17 Million Americans at Risk of Losing Health Insurance by 2034

The Impact of the 2025 Tax and Spending Package on Health Care Access

The tax and spending package signed into law by President Donald Trump in July 2025 has significant implications for health care access in the United States. One of the most notable aspects of this legislation is a reduction in government spending on health care by over $1 trillion over the next decade. This decision has sparked concerns among public health experts, as it could lead to a substantial increase in the number of Americans losing their health insurance.

Estimates from the nonpartisan Congressional Budget Office (CBO) suggest that nearly 12 million Americans could lose their health insurance coverage by 2034 due to this legislation. However, some experts believe the number could be even higher, potentially reaching over 17 million. This projection takes into account the expiration of subsidies that help fund Affordable Care Act (ACA) marketplace policies at the end of 2025. These subsidies have been crucial for many individuals who rely on them to afford health insurance. Unfortunately, very few Republicans have expressed support for renewing these subsidies, which could leave millions without financial assistance.

In addition to the subsidy expiration, the Trump administration introduced new regulations earlier in the year that are expected to further increase the number of people losing their ACA marketplace coverage. As a public health professor, I see these changes as the beginning of a reversal of the progress made in expanding access to health care since the ACA was enacted in 2010. The ACA helped reduce the number of uninsured Americans from 46.5 million in 2010 to 25.3 million in 2023. However, the current legislative changes could eliminate three-quarters of this progress.

Medicaid Coverage Under Threat

The biggest impact on health care access will likely be felt by those enrolled in Medicaid, which currently covers more than 78 million people. An estimated 5 million individuals could eventually lose Medicaid coverage due to new work requirements that will go into effect nationally by 2027. These requirements target individuals eligible for Medicaid through the ACA’s expansion, who typically have slightly higher incomes than other program participants.

Medicaid applicants between the ages of 19 and 64 will need to certify they are working at least 80 hours a month or engaging in comparable activities such as community service. When similar rules have been implemented in other safety net programs, most people lost their benefits due to administrative challenges rather than not meeting the hour requirements. Experts predict a similar outcome with Medicaid.

Additional increases in paperwork required to enroll in and remain enrolled in Medicaid could render more than 2 million people uninsured, according to CBO estimates. Another 1.4 million may lose coverage due to new citizenship or immigration requirements. In total, these changes could lead to more than 8 million people becoming uninsured by 2034.

Those who retain Medicaid coverage may also face new copayments of up to $35 for appointments and procedures, making them less likely to seek care even if they still have health insurance. The new policies also make it harder for states to pay for Medicaid, which is jointly funded by the federal government and states. By limiting the taxes states charge medical providers, which are used to fund their share of Medicaid, the legislation could force some states to reduce enrollment or cut benefits in the future.

Challenges for the ACA Marketplace

The new law will also make it harder for the more than 24 million Americans who currently get health insurance through ACA marketplace plans to remain insured. Subsidies that were increased in 2021 are set to expire at the end of 2025, and given Republican opposition, it seems unlikely that these subsidies will be extended. Not extending the subsidies alone could mean premiums will increase by more than 75% in 2026, leading to an additional 4.2 million Americans losing coverage.

With more political uncertainty and reduced enrollment, more private insurers may also withdraw from the ACA market. Large insurance companies such as Aetna, Cigna, and UnitedHealth have already raised concerns about the ACA market’s viability. Should they exit, there would be fewer choices and higher premiums for people getting their insurance this way, potentially leaving some counties without any ACA plans offered at all.

Consequences for the Uninsured and Rural Hospitals

When people lose their health insurance, they often experience worse health outcomes, and their medical debts can accumulate rapidly. Early diagnosis is crucial for effective treatment, so individuals who become uninsured may die sooner than those who maintain coverage. Struggling to pay high medical bills also takes a physical, mental, and financial toll on individuals, their families, and friends, while also harming medical providers who do not receive reimbursement for their care.

Public health scholars like me are concerned about the impact on hospitals and other health care providers. Some may have to close, while others may offer fewer services and lay off health care workers. Emergency room wait times will increase for everyone, not just those who lose their insurance due to the new legislation.

Rural hospitals, which were already facing a funding crisis, will experience some of the most acute financial pressure. By one estimate, more than 300 hospitals are at risk of closing. Children’s hospitals and hospitals located in low-income urban areas, which disproportionately rely on Medicaid, will also struggle to keep their doors open.

Republicans tried to protect rural hospitals by designating $50 billion in the legislative package for them over 10 years. However, this funding comes nowhere near the $155 billion in losses KFF expects those health care providers to incur due to Medicaid cuts. Additionally, the funding includes several restrictions that could limit its effectiveness.

What Comes Next?

Some Republicans, including Sens. Mike Crapo and Ron Johnson, have indicated that more health care policy changes could be coming in another large legislative package. These changes could include harsher provisions that were left out of the final version of the legislation Congress approved. For example, Republicans may try to roll back the ACA’s Medicaid expansion.

Moving forward, spending on Medicare, the insurance program that primarily covers Americans 65 and older, could also decline. Without any further action, the CBO says the law could trigger an estimated $500 billion in mandatory Medicare cuts from 2026 to 2034 because of the trillions of dollars in new federal debt the law creates.

Trump has repeatedly promised not to cut Medicare or Medicaid, but it is possible that the Trump administration will issue executive orders that further reduce what the federal government spends on health care, rolling back the coverage gains the ACA brought about.