by Maggie Davis
Public health insurance is a cornerstone of the American health care system.
Medicare and Medicaid will account for more than $2 trillion in health spending in 2024, covering tens of millions of Americans across various income levels, age groups and health conditions, according to a Valupenguin study.
Here’s a closer look at who relies on public coverage.
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- Medicare And Medicaid accounts for more than $2 trillion in health spending in 2024. Combined, Medicare ($1.1 trillion) and Medicaid ($931.7 billion) spending represented 38.8% of US health spending that year.
- 36.8% of Americans were covered by public health insurance in 2024. New Mexico (51.4%), West Virginia (46.7%) and Louisiana (46.3%) have the highest rates of universal coverage, while Utah (22.2%), Texas (28.2%) and North Dakota (28.6%) have the lowest.
- A clear indicator of who relies on public coverage is health status. In 2024 79.4% of people in poor health had public coverage, of whom 23.2% were in good health. Beyond illness, age and income are other defining factors. Nearly all adults age 65 and older (94.1%) had public health coverage in 2024, and nearly two-thirds (66.0%) of people below the federal poverty line were covered. Public coverage also extended to the workforce, covering 9.0 million full-time, year-round workers.
- Medicaid enrollment rose during the pandemic but is now declining, while Medicare continues to grow. Enrollment in Medicaid and the Children’s Health Insurance Program (CHIP), which primarily covers low-income children, families, adults and people with disabilities, peaked at 92.3 million in 2022 but has since declined by 17.1%, or 15.8 million enrollees. In contrast, Medicare enrollment has increased every year since 2019, driven largely by an aging population.
Medicare and Medicaid account for more than $2 trillion in health spending
Scale of public health insurance — such as government-funded programs Medicare and Medicaid — Difficult to oversleep. These programs cost $2 trillion for health in 2024, with $1.1 trillion for Medicare and $931.7 billion for Medicaid.
This represented 38.8% of US health spending that year.
As of November 2025, Medicare enrolls 68.4 million, while Medicaid and CHIP reach 76.5 million. This adds up to 144.9 million program enrollments. About 12.1 million people are enrolled in both programs.
“These high levels of spending tell us that public health insurance is one of the cornerstones of health coverage in the United States,” said ValuePenguin health insurance expert Kate Deventer. “Changes to these programs could affect not only state and federal budgets but also access to health care for millions of people.”
Public health insurance covers 36.8% of Americans
In 2024, 36.8% of Americans relied on public health insurance. However, this number varies significantly by state.
New Mexico has the highest rate of residents covered by public health insurance, at 51.4%, making it the only state with more than half enrolled. West Virginia (46.7%) and Louisiana (46.3%) followed.
At the other end of the spectrum, Utah (22.2%), Texas (28.2%) and North Dakota (28.6%) have the lowest coverage rates.
West Virginia stands out for its high rankings for both Medicare and Medicaid. Breaking it down by program, Maine (25.2%), West Virginia (24.4%) and Vermont (24.0%) have the highest rates of Medicare coverage. Meanwhile, New Mexico (32.9%), Louisiana (30.2%) and New York (29.1%) lead in Medicaid coverage rates.
Notably, Utah had the lowest coverage rates across Medicare, Medicaid and overall public health insurance in 2024.
Deventer believes the gap in public health coverage rates is likely due to a variety of factors, including state demographics and state laws surrounding Medicaid eligibility.
“For example, if a state has an older population, more of its residents are likely to be on Medicare than a state with a younger population,” she says. “And in some states, like Texas, it’s very difficult to qualify for Medicaid coverage. That may account for the low number of people with public coverage.”
Complete ranking: Public health insurance coverage by state
|
% covered by public health insurance |
||||
|---|---|---|---|---|
| 1 | New Mexico | 683,227 | 472,749 | 51.4% |
| 2 | West Virginia | 491,398 | 456,202 | 46.7% |
| 3 | Louisiana | 1,412,524 | 959,150 | 46.3% |
| 4 | New York | 6,561,223 | 4,018,426 | 43.6% |
| 5 | kentucky | 1,333,620 | 1,004,030 | 43.5% |
| 6 | Arkansas | 806,626 | 688,890 | 42.6% |
| 7 | Oregon | 1,308,255 | 964,257 | 42.2% |
| 8 | California | 12,778,416 | 7,153,854 | 41.0% |
| 9 | Maine | 341,522 | 387,321 | 40.8% |
| 10 | Mississippi | 593,696 | 652,847 | 40.7% |
| 11 | Vermont | 151,811 | 168,973 | 40.5% |
| 12 | Michigan | 2,299,761 | 2,302,701 | 40.4% |
Source: Standard Penguin analysis of Medicare and Medicaid Services (CMS) enrollment data with one-year projections for November 2025 and US Census Bureau 2024 American Community Survey (ACS) coverage rates. Note: Rankings are based on public health insurance coverage rates.
Public health insurance coverage by program type
|
% covered by public health insurance |
||||
|---|---|---|---|---|
| 1 | New Mexico | 51.4% | 22.2% | 32.9% |
| 2 | West Virginia | 46.7% | 24.4% | 25.6% |
| 3 | Louisiana | 46.3% | 19.8% | 30.2% |
| 4 | New York | 43.6% | 19.8% | 29.1% |
| 5 | kentucky | 43.5% | 20.4% | 26.2% |
| 6 | Arkansas | 42.6% | 21.1% | 24.9% |
| 7 | Oregon | 42.2% | 21.0% | 24.5% |
| 8 | California | 41.0% | 16.9% | 27.9% |
| 9 | Maine | 40.8% | 25.2% | 20.2% |
| 10 | Mississippi | 40.7% | 20.7% | 23.9% |
| 11 | Vermont | 40.5% | 24.0% | 20.4% |
| 12 | Michigan | 40.4% | 21.2% | 22.5% |
Source: ValuePenguin analysis of US Census Bureau 2024 ACS with one-year projections. Note: Medicare and Medicaid coverage rates are reported alone or as combined, meaning individuals may be counted in multiple categories if they have more than one type of coverage. The ranking for continuity is the same as in the previous table.
Health is a strong predictor of public coverage
A strong predictor of public health insurance dependence is health status. In 2024, 79.4% of people who self-reported health as poor had public coverage. This compares to only 23.2% who describe their health as excellent.
Apart from illness, age and income are also key factors. In 2024, 94.1% of adults aged 65 and older had public health coverage, and nearly two-thirds (66.0%) of people whose incomes fell below 100% of the federal poverty line were covered. For reference, according to the US Department of Health and Human Services (HHS), in 2024, households below 100% of the federal poverty line were defined as households earning less than the following amounts:
- 1 person: $15,060 annually
- 2 people: $20,440
- 3 people: $25,820
- 4 people: $31,200
Public health coverage by income-poverty ratio
| 100% below the federal poverty level | 66.0% |
| 100% to 199% of the federal poverty level | 57.6% |
| 200% to 299% of the federal poverty level | 40.2% |
| 300% to 399% of the federal poverty level | 31.0% |
| 400%+ of the federal poverty level | 20.7% |
Source: Valupenguin analysis of US Census Bureau Current Population Survey (CPS) 2025 Annual Social and Economic Supplement (ASEC), covering calendar year 2024.
Public coverage has also expanded somewhat among the workforce, with 9.0 million full-time, year-round workers aged 15 to 64 covered by public programs. However, a greater number — 21.6 million — of enrollees did not work at least one week a year.
Public health coverage by work experience among 15- to 64-year-olds
| Worked full time, year round | 7.8% | 9.0 million |
| Less than full time, year round | 22.8% | 10.6 million |
| Didn’t work for at least 1 week | 39.4% | 21.6 million |
Source: ValuePenguin analysis of US Census Bureau CPS 2025 ASEC, covering calendar year 2024.
Deventer believes this likely indicates that there are gaps in private health insurance and that public programs target those who need them.
Medicaid enrollment declines while Medicare grows
Enrollment in Medicaid and CHIP, which primarily covers low-income children, families, adults and individuals with disabilities, will reach 92.3 million in 2022. Since then, enrollment has increased by 17.1%, or 15.8 million enrollees.
In contrast, Medicare, which is primarily for seniors 65 and older, has grown every year since 2019, largely driven by an aging population. Medicare enrollment is projected to increase by 1.2 million between 2024 and 2025. By contrast, Medicaid and CHIP lost 3.1 million enrollees over the same period.
Deventer attributes the decline in Medicaid enrollment to the “Medicaid unwinding” process that begins in 2023. The process reverses the continuous-enrollment provision that was active during the pandemic, which kept people on Medicaid.
“Some people may have lost Medicaid because they started a new job or purchased private coverage, but others are not being enrolled because of incorrect paperwork, outdated contact information or other administrative problems, even if they technically still qualify,” she says. “The risk is that more people will remain uninsured, which often leads to delays in medical care. Those people get sicker and need more intensive care later, which contributes to higher costs throughout the health care system.”
Understanding the Public Health Insurance System: Top Expert Tips
Navigating public health insurance can be overwhelming, but a few smart steps can help you get — and keep — the coverage you need. Here’s what we recommend:
- Don’t assume you’re not qualified. “Medicaid can be confusing, but most states have dedicated websites or support tools to help guide you through the application process,” says Deventer. “If you think you might get Medicaid, it doesn’t hurt to check.”
- Keep your paperwork up to date. “If you move, update your address,” she says. “If you receive official mail or notices from Medicaid, open them and respond quickly. This reduces the risk of your name being listed due to administrative issues.”
- Check for state-specific resources. “Some states have non-Medicaid programs that can help you get health care,” she says. “You can also get care at a community health center. Payments at these centers work on a sliding scale; the less you do, the less you pay.” To find a community health center, use the tool available at Health Resources and Services Administration (HRSA) website.
method
Valupenguin researchers combined multiple data sources to assess reliance on public health insurance in the United States:
- Medicaid and Children’s Health Insurance Program (CHIP) Enrollment: Centers for Medicare and Medicaid Services (CMS). November point-in-time enrollment was used for each year.
- Medicare Enrollment: Centers for Medicare and Medicaid Services (CMS). November point-in-time calculations were used for consistency.
- Health Insurance Coverage: US Census Bureau American Community Survey (ACS) with one-year estimates, 2019-24.
- Demographic breakdown (age, income, health status, and employment): US Census Bureau Current Population Survey (CPS) 2025 Annual Social and Economic Supplement (ASEC), covering calendar year 2024.
- HGlobal Spending: CMS National Health Expenditure Account (NHEA).
Enrollment figures reflect point-in-time counts from November, when ACS estimates whether individuals were currently covered at the time of the interview, through interviews through 2024. CPS estimates measure whether individuals had coverage at any point in the previous calendar year. Both survey systems may include people with multiple types of insurance.
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This post was Previously published on VALUEPENGUIN.COM.
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Photo credit: iStock.com
