Falling Through the Cracks: America’s Health Insurance Divide

Introduction

In the United States, health insurance plays a significant role in gaining access to proper health care. However, in 2023, eight percent of the population, around 29 million people, did not have access to health insurance (Keisler-Starkey and Bunch, 2024). The majority of these individuals are members of underserved communities — those with limited access to essential services. Despite reforms such as the Affordable Care Act (ACA), insurance gaps continue to persist in disadvantaged communities, leading to preventable health disparities and long-term consequences.

Disparities with Health Insurance Coverage

In 2010, the ACA was passed and decreased the number of uninsured Americans from roughly 50 million to 29 million (Tolbert et al., 2023). However, inequalities began to reveal themselves, starting with income-based disparities. Nearly half of U.S. adults with average or below-average incomes have reported at least one finance-related problem regarding health care, including not visiting a doctor or following medical instructions due to high costs (The Commonwealth Fund, 2023). In addition, health care inflation is prevalent, with the average price of health care increasing by 3.2% solely in January of 2026 (Health Care Inflation in the United States | US Inflation Calculator, 2021). This presents a very dangerous problem, as not seeking the necessary care prevents treatment — such as for a chronic illness — potentially reaching a fatal state. 

Specifically, racially marginalized communities face heightened struggles. Hispanics have the highest probability of losing insurance coverage (30%), while Non-Hispanic Whites have the lowest probability (12%) (Sohn, 2016). When combined with financial challenges, disparity creates an even larger burden for Hispanic communities. Not only do many individuals of these communities already struggle to afford healthcare services with insurance, but they are also significantly more likely to lose their coverage altogether, further limiting their access to necessary care.

Finally, there are geographic disparities that need to be considered, most notably the non-expansion states. A non-expansion state is a state that has chosen not to adopt the ACA Medicaid expansion — including Alabama, Florida, Texas, etc. Those who reside in these states are more likely to be without coverage, with 46% of adults uninsured (Decker et al., 2014). This can lead to a higher volume of health issues within their communities. Unlike disparities based on income or race, which affect individuals across all states, this gap is determined by state-level policy decisions, meaning the whole state population can face limited access to coverage depending on where they live.

Consequences of Insurance Gaps

As a result of these gaps, significant consequences take form in late diagnoses, increased emergency room use, and accumulated medical debt. It was found that uninsured and Medicaid patients are significantly more likely to be diagnosed with late-stage breast cancer than privately insured women (Sala et al., 2008). This reveals that while the ACA has provided more opportunities to insure individuals, the difference in income and rising expenses can still prevent ill patients from coming in for diagnoses, thus delaying essential treatment and causing preventable premature deaths. 

Furthermore, through American Community Survey data and Utah emergency department records, it was found that lower-income individuals made preventable ER visits about 2.5 times more often than those in higher-income communities (Bureau, 2023). A preventable ER visit includes conditions that are treatable in non-emergency settings or avoidable with proper care. Health insurance could help reduce these visits by improving access to primary care, treatment, and routine checkups — helping address conditions early on before they escalate to emergencies.

Finally, medical debt has increased for many, with around 6% of U.S. adults owing more than $1,000 (Abdullahi Tunde Aborode et al., 2024). Moreover, those of lower-income communities who cannot pay their bills for necessary treatment are likely to get sued by the hospitals: around 25% of high-income hospitals sue patients over unpaid medical bills, increasing overall medical debt (Abdullahi Tunde Aborode et al., 2024).  Struggles like these can lead to stress, anxiety, and could induce various health problems, making it imperative to go see a health professional, thus owing more money to the health industry. This creates a vicious and harmful cycle for many.

Conclusion

Even with essential reforms such as the ACA, many individuals of low income and minority communities, or sometimes both simultaneously, face a multitude of struggles regarding health insurance and obtaining proper health care. For these reasons, policy reforms to reduce these disparities are crucial. This could range from expanding coverage and closing the medicaid gap by encouraging remaining states to incorporate Medicaid, to reducing out-of-pocket costs.