17 million Americans at risk of losing health coverage by 2034

Impact of the New Tax and Spending Package on Health Care Access

The recent tax and spending package signed into law by President Donald Trump has significant implications for health care access in the United States. This legislation is expected to cut government spending on health care by more than $1 trillion over the next decade, with far-reaching consequences for millions of Americans.

Potential Loss of Health Insurance Coverage

Estimates 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 exceeding 17 million. A major factor contributing to this loss is the expiration of subsidies that help fund Affordable Care Act (ACA) marketplace health insurance at the end of 2025. These subsidies are critical for many Americans, and very few Republicans have expressed support for renewing them.

In addition, regulations introduced by the Trump administration earlier in the year 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’s passage in 2010.

Medicaid Coverage at Risk

One of the most significant impacts of the new legislation will be on 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 people eligible for Medicaid through the ACA’s expansion and require applicants between 19 and 64 years old to certify they are working at least 80 hours a month or engaging in comparable activities.

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 for enrollment and continued enrollment 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 to Medicaid could lead to more than 8 million people becoming uninsured by 2034. Many of those who remain enrolled in Medicaid 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 insurance.

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. One key issue is the difficulty of purchasing insurance and qualifying for subsidies for 2026. Regulations from the Trump administration are expected to lead to almost 1 million people losing coverage through the ACA marketplace, including reduced spending on outreach and enrollment.

Increased subsidies in place since 2021 are set to expire at the end of the year. 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. Once premiums become unaffordable, an additional 4.2 million Americans could lose coverage, according to CBO estimates.

With more political uncertainty and reduced enrollment, more private insurers may 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. It could also mean that some counties could have no 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 accumulate medical debt. Early diagnosis and treatment are crucial for effective medical care, so people who become uninsured may die sooner than if they had coverage. Struggling to pay high medical bills takes a physical, mental, and financial toll on individuals, their families, and friends. It also harms medical providers who do not get reimbursed for their care.

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

Rural hospitals play a crucial role in health care access. Already facing a funding crisis, they 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 also disproportionately rely on Medicaid and will struggle to keep their doors open.

Future Policy Changes and Medicare Concerns

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. 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 decline too. Without any further action, the CBO says that 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.

Despite Trump's repeated promises not to cut Medicare or Medicaid, it’s possible that the Trump administration will issue executive orders that further reduce what the federal government spends on health care. This could roll back the coverage gains the Affordable Care Act brought about.