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Updated February 6, 2023
U.S. Health Care Coverage and Spending
In 2021, the United States had an estimated population of
professional services (Figure 1). Private health insurance
327 million individuals. Most of those individuals had
spending experienced a decline from 2019 to 2020 (Figure
private health insurance or were covered under a federal
2), which was predominantly caused by enrollment
program (such as Medicare or Medicaid). About 8.6% of
decreases and lower health care utilization stemming from
the U.S. population was uninsured. Individuals (including
the Coronavirus Disease 2019 (COVID-19) pandemic.
those who were uninsured), health insurers, and federal and
state governments spent approximately $4.0 trillion on
Medicare
various types of health consumption expenditures (HCE) in
Medicare is a federal health insurance program that pays for
2021, which accounted for 17.4% of the nation’s gross
covered health care services for most people aged 65 and
domestic product.
older and for certain permanently disabled individuals
under the age of 65.
Table 1. Health Care Coverage, 2021
An estimated 60 million individuals (18.2% of the U.S.
Enrollment
population) were enrolled in Medicare in 2021. The
(millions/percentage
program accounted for $901 billion (22.3% of overall
Source
of U.S. population)
HCE); this share is about 11 percentage points higher than
Medicare’s percentage
Insured
299 (91.4%)
of HCE in 1970 (Figure 2). In 2021,
most of the spending was for hospital care and physician
Private Health Insurance—Group
179 (54.7%)
and professional services (Figure 1).
Private Health Insurance—Non-group
45 (13.7%)
Figure 1. Health Consumption Expenditures by Type
Medicare
60 (18.2%)
and Source, 2021
(in bil ions of dol ars)
Medicaid/CHIP
69 (21.1%)
Military—TRICARE
9 (2.7%)
Military—VA Care
7 (2.2%)
Uninsured
28 (8.6%)
Source: U.S. Census Bureau, Table HIC-4_ACS, “Health Insurance
Coverage Status and Type of Coverage by State-Al Persons: 2008 to
2021,” in American Community Survey, September 2022.
Notes: Italicized = does not add to total. Coverage estimates are not
mutual y exclusive. CHIP = State Children’s Health Insurance
Program. Medicaid/CHIP coverage estimate includes al means-tested
public coverage (e.g., state and local y financed public coverage).
Source: Centers for Medicare & Medicaid Services, National Health
Private Health Insurance
Expenditure Accounts—National Health Expenditures by Type of
Expenditure and Program, December 2022.
Private health insurance is the predominant source of health
Notes: Al of the terms used in this figure are defined in the source
insurance coverage in the United States. The private health
document, except long-term services and supports, which is defined in
insurance market includes both the group market (largely
the text of this In Focus. CHIP = State Children’s Health Insurance
made up of employer-sponsored insurance) and the non-
Program; DME = durable medical equipment.
group market (commonly referred to as the individual
market, which includes plans directly purchased from an
Medicaid/CHIP
insurer both on and off health insurance exchanges). In
Medicaid is a joint federal-state program that finances the
2021, these markets covered an estimated 179 million
delivery of primary and acute medical services, as well as
individuals (54.7% of the U.S. population) and 45 million
long-term services and supports, to a diverse low-income
individuals (13.7% of the U.S. population), respectively.
population, including children, pregnant women, adults,
individuals with disabilities, and people aged 65 and older.
In 2021, private health insurance expenditures accounted
The State Children’s Health Insurance Program (CHIP) is a
for $1,211 billion (29.9% of overall HCE). Private health
means-tested program that provides health coverage to
insurance expenditures include amounts paid by insuring
targeted low-income children and pregnant women in
organizations to providers and all insuring organizations’
families that have annual income above Medicaid eligibility
nonmedical net costs, which include but are not limited to
levels but have no health insurance.
taxes, net gains or losses to reserves, and profits. A majority
of this spending was for hospital care and physician and
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U.S. Health Care Coverage and Spending
An estimated 69 million individuals (21.1% of the U.S.
Out-of-Pocket Spending
population) received Medicaid or CHIP in 2021, and the
Out-of-pocket spending (other than premiums) includes all
programs accounted for $756 billion (18.7% of overall
amounts paid by the privately insured and other insured
HCE). This spending is about 11 percentage points higher
individuals for coinsurance, deductibles, and services not
than Medicaid/CHIP’s percentage of total HCE in 1970
covered by insurance. It also includes amounts paid by the
(Figure 2). Furthermore, relative to other coverage,
uninsured for health care goods and services. Among all
Medicaid spends the highest percentage of its expenditures
individuals, out-of-pocket spending was $433 billion
on long-term services and supports, which include (1) other
(10.7% of total HCE) in 2021, with roughly 30%
health, residential, and personal care; (2) nursing care
attributable to durable medical equipment and other non-
facilities and continuing care retirement communities; and
durable medical products.
(3) home health care (Figure 1).
The Uninsured
Figure 2. Health Consumption Expenditures (HCE) by
Approximately 28 million individuals (8.6% of the U.S.
Source as a Percentage of Total HCE, 1961-2021
population) were uninsured in 2021. The uninsured rate was
relatively stable from 2008 to 2013 before dropping 6
percentage points by 2016 to 8.6% (Figure 3). This drop in
the uninsured rate corresponds with increases in non-group
coverage and Medicaid/CHIP coverage, which are
associated with the implementation of various provisions of
the Patient Protection and Affordable Care Act (ACA; P.L.
111-148, as amended), such as the exchanges, premium tax
credit, and Medicaid expansion. Since 2016, the uninsured
rate slowly increased to 9.2% in 2019 before falling to 8.6%
in 2021, a decline that again corresponds with increases in
non-group coverage and Medicaid/CHIP coverage.
Source: Centers for Medicare & Medicaid Services, National Health
Figure 3. Health Insurance Coverage as a Percentage
Expenditure Accounts—National Health Expenditures by Type of
of Total U.S. Population, 2008-2021
Service and Source of Funds, CY1960-2021, December 2022.
Notes: CHIP = State Children’s Health Insurance Program.
Military
Health care services for military servicemembers, veterans,
and their dependents are provided by the Department of
Defense, through programs such as TRICARE, and the
Department of Veterans Affairs. In 2021, an estimated
9 million individuals (2.7% of the U.S. population) had
TRICARE and 7 million (2.2% of the U.S. population)
individuals had VA Care. Together, these departments
accounted for $150 billion (3.7%) of total HCE.
Other Health Services
Source: U.S. Census Bureau, Table HIC-4_ACS, “Health Insurance
Coverage Status and Type of Coverage by State-Al Persons: 2008 to
Other health care spending covers services provided
2021,” in American Community Survey, September 2022.
through public and private programs not listed above,
including worksite health care programs, philanthropic
Notes: Estimates not available for 2020. Coverage estimates are not
support, Indian Health Service activities, workers’
mutual y exclusive. CHIP = State Children’s Health Insurance
compensation, general assistance, the Maternal and Child
Program. Medicaid/CHIP coverage estimate includes al means-tested
Health program, vocational rehabilitation, Substance Abuse
public coverage, such as state and local y financed public coverage.
and Mental Health Services Administration grants, federal
and state public health activities, school health programs,
The cost of care for the uninsured population is accounted
and other programs whose primary focus is the provision of
for in multiple spending categories (Figure 1 and Figure
care or treatment of disease. Other health services saw a
2). Payments made by uninsured individuals for health care
sharp, temporary increase in spending in 2020 to $752
services are included in the out-of-pocket total. (Payments
billion (19.0% of total HCE) (Figure 2). This increase was
that help cover the costs of services provided to uninsured
primarily due to federal health spending addressing the
individuals are included in other source totals.) Any
COVID-19 pandemic, such as Paycheck Protection
amounts received by providers that help to partially and/or
Program loans, Provider Relief Fund payments, and public
indirectly cover the cost of care for the uninsured are
health activities. Federal spending addressing COVID-19
accounted for in corresponding source totals (e.g., Medicare
declined in 2021, which contributed to the decline in other
and Medicaid disproportionate share hospital payments are
health care spending to $597 billion (14.7% of total HCE).
included in program totals).
https://crsreports.congress.gov
U.S. Health Care Coverage and Spending
For more information about federal health programs, see
Ryan J. Rosso, Analyst in Health Care Financing
the CRS Health Care issue area page at http://www.crs.gov/
IF10830
iap/health-care.
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