More Hoosiers go uninsured – and to the ER

Indiana hospitals are reporting a double-digit increase in the percentage of emergency department visits since the start of 2025 - a rate that is expected to climb as more Hoosiers go without health insurance or opt for high-deductible plans to offset surging premiums.

Nearly 60,000 fewer Hoosiers signed up for insurance through the Affordable Care Act exchanges this year following the expiration of enhanced tax credits that once kept their monthly premiums affordable, researchers from health policy group KFF found in an analysis last month.

Another 400,000 Hoosiers are no longer covered by Medicaid since the Indiana Family and Social Services Administration imposed additional eligibility requirements, with still more Hoosiers expected to lose coverage when work requirements take effect in January.

Meanwhile, those insured through employer plans are reporting unsustainable monthly premiums, pressuring them to consider high-deductible plans or forgo coverage altogether.

Health and anti-poverty advocates say the trends could result in worse health outcomes, delayed and uncompensated medical care - and ultimately more medical debt for Hoosiers.

The exchanges

The expiration of enhanced tax credits from the American Rescue Plan, adopted in 2021 to lower monthly premiums for Americans insured through ACA plans, resulted in 23 million fewer Americans signing up for ACA coverage this year, according to KFF.

The plans are used by Americans who earn too much for Medicaid, yet cannot afford or are not eligible for insurance through their employer.

The health policy group found the average ACA premium hit $178 a month - a 58% increase over 2025. That is still lower than anticipated, as people either declined coverage or opted for high-deductible plans.

Indiana reported the fourth-highest decline in ACA sign-ups this year, tied with Delaware and Arizona at a 16% decrease from 2025, when 359,240 Hoosiers were covered by ACA plans.

KFF found 300,049 Hoosiers enrolled in ACA plans this year.

The health policy group anticipates more Americans will lose coverage as the year progresses and they are unable to keep up with premiums.

Premium surge

The KFF report found a disproportionate share of Americans who dropped ACA coverage are in middle-income households earning too much for what remains of the premium subsidies.

Allen County resident Sarah Conrad told the Indiana Capital Chronicle she declined ACA coverage this year upon learning her monthly premiums would go from $60 to $800 when her tax credits expired.

"There's no way I could have paid that," she said.

Now uninsured, Conrad declined coverage through her employer, saying a simple plan covering a single primary care visit a year and no prescriptions would have cost her at least $175 a month. "No prescriptions, no therapy, nothing," Conrad said.

"If I can't get on state health insurance, I probably will be uninsured indefinitely unless some policy changes happen, because there's just no way that I can afford insurance through my job," she said. "Even if I could, it wouldn't be worth it."

Hoosiers insured through their employers are struggling to afford their premiums, too.

Emily Meyer, a Martin County case manager who sits on the board of the Indiana Community Action Poverty Institute, said her family's premium increased from $400 to $1,000 a month this year for a high-deductible plan.

"So, not only am I paying $1,000 a month for insurance, I've got an $8,000 to $10,000 out-of-pocket expense on top of it," she said. "What's the point of having insurance if I'm already paying that much out of pocket?"

Surge in uninsured

Indiana hospitals are reporting a surge in uninsured or under-insured patients seeking care through the emergency department, "the most expensive setting for routine and preventative services," Indiana Hospital Association President Scott B. Tittle said in a statement to the Indiana Capital Chronicle.

Emergency department visits in Indiana rose by almost 17% in 2025, far higher than the 1.4% increase reported nationally, Tittle said.

The hospital association reports much of the decline in coverage is due to the Medicaid eligibility redetermination process, while federal policy changes including Medicaid work requirements and the expiration of ACA premium tax credits is expected to further fuel the trend this year.

Some hospitals are reporting to the Indiana Hospital Association a projected doubling of bad debt this year, at a time when the association is already projecting an additional $3.3 billion in uncompensated care for Indiana hospitals over the next decade due to federal policy.

"Hospitals will continue to care for every patient who walks through their doors. But as coverage declines, uncompensated care rises, which adds to the financial strain for hospitals already operating on thin or negative (profit) margins," Tittle said. "Ensuring continuous coverage for eligible Hoosiers is essential to keeping patients healthy and our healthcare system sustainable."

Uncompensated care

Jonathan Levin, vice president of healthcare economics and policy research at the Employers' Forum of Indiana, said in a statement that if the decline in ACA enrollment results in higher uninsured rates, hospitals could point to any resulting increase in uncompensated care to advocate for higher prices for commercial plans.

But Levin said there is little evidence this is needed, as research finds commercial prices are primarily linked to hospital market power and negotiating leverage, rather than uncompensated care or public payer reimbursement levels.

"In Indiana, where many hospitals already receive commercial payments far above Medicare rates, the available evidence has not supported the conclusion that higher employer-sponsored insurance prices are necessary to offset increases in uncompensated care," he said. "Indiana employers already pay some of the highest hospital prices in the country, and increases in employer-sponsored insurance prices could worsen healthcare affordability challenges facing Hoosier business, workers and their families."

More medical debt

Erin Macey, director of the Indiana Community Action Poverty Institute, said people who forego health insurance either delay medical care until an emergency or accrue medical debt.

The anti-poverty group recently advocated for legislation that would have allowed Hoosiers to deduct health insurance premiums from their taxes, as well as a bill to protect Hoosiers who rely on charity care or medical payment plans from debt collectors. Neither bill advanced.

"People are fearful," Macey said. "There's a lot of changes coming quickly in terms of work requirements and copays and documentation that will be ramped up or needed, and I think it will mean people lose coverage beyond what you're seeing with the ACA Marketplace. That spells more medical debt and potentially a less healthy Indiana."

Indiana Capital Chronicle is part of States Newsroom, a nonprofit news network supported by grants and a coalition of donors as a 501(c)(3) public charity. Indiana Capital Chronicle maintains editorial independence. Contact Editor Niki Kelly for questions: [email protected].