Health Insurance
7.7% of Americans Across Largest Metros Don’t Have Health Insurance, Leading With Texas
The percentage of uninsured Americans in the 100 largest metros has shrunk in recent years.
According to the latest ValuePenguin analysis, an average of 7.7% of Americans in these metros were uninsured in 2023, down from 8.9% in 2019.
Here’s what else we found.
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Key findings
- The vast majority of Americans in the biggest metros have health insurance coverage. An average of only 7.7% of Americans across the 100 largest metros didn’t have health insurance in 2023. That’s nearly identical to 7.6% in 2022 but better than 8.3% and 8.9% in 2021 and 2019.
- Texas metros have the highest uninsured rates. Across the biggest metros, the five with the highest uninsured rates are all in Texas, led by McAllen (25.3%), El Paso (21.8%) and Houston (18.1%). Meanwhile, Massachusetts metros have the lowest uninsured rates, with 2.6% of Boston and 2.7% of Worcester residents reporting not having insurance.
- Private health insurance is far more popular than public health insurance. On average, 68.4% of Americans in the largest metros have private health insurance. Comparatively, 36.1% have public health insurance.
- Provo, Utah, residents are most likely to have private health insurance, while Fresno, Calif., residents are most likely to have public insurance. In Provo, 82.9% have private insurance, followed by Madison, Wis. (82.1%), and Ogden, Utah (81.3%). Meanwhile, 51.1% of residents in Fresno have public health insurance, followed by Bakersfield, Calif. (50.8%), and Albuquerque, N.M. (49.5%).
7.7% of Americans in largest metros are uninsured
Americans in the biggest metros are more likely to have insurance than not, and uninsured figures have fallen recently. In 2023, an average of 7.7% of Americans across the 100 largest metros didn’t have health insurance.
Note: Based on Census Bureau data, this study compares the total noninstitutionalized population (those who aren’t in jail or nursing homes) without insurance to the total noninstitutionalized population.
Uninsured rates by year (across the 100 largest U.S. metros)
Year | % uninsured |
|---|---|
| 2019 | 8.9% |
| 2021 | 8.3% |
| 2022 | 7.6% |
| 2023 | 7.7% |
Source: ValuePenguin analysis of U.S. Census Bureau data. Note: 2020 was omitted due to the coronavirus pandemic.
While that’s up slightly from 7.6% in 2022, it’s down from 8.3% in 2021 and 8.9% in 2019. (Note: 2020 was excluded due to the coronavirus pandemic data oddities.)
According to ValuePenguin health insurance expert Divya Sangameshwar, enhanced health insurance subsidies via the American Rescue Plan Act contributed to falling uninsured rates.
These subsidies increased aid for those eligible for financial assistance with their Affordable Care Act (ACA) health insurance premiums. Subsidies were also expanded to cover enrollees making more than 400% above the poverty level who were previously denied aid. According to the Centers for Medicaid & Medicare Services (CMS), 4 in 5 marketplace plan enrollees can get health insurance for $10 or less per month.
"These subsidies, combined with more awareness around the importance of health insurance in the aftermath of the pandemic, led to record-high enrollment in private health plans on the ACA marketplaces," Sangameshwar says.
Uninsured rates are highest in Texas, lowest in Massachusetts
Everything’s bigger in Texas — including uninsured rates. The five metros with the highest uninsured rates are all in Texas. McAllen leads at 25.3%, followed by El Paso (21.8%) and Houston (18.1%).
"Texas has always had a historically high uninsured rate," Sangameshwar says. "While the number of uninsured Texans has fallen, the state’s uninsured rate remains significantly above the national average."
While it’s easy to assume that poverty, immigration or employment status might be the key drivers of high uninsured rates, Sangameshwar says a 2023 report from nonpartisan think tank Texas 2036 found that nearly a third of the uninsured population in Texas consists of middle-class residents making between 200% and 400% of the federal poverty level. Over 70% of uninsured Texans are also currently in the labor force.
Not only that, but between 56% and 71% of the uninsured in Texas likely qualify for Medicaid or subsidized private health insurance via the ACA. However, many assumed attaining health insurance would be too expensive, despite qualifying for lower rates. Therefore, a lack of education surrounding insurance likely plays the biggest role here.
Metros with the highest uninsured rates
Rank | Metro | % uninsured |
|---|---|---|
| 1 | McAllen, TX | 25.3% |
| 2 | El Paso, TX | 21.8% |
| 3 | Houston, TX | 18.1% |
| 4 | Dallas, TX | 15.7% |
| 5 | San Antonio, TX | 13.8% |
Source: ValuePenguin analysis of U.S. Census Bureau data.
Meanwhile, Massachusetts metros have the lowest uninsured rates among the 100 largest, leading with Boston (2.6%) and Worcester (2.7%). Honolulu and Albany, N.Y., follow, tied at 3.0%.
Full rankings
Metros with the highest/lowest uninsured rates
Rank | Metro | % uninsured |
|---|---|---|
| 1 | McAllen, TX | 25.3% |
| 2 | El Paso, TX | 21.8% |
| 3 | Houston, TX | 18.1% |
| 4 | Dallas, TX | 15.7% |
| 5 | San Antonio, TX | 13.8% |
| 6 | Lakeland, FL | 12.0% |
| 7 | Miami, FL | 11.7% |
| 7 | Cape Coral, FL | 11.7% |
| 9 | Las Vegas, NV | 11.6% |
| 10 | Tulsa, OK | 11.5% |
| 11 | Fayetteville, AR | 11.2% |
| 11 | Atlanta, GA | 11.2% |
Source: ValuePenguin analysis of U.S. Census Bureau data.
Private insurance is most popular — here’s how that varies by metro
Private health insurance — insurance from your employer or the health insurance marketplace — is generally more popular than public health insurance. While just 36.1% of Americans in the top metros have public insurance, 68.4% have private health insurance. (Note: Some consumers are enrolled in multiple insurance plans.)
Sangameshwar believes this boils down to accessibility.
"It’s easier to obtain private health insurance via your employer or on the health care exchanges," she says. "Public health insurance plans come with stringent qualification requirements, making them harder to obtain. While public health care costs significantly less than private health insurance, enrollers in public insurance find fewer options for health care providers and face restrictions around the care they can access. Private health care plans typically offer a wider range of included services, making it easier for policyholders to access the care they need."
By metro, Provo, Utah, residents are most likely to have private health insurance, at 82.9%. That’s followed by Madison, Wis. (82.1%), and Ogden, Utah (81.3%).
Metros with the highest rate of residents with private health insurance
Rank | Metro | % with private insurance |
|---|---|---|
| 1 | Provo, UT | 82.9% |
| 2 | Madison, WI | 82.1% |
| 3 | Ogden, UT | 81.3% |
Source: ValuePenguin analysis of U.S. Census Bureau data.
Conversely, 51.1% of residents in Fresno have public health insurance — mainly Medicare and Medicaid — the highest by metro. That’s followed by Bakersfield, Calif. (50.8%), and Albuquerque, N.M. (49.5%).
Metros with the highest/lowest rate of residents with public health insurance
Rank | Metro | % with public insurance |
|---|---|---|
| 1 | Fresno, CA | 51.1% |
| 2 | Bakersfield, CA | 50.8% |
| 3 | Albuquerque, NM | 49.5% |
Source: ValuePenguin analysis of U.S. Census Bureau data.
A large part of this is likely due to California's Medi-Cal program, which is widely considered one of the best Medicaid programs in the U.S., as well as the highest-funded Medicaid program in the nation. Most notably, California’s expanded program provides Medicaid to all income-eligible immigrants, regardless of immigration status. In total, more than one-third of the state's population is covered by Medi-Cal, according to the state Department of Health Care Services.
Full rankings
Metros with the highest/lowest rate of residents with private health insurance
Rank | Metro | % with private insurance |
|---|---|---|
| 1 | Provo, UT | 82.9% |
| 2 | Madison, WI | 82.1% |
| 3 | Ogden, UT | 81.3% |
| 4 | Honolulu, HI | 78.1% |
| 5 | Minneapolis, MN | 76.9% |
| 5 | Washington, DC | 76.6% |
| 5 | Austin, TX | 76.6% |
| 5 | Raleigh, NC | 76.6% |
| 5 | Salt Lake City, UT | 76.6% |
| 10 | Boston, MA | 75.8% |
| 10 | San Jose, CA | 75.8% |
| 12 | Seattle, WA | 74.7% |
Source: ValuePenguin analysis of U.S. Census Bureau data.
Metros with the highest/lowest rate of residents with public health insurance
Rank | Metro | % with public insurance |
|---|---|---|
| 1 | Fresno, CA | 51.1% |
| 2 | Bakersfield, CA | 50.8% |
| 3 | Albuquerque, NM | 49.5% |
| 4 | New Orleans, LA | 46.4% |
| 5 | Buffalo, NY | 44.4% |
| 6 | Spokane, WA | 43.9% |
| 7 | North Port, FL | 43.8% |
| 7 | Riverside, CA | 43.8% |
| 9 | Deltona, FL | 43.6% |
| 10 | Syracuse, NY | 43.5% |
| 11 | Cape Coral, FL | 42.7% |
| 12 | Rochester, NY | 42.5% |
Source: ValuePenguin analysis of U.S. Census Bureau data.
Getting on health insurance: Top expert tips
Even if you’re worried about affording health insurance, having it is better than going uninsured, Sangameshwar says.
"Choosing a plan that’s right for you at a price point you can afford will give you the peace of mind that you have some financial protection against unexpected medical expenses," she says. In particular, she recommends the following:
- If your health insurance is subsidized, be prepared for potential premium hikes next year. Under the 2021 American Rescue Plan Act’s enhanced subsidies program, many Americans currently qualify for heavily subsidized private health insurance plans. However, these enhanced premium subsidies are set to expire next year if the federal government doesn’t extend them. If that happens, millions of Americans — according to KFF — will see their premiums go up by an average of $705 a year when they shop around for insurance at the end of next year for 2026 coverage.
- Shop around. "The best way to deal with higher subsidies is to shop around for a plan that’s affordable and offers the level of coverage you’ll need," Sangameshwar says. "You should also do your research before enrolling in a health insurance plan, as the cheapest plan could cost you the most if you get sick."
- Explore other options. "If you’re still facing financial hardship and unable to qualify for public health insurance or afford private health insurance, you can explore options like a health cost sharing plan or a short-term insurance plan," she says. "These plans aren’t ACA-compliant and may not offer the level of care you’d expect. However, they can hold you over temporarily until you can find an alternative."
Methodology
ValuePenguin researchers analyzed U.S. Census Bureau 2023 data to rank the 100 largest metros by their uninsured rates. Specifically, we compared the total noninstitutionalized population without insurance to the total noninstitutionalized population.
We also ranked the largest metros by the percentage of residents with private or public health insurance in 2023.
Data comes from Census Bureau American Community Surveys with one-year estimates.