The Psychedelic Donut Returns: Healthcare Coverage Breakout For The Entire U.S. Population In 1 Chart

Thu, 01/30/2025 - 11:36pm

Note: Yes, I'm aware that the upcoming MAGA trifecta will likely make much of this moot over the next couple of years, but that's kind of the point: To see where things stand as of this moment.

9 years ago, I compiled the best breakout I could estimate of the healthcare coverage status of the entire U.S. population, in a post (and graphic) which gained quite a bit of praise. It even (to my surprise) ended up as a finalist in the National Institute for Health Care Management (NIHCM) Digital Media Awards in 2017.

Seven years, two administrations, one federal insurrection and one global pandemic later, I figured it was time to finally update the breakout of what I've since decided to refer to as the Psychedelic Donut, and did just that in 2023.

Well, it's been two more years, and with the post-pandemic Medicaid Unwinding completed, the Inflation Reduction Act's beefed-up ACA subsidies, and a jaw-droppingly horrific administration change, it seemed like a good idea to update it once again.

It's important to note that while most of the figures below should be accurate, up to date estimates, a few of are fairly rough, while others are a bit fuzzy because many Americans have more than one type of healthcare coverage, such as "dual-eligibles" who are enrolled in both Medicare and Medicaid, veterans who are covered by both the VA and Medicare, those who are only covered for certain services by Medicaid, and so on.

Having said that, I've done my best to account for these overlaps and to make reasonable guesstimates where necessary. I've also linked to my data sources and/or provided my reasoning for updated numbers where the original source is out of date. I've broken the total population out into 10 categories and 29 subcategories. For obvious reasons, I'm rounding each off to the nearest 100,000 people.

TOTAL U.S. POPULATION via the United States Census Bureau:

As the nation prepares to ring in the new year, the U.S. Census Bureau today projected the U.S. population will reach 341,145,670 at midnight EST, on Jan. 1, 2025. This represents an increase of 2,640,171 (0.78%) from Jan. 1, 2024, and 9,696,329 (2.93%) from Census Day (April 1) 2020.

OK, that's our starting point: 341.1 million people. Remember, this includes all 50 states, DC, Puerto Rico and the other U.S. territories like Guam, the U.S. Virgin Islands, American Samoa and the Northern Mariana Islands.

MEDICARE via the Centers for Medicare & Medicaid Services (CMS):

,,,as of September 2024:

Total Medicare beneficiaries reached 67,962,377...up 78,189 from August.

Traditional/FFM Medicare beneficiaries stood at 33,644,475...down 22,861.

Medicare Advantage beneficiaries reached 34,317,902...up 101,050.

12,406,929 Medicare enrollees were "Dual Eligibles"...that is, enrolled in both Medicare and Medicaid.

This was as of September 2024. Medicare enrollment has been increasing by an average of roughly 90,000 people per month over the past year, so it likely stands at around 68.3 million as of January 2025.

Within Medicare as a whole, I've broken it out into five subcategories based on type (Original/FFM vs. Medicare Advantage); age (65+ vs. under 65 w/disabilities); and whether or not they also have MediGap coverage (Original Medicare only).

The CMS report breaks out Traditional vs. Medicare Advantage. Medicare Advantage has been gradually increasing as a percentage of total Medicare enrollment for years, and last yearenrollment in Med Advantage overtook traditional Medicare. In other words, that ~90K monthly increase is actually composed of Medicare Advantage increasing by ~150K/month + Traditional Medicare dropping by ~60K/month.

This gives a January 2025 estimate of:

Original Medicare: 33.4 million
Medicare Advantage: 34.9 million

Next, we have to break each of these out by age and, for Original Medicare only, MediGap status.

The former is easy. Again, the historical data via Data.CMS.Gov breaks it out as of September at 60,764,196 age 65+, plus another ~81K/month and 7,198,181 under 65, plus another ~9K/month. As of January 2025, that would be:

65 and older: 61.1 million
Under 65: 7.2 million

According to this Kaiser Family Foundation report from 2016 (using data from 2012, I'm afraid):

A smaller share of beneficiaries under age 65 with disabilities than older beneficiaries have...Medigap (2% and 17%, respectively), or are enrolled in a Medicare Advantage plan (27% and 31%, respectively).

Obviously much has changed since that point, especially with the rapid growth of Medicare Advantage as a portion of total Medicare enrollment. Overall Medicare Advantage now makes up around 50.5% of total Medicare enrollment, but I'm assuming that this percent is still a few points lower among those under 65 than among seniors.

Assuming 47.1% of those 65+ and 42.2% of those under 65 gives the following breakout:

65+ Original: 30.5 million
< 65 Original: 4.6 million
65+ Advantage: 27.1 million
< 65 Advantage: 3.3 million

As for MediGap, that gets trickier. Again, via the Kaiser Famiily Foundation (KFF), around 34% of Original Medicare enrollees had MediGap supplemental coverage as of 2018, or twice as high a percent as in 2012. As for the tiny number of those under 65 who have Medigap:

The small share of beneficiaries under age 65 with disabilities who report having a supplemental Medigap policy may be largely due to the fact that federal law does not require insurance companies to sell Medigap policies to people under age 65, and while some states do impose this requirement, others do not.11 Insurers also may use medical underwriting in deciding whether to issue a Medigap policy to people with disabilities and how much to charge

As far as I can tell, Medigap enrollees under age 65 appear to be fewer than 100,000 people, so I'm not bothering to list them at all.

This therefore suggests the total Medicare breakout as of January 2023 to be something like:

65+ Original: 20.1 million
65+ Original + Medigap: 10.4 million
< 65 Original: 4.5 million
65+ Advantage: 27.1 million
< 65 Advantage: 3.3 million

Next up...

MEDICAID via the Centers for Medicare & Medicaid Services (CMS):

In October 2024, 79.3 million individuals were enrolled in Medicaid and CHIP.

72.1 million individuals were enrolled in Medicaid, and 7.2 million individuals were enrolled in CHIP.

41.7 million adults were enrolled in Medicaid, and there were 37.6 million Medicaid child and CHIP enrollees.

However, as I note in that same blog post, the actual total is around 1.54 million higher when you include the residents of the 5 U.S. territories (Puerto Rico, Am. Samoa, Guam, N. Mariana Islands and the U.S. Virgin Islands). That brings total Medicaid/CHIP enrollment up to around 80.8 million.

The actual breakout is:

Medicaid (Adult): 43.2 million
Medicaid (Children): 30.4 million
CHIP: 7.2 million

The other major factor here is ACA Medicaid expansion (aka "Group VIII" enrollees according to CMS). As far as I know, all of these enrollees are part of the Adult Medicaid population...but also see below. Interestingly, around 650,000 of these "Group VIII" enrollees can be found in Puerto Rico, Guam and the U.S. Virgin Islands.

ACA Medicaid expansion stood at roughly 20.9 million people nationally as of June 2024 (including the territories). This further breaks out between newly eligible enrollees (who are only legally eligible for Medicaid thanks to ACA expansion) and those who were previously eligible for the program before the ACA, but who are only enrolled now thanks to ACA expansion:

Most children in families with low incomes were eligible for Medicaid before the ACA, but Medicaid eligibility for parents was limited and varied considerably across states. The median pre-ACA income eligibility limits were just 61 percent of the poverty line for working parents and 37 percent for unemployed parents.

Medicaid expansion produces a “welcome mat” effect, research has found, so that extending coverage to adults increases children’s coverage as well. Children in states that extended Medicaid coverage to parents before the ACA, for instance, participated in Medicaid at a rate that was 20 percentage points higher than children in states with no such extensions. The ACA’s Medicaid expansion has had a similar impact, with enrollment increasing disproportionately among children of parents who became newly eligible.

Over 700,000 children who were previously eligible for Medicaid gained coverage from 2013 to 2015, and the gains were twice as large in expansion states as in non-expansion states. Coverage gains for parents, and the associated gains for children, also improve children’s access to care, with a 2017 study finding that children are 29 percentage points likelier to have an annual well-child visit if their parents are enrolled in Medicaid.

According to Medicaid Enrollment Data via the Medicaid Budget & Expenditure System (MBES), ACA expansion ("Group VIII") enrollees are split roughly 4:1 (80% / 20%) between newly eligible & previously eligible enrollees. Around 20% are in the "previously eligible" category. Again, these should all be adults, but the language above makes it sound like some of them might be children? Since I'm not sure about this, I'm just listing them all as "previously eligible" and leaving it at that:

Medicaid (Adult) Non-ACA related: 22.3 million
Medicaid (Adult) ACA expansion newly eligible: 16.7 million
Medicaid ACA expansion previously eligible: 4.2 million
Medicaid (Children): 30.4 million
CHIP: 7.2 million

The grand total between Medicare, Medicaid & CHIP comes to around 149.1 million people, although 12.0 million are dual-eligibles; they're enrolled in both Medicare and Medicaid at the same time. That knocks their combined enrollment down to ~137.1 million, or 40.2% of the total U.S. population.

OK, next we get into my bread & butter: The ACA individual market. This one is fairly easy thanks to the recent 2025 Open Enrollment Period (OEP) report released by CMS along with some additional data & estimates from state-based ACA exchanges which had later OEP deadlines.

QHPs = on-exchange Qualified Health Plans; BHPs = Basic Health Plans, available only in Minnesota, New York and Oregon at the moment:

QHP selections: 24.18 million
BHP enrollments: 1.75 million

Historically, in recent years, roughly 3% of those who "enroll" in QHPs don't end up actually being effectuated--they either never pay their first monthly premium, get rejected due to issues with their legal residency paperwork, and so on. This means on- exchange effectuated QHP enrollment is likely a bit lower, perhaps 23.5 million.

Last year, 93% of all on-exchange QHP enrollees received financial assistance in the form of Advance Premium Tax Credits (APTC) and/or Cost Sharing Reductions (CSR). Assuming roughly the same breakout this year, that would mean:

QHPs, on-exchange, subsidized: 21.85 million
QHPs, on-exchange, unsubsidized: 1.65 million
BHPs (MN/NY/OR only): 1.75 million

What about the off-exchange, ACA-compliant individual market? This one is tricky, as many insurance carriers consider their enrollment data to be trade secrets (or just lump all their enrollees together regardless of what category they are). In September 2023 KFF estimated total off-exchange individual market enrollment to be roughly 2.5 million people...as of March 2023. Further complicating this is that the 2.5M figure includes some non-ACA compliant policies such as "grandfathered", "transitional" and the dreaded "short-term, limited duration" (STLD) plans.

It's hard to say how that's changed since early 2023, but I'm assuming that perhaps 1.5 million of the total are ACA compliant:

QHPs, on-exchange, subsidized: 21.85 million
QHPs, on-exchange, unsubsidized: 1.65 million
BHPs (MN/NY/OR only): 1.75 million
QHPs, off-exchange: ~1.5 million

Grandfathered, Transitional and STLD plans: As noted above, this gets a bit fuzzy. I'm pretty sure these three combined come to perhaps 2.6 million total. A 2020 investigation by the House Energy & Commerce Committee found that around 3 million Americans were enrolled in STLD plans...but again, this was prior to the dramatic ACA subsidy upgrade & expansion to middle-income households; I'd imagine this number has dropped considerably since then.

Similarly, while the Kaiser Family Foundation put combined Grandfathered + Transitional plan enrollment at 2.1 million as of 2017, this has also dropped dramatically since that point--I pegged it at perhaps 1.7 million combined a year later, and grandfathered plan enrollment specifically has continued to plummet each year as people either die, age off of it into Medicare, gain employer-based coverage, shift to Medicaid, or switch to ACA-compliant plans which are now dramatically more affordable thanks to the enhanced subsidies than they were prior to 2021. I'm guessing the grandfathered/transitional numbers have dwindled down to perhaps 300K or so nationally.

STLD plans: ~2.0 million
Grandfathered/Transitional individual market plans: ~300,000

Health Care Sharing Ministries:

According to this article from Becker's Payer from July 2022,

Membership in these organizations soared during the 2010s after passage of the ACA. In 2014, there were about 160,000 people involved in healthcare-sharing ministries, according to PBS. By 2018, that figure rose to 1 million. In 2014, the ACA granted ministry enrollees exemption from the law's penalty for not having health insurance.

...There are now 1.5 million Americans who belong to healthcare-sharing ministries, according to data from the Alliance of Health Care Sharing Ministries, a trade group representing seven of the nine largest organizations.

According to this article from MedCity News in February 2024, this had grown a bit more:

Enrollment in HealthCare Sharing Ministry (“HCSM”) plans has been on the rise, with one report finding that more than 1.7 million Americans use HCSMs as their primary health coverage. Hospital systems must be aware of how these entities work to secure payment for services rendered to HCSM enrollees, especially if the HCSM does not have an agreement with the provider to govern claim payment and processing, as often is the case.

Student Health Plans (Colleges, Universities, etc):

Via CMS:

Student health plans are often purchased when family coverage is not available. According to some estimates, as many as 3 million students are covered through student health plans offered by colleges, universities, or other institutions of higher education.

"As many as" 3 million is pretty vague, but it's the best I can do for now.

Indian Health Service: According to the official IHS website, the IHS served 2.8 million Native Americans and Alaska Natives across 574 federally recognized Tribes in 37 states as of January 2022. I'm assuming this number hasn't changed much over the past 3 years.

TriCare/Veterans Administration:

According to the Health.mil website (the official website of the U.S. Military Health System), TRICARE serves appx. 9.5 million beneficiaries. According to this slide from the official VA website, as of December 2021, there were a total of 9.6 million enrollees in the VA Health Care System. This confused me because I always thought that TriCare was the U.S. military healthcare system for active duty service members & their families, while the VA was specifically for retirees, but apparently the 9.6M figure covers both:

Does VA participate in the TRICARE Network?

Yes, since 1995, all VA health care facilities have participated as TRICARE Network Providers.

VA can provide care for Active Duty Service Members, military retirees, & family members under their TRICARE benefit - on a space available basis.

Each VA health care facility can serve as primary care manager for TRICARE beneficiaries, but more often TRICARE referrals are used for specialty care.

Let's see where things stand as of now:

Medicare (all categories): ~68.0 million
Medicaid/CHIP (all categories): ~79.3 million
Subtract dual-eligibles from double-counting: -12.0 million
QHPs + BHPs (On + Off-exchange): ~26.5 million
Grandfathered, Transitional, STLDs, Student, Sharing Ministry: ~7.0 million
Indian Health Service: ~2.8 million
TriCare/VA: ~9.5 million

Subtotal: ~181.1 million people

That leaves roughly 160 million Americans split across the following categories:

Large Group Market
Small Group Market
Public Employees
Uninsured

Small Group Market: According to this Urban Institute brief from January 2022:

...Since the implementation of the Affordable Care Act (ACA), the small group market has been characterized by relative stability, rather than a sudden decline as some policy analysts predicted. The main findings of our study are as follows:

The rate at which small firms offer health insurance coverage decreased by just 2.6 percentage points from 2013 to 2020. For comparison, it declined by 10.6 percentage points from 2002 to 2012. Steady offer rates likely reflect consistent demand for employer-sponsored coverage from small-firm employees and greater stability in health insurance costs resulting from ACA reforms.

Health insurance enrollment among small-firm employees remained relatively stable from 2013 to 2019, hovering between 8.9 and 9.6 million enrollees. Small-firm enrollment dropped to 7.9 million in 2020, likely because of decreases in small business employment resulting from the COVID-19 pandemic.

On the other hand, this report from the National Association of Insurance Commissioners (via AHIP) claimed that the small group market covered 13 million lives as of 2019.

Hmmm...obviously there's a discrepancy here, as well as both of these being outdated (I assume the market has recovered somewhat as the economy has recovered from the pandemic). I'm going to split the difference and assume that the Small Group Market as of early 2023 covers an even 10 million people...again, unless/until I'm able to find more reliable data on it.

Federal Public Employees: According to the U.S. Office of Personnel Management (OPM), as of October 2022, the Federal Employee Health Benefit Program (FEHBP) had roughly 8.3 million covered individuals (which includes both federal employees and their families).

State/Local Public Employees:

According to the U.S. Bureau of Labor Statistics:

The BLS identifies approximately 19.5 million employees of state and local government as of January 2023. Local governments, which include most school districts, account for nearly three-quarters of total state and local employment, with state governments accounting for around one-quarter of the total. Overall, state and local employment accounts for approximately 13 percent of the nation's workforce.

If you assume an average of 1.5 lives covered by state/local municipal group policies per state/local employee (remember, while the average U.S. household size is 2.5 people, that doesn't necessarily mean that everyone in those households has the same type of healthcare coverage), that'd be roughly 29.3 million Americans total. I assume that the vast majority of these would fall into the large group category, but I suppose some smaller municipalities would utilize small group plans. Again, I'll modify this if someone can correct me on my assumptions here.

A NOTE REGARDING SELF-INSURED COVERAGE:

19.5 million is 13% of right around 150 million workers total. Regarding self-insured health insurance plans, the Employee Benefit Research Institute said that 73 million Americans (including both employees and their dependents) were in self-insured health plans as of 2007...roughly 55% out of 132.8 million individuals in plans governed by ERISA that year.

This is the same 55% reported by Statista.com, which shows this percentage rising to 65% as of 2022. This suggests that roughly 97.5 million Americans were enrolled in self-insured coverage as of last year.

However, I have no idea how this 97.5 million figure breaks out between private firms and government employee policies, so I'm not including that on the donut graph for the time being.

LARGE GROUP COVERAGE: This is The Big One: Employees (and their dependents) who receive health insurance via large private employers (ie, those with more than either 50 or 100 full-time employees, depending on the state)...although, once you subtract all the other categories above, as well as the "uninsured" portion of the population broken out below, it's not as large as you might think: Around 86 million people. This is smaller than you'd expect because I've broken out federal, state & local employees and their dependents; if they were included, it would total more like 134 million.

As noted above, I thought about breaking Large Group coverage out between self-insured and not, but there's too many variables for me to consider so I'm leaving that off the graph for now.

Finally...

UNINSURED: . In December, KFF estimated that there were roughly 25.3 million uninsured Americans...as of 2023. At the time, they broke this population out as roughly:

24.9% eligible for Medicaid/CHIP (~6.3 million)
5.4% caught in the Medicaid Gap (~1.4 million)
32.2% eligible for ACA subsidies (~8.1 million)
19.1% ineligible for financial assistance due to earning too much (~4.8 million)
18.4% ineligible for financial assistance due to their immigration status (~4.7 million)

The only problem with this is that it was as of 2023, before the Medicaid Unwinding process went through. According to the 2024 National Health Interview Survey, around 27.1 million Americans were uninsured in the first quarter of 2024, which is about as recent as I can get a reliable number for.

As it happens, subtracting the other various categories from the 341.1 million total population leaves ~26.4 million uninsured...which is right in between the KFF & NIHS estimates.

Assuming a similar breakout, that would make it roughly: