“On January first, we’re going to fall off a cliff in this country,” Chris Dickey told a listening audience on September 24. Dickey is a clinical associate professor of global and environmental health with the New York University School of Global Health; on the day, he was leading a panel discussion that accompanied a quartet of health care-related films at the Big Eddy Film Festival in Narrowsburg, NY. 

“Medicaid rules are changing; the money is being pulled out of the system; the services are going to go even farther [down],” Dickey said. “The lack of health insurance is going to become a crisis in this country.”

Additional reporting provided by Sonia Ahmed. 

Work requirements

The coming changes to the health care economy stem from the One Big Beautiful Bill, a piece of Trump-administration legislation signed into law on July 4, 2025. 

Among other changes, the One Big Beautiful Bill included new eligibility rules for Medicaid that required certain adults under age 65 enrolled in the program to report at least 80 hours of work, community volunteering or caregiving per month, or be kicked off the program. That requirement will begin to go into effect nationwide by January 1, 2027, although some states have implemented the changes already.

“Medicaid should be a short-term hand up, not a lifetime handout,” reads the final rulemaking for the change. “Implementing the community engagement requirement, we believe, will assist in prioritizing coverage for Medicaid’s most vulnerable populations such as seniors, individuals with disabilities, pregnant women and children while empowering able-bodied individuals through community engagement.”

The full implications of that change have yet to be felt. The Congressional Budget Office, a non-partisan government body charged with evaluating the costs and benefits of legislation, estimates that around 5.3 million people will lose their health coverage by 2034 due to the work requirements; around half of these people, 2.8 million, will lose coverage not because they don’t qualify but because of the added difficulty of navigating the extra enrollment step.

Jerry Dunlavey, CEO of Garnet Health Medical Center - Catskills, said there are still uncertainties about the new work requirement and about how it will impact people’s ability to make use of the program. “What we don’t know is how that going to be administered and how reliable is it that people aren’t going to end up with a gap in care,” he said. 

“We’re hoping that [the unknowns] are addressed properly,” he said. “But we’re prepared to take care of anybody that comes to our door.”

Denise Frangipane, CEO of Sullivan 180, has her own concerns about the upcoming changes to Medicaid; while it’s not her area of expertise, she said, she has been familiarizing herself with the proposed changes. 

“I think like anything else, when you make these types of changes, you have to have a plan and a rollout and a safety net, and I don’t know what that translates to in our community at this time,” she said. 

Economic effects

The changes to Medicaid, as well as other factors and changes in the health care system, will make it harder for people to find coverage for care; see below for more on the anticipated effects this will have on people. The changes are going to have broader implications for the financial state of the health care industry. 

Speaking with the River Reporter, Dickey estimated that $1 trillion will be pulled out of Medicaid over the next 10 years. Hospitals and clinics that rely on Medicaid funding will struggle, he said—and, with rural hospitals relying more on Medicaid than urban hospitals, they’re facing particular strain. 

“The risk of closure for clinics and hospitals in rural communities is going up really high” as of January 1, 2027, he said. 

Dunlavey talks about the changes to Medicaid more in terms of access to care than in terms of payment for care. 

“When people delay their care, their conditions have the potential to worsen, and then, when they do ultimately show up, they’re in a much sicker state than had they had access to care early on,” said Dunlavey. 

Still, Dunlavey said, “If those services are not available, it ultimately ends up here within the hospital. And we take care of everybody. We don’t turn anybody away.”

Medicaid

When people lose Medicaid coverage, they can try and seek coverage on the individual marketplace, or they can go without insurance. 

However, according to Louise Norris, a health care policy expert with healthinsurance.org, it’s unlikely that someone who loses their Medicaid coverage due to failing the work requirements will be able to afford health care on the individual marketplace. 

The individual marketplace has subsidies available to help people afford coverage. However, those subsidies don’t kick in until people are making too much money to qualify for Medicaid; if people aren’t working enough to keep their Medicaid coverage, it’s unlikely they’ll be making enough to qualify for an individual marketplace subsidy, and it’s even more unlikely they’ll be able to afford a full-priced marketplace plan. 

Norris expects a lot of people will lose their Medicaid coverage either because they won’t be able to work or for paperwork reasons. 

According to Erin McFadden, chief medical officer with The Wright Center, “When we continue to cut Medicaid, we are excluding individuals in our community from necessary life-sustaining health care.”

Marketplace

Nationwide, individual marketplace insurance plans are expected to see a median 15 percent increase in 2027, said Norris. (That’s before subsidies get calculated in, which substantially decrease the cost of care for many payees.)

The proposed average rate increase is 21 percent in New York and 17 percent in Pennsylvania, both pre-subsidies, said Norris. The steepness of those rate increases will likely level off, somewhat, after the states each make their review; it’s the state insurance body that reviews and edits the increase. 

These rate increases come on the heels of a major change to the marketplace at the end of 2025. From 2021 to 2025, a set of subsidy enhancements provided expanded assistance to payees on the individual marketplaces. Those enhancements lapsed at the end of 2025, with a political push to reinstate them faltering. 

“There are certainly legislators in Congress that would love to reinstate these subsidy enhancements, but it is a political hot potato,” said Norris, adding that it would take a change in the makeup of Congress for that to happen. 

Uninsured

“What we’re worried about as a hospital and as an emergency department within a hospital is that when folks have nowhere else to go and they can’t get care from a primary care provider or at a local urgent care, they end up in our emergency department,” said Dunlavey. 

That’s a problem from the payment side for the hospital: If someone without insurance shows up in a hospital’s emergency room, the hospital’s responsible for providing that care without a guarantee that they’ll be able to get payment for that care. 

Still, Dunlavey said, “If those services are not available, it ultimately ends up here within the hospital. And we take care of everybody. We don’t turn anybody away.”

Norris encourages people to keep some level of coverage that’s ACA compliant. Going without insurance can be expensive, and some alternative insurance options aren’t much better.

“Do whatever you can to maintain coverage,” said Norris. “It’s much better to have a bronze plan… than to have nothing or a non-ACA compliant plan that could leave you with hundreds of thousands of dollars in out-of-pocket costs.”