In February 2026, the Congressional Budget Office (CBO), Congress’s official nonpartisan economic and budget agency, updated its projected baseline for health programs for the first time since June 2024. Since then, President Trump took office, changed rules to reduce Affordable Care Act (ACA) health insurance marketplace coverage, let lapse enhanced premium tax credits for that coverage, and signed into law H.R. 1, the megabill formerly called the One Big Beautiful Bill Act. That law partly funded tax cuts for high-income people and corporations through policies that reduce enrollment for people covered by the ACA’s marketplace and Medicaid expansion.
The new CBO baseline offers insight into changes in health coverage in the coming years. The estimates are not significantly different from what CBO provided to members of Congress before and after they voted on the passage of H.R.1 last year. CBO projected at the time that federal health spending would be roughly $1 trillion below projected spending under current law (that is, baseline) from fiscal years 2025 to 2034. Nonetheless, the new baseline reaffirms that health coverage losses are likely to be significant. Such a loss of health coverage would put needed health care out of reach for millions of Americans.
Enrollment in ACA Health Coverage Options Is Projected to Drop by 44 Percent by 2032
According to the CBO, the number of people with ACA premium tax credits is expected to decline from 20.9 million to 9.7 million (a 54 percent drop) from 2025 to 2028, the end of the Trump presidency (Figure 1). In 2014, the ACA began providing income-based tax credits for people without affordable alternatives who buy insurance on their own. Congress increased the amount of and eligibility for such tax credits from 2021 to 2025. The current Congress failed to continue these enhanced tax credits in 2026, resulting in at least over 1 million fewer people signing up for health plans. This decline in people getting tax credits will continue throughout 2026 and in 2027, when H.R. 1 legislative changes start to take effect. Furthermore, marketplace enrollment will drop even more than CBO projects, if the administration finalizes its proposed rule that increases barriers to affordable coverage, or if Congress enacts the president’s plan to replace these tax credits with cash to people.
FIGURE 1
Additionally, the number of people with coverage through the ACA’s Medicaid expansion is projected by CBO to fall from 17 million to 10 million (a 41 percent drop) from 2025 to 2032 (Figure 2). The ACA incentivizes states to expand Medicaid to people with income up to 138 percent of the federal poverty level ($22,025 for a single person) to align with the level of required eligibility for children. H.R.1 imposed on ACA Medicaid expansion enrollees work requirements, redetermination of eligibility every six months, and co-pays. KFF estimates that over half of the $911 billion in ten-year federal Medicaid savings would come only from ACA-expansion states. Unlike the aggressive implementation of ACA marketplace changes, the new law staggers effective dates for Medicaid policy changes so the full effect is likely to occur in 2032.
FIGURE 2
President Trump failed to repeal and replace the ACA in 2017. However, CBO projects that his policies will lower the number of Americans helped by the law’s tax credits and Medicaid expansion by 16.5 million between 2025 and 2032—a 44 percent decrease.
The Number of Uninsured People Is Projected to Rise by 33 Percent by 2028
While not all people losing ACA tax credits or Medicaid coverage will become uninsured, many will. After reaching record low rates in recent years, the rate and number of uninsured is projected to rise rapidly by CBO—starting now. Compared to 2025, the number of uninsured in the United States is expected to increase by 3.4 million in 2026, 7.5 million in 2027, and 8.7 million in 2028 (Figure 3). CBO projects that the 2028 number of uninsured will be over 35 million people—33 percent higher than it was in 2025.
FIGURE 3
Being uninsured has well-studied consequences: people without coverage have less access to health care, greater financial insecurity and medical debt, worse outcomes when they get care, and premature mortality.
According to the new CBO baseline, that harm has already begun.
Tags: affordable care act, cbo, donald trump, healthcare
CBO Reaffirms Forecast of a Dramatic Reduction in Health Coverage in 2026 and Beyond
In February 2026, the Congressional Budget Office (CBO), Congress’s official nonpartisan economic and budget agency, updated its projected baseline for health programs for the first time since June 2024. Since then, President Trump took office, changed rules to reduce Affordable Care Act (ACA) health insurance marketplace coverage, let lapse enhanced premium tax credits for that coverage, and signed into law H.R. 1, the megabill formerly called the One Big Beautiful Bill Act. That law partly funded tax cuts for high-income people and corporations through policies that reduce enrollment for people covered by the ACA’s marketplace and Medicaid expansion.
The new CBO baseline offers insight into changes in health coverage in the coming years. The estimates are not significantly different from what CBO provided to members of Congress before and after they voted on the passage of H.R.1 last year. CBO projected at the time that federal health spending would be roughly $1 trillion below projected spending under current law (that is, baseline) from fiscal years 2025 to 2034. Nonetheless, the new baseline reaffirms that health coverage losses are likely to be significant. Such a loss of health coverage would put needed health care out of reach for millions of Americans.
Enrollment in ACA Health Coverage Options Is Projected to Drop by 44 Percent by 2032
According to the CBO, the number of people with ACA premium tax credits is expected to decline from 20.9 million to 9.7 million (a 54 percent drop) from 2025 to 2028, the end of the Trump presidency (Figure 1). In 2014, the ACA began providing income-based tax credits for people without affordable alternatives who buy insurance on their own. Congress increased the amount of and eligibility for such tax credits from 2021 to 2025. The current Congress failed to continue these enhanced tax credits in 2026, resulting in at least over 1 million fewer people signing up for health plans. This decline in people getting tax credits will continue throughout 2026 and in 2027, when H.R. 1 legislative changes start to take effect. Furthermore, marketplace enrollment will drop even more than CBO projects, if the administration finalizes its proposed rule that increases barriers to affordable coverage, or if Congress enacts the president’s plan to replace these tax credits with cash to people.
FIGURE 1
Additionally, the number of people with coverage through the ACA’s Medicaid expansion is projected by CBO to fall from 17 million to 10 million (a 41 percent drop) from 2025 to 2032 (Figure 2). The ACA incentivizes states to expand Medicaid to people with income up to 138 percent of the federal poverty level ($22,025 for a single person) to align with the level of required eligibility for children. H.R.1 imposed on ACA Medicaid expansion enrollees work requirements, redetermination of eligibility every six months, and co-pays. KFF estimates that over half of the $911 billion in ten-year federal Medicaid savings would come only from ACA-expansion states. Unlike the aggressive implementation of ACA marketplace changes, the new law staggers effective dates for Medicaid policy changes so the full effect is likely to occur in 2032.
FIGURE 2
President Trump failed to repeal and replace the ACA in 2017. However, CBO projects that his policies will lower the number of Americans helped by the law’s tax credits and Medicaid expansion by 16.5 million between 2025 and 2032—a 44 percent decrease.
The Number of Uninsured People Is Projected to Rise by 33 Percent by 2028
While not all people losing ACA tax credits or Medicaid coverage will become uninsured, many will. After reaching record low rates in recent years, the rate and number of uninsured is projected to rise rapidly by CBO—starting now. Compared to 2025, the number of uninsured in the United States is expected to increase by 3.4 million in 2026, 7.5 million in 2027, and 8.7 million in 2028 (Figure 3). CBO projects that the 2028 number of uninsured will be over 35 million people—33 percent higher than it was in 2025.
FIGURE 3
Being uninsured has well-studied consequences: people without coverage have less access to health care, greater financial insecurity and medical debt, worse outcomes when they get care, and premature mortality.
According to the new CBO baseline, that harm has already begun.
Tags: affordable care act, cbo, donald trump, healthcare