After years of coverage growth, the very factors that are protecting more Americans could reverse progress.
New Congressional Budget Office projections factor the end of Marketplace premium subsidies
While the number of Americans without health insurance dropped to 7.7% in 2024, the Congressional Budget Office expects this number to rise to 8.9% over the next decade. This from the CBO’s latest report on the issue — Health Insurance Coverage Projections For The US Population And Sources Of Coverage, By Age, 2024–34— published in Health Affairs.
Why uninsured rates are at record lows
There are two primary reasons why uninsured rates have dropped below 8%: Expanded Marketplace subsidies and a pause in Medicaid eligibility redeterminations.
Before COVID-19, the ACA-created Marketplace was still struggling. [pull from my priors]. In 2019, Marketplace enrollment was 10 million. Five years later, enrollment has more than doubled as 22 million people now have Marketplace coverage. The CBO projects that number will rise to 23 million in 2025 — an all-time high — before tapering if expanded Marketplace subsidies end.
The CBO anticipates that some Marketplace gains will stand. Even the projected enrollment drop to 16 million by 2034 is still 60% higher than pre-pandemic rates.
The pandemic also reduced uninsured rates by suspending Medicaid and CHIP eligibility review and keeping members on the books that no longer qualify for enrollment. The result? Some 92 million adults and children were enrolled in the two programs in 2023.
The combined Marketplace and Medicaid enrollment gains had another effect: Less delayed care due to high healthcare costs. In a separate Urban Institute study, the share of adults who delayed care dropped from 12.1% in 2019 to 9.7% in 2022.
But headwinds are coming.
Why gains will become losses
The CBO projects that the number of uninsured Americans will increase from 26 million in 2024 to 32 million in 2027.
Urban Institute study author Michael Karpman noted: “The continued unwinding of the Medicaid continuous coverage requirement and the potential expiration of enhanced Marketplace subsidies after 2025 could make these gains in coverage and access difficult to sustain.”
In other words, the very factors that have brought uninsured rates down will likely raise them again: the return of Medicaid eligibility determinations, the possible end of expanded Marketplace summaries — plus another factor, growth in immigration.
The CBO projects a “surge in immigration through 2026.” While some will gain health insurance coverage during this period, the overall uninsured rate for this population is approximately four times higher than the rest of the U.S.
As for Medicaid, most of the COVID-19 waivers that suspended redeterminations have expired. With eligibility again under review, the CBO projects that enrollment in the two programs will decline 14% — from 92 million in 2023 to 79 million in 2024 as states complete redeterminations through September of this year.
Then there is the Marketplace. If Congress does not renew the expanded subsidies currently in place, the CBO projects enrollment will drop by 5 million between 2025 and 2026. The agency notes that most of that decrease will occur for those making more than 250 percent of the federal poverty level. The current subsidies give premium tax credits to those who earn more than 400% above the FPL.
The biggest losses and gains
The CBO projects that the biggest increases in uninsured rates will be for any adults between the ages of 19–44, who are “more likely to be eligible for Medicaid than older nonelderly adults (ages 45–64) but less likely to take up available private coverage, leading more to be uninsured.”
While lack of insurance may rise for this group, access is projected to increase for those with employer-based coverage — from 164 million to 170 million, and again related to possible Marketplace changes.
“In 2026 and 2027, employment-based coverage will expand after the scheduled expiration of
the enhanced Marketplace subsidies, as some workers newly take up existing offers (particularly those defined as not affordable under the Affordable Care Act) and some employers newly offer coverage to their workers,” notes the CBO, adding: “That increase
will be spread over two years because, the agency expects, employers and workers will react slowly to the change.”
The CBO expects Medicare enrollment to jump from 61 million in 2024 to 74 million by 2034, calling out that Medicare Advantage now represents more than half of this population and could be nearly two-thirds by 2034 based on enrollment and payment trends.
The caveats
Projections can be wrong and the circumstances that drive them often change.
For example, the CBO underestimated the effect that both continuous Medicaid eligibility and expanded Marketplace subsidies would have on enrollment.
The agency adds: “The CBO’s projections are intended to show what would happen to health insurance coverage if current law and regulation remained in place. But over time, applicable laws and regulations do change, and uncertainty increases as the projections extend. Certain changes to laws and regulations, such as extending the temporary enhanced Marketplace subsidies, would cause enrollment outcomes to diverge considerably from the CBO’s projections.”
Time — and the results of this year’s presidential election — will tell.
Laura Beerman is a contributing writer for HealthLeaders.
KEY TAKEAWAYS
The Congressional Budget Office projects that the number of Americans without insurance coverage will increase from 24 million to 32 million by 2034.
This is a reversal from the past five years, in which Marketplace enrollment alone has more than doubled.
Details on coverage losses, gains — and why — are all below.