More working-age Americans are going without health insurance, and the losses so far have come before the biggest policy changes have even started. On 22 October 2026, the Commonwealth Fund published findings from its 2026 Biennial Health Insurance Survey, conducted by SSRS from 7 May to 20 July 2026 through telephone and online interviews in English and Spanish with a nationally representative sample of 9,360 adults aged 19 and older living in the continental United States. The survey found the uninsured rate among working-age adults aged 19 to 64 rose from 8.9% in 2024 to 11.2% in 2026, a statistically significant increase that Becker's Hospital Review, reporting the findings the same day, linked to the expiration of enhanced ACA marketplace premium subsidies at the end of 2025 and continued Medicaid enrolment declines after pandemic-era protections ended. Lead author Sara R. Collins, a Commonwealth Fund senior scholar, said the country was on the brink of undoing years of progress in health coverage.
What the Survey Found
The survey's broadest measure is the one clinics and hospitals should watch first: by mid-2026, 46% of working-age adults had inadequate insurance coverage. That group is made up of three parts: 11% who were uninsured, 12% who had a gap in coverage during the year, and 23% who were underinsured, meaning their plan did not provide affordable access to care. The two programmes that drove coverage gains under the ACA both shrank: marketplace and individual market coverage fell from 8.5% of working-age adults in 2024 to 6.4% in 2026, and Medicaid coverage among working-age adults fell from 15.5% in 2022 to 13% in 2026. The survey notes that the end of the more generous premium tax credit triggered a near doubling of marketplace enrolment between 2020 and 2025, and that its expiration led to average annual premium increases of $750 to $4,035 depending on income, according to the Urban Institute. About 19% of marketplace enrollees surveyed said they had moved to lower-premium plans with higher deductibles and out-of-pocket costs, and the Fund estimates around 3 million people dropped marketplace coverage after the credits ended.
Who Lost Coverage
The losses were not spread evenly. Young adults aged 19 to 34 were hit hardest, with their uninsured rate rising from 11% to 16% over two years, alongside falling marketplace and Medicaid enrolment in that age group. Working-age adults with household incomes below 200% of the federal poverty level, $31,300 for an individual and $64,300 for a family of four, also saw coverage losses in both the marketplaces and Medicaid, and their uninsured rate rose. The survey also measures underinsurance among people who were insured all year: 30% of them were underinsured by the Fund's definition, including 29% of people with employer-sponsored insurance and half of people in marketplace plans. People under 65 who qualify for Medicare because of a disability or serious illness fared worse still, with higher underinsurance rates than other adults, and more than half also eligible for Medicaid, a group the survey describes as among the poorest surveyed, with the greatest health needs and out-of-pocket costs.
The Cost Barrier
Coverage on paper is not translating into care in practice. The share of working-age adults who reported going without needed care because of cost rose to 50% in 2026, up from 46% in 2022, a statistically significant increase that held even among people who had insurance all year. People were asked whether, because of cost, they had not filled a prescription, skipped a test or treatment a doctor recommended, not gone to the doctor when sick, or not received needed specialist care. Rates were highest among the nearly half of respondents with inadequate coverage. Three in 10 working-age adults reported paying off medical debt, with underinsured adults and those with a coverage gap reporting debt at the highest rates. The pattern held inside employer coverage too: 43% of people in employer-sponsored plans had avoided care for cost reasons and 31% were paying off medical bills, while more than half of marketplace enrollees had not received needed care because of cost and one-third were paying off bills over time.
What Comes Next in 2027
The survey stresses that these findings predate the largest scheduled changes. From January 2027, H.R. 1 requires most enrollees eligible under the ACA's Medicaid expansion to prove they are working or engaging in approved community service activities for 80 hours a month, unless they qualify for an exemption, and requires states to redetermine expansion enrollees' eligibility every six months. The Fund cites projections that the administrative complexity of those changes will lead to net Medicaid enrolment losses of 11.5 million people over the next decade, while the Congressional Budget Office projects marketplace enrolment will fall by 7.5 million over the same period as premium tax credit eligibility narrows and documentation requirements tighten. Together, the Fund says, the uninsured population could reach 37 million by 2036. Against that outlook, the survey also records public opinion: nearly three-quarters of adults aged 19 and older said the federal government has a responsibility to ensure all Americans have health care coverage, including 93% of Democrats, 76% of independents and 45% of Republicans.
What This Means for Clinic Front Desks
For clinics, hospitals and health systems, this survey is a payer-mix warning, not just a policy story. A rising uninsured rate and a growing underinsured population mean more patients arriving with no coverage, a recent gap, or a plan whose deductible makes care unaffordable, the exact situations that produce uncompensated care, delayed treatment and missed follow-up. Front-desk and revenue teams should expect more eligibility checks to fail, more patients to ask about payment options before booking, and more rescheduling when a deductible has not been met. The timing matters for planning: the survey's losses arrived alongside the separate CMS proposal to verify marketplace eligibility before subsidies are paid (see https://medclinicx.com/news/cms-marketplace-pre-eligibility-verification-proposed-rule), so practices should treat coverage verification, financial counselling and clear cost information at booking as core operations for 2027, not administrative extras (see https://medclinicx.com/solutions/ai-patient-portal). Hospitals in particular should note the Becker's follow-up warning from health plan leaders that more uninsured patients may return to emergency departments for care they once received elsewhere.
Analysis: Coverage Is Becoming a Front-Desk Problem
Analysis (MedClinicX): The most important number in this survey is not 11.2% but 46%. An uninsured patient is visible to a practice. An underinsured one often is not, until the appointment is booked, the deductible is checked and the patient quietly cancels. That is why the survey's cost-avoidance figures, half of working-age adults skipping needed care, should change how practices think about access: the barrier is no longer only whether a patient has a card, but whether the plan behind it is usable. Practices that surface coverage and cost information before the visit, offer payment plans without friction, and keep a clear route for patients who have just lost coverage will hold more of their schedule intact through 2027 than practices that discover the problem at check-in. The survey's policy options, from extending the enhanced tax credits to longer continuous Medicaid eligibility, are for Congress. The operational response is for every clinic's front desk, now.
Sources and References
- Commonwealth Fund, State of Health Insurance Coverage: 2026 Biennial Survey, 22 October 2026: https://www.commonwealthfund.org/publications/surveys/2026/oct/state-health-insurance-coverage-2026-biennial-survey
- SSRS, The State of Health Insurance Coverage in 2026 (findings from the Commonwealth Fund 2026 Biennial Health Insurance Survey conducted by SSRS), 22 October 2026: https://ssrs.com/news/the-state-of-health-insurance-coverage-in-2026/
- Becker's Hospital Review, Uninsured rate rises to 11.2%: Survey, 22 October 2026: https://www.beckershospitalreview.com/finance/uninsured-rate-rises-to-11-2-survey/
- NPR, High health costs squeeze workers, even if you have good insurance through a job, 22 October 2026: https://www.cfpublic.org/2026-10-22/high-health-costs-squeeze-workers-even-if-you-have-good-insurance-through-a-job
- STAT, Health insurance premiums jump 9%, and more Americans don't have access to coverage (Morning Rounds), 22 October 2026: https://www.statnews.com/2026/10/22/health-news-insurance-premiums-jump-more-americans-lose-coverage/
Reporting based on the sources above, accessed 26 October 2026. The Commonwealth Fund survey findings were read directly in full, and the Becker's and NPR reports were read directly in full and cross-checked against them. MedClinicX did not conduct original reporting or interviews for this article. Corrections: contact us via https://medclinicx.com/contact