The Quiet Unraveling of Health Insurance Coverage in America
Widespread coverage losses will affect communities across America. People will suffer from treatable illnesses, and some will die.
By Katherine Hempstead
In 2023, America’s uninsured rate reached an all-time low. Sadly, that remarkable achievement was short-lived. Over the next few years, more than 15 million Americans are expected to lose the healthcare coverage they have now.
This dramatic reversal is being driven by Trump administration policies intentionally designed to take away people’s healthcare. Worry over the ability to afford and access healthcare now leads the list of problems for households, largely because of recent federal policies that have made it harder for people to stay healthy or afford care if they get sick. Policymakers should be recommitting to making healthcare coverage accessible, affordable, and permanent for all.
America’s health insurance system is broken. It costs too much and corporate profits are prioritized over good health. But the most damning feature of the system is that millions of people have no coverage at all. People without insurance do not have regular access to healthcare providers. Many delay care or skip it entirely. Paying for care can mean not paying for food or rent. As we know well, losing coverage has dire economic and health consequences, and deepens existing inequities, as the impact of uninsurance hits people of color and Indigenous communities the hardest.
For a time, America was significantly reducing the uninsured rate. The Affordable Care Act (ACA) established a new subsidized marketplace for individual coverage, and 40 states eventually expanded eligibility for Medicaid. During the Covid-19 pandemic, Congress and the Biden administration provided additional support to lower the cost of ACA premiums and keep people enrolled in Medicaid. Between 2014 and 2023, over 38 million Americans gained health coverage, and the uninsured rate was reduced by half.
This administration is throwing that progress into reverse. The One Big Beautiful Bill Act, passed by Congress last year with the enthusiastic support of the administration, cut more than $1 trillion from Medicaid. The administration has tightened eligibility rules for Medicaid and ACA coverage, shortened enrollment periods, and required states to impose restrictive work requirements for Medicaid recipients beginning in 2027. These additional restrictions and administrative burdens will cause millions more to lose coverage even though many will remain eligible.
Congress also allowed the ACA’s enhanced premium tax credits to expire at the end of 2025, causing premium payments to soar. Not surprisingly, enrollment has declined, with new sign-ups down and existing enrollees dropping off when premiums come due. State-based marketplaces are reporting increased disenrollment from failure to pay.
The smaller ACA marketplace is also less healthy, because people who require the most care will hold onto their coverage the longest. This drives costs higher. States are already projecting significant rate increases for the 2027 plan year. Some insurers have announced they are leaving the individual market altogether, increasing the number of counties that will have only one insurer. The total coverage loss associated with the deteriorating conditions in the ACA marketplace is projected to be about five million.
An even bigger threat to coverage comes from Medicaid work requirements, which will begin in most states in January. Most people on Medicaid are already working to support themselves and their families, but many either work at jobs that do not offer health insurance or are ineligible for the coverage that is offered. For many people and families, Medicaid is the only lifeline.
Studies of prior efforts show that work requirements result in people losing Medicaid coverage without increasing employment. Repeating those failed experiments will only hurt families already struggling to get by: Estimates predict the new requirements will result in 5 to 10 million people losing coverage. A sizable share of those losing coverage will be those who are eligible but fail to successfully navigate increased administrative hurdles. In other words, these requirements will make it harder, not easier, for people to stay healthy enough to work.
The administration tries to downplay the human consequences of these policies by arguing that coverage loss reflects their successful efforts to improve program integrity and eliminate waste, fraud, and abuse. Yet their story doesn’t fit the facts. Excessively raising the complexity of eligibility processes deters many who are eligible. Falsely claiming that those who lose their coverage do not deserve it allows the administration, at least in the short run, to avoid responsibility for the problem it created.
Just three years ago, we reached the lowest uninsured rate in our history. Now, some studies estimate that our uninsured population could increase by 35-40 percent over the next 10 years, a magnitude of change that is truly hard to imagine. To simply regain the coverage environment that we had would require major reversals of recent federal policies. In the short run, such changes are highly unlikely.
Widespread coverage losses will affect communities across America. People will suffer from treatable illnesses, and some will die. More families will struggle to pay medical bills. The health and economic impacts will be greatest for those losing coverage, but, ultimately, they will affect everyone, and our country will suffer for it. We cannot and will not reach our potential as a nation if millions lack access to healthcare. Achieving universal coverage will not be easy. It will require many tradeoffs and difficult choices. But this must be our north star.
Katherine Hempstead is a senior policy officer at the Robert Wood Johnson Foundation. She is the author of “Uncovered: The Story of Insurance in America.”