Trends in Private Health Insurance Purchased Through Exchanges Among Adults Ages 18–64, by Family Income and State Medicaid Expansion Status: United States, 2019–2023

Print
Related Pages
On This Page

by Robin A. Cohen, Ph.D., and Laryssa Mykyta, Ph.D.

PDF Version [PDF – 257 KB]

Health insurance coverage provides access to and reduces the cost of medical care (1). Among adults ages 18–64, private health insurance is the most common type of coverage, with most adults obtaining their private coverage through employer benefits (2). However, about 9% of adults younger than age 65 purchase private health insurance directly from insurance companies or through the federal Health Insurance Marketplace or state-based health insurance exchanges (exchange-based coverage), which are available in all states (2,3). Health insurance exchanges provide access to affordable healthcare plans and offer subsidies to reduce health insurance premiums and out-of-pocket costs for people with low incomes or those with health problems (4,5). Medicaid expansion is another way for people with low incomes to receive health insurance coverage, but not all states have opted to expand Medicaid eligibility. By January 1, 2023, 38 states and the District of Columbia had expanded eligibility for Medicaid (expansion states), and 12 states had not expanded eligibility for Medicaid (nonexpansion states) (6). In nonexpansion states, people with low incomes who are not eligible for Medicaid may only have the option of exchange-based coverage. This Health E-Stat reports the percentage of adults ages 18–64 with exchange-based coverage by state Medicaid expansion status and family income as a percentage of the federal poverty level (FPL).

In 2023, 6.0% of adults ages 18–64 purchased health insurance coverage through an exchange, up from 4.8% in 2019 (Figure 1, Table). The percentage of adults with exchange-based coverage increased in Medicaid expansion states from 4.2% in 2019 to 5.1% in 2023, and in nonexpansion states from 5.7% to 8.0%.

For adults living in Medicaid expansion states, the percentage with exchange-based coverage did not significantly change from 2019 to 2023 among those with incomes less than 139% FPL, 139% to 250% FPL, and 251% to 400% FPL (Figure 2, Table). However, exchange-based coverage increased for adults with incomes greater than 400% FPL, from 3.0% in 2019 to 3.9% in 2023.

Among adults living in Medicaid nonexpansion states, the percentage with exchange-based coverage increased for all income groups shown (Figure 3, Table). Exchange-based coverage increased from 6.8% in 2019 to 10.5% in 2023 for those with incomes less than 139% FPL, from 9.9% in 2019 to 12.8% in 2023 for those with incomes 139% to 250% FPL, from 5.3% in 2019 to 7.9% in 2023 for those with incomes 251% to 400% FPL, and from 2.8% in 2019 to 4.3% in 2023 for those with incomes greater than 400% FPL.

Data source and methods

Data from the 2019–2023 National Health Interview Survey, a survey of the U.S. civilian noninstitutionalized population, were used to present estimates of the percentage of adults ages 18–64 with private health insurance coverage obtained through an exchange. Estimates are shown by 1) state Medicaid expansion status (expansion states and nonexpansion states) and 2) family income (less than 139% FPL, 139% to 250% FPL, 251% to 400% FPL, and greater than 400% FPL). Differences in percentages between subgroup characteristics by state Medicaid expansion status were evaluated using two-sided significance tests at the 0.05 level. Trends by year and family income were evaluated using orthogonal polynomials in logistic regression.

References

  1. Keisler-Starkey K, Bunch LN, Lindstrom RA. Health insurance coverage in the United States: 2022. U.S. Census Bureau, Current Population Reports P60–281. U.S. Government Publishing Office, Washington, DC. September 2023.
  2. Cohen RA, Sohi IS. Demographic variation in health insurance coverage 2023. National Center for Health Statistics. October 2024; [cited 2025 Jan 21].
  3. Affordable Care Act of 2010, Pub L No 111–148, Pub L No 111–152. (March 2010).
  4. Claxton G, Levitt L, Brodie M, Garfield R, Damico A. . Data Note, Kaiser Family Foundation. April 2014; [cited 2025 Jan 21].
  5. HealthCare.gov [Internet]. U.S. Centers for Medicare & Medicaid Services. [cited 2025 Jan 21].
  6. Kaiser Family Foundation [Internet]. [cited 2025 Jan 21].

Suggested citation

Cohen RA, Mykyta L. Trends in private health insurance purchased through exchanges among adults ages 18–64, by family income and state Medicaid expansion status: United States, 2019–2023. NCHS Health E-Stats. 2025. DOI: .

Figures

Figure 1. Percentage of adults ages 18–64 with exchange-based private health insurance coverage, by state Medicaid expansion status: United States, 2019–2023

Figure 1 is a line graph showing the percentage of adults ages 18–64 with exchange-based private health insurance coverage by state Medicaid expansion status from 2019 through 2023. border=
1Significant linear trend by year (p < 0.05).
NOTE: Exchange-based coverage is a private health insurance plan purchased through the federal Health Insurance Marketplace or state-based exchanges that were established as part of the Affordable Care Act of 2010 (P.L. 111–148, P.L. 111–152).
SOURCE: National Center for Health Statistics, National Health Interview Survey, 2019–2023.

Figure 2. Percentage of adults ages 18–64 living in Medicaid expansion states with exchange-based private health insurance coverage, by family income: United States, 2019–2023

Figure 2 is a line graph showing the percentage of adults ages 18–64 living in Medicaid expansion states with exchange-based private health insurance coverage by family income from 2019 through 2023. Income categories shown are less than 139%, 139% to 250%, 251% to 400%, and greater than 400%.
1Significant linear trend by year (p < 0.05).
NOTES: Family income is based on a percentage of the federal poverty level (FPL). Exchange-based coverage is a private health insurance plan purchased through the federal Health Insurance Marketplace or state-based exchanges that were established as part of the Affordable Care Act of 2010 (P.L. 111–148, P.L. 111–152).
SOURCE: National Center for Health Statistics, National Health Interview Survey, 2019–2023.


Figure 3. Percentage of adults ages 18–64 living in Medicaid nonexpansion states with exchange-based private health insurance coverage, by family income: United States, 2019–2023

Figure 3 is a line graph showing the percentage of adults ages 18–64 living in Medicaid nonexpansion states with exchange-based private health insurance coverage by family income from 2019 through 2023. Income categories shown are less than 139%, 139% to 250%, 251% to 400%, and greater than 400%.border=
1Significant linear trend by year (p < 0.05).
NOTES: Family income is based on a percentage of the federal poverty level (FPL). Exchange-based coverage is a private health insurance plan purchased through the federal Health Insurance Marketplace or state-based exchanges that were established as part of the Affordable Care Act of 2010 (P.L. 111–148, P.L. 111–152).
SOURCE: National Center for Health Statistics, National Health Interview Survey, 2019–2023.

Table

Table. Percentage of adults ages 18–64 with exchange-based private health insurance coverage, by family income and state Medicaid expansion status: United States, 2019–2023

Table. Percentage of adults ages 18–64 with exchange-based private health insurance coverage, by family income and state Medicaid expansion status: United States, 2019–2023
Table. Percentage of adults ages 18–64 with exchange-based private health insurance coverage, by family income and state Medicaid expansion status: United States, 2019–2023
Characteristic 2019 2020 2021 2022 2023
Percent (95% confidence interval)
Total1 4.8 (4.4–5.2) 4.7 (4.3–5.1) 5.3 (5.0–5.7) 5.3 (5.0–5.7) 6.0 (5.6–6.4)
Family income2
Less than 139% FPL1 35.3 (4.3–6.4) 34.0 (3.2–5.1) 36.7 (5.6–7.9) 35.7 (4.8–6.7) 36.6 (5.6–7.7)
139% to 250% FPL 7.5 (6.5–8.6) 8.0 (7.0–9.2) 7.8 (6.8–8.9) 8.5 (7.3–9.7) 9.0 (8.0–10.1)
251% to 400% FPL1 5.2 (4.4–6.1) 5.6 (4.9–6.5) 6.0 (5.2–6.9) 6.1 (5.2–7.2) 7.0 (6.2–8.0)
Greater than 400% FPL1 2.9 (2.5–3.4) 2.9 (2.5–3.4) 3.4 (3.0–3.9) 3.5 (3.1–4.0) 4.0 (3.5–4.5)
State Medicaid expansion4 status
and family income2
Expansion1 54.2 (3.8–4.7) 54.4 (3.9–4.8) 54.8 (4.4–5.2) 54.6 (4.2–5.1) 55.1 (4.6–5.5)
    Less than 139% FPL 3,54.2 (3.1–5.6) 33.7 (2.6–5.2) 3,55.3 (4.1–6.6) 3,54.7 (3.7–5.9) 3,54.4 (3.4–5.6)
    139% to 250% FPL 55.9 (4.8–7.2) 7.1 (5.9–8.6) 7.1 (5.9–8.5) 57.2 (5.9–8.6) 57.0 (5.9–8.3)
    251% to 400% FPL 5.1 (4.2–6.2) 5.4 (4.5–6.5) 6.1 (5.1–7.3) 5.6 (4.6–6.7) 6.6 (5.6–7.8)
    Greater than 400% FPL1 3.0 (2.5–3.6) 3.0 (2.5–3.6) 3.2 (2.7–3.7) 3.3 (2.8–3.8) 3.9 (3.3–4.5)
Nonexpansion1 5.7 (5.1–6.4) 5.3 (4.6–6.0) 6.3 (5.7–7.0) 6.9 (6.2–7.6) 8.0 (7.2–8.8)
    Less than 139% FPL1 36.8 (5.1–8.7) 34.5 (3.2–6.2) 69.0 (6.9–11.5) 37.6 (6.0–9.5) 310.5 (8.6–12.7)
    139% to 250% FPL1 9.9 (8.1–12.0) 9.4 (7.5–11.7) 9.0 (7.3–10.9) 10.9 (8.9–13.2) 12.8 (10.7–15.2)
    251% to 400% FPL1 5.3 (4.0–6.8) 5.9 (4.5–7.7) 5.8 (4.6–7.2) 7.2 (5.5–9.3) 7.9 (6.2–9.9)
    Greater than 400% FPL1 2.8 (2.1–3.6) 2.8 (2.1–3.7) 3.9 (3.2–4.8) 4.2 (3.4–5.3) 4.3 (3.4–5.3)
1Significant linear trend by year (p < 0.05).

2Family income is based on a percentage of the federal poverty level (FPL) and was calculated using the U.S. Census Bureau’s poverty thresholds for the previous calendar year, which consider family size and age (available from: ). Adults were classified into four groups based on their family income. In the National Health Interview Survey, family income was imputed for about 24% of adults (see: “Multiple Imputation of Family Income in 2023 National Health Interview Survey: Methods,” available from: ).

3Significant quadratic trend with increasing income (p < 0.05).

4Under provisions of the Affordable Care Act of 2010, states have the option to expand Medicaid eligibility to cover adults who have family incomes up to and including 138% FPL. There is no deadline for states to choose to implement the Medicaid expansion, and they may do so at any time. For 2019, states moving forward with Medicaid expansion included: Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, Hawaii, Illinois, Indiana, Iowa, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Montana, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Dakota, Ohio, Oregon, Pennsylvania, Rhode Island, Vermont, Virginia, Washington, and West Virginia. The District of Columbia also moved forward with Medicaid expansion. Beginning with 2020, two states were added to this grouping: Idaho and Utah. Beginning with 2021, Nebraska was added to this grouping. Beginning with 2022, two states were added to this grouping: Missouri and Oklahoma. For 2019, states not moving forward with Medicaid expansion included: Alabama, Florida, Georgia, Idaho, Kansas, Mississippi, Missouri, Nebraska, North Carolina, Oklahoma, South Carolina, South Dakota, Tennessee, Texas, Utah, Wisconsin, and Wyoming.

5Significantly different from nonexpansion states (p < 0.05).

6Significant linear decrease with increasing income (p < 0.05).
NOTES: Exchange-based coverage is a private health insurance plan purchased through the federal Health Insurance Marketplace or state-based exchanges that were established as part of the Affordable Care Act of 2010 (P.L. 111–148, P.L. 111–152). Due to the COVID-19 pandemic, data collection switched to a telephone-only mode beginning March 19, 2020. Personal visits (with telephone attempts first) resumed in all areas in September 2020. In addition, from August through December 2020, a subsample of adult respondents who completed the National Health Interview Survey in 2019 were recontacted by telephone and asked to participate again. Response rates were lower, and respondent characteristics were different during April–December 2020. Differences observed in estimates between April–December 2020 and other periods may have been impacted by these differences in respondent characteristics. Data are based on household interviews of a sample of the U.S. civilian noninstitutionalized population.
SOURCE: National Center for Health Statistics, National Health Interview Survey, 2019–2023.