High costs prevent 63% of uninsured adults from getting coverage, report shows

By Julie Washington / August 29, 2025

CLEVELAND, Ohio — While Americans lacking health insurance may be eligible for Medicaid or a plan under the Affordable Care Act, they may face barriers to enrolling, be unaware of their eligibility or be unable to find affordable plans, according to research from KFF.

Understanding why and how people are uninsured is at the center of MetroHealth System’s recently proposed push to get patients lacking health insurance signed up with Medicaid, Medicare or an Affordable Care Act plan.

MetroHealth aims to reduce the amount of charity care that is creating a drag on its bottom line. The health system says it now spends $1 million daily on charity care, which is up dramatically from just a few years ago.

The charity care reductions would be the latest in a series of moves— including layoffs and closures of outpatient offices — undertaken by the county’s safety net hospital to deal with financial headwinds and uncertainty about future funding due to changes in government policies.

Medical bills that aren’t covered by charity care can quickly translate into medical debt since most people who are uninsured don’t have much in savings, according to a 2024 KFF research paper looking at who is uninsured, the reasons why they lack insurance and how that lack affects access to health care. KFF is a nonpartisan source for health policy research, polling and journalism.

Future changes to Medicaid — including proposals that would alter how Medicaid is financed or impose work requirements — could lead to fewer people getting Medicaid, KFF said.

Marketplace subsidies will expire after 2025, and without a permanent extension, the Congressional Budget Offic estimates that the number of uninsured people will increase by an average of 3.8 million, each year from 2026 to 2034, KFF said.

The Affordable Care Act’s Health Insurance Marketplace is a federal service that helps people, families, and small businesses compare health insurance plans for coverage and affordability, and enroll in one.

In 2021, MetroHealth spent about $176 million on charity care. That category of spending rose to $276 million in 2024, and is already at about $184 million for the first half of 2025, according to the board’s financial report.

KFF’s research focused on health care insurance coverage among people 64 and younger, since Medicare covers almost everyone ages 65 and older. KFF used 2022 and 2023 data from the federal American Community Survey.

Here are some key facts about Americans who lack health insurance, from KFF:

• The number of people age 64 and under who were uninsured held steady at 25.3 million in 2023, a historic low.

• However, the number of uninsured children rose from 3.8 million in 2022 to 4.0 million in 2023.

• Most uninsured people are in low-income families and have at least one worker in the family. Adults ages 19-64 are more likely to be uninsured than children.

• In 2023, 63% of uninsured adults ages 18-64 said that they were uninsured because the cost of coverage was too high.

• Many uninsured people do not have health insurance through their jobs.

• Those without health insurance are more likely to delay or skip care because of costs. Some studies have suggested a link between Medicaid expansion and lower mortality rates from cancer, heart and liver disease, liver disease, and maternal mortality.

West Virginia, Indiana have high rates of uninsured

The rate of people lacking health insurance in the United states in 2023, ages 64 and under, is 9.5%, KFF said.

Here is a ranking of Ohio and its surrounding states regarding rates of uninsured residents.

States are listed from highest to lowest percentage of uninsured rates among residents 64 and under. All of the states listed have adopted Medicaid expansion.

Indiana: 8.1%

West Virginia: 7.5%

Ohio: 7.4%

Kentucky: 6.7%

Pennsylvania: 6.6%

Michigan: 5.4%

Nonprofit hospitals required to give charity care

Charity care is defined as free or discounted health services given to patients who meet eligibility requirements and are unable to pay for all or part of their care, according to the Internal Revenue Service.

Under federal law, nonprofit hospitals are required to provide some charity care as a condition of receiving tax-exempt status, according to health policy experts.

Depending on their eligibility criteria, hospitals may provide charity care to both uninsured and insured patients.

Currently, MetroHealth uses a sliding scale, based on federal poverty guidelines, to determine who qualifies for charity care. In some cases, residents of Ohio or Cuyahoga County receive a higher percentage of charity care than non-residents.

For patients whose income is at or below the federal poverty guidelines and meet additional eligibility criteria, MetroHealth offers 100% reduction of the bill, the system’s website states.

Medicaid cuts to increase strain on hospitals

MetroHealth, along with other U.S. hospitals, face uncertainty about future funding due to expected changes in government policy.

In July, Congress passed the largest Medicaid cuts in the program’s 60-year history as part of President Donald Trump’s “Big Beautiful Bill,” healthcare analysts said. The bill included cuts to Medicaid of almost $1 trillion over the next 10 years, according to health policy experts at UC Berkeley Public Health.

Proponents say the cuts will address waste and fraud in the program, and ensure that people who are able to work aren’t taking advantage of the system. But the non-partisan Congressional Budget Office estimated that about 11.8 million Americans may lose their health insurance, Berkeley policy experts said.

As a result, hospitals may be faced with increased financial pressure due to the need to care for more uninsured people, while absorbing more unpaid medical bills, price hikes and cuts in services, healthcare experts said.

About 30% of Cuyahoga County residents are on Medicaid — the second-highest rate among Northeast Ohio counties — according to the Center for Community Solutions, a think tank focused on health, social, and economic policy advocacy.