10 Years of Coverage Gains Threatened by Proposed Federal Policy Changes, Report Finds

At least a decade's worth of progress in expanding health coverage and improving access to care is in jeopardy, according to this year’s 2025 Scorecard on State Health System Performance published by the Commonwealth Fund.¹ The report, released today, shows that all 50 states and Washington, DC have seen historic reductions in uninsured rates and improvements in affordability since the implementation of the Affordable Care Act (ACA).

“This report shows how much progress states have made expanding health coverage for millions through Medicaid expansion and subsidized marketplace coverage. But these gains are fragile,” study author Sara R. Collins, PhD, senior scholar and vice president for Health Care Coverage and Access at the Commonwealth Fund, said in a statement.²

“If Congress allows the extra premium subsidies passed during the pandemic to expire and makes it harder to get and keep Medicaid and marketplace coverage, the number of uninsured will climb toward pre-ACA levels, when 49 million people lacked health insurance,” she continued. “States already facing the biggest challenges will fall even further behind.”

Based on 2023 data, the report evaluates states across 5 core categories: health care access, affordability, quality, outcomes, and equity. The findings reflect the long-term impacts of the ACA’s Medicaid expansion, marketplace subsidies, and consumer protections.¹

Leading the nation in overall health system performance were Massachusetts, Hawaii, New Hampshire, Rhode Island, and Washington, DC. States at the bottom of the rankings included Mississippi, Texas, Oklahoma, Arkansas, and West Virginia.

Uninsured rates vary widely across the US due largely to state and federal policy decisions, especially around ACA implementation. States that fully embraced the ACA—including Medicaid expansion—have seen the greatest improvements in coverage since 2013. For example, Massachusetts and Hawaii, both early adopters of expanded health coverage, now have some of the lowest uninsured rates. In contrast, 10 states have not expanded Medicaid, including 3 of the 5 states with the lowest access and affordability: Texas, Mississippi, and Georgia. Texas’s adult uninsured rate, 21.6%, was the nation’s highest in 2023.

In states without Medicaid expansion, 1.4 million low-income individuals are left in a coverage gap where they earn too much to qualify for Medicaid but not enough for subsidized marketplace plans. This gap is especially evident when comparing neighboring states: Kentucky, which expanded Medicaid, reduced its uninsured rate among low-income residents by two-thirds over the past decade, while Tennessee, which did not expand, saw only a one-third decline. States with larger undocumented populations, like Nevada and Texas, also tend to have higher uninsured rates, since undocumented immigrants are excluded from ACA coverage options.

Data sourced from the Commonwealth Fund 2025 Scorecard.

Graph developed with Gemini AI.

Coverage Gains Driven by ACA, Now at Risk

Since 2013, the nationwide uninsured rate among working-age adults has dropped from 20.4% to 11%, while the share of adults skipping needed care due to cost declined from 15.9% to 11.7%. While there are still gaps to close, barriers to overcome, and improvements to be made, these figures highlight how federal policy has helped millions obtain coverage and reduce financial barriers to care.

Shifts in federal oversight responsibilities that followed the inauguration of President Donald Trump earlier this year, along with current proposals, including the “one big beautiful” reconciliation bill and the HHS 2026 budget plan, point to funding cuts that put this progress at risk.³

If enhanced ACA premium subsidies expire and new enrollment hurdles are introduced, the report estimates that more than 8 million Americans could lose their insurance.¹ Meanwhile, proposed Medicaid work requirements and stricter eligibility checks could cause nearly 8.8 million to become uninsured. These policies are also expected to raise marketplace premiums and out-of-pocket costs, eroding affordability and access.

Troubling Trends in Public Health

In addition to threats to coverage, the report highlights decreasing childhood vaccination rates and increasing rates of infant mortality and avoidable deaths.

As of 2023, fewer than 75% of young children in most states received all 7 recommended early childhood vaccines. Between 2019 and 2023, nearly every state saw declines, with Nebraska and Minnesota reporting decreases of 18 and 15 percentage points, respectively. Massachusetts had the highest coverage rate at 90%, while Montana lagged far behind at just 60%.

Infant mortality also worsened in 20 states between 2018 and 2022. Black infants across the country faced a mortality rate of 10.9 per 1000 live births in 2022—more than double the rate for White infants (4.5). Geographic disparities were equally stark, with Mississippi reporting the highest infant mortality rate (9.1), compared with a rate of 3.3 in Massachusetts.

The report also documented troubling rates of avoidable death. In 2023, there were 278 premature, preventable deaths per 100,000 Americans under age 75. West Virginia saw the highest rate with 445 per 100,000, compared with Massachusetts at 201. The burden of these deaths falls disproportionately on Black Americans, who experience 2 to 3 times the rate of premature mortality compared with other racial and ethnic groups in every state.

“This scorecard makes one thing very clear: where you live continues to define your health and your ability to get and afford the health care you need," Joseph R. Betancourt, MD, president of the Commonwealth Fund, said in the statement.² "While some states have taken bold steps to improve coverage and invest in primary care and public health, others are falling behind. We need commonsense, people-centered federal and state policies so all Americans, no matter who they are, where they live, or how much money they make, can live a healthy life.”

References

1. 2025 scorecard on state health system performance. The Commonwealth Fund. June 18, 2025. Accessed June 18, 2025. https://www.commonwealthfund.org/publications/scorecard/2025/jun/2025-scorecard-state-health-system-performance

2. New state-by-state health scorecard: historic insurance coverage gains, improvements in access and affordability may now be at risk. News release. The Commonwealth Fund. June 18, 2025. Accessed June 18, 2025.
3. Grossi G. Trump's budget and tax proposals mark historic shift in US approach to health care policy. The American Journal of Managed Care^®.

https://www.ajmc.com/view/trump-s-budget-and-tax-proposals-mark-historic-shift-in-us-approach-to-health-care-policy