Over the last decade and prior to the COVID-19 pandemic, health care access improved across subpopulations, with declining disparities in rates of uninsured and avoiding care due to cost.


Health insurance is central to people’s ability to access preventive and medical care to achieve and maintain good health. Between 2010-2014 and 2015-2019, the national rate of uninsured declined 37% from 14.6% to 9.2%. During this period, all subpopulation groups experienced improvements, with notable progress made in reducing disparities by education and race and ethnicity. These strides in health insurance coverage coincide with the implementation of the Affordable Care Act’s range of health insurance expansion programs.1, 2
Despite this progress, there remains considerable room for improvement to close gaps in coverage. In 2015-2019, the rate of uninsured was 3.5 times higher among high school graduates (13.6%) than college graduates (3.9%). During this same period, the rate of uninsured was nearly three times higher for American Indian/Alaska Native (20.2%) and Hispanic (18.5%) populations than white (6.2%) populations.

Rates of uninsured by race and ethnicity also varied substantially across and within states. Across states, there was a 24-fold difference in rates of uninsured by race and ethnicity.
The Hispanic population in 28 states and the District of Columbia, and the American Indian/Alaska Native population in 17 states continued to face the highest rates of uninsured across the country in 2015-2019.
In 2015-2019, Wyoming, South Dakota, Tennessee, Georgia and Utah (all five states without Medicaid expansion prior to 2020) had the highest racial and ethnic disparities in rates of uninsured within their states, whereas Hawaii, Vermont, Massachusetts, Michigan and New York (all five states that expanded Medicaid in 2014) had the lowest disparities.

Avoided Care Due to Cost

Avoided care due to cost refers to the percentage of adults who reported a time in the past 12 months when they needed to see a doctor but could not because of cost. Avoided care is driven in large part by a lack of health insurance coverage and other access barriers. However, when people can afford and access care, they are more likely to utilize preventive services and less likely to delay necessary treatment, leading to better health outcomes.
Coinciding with the significant decrease in uninsured rates, there was notable progress in reducing disparities in avoided care due to cost. Across all subpopulation groups, there was an 18.4% decline in the percentage of adults who avoided care due to cost between 2011-2013 and 2017-2019. However, Hispanic and American Indian/Alaska Native adults and adults with less than a high school education continued to face the greatest challenges.
In 2017-2019, adults with less than a high school education (22.1%) had a three times higher rate of avoided care due to cost than college graduate adults (7.9%). During this same period, Hispanic (20.7%) and American Indian/Alaska Native adults (18.2%) had a nearly two times higher rate of avoided care due to cost than Asian/Pacific Islander adults (10.2%).

Flu Vaccination

The annual flu vaccine provides protection against seasonal influenza (or flu) viruses that lead to contagious respiratory illness. Prior to the COVID-19 pandemic, the rate of seasonal flu vaccination increased for many subpopulation groups, including: male and female adults; Hispanic, Black, Asian and Pacific Islander and white adults; and adults with some college or college graduates. At the same time, high school graduate adults experienced a 2% decline in flu vaccination.
In 2017-2019, college graduate (47.3%) adults had a 43% higher rate of flu vaccination than adults with less than a high school education (33.0%). Among racial and ethnic groups, white (41.6%) adults had the highest rate of flu vaccination—a rate 35% and 27% higher, respectively, than Hispanic (30.9%) and Black (32.7%) adults who had the lowest rates. Females (43.6%) had a 19% higher rate of flu vaccination than males (36.7%).

[1] Buchmueller, T., et al. (2016 August). “Effect of the Affordable Care Act on Racial and Ethnic Disparities in Health Insurance Coverage.” American Journal of Public Health, 106(8):1416-1421. doi: 10.2105/AJPH.2016.303155
[2] Griffith, K., et al. (2017 August). The Affordable Care Act Reduced Socioeconomic Disparities in Health Care Access. Health Affairs, 36(8). https://www.healthaffairs.org/doi/10.1377/hlthaff.2017.0083

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