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Research: Rates of Uninsured Americans by City

By Ana Gonzalez-Ribeiro, MBA, AFC®
Published on: 03/25/2020

Efforts to contain the spread of COVID-19 depend on the nation’s ability to provide testing and treatment for all Americans, even the 28.5 million who lack health insurance.

As the number of coronavirus cases rise, issues surrounding access to healthcare and insurance have reached new levels of importance. Unfortunately, after sharp declines in the number of Americans without health insurance following the passage of the Affordable Care Act (ACA) in 2010, the uninsured rate rose for the first time in 2018.

Between 2010 and 2017, the uninsured rate decreased from 15.5 to 8.7 percent. However, new figures from the U.S. Census Bureau place the national uninsured rate at 8.9 percent for 2018—an increase likely due to a variety of factors, including rising premiums, fewer insurers in the ACA exchange, a shortened ACA enrollment period, and the elimination of the ACA’s individual mandate penalty.

uninsured Chart1 Uninsured rates over time

uninsured Chart1 Uninsured rates over time

While the national overall uninsured rate stands at 8.9 percent, the uninsured rate in different locations and among different demographic groups varies considerably, making certain populations more vulnerable in times of crisis. Americans aged 26 to 34 are the largest uninsured age group, 15.8 percent of whom do not carry a health insurance plan. Thanks to Medicare, people over age 65 have the lowest uninsured rate. Looking at U.S. Census Bureau designations for race and ethnicity, American Indian, Alaskan Natives, Hispanics, and Latinos have the highest uninsured rates, while white and Asian Americans have the lowest uninsured rates.

Among educational attainment levels, individuals with less than a high school degree are the most likely to be without health insurance—21.4 percent are uninsured. Many Americans receive health insurance benefits through their employer, but lower paid, hourly workers are less likely to receive such benefits. Not surprisingly, households in higher income brackets have lower uninsured rates. The uninsured rate for people in households earning less than $49,999 per year is 13.2 percent, more than one and a half times higher than the national rate of 8.9 percent.

uninsured Chart2 Uninsured rates by demographic

uninsured Chart2 Uninsured rates by demographic

At the state level, Texas has the highest uninsured rate in the country at 17.7 percent, about twice as high as the national rate. Other states in the South and Southeast, including Oklahoma, Florida, and Georgia, also have high rates of uninsured residents. At the other end of the spectrum, Massachusetts has the lowest uninsured rate in the country, with just 2.8 percent of its residents lacking health insurance.

uninsured Chart3 Uninsured rates by state

uninsured Chart3 Uninsured rates by state

To determine the cities with the highest and lowest uninsured rates, researchers at Self Financial analyzed the latest data from the U.S. Census Bureau's 2018 American Community Survey (ACS) and the Center for Disease Control’s 500 Cities Project. The researchers ranked cities according to the share of residents without health insurance. Researchers also looked at the uninsured rate for individuals below the poverty line, the number of uninsured people, the number of uninsured children, and the percentage of adults reporting good physical health.

To improve relevance, only cities with at least 100,000 people were included in the analysis. Additionally, cities were grouped into the following cohorts based on population size:

Small cities: 100,000-150,000
Midsize cities: 150,000-350,000
Large cities: more than 350,000

Here are the cities with the highest and lowest uninsured rates.

uninsured Chart4 Uninsured rates for small and midsize cities