Health Insurance Coverage Declined for Nonelderly Americans Between 2017 and 2018, Leaving Nonexpansion States Further Behind

Ambulance pulling out of hospital emergency area.

A strong economy, rising salaries, and increasing employer-sponsored insurance (ESI) coverage did not prevent an increase in the number of people uninsured in America between 2017 and 2018.

The Issue

Even during a period that is generally accepted as prosperous, policies that reduced marketing, access, and affordability of private nongroup coverage led to uninsurance rates rising.

Key Findings

Researchers used data from the American Community Survey to examine coverage changes, particularly in context of the Affordable Care Act (ACA).

  • In 2018, 10.4 percent of the nonelderly were uninsured, compared with 10.2 percent in 2017, equivalent to 500,000 more uninsured (0.2 percentage point increase).

  • While ESI coverage increased by 1 million people (0.4 percentage point increase) during this period, those increases were not enough to offset losses of other coverage types, such as Medicaid or Children’s Health Insurance Program (CHIP) coverage (0.3 percentage point decrease) and private nongroup coverage purchased on the health insurance marketplaces (0.1 percentage point decrease).

  • Coverage losses between 2017 and 2018 were concentrated in states that did not expand Medicaid eligibility under the ACA. Uninsurance did not increase significantly in Medicaid expansion states between 2017 and 2018, but it rose 0.3 percentage points in nonexpansion states.

  • In expansion states, 24.7 percent of nonelderly people had Medicaid or CHIP coverage in 2018, compared with 18.2 percent in nonexpansion states.


Uninsurance rates rose in part due to cuts to marketplace outreach and enrollment funds, shorter open enrollment periods for ACA marketplace coverage, and the federal government’s refusal to pay insurers to provide cost-sharing reductions for low-income marketplace enrollees. Coverage losses are expected to mount further in 2020 as a result of the COVID-19 recession.

About the Urban Institute

The nonprofit Urban Institute is dedicated to elevating the debate on social and economic policy. For nearly five decades, Urban scholars have conducted research and offered evidence-based solutions that improve lives and strengthen communities across a rapidly urbanizing world. Their objective research helps expand opportunities for all, reduce hardship among the most vulnerable, and strengthen the effectiveness of the public sector. Visit the Urban Institute’s Health Policy Center for more information specific to its staff and its recent research.