Cost is the dominant reason. Roughly three out of four uninsured adults in the United States say they don’t have health insurance because they can’t afford it. But affordability is only part of the picture. Eligibility gaps, confusing enrollment processes, employer coverage limits, immigration status, and personal choice all play a role, and these factors overlap in ways that keep tens of millions of people uncovered.
Cost Is the Biggest Barrier by Far
In a national survey of uninsured adults aged 18 to 64, 73.7% said coverage was not affordable. That dwarfs every other reason. The next most common response, not being eligible for coverage, was cited by 25.3%. About 21% said they didn’t need or want insurance, 18.4% said signing up was too difficult or confusing, and 18% said they couldn’t find a plan that met their needs. (Respondents could select more than one reason, which is why the numbers add up to more than 100%.)
The cost barrier isn’t just about monthly premiums. Many people who technically qualify for a plan still face high deductibles, copays, and out-of-pocket maximums that make coverage feel useless in practice. A plan with a $300 monthly premium and a $6,000 deductible might be technically “available,” but for a family earning $45,000 a year, it can feel like paying for something they’ll never actually be able to use.
Millions Qualify for Help but Don’t Know It
One of the most striking findings in insurance data is how many uninsured people are already eligible for free or subsidized coverage. In 2023, nearly 6 in 10 uninsured individuals, about 14.5 million people, qualified for either Medicaid or subsidized marketplace plans. Specifically, about 25% of the uninsured were eligible for Medicaid, and another 32% were eligible for tax credits that reduce marketplace premiums.
Why don’t they enroll? The reasons vary. Some don’t realize they qualify. Others find the application process overwhelming, especially if they’ve never navigated government benefit systems before. The 18.4% who said signing up was “too difficult or confusing” likely includes many of these people. Language barriers, lack of internet access, and distrust of government programs all contribute. And some people fall into what’s known as the coverage gap: they earn too much for Medicaid in their state but too little to qualify for marketplace subsidies.
Where You Live Changes Your Options
Whether your state expanded Medicaid under the Affordable Care Act has a measurable impact on your chances of being insured. In 2021, the uninsured rate was 6.6% in states that expanded Medicaid compared to 12.7% in states that did not. That’s nearly double the rate in non-expansion states.
Ten states still have not expanded Medicaid. In those states, a single adult earning less than roughly $15,000 a year may earn too much for traditional Medicaid but too little to qualify for marketplace subsidies. This coverage gap leaves some of the poorest Americans with no affordable path to insurance at all. The gap disproportionately affects people in Southern states, where non-expansion is most common and where poverty rates tend to be higher.
Many Jobs Don’t Come With Benefits
Employer-sponsored insurance is how most working-age Americans get covered, but it’s far from universal. Only 56% of civilian workers had access to medical care benefits through their employer in March 2024, and just 33% actually participated. Small businesses in particular struggle to offer health plans because premiums are significantly more expensive per employee than at large firms.
Workers in part-time, gig, seasonal, or contract positions are the most likely to go without employer coverage. The rise of app-based work and independent contracting over the past decade has expanded this group considerably. If your employer doesn’t offer insurance, you’re left to navigate the individual marketplace on your own, which brings you back to the cost and complexity barriers that keep so many people uninsured.
Young Adults Often Opt Out
Adults under 35 are disproportionately uninsured, and health economists have a term for the phenomenon: “young invincibles.” These are people who feel healthy enough to skip coverage, betting that they won’t need expensive medical care. During the first ACA marketplace enrollment period in 2013-2014, only 28% of enrollees were aged 18 to 34, while 48% were 45 or older.
This isn’t purely a matter of attitude. Young adults are also more likely to work in jobs that don’t offer benefits, more likely to be in transitions between school and career, and more sensitive to monthly costs when they’re early in their earning years. A 26-year-old making $35,000 with no chronic conditions may look at a $250 monthly premium and decide the money is better spent elsewhere. That calculation changes fast after an emergency room visit or an unexpected diagnosis, but by then the enrollment window may have closed.
Immigration Status Creates Major Gaps
Non-citizens face some of the highest uninsured rates in the country. About 23% of documented immigrants and 45% of undocumented immigrants lack health insurance, compared to 9% of U.S. citizens. Undocumented immigrants are generally ineligible for Medicaid and cannot purchase marketplace plans, leaving charity care and community health centers as their primary options.
Even lawfully present immigrants face barriers. Many are subject to a five-year waiting period before they can enroll in Medicaid, regardless of income. Language barriers, fear of interacting with government agencies, and confusion about eligibility rules compound the problem. Between 2010 and 2019, uninsured rates among non-citizens did drop significantly, falling from about 48% to 31% for recent arrivals and from 53% to 36% for longer-term residents. But the rates remain far above those of citizens.
Race and Ethnicity Play a Role
Uninsured rates vary sharply by race and ethnicity, reflecting broader patterns in employment, income, and geographic access. In 2024, among adults under 65, Hispanic individuals had the highest uninsured rate at 19.8%. Black adults were uninsured at a rate of 8.4%, white adults at 6.9%, and Asian adults at 4.9%.
The disparity for Hispanic Americans is driven by several overlapping factors: higher rates of employment in industries that don’t offer benefits (agriculture, construction, food service), immigration-related eligibility restrictions, and concentration in states that have not expanded Medicaid. These aren’t separate problems. They compound each other, creating a situation where a Hispanic worker in Texas doing construction may face every barrier simultaneously: no employer coverage, no Medicaid eligibility, a confusing marketplace, and language obstacles during enrollment.
Medicaid Unwinding Pushed People Off Coverage
A recent and significant driver of coverage loss was the Medicaid “unwinding” that began in 2023. During the COVID-19 pandemic, states were required to keep people enrolled in Medicaid regardless of changes in income or eligibility. When that protection ended, states had to re-evaluate every enrollee’s eligibility, a process affecting tens of millions of people.
The results were dramatic. KFF tracking shows that 20.1 million people were disenrolled from Medicaid during the unwinding. While most people (83% of adults who had Medicaid before the process began) either kept their coverage or re-enrolled, 8% ended up uninsured. Among those who lost coverage in states that hadn’t expanded Medicaid, the uninsured rate was even higher at 17%, compared to 6% in expansion states. More than half of those who became uninsured said cost was the reason they hadn’t gotten other coverage.
Many of these disenrollments were procedural rather than based on actual ineligibility. People lost coverage because they didn’t receive renewal paperwork, didn’t respond in time, or had their applications rejected due to administrative errors. States processed millions of cases in a compressed timeline, and the system wasn’t built for that kind of volume.