How do Americans get their health insurance in the years since the Affordable Care Act passed?

The Affordable Care Act (ACA), which was signed into law in 2010, continues to affect how many people have health insurance.

In 2020, 297.6 million Americans, 91.4% of the population, were covered by some form of health insurance, according to the Census Bureau’s Current Population Survey. That’s compared with 83.7% in 2013, the year before ACA went into effect.

To be considered covered by health insurance, an individual must have a qualifying plan for some portion of the year^[1]. This “minimum essential coverage” must be comprehensive, and cover things such as vaccinations and annual doctor visits^[2]. Some programs such as the Indian Health Service, dental and vision plans, and religious healthcare sharing ministries don’t qualify and would need to be supplemented with some other plans for someone to be considered insured.

How did the Affordable Care Act affect insurance rates?

From 2014 until 2018, the ACA implemented an “individual mandate,” which required every American to have health insurance or pay a tax penalty. The Tax Cuts and Jobs Act removed the tax for the uninsured starting in 2019.

With the tax in place, the national uninsured rate reached an all-time low of 7.9% in 2017.

After the removal of the penalty, private insurance rates dropped by 1.5% the following year. The overall uninsured rate hit 8.6% as of 2020.

Following the implementation of the ACA and its expansion of Medicaid, the rate of public insurance increased from 32.6% in 2012 to a peak of 37.3% in 2016. In 2020, 34.8% of Americans had public coverage.

What are the types of public health insurance?

Public health insurance is provided, sometimes for free, by the government to qualifying individuals. In 2020, 18.4% of Americans had Medicare, which is a federally sponsored program for people over the age of 65 and those of all ages with certain disabilities^[3].

Medicare has four parts. Part A covers inpatient care in hospitals and home health care. Part B covers services from doctors and outpatient care. Part C plans are Medicare-approved private insurance plans that serve as an alternative to traditional Medicare. These plans can include all of Part A, B, and parts of Part D. Some of these plans also include additional benefits not included in Medicare. And Part D helps with costs associated with prescription drugs. Most people who have Medicare do not pay a premium but are required to pay a deductible.

Medicare membership rates have increased over the last decade as the elderly continue to occupy a larger share of the population.

Medicaid is a joint federal-state program for low-income people. About 18.1% of Americans received their insurance through the program. Federal law requires^[4] states to cover groups such as low-income families, some pregnant women and children, and those receiving supplemental income through governmental programs.

As part of the ACA, states have the option to cover adults with incomes up to 133% of the federal poverty level. This level can vary by household size; it was $18,074 for a single adult but $36,907 for a family of four in 2022.

As of July 2022, 38 states and Washington, DC had expanded Medicaid. Twelve states did not.

The Department of Veterans Affairs (VA) is tasked with providing healthcare to qualifying veterans. To enroll in and receive priority VA care that remains in effect after five years, an individual must have participated in combat operations and enroll within five years of returning from combat^[5]. Those covered by VA healthcare can receive treatment at any of the 171 medical centers operated by the department and sometimes through non-VA medical centers^[6]. Veterans pay no premiums but, depending on their income and disability status, may be charged a copayment for medical services.

The VA helps with the cost of some health services for families of veterans through the department’s civilian medical program. In 2020, 0.9% of Americans, or 2.9 million people, had coverage through the VA or its civilian program.

What are the types of private insurance?

Most private coverage is through employment-based insurance. In 2020, over 177 million Americans — more than half of the population — had their health insurance financed as a part of their employment. Plans vary, but employers often pay a portion of the plan’s monthly premium.

In 2020, about 10.5% of Americans had direct-purchase coverage, or insurance that they purchased from a private company or exchange program. Direct-purchase coverage reached a peak of 16.3% of Americans in the mid-2010s.

Many Americans who purchase insurance directly do so through online marketplaces created by the ACA. People can sign up for a marketplace plan during an open enrollment period. Only US citizens or nationals living in the country can get insurance coverage this way. Under a marketplace plan, employers cannot contribute to the monthly premium, but individuals may receive a tax credit for their premiums depending on their income and household size. In 2020, 3.3% of Americans — about one third of those purchasing their insurance directly — used the marketplace.

Tricare is considered a type of private health insurance. It provides civilian healthcare to military members, military retirees, and their family members. Tricare incorporates elements of VA coverage, but the key difference is that it allows eligible people to get private healthcare when they cannot access a military facility, which is not typically allowed under VA. In 2020, 2.8% of Americans received Tricare.

For more on health insurance, read USAFacts’ analysis of racial and ethnic differences in coverage get the facts every week by signing up for our newsletter.