Health Care Futures
Protecting Healthcare in the Time of HR1
With the implementation of HR1 playing out, millions of Americans are seeing cuts and changes that impact their health care and services. These changes impact Medicaid enrollees nationwide. The Modern Medicaid Alliance has created four issue briefs that outline a few of the Medicaid changes that could negatively impact access to care this coming year:
These changes are expected to reduce overall enrollment as well as usage of care for those that keep their coverage. This is on top of the expected reduction in HCBS programs as states try to balance their Medicaid budgets. Ahead of the midterms, KFF has mapped out 2025 Medicaid enrollment by Congressional district, showing a higher share of disabled enrollees in Republican districts, and at least 52,900 enrollees per district.
States will also struggle to administer these changes, and communities could see providers and hospitals forced to close in response. States are tasked with balancing their Medicaid budgets with less federal support. Even at a city level, public officials are taking initiative to keep people covered. In New York City, the Commonwealth Fund’s podcast, The Dose, covers the Health Commissioner’s efforts to support health care access for New Yorkers through these changes. Modern Medicaid Alliance has a tracker of HR1 implementation, including a specific tool to follow the roll-out of Medicaid work requirements, from KFF.
Further KFF analysis has shown that ACA Marketplace coverage has declined mostly in Republican districts from 2025 to 2026, with 67% of the enrollment decline, with lower Marketplace enrollment in states that have broader options for public coverage through Medicaid expansion. The costs of Marketplace plans soared following the expiration of enhanced premium tax credits earlier this year. ACA enrollees have seen their average premiums increase in 2026, up to $625 from $497/month in 2025, according to data analysis from KFF. Premium costs are the primary health care concern for U.S. adults. Further increases are expected nationwide going into 2027.
ACA Marketplace insurers will be increasing rates by a median of 15% for 2027, with some plans expected to increase by up to 50% in certain states. The Commonwealth Fund covered these trends, indicating that general inflation, ongoing health workforce shortages, increased drug prices and usage, and growing provider rates have all contributed to these increases, in addition to policy developments that have decreased enrollment. The exit of insurers from the marketplace is also impacting costs, as competition among the remaining carriers is reduced.
Future of the U.S. Health Economy
A recent Health Affairs podcast covered the highlights from this year’s Trends Shaping the Health Economy Report, indicating that the U.S. health care system may be reaching a structural breaking point. They noted an increase in underinsurance, where people may have access to health coverage, but are less likely to actually use it. This is the case as people elect plans with cheaper premiums, but higher deductibles. People have less choice in this environment to select a health plan that meets their needs. Looking to the future might require looking to other models of coverage.
The Commonwealth Fund’s 2026 report on U.S. Health Care from a Global Perspective showed the mismatch between our spending on care, and health outcomes. U.S. spending is consistently over 18% of GDP (about double the amount of most OECD nations). The U.S. continues to have the highest per capita spending on health care and pharmaceutical spending of any nation included. At the same time, Americans are the most likely to skip needed care due to cost. According to the report, “[t]he U.S. is one of the only countries to have enacted policies that reduce coverage.”
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