Coverage in the Private Health Insurance Market
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Updated November 2, 2017
Coverage in the Private Health Insurance Market
Americans obtain health insurance through a variety of
Private Health Insurance Coverage
methods and from different sources. People may get
Private health insurance is the predominant source of health
insurance through the private sector or from a government
insurance coverage in the United States. In 2016, 67.5% of
source, or individuals may go uninsured.
the U.S. population (216.2 million people) had private
coverage through either the group or the non-group market
Private Health Insurance Market
during all or part of the year (see Figure 2).
The private health insurance market includes both the group
market (largely made up of employer-sponsored insurance,
Figure 2. Private Health Insurance Coverage in the
or ESI) and the non-group market (commonly referred to as
United States, 2013-2016
the individual market, see Figure 1). Private health
insurance does not include government sources of coverage,
such as Medicare or Medicaid.
Figure 1. Private Health Insurance Sources of
Coverage
Source: U.S. Census Bureau, Current Population Survey, 2014,
2015, 2016 and 2017 Annual Social and Economic Supplements.
Notes: Coverage is measured during al or part of the year. The
estimates by type of coverage are not mutual y exclusive; people can
be covered by more than one type of health insurance during the
year.
Source: Congressional Research Service (CRS).
Group Insurance
Notes: SHOP = Smal Business Health Options Program. A SHOP
Group health insurance is typically offered by employers
exchange is where smal businesses can purchase smal -group
and is divided into small-group and large-group segments.
insurance and apply for smal business health insurance tax credits.
The distinction between the small-group and large-group
markets is defined by the size of the employer or other
The dynamic nature of health insurance coverage results in
organization purchasing a group plan. Most states define
nuanced estimates of coverage, which often depend on the
small group as businesses having 50 or fewer employees
time frame being measured. For example, at the time of the
and large group as businesses having more than 50
measurement, an individual may indicate having Medicare
employees.
coverage only. However, when measuring coverage in the
past year, that same individual may indicate having had
A majority of Americans obtain health coverage through
private insurance coverage for part of the year and
the group market. In 2016, 55.7% of the U.S. population
Medicare for part of the year. People also may have
(178.5 million people) had group coverage during all or part
multiple sources of coverage simultaneously within a time
of the year (see Figure 2). The CPS ASEC does not further
frame (e.g., Medicare and supplemental private health
differentiate between small-group and large-group
insurance at the time of interview); thus, estimates by type
coverage.
of coverage are not always mutually exclusive.
Non-group Insurance
This In Focus primarily uses estimates from the Census
Consumers who are not associated with a group can obtain
Bureau’s Current Population Survey Annual Social and
health coverage by purchasing it directly from an insurer in
Economic Supplement (CPS ASEC) to provide estimates of
the non-group insurance market. In general, the non-group
coverage in the private health insurance market for 2013-
market enrolls many people who do not receive coverage
2016. The CPS ASEC measures any coverage and type of
from an employer and who are otherwise ineligible for
health insurance coverage for all or part of the year.
public insurance programs, such as Medicare or Medicaid.
https://crsreports.congress.gov
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Coverage in the Private Health Insurance Market
In 2016, 16.2% of the U.S. population (52.0 million people)
During the 2017 OEP, pre-effectuated enrollment in the
had non-group coverage during all or part of the year (see
exchanges was 12.2 million individuals (see Figure 3).
Figure 2).
Effectuated enrollment for February 2017 coverage in the
exchanges was 10.3 million individuals (see Figure 3).
Health Insurance Exchanges
The Patient Protection and Affordable Care Act’s (ACA’s;
The 2018 OEP is currently underway and is to run from
P.L. 111-148, as amended) individual health insurance
November 1, 2017 to December 15, 2017. CMS will likely
exchanges (marketplaces where individuals may purchase
provide enrollment estimates during OEP.
coverage for themselves or their families) are part of the
non-group health insurance market. Generally, plans
Other Data Estimates of Private Health
offered in the exchanges are known as Qualified Health
Insurance Coverage
Plans (QHPs). QHPs undergo an additional certification
Estimates of private health insurance coverage can be
process compared to other plans in the non-group market.
obtained from a number of reputable data sources. Data
Accordingly, non-group plans often are categorized as
sources may focus on particular aspects of the private
either “inside the exchanges” or “outside the exchanges”
health insurance market. Data sources also may produce
(see Figure 1). QHPs can, however, be offered both inside
different estimates because they may vary in terms of
the exchanges and outside the exchanges.
methodology, questions, and time frames. Table 1 provides
summary information for selected data sources.
This In Focus uses administrative data from the Department
of Health and Human Services (HHS) and the Centers for
Table 1. Selected Data Sources for Coverage
Medicare & Medicaid Services (CMS) to provide estimates
Estimates in the Private Health Insurance Market
of coverage inside the individual exchanges (see Figure 3).
Data Source
Summary
Data on exchange enrollment often are released in stages,
pre-effectuated and effectuated enrollment. Pre-effectuated
Agency for Healthcare
Provides estimates on the number and types
Research and Quality’s
of ESI plans offered by employers, benefits
enrollment is the number of individuals who have selected a
(AHRQ’s) Medical
associated with these plans, annual
plan. Effectuated enrollment is the number of individuals
Expenditure Panel
premiums, annual contributions by employers
who have selected a plan and have submitted the first
Survey–Insurance
and employees, eligibility requirements, and
premium payment for a plan. Pre-effectuated enrollment
Component (IC)
employer characteristics in a calendar year at
the state and national level.
estimates are generally provided at the end of an Open
Enrollment Period (OEP) but may include enrollment
Centers for Disease
Provides estimates of private health
associated with a Special Enrollment Period (SEP) that
Control and
insurance coverage averaged throughout a
Prevention’s National
calendar year. Early estimates do not
directly follows an OEP. Effectuated enrollment estimates
Health Interview Survey
differentiate between group and non-group
are generally provided throughout the year.
(NHIS)
coverage. Provides estimates of exchange
coverage.
Figure 3. Enrollment in the Health Insurance
Exchanges, 2014-2017
Centers for Medicare
Provides pre-effectuated and effectuated
and Medicaid Services
enrollment estimates for the health insurance
(CMS)
exchanges.
Kaiser Family
Provides detailed look at trends in ESI
Foundation/Health
coverage. Provides estimates of large-
Research and Education
(defined as 200+ employees) and smal -group
Trust (KFF/HRET)
(defined as 3-199 employees) markets in a
Employer Health
calendar year.
Benefits Survey
U.S. Census Bureau’s
Provides estimates of private health
American Community
insurance coverage averaged over the past 1
Survey (ACS)
year, 3 years, or 5 years. Provides estimates
at state, county, and congressional district
levels.
Source: Administrative data from HHS and CMS.
U.S. Census Bureau’s
Provides estimates of private health
Notes: The pre-effectuated enrol ment estimate for 2014 is during
Current Population
insurance coverage during the last calendar
the 2014 OEP (October 1, 2013-March 31, 2014) and an SEP that ran
Survey Annual Social
year. Differentiates between group and non-
through April 19, 2014. The effectuated enrol ment estimate for 2014
and Economic
group coverage.
is as of October 15, 2014. The pre-effectuated enrol ment estimate
Supplement (CPS
for 2015 is during the 2015 OEP (November 15, 2014-February 15,
ASEC)
2015) and an SEP that ran through February 22, 2015. The
Source: CRS compilation of data sources.
effectuated enrol ment estimate for 2015 is as of December 31, 2015.
Notes: This is not a comprehensive list of data sources for coverage
The pre-effectuated enrol ment estimate for 2016 is during the 2016
estimates in the private health insurance market or a comprehensive
OEP (November 1, 2015-February 1, 2016). The effectuated
discussion of the advantages and disadvantages of each data source.
enrol ment estimate for 2016 is for the “end of the year.” The pre-
effectuated enrol ment estimate for 2017 is during the 2017 OEP
Vanessa C. Forsberg, Analyst in Health Care Financing
(November 1, 2016-January 31, 2017). The effectuated enrol ment
estimate for 2017 is as of March 15, 2017, for individuals with
IF10558
effectuated coverage for February 2017.
https://crsreports.congress.gov
Coverage in the Private Health Insurance Market
Disclaimer
This document was prepared by the Congressional Research Service (CRS). CRS serves as nonpartisan shared staff to
congressional committees and Members of Congress. It operates solely at the behest of and under the direction of Congress.
Information in a CRS Report should not be relied upon for purposes other than public understanding of information that has
been provided by CRS to Members of Congress in connection with CRS’s institutional role. CRS Reports, as a work of the
United States Government, are not subject to copyright protection in the United States. Any CRS Report may be
reproduced and distributed in its entirety without permission from CRS. However, as a CRS Report may include
copyrighted images or material from a third party, you may need to obtain the permission of the copyright holder if you
wish to copy or otherwise use copyrighted material.
https://crsreports.congress.gov | IF10558 · VERSION 8 · UPDATED
Updated November 2, 2017
Coverage in the Private Health Insurance Market
Americans obtain health insurance through a variety of
Private Health Insurance Coverage
methods and from different sources. People may get
Private health insurance is the predominant source of health
insurance through the private sector or from a government
insurance coverage in the United States. In 2016, 67.5% of
source, or individuals may go uninsured.
the U.S. population (216.2 million people) had private
coverage through either the group or the non-group market
Private Health Insurance Market
during all or part of the year (see Figure 2).
The private health insurance market includes both the group
market (largely made up of employer-sponsored insurance,
Figure 2. Private Health Insurance Coverage in the
or ESI) and the non-group market (commonly referred to as
United States, 2013-2016
the individual market, see Figure 1). Private health
insurance does not include government sources of coverage,
such as Medicare or Medicaid.
Figure 1. Private Health Insurance Sources of
Coverage
Source: U.S. Census Bureau, Current Population Survey, 2014,
2015, 2016 and 2017 Annual Social and Economic Supplements.
Notes: Coverage is measured during al or part of the year. The
estimates by type of coverage are not mutual y exclusive; people can
be covered by more than one type of health insurance during the
year.
Source: Congressional Research Service (CRS).
Group Insurance
Notes: SHOP = Smal Business Health Options Program. A SHOP
Group health insurance is typically offered by employers
exchange is where smal businesses can purchase smal -group
and is divided into small-group and large-group segments.
insurance and apply for smal business health insurance tax credits.
The distinction between the small-group and large-group
markets is defined by the size of the employer or other
The dynamic nature of health insurance coverage results in
organization purchasing a group plan. Most states define
nuanced estimates of coverage, which often depend on the
small group as businesses having 50 or fewer employees
time frame being measured. For example, at the time of the
and large group as businesses having more than 50
measurement, an individual may indicate having Medicare
employees.
coverage only. However, when measuring coverage in the
past year, that same individual may indicate having had
A majority of Americans obtain health coverage through
private insurance coverage for part of the year and
the group market. In 2016, 55.7% of the U.S. population
Medicare for part of the year. People also may have
(178.5 million people) had group coverage during all or part
multiple sources of coverage simultaneously within a time
of the year (see Figure 2). The CPS ASEC does not further
frame (e.g., Medicare and supplemental private health
differentiate between small-group and large-group
insurance at the time of interview); thus, estimates by type
coverage.
of coverage are not always mutually exclusive.
Non-group Insurance
This In Focus primarily uses estimates from the Census
Consumers who are not associated with a group can obtain
Bureau’s Current Population Survey Annual Social and
health coverage by purchasing it directly from an insurer in
Economic Supplement (CPS ASEC) to provide estimates of
the non-group insurance market. In general, the non-group
coverage in the private health insurance market for 2013-
market enrolls many people who do not receive coverage
2016. The CPS ASEC measures any coverage and type of
from an employer and who are otherwise ineligible for
health insurance coverage for all or part of the year.
public insurance programs, such as Medicare or Medicaid.
https://crsreports.congress.gov
link to page 1 link to page 1 link to page 2 link to page 2 link to page 2 link to page 2
Coverage in the Private Health Insurance Market
In 2016, 16.2% of the U.S. population (52.0 million people)
During the 2017 OEP, pre-effectuated enrollment in the
had non-group coverage during all or part of the year (see
exchanges was 12.2 million individuals (see Figure 3).
Figure 2).
Effectuated enrollment for February 2017 coverage in the
exchanges was 10.3 million individuals (see Figure 3).
Health Insurance Exchanges
The Patient Protection and Affordable Care Act’s (ACA’s;
The 2018 OEP is currently underway and is to run from
P.L. 111-148, as amended) individual health insurance
November 1, 2017 to December 15, 2017. CMS will likely
exchanges (marketplaces where individuals may purchase
provide enrollment estimates during OEP.
coverage for themselves or their families) are part of the
non-group health insurance market. Generally, plans
Other Data Estimates of Private Health
offered in the exchanges are known as Qualified Health
Insurance Coverage
Plans (QHPs). QHPs undergo an additional certification
Estimates of private health insurance coverage can be
process compared to other plans in the non-group market.
obtained from a number of reputable data sources. Data
Accordingly, non-group plans often are categorized as
sources may focus on particular aspects of the private
either “inside the exchanges” or “outside the exchanges”
health insurance market. Data sources also may produce
(see Figure 1). QHPs can, however, be offered both inside
different estimates because they may vary in terms of
the exchanges and outside the exchanges.
methodology, questions, and time frames. Table 1 provides
summary information for selected data sources.
This In Focus uses administrative data from the Department
of Health and Human Services (HHS) and the Centers for
Table 1. Selected Data Sources for Coverage
Medicare & Medicaid Services (CMS) to provide estimates
Estimates in the Private Health Insurance Market
of coverage inside the individual exchanges (see Figure 3).
Data Source
Summary
Data on exchange enrollment often are released in stages,
pre-effectuated and effectuated enrollment. Pre-effectuated
Agency for Healthcare
Provides estimates on the number and types
Research and Quality’s
of ESI plans offered by employers, benefits
enrollment is the number of individuals who have selected a
(AHRQ’s) Medical
associated with these plans, annual
plan. Effectuated enrollment is the number of individuals
Expenditure Panel
premiums, annual contributions by employers
who have selected a plan and have submitted the first
Survey–Insurance
and employees, eligibility requirements, and
premium payment for a plan. Pre-effectuated enrollment
Component (IC)
employer characteristics in a calendar year at
the state and national level.
estimates are generally provided at the end of an Open
Enrollment Period (OEP) but may include enrollment
Centers for Disease
Provides estimates of private health
associated with a Special Enrollment Period (SEP) that
Control and
insurance coverage averaged throughout a
Prevention’s National
calendar year. Early estimates do not
directly follows an OEP. Effectuated enrollment estimates
Health Interview Survey
differentiate between group and non-group
are generally provided throughout the year.
(NHIS)
coverage. Provides estimates of exchange
coverage.
Figure 3. Enrollment in the Health Insurance
Exchanges, 2014-2017
Centers for Medicare
Provides pre-effectuated and effectuated
and Medicaid Services
enrollment estimates for the health insurance
(CMS)
exchanges.
Kaiser Family
Provides detailed look at trends in ESI
Foundation/Health
coverage. Provides estimates of large-
Research and Education
(defined as 200+ employees) and smal -group
Trust (KFF/HRET)
(defined as 3-199 employees) markets in a
Employer Health
calendar year.
Benefits Survey
U.S. Census Bureau’s
Provides estimates of private health
American Community
insurance coverage averaged over the past 1
Survey (ACS)
year, 3 years, or 5 years. Provides estimates
at state, county, and congressional district
levels.
Source: Administrative data from HHS and CMS.
U.S. Census Bureau’s
Provides estimates of private health
Notes: The pre-effectuated enrol ment estimate for 2014 is during
Current Population
insurance coverage during the last calendar
the 2014 OEP (October 1, 2013-March 31, 2014) and an SEP that ran
Survey Annual Social
year. Differentiates between group and non-
through April 19, 2014. The effectuated enrol ment estimate for 2014
and Economic
group coverage.
is as of October 15, 2014. The pre-effectuated enrol ment estimate
Supplement (CPS
for 2015 is during the 2015 OEP (November 15, 2014-February 15,
ASEC)
2015) and an SEP that ran through February 22, 2015. The
Source: CRS compilation of data sources.
effectuated enrol ment estimate for 2015 is as of December 31, 2015.
Notes: This is not a comprehensive list of data sources for coverage
The pre-effectuated enrol ment estimate for 2016 is during the 2016
estimates in the private health insurance market or a comprehensive
OEP (November 1, 2015-February 1, 2016). The effectuated
discussion of the advantages and disadvantages of each data source.
enrol ment estimate for 2016 is for the “end of the year.” The pre-
effectuated enrol ment estimate for 2017 is during the 2017 OEP
Vanessa C. Forsberg, Analyst in Health Care Financing
(November 1, 2016-January 31, 2017). The effectuated enrol ment
estimate for 2017 is as of March 15, 2017, for individuals with
IF10558
effectuated coverage for February 2017.
https://crsreports.congress.gov
Coverage in the Private Health Insurance Market
Disclaimer
This document was prepared by the Congressional Research Service (CRS). CRS serves as nonpartisan shared staff to
congressional committees and Members of Congress. It operates solely at the behest of and under the direction of Congress.
Information in a CRS Report should not be relied upon for purposes other than public understanding of information that has
been provided by CRS to Members of Congress in connection with CRS’s institutional role. CRS Reports, as a work of the
United States Government, are not subject to copyright protection in the United States. Any CRS Report may be
reproduced and distributed in its entirety without permission from CRS. However, as a CRS Report may include
copyrighted images or material from a third party, you may need to obtain the permission of the copyright holder if you
wish to copy or otherwise use copyrighted material.
https://crsreports.congress.gov | IF10558 · VERSION 8 · UPDATED