2027 trends to watch: Coverage losses will challenge healthcare growth strategies

Healthcare organizations (HCOs) have been planning around the One Big Beautiful Bill Act (OBBBA), or H.R. 1, since its passage in mid-2025, but 2027 marks the start of several key provisions. Their effects will compound coverage losses already emerging in the individual market following the expiration of enhanced ACA subsidies in 2026.

Downstream, changes in coverage and affordability are expected to alter care-seeking behavior, including when and where patients seek care and the services they ultimately use, with operational and financial impacts spanning capacity allocation, staffing models, reimbursement capture, uncompensated care exposure, and operating margins.

The impacts will vary considerably by market, and not all organizations will feel them equally. Understanding how these dynamics play out locally will be increasingly important to evaluating growth opportunities and informing strategic planning in the year ahead.

ACA subsidy expirations have pushed millions out of marketplace coverage

Enhanced premium tax credits introduced during the pandemic expired in 2026, raising premiums significantly for many marketplace enrollees. Millions responded by dropping coverage, while others moved into lower-premium, high-deductible bronze plans. By February 2026, effectuated enrollment had fallen 13%, and further erosion is expected as higher premiums continue to pressure affordability, with insurers proposing a median premium increase of 15% for 2027.

ACA enrollment dropped 13% between 2025 and 2026

Figure 1. February ACA marketplace effectuated enrollment (in millions) shown for each year, 2019-2026. Source: Centers for Medicare & Medicaid Services, Health Insurance Exchanges Monthly Effectuated Enrollment, accessed August 24, 2026.

States are taking different paths as premiums rise. State responses to rising premiums could determine how far enrollment falls and who remains in the market. Some are using state-funded subsidies to cushion the impact of premium increases and retain younger, healthier consumers, while others have taken a more hands-off approach that could leave a smaller, higher-risk pool, creating increasingly divergent exchange market conditions across states.

A shrinking market could accelerate insurer retrenchment. Aetna exited the exchange market for 2026, and Cigna is set to follow after year-end, while other major carriers, including Centene, have scaled back. Continued enrollment declines and worsening risk pools could prompt further insurer retrenchment in 2027, reshaping commercial market dynamics and shifting referral patterns, network access, and commercially insured volume across local markets.

More care may shift from planned to emergent. Coverage losses may cause patients to delay care until conditions become more acute. One study found that uninsured patients with access-sensitive surgical conditions, including colon cancer, ventral hernia, and abdominal aortic aneurysm, underwent unplanned surgery at more than twice the rate of privately insured patients, 73% versus 33%, and had worse outcomes and longer hospital stays.

Elective procedures could come under pressure. Community Health Systems is already seeing signs of this pressure, citing rising numbers of cost-conscious and uninsured patients delaying elective procedures as factors behind a 3.8% decline in inpatient surgeries in the second quarter of 2026, with orthopedic and cardiac procedures seeing the steepest declines. Sustained reductions in elective care would require providers to reassess capacity allocation, including OR time, staffing, and service-line investments, as volumes shift.

The financial effects are already emerging. HCA Healthcare said that patients who dropped ACA coverage are showing up as uninsured at roughly a one-to-one rate, while Community Health Systems reported uncompensated care was roughly 20% higher in the second quarter of 2026, with uninsured patients who had dropped ACA coverage appearing to be the primary driver of the increase.

Rising patient cost exposure could increase prescription abandonment.Affordability could become an even bigger barrier to medication access, increasing the risk of prescription abandonment and nonadherence. For branded and specialty therapies, that could translate into greater demand for patient assistance programs (PAPs) and copay foundation support, putting pressure on net realized prices.

Already, about 4 in 10 U.S. adults report they did not take their medication as prescribed in the past year because of cost, according to a KFF poll. Among those taking cost-cutting measures, 31% said they switched to over-the-counter alternatives, 27% did not fill a prescription, and 19% skipped or split doses.

Medicaid changes will create another wave of coverage churn

Starting in 2027, states must implement community engagement requirements for certain adults ages 19 to 64. Medicaid expansion enrollees will also move from annual to six-month eligibility renewals, while the window for retroactive coverage will shrink from three months to one.

Prior state experience shows reporting requirements can cause eligible people to lose coverage. Arkansas, for example, disenrolled more than 18,000 people under a Medicaid work requirement, while New Hampshire saw similar coverage losses during its brief implementation.

The Congressional Budget Office estimates these changes will result in 7.8 million more people becoming uninsured by 2034. The scale of coverage losses, however, will vary by state. People who lose Medicaid under the new requirements also will not qualify for subsidized marketplace coverage. Medicaid exposure will therefore become a more important consideration when evaluating a market’s growth outlook.

Share of Medicaid enrollees at risk of losing coverage

Figure 2. Projected share of Medicaid enrollees at risk of losing coverage under Medicaid community engagement requirements. Source: Center on Budget and Policy Priorities.

Coverage churn will make RCM and patient outreach more critical. Providers could see more frequent changes in patients’ coverage status, increasing pressure on revenue cycle operations. Patients who regain coverage after an eligibility gap may also return with deferred needs, creating less predictable utilization and costs. Providers will need to identify coverage changes and communicate financial responsibility earlier to reduce denials, billing surprises, uncompensated care, or delayed or abandoned treatment.

Providers will be differentially impacted. Hospitals with higher Medicaid exposure will face greater pressure as eligibility changes take effect, while organizations with a larger commercial base may have more ability to offset payor mix shifts. For example, Medicaid accounts for an average of 22% of patient days at rural emergency hospitals, compared with 8% at short-term acute care hospitals, making rural facilities more vulnerable to service reductions or even closures—moves that would shift uncompensated care to remaining providers.

Average percentage of payor days by hospital type

Figure 3. Percentages represent the average share of patient days attributed to each payor by hospital type in 2024. Source: Definitive Healthcare HospitalView data, based on Medicare Cost Reports.

Disruption could create opportunities for financially stronger providers. Well-capitalized systems in non-expansion states may see opportunities to capture market share. Virtual care providers could also see increased demand as consumers seek lower-cost alternatives to traditional physician offices. With coverage less stable, price sensitivity could also drive more patients toward urgent care.

Eligibility volatility could make revenue capture more tech-dependent. More frequent coverage changes and shorter windows to verify eligibility will increase the value of tools that can continuously monitor coverage, surface changes before an episode of care, and flag reimbursement risk earlier. For RCM vendors, that creates an opportunity to help providers shift from retrospective denial management toward proactive revenue protection as Medicaid churn increases.

Turn market intelligence into your next growth move

The organizations poised to grow in 2027 will be those that understand how coverage changes are playing out in their local markets, including shifts in payor mix and care-seeking patterns. That visibility can help organizations spot market risks earlier and identify pockets of durable demand in a dynamic landscape.

Find the markets with the strongest growth potential. Learn how Definitive Healthcare combines trusted claims, provider, affiliation, and consumer data to help organizations evaluate local markets and focus commercial efforts where they matter most. Book a demo.