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The GOP’s Big, Beautiful Bill sought to roll back the Affordable Care Act. Now, the human costs are becoming clear.

GiftThe US uninsured rate is expected to rise significantly in the coming years. Malte Mueller/Getty ImagesDylan Scott covers health for Vox, guiding readers through the emerging opportunities and challenges in improving our health. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo, and STAT before joining Vox in 2017.One of the clearest success stories in US healthcare over the past 20 years has been the dramatic decline in the number of Americans without health insurance. In 2010, the year the Affordable Care Act was enacted, 16 percent of the population lacked coverage. By 2025, according to estimates from the US government, that figure was cut nearly in half, to 8.3 percent.

The increase in coverage hasn’t been a panacea; even people with an insurance card can struggle to afford their medical bills or to secure a doctor’s appointment. But with the US standing alone among its international peers in its failure to offer universal healthcare, it represented significant progress toward ensuring every American had a basic level of access to routine medical services.

Last year, when drafting their One Big Beautiful Bill, Republicans had a chance to strike a blow against the ACA — a law they’d vilified for years — 15 years after its passage and eight years after failing to repeal the law in President Donald Trump’s first term. They established work requirements to target the people covered by the ACA’s Medicaid expansion and allowed subsidies that had helped millions of people to buy private coverage on the ACA marketplaces to lapse.

As a result, millions of Americans are dropping their health insurance this year, and millions more are expected to lose their coverage in the years to come.

The uninsured rate has spiked before, but it’s usually the byproduct of an economic crisis; people lose their jobs, and they lose their coverage. What makes the current turmoil different is that it is entirely a matter of policy choices.

“I don’t think there’s any historical precedent for the rollback in federal support for health coverage coming with the cuts in Medicaid plus the expiration of enhanced ACA premium subsidies,” Larry Levitt, executive vice president for health policy at the healthcare think tank KFF, told me. “The expected effects of OBBBA on coverage are self-inflicted and dwarf even the historical losses due to changes in the economy.”

One of the major ways that the ACA expanded health insurance coverage was by setting up insurance marketplaces where individuals and families could purchase private health plans with the help of government subsidies.

Enrollment in those marketplaces has ballooned — particularly since 2021, when Democrats in Congress approved an expansion of the ACA’s financial aid that made more people eligible for assistance. Prior to 2021, there had been a strict cutoff at 400 percent of the federal poverty level (about $64,000 for an individual in 2026, or $132,000 for a family of four). Anybody who made a higher income was ineligible for aid. After 2021, anybody could qualify for ACA subsidies, and their insurance premiums were capped at a percentage of their income. (The subsidies were initially authorized for two years and, then, were extended to 2026 through the Inflation Reduction Act.)

It seemed to have plugged one of the obvious holes in the healthcare law: While many people below 400 percent of the poverty level had enjoyed both mandated comprehensive coverage and new government subsidies that offset any increases in costs, people above that threshold had been subjected to significant premium hikes since the ACA passed. Now, they were able to access the same subsidies, and sign-ups boomed. Marketplace enrollment grew from 9.8 million Americans in 2019 to 22.3 million in 2025.

So, we knew some people would drop their insurance as a result of the expired subsidies, but it was hard to be sure how many. Now, we’re starting to get hard data, and it does not look good. Based on KFF’s preliminary analysis of enrollment data and premium payments, about 4.7 million fewer people will actually end up being enrolled in an ACA marketplace plan in 2026 compared to 2025 — a 21 percent drop in a single year.

The ACA’s other major coverage provision was the expansion of Medicaid eligibility to any American with an income at or below 133 percent of the poverty level (about $21,000 for an individual in 2026, or $44,000 for a family of four). It replaced the preexisting patchwork system for eligibility that created significant differences across states — in particular, millions of childless adults, some of whom were living in deep poverty but had been left out of the program in many states before the ACA, now qualified for Medicaid.

As of June 2025, more than 16 million Americans who became newly eligible for Medicaid through the ACA had been enrolled in the program, making up nearly a quarter of all Medicaid enrollees.

Republicans in Congress had been sharply critical of Medicaid expansion, even as many GOP-led states adopted it, and 2025’s OBBBA gave them a chance to roll it back. They approved, for the first time, national work requirements for Medicaid, targeted to expansion-eligible enrollees, and made several other technical changes to constrain states’ Medicaid financing. People on the program will be required to work or perform other approved activities for at least 80 hours per month or show they should be exempted from the requirement. Otherwise, they could lose their benefits.

And based on what we know from historical precedent, many of the coverage losses won’t be because people are actually ineligible for Medicaid, but because of the administrative burden of complying with these new requirements, even if you are working, or if you are someone — like a pregnant person — who is supposed to be exempted. Arkansas is the only state to implement Medicaid work requirements prior to the OBBBA, and only a fraction of the people required to submit work activities to the state actually did so; many of the people who lost coverage lost it because they failed to turn in paperwork.

The Medicaid population is, by nature, hard to reach. This group is lower-income and might work irregular hours, move around more, or have less access to the internet. It’s easy for people to fall through the cracks.

The OBBBA’s requirements go into effect nationally in January 2027 (after this year’s midterm elections), but some states are instituting them early. Nebraska implemented work requirements on May 1, Montana and Arkansas are starting theirs on July 1, and Iowa will adopt the requirements on December 1. Then, starting on January 1, 2027, they will apply in every state.

The coverage losses are difficult to project, and they could take time to accrue, but they are expected to be sizable. The nonprofit research group RAND estimated Medicaid enrollment will drop by 7.6 million people by 2034.

And they, much like those people dropping ACA coverage, will lose more than just their insurance card. Health insurance, even with its shortcomings, does a lot to help people. Americans with health insurance accrue less medical debt. They are more likely to go to routine medical appointments and receive routine screenings. Prior research on Medicaid expansion’s effects has estimated that it saved tens of thousands of lives.

In other words, the coming increase in the uninsured rate will do more than change some percentage points on a spreadsheet; it will make it harder for millions of Americans to stay healthy and stay alive.

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