Research · Health Policy

Healthcare Access in America: Who Gets Left Out — and Why

Doodle Design Co Research  ·  May 2026

In 2024, roughly 26 million Americans under 65 had no health insurance. That number increased for the first time in five years — not because people stopped wanting coverage, but because pandemic-era Medicaid protections expired and millions were dropped from the rolls.

The people most likely to be uninsured are not randomly distributed. They are disproportionately low-income, and disproportionately Black, Hispanic, American Indian, or Alaska Native. This post documents what the data shows — who is left out, why, and what the evidence says about fixing it.

All data comes from federal agencies and nonpartisan research institutions: the U.S. Census Bureau, Kaiser Family Foundation (KFF), the Commonwealth Fund, and the Agency for Healthcare Research and Quality (AHRQ).

1. Who Is Uninsured? The Racial Gap

The national uninsured rate of 9.8% hides enormous variation by race and ethnicity. American Indian and Alaska Native (AIAN) adults are uninsured at nearly three times the rate of White non-Hispanic adults. Hispanic adults face similar odds. These gaps have persisted for decades — even as the Affordable Care Act narrowed them significantly after 2014.

Figure 1. Uninsured rate by race and ethnicity, adults under 65, 2024. Dashed line = national average (9.8%). Source: KFF analysis of U.S. Census Bureau ACS, 2024.

Hispanic adults make up 36% of the entire uninsured population — roughly double their share of the U.S. population. Many work in industries with low rates of employer-sponsored insurance — agriculture, construction, food service — and immigration rules restrict public program eligibility for many lawfully present residents.

Asian Americans have the lowest aggregate uninsured rate at 6.2%, but this number can be misleading. Within the Asian population, Hmong, Bangladeshi, and Pakistani Americans have uninsured rates well above the group average — a reminder that aggregated statistics can conceal distinct subgroup needs.

2. The ACA Made Things Better — Then They Got Worse

The Affordable Care Act, implemented in 2014, produced the largest expansion of health coverage in U.S. history. Hispanic adults saw their uninsured rate fall by nearly 15 percentage points between 2013 and 2022. Black adults saw a drop of nearly 11 points.

Then, starting in April 2023, states resumed annual Medicaid eligibility checks that had been paused since the pandemic began. Over 22 million people were removed from Medicaid rolls by the end of 2024. Studies found that a large share of disenrollments were procedural — people lost coverage because of outdated addresses or missed paperwork, not because they were actually ineligible.

The groups hit hardest were the same groups the ACA had helped the most.

Figure 2. Uninsured rate trends by race and ethnicity, 2010–2024. Vertical line marks 2014 ACA implementation. Uptick in 2023–24 reflects end of Medicaid continuous enrollment. Source: KFF analysis of Census Bureau CPS/ACS data.

3. The Lower Your Income, the Less Coverage You Have

Adults living below the federal poverty line — about $15,060 per year for a single person in 2024 — are uninsured at a rate of 24%. That is six times higher than adults earning above 400% of the poverty level, who are uninsured at just 4%.

Figure 3. Uninsured rate by family income as % of federal poverty level, adults 19–64, 2024. Source: U.S. Census Bureau P60-288, 2025.

10 states still had not adopted Medicaid expansion as of 2024, creating what researchers call the "coverage gap" — people who earn too little for Marketplace subsidies but are not eligible for Medicaid. About 1.9 million adults are stuck here. Black adults make up 35% of that group, Hispanic adults 28% — meaning more than 60% of gap adults are people of color.

80% of uninsured Americans live in families where at least one person works. Being uninsured is not primarily about being outside the workforce — it is about working jobs that do not offer coverage and earning too little to afford it independently.

— KFF, Key Facts about the Uninsured Population, 2024

4. Barriers to Care: It Is Not Just About Insurance

Having insurance does not guarantee access to care. Cost, appointment availability, transportation, and workplace constraints all get in the way. Among adults below 200% of the poverty line, cost is cited by 64% as the top reason they did not get needed care.

Figure 4. Top barriers to care among low-income adults (under 200% FPL), 2023. Respondents could select multiple barriers. Source: KFF Health Reform Monitoring Survey; Commonwealth Fund Biennial Health Insurance Survey, 2023.

AHRQ's Medical Expenditure Panel Survey found that just 5% of the U.S. population accounts for nearly half of all health spending. Among those high-cost patients, racial and ethnic minorities are overrepresented — often because they accessed care too late, for conditions that had progressed further than they needed to.

5. Skipping Care Due to Cost — By Race

The Commonwealth Fund's 2023 survey found that 26% of all adults under 65 skipped or delayed needed medical care due to cost in the past year. That rate was 34% for Hispanic adults and 30% for Black adults — compared to 22% for White non-Hispanic adults.

Figure 5. Adults who skipped or delayed care due to cost in the past year, by race and ethnicity, 2023. Source: Commonwealth Fund Health Care Affordability and Access Survey, 2023.

6. Quality Gaps Persist Even With Coverage

Closing the coverage gap matters, but it is not the whole story. The AHRQ's 2023 National Healthcare Quality and Disparities Report documents that Black, Hispanic, and AIAN patients receive measurably lower-quality care than White patients across a majority of tracked indicators — even after controlling for income and insurance status.

These gaps appear in:

• Preventive screening rates
• Management of chronic conditions like diabetes and hypertension
• Maternal health outcomes — Black women die from pregnancy-related causes at more than twice the rate of White women
• Patient safety events

A study in Health Services Research (Kwok & Léger, 2023) found that physicians lose about 18% of Medicaid revenue to administrative costs — compared to just 2.4% for commercial payers. That creates a financial disincentive to see Medicaid patients that limits access, especially for specialty care.

7. What the Policy Evidence Says

Three interventions have strong empirical support for reducing racial and income-based disparities:

Medicaid expansion in remaining states. Full expansion would bring approximately 1.9 million adults into coverage, with the majority being people of color.

Permanent enhanced premium tax credits. The enhanced credits enacted in 2021 produced record Marketplace enrollment of 21.4 million in 2024. Their expiration at the end of 2025 would push millions off plans, with the greatest impact on lower-income enrollees.

Higher Medicaid reimbursement rates. Increasing provider payment rates would improve physician and specialist participation in Medicaid — particularly for Black and Hispanic adults who rely heavily on it.

The Congressional Budget Office estimates that proposed 2025 Medicaid restructuring would result in 14 million or more additional uninsured Americans by 2034 — reversing more than a decade of coverage gains.

— CBO (2025); Urban Institute; KFF

Conclusion

Healthcare access in the U.S. is not a uniform experience. Whether you can see a doctor, afford your prescriptions, or get a diagnosis before a condition becomes serious depends heavily on your income and your race — not just the quality of your insurance plan or your proximity to a hospital.

The data reviewed here represent 26 million people without insurance, 1.9 million adults trapped in a policy gap, and millions more who skip needed care every year because they cannot afford the bill. The policy tools that could close these gaps are known and tested. The question is whether they will be applied.

Sources

Agency for Healthcare Research and Quality. (2024). National Healthcare Quality and Disparities Report: 2023 edition. https://www.ncbi.nlm.nih.gov/books/NBK600459/

Commonwealth Fund. (2023). Biennial Health Insurance Survey. https://www.commonwealthfund.org

Commonwealth Fund. (2025). 2025 Scorecard on state health system performance. https://www.commonwealthfund.org/publications/scorecard/2025/jun/2025-scorecard-state-health-system-performance

Kaiser Family Foundation. (2024). Key facts about the uninsured population. https://www.kff.org/uninsured/key-facts-about-the-uninsured-population/

Kaiser Family Foundation. (2024). Health coverage by race and ethnicity, 2010–2024. https://www.kff.org/racial-equity-and-health-policy/health-coverage-by-race-and-ethnicity/

Kaiser Family Foundation. (2024). The coverage gap. https://www.kff.org/medicaid/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid/

Kwok, J., & Léger, P. T. (2023). Administrative costs and Medicaid reimbursement. Health Services Research, 58(3), 512–528. https://doi.org/10.1111/1475-6773.14240

U.S. Census Bureau. (2025). Health insurance coverage in the United States: 2024 (P60-288). https://www.census.gov/library/publications/2025/demo/p60-288.html