The uninsured rate among working-age adults is already climbing before looming coverage losses are expected to hit next year, leaving some healthcare leaders warning of the times 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, published Oct. 22, found 11.2% of adults ages 19 to 64 were uninsured in 2026, up from 8.9% in 2024. The survey reached more than 9,300 adults from May 7 to July 20. The Commonwealth Fund’s uninsured estimates have historically run lower than federal survey figures but have tracked the same trends, and federal data covering 2026 won’t be available until next year.
“We had this exact same thing happen before the 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 projects that its total membership could fall by about 300,000 over the next few years as HR 1 provisions take effect in January, predominantly among its Medi-Cal and Medicare enrollees. Mr. McNaughton said in turn, he expects more of those uninsured former enrollees to turn to emergency departments for care, just as they did before the ACA expanded coverage following its passage in 2010. He also predicted complex or acute conditions will go undiagnosed until patients return needing treatment for 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 in the United States,” 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 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 with marketplace or other individual-market plans fell to 6.4% from 8.5% in 2024, and the share with Medicaid fell to 13% from 15.5% in 2022, according to the Commonwealth survey. The Urban Institute estimated the subsidy expiration would raise average annual premiums by $750 to $4,035, depending on income.
ACA insurers requested a median premium increase of 15% for 2027 after a median finalized increase of 20% for 2026, the second consecutive year of double-digit hikes, according to a Peterson-KFF Health System Tracker analysis, citing the subsidy expiration and a sicker risk pool.
Beginning in 2027, HR 1 requires most adults covered through the ACA’s Medicaid expansion to document 80 hours a month of work or other qualifying activities unless they are exempt, and states must check their eligibility every six months. Federally funded Medicaid eligibility also narrowed Oct. 1 for certain immigrants, including refugees and asylees. The CBO projects the Medicaid changes will reduce enrollment by 11.5 million over the next decade, while the law’s marketplace provisions and rising premiums will cut marketplace enrollment by 7.5 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 federal policy changes could push the uninsured population to 37 million by 2036, about the same as in 2014, when most of the ACA’s coverage expansions took effect. Sara Collins, the report’s lead author and a senior scholar and vice president at the foundation, said the country is close to reversing years of coverage gains and called on Congress to restore the enhanced marketplace subsidies and reverse the Medicaid cuts.
Joseph Betancourt, MD, the foundation’s president, said in a news release that patients are skipping doctor’s visits and medications they can’t afford, and “treatable illnesses become medical emergencies.” Half of working-age adults went without needed care because of cost in 2026, up from 46% in 2022, the survey also found.
Younger and lower-income adults have been hit the hardest so far, per the survey. The uninsured rate for adults ages 19 to 34 rose to 16% 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 published Oct. 22, covered employees 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, workers’ wages grew only 3.7%.
And just because someone has insurance, it does not mean they necessarily have the full services they need. The Commonwealth Fund also found 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 and 23% who were underinsured.
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