The Coverage Shift Has Already Started

November 11, 2026

The Uninsured Surge: What Coverage Losses Mean for Patients and Hospitals

An Interview with Dr. Prioreschi, Middlesex Health

The Monday Huddle #1

A Provider Compensation Software, Shaped by Healthcare Teams

For much of the past year, healthcare organizations have discussed potential coverage losses as a future concern. The latest data suggest the shift has already begun.

Enhanced Affordable Care Act premium tax credits expired at the end of 2025. Those credits had reduced what individuals and families paid for Marketplace coverage and helped drive enrollment to record levels. Their expiration, combined with new eligibility and enrollment requirements, has changed both coverage costs and the number of people maintaining it.

The implications extend beyond the individual insurance market. Hospitals and health systems need to understand how changing coverage may affect payer mix, patient access, bad debt, uncompensated care, and demand across service lines.

The 2026 Coverage Picture

Measure	2026 Signal	What It Means
Marketplace plan selections	Down 5%	About 1.2 million fewer selections than in 2025
Individual market enrollment	Down 18%	More than 4.6 million fewer enrollees by June 2026
Average monthly premium payment	Up 58%	$113 in 2025 to $178 in 2026
Average Marketplace deductible	Up 37%	A $1,027 increase to a record $3,786
Bronze plan selection	30% to 40%	More consumers chose lower premiums with higher cost sharing

Enrollment Is Moving in the Wrong Direction

During the 2026 open-enrollment period, 23.1 million consumers selected or were automatically reenrolled in Marketplace plans. That represented approximately 1.2 million fewer plan selections than in 2025, a 5% decline. New consumer enrollment fell 13%, while automatic reenrollment declined 19%.^[1]

The decline continued after open enrollment. KFF’s analysis of insurer regulatory filings found that total individual-market enrollment fell from approximately 25.2 million people in June 2025 to 20.5 million in June 2026. That is a decrease of more than 4.6 million people, or 18%, in one year. Approximately nine out of ten people in the individual insurance market receive their coverage through an ACA Marketplace.^[2]

This does not mean that all 4.6 million people became uninsured. Some may have moved to employer-sponsored coverage, Medicaid, Medicare, or another source of insurance. The available data do not yet show where every person went.

Nevertheless, an 18% reduction in individual-market enrollment is a meaningful early warning for healthcare organizations, particularly those serving communities with high Marketplace participation, limited employer-sponsored coverage, or large rural populations.

Patients Who Retained Coverage Are Paying More

Enrollment is only part of the story. The coverage people retained also became more expensive.

Average monthly premium payments increased 58%, from $113 in 2025 to $178 in 2026.
Average Marketplace deductibles increased 37%, rising by $1,027 to a record $3,786.
The percentage of consumers choosing bronze plans increased from 30% to 40%.
The share selecting plans with cost-sharing reductions fell to its lowest level on record.
The percentage of consumers receiving premium tax credits declined from 92% to 87%.^[3]

These changes matter even when a patient technically remains insured. A patient with a high deductible may postpone an office visit, diagnostic study, procedure or prescription because the out-of-pocket cost is unaffordable. Coverage on paper does not necessarily translate into timely access to care.

This creates two related risks for hospitals: more patients may enter the system without insurance, and more insured patients may delay care because they cannot afford to use their coverage.

2026 Is the Beginning of the Transition

The expiration of the enhanced premium tax credits is not the only coverage change facing healthcare organizations.

The 2025 federal reconciliation law made additional changes to Medicaid and the ACA Marketplaces. Beginning in 2027, states generally must implement work or community-engagement requirements for certain adults covered through Medicaid expansion. The federal requirement includes 80 hours per month of qualifying work or other approved activities, subject to exemptions.^[4]

Additional Marketplace eligibility and verification changes are also being implemented. CMS has already resumed enforcement involving individuals who did not file tax returns and reconcile prior advance premium tax credits. Approximately 366,000 households had premium assistance removed during the 2026 reenrollment process under that policy.^[5]

Not all enrollment reductions represent eligible people losing coverage. CMS has also removed unauthorized, duplicate, or otherwise improper enrollments. That program-integrity activity should be distinguished from people leaving coverage because premiums or deductibles became unaffordable.

The overall direction, however, remains clear. The Congressional Budget Office projects that the number of uninsured people will grow from approximately 30 million in 2026 to 37 million in 2036, largely because of provisions expected to reduce Medicaid and CHIP enrollment and, to a lesser extent, Marketplace enrollment.^[6]

Why This Matters to Hospitals

Payer mix. Organizations may see commercially insured or Marketplace-covered patients shift into self-pay, charity care, or Medicaid categories. Even modest payer-mix changes can materially affect service-line economics.

Uncompensated care and bad debt. The American Hospital Association has warned that coverage losses will increase hospital financial pressure through higher uncompensated care and bad debt. An AHA-supported analysis estimated that expiration of the enhanced premium tax credits could reduce hospital spending by approximately $28 billion over ten years.^[7]

Delayed and deferred care. Higher premiums and deductibles may cause patients to delay primary care, diagnostic testing, specialty consultations, and elective procedures. Patients may eventually present with greater clinical complexity or require more resource-intensive care.

Service-line planning. Service lines with significant Marketplace or Medicaid exposure may experience changes in demand, reimbursement, and patient financial responsibility. Strategic growth assumptions based on prior payer mix may no longer be reliable.

Rural and safety-net vulnerability. Hospitals serving rural, low-income or medically underserved populations may experience the effects earlier because their patients often have fewer coverage alternatives and fewer nonhospital access points.

What Leadership Should Examine Now

This is not a reason for hospitals to make decisions based on projections alone. It is a reason to identify whether the national coverage shift is already visible locally. Leadership teams should begin reviewing:

Marketplace, Medicaid, and self-pay volumes by month
Changes in charity-care applications and bad debt
Eligibility denials and coverage-verification failures
Patient cancellations related to financial concerns
Deferred diagnostic tests and elective procedures
Changes in primary and specialty care access
Payer mix by service line
High-deductible plan exposure
Financial-counseling and Medicaid-redetermination capacity
Community populations most vulnerable to losing coverage

Organizations should also model multiple scenarios rather than rely on one national projection. The effect will vary by state, Medicaid-expansion status, local employment patterns, rurality, and the proportion of patients who previously relied on enhanced Marketplace assistance.

The Leadership Takeaway

Hospitals do not yet have complete data showing where every individual who left Marketplace coverage ultimately went. They should not assume that every enrollment decline represents a newly uninsured patient. They also should not wait for perfect data before examining the potential impact.

“The important question is not simply how many people have left the individual insurance market. Hospital leaders need to understand where those patients are going, whether they are delaying care, and how the change is beginning to affect payer mix, patient access, and service-line performance. The coverage shift has already started. The work now is determining what it means in each market.”
Kelly Witter, RN, MSN, CLC, CNE | Senior Consultant | Dynafios

The most prepared organizations will not treat coverage change solely as a policy or reimbursement issue. They will recognize it as a patient-access, operating and service-line planning issue and begin measuring it accordingly.