrophic Coverage Stage until January 1. This process resets every January 1.

What is Stage 3 coverage gap? ›

Stage 3 – Coverage Gap

In Stage 3, you generally pay no more than 25% of the cost of generic and brand name drugs. You stay in Stage 3 until the amount of your year-to-date “out-of-pocket drug costs” (costs paid by you or a subsidy program) reaches $7,400.

How to avoid the Medicare gap? ›

Five Ways to Avoid the Medicare Part D Coverage Gap (“Donut Hole”...
  1. Buy Generic Prescriptions. ...
  2. Order your Medications by Mail and in Advance. ...
  3. Ask for Drug Manufacturer's Discounts. ...
  4. Consider Extra Help or State Assistance Programs. ...
  5. Shop Around for a New Prescription Drug Plan.
Sep 10, 2022

What is Medicare coverage gap discount program? ›

The Medicare Coverage Gap Discount Program (Discount Program) makes manufacturer discounts available to eligible Medicare beneficiaries receiving applicable, covered Part D drugs, while in the coverage gap.

How many lives did Medicaid save? ›

Medicaid Expansion Has Saved at Least 19,000 Lives, New Research Finds. The Affordable Care Act's (ACA) expansion of Medicaid to low-income adults is preventing thousands of premature deaths each year, a landmark study finds.

How do you fix coverage gap? ›

Most of the funds for closing the coverage gap go to payments for health care services, allowing more rural hospitals, safety net hospitals, and community health centers — many of which disproportionately serve people with low incomes and people of color — to stay open and even to provide more services in their ...

Why was the coverage gap created? ›

The decision not to implement Medicaid expansion in some states after the ACA took effect in 2014 led to a "gap" in coverage for residents of those states with incomes too low for subsidized insurance in the ACA's newly established health insurance marketplaces and incomes too high to qualify for the non-expanded ...

What are the changes to Part D in 2023? ›

What Other Changes Are Being Made to Part D? As of 2023, the out-of-pocket cost of insulin products is limited to no more than $35 per month in all Part D plans. In addition, adult vaccines covered under Part D, such as the shingles vaccine, are covered with no cost sharing.

What will the Medicare donut hole be in 2024? ›

In 2024, after paying the initial deductible, a person on Medicare will pay 25 percent of drug costs. They will have a cap of about $3,250 and will no longer pay five percent of drug costs in the catastrophic phase. In 2025, after paying the initial deductible, a person on Medicare will pay 25 percent of drug costs.

What is the out-of-pocket limit for Medicare Part D in 2023? ›

Medicare Part D plans don't have hard out-of-pocket maximums. However, in all Part D plans, you enter what's called the catastrophic coverage phase after you hit $7,400 in out-of-pocket costs for covered drugs.

How much do you have to spend to get out of the donut hole? ›

The pharmaceutical company then discounts the medication by $70, and the insurance company pays the remaining $5. The person continues paying 25% out of their own money until they have spent $6,350. When this occurs, they are out of the donut hole. A person is now in the catastrophic coverage portion of their coverage.

What do you pay after the donut hole? ›

Once in the gap, you'll pay no more than 25% of the cost for brand-name and generic prescription drugs covered by your Part D plan, although the full cost of those drugs will be used to move you closer to the Catastrophic Coverage stage.

How do seniors pay for eliquis? ›

Patients who have prescription insurance through Medicare pay, on average, $44 per month. And 5 out of 10 ELIQUIS patients pay $30 or less. Low-Income Subsidy patients may pay $0 to $10.35 per month through the Social Security Administration's Extra Help4 program. Use this link to learn about Extra Help.


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