By repealing the Affordable Care Act’s individual mandate, policymakers allowed healthy Americans to walk away—leaving insurers with risk pools dominated by those most likely to need care. The result was inevitable: premiums soared, markets destabilized, and families were left paying the price.
When Congress passed the ACA, its most controversial feature was the individual mandate—the requirement that all Americans carry health insurance or pay a penalty. Critics called it coercion. In reality, it was the glue holding the system together.
Insurance depends on shared risk. By blending healthy and sick participants, insurers could keep premiums stable and coverage accessible. When the Trump administration eliminated the penalty, that balance collapsed. Healthy Americans had little incentive to stay in, and many walked away. What remained was a pool dominated by older, sicker, and higher‑cost enrollees.
This is the insurance equivalent of running a car company that only covers reckless drivers. Without the steadying presence of low‑risk participants, costs spiral. The Congressional Budget Office projected that repealing the mandate would increase the number of uninsured by 18 million in the first year and drive premiums up by double digits. More recent analyses warn that the expiration of enhanced ACA subsidies in 2026 could trigger premium hikes of over 100%.
Why It Matters
The consequences ripple far beyond the individual marketplace.
• Families: Middle‑class households not eligible for subsidies bear the brunt of higher premiums. For them, insurance becomes a luxury rather than a necessity.
• Markets: Shrinking risk pools push insurers to exit, reducing consumer choice and leaving some regions with only one or two carriers.
• Public health: More uninsured means delayed care, higher uncompensated hospital costs, and taxpayers footing the bill.
The Policy Lesson
The mandate was never about punishment—it was about fairness. Removing it shifted the burden onto those least able to absorb it. Temporary subsidies masked the damage, but as they expire, the imbalance resurfaces. Without a mechanism to keep healthy Americans in the system, premiums will continue to climb, and affordability will erode further.
The Path Forward
If we want health insurance to remain affordable and accessible, we must restore the principle of shared responsibility. Policymakers should either reinstate broad participation or commit to permanent subsidies that stabilize risk pools. Without decisive action, premiums will continue to climb, insurers will retreat, and families will be left stranded.
The ACA’s original design recognized a simple truth: insurance only works when everyone plays. The repeal fractured that principle, and Americans are paying the price.
The time to act is now—before the system collapses under its own weight.
Bruce Lowe is a homeowner advocate and community leader in Lubbock, Texas. He writes about civic integrity, public health, and principled reform. His book, "Honesty and Integrity: The Pillars of a Meaningful Life", explores how ethical leadership can strengthen families, uplift communities, and create a better life for all.
Native American women face higher rates of death than other demographics. (Oona Zenda/KFF Health News)
