America's Uninsured Map Mirrors Its Electoral Map

Forty-two percent of America's uninsured live in just 10 states. All 10 voted for Donald Trump in 2024 and declined federal Medicaid expansion. The gap is stark. Non-expansion states average 12.1% uninsured, while expansion states average 6.7%. Texas alone has about 588,000 people in the coverage gap. They earn too much for Medicaid but too little for marketplace subsidies. These people must find health insurance through alternative options. 

Health care policy creates a clear divide. Some states took federal money and expanded Medicaid right away. Fewer people lack insurance in those states, and the economy benefits. Other states said no. They want to control their own budgets and avoid federal strings. Expansion opponents worry Washington will eventually cut funding and stick states with the tab.

The map below shows uninsured rates by state using 2024 ACS data. Hover over any state to see its uninsured rate, estimated uninsured count, expansion status and election outcome. Medicaid expansion correlates with lower uninsured rates across nearly every state.

MoneyGeek calculated population-weighted averages based on 2024 election results. States that voted Republican average 9.8% uninsured. States that voted Democratic average 6%.

Does this mean politics drives health care policy? The data shows that both factors reinforce each other. States made expansion decisions based on fiscal philosophy and federal trust. These same priorities shape voting patterns. Health coverage now functions as a policy debate and a political identifier.

The average number of uninsured in non-expansion states is 12.1% (11.6 million people) compared to 6.7% (16.2 million) in expansion states. The national uninsured total rose by about 1.0 million people from 2023 to 2024, pushing the rate from 7.9% to 8.2%. The South and Midwest experienced the sharpest increases after pandemic-era Medicaid protections expired.

The table below ranks all 50 states and Washington, D.C., by uninsured rate and shows how expansion status and election outcomes align across the country.

The divide sharpens when states are grouped by expansion status. Ten non-expansion states hold 28% of the U.S. population but account for 42% of the uninsured. The 41 expansion states and Washington, D.C., represent 72% of the population but only 58% of the uninsured.

States that haven't expanded Medicaid cite long-term cost concerns. Texas Lt. Gov. Dan Patrick told KERA in January 2025: "We are one of the states that didn't go along with that Medicaid expansion and thank goodness, because I wouldn't say we'd be bankrupt now, but a lot of the states that did are in deep fiscal trouble."

A 2025 Paragon Health Institute survey found 58% of respondents agreed with this statement: "It's wrong for the federal government to pay so much more for able-bodied adults than traditional Medicaid recipients." Critics fear federal funding won't last and believe states should control their own health policy decisions.

Wisconsin doesn't fit the pattern. The state refused Medicaid expansion, yet only 5.3% of residents lack insurance. How? Wisconsin uses its own money to cover adults who are earning up to the poverty line. Taxpayers pay more this way, but fewer people go uninsured.

Nevada shows the opposite outcome. It expanded Medicaid but records an 11.4% uninsured rate, one of the nation's highest. Heavy reliance on service sector jobs, large immigrant populations with coverage barriers and rural access challenges drive the high rate.

North Carolina expanded Medicaid in late 2023, yet its uninsured rate is 8.6%. Expansion takes time to reach eligible residents, so active enrollment efforts continue.

Expansion strongly predicts lower uninsured rates, but state economies and local policy choices matter, too.

The enhanced ACA premium tax credits expired on December 31, 2025, and Congress did not renew them. The One Big Beautiful Bill Act, signed in July 2025, let the enhanced credits lapse on schedule, so the larger subsidies that covered more enrollees through 2025 are gone as of 2026. Marketplace shoppers now pay under the pre-2021 subsidy rules, and the 400% federal poverty level subsidy cliff returned on January 1, 2026.

The cost effect landed quickly. Average monthly premium payments rose about 58%, from $113 to $178, and average 2026 ACA premiums include deductibles that climbed about 37% to a record $3,786. Because subsidies shrank while sticker prices rose, the amount enrollees owe each month went up even where the underlying plan premium changed little.

Enrollment fell as a result. ACA Marketplace signups are projected to drop from 22.3 million in 2025 to about 17.5 million in 2026, a decline of roughly 4.8 million people. A KFF survey in early 2026 found that about 9% of people who held Marketplace coverage in 2025 are now Americans without coverage, an early signal that the coverage gains of recent years are reversing.

The divide this study documents got wider, not narrower. The 10 states that have not expanded Medicaid still account for 42% of the nation's uninsured while holding 28% of its population, and the subsidy expiration removes one of the few tools that had been narrowing the gap in those states. About 1.4 million people remain in the coverage gap nationally, earning too much for traditional Medicaid but too little for Marketplace subsidies, and Texas alone holds roughly 42% of that group, about 588,000 people.

What changes the picture from here is state policy, not federal subsidy timing. A non-expansion state that adopts Medicaid expansion closes its coverage gap directly, because expansion covers adults up to 138% of the federal poverty level regardless of the Marketplace subsidy rules. Until that happens, residents in the 10 non-expansion states will keep carrying the highest uninsured rates in the country, led by Texas at 16.7% as of the 2024 American Community Survey.

Below, we answer the questions readers ask most about which states have the highest uninsured rates, why the Medicaid expansion divide persists and what the 2025 subsidy expiration changed.

MoneyGeek analyzed American Community Survey data from 2023 and 2024 to calculate uninsured rates in each state. We then matched those rates against 2024 election results to see how red and blue states compare.

We weighted our averages by state population to compare expansion states against non-expansion states and red states against blue states.

The Kaiser Family Foundation provided coverage gap numbers. We marked the expansion status based on each state's policy in October 2025. North Carolina expanded in December 2023, so we counted it as an expansion state. The ACS data lets us track changes year over year — the national uninsured rate climbed from 7.9% in 2023 to 8.2% in 2024.