One of the most significant achievements in US healthcare over the past two decades has been the steady reduction in the number of Americans without health insurance. In 2010, when the Affordable Care Act (ACA) was signed into law, 16 percent of the population lacked coverage. By 2025, government estimates showed that figure had dropped to 8.3 percent, nearly halving the uninsured rate.
Progress Under Threat
While having insurance does not guarantee affordable care or easy access to doctors, it marked meaningful progress toward universal coverage in a country that remains the only developed nation without it. However, recent policy decisions are now reversing these gains.
Last year, Republicans used their legislative vehicle, the One Big Beautiful Bill (OBBBA), to target the ACA. They introduced work requirements for Medicaid expansion enrollees and allowed enhanced premium subsidies for marketplace plans to expire. As a result, millions are losing coverage this year, with many more expected to follow.
Historically, spikes in the uninsured rate were tied to economic downturns, but this time the cause is deliberate policy. Larry Levitt, executive vice president for health policy at KFF, noted, 'There is no historical precedent for such a rollback in federal support for health coverage. The expected effects are self-inflicted and dwarf even the losses from economic changes.'
Marketplace Enrollment Collapse
The ACA expanded coverage through marketplaces where individuals and families could buy private plans with subsidies. Enrollment surged after 2021 when Democrats expanded subsidies to all income levels, capping premiums at a percentage of income. Marketplace enrollment grew from 9.8 million in 2019 to 22.3 million in 2025.
But those enhanced subsidies expired in 2026, and the Republican-controlled Congress did not renew them. Early data from KFF shows a projected 4.7 million drop in marketplace enrollment for 2026 compared to 2025, a 21 percent decline in one year.
Medicaid Work Requirements
The ACA also expanded Medicaid eligibility to those earning up to 133 percent of the poverty level. As of June 2025, over 16 million newly eligible Americans were enrolled. The OBBBA imposed national work requirements for expansion enrollees, mandating 80 hours of work or approved activities per month, with exemptions for some groups.
Historical precedent from Arkansas, the only state to previously implement such requirements, shows that many lose coverage due to administrative burdens rather than ineligibility. The RAND Corporation estimates Medicaid enrollment will drop by 7.6 million by 2034.
These losses have real consequences: insured Americans accrue less medical debt, attend routine checkups more often, and benefit from screenings. Research links Medicaid expansion to tens of thousands of lives saved. The rising uninsured rate will not just change statistics but will harm the health and survival of millions.
