Uninsured rates rose in 427 counties and fell in 65
The share of Americans under 65 without health insurance rose in 427 counties between 2023 and 2024 and fell in 65, according to Small Area Health Insurance Estimates released August 6 by the U.S. Census Bureau. The country has 3,143 counties, so most didn't move measurably in a single year. Among the ones that did, deterioration outnumbered improvement by more than six to one.
The median county uninsured rate climbed to 9.8 percent, from 9.3 percent in 2023, and the share of counties keeping their rate under 10 percent fell from 46.3 percent to 41.4 percent. Those aren't dramatic moves, but they all point the same way, and they follow years of the opposite. We traced the long arc in how Obamacare affected the uninsured rate: a steep national drop from 2013 to 2019, then a plateau. At the county level, the plateau now looks like it's tipping into a climb.
The children's numbers lean hardest. Uninsured rates among kids under 19 rose in 185 counties and fell in nine, a ratio of about twenty to one. Working-age adults went 296 up against 73 down. And among working-age adults living at or below 138 percent of the poverty line, the income range where Medicaid eligibility sits in expansion states, the median county rate rose to 18.4 percent from 17.7 percent, meaning nearly one in five of the lowest-income adults in a typical county has no coverage.
One more pattern from the release: working-age women had lower uninsured rates than working-age men in 70.2 percent of counties, which is 2,205 of them.
Where the highest rates already are
SAHIE is the only source of single-year insurance estimates for every county, and it feeds programs that target help by county. Our own American Community Survey data shows where the problem concentrates, and the answer is one state. Among counties with at least 50,000 people, the eight highest uninsured rates in the country are all in Texas: Starr County at 28.9 percent, Hidalgo County at 28.2, Webb County at 27.3, then Liberty, Cameron, Maverick, Ector and Bastrop. Hidalgo County alone holds more than 920,000 people, so that 28 percent isn't a small-town artifact. Those ACS figures cover all ages rather than SAHIE's under-65 universe, so the levels aren't directly comparable, but the geography is the same either way.
The full county list is at highest uninsured counties, and any county's own rate is on its data page. This SAHIE release is also the first to break out estimates for ages 21 to 29, the group most likely to age off a parent's plan and go without.
Sources
County change counts, medians and demographic breakdowns are from the U.S. Census Bureau's Small Area Health Insurance Estimates for 2024, tip sheet CB26-TPS.45, released August 6, 2026, with county-level detail in the Bureau's interactive SAHIE tool. County uninsured rates for all ages are CensusEasy analysis of American Community Survey data, which is a different program from SAHIE and not directly comparable on levels.
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What did the 2024 SAHIE data show about uninsured rates?
Between 2023 and 2024, the uninsured rate for people under 65 rose in 427 counties and fell in 65, with the remaining counties showing no measurable change. The median county rate climbed to 9.8 percent from 9.3 percent, and the share of counties under 10 percent uninsured fell from 46.3 to 41.4 percent.
What is SAHIE and how is it different from other insurance data?
The Small Area Health Insurance Estimates program is the Census Bureau's only source of single-year insurance estimates for all 3,143 counties, covering people under 65, broken out by age, sex, and income levels tied to program eligibility like Medicaid. The 2024 release is the first to include a breakdown for ages 21 to 29.
Which counties have the highest uninsured rates?
By American Community Survey data covering all ages, the eight highest-rate counties with at least 50,000 people are all in Texas: Starr (28.9 percent), Hidalgo (28.2), Webb (27.3), then Liberty, Cameron, Maverick, Ector, and Bastrop. Hidalgo County holds more than 920,000 people, so the pattern is not limited to small border towns.
