Sign-ups were already down in January by about from last year’s . For this year, enrollees then faced premiums that increased, on average, . On top of that, subsidies that help people purchase coverage shrank or vanished.

Now experts are watching how many of the approximately 23 million people who enrolled will fail to pay their share of premiums.

While available data on premium payments is mainly from January, a few states that run their own ACA markets have released information for later months. The sharpest drop in people paying premiums, based on limited data, is , which saw a 28% drop in April compared with the same period a year ago, according to an analysis by Charles Gaba, a healthcare policy analyst and blogger who specializes in the ACA.

The news website NOTUS that it had internal Centers for Medicare & Medicaid Services data showing that roughly 21% of people using the federal ACA marketplace 鈥� 鈥� failed to pay their share of January premiums, which, if correct, is far higher than at the same time last year.

CMS did not answer questions from 麻豆女优 Health News about the enrollment data.

In looking at the early numbers analysts released, “we can’t yet quantify how much worse it will be than in previous years, but it will absolutely be worse because of the sticker shock,” said Ellen Montz, a managing director with the Manatt Health consultancy, who helped oversee the ACA during her tenure with the Biden administration.

The initial results come amid rising public concern about affordability, that are often .

A 麻豆女优 analysis , for instance, found that the average ACA plan deductible saw the steepest increase in history 鈥� growing by 37%, or over $1,000, from $2,759 in 2025 to $3,786 in 2026 as enhanced premium tax credits expired.

Those rising costs pose a political challenge for President Donald Trump and the broader GOP, which has opposed enhanced subsidies to help people purchase Obamacare coverage. Republican lawmakers also passed a spending package last year 鈥� enacted as the One Big Beautiful Bill Act 鈥� that included provisions expected to reduce ACA enrollment and fueling higher premiums this year.

The enrollment reductions “are real people with real consequences,” Montz said. “The Affordable Care Act is a political lightning rod, but it’s a critical component of the coverage landscape.”

Following the Numbers

Right now, the drop-off rate aligns with what some policy experts predicted, partly because Congress did not extend generous benefits that expired at the end of last year. Those enhanced subsidies had been in place since 2021.

“Overall, the individual market does appear to be trending toward a significant contraction in 2026, and may well resemble” drops projected by the , said a , an analysis arm of the HMA Co.

Based on its analysis, drawn from data provided by 75 insurers, Wakely estimates that average ACA enrollment will end up being 17% to 26% lower this year than last.

So far, the Wakely report says, an average 86% of enrollees made their first payment in January.

Failure to pay premiums varied by state. Those with the lowest drop-off rates had enacted additional help 鈥� such as backfilling part or all of the reduced subsidy amounts with state money 鈥� or experienced lower premium increases. States that run their own exchanges had higher payment rates (92%) than those served by the federal marketplace (82% to 84%).

Gaba’s initial analysis of data includes more recent numbers from nine of the 20 states that run their own Obamacare marketplaces.

“Georgia could be fairly representative” of other states that did not enact additional protections, Gaba said. For example, payment failure rates, year over year, were 11.6% as of April in New Jersey, and, as of February, 15.7% in Washington state and 8.5% in California.

Only one state in his sample 鈥� New Mexico 鈥� saw an increase in the percentage of people making premium payments, according to the latest available monthly data. Unlike most, it to fully make up for the lower federal subsidy amounts.

Enrollment figures for the ACA are never static. Traditionally, more people sign up 鈥� either through auto reenrollment or by taking initiative to shop 鈥� than actually pay premiums, so the numbers tend to be higher at the start of the year.

People drop out over the course of a year for many reasons, such as finding other coverage through a job or by marrying someone with insurance.

Cost, of course, is a factor. This year, because premiums went up and subsidies went down, many people faced what they previously paid toward their coverage.

And the Trump administration ended a special enrollment program that let low-income people enroll year-round.

drops should not be seen solely in the context of rising costs. Paragon Health Institute, a free-market think tank that has become influential among conservatives on Capitol Hill, has long argued that record enrollment numbers in recent years were fueled by fraudulent sign-ups, perhaps in the millions.

, , and policy experts took issue with the methodology Paragon used to estimate improper enrollments, saying they likely were vastly overestimated.

In a , the organization’s president, Brian Blase, doubled down on the fraud findings. Using data that detailed how many people failed to make premium payments each year, on average, from 2014 to 2019 鈥� the year before covid emerged and two years before enhanced subsidies kicked in 鈥� he offered this prediction for 2026: About 19 million people would be enrolled by year’s end. Even at that, the note says, the “market would be 90% higher than the pre-COVID average.”

For other experts, however, the biggest explanation for falling enrollment is cost.

Some people had never experienced the ACA before the enhanced tax credits kicked in, so they faced extra sticker shock.

“In economic theory, no matter whether one is left, right, or center, it’s a simple fact that when you raise prices of something, fewer people will buy it,” said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University.

The Long View

The expectation of a lower enrollment trend holding up is one of the key factors likely to translate into higher cost estimates as insurers draw up 2027 rates.

For one thing, though it is still unclear how many people will stay enrolled, it is also unknown whether those enrollees will submit more medical claims than insurers projected. It’s generally thought that younger or healthier people are more likely to drop coverage when faced with growing premiums.

Secondly, there has been a sharp shift by consumers to purchase bronze-level plans, which have smaller monthly premiums but higher deductibles 鈥� the amount people must pay out-of-pocket for most treatment, except preventive care, before insurers pitch in. The found that sign-ups for bronze plans jumped from 30% to 40% of total plan selections 鈥� growing from 7.3 million in 2025 to 9.2 million people this year. Will they pay? Or will hospitals and doctors be on the hook for uncollected copays or deductibles, and then raise prices to compensate?

Insurers base their premiums, in part, on such analyses.

Another troubling factor for actuaries is the late posting of a key regulation that sets the next year’s rules for ACA health plans. The initial 2027 proposal from the Trump administration came out in mid-February and included aggressive new ideas 鈥� such as sharply increasing deductibles for certain types of ACA plans or allowing insurers to offer plans with no set networks of medical providers. It was , well into the time when insurers are calculating premiums for the following year. Many of the proposed changes, with some modifications, were approved, such as allowing for higher annual deductibles in some types of coverage.

“This is definitely a challenging year to be an actuary,” said Louise Norris, a health policy analyst for healthinsurance.org, a consumer information and referral website affiliated with Trove Group, an insurance agency.

“We know for sure that the individual market has gotten smaller and almost certainly sicker, as the people dropping coverage are more likely to be healthy.”

While they “aren’t waving huge red flags” yet, insurers are closely watching trends, said Michelle Anderson, a director at Wakely and co-author of the recent report.

Anderson does not expect an average 26% premium increase like the one seen this year.

Still, Anderson expects the ongoing uncertainty and predicted decline in enrollment, which will vary by state and insurer, to play a role in setting next year’s premium rates.

“It would not surprise me if there were some double-digit increases,” Anderson said.

麻豆女优 Health News reporter Rachel Spears contributed to this article.

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Recently divorced, the former stay-at-home mother had started working again in her mid-40s, taking a human resources job that paid $41,000 a year. Then, despite having insurance, she was hit with more than $8,000 in medical bills.

“I had my car and a basket of clothes,” Roberts recalled. “Medical bills were not something I could have afforded.”

Roberts sought financial assistance from CentraCare, the St. Cloud-based health system that treated her. It’s a nonprofit charity that receives millions of dollars in federal, state, and local tax breaks. In exchange, it’s obliged to offer charity care to patients who can’t afford their medical bills. But Roberts said CentraCare told her she made too much to qualify.

Roberts instead scrimped on groceries and Christmas gifts for her kids and paid off more than $6,000 over two years. Then CentraCare sued her last year because she hadn’t paid off all the debt.

“They’re supposed to be a nonprofit,” Roberts said. “It’s like, ‘Come on!’”

CentraCare earmarks a tiny fraction of its budget for helping patients with medical bills they can’t pay, but it’s not alone, a Minnesota Star Tribune-麻豆女优 Health News investigation found.

Minnesota’s hospitals and health systems are among the least charitable in the country, the investigation found, providing less financial aid as a percentage of their operating budgets on average than hospitals in almost every other state, including Illinois, Iowa, Nevada, and Texas.

The investigation drew on a detailed review of every hospital charity care program in the state, an analysis of five years of hospital financial data, and dozens of interviews with patients, hospital executives, and state officials.

Nationally, hospitals spend an average of about 2.4% of their operating budgets on charity care, according to federal hospital data compiled by Hossein Zare, a researcher at Johns Hopkins University. Minnesota hospitals spend about a third of that, on average.

Some spend considerably less. Of Minnesota’s 123 general hospitals, 62 devoted less than 0.5% of their operating budgets to charity care from 2020 through 2024, the Star Tribune-麻豆女优 Health News investigation found.

“The system is not working,” said Erin Hartung, director of legal services at Cancer Legal Care, a Minnesota nonprofit that helps patients with medical debt and other financial challenges. “And the burden is falling hardest on the people who are least able to bear it.”

CentraCare’s flagship St. Cloud Hospital spent less than 0.25%, according to the analysis. That works out to $25 in patient aid for every $10,000 spent on hospital operations.

Charity care will become even more vital in coming years as Minnesotans lose health coverage or can’t afford rising copays and deductibles. The state’s uninsured rate rose sharply last year, since 2017, and it’s expected to increase further as budget cuts pushed by President Donald Trump force states to pare Medicaid and other safety net programs. Charity care is also critical to many people with health insurance who can’t afford their bills.

Hospital officials say it’s unfair to expect them to solve this affordability problem when many of their facilities are financially strained. “No amount of charity care from hospitals will ever fully meet the needs of uninsured or underinsured Minnesotans. The need is simply too great,” Minnesota Hospital Association spokesperson Tim Nelson said in a statement.

But state Attorney General Keith Ellison said hospitals have a duty to boost charitable help for all needy patients in exchange for the tax breaks they receive.

“There is a benefit you get from being a nonprofit hospital in the state of Minnesota,” he said. “But do the people get the benefit?”

Several small Minnesota hospitals give financial aid to fewer than two dozen patients a year. Mahnomen Health Center, which recently converted to a rural emergency center, didn’t provide any charity care in eight years, despite serving one of Minnesota’s . Other hospitals serving large low-income populations were among those providing the least charity care, the analysis found.

Several factors help explain why Minnesota hospitals provide so little financial aid. For one, job-based insurance and an expanded Medicaid program offer broad coverage. Hospitals in states with less government assistance and more uninsured people typically spend more on charity care.

But Minnesota patients also face significant barriers accessing financial aid at many hospitals, including inconsistent eligibility standards and extensive applications, the Star Tribune-麻豆女优 Health News investigation found.

To qualify at many hospitals, patients must submit detailed personal information, including bank statements, retirement accounts, mortgage documents, and estimates of other assets such as cars, homes, or livestock.

And because Minnesota has not standardized the criteria for charity care, patients might receive aid at one hospital but not another. The investigation found that some hospitals give free care to patients with an annual household income of $47,000, while others cap it at about $15,000.

Had Roberts driven 30 miles east to Princeton or 35 miles north to Little Falls, she would have found medical providers with more generous financial aid policies than CentraCare. But she didn’t know to look.

Roberts, now 49, has remarried and lives in a split-level home in St. Cloud decorated with inspirational plaques such as “Faith, Family, Friends.” CentraCare recently dropped the lawsuit against her, but only after she took out a loan against her retirement plan to pay off the medical debt. “It just feels very unfair,” she said.

‘We Have To Defend Being Paid’

CentraCare spokesperson Karna Fronden said medical privacy laws prevented her from discussing Roberts’ case. She also declined interview requests about the health system’s charity care spending.

In a statement, Fronden said CentraCare provides assistance in addition to charity care, such as helping enroll patients in insurance. “This helps provide broader, longer-term protection for patients,” she said.

Other hospital leaders said they serve their communities in ways besides forgiving medical bills, including training doctors and nurses and preserving money-losing services such as obstetrics and mental health care.

“Rural hospitals like ours are often portrayed as though we are sitting on piles of cash and simply choosing not to spend it on charity care. That is far from the reality,” said Robert Pastor, chief executive of Rainy Lake Medical Center in International Falls.

“We are the second- or third-largest employer in town, running on razor-thin margins while navigating escalating labor and supply costs and routine underpayment by public programs,” Pastor said. “Meanwhile, many health insurers post billions in profits.”

Hospitals typically are paid less for care provided to Medicare and Medicaid patients. More than 80% of Rainy Lake’s patients are on one of those government programs.

Minnesota hospitals collectively write off about $200 million of what’s deemed bad debt every year after trying unsuccessfully to collect unpaid bills from patients through calls, letters, and even lawsuits. By comparison, they devote about $163 million annually to charity care, state figures show. In 2024, hospitals collectively posted $2.4 billion in net income.

“I feel like I’m put in the position, being the hospital, where we have to defend being paid,” said Patti Banks, the head of Ely-Bloomenson Community Hospital and a senior Minnesota Hospital Association board member.

Some hospitals face intense financial pressures. Thirty-one have lost money on operations in four of the past eight years. HCMC in Minneapolis — the state’s largest safety net hospital, which provides the most charity care — is losing so much money that, without additional taxpayer support, .

But larger health systems such as Mayo Clinic, Essentia Health, and Sanford Health have remained financially sound. And the operating margins at most CentraCare hospitals exceeded 10% in 2024, state data shows.

Medical Debt’s High Toll

Nationwide, health care debt — much of it from hospitals — burdens an estimated 100 million people, increasing their stress and even leading to premature deaths, .

Abby Kelley-Hands, a special education coordinator in St. Paul, has a rare immune condition that causes frequent, severe allergic reactions. Her illness can be controlled only with a costly drug, which a Mayo Clinic doctor prescribed.

When Kelley-Hands briefly lost health coverage in 2021 in an insurance mix-up, she was hit with more than $20,000 in bills. And although she and her husband earned less than $100,000 a year, Kelley-Hands said Mayo denied her financial assistance because she earned too much.

“I was in tears,” Kelley-Hands said. “It was so scary and so hard. And it causes all of this additional stress, which then makes you sicker and less able to even figure things out.”

Kelley-Hands and her husband sold a car and agreed to a payment plan before Mayo would resume her treatment, she said. Her husband now bikes 5 miles to work. They have no dishwasher. And she and her husband took a honeymoon only last fall, seven years after their wedding. “We live very simply,” she said.

Mayo spokesperson Kristyn Jacobson declined to discuss Kelley-Hands’ case.

In 2024, state lawmakers from denying care to patients with outstanding debt. And in 2025, Attorney General Ellison reached an agreement with Mayo to overhaul its charity care program after an investigation found the multibillion-dollar institution was systematically discouraging patients from applying.

After the state began investigating Mayo, the system’s , topping 1.5% of operating expenses in 2024.

‘Optimized To Get Payment’

Complying with a 2023 , Minnesota hospitals now post their financial aid policies online, although several, including CCM Health in Montevideo and Northfield Hospital, did so only after being contacted by the Star Tribune or 麻豆女优 Health News.

But many hospitals make financial aid more difficult to find than information about paying bills, said Jared Walker, founder of Dollar For, a nonprofit that helps patients nationally apply for charity care.

“Hospitals have optimized to get payment,” he said. “If you want to get on a payment plan, if you want to get on a credit card, it’s so easy.”

Glacial Ridge Health System in Glenwood posts a “Bill Pay” tab at the . But it takes several clicks to find the hospital’s financial assistance plan. The information couldn’t be found on the site searching for “charity care” or “financial assistance.” The public hospital 130 miles northwest of Minneapolis devoted less than 0.7% of its operating budget to charity care from 2019 to 2024.

Patients in interviews frequently said they weren’t told about charity care.

Joe Robling, 29, was treated at St. Francis Regional Medical Center in Shakopee for a broken pelvis and fractured spine after a 2024 motorcycle accident. His mother, Janet, who helped him navigate the bills, said the hospital never informed him about financial aid.

“They didn’t offer any of that,” she said.

Robling, a construction worker in Henderson, was between jobs and uninsured. “He had zippo,” Janet Robling said. “What he had in reserves were all depleted.”

The Allina Health-affiliated hospital billed him more than $19,000, the Roblings said.

An internet ad connected the family to Dollar For, which helped Robling qualify for charity care five months after his accident.

Allina spokesperson Jennifer Steingas declined to comment on the case, citing medical privacy restrictions, but said the health system has since reached out to the family.

In another case, M Health Fairview’s University of Minnesota Medical Center didn’t offer financial aid to an unemployed and uninsured man from Idaho while he was hospitalized for two months for psychiatric care and amassed $150,000 in bills.

Attorney Margaret Henehan, who represented the man, said the hospital instead offered him a two-year payment plan at $6,500 a month. “He had no income, which he told Fairview,” Henehan said.

The man, who is not identified because of his mental health condition, eventually received charity care after his sister, a doctor, reached out to Henehan for help.

Aimee Jordan, a Fairview spokesperson, said she couldn’t comment on the case because of patient privacy laws, but she said patients who are offered payment plans can always apply for charity care, even after a hospitalization.

A Maze of Standards

State law prohibits hospitals from making “unreasonable” demands of patients when they apply for charity care. But the law sets few specific standards.

The result is a dizzying array of policies, including 11 income thresholds used by Minnesota hospitals to determine whether patients qualify for free care, the Minnesota Star-Tribune-麻豆女优 Health News review found.

HCMC parent company in Minneapolis and Olmsted Medical Center in Rochester offer the highest threshold for free care, at — almost $48,000 a year for an individual.

Sometimes standards vary even between neighboring hospitals. Madelia Health in south-central Minnesota to patients who make less than twice the federal poverty level. About 13 miles away at Mayo’s hospital in St. James, can qualify for aid.

To determine eligibility, some Minnesota hospitals consider only income, but most demand information about patients’ bank accounts as well. More than two-thirds require even more information, including the value of retirement accounts, life insurance policies, property, and vehicles. Madelia’s “may be required to sell recreational vehicles.”

Stringent requirements ensure that limited resources go to patients who need them, said Travis Olsen, chief executive of Hendricks Community Hospital, near the South Dakota border. “We don’t feel it’s fair for someone with lower annual income but yet owns numerous acres of land, debt-free, to be able to qualify for charity care.”

In addition to copies of tax returns, W-2 forms, pay stubs, and bank statements, 53 questions about their finances. These include questions about the make, model, and value of vehicles; the current market value of farm equipment, livestock, and land; and the purchase price and square footage of homes.

Other hospital applications ask patients to detail their monthly spending on food, utilities, and other medical bills.

Olsen said community pressure is more of a deterrent to applying for aid than the application: “People are too proud to pick up an application. We all know each other.”

But Walker at Dollar For said the biggest barrier is complexity. “The drop-off rates are much higher the more questions you ask and the more documentation you have to provide,” he said.

Arleen Mullenax had a cancerous tumor removed from her neck at Mayo in Rochester. Assembling her aid application and following up with the hospital billing department amid her “cancer fog” was almost more than she could take, she said.

“I knew as a former office manager I had to stay on top of it,” she said. “But it was the most daunting thing I had to do as a patient.”

Fixing the System

Ellison and several state lawmakers say Minnesota’s hospitals should make it simpler for patients to access charity care.

They’ve called for, among other things, common eligibility standards and a standard application across hospitals. New York and Maryland already have both.

“Eliminating as many barriers as possible for people is really important,” said state Sen. Liz Boldon, who also said she hopes lawmakers can enact these standards next session.

The Minnesota Hospital Association has opposed standardizing financial assistance, saying hospital boards are in the best position to assess the need for charity care in their communities. “Adding mandates for providers across the state will not close that gap, and will only increase bureaucratic and procedural barriers to patient care,” spokesperson Nelson said.

Ellison also has pushed to require hospitals to use a process that automatically screens and qualifies low-income patients for financial aid without requiring an application.

Some hospital systems, including South Dakota-based Sanford Health, already use software that checks patients’ eligibility based on information such as their credit history, said Nick Olson, the system’s chief financial officer. At Sanford Health’s 10 hospitals in Minnesota, about a quarter of the patients who receive financial aid get it this way, he said.

Nearly all Sanford hospitals devote more than 1% of their operating expenditures to charity care — higher than most hospitals in the state.

Screening software can be costly. Several executives at small Minnesota hospitals said they can’t afford it. But there are other options. In California, Los Angeles County is developing a public system to allow hospitals to quickly assess patients’ eligibility so they don’t have to buy a system themselves.

Other states — including Texas and Nevada — have laws requiring hospitals to provide minimum amounts of charity care.

Back in St. Cloud, Roberts said that when she drives past CentraCare’s $200 million expansion at its Plaza campus in St. Cloud, she wonders why Minnesota hospitals don’t live up to higher standards themselves.

“They have all the money,” she said. “But they can’t grant a good person some grace?”

Minnesota Star Tribune staff writers Bill Lukitsch and Victor Stefanescu contributed to this report.

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Public schools and her church’s pantry help Lafortune accomplish the first two goals. But insurance to cover doctor visits has been the most difficult to secure.

As nursing assistants at a traumatic brain injury rehab center near Tampa, Florida, Lafortune and her husband cannot afford the health insurance benefits offered by their employer. And they earn too much for their daughters to qualify for subsidized coverage through , the state’s safety net health insurance program for children in low-income families.

Her family also can’t afford the $525 monthly cost to enroll her two daughters in KidCare at full price, so she purchased a family plan for $500 a month on the Affordable Care Act marketplace with no dental coverage and higher out-of-pocket costs.

“KidCare is better for children,” she said. “But at least I have something for them.”

In 2023, Florida lawmakers unanimously approved expanding KidCare to close the gaps for families like Lafortune’s, raising the eligibility threshold so that coverage would extend to more than 40,000 children. But the expanded coverage has not taken effect 鈥� even after it was approved by federal regulators following a federal lawsuit 鈥� because the administration of Florida Gov. Ron DeSantis, a Republican, has not implemented the changes.

Instead, Florida’s KidCare expansion has been mired in lawsuits and ongoing negotiations between the state and federal regulators. While the delay continues, Florida could be violating the law.

“I don’t know what they’re waiting for,” Lafortune said. “They should see people in Florida have needs.”

Asked to comment on the delay, DeSantis’ office referred 麻豆女优 Health News to a on March 31, during which the governor directed questions to the state’s Agency for Health Care Administration, which oversees KidCare. The state agency did not respond to 麻豆女优 Health News’ repeated requests for an interview or information on the delayed expansion.

Entitlement vs. Personal Responsibility

At issue is a , adopted under the Biden administration, that requires all states to continue to provide 12 months of coverage for children in Medicaid and in the Children’s Health Insurance Program, known as KidCare in Florida. That means insurance coverage would not lapse even if parents miss a monthly premium payment.

But only Florida has challenged the rule in court, suing the federal government for the right to disenroll children from KidCare for unpaid premiums and delaying the planned expansion.

“We’ve had to do a lot of back and forth with CMS on various things,” DeSantis said during the March press conference, referring to the Centers for Medicare & Medicaid Services, which regulates public health insurance programs.

In December, Texas also said it opposed the rule. Cecile Erwin Young, who was then the executive commissioner of Texas Health and Human Services, wrote to Mehmet Oz, the CMS administrator, asking him to rescind CHIP rules that require states to keep children enrolled for 12 months at a time, prohibit waiting periods for coverage, and prevent states from imposing financial benefit limits.

“These policy changes effectively redefine CHIP to be more like an entitlement program 鈥� a strategy not supported by law and which conflicts with the core program design adopted by Texas,” Young wrote.

Like Texas, Florida views KidCare as a “personal responsibility program” designed to help families by “supporting independence and a ladder towards economic self sufficiency,” according to legal filings and .

“It’s something that goes back to this mentality of people needing to pull themselves up by their bootstraps,” said , policy director for the Florida Health Justice Project. The nonprofit legal aid group, together with the National Health Law Program, on March 9, asking a judge to order the state to implement the approved expansion.

The state agencies had not filed a response to that lawsuit as of April 22. The court ordered the state to explain by mid-May why the expansion should not be implemented.

Williams called the state’s tactic “largely political theater.”

Health policy researchers and advocates also noted that Florida’s refusal to implement the KidCare expansion goes against the Trump administration’s strategy to “.” Last year, a commission appointed by President Donald Trump recommended a series of policy changes, including a collaboration between CMS and state CHIP programs, to promote “evidence-based prevention and wellness initiatives for children at the local level.”

Numerous studies have found that CHIP coverage can improve children’s health by , , and .

“This should go without saying, but you can’t make children healthy again by taking away their health coverage,” said , chief strategy and development officer for Florida Policy Institute, a nonprofit that has advocated for the state to implement the KidCare expansion.

The White House did not respond to a request for comment on Florida’s and Texas’ opposition to the rule requiring continuous enrollment in CHIP.

Those two states have among the . In Texas, more than 1 million children, or 13.5%, have no health insurance, while in Florida more than 400,000 children, or 8.5%, are uninsured.

Texas has followed the federal rule on continuous coverage despite its opposition, but Florida has ignored the requirement and continues to disenroll children for unpaid premiums.

Choosing Between School Supplies and Health Insurance

According to the Florida Healthy Kids Corp., the nonprofit contracted by the state to determine eligibility for and administer KidCare, about 250,000 children received subsidized coverage from Dec. 1, 2024, to Nov. 30, 2025. Of those, 43,000 children were disenrolled after their parents failed to pay the premium.

, director of the Center for Children and Families at Georgetown University, said the Trump administration should act on the evidence that Florida is the only state defying the rule.

“Thousands and thousands of children are routinely losing their coverage in violation of federal law,” she said, “and the Trump administration has done nothing about that. At the same time, they’re pulling money from states like Minnesota for alleged fraud violations that haven’t even been proven yet.”

Families tend to miss premium payments in July and August, when it’s time to buy back-to-school supplies, and again in December and January, around the holidays, Alker said.

“That is very, very sad,” Alker said. “You have working parents here who are struggling and they have to choose between their child’s school supplies and their health insurance.”

This year, enrollment in KidCare has fallen below the state’s projections, leading to a $32 million surplus in the program. On April 17, legislators from the program and redirect it to the general fund, with that the expansion had not yet been implemented.

Lawmakers voted to expand KidCare eligibility to families earning up to 300% of the federal poverty level. The change would raise the income threshold for a family of four from about $5,500 a month to about $8,250 a month. Monthly premiums for subsidized coverage would also rise, from the current $15 to $20 a month to a maximum of $195 a month, regardless of the number of children a family enrolls.

The program provides coverage than ACA marketplace plans. KidCare has no deductible or coinsurance, and maximum copayments of $15. It also includes dental and vision coverage.

With her ACA plan, Lafortune must pay a $35 copayment for doctor visits. Her family deductible is $1,600, and the coinsurance 鈥� or the share of covered services she must pay after meeting the deductible 鈥� is 20%. The plan’s maximum out-of-pocket cost is $7,250.

“I tried to get something cheaper, but it’s not like I cannot have it,” Lafortune said of the need for health insurance. “I have to do something.”

The state’s initial lawsuit challenging the continuous eligibility rule was dismissed in May 2024, and a second lawsuit was withdrawn this February. The state and CMS told the judge they were “working to determine the most expeditious way to resolve the dispute” and have yet to update the court on their discussions.

But three days after withdrawing the lawsuit, Florida sued CMS for a third time, accusing the federal agency of ignoring the state’s public records request related to CMS’ approval of the KidCare expansion.

As the legal wrangling continues, the cost of health insurance has skyrocketed.

For those with ACA marketplace coverage, the expiration of enhanced subsidies has hit hard. About half of those who re-enrolled in ACA marketplace coverage for 2026 said their healthcare costs are “a lot higher” this year, according to .

For Lafortune, Florida’s KidCare expansion can’t come soon enough.

“Children are the ones who are going to replace everyone here,” she said. “When you give them opportunities 鈥� for their health, for school, to eat 鈥� you make your country healthy and better.”

Are you struggling to afford your health insurance? Have you decided to forgo coverage? Click here鈥痶o contact 麻豆女优 Health News and share your story.

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LISTEN: Can’t afford health insurance this year? Don’t be afraid to talk to your doctor about money and the cost of care. On WAMU’s “Health Hub” on March 4, 麻豆女优 Health News correspondent Sam Whitehead shared tips for people seeking affordable options without skipping care.

Health insurance could be out of reach for many Americans in 2026.

About a for Affordable Care Act marketplace coverage this year. The Congressional Budget Office told lawmakers that more could opt out in coming years after the GOP-led Congress let expire subsidies that helped many afford a plan. Meanwhile, plan premiums jumped, and new, stricter Medicaid eligibility rules kicked in.

If you lost health insurance this year, there may be ways to see the doctor without breaking the bank. On March 4, in conversation with WAMU host Esther Ciammachilli, 麻豆女优 Health News correspondent Sam Whitehead shared tips on .

Renuka Rayasam and Taylor Cook contributed reporting.

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LISTEN: If you’re newly pregnant and not able to afford health insurance, you may qualify for Medicaid. Reporters Cara Anthony and Blake Farmer 鈥� hosts of the new series “HealthQ” 鈥� explain that every state has a program to provide coverage for pregnant people.

When she noticed an unusual craving for hot dogs, Matte’a Brooks suspected her body was telling her something, so she decided to take a pregnancy test. She took two just to be sure. Both were positive.

“I was definitely scared,” said Brooks, 23, who was uninsured. “I was like, OK 鈥� I’m pregnant, so where do I go from here?”

Until then she hadn’t thought much about health care, but that changed when she found out that her daughter was on the way.

Brooks got that news last winter. The mix of joy, anxiety, and excitement she felt mirrors what many new parents feel at this time of year. Many Americans find out in January or February that they’re expecting, because in the U.S., August has consistently high birth rates.

A growing body of research shows that prenatal care can make a huge difference to the long-term health of both the parent and baby. This is part of why offers health coverage to pregnant women who meet income requirements and might otherwise go uninsured.

As a result, Medicaid pays for more than 40% of births in the U.S. and an even higher percentage in rural areas, according to 麻豆女优. But Medicaid also comes with limitations, and providers may restrict how many Medicaid patients they take, since the payments are than other insurers’.

Here are three things to know about signing up for Medicaid when pregnant.

1. Pregnancy Makes You a Priority

To sign up for government health care, you have to meet a number of requirements that vary widely by state. Most importantly, your income has to be below a certain threshold. In several states, most adults cannot qualify, regardless of income, if they’re not disabled or the parent of a child.

But the math is different for pregnancy. In Tennessee, for example, the eligibility cutoff in pregnancy is the income threshold for some other residents. So if you didn’t qualify for Medicaid previously and are now pregnant, it’s worth double-checking your state’s requirements.

2. Getting Covered Can Be Surprisingly Easy

To apply, you’ll likely proof of income, your Social Security number, and proof of residency. Brooks, an Illinois resident, told HealthQ that she found the sign-up process surprisingly easy. She learned about Medicaid from the provider at her initial prenatal visit.

“They asked if I had insurance. I didn’t know anything at the time,” she said. The nonprofit clinic gave her some phone numbers for the state Medicaid agency. She called and went to an in-person appointment to complete her application. She walked out of the office with coverage. In , pregnancy results in “presumptive eligibility,” which provides immediate coverage 鈥� even without confirmation of the pregnancy 鈥� while the application goes through the approval process.

3. Coverage Can Go Beyond Standard Medical Care

Medicaid provides all prenatal care at no out-of-pocket cost and usually a of postpartum care. That’s what happened to Brooks: Her appointments, medications, and delivery were free.

States cover dental, vision, and mental health care to varying degrees. Ashley Farrell, who lost her job when she was pregnant and applied to Medicaid in Georgia, said she received “rewards for going to your appointments,” including . Benefits vary by state.

People and Policy

Some maternal health advocates about how Medicaid cuts in the One Big Beautiful Bill Act will affect pregnancy coverage. Though it’s unclear when or how, states might scale back eligibility or offerings for expectant mothers.

Katherine Ruppelt at Nashville Public Radio contributed to this report.

HealthQ is a health series from reporters Cara Anthony and Blake Farmer 鈥� approachable guides to an unapproachable health care system. It’s a collaboration between Nashville Public Radio and 麻豆女优 Health News.

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Loretta Forbes realized she would have to drop her plan after her monthly ACA marketplace premiums jumped tenfold in 2026. So the 56-year-old, who lives outside Nashville, Tennessee, started rationing her rheumatoid arthritis medications. Her husband, Jim, gave up on his fledgling handyman business and started looking for a job with insurance coverage.

And when Nicole Wipp learned the monthly premium for her family’s ACA plan would be more than their mortgage payment, she and her husband decided to drop their family plan and buy coverage only for their 15-year-old son.

After crunching the numbers, Wipp, 54, a self-employed lawyer in Aiken, South Carolina, said she and her family made the tough call.

“We decided that, ultimately, it would be better for us to gamble.”

Despite a contentious back-and-forth and the longest government shutdown in history last fall, the GOP-led Congress allowed enhanced ACA subsidies, which had helped millions of Americans cover all or part of their marketplace premiums since 2021, to expire on Dec. 31. With the loss of the subsidies and health care costs already surging, more middle-income people face tough decisions about their health coverage this year.

Hulsman, Forbes, and Wipp don’t qualify for Medicaid, the public insurance program for those with low incomes or disabilities. But like many others, they are being squeezed by the increasing costs of groceries, housing, and other necessities. Rising monthly health insurance premiums, along with copayments, high deductibles, and other out-of-pocket medical costs, can often push families like these to the brink.

More than 80% of Americans said their cost of living has increased in the past year, according to from that includes 麻豆女优 Health News. Health care costs ranked at the top of their concerns, with about two-thirds saying that they are somewhat or very worried about affording health care 鈥� more than said the same about other necessities, such as food and housing, the poll found.

“Premiums are getting quite unaffordable for a lot of people. The cost of both health care and other basic needs is rising,” said , director of private coverage at the health consumer group Families USA. “This is an especially critical time for Congress to do something.”

Most Republican lawmakers have refused to renew the enhanced subsidies. Most of the public says that inaction by Congress was the “wrong thing,” according to the 麻豆女优 poll. Instead, GOP lawmakers have advocated for an expansion of health savings accounts and for more plans with lower premiums and steeper deductibles and copays that don’t reduce overall costs.

President Donald Trump released in January with few details about how to lower out-of-pocket costs for millions of Americans. The One Big Beautiful Bill Act, which he signed in July, is expected to leave millions uninsured over the next decade as it reduces federal health spending by nearly $1 trillion, mostly from Medicaid.

Already about 1.2 million fewer people have signed up for plans for this year under the ACA, also known as Obamacare, according to . Health policy analysts expect more people to stop making payments and drop coverage in the coming months. ACA marketplace insurers have said that they are charging 4 percentage points more in 2026 because they expect healthier people to drop plans as enhanced tax credits expire, leaving more sick and high-cost patients.

When You Have Health Insurance, But Can’t Afford To Get Hurt

Noah Hulsman, 37
Louisville, Kentucky听

Last year Noah Hulsman, who owns a skate shop, had a gold Affordable Care Act plan with a $750 deductible. But this year with the loss of his enhanced subsidy, Hulsman is paying the same monthly premium for a skimpier bronze plan with a deductible听that’s听over $8,400 鈥� about a quarter of his yearly income. Now听he’s听worried that a major accident could wipe out his skate shop. He听won’t听be able to buy inventory or pay shop bills if he听has to听meet his full deductible, he said. “Getting hurt right now is not much of an option.”

Rising costs and lack of congressional action are forcing many to make “untenable choices,” said , executive director and co-founder of the Center for Children and Families at Georgetown University.

“People are faced with absorbing this huge financial and health risk,” she said.

Forbes, the woman with rheumatoid arthritis near Nashville, had been on an ACA marketplace plan since 2018. But this year she and her husband, Jim, dropped their coverage after learning the monthly premium would jump from $250 to $2,500 because the enhanced subsidies expired. Jim, 59, gave up his handyman business and began searching for a job with health insurance.

“We were like: 鈥極K, we can’t breathe. We’re gonna tap out,’” said Forbes, who was diagnosed with cervical cancer in 2021. Last year she lost her job at a retirement facility because she couldn’t work after she had a hysterectomy.

A day before their ACA coverage lapsed, her husband got a job offer at a property management company that provides health coverage. In January, they learned that Forbes was approved for Medicare because of her disability. The $155 monthly premium is automatically deducted from her disability check, she said.

Forbes’ Medicare plan starts in February, just in time for her next cancer screening.

“You cannot imagine what a relief it is to know I will have care,” Forbes said.

Even those who are insured face drastically higher out-of-pocket costs. This year, health insurers’ premiums for ACA marketplace plans , the result of higher hospital costs, the popularity of pricey GLP-1 drugs for obesity and diabetes, and the threat of tariffs, according to 麻豆女优. Nearly 4 in 10 adults said they were skipping or postponing necessary care because of costs, showed.

Hulsman, the Louisville shop owner, said he takes home about $33,000 a year from his business. Last year he paid about $105 a month for a gold plan on the marketplace, with a $750 deductible. This year, with the loss of the enhanced subsidy, Hulsman is paying the same monthly premium for a “bronze” plan, but with a deductible of $8,450, which he must pay out-of-pocket before his insurer starts paying for care. On average, deductibles for bronze plans are more than four times those of gold plans, according to .

Hulsman didn’t consider dropping health insurance, because Kentucky has limited . But he said he’ll try to get an estimate if he needs to go to a doctor. And he’s worried that a major accident could wipe out his skate shop. He won’t be able to buy inventory or pay shop bills if he has to meet his full deductible, he said.

“I’m just riding the line right now,” the skateboarder said. “One slip and it’s gonna be uncomfortable.”

In South Carolina, Wipp dragged her family to get routine vaccinations on New Year’s Eve 鈥� the last day that she and her husband had health coverage.

This year’s monthly premium for a bare-bones bronze family plan would have cost them $1,400, up from $900 last year. They would still have faced high copays for doctor visits and need to meet a deductible of more than $10,000. Instead, they’re paying around $200 to cover just her son.

Wipp, who has a rare condition that causes cysts and other growths to form in the lungs, said she and her husband plan to pay out-of-pocket this year for any initial preventive care. Their second source of money, for larger medical expenses, is an old health savings account. But she said that account doesn’t have enough to cover a major accident or illness. And Wipp can’t add to the account while she is uninsured.

“The third source would be, I don’t know,” Wipp said. “The fourth is bankruptcy.”

Are you struggling to afford your health insurance? Have you decided to forgo coverage? Click here to contact 麻豆女优 Health News and share your story.

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Health policy changes in Washington will ripple through the country, resulting in millions of Americans losing their Medicaid or Affordable Care Act coverage. But there are still ways to find care.

Over the next decade, the GOP’s One Big Beautiful Bill Act is expected to slash nearly $1 trillion in spending from Medicaid, the state-federal program for people with low incomes and disabilities. The implementation of new work rules will cause some beneficiaries to lose their Medicaid coverage.

Millions of Americans are facing enormous increases in their out-of-pocket costs for ACA coverage. So far, 1.2 million fewer people have signed up for Obamacare plans compared with last year, and health policy analysts estimate more will lose coverage as they fail to pay their premiums.

Health costs are a top concern for Americans. Two-thirds of the public say they are somewhat or very worried about affording health care, more than express the same worries about utilities, food, housing, or gas, according to a , a health information nonprofit that includes 麻豆女优 Health News.

“All of this pain just doesn’t have to be there,” said Cheryl Fish-Parcham, director of private coverage at the health consumer group Families USA.

Doctors and health policy researchers say health coverage, of any kind, is the best protection against major medical debt.

Caitlin Donovan, a senior director at the Patient Advocate Foundation, recommends exhausting every available option for health coverage before going uninsured.

Even a high-deductible plan can protect patients from medical bankruptcy “if the absolute worst-case scenario happens,” she said.

Here are five ways that the uninsured can find affordable care.

1. Don’t be afraid to talk with your doctor about money

Patients can be hesitant to tell their doctors they’re uninsured or be wary of expressing concern about being able to afford care.

But some hospitals, physicians, and other providers offer cheaper cash pay options, said Cynthia Cox, a senior vice president and the director of the Program on the ACA at 麻豆女优.

Often prices are negotiable. “Always ask,” she said.

Health care providers can make adjustments if they know patients are worried about money, said Ateev Mehrotra, a doctor and researcher at Brown University.

“If my patient tells me, 鈥楧oc, I’m gonna have to pay for this out-of-pocket,’ I’m gonna make a different risk calculus,” Mehrotra said.

That doesn’t mean a patient won’t get the care they need, he said. A doctor, for instance, might order an ultrasound instead of an MRI, which is more expensive.

2. Search for providers that specifically work with uninsured patients

If your usual provider won’t budge on prices, then search for providers that cater to patients without insurance.

Federally qualified health centers, or FQHCs, and other community clinics offer routine and non-emergency care, such as treatment for flu or infection, for low-income residents and the uninsured. Community health centers charge based on a sliding scale and see annually in some of the country’s most underserved areas, according to the National Association of Community Health Centers.

The Trump administration has made funding cuts that might lead some of the country’s approximately 1,500 FQHCs to close or cut services. But the administration still maintains .

Planned Parenthood also accepts uninsured patients. Its centers test for sexually transmitted diseases, provide birth control options, and offer postpartum and gender-affirming care .

And the National Association of Free & Charitable Clinics also offers to help people find free or low-cost care.

Most community clinics don’t offer specialty care, but they can usually refer patients who need more intensive services to providers willing to work with uninsured patients.

And academic medical centers tend to have more charity care programs that help uninsured patients lower their bills.

“If you’re uninsured or even underinsured, you might be able to qualify for a significant discount on the cost of your care,” Cox said.

Still, be wary of heading to the emergency room, which is the most expensive place to get care. While ERs are federally required to stabilize all patients regardless of their ability to pay, they can still leave you with a big bill 鈥� and often do.

3. Call your local health department

Health services vary widely from county to county, but many offer free vaccinations, family planning services, and testing for sexually transmitted infections, as well as for flu, covid, and tuberculosis.

Some county health departments also offer more advanced care, such as dental services and mental health or substance abuse programs. And some states have consumer assistance programs that can guide residents in finding care, Fish-Parcham said.

In addition, the Centers for Disease Control and Prevention’s makes free or low-cost breast and cervical cancer screenings available to low-income women in all states and territories. And some states cover screenings for other types of cancer as well.

4. It’s easier to shop around for drugs than doctors

Don’t just fill your prescription at the closest pharmacy. Instead, research generic drug options and look around for the best price on brand names.

A handful of sites such as and offer comparison shopping tools and information on other ways to get drug discounts.

And some retailers offer low-cost access to common prescription drugs 鈥� at prices cheaper than you would find if you had insurance. Walmart, for instance, sells 90-day prescriptions of of drugs for $10. As do , , and a new site called the .

Many drugmakers also offer patient assistance programs, coupons, and rebates on some medications. Check their websites for details on how to apply.

States also offer drug assistance programs. The steps to qualify and types of drugs vary, but has a list of programs and how they work.

Joining a clinical trial is another way to access treatment. The and its have lists, but patients must first meet the criteria. Clinical trials aren’t necessarily free, even with insurance, Donovan said, so be sure to ask about any associated costs.

5. Your diagnosis might lead you to specialized resources

Patients with a specific diagnosis might have additional options for specialty treatment.

For example, someone with breast cancer should check with the and the nonprofit , Cox said.

The Patient Advocate Foundation hosts that can help offset the cost of medical bills and provide other resources such as transportation and lodging, Donovan said. Just type in basic information such as age, location, and diagnosis to see what is available.

Disorder-specific foundations, such as those for lupus or irritable bowel syndrome, can also steer patients to free or low-cost resources or cover some costs of care, Donovan said.

“Everything is out there,” she said.

As you research affordable care options, don’t be tricked by plans that look like health insurance but don’t offer guaranteed protection against big bills.

Some short-term plans and health care sharing ministries might seem like good deals, but read the fine print. Some red flags to look for: too-good-to-be-true monthly payments; no coverage for preexisting conditions; morality clauses such as those prohibiting the use of alcohol or drugs; or a lack of coverage for benefits such as mental health counseling that are required in ACA plans.

麻豆女优 Health News correspondent Sam Whitehead contributed to this report.

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After Susannah Reed-McCullough’s husband died in 2018, she and their young daughters continued to receive health insurance through his job as a firefighter in Maryland.

Then, in 2024, she got an unexpected medical bill: $377 for a checkup for one of her children the previous fall. Reed-McCullough said she called the doctor’s billing department and learned the insurance company had dropped the children’s coverage.

The drop turned out to be a mistake. But Reed-McCullough said she was forced to act as the go-between for her late husband’s human resources department and their insurer — all while worried about her daughters’ being uninsured.

In this installment of InvestigateTV and 麻豆女优 Health News’ “Costly Care” series, Caresse Jackman, InvestigateTV’s national consumer investigative reporter, explores how administrative errors can leave patients on the hook for medical bills they shouldn’t owe, sometimes with few options to correct a problem they didn’t create.

Jackman interviewed Elisabeth Rosenthal, senior contributing editor at 麻豆女优 Health News, who said accidental coverage drops are “a common problem” in need of attention from state regulators.

“People make mistakes, systems make mistakes, and they should be held responsible for them, not the patient,” Rosenthal said.

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It’s feeding time for the animals on this property outside Nashville, Tennessee. An albino raccoon named Cricket reaches through the wires of its cage to grab an animal cracker, an appetizer treat right before the evening meal.

“Cricket is blind,” said Robert Sory, who is trying to open a nonprofit animal sanctuary along with his wife, Emily. “A lot of our animals come to us with issues.”

The menagerie in Thompson’s Station includes Russian foxes, African porcupines, emus, bobcats, and some well-fed goats.

The Sorys are passionate about their pets and seem to put the animals’ needs before their own.

Both Robert and Emily started 2026 without health insurance.

Robert had been covered through a marketplace plan subsidized through the Affordable Care Act. His share of the monthly premiums was $0. When he looked up the rates for 2026, he saw that a barebones “bronze”-level plan would cost him at least $70 a month. He decided to forgo coverage altogether.

“When you don’t have any income coming in, it doesn’t matter how cheap it is,” he said. “It’s not affordable.”

Dumping Coverage

Marketplace plans from the Affordable Care Act no longer feel very affordable to many people, because Congress did not extend a package of enhanced subsidies that expired at the end of 2025. Last week, the House did pass legislation to extend the听expired subsidies, and negotiations have moved to the Senate. Without a deal, an estimated will go without coverage this year.

But even without a health plan, people will still need medical care. Many, like the Sorys, have been thinking through their plan B to maintain their health.

The Sorys both lost jobs in November, within days of each other. Robert worked as a farmhand. Emily worked at a staffing firm and lost her insurance along with her position.

“It’s a horrible, horrible market right now. Really tough,” she said.

The first time she had to pay out-of-pocket for her three monthly prescriptions, the cost was $184.

“To equate that to kind of how we think about it, you’re talking about 350 pounds of food for these animals,” Robert said. He pointed to his bobcats, who eat only meat.

Workarounds for the Newly Uninsured

To keep kibble in the food bowls, the Sorys are prepping for an uninsured future. They see the same psychiatrist and met with him to make a plan. He was willing to work with them by charging $125 per visit. They’ll have to go every three months to keep their prescriptions current.

And if other medical problems emerge? They’re hoping for the best.

“I’m not somebody who gets sick super often, thank God,” Robert said. “And if I do, generally I go to an emergency room where they’re going to bill me later.” Robert said he would arrange a repayment plan for bills like that.

Emily has costly health conditions and has already taken on substantial medical debt. “It’s just sitting there, and I’ve racked up money,” she said. “But I’ve had to go to the doctor.”

Donated Drugs and Sliding Scales

Hospitals and clinics are of newly uninsured patients. They’re also concerned that people won’t know about alternative ways to get medical care.

“We don’t have marketing dollars, so you’re not going to see big billboards or radio ads,” said , CEO of in Nashville. It’s one of the country’s 1,400 federally qualified health centers, also called FQHCs.

FQHCs are by the federal government. Although they do not usually offer free care, their fees tend to be lower or on a sliding scale.

Uninsured people who get care receive a bill, Beard said, “but the bill will be based on their ability to pay.”

FQHCs often have on-site pharmacies, and some offer prescription medications free of charge through a partnership with the , a Nashville-based nonprofit.

Many hospital pharmacies also partner with the nonprofit, which has donated by pharmaceutical companies to 277 sites in 38 states. must make the medicine available free of charge to people without insurance who have annual incomes below 300% of the federal poverty limit.

The organization primarily sources medications for chronic conditions such as high blood pressure, diabetes, and mental health. Demand is expected to outstrip supply in the new year, according to .

“We’re projecting and engaging with our manufacturers and asking them, 鈥楢re you willing to help support, for this future status that we are anticipating?’” he said. “By and large,” he said, pharmaceutical companies have said they’re willing to step up.

“It’s a continuous conversation that we’re having,” Cornwell said.

A Medicaid 鈥楪ap’ in 10 States

Hospitals will also have to find a way to care for more patients who cannot pay. Industry groups such as the have been vocal about the threat to hospitals’ financial health and have urged Congress to extend the enhanced subsidies, which take the form of tax credits.

The impact might be most acute in states like Tennessee that have not expanded Medicaid to cover people who work but do not have job-based insurance and cannot afford it on their own.

Ten states have chosen not to expand Medicaid to uninsured, low-income adults 鈥� an optional provision of the ACA that is mainly paid for by federal funds.

This Medicaid “gap” is , at the high end of the spectrum, by as much as 65% in Mississippi and by 50% in South Carolina, according to the Urban Institute.

As Emily Sory pets a Russian fox, she admits she is keenly aware that she will soon become part of this growing population. After all, her last job involved health care staffing. Her mother is a nurse.

“I understand the system. And I get it’s people like me that don’t pay their bill are why it suffers. And I feel bad,” she said. “But at the same time, I don’t have the money to pay it.”

This article is from a partnership that includes , , and 麻豆女优 Health News.

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For several years, that number has been zero in the predominantly white, largely rural county stretching from Sacramento’s eastern suburbs to the shores of Lake Tahoe.

The trend could be short-lived.

County health officials there and across the country are bracing for an newly uninsured patients over the next decade in the wake of Republicans’ One Big Beautiful Bill Act. The act, which President Donald Trump signed into law this past summer, is also expected to reduce Medicaid spending by over that period.

“This is the moment where a lot of hard decisions have to be made about who gets care and who doesn’t,” said Nadereh Pourat, director of the Health Economics and Evaluation Research Program at UCLA. “The number of people who are going to lose coverage is large, and a lot of the systems that were in place to provide care to those individuals have either gone away or diminished.”

It’s an especially thorny challenge for states and New Mexico where counties are legally required to help their poorest residents through what are known as indigent care programs. Under Obamacare, both states were to include more low-income residents, alleviating counties of patient loads and redirecting much of their funding for the patchwork of local programs that provided bare-bones services.

Placer County, which estimates that 16,000 residents could lose health care coverage by 2028, quit operating its own clinics nearly a decade ago.

“Most of the infrastructure that we had to meet those needs is gone,” said Rob Oldham, Placer County’s director of health and human services. “This is a much bigger problem than it was a decade ago and much more costly.”

In December, county officials that provides care to mostly small, rural counties, citing an expected rise in the number of uninsured residents.

New Mexico’s second-most-populous county, Doña Ana, added dental care for seniors and behavioral health benefits after many of its poorest residents qualified for Medicaid. Now, federal cuts could force the county to reconsider, said Jamie Michael, Doña Ana’s health and human services director.

“At some point we’re going to have to look at either allocating more money or reducing the benefits,” Michael said.

Straining State Budgets

Some states, such as Idaho and Colorado, abandoned laws that required counties to be providers of last resort for their residents. In other states, uninsured patients often delay care or receive it at hospital emergency rooms or community clinics. Those clinics are often supported by a mix of federal, state, and local funds, according to the National Association of Community Health Centers.

Even in states like Texas, which opted not to expand its Medicaid program and continued to rely on counties to care for many of its uninsured, rising health care costs are straining local budgets.

“As we have more growth, more people coming in, it’s harder and harder to fund things that are required by the state legislature, and this isn’t one we can decrease,” said Windy Johnson, program manager with the Texas Indigent Health Care Association. “It is a fiscal issue.”

California lawmakers face a nearly in the 2026-27 fiscal year, according to the latest estimates by the state’s nonpartisan Legislative Analyst’s Office. Gov. Gavin Newsom, who has acknowledged he is , has rebuffed to significantly raise taxes on the ultra-wealthy. Despite blasting the bill passed by Republicans in Congress as a that guts health care programs, in 2025 the Democrat rolled back state Medi-Cal benefits for seniors and for immigrants without legal status after rising costs forced the program to borrow $4.4 billion from the state’s general fund.

H.D. Palmer, a spokesperson for the state’s Department of Finance, said that the Newsom administration is still refining its fiscal projections and that it would be “premature” to discuss potential budget solutions.

Newsom will unveil his initial budget proposal in January. State officials have said California a year in federal funding for Medi-Cal under the new law, as much as 15% of the state program’s entire budget.

“Local governments don’t really have much capacity to raise revenue,” said Scott Graves, a director at the independent California Budget & Policy Center with a focus on state budgets. “State leaders, if they choose to prioritize it, need to decide where they’re going to find the funding that would be needed to help those who are going to lose health care as a result of these federal funding and policy cuts.”

Reviving county-based programs in the near term would require “considerable fiscal restructuring” through the state budget, the Legislative Analyst’s Office said in .

No Easy Fixes

It’s not clear how many people are currently enrolled in California’s county indigent programs, because the state doesn’t track enrollment and utilization. But enrollment in county health safety net programs dropped dramatically in the first full year of ACA implementation, going from about 858,000 people statewide in 2013 to roughly 176,000 by the end of 2014, at the time by Health Access California.

“We’re going to need state investment,” said Michelle Gibbons, executive director of the County Health Executives Association of California. “After the Affordable Care Act and as folks got coverage, we didn’t imagine a moment like this where potentially that progress would be unwound and folks would be falling back into indigent care.”

In November, voters in affluent Santa Clara County approved a sales tax increase, in part to backfill the loss of federal funds. But even in the home of Silicon Valley, where the median household income is about 1.7 times the , that is expected to of the $1 billion a year the county stands to lose.

Health advocates fear that, absent major state investments, Californians could see a return to the previous , with local governments choosing whom and what they cover and for how long.

In many cases, indigent programs didn’t include specialty care, behavioral health, or regular access to primary care. Counties can also exclude people or income. Before the ACA, many uninsured people who needed care didn’t get it, which could lead to them winding up in ERs with untreated health conditions or even dying, said Kiran Savage-Sangwan, executive director of the California Pan-Ethnic Health Network.

Rachel Linn Gish, interim deputy director of Health Access California, a consumer advocacy group, said that “it created a very unequal, maldistributed program throughout the state.”

“Many of us,” she said. “including counties, are reeling trying to figure out: What are those downstream impacts?”

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