By NextBestFitTens of millions of people have no coverage
About 28 million people (8.2%) were uninsured in 2024. They delay care, use emergency rooms as a safety net, and leave hospitals with uncompensated costs that are shifted onto everyone else.
Evidence
- 28M uninsured in 2024; insured share fell from 92.5% (2023) to 91.8%.Sources: CMS Office of the Actuary (2025)
- Three-quarters of uninsured adults skipped or postponed needed care because of cost.Sources: KFF (2025)
Who's affected
- Uninsured people: They delay care, go without, or pay full price.
- Employers: Employers that don't offer coverage avoid its cost.
- Taxpayers and public budgets: Public budgets avoid subsidy costs in the short run.
Under your mix of paths
- Coverage tied to employment
- State-by-state Medicaid eligibility
- Premiums unaffordable above subsidy cliffs
- Eligibility rules that exclude some immigrants
Related costs
Open questions
- Who counts as a resident for coverage (citizens only, lawful residents, everyone living here)?
- Is coverage automatic, or must people enroll?
Solution paths (6)
Open a path for what it fixes, what it creates or worsens, who gains and who loses, precedents, and how it connects to other paths. See all paths as a decision tree.
One public program covers every resident automatically. Private insurance for covered services ends; providers stay mostly private and bill one payer at one set of rates.
- +Tens of millions of people have no coverage
- +People lose coverage when their life changes (churn)
- +Job lock: people stay in jobs to keep insurance
- +Narrow networks and out-of-network surprises
- +Premiums are a large, flat, hidden tax on wages
- +Surprise billing and a runaway arbitration system
- +Insurer overhead and profit
- +About $1 trillion a year in administrative cost
- +Claim denials
- +U.S. prices are far higher than in other countries
- −Transition disruption: jobs, companies, and familiar coverage
- −Simplifying billing would displace hundreds of thousands of workers
- −Longer waits if demand grows faster than capacity
- −Losing the choice of health plan and insurer competition
- −Replacing premiums with taxes
- −Central coverage decisions can feel like rationing
- −States lose control and budgets shift between levels of government
Everyone is required to join one of several competing plans (sickness funds or private insurers) that must accept all applicants, cover a standard benefit, and pay providers mostly uniform rates.
- +Tens of millions of people have no coverage
- +People lose coverage when their life changes (churn)
- +Job lock: people stay in jobs to keep insurance
- +Narrow networks and out-of-network surprises
- +Surprise billing and a runaway arbitration system
- +Losing the choice of health plan and insurer competition
- +Transition disruption: jobs, companies, and familiar coverage
- +About $1 trillion a year in administrative cost
- −Requires difficult enforcement
- −Concentrates costly patients in some plans
- −Replacing premiums with taxes
- −Targets and quality metrics invite gaming
Anyone can buy into a public plan (Medicare-like) at a subsidized premium; employer and private plans continue. Uninsured people can be auto-enrolled.
- +Tens of millions of people have no coverage
- +Job lock: people stay in jobs to keep insurance
- +Transition disruption: jobs, companies, and familiar coverage
- +Replacing premiums with taxes
- +About $1 trillion a year in administrative cost
- −Depends on other changes to work
- −Concentrates costly patients in some plans
- −Two-tier care: a private fast lane for those who can pay
Expand Medicare from both ends: children at birth and the age threshold lowered in stages (65 → 60 → 55 ...) until everyone is covered.
- +Tens of millions of people have no coverage
- +Transition disruption: jobs, companies, and familiar coverage
- −Takes years, or money up front, before it pays off
- −Raises spending or loosens control over it
- −Solves only part of the problem
- −Replacing premiums with taxes
Keep today's mix of coverage, but automatically enroll anyone without coverage into a zero-premium plan (Medicaid or a free marketplace plan) using tax and benefit data.
- +Tens of millions of people have no coverage
- −Solves only part of the problem
Require everyone to buy coverage, with a penalty for not doing so, and raise ACA subsidies so it is affordable.
- +Tens of millions of people have no coverage
- −Directs benefits or burdens imperfectly
- −Solves only part of the problem