How Americans actually get health insurance

How do Americans actually get health insurance? Most Americans get health insurance through an employer. About 54.8 percent are covered that way, 20.9 percent are on Medicaid, 18.4 percent on Medicare, and 13.8 percent buy a plan directly. Meanwhile around 8.4 percent have no health insurance coverage at all.

Note that those figures sum up to more than 100 percent because some people hold more than one at once. A retiree on Medicare often carries a supplemental private plan, and a child can be covered by both a parent's employer plan and Medicaid.

Where each type concentrates

Employer coverage runs highest in affluent suburbs with professional workforces. Loudoun County, Virginia is at 75.6 percent and Arlington County at 75.3 percent, followed by Delaware County, Ohio at 74.2 percent and Hunterdon County, New Jersey at 74.1 percent. All are commuter counties outside Washington, Columbus, and New York.

Medicare concentrates by age, so the map matches the retirement map exactly. Sumter County, Florida, home to The Villages, is 61.5 percent on Medicare, more than three times the national rate. Charlotte, Citrus, Highlands, Sarasota, and Indian River counties in Florida follow, along with Yavapai County, Arizona and Brunswick County, North Carolina.

Medicaid concentrates by income and by state policy. Bronx County, New York is highest at 52.5 percent, and the next several are agricultural counties in California's Central Valley: Imperial at 49.8 percent, Tulare at 45.7, Merced at 42.5, Kern at 40.4, and Fresno at 39.3. New York and California both expanded Medicaid and both run generous eligibility rules.

Every one of the eight most uninsured large counties in the country is in Texas. Texas has not expanded Medicaid under the Affordable Care Act, and it has the largest coverage gap of any state: adults who earn too much for the state's narrow Medicaid rules but too little for marketplace subsidies. Hidalgo, Webb, Cameron, and El Paso counties sit on the Mexican border and combine that policy gap with large populations of low-wage and noncitizen workers, many of whom are ineligible for public coverage regardless of income.

Dallas County is the outlier on size. It has 2.6 million residents and a 21.5 percent uninsured rate, so it holds more uninsured people than most states.

The long-run change in the uninsured rate is covered in how the Affordable Care Act changed the uninsured rate, and recent county-level movement is in county uninsured rates rising.

Sources

Figures are from the U.S. Census Bureau American Community Survey 2020-2024 5-year estimates, tables B27010 and C27001 through C27007 (health insurance coverage by type). Shares are of the civilian noninstitutionalized population and sum to more than 100 percent because people can hold more than one type of coverage at once. Counties shown have at least 100,000 residents. National figures are population-weighted averages across states. Medicaid expansion status is as of the survey period.