Where Affordable Care Act insurance coverage has dropped most in WA

Washington's rural counties saw the largest drops in insurance coverage under the Affordable Care Act after the Republican-controlled Congress failed to extend subsidies that helped consumers afford the plans.

About 250,000 Washingtonians are enrolled this year through the Washington Health Benefit Exchange, down roughly 36,500 from 2025. That amounts to a nearly 13% reduction, the biggest falloff since the marketplace launched in 2013.

The decline isn't as steep as had been feared.

State officials estimated last year that as many as 80,000 people could forgo coverage with Congress not extending tax credits for these policies. The issue was at the heart of last fall's lengthy federal government shutdown as congressional Democrats wanted to see the subsidies extended while Republicans refused.

Premiums rose an average of 21%, due in part to the loss of the enhanced tax credits, which started during the COVID pandemic. The increase was in line with similar hikes nationwide. But losing the subsidies meant even steeper price hikes for some customers.

Those most likely to drop their coverage were young and lower-income.

This coverage is meant for people not covered through their work or government programs like Medicaid or Medicare. Many of those no longer covered could've found insurance elsewhere, like joining a family member's plan or getting employer-sponsored coverage.

"What we expect is that a majority of these folks are now uninsured, and that what we're going to see is a pretty steep increase from the historically low uninsured rates that we've had," said Laura Kate Zaichkin, director of market competition and affordability at Washington's exchange.

In February, state officials reported a 19,000-person drop in coverage through Washington's online marketplace, but more customers fell off as they faced their initial monthly payments with high premiums.

Future adjustments to marketplace plans still to come have left state officials expecting to see a 30% drop in enrollment over the next few years compared to 2025.

Where coverage losses were sharpest

Enrollment increased nowhere in the state, but some areas have been hit harder than others.

Rural counties saw some of the biggest drops in coverage between March 2025 and this March. Over 1,100 Yakima County residents went without insurance via Washington Healthplanfinder, amounting to a nearly 18% fall.

Garfield, San Juan, Franklin, Pacific, Wahkiakum and Asotin counties all saw drops above 20%. But some of those are so small that a few dozen people no longer covered could result in a major percentage decrease.

Meanwhile, residents of rural areas are more likely to rely on Healthplanfinder for their coverage, said Emily Brice, co-executive director at Northwest Health Law Advocates.

"The real challenge there is that folks in rural areas are hit by this double whammy," Brice said. "They have the soaring prices on one end and then access challenges on the other end, because providers are increasingly less available, more consolidated in rural areas."

Rural hospitals, also, are expected to be particularly hard hit by the federal cuts to Medicaid coming over the next couple years, though a major infusion of federal dollars to rural healthcare is meant to offset some of that. And fewer patients will be able to afford to get care from these hospitals, Brice said.

Bigger counties like King, Pierce, Clark and Whatcom saw drops between 9% and 12%. Though King County makes up roughly one-third of the state's total decrease in enrollment.

Also on the bigger side, Snohomish and Spokane counties saw above-average dips in enrollment, both around 15%. Those counties are larger and the number of people losing coverage totaled 4,407 and 2,789, respectively.

As for congressional districts, the area represented by U.S. Rep. Adam Smith, D-Bellevue, saw nearly a quarter of its enrollees drop coverage so far this year. The roster in Rep. Marilyn Strickland's district in Pierce and Thurston counties fell 16%.

The central and eastern Washington districts represented by Washington's two Republican congressmen, Dan Newhouse and Michael Baumgartner, saw decreases of 11% and 14%, respectively.

A change included in Republicans' "big, beautiful bill" also hurt enrollment. The law eliminated all federal tax credits for lawfully present immigrants whose income is under 100% of the federal poverty line.

"We're seeing really significant drops from that population," Zaichkin said.

Asked about the decline in his district, Baumgartner said "healthcare is extremely important," but otherwise focused on the cuts to Medicaid he voted for last summer and criticized the state for extending Medicaid coverage to some noncitizens.

The state's own premium assistance, known as Cascade Care Savings, helped avert some of the more dire notions of the drops in coverage.

This year, 65% of enrollees are still accessing some form of federal subsidy to help pay for their health plan on the marketplace, compared to 75% last year. Some of the biggest drops in this aid came in places like Chelan, Island and Jefferson counties.

Obstacles ahead

Premiums are expected to rise further next year, with insurers requesting an average 22.4% rate increase for individual health insurance. The state Office of the Insurance Commissioner will review the proposals to see if they're justified before potentially approving them around September.

A slew of changes in the coming years are expected to further curb enrollment.

In 2027, lawfully present noncitizens will lose eligibility for federal premium tax credits, with some exceptions. Medicaid access for refugees and asylees will be cut this year. Nationwide, the Congressional Budget Office has estimated the loss of the subsidies would kick 900,000 people off coverage by 2034.

People losing access to Medicaid due to new work requirements Congress approved last year won't be able to get premium tax credits to switch over to marketplace coverage.

"That's going to be a major affordability and access barrier," Zaichkin said.

Open enrollment will be reduced to nine weeks. This past year, it lasted from Nov. 1 to Jan. 15.

And in 2028, returning customers can't automatically renew their coverage in plans that are the same or similar each year. Other changes will require more paperwork to sign up in the first place.

"Nobody thinks that signing up for health coverage is easy now," Brice said. "Who asked for this? Nobody said 'I want my health insurance coverage process to be more complicated and annoying.'"