June-July Research Roundup: Anticipated Effects of H.R. 1 on health insurance coverage, affordability, and uncompensated care

On July 4, 2025, President Trump signed into law some of the most dramatic changes to our healthcare system since the Affordable Care Act (ACA) was enacted in 2010. The new law includes over $1 trillion in cuts to the social safety net and reverses a decade in coverage gains. But you don’t need to take our word for that: In this June-July Research Roundup, we provide a survey of key economic and actuarial publications projecting the impact of H.R. 1’s Marketplace provisions and the U.S. Health & Human Services Department’s proposed rule for Marketplaces, combined with the expiration of enhanced premium tax credits (EPTCs), on health insurance coverage rates, premium affordability, and uncompensated care costs. 

Projected Changes in Health Insurance Coverage

The Congressional Budget Office (CBO) published a completed score of H.R. 1 on July 21st. They project that 10 million people will lose health insurance under the bill within the 10-year budget window. In addition, Congress’ budget scorers expect that 4.2 million people will become uninsured because of the expiration of EPTCs. 

Separately, the Trump administration finalized changes to eligibility, enrollment, and health plan standards for the ACA Marketplaces. The Centers for Medicare & Medicaid Services (CMS) estimates that up to 1.8 million people will lose their health insurance because of those changes.

Other studies have also evaluated the coverage impacts of recent policy changes:

• Urban Institute found that nongroup and basic health plan (BHP) coverage will decline by 5.2 million people in 2026 alone due to the House-passed version of H.R. 1.
• A Wakely analysis found that the House-passed version of H.R.1 combined with the expiration of EPTCs could reduce current enrollment by up to 13.6 million individual market enrollees. 
• Among the people losing eligibility for coverage and financial assistance through ACA Marketplaces are those unable to navigate the newly complex red tape.
  • A Brookings analysis concludes that the added administrative burdens will particularly impact people getting married or divorced, people who have lost their jobs, and people with variable income.

Projected Changes in Health Insurance Costs

• The expiration of EPTCs is expected to significantly increase premium costs for ACA Marketplace enrollees, with KFF predicting average increases of about 75% for previously subsidized enrollees, and 90% average increases for people living in rural areas.
• The Wakely analysis found that the combined effects of House-passed H.R. 1 and the expiration of EPTCs could increase market average premiums up to 11.5%.
• A CAP analysis found that the House-passed version of H.R. 1 would have prompted net premiums to skyrocket for most Marketplace enrollees. For example, the study finds that a 60-year-old couple making $85,000 per year would see their annual premium costs skyrocket by $15,400, from about $6,900 to about $22,300.
• Young adults will be particularly hard hit by the recent policy changes. Another CAP analysis finds for example that a single 28-year-old earning $39,000 per year will see their premiums for a silver plan nearly double, while someone with a higher income, making $63,000, would see a 12% premium decrease.
• The House-passed version of H.R. 1 would have eliminated “silver loading,” raising premiums and out-of-pocket costs for millions of Marketplace enrollees who are currently enrolled in bronze or silver-level plans. Without silver loading, for example, a married, 60-year-old couple earning $62,000 a year with a gold plan would see their monthly premiums rise by $350, according to a Brookings analysis. While the provision was not included in the bill that was passed, the issue could resurface later this year, either through legislative or regulatory action.

Projected Changes in Uncompensated Care Costs

Previous research has consistently shown a strong link between higher uninsurance rates and increased levels of uncompensated care. Given the substantial rise in uninsurance projected under this bill, a corresponding increase in uncompensated care is highly likely.

• Urban Institute found that, attributable to the expiration of EPTCs and the House-passed reconciliation bill, there would be a decrease in healthcare spending from all payers between 2025-2034 of $1.03 trillion:
  • $408 billion decline in hospital payments
  • $118 billion decline in physician payments
  • $234 billion decline in prescription drug payments
  • and a $272 billion decline in payments for other services
• Urban Institute also found that, attributable to the expiration of EPTCs and the House-passed reconciliation bill, there would be a $278 billion increase in uncompensated care sought by uninsured people between 2025-2034:
  • $83 billion in uncompensated hospital services
  • $34 billion in uncompensated physician services
  • $54 billion in uncompensated prescription drug costs
  • and $107 billion in uncompensated other services
• Hospitals—particularly those in rural areas that serve a high proportion of low-income patients or have limited commercial insurance revenue—already experience elevated levels of uncompensated care. The policies in this bill further strain their financial stability, increasing the risk of service reductions, higher operating costs, or, in some cases, permanent closure. CAP estimates how each state could be affected.

An analysis from the Sheps Center found that hundreds of rural hospitals would be put at risk by H.R. 1. Based on an analysis model relying on hospital financial performance, organizational traits, and market performance, this study found that 83 rural hospitals are at the “highest relative risk of financial distress.”