The risk of losing health insurance in the United States is large, and remained so after the Affordable Care Act

Health insurance coverage in the United States is highly uncertain. In the post-Affordable Care Act (ACA), pre-COVID United States, we estimate that while 12.5% of individuals under 65 are uninsured at a point in time, twice as many-one in four-are uninsured at some point over a 2-y period. Moreover, the risk of losing insurance remained virtually unchanged with the introduction of the landmark ACA. Risk of insurance loss is particularly high for those with health insurance through Medicaid or private exchanges; they have a 20% chance of losing coverage at some point over a 2-y period, compared to 8.5% for those with employer-provided coverage. Those who lose insurance can experience prolonged periods without coverage; about half are still uninsured 6 mo later, and almost one-quarter are uninsured for the subsequent 2 y. These facts suggest that research and policy attention should focus not only on the headline number of the share of the population uninsured at a point in time, but also on the stability and certainty (or lack thereof) of being insured.

Automated summary

Health insurance coverage in the United States is uncertain and unstable. Even with the Affordable Care Act (ACA), a significant number of people remain uninsured at some point over a 2-year period. The risk of losing insurance is higher for those with Medicaid or private exchange coverage compared to those with employer-provided coverage. It is important to focus on both the percentage of uninsured individuals at a specific time and the stability and certainty of insurance coverage.