The uninsured is not the most politically salient problem in health care now—that’s affordability—nor is it the non-problem some say it is. But it’s coming back. And the problem of the chronically ill uninsured is glaring.
With 92% of the population covered by some kind of health insurance, the problem driving health to the forefront in polls now is no longer the uninsured—as it was back in 2010 when the Affordable Care Act passed and for years before that—it’s the cost concerns of the vast majority of the population people WITH insurance. That’s one reason why affordability is displacing universal coverage as a rallying cry in health care. Another is the heightened concern the public has about affordability generally—for food, housing, utilities, gas, and for health care. But the uninsured haven’t disappeared and one large group, the chronically ill uninsured, is particularly hard hit in our health system.
People who are uninsured and have a major chronic illness need a lot of health care and use more prescription drugs with no financial protection. They are part of a larger problem that has receded but will soon reemerge.
We just put out our latest review of the uninsured, which shows that the number of uninsured ticked up by more than a million in 2024, to 26.7 million. That’s sadly the latest year for which we have official data. It’s expected to climb to about 40 million as ACA and Medicaid cuts kick in (the high point was almost 47 million in 2010, which was an impetus for the ACA). Tucked away in the report is part of the story of the chronically ill uninsured.
We found that uninsured people with a common chronic illness can be as much as four times more likely to skip or delay the care that they need due to cost than insured people with the same chronic illness.
It’s also a lot of people. In 2024, 11.3 million uninsured adults aged 18-64 had one or more of five common chronic conditions: kidney disease, asthma, diabetes, hypertension, and obesity. According to our analysis of the 2024 National Health Interview Survey, a striking 66.5% of uninsured people with kidney disease delayed or didn’t get the care they needed because of cost. It was 42.2 % for uninsured people with diabetes; 42% for asthma; 36.8% for hypertension; and 29.3% for obesity.
My guess is the numbers of people delaying or skipping care look somewhat similar for many people who have various forms of cancer and heart disease or other serious illnesses who are uninsured and need a lot of care. It’s a glaring failure of our health care system; a functioning system would at least protect people who are sick.
The impact extends beyond health care and health outcomes. The chronically ill uninsured, and like most of the uninsured generally, are low- or modest-income working people. Eight in 10 uninsured people in 2024 were in families with incomes below 400% of the federal poverty level ($15,960 for an individual and $33, 000 for a family of four in 2026), and nearly half had incomes below half that level. That’s despite the fact that 85% had someone in the family working full (73.8%) or part time (11.3%). Their modest incomes mean health costs ripple through their family budgets. I agree with those who believe work is intrinsically good, but it’s also true that work doesn’t always “pay” in our society.
Affordability is the most salient issue in health care politics and with the so many Americans struggling with health care bills, it will have staying power as health care’s dominant issue. However, if the number of uninsured does continue to climb as expected, look for the issue of the uninsured to make a comeback.
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