A Commonwealth Fund survey published October 22 finds that the share of working-age adults without health insurance rose from 8.9 percent in 2024 to 11.2 percent in 2026. Half of all adults aged 19 to 64 said they had gone without needed medical care in the past year because of its cost.
Between 2010 and 2025, the national uninsured rate fell by half, from nearly 16 percent to 8 percent, after the Affordable Care Act (ACA) took effect. The Congressional Budget Office (CBO) now projects 37 million people uninsured by 2036. “The country is on the brink of undoing years of progress in health coverage,” Sara R. Collins, the survey’s lead author, said. The survey, taken between May and July, is a baseline: the main provisions of H.R. 1, the “One Big Beautiful Bill Act,” take effect on January 1.
The “progress” was never the establishment of a social right. The ACA reduced the number of uninsured by paying private insurers to cover people and by an optional expansion of Medicaid, both resting on appropriations that Congress could withdraw. It was, as the WSWS wrote in 2016, a plan “concocted by and for the insurance companies and corporate America.” What is now being withdrawn was always a subsidy to capital.
The losses came from the publicly supported forms of coverage. ACA marketplace and individual plans fell from 8.5 to 6.4 percent of working-age adults between 2024 and 2026, and Medicaid fell from 15.5 percent in 2022 to 13 percent. Employer coverage held at 57 to 58 percent. Young and low-income workers were hit first. Uninsurance among adults aged 19 to 34 rose from 11 to 16 percent, and among adults below twice the poverty line from 14 to 17 percent.
Holding insurance is no guarantee of care. The survey finds 46 percent of working-age adults inadequately insured: 11 percent entirely uninsured, 12 percent with a gap in coverage during the year, and 23 percent insured all year but underinsured. The last is the largest group, and it consists of people who never lost their coverage.
Insured and unable to pay
A deductible is what the patient pays each year before the plan covers most care; the premium, the monthly price of coverage, is in addition to that. The survey counts people as underinsured when their medical bills, excluding premiums, reach 10 percent of household income, or 5 percent for those below twice the poverty line, or when the deductible alone reaches 5 percent of income.
These lines are easily crossed. A worker earning $50,000 with a $3,000 deductible is underinsured before she sees a doctor even once. A family paying the average worker’s share of the premium, $7,471, gives up 10 percent of a $75,000 income, before receiving any care, and the survey does not count this at all, because premiums are excluded in the calculation.
Among continuously insured adults with employer plans, 29 percent are underinsured, 43 percent went without care because of cost and 31 percent are paying off medical bills. Even among adults the survey classes as adequately insured, 36 percent went without care because of cost.
The premium is part of the wage. The employer’s share is compensation the worker earns and never sees, handed directly to an insurance company, and the worker’s own share is taken from the paycheck. The average family premium reached $28,303 in 2026, according to the KFF Employer Health Benefits Survey. The worker’s share rose 9 percent, to $7,471, while wages rose 3.7 percent, a wage cut administered through the health system. Next year the ceiling on out-of-pocket costs in commercial plans rises to $24,000 for a family, 30 percent of an $80,000 income. The survey’s authors acknowledge that deductibles let insurers, employers and policymakers hold down premiums by shifting costs onto patients. The trade unions have signed these premium shares and deductibles into contract after contract, functioning as the employers’ agents in administering the plans.
Coverage stripped by statute and by rule
The first blow required no new law. The enhanced premium tax credits that had nearly doubled marketplace enrollment between 2020 and 2025 expired on December 31, 2025. The Democrats enacted them in 2021 as temporary payments, made to private insurers on enrollees’ behalf, with an expiration date written in. They made extension the central demand of last year’s 43-day government shutdown, then ended the shutdown without it.
By spring, the federal government counted nearly 3 million fewer marketplace enrollees, and KFF found the average marketplace deductible had risen 37 percent, to $3,786.
According to KFF, Melody Stephens, 55, a geriatric nurse in Berryville, Arkansas, saw the premium for herself and her daughter rise from just over $200 a month to more than $2,000. Her employer’s plan cost $1,000 a month. Now uninsured, the cancer survivor has stopped taking her diabetes and nerve-pain medications. A nurse who cares for others has been priced out of her own treatment.
H.R. 1 accelerated this erosion of coverage. From January 1, adults aged 19 to 64 covered under the Medicaid expansion must document 80 hours a month of work, schooling, job training or volunteer service, or earnings of $580 a month, and prove it again at least once every six months. Their eligibility will be reviewed every six months instead of once a year, and Medicaid will cover only one month of bills incurred before an application instead of three. The law also bars most lawfully present immigrants from marketplace tax credits next year and adds new enrollment paperwork in 2028.
CBO projects that the work requirement alone could remove about 5.2 million people from Medicaid by 2034, and that the law will reduce Medicaid enrollment by 11.5 million and marketplace enrollment by 7.5 million over the decade.
The requirement removes people through paperwork. In a study of Michigan Medicaid, only 13 percent of non-disabled adults stayed continuously enrolled over nine years as they moved in and out of unstable jobs, and when Arkansas imposed work requirements in 2018, 18,000 people lost coverage and there was no increase in employment. In the Commonwealth survey, Medicaid enrollees had the lowest rate of underinsurance, 20 percent, and the lowest rate of medical debt, 18 percent. The Trump administration has used regulation to end the year-round marketplace enrollment window for the lowest-income buyers.
Where the money goes
There is no shortage of money in American health care. National health spending reached $5.3 trillion in 2024, 18 percent of gross domestic product (GDP), and the government’s actuaries project 20.6 percent of GDP by 2034. The same actuaries project the number of uninsured rising from 28 million in 2024 to 33.3 million in 2028. The United States spends more than any other advanced nation and has lower life expectancy and higher infant and maternal mortality, the Commonwealth authors note. The crisis is the result of political choices, not scarcity: the same economy that cannot provide care to half its working-age adults finances tax cuts for the wealthy and a swelling war budget.
H.R. 1 strips the financing states use to support their hospitals. It lowers the cap on the taxes states levy on hospitals to fund their share of Medicaid, and caps at Medicare rates the extra “state-directed payments” that hospitals serving the poor depend on, a change KFF estimates will remove about $60 billion in federal spending in 37 states. Of the 109 hospitals Harvard researchers found most exposed, 85 percent are urban and ineligible for the law’s rural fund, and the researchers warn the strain may hasten takeovers by private equity.
Lost coverage leaves safety-net hospitals with more unpaid bills. Their distress opens them to acquisition, acquisition raises prices and cuts staff and services, and the higher prices return as higher premiums and deductibles, pushing more insured workers into the ranks of the underinsured.
The political verdict
In the Commonwealth survey, 73 percent of adults said the federal government has a responsibility to ensure that everyone has health coverage, including 45 percent of Republicans. In a KFF poll in September, nine in 10 Democrats and three-quarters of Republicans said the health system needs a complete overhaul or major changes.
But the government is the instrument of the class that profits from the present system. It is the same state that has cut an estimated $911 billion from Medicaid over the decade to help pay for tax cuts for the wealthy and immigration enforcement, and that is requesting $1.5 trillion for the military. Under capitalism, “government responsibility” for health care becomes its responsibility to cut the costs of health care for the ruling class, to safeguard and increase profits.
Both parties respond to the needs of the ruling class, not the popular demand for healthcare for all. The Republicans carried out the cuts. The Democrats built the ACA as a bailout of the insurance industry and paid for its coverage expansion with subsidies on a timetable that expired. Their congressional fight last year was to keep paying the insurers. Their healthcare policy, from 2010 to the present, has been a subsidy program for capital.
The pseudo-left serves as the Democrats’ organized left cover. Sanders, Warren, the Democratic Socialists of America and Jacobin promote “Medicare for All” to capture working-class anger and return it to the party of the insurance bailout, as the WSWS showed of Sanders’ 2017 bill and Warren’s 2019 plan, and Democratic candidates are reviving the slogan in this year’s primaries. Their proposals leave the hospital chains, drug companies, investors and the capitalist state intact. It is an electoral gimmick, not a program.
The Commonwealth Fund concedes that deductibles have become a barrier to care and that the prices hospitals charge must be capped. It addresses its proposals to the same Congress that is carrying out the cuts.
Healthcare is a social right. Its conversion into a commodity, like the gutting of public health, shows that capitalism cannot meet the essential health needs of the working class. Securing that right requires the expropriation of the insurance companies, hospital chains, pharmaceutical corporations and private equity firms, and their transformation into a unified, publicly owned health service, free at the point of use, financed by taxing the corporations and the wealthy and placed under the democratic control of the working class.
That program cannot be won through either party or through the trade unions. It requires rank-and-file committees of healthcare workers and patients, independent of the union apparatus, and the independent political mobilization of the working class on a socialist program to reorganize medicine to meet human need.