America was the only large rich country that did not have universal health care. Instead, its system was a patchwork. The old, poor and disabled were covered by government programmes. Most working-age Americans got insurance through their jobs. But pity those without such coverage, who had to navigate the fragmented, expensive and often bewildering individual insurance market.
“HEALTH-CARE reform…is the great unfinished business of our society,” observed Ted Kennedy, a Democratic senator, before he died in 2009.
To help expand coverage for individuals, Obamacare gave subsidies to help poor and middle-class Americans cover the cost of plans on the new exchanges. Now that those subsidies are diminished , the individual market looks more frail than ever. But the mandate to buy insurance was effectively eliminated in 2019. Uptake was limited until 2021, when Congress made subsidies more generous for those who already qualified and available to some who hadn’t. Enrolment then nearly doubled by 2025. Democrats sought unsuccessfully to extend the extra financial assistance, which would have cost about $35bn this year—about as much as the Iran war so far, according to the Pentagon’s estimate.
This has raised fears of an adverse-selection feedback loop, where higher premiums and skimpier plans make insurance still less attractive, particularly to healthier customers. As they leave the exchanges, premiums are driven higher yet. These increases must be reviewed by state regulators. There will also be more people without insurance. Evidence suggests that they will put off needed treatment, like certain prescription medicines and surgeries. Hospitals must still provide emergency care for them, even if they cannot pay.
Insurers have proposed a median premium increase of 15% for 2027, according to KFF, a health-policy think-tank. If they materialise, pre-subsidy premiums will have grown by more than a third since 2025. The KFF imagines a 40-year-old in Indiana earning $65,000. In 2025, with subsidies, her monthly premium was $316. This year it is $477. Next year it will probably be close to $550. In May unpaid care was up by an average of 16% compared with a year earlier, according to Kaufman Hall, a consultancy. HCA Healthcare, a for-profit hospital group, reckons the new uninsured population will cost the chain at least $1bn in operating profits this year, equivalent to about 15% of predicted net income.
“We know that from a decade or more of research on the Affordable Care Act,” explains Mr Sommers. The experience shows “people generally want health insurance,” says Cynthia Cox of KFF. “It’s just a question of whether they can afford it or not.”
