The U.S. uninsured rate among working-age adults is already climbing before more coverage losses are expected to hit next year, leaving some healthcare leaders warning of the time before the Affordable Care Act when more Americans went without insurance and relied on emergency settings for receiving care.
The Commonwealth Fund’s Biennial Health Insurance survey of more than 9,300 adults, published Oct. 22, found 11.2% of adults ages 19 to 64 were uninsured as of this past summer, up from 8.9% in 2024. The Commonwealth Fund’s uninsured estimates have historically run lower than federal survey figures but have tracked the same trends. Official federal data covering 2026 won’t be available until next year.
“We had this exact same thing happen before ACA,” Inland Empire Health Plan CEO Jarrod McNaughton told Becker’s Oct. 23. “It’s ‘Back to the Future,’ if you will.”
IEHP, which covers about 1.4 million people in Riverside and San Bernardino counties in Southern California, is among the top five largest Medicaid managed care plans in the country. The publicly operated insurer is preparing for its total membership to fall by up to 350,000 over the next few years as HR 1 provisions take start to take effect in January, predominantly among Medi-Cal (California’s Medicaid program) and Medicare enrollees. Mr. McNaughton said in turn, he expects more of those uninsured former members to turn to the hospital EDs for care, just as they did before the ACA expanded coverage following its passage in 2010. He also predicts many complex or acute conditions will go undiagnosed until patients return needing treatment for things like cancer, diabetes or hypertension, which, he said, “will actually cost the system more later on.”
“I was just incredibly sad to see that we’re going backwards in the coverage that’s made available to our citizens,” Mr. McNaughton added. “We had worked so hard for so many years to make sure that people actually had access to high-quality networks, and now it’s just a backtrack of all of that work.”
The coverage losses mostly stem from the expiration of enhanced ACA premium tax credits at the end of 2025 and the end of pandemic-era protections that kept people enrolled in Medicaid. The share of working-age adults nationally with exchange or other individual market plans fell to 6.4% this year from 8.5% in 2024, and the share with Medicaid fell to 13% this year from 15.5% in 2022, according to the Commonwealth survey.
Largely citing the expiration of the enhanced subsidies and a sicker risk pool, ACA insurers requested a median premium increase of 15% for 2027 after a median finalized increase of 20% for coverage this year, the second consecutive year of double-digit hikes, according to a Peterson-KFF Health System Tracker analysis.
Beginning in 2027, HR 1, the federal reconciliation bill passed in the summer of last year, will require most adults ages 19 to 64 covered through the ACA’s Medicaid expansion provision to document 80 hours a month of work or other qualifying activities unless they qualify for an exemption. States must also check their eligibility every six months, up from once a year. Federally funded Medicaid eligibility also narrowed Oct. 1 for certain immigrants, including refugees and asylees. The CBO has projected that 10 million more people will be uninsured by 2034 as a result of the law, mostly stemming from the Medicaid changes (7.5 million) and ACA changes (2.1 million).
“We’ve seen this movie before, and we warned where it would lead: more people without coverage and more care delayed,” ACHP, the trade group that represents provider-owned insurers, said in an Oct. 23 statement shared with Becker’s. “With Medicaid and ACA marketplace changes arriving next year, we risk a deeper coverage crisis. Locally operated, nonprofit health plans are working to keep people covered, but policymakers must simplify enrollment and renewal and protect affordable options. When families lose coverage, the entire healthcare system and taxpayers pay the price.”
Citing CBO projections, the Commonwealth Fund said that could push the uninsured population to 37 million by 2036, about the same as it was in 2014, the same year most of the ACA’s coverage expansions took effect. Joseph Betancourt, MD, the foundation’s president, said in a news release that patients are skipping physician visits and medications they can’t afford, and “treatable illnesses become medical emergencies.” Half of working-age adults went without needed care because of the cost this year, up from 46% in 2022, the survey also found.
Younger and lower-income adults have been hit the hardest so far by the coverage losses, per the survey. The uninsured rate for adults ages 19 to 34 rose to 16% this year from 11% in 2024. For working-age adults with household incomes under 200% of the federal poverty level, it rose to 17% from 14%.
And that’s not all for rising insurance costs: Employer-sponsored coverage for families has been getting more expensive, as well, and companies have been shifting much of that burden onto their workers. According to a KFF survey of employers published Oct. 22, employees with insurance on average contributed $7,471 toward their family coverage in 2026, 9% more than they did in 2025. Average family premiums hit $28,303 in 2026, up 5% from 2025. Meanwhile, wages grew only 3.7% on average during the same time period.
And just because someone has insurance, that doesn’t mean they always have access to the full services they need. The Commonwealth Fund also found in its survey that nearly half of working-age adults were inadequately insured in 2026, including the 11% who were uninsured, 12% who had a gap in coverage at some point, and 23% who were considered underinsured.
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