Our Country Is Eroding Its Health Insurance Safety Net While Americans Need It More than Ever

On Oct. 8, 2025, I suffered a perforated bowel. My treatment included a great deal of inpatient and outpatient care over a period of six months. Yet I was lucky — not in experiencing a health crisis, but in having excellent health insurance. My healthcare providers billed hundreds of thousands of dollars, but my out-of-pocket expenditures were capped at a few thousand dollars. 

Currently, there are approximately 30 million uninsured Americans. That number is expected to grow dramatically because of numerous new government policies, many of which have received little public attention. The Congressional Budget Office estimates that as many as 16 million additional people will lose insurance by 2034. This coverage erosion coincides with other legal developments that are likely to generate more illness and a greater need for medical care in the United States.

The Assault on Healthcare Coverage

The vehicle for most contemporary coverage rollbacks is the 2025 One Big Beautiful Bill Act (OBBBA) along with its implementing regulations. Its proponents enthuse that it will achieve dramatic cost savings, promote low-income individuals’ independence, and combat distortions caused by flawed regulations and physician payment methods. Its critics, however, have called it “the worst piece of healthcare legislation ever.” 

The Affordable Care Act (ACA) Marketplace suffered a severe setback when COVID-19-era enhanced premium tax credits expired at the end of 2025. Without those subsidies, premiums for many consumers rose by 100 percent or more. 

The OBBBA and the 2025 Marketplace Integrity and Affordability Final Rule added other burdens as well. The legal provisions ended automatic re-enrollment, eliminated the year-long special enrollment period for people with household incomes below 150 percent of the federal poverty level, shortened the open enrollment window, and  cut funding for Navigators that help consumers select and enroll in Marketplace policies by 90 percent. These and other changes will shrink enrollment, particularly among younger and healthier consumers who are less motivated to tackle cumbersome paperwork. When healthier people who pay premiums but use minimal medical services exit the insurance market, premium costs generally rise for the sicker, costlier consumers who remain enrolled.

Medicaid also faces severe disruption. Beginning in January 2027, the OBBBA will require that, with some exceptions, able-bodied adults aged 19 to 64 spend 80 hours per month working, volunteering, or receiving job training. The law also mandates that states verify Medicaid eligibility every six months (rather than yearly) and suspends two Biden-era rules designed to streamline Medicaid enrollment. Experts predict that millions will lose Medicaid coverage simply because they fail to navigate the bureaucracy, file correct paperwork, or meet deadlines.

As an additional hurdle, the OBBBA requires that starting in 2028, states impose copayments of up to $35 per service on certain Medicaid enrollees. Of particular importance are new limitations on the ability of states to tax healthcare providers to cover their Medicaid spending. Loss of this tax revenue may cause states to cut physician Medicaid reimbursement, which in turn could lead to fewer clinicians accepting Medicaid patients and greater healthcare access barriers.

Medicare has not been spared. The OBBBA strips eligibility from immigrants who received U.S. humanitarian protection, such as refugees and successful asylum seekers. The law also places a nine-year moratorium on a Biden rule that would have improved Medicare Savings Programs that help low-income seniors pay for premiums and other Medicare costs. A new pilot program called WISeR is testing prior authorization (PA) requirements in traditional Medicare and use of artificial intelligence (AI) for PA purposes in six states. Evidence suggests that AI-driven algorithms increase denial rates. The combination of PA and AI assessment tools will impose new hardships on Medicare patients.

The Simultaneous Dismantling of Public Health Protections

The coverage rollbacks coincide with other troubling legal developments. A variety of regulatory and policy changes may jeopardize Americans’ health and increase the need for medical care. 

The Department of Health and Human Services has decreased the number of universally recommended childhood vaccines from 17 to 11. Because of government messaging, vaccine hesitancy is rising, measles cases are climbing, and experts are warning of a potential resurgence of other preventable diseases. State abortion bans and restrictions are producing care delays and worse health outcomes as clinicians worry about the personal consequences of treating individuals with pregnancy complications. In the environmental arena, the EPA revoked its foundational 2009 finding that climate change endangers human health, eliminated federal emission standards, and is abandoning calculations of health benefit gains from regulating fine particulate matter. Experts warn of increased incidence of asthma, heart disease, and premature death. 

Addressing Contemporary Health Insurance Rollbacks

Comprehensive solutions to the problem of the uninsured, such as a single payer system and sweeping cost reductions, are unattainable in the current political climate. But other, more modest interventions are available. 

• Litigants can challenge federal regulations (but not statutes) under the Administrative Procedure Act, and courts can revoke regulations that are arbitrary, capricious, or contrary to law. For example, a Maryland court stayed six provisions of the 2025 Marketplace Integrity and Affordability Final Rule that hindered ACA Marketplace enrollment. Other courts have suspended or invalidated regulations that undermined the ACA’s and Medicaid’s core purpose of expanding healthcare coverage. Future litigants could likewise contest regulations that systematically shrink public insurance enrollment.
• Hospital financial assistance policies (FAPs), which all tax-exempt hospitals must have, are an often underutilized lever that requires more robust regulation and enforcement. Congress could follow the precedent of Oregon state law and establish national requirements that all hospitals apply the same FAP eligibility standards, automatically screen uninsured and financially delinquent patients for FAP eligibility, comply with detailed reporting requirements, and meet minimum standards for FAP expenditures. 
• In the absence of Congressional action, states can fill many FAP and health insurance voids. Some states are fully or partially replacing the expired ACA Marketplace subsidies. Five states have individual mandates that require all residents to purchase policies.

Conclusion

I know how fortunate I am for having received so much medical care during my illness and long recovery. But it is profoundly distressing that so many others cannot expect the same benefits. We must not greet millions of Americans’ reversal of fortune with indifference. Our country’s healthcare coverage deficit deserves renewed attention and a sustainable solution.