Health Issues

There are more than enough needs to go around in American health care, but if I had to pick the one group that struggles the most with costs and access, it would be people with chronic illnesses who are also uninsured. These are people with cancer or heart disease or diabetes or mental health conditions, or multiple chronic health problems, who also don’t have insurance coverage. We don’t have an exact count of the number of people with multiple medical conditions who are uninsured, but we can say it’s millions of people: about a quarter of the uninsured report that they have been treated for one or two health conditions over the past year and 1 in 10 for three or more conditions. There are about 27 million uninsured people in the U.S., and that number is projected to grow into the low 40 millions when the cuts in federal funding for Medicaid and ACA coverage fully kick in (unless they are reversed).

You could say that’s no surprise—people with multiple conditions use the most care, so they experience greater problems getting and paying for care; that result is so expected in our health system it’s almost tautological to treat it as a discovery. Fair enough, no tenure for me. You could also say that the first obligation of any health system is to take care of people who are sick; it’s a leading indicator of a health system that isn’t working as it should.

Here are a few of the numbers and a chart from a new survey of over 25,000 adults focusing on the chronically ill, which we’ll release tomorrow:

• Seventy-two percent of adults with multiple health conditions who are uninsured had problems paying for their care or could not pay their medical bills in the last year.
• Fifty percent had to cut back on other household needs as a result.
• Sixty-eight percent skipped care because of costs over the last year.

These are about double the already very high rates experienced by people with conditions like cancer, heart disease, diabetes and mental health issues who have insurance. (The chronically ill with insurance experience cost and access problems at rates that are much higher than people who are generally healthy and use less health care).  

And when they need care, the chronically ill uninsured rely on emergency rooms three times as often as their insured counterparts do.

Looking at the chronically ill uninsured as a research grouping enables us to examine what’s happening in the health care system more broadly, in this case to people with serious medical problems without insurance. There is no Association for the Multiply Chronically Ill Uninsured on K Street in Washington, D.C., and they don’t have their own powerful advocacy group working on their behalf, although the big disease groups in D.C. have combined forces to advocate for Medicaid and the ACA, which provide coverage for constituents who otherwise would be uninsured. Most of the members of these groups, however, have insurance coverage and advocacy and lobbying focuses on the problems they face paying for and getting care and the drugs they need, including the problems people with significant illnesses have navigating the health insurance system, such as their encounters with prior authorization review. People tell us in polls that prior authorization review is their top concern after costs in health care. The uninsured, of course, would feel lucky to have that problem.

There has been substantial discussion of the chronically ill in health care for years. In October, I’m delivering the keynote address at the annual meeting of the National Academy of Medicine, which is focused on chronic disease. However, most of the discussions to date have focused on prevention and disease management, including better delivery and payment models. Almost none have focused on the fact that when it comes to the “affordability crisis” driving the national discussion of health care today, the chronically ill, and most of all the chronically ill uninsured, are the tip of the spear. 

View all of Drew’s Beyond the Data Columns

The ACA (Affordable Care Act) open enrollment period for plan year 2027 begins November 1, 2026, in most states – and for people who buy their own health coverage, this year’s enrollment period comes with a number of important changes.

Insurers are leaving the Marketplace in more than 20 states, premiums are rising substantially in many areas, and federal rules have changed who will qualify for subsidies and how much consumers will pay out of pocket. There are also changes to Marketplace platforms, state-funded subsidies, HSA contribution limits, and Catastrophic plan eligibility.

Whether you already have Marketplace coverage or are shopping for a plan for the first time, you’ll want to carefully compare your 2027 options during open enrollment. Here’s a look at the key changes to know before you enroll.

As is always the case, insurers are joining the Marketplace in some areas, and others are exiting the Marketplace. For 2027, there are far more exits than entries.

• Who’s affected? Hundreds of thousands of Marketplace enrollees have plans that will be terminated at the end of 2026 because of carrier exits. But in some states, many enrollees will have access to new plans due to a carrier entry.
• What can you do? Carefully compare the plan options available to you during open enrollment. Don’t rely on auto-renewal. If your Marketplace plan is ending, the auto-renewal process will use an algorithm to pick a new plan for you, and it’s in your best interest to pick your own replacement plan. If new plans will be available in your area, comparison shopping during open enrollment will help you know whether any of those plans (or any other available plan) might be the best option for you.

What you need to know if your insurer is exiting the market.

Nationwide, the median proposed rate increase (the midpoint of insurers’ proposed increases) for individual-market policies is about 15% for 2027. ^{This means that roughly half of Marketplace insurers have proposed increases above 15% and the other half have proposed increases of less than 15%. The weighted average proposed increase (which accounts for how many people are enrolled in each insurer’s plans)} ranges from under 7% in Vermont, Iowa, and Utah to 29% in Arizona.

But those increases are for full-price premiums, and most individual-market enrollees do not pay full price. The majority of people with individual-market coverage buy it through the Marketplace (as opposed to off-exchange). ^{And 87% of Marketplace enrollees were receiving premium subsidies at the start of 2026.}

Subsidy amounts are based on the cost of the second-lowest-cost Silver (benchmark) plan. When the benchmark plan’s premium increases, subsidies also increase. Many enrollees will be fully or partially insulated from the rising premiums, due to increases in their subsidy amounts. But the benchmark plan’s premium change won’t be the same as other plans’ premium changes, and people who don’t get a subsidy (including everyone who buys coverage outside the exchange) will bear the full brunt of the rate increases.

• Who’s affected? More than 19 million people had Marketplace coverage as of early 2026, ^{and the proposed rate increases also apply to off-exchange plans (where there are no subsidies available to offset the rate increases).}
• What can you do? Pay close attention to the renewal notices you get from your insurer and the Marketplace as we get closer to open enrollment. The notices will tell you your plan’s premium, and if applicable, your after-subsidy premium. Then you can comparison shop during open enrollment to see if a different plan might be a better value.

Out-of-pocket limits are increasing

For 2027 coverage, the maximum allowable out-of-pocket cap is $12,000 – up from $10,600 in 2026.

The Department of Health and Human Services set the $12,000 maximum in January 2026 using a formula set by the ACA. (In the spring of 2026, HHS finalized a rule that would have allowed some Bronze plans to have out-of-pocket limits as high as $15,600. ^{But that was stayed by a court in July, so the highest out-of-pocket limit you’ll see for a single person in 2027 is $12,000.)}

• Who’s affected? The limit on out-of-pocket costs applies to all non-grandfathered (and non-grandmothered) individual and group health plans. Combined, these plans cover more than half of the population. ^{Many plans have out-of-pocket caps that are well below the federal limits, but any individual or group plan can increase its out-of-pocket limit for 2027 as long as it doesn’t go over the federal limits.}
• What can you do? Pay close attention to any communications you get from your health plan, to see if there will be any changes in your deductible and total out-of-pocket exposure for the coming year.

Fewer immigrants will qualify for Marketplace subsidies

Starting with plan year 2027, the only immigrants who qualify for Marketplace subsidies will be:

• Lawful Permanent Residents (LPR)
• Cuban-Haitian Entrants (CHE)
• Compact of Free Association (COFA) migrants.

All other immigrants will no longer qualify for Marketplace subsidies.

• Who’s affected? Any non-citizens who aren’t in one of the three categories listed above. Immigrants who will no longer qualify for Marketplace subsidies include asylees, refugees, people with Temporary Protected Status (TPS), and people with various types of temporary visas, such as work visas, student visas, U-visas (for victims of certain crimes) and T-visas (for victims of trafficking). An estimated one million people are expected to become uninsured by 2035 as a result of this change.
• What can you do? If you’re not a U.S. citizen and you currently have subsidized Marketplace coverage, be sure you understand whether your immigration status makes you eligible for ongoing subsidies in 2027. If not, you’ll want to understand how much full-price coverage will cost, and consider whether any of the lower-priced Marketplace plans in your area (a Bronze plan, for example) might be a better fit for your budget.

Oregon will utilize a state-run Marketplace platform

Starting this fall, Oregon residents will use the state-run Explore Health platform to obtain their coverage for 2027, instead of HealthCare.gov. ^{Oregon is the latest state to switch from HealthCare.gov to a state-run Marketplace enrollment platform.}

• Who’s affected? Nearly 106,000 Oregon residents had Marketplace coverage as of early 2026, ^{All of them will transition to Explore Health for 2027 if they wish to keep Marketplace coverage.}
• What can you do? If you’re in Oregon and have Marketplace coverage in 2026, pay close attention to any communications you get from HealthCare.gov and Explore Health (the Oregon Health Insurance Marketplace). Your account should be automatically migrated to the new platform, and you should receive details in early October about how to activate your new account. Window shopping will begin on the new platform on October 15, and open enrollment will begin November 1.

Virginia and Rhode Island introduce state-funded subsidies

For the 2027 plan year, Virginia is joining the list of states that offer state-funded health insurance subsidies in addition to the ACA’s federal subsidies. The Virginia Premium Savings program will be available starting November 1, 2026, when consumers are enrolling in coverage for 2027.

• Who’s affected? People in Virginia who buy their own health insurance and have household incomes between 138% and 250% of the federal poverty level. For 2027 coverage, that amounts to:
  • Above $22,025 but not more than $39,900 for an individual.
  • Above $45,540 but not more than $82,500 for a family of four.
• What can you do? If you’re in Virginia and your income makes you eligible for the new Virginia Premium Savings program, the subsidy will be automatically applied to any metal-level plan you select in the Virginia Marketplace. You won’t get the subsidy if you buy coverage outside the Marketplace, or if you buy a Catastrophic plan in the Marketplace.

Rhode Island’s Fiscal Year 2027 budget includes $19 million in state funding to replace some of the federal subsidy enhancements that expired at the end of 2025. ^{But as of late August 2026, Rhode Island’s exchange has not yet clarified how eligibility for the state-funded subsidies will be determined.}

Note: HSA contributions will lower your household income under the ACA’s rules for how modified adjusted gross income is calculated. This could make you eligible for a larger premium subsidy, or make you eligible for a subsidy when you would otherwise be over the “subsidy cliff.” It’s important to check with a tax advisor for any tax-related questions you might have.

• Who’s affected? Anyone with an HSA-eligible high-deductible health plan (HDHP) who wants to contribute to an HSA in 2027. As was the case in 2026, all Marketplace Bronze and Catastrophic plans will continue to be HSA-eligible in 2027.
• What can you do? If you’ll have an HSA-eligible HDHP in 2027, consider whether you’d like to make HSA contributions. You can make the contributions at any point during the year, or even up until the tax filing deadline in April 2028. The money you put into the HSA is pre-tax, and there’s no use-it-or-lose-it rule for HSAs. So if you don’t need to withdraw HSA funds to pay for medical expenses, they will remain in the account (along with any interest, dividends, or investment growth) and you can use the funds to pay medical bills in the future.

Learn more about how HSAs work.

• Who’s affected? During the open enrollment period for 2026 coverage, 67,489 people enrolled in Catastrophic plans through the Marketplaces nationwide, amounting to about 0.3% of Marketplace enrollees. ^{And more than 20,000 of these enrollees had been eligible to purchase Catastrophic coverage simply because they were not eligible for Marketplace subsidies, due to the expanded eligibility rule that had been issued in September 2025. Any enrollees who are 30 or older will only be able to keep Catastrophic coverage for 2027 if they qualify for and obtain a hardship exemption.}
• What can you do? If you’re 30 or older and you want to enroll in a Catastrophic plan for 2027, you’ll need to obtain a hardship or affordability exemption certificate. That process isn’t immediate; it requires paperwork that has to be processed after you complete it, so you’ll want to start early.

Learn more about Catastrophic health plans.