US uninsured rates had reached record lows, but coverage began slipping after pandemic-era tax credits expired at 2025's end, reducing 2026 marketplace enrollment by >2.5M.
New work requirements and funding changes for the state-federal program were taking effect, with enrollment projected to fall by ~7.6M people by 2034.
Those shifts were expected to cut federal health spending, while states faced a complex balance of lost federal funds, lower coverage costs, and rural aid.
State benchmark caps on annual health cost growth did not show sustained reductions in premiums or hospital prices, largely because enforcement tools stayed limited.
A more promising path may be simplifying insurance administration to trim costs without hurting quality, though less complexity could also mean fewer plan choices.
