In recent years, more and more Utahns have been able to access health insurance, but following the passage of President Donald Trump’s mega-budget bill, industry experts say changes to the Affordable Care Act could result in skyrocketing insurance costs and mass coverage losses.
The rate of Utahns without health insurance dropped dramatically between 2014 and 2022, from 14.3% of people under the age of 64 to just 8.8%, according to the state’s Department of Workforce Services. That drop, the department wrote last October, came with the advent of the Affordable Care Act, implemented under former President Barack Obama in 2014.
The shrinking uninsured rate reflects a trend that Matthew Rae, the associate director of the health care marketplace program at the health policy organization KFF, has been watching for some time.
“As long as I’ve been alive, we’ve been expanding health insurance to cover a higher percentage of the population,” Rae said during a recent interview, noting the particular impact of the ACA. “The vast majority of people now are eligible for health coverage or have health coverage.”
But in the coming months, Utahns who have been able to access health care through the Affordable Care Act may be forced to look elsewhere for coverage — if they can find it at all.
On the Fourth of July, Trump signed the “Big Beautiful Bill” into law, a budget package that makes current tax rates permanent, increases funding for border security and, among other things, implements major changes to Medicaid and Affordable Care Act programs that the nonpartisan Congressional Budget Office estimates could put the health coverage of more than 10 million Americans at risk.
Every member of Utah’s all-Republican congressional delegation voted for the megabill.
The changes under the new law — particularly the expiration of enhanced premium tax credits at the end of this year — could have dramatic consequences for thousands of Utahns who rely on ACA coverage, potentially significantly increasing premium costs, making it more difficult to renew coverage and putting a particular burden on members of Utah’s immigrant and small business communities.
(Tierney L. Cross | The New York Times) President Donald Trump signs his signature policy bill legislation during a Fourth of July celebration event outside the White House in Washington, on Friday, July 4, 2025.
In Utah alone, the changes could mean nearly 200,000 people risk losing access to insurance, according to a KFF assessment from early June of the House version of the bill. (The organization has not yet released an updated assessment since the passage of the bill, but the final changes to the ACA in the legislation were nearly identical to the House bill.)
Those projected losses include an estimated 52,000 Medicaid recipients in Utah losing access to the program and another 130,000 people in the state losing access to care under the ACA.
Already, Rae said, many Americans — even some with health insurance — say they find health care prohibitively expensive.
“They skip doctors’ visits and they don’t get prescriptions, and they don’t get all the care we want them to be getting, which is preventive care that makes you live a longer and happier life,” he said. “Your prevalence in not doing all those things goes up astronomically when you don’t have health insurance.”
Tax credits set to expire
Among the most significant changes to the ACA under the new law is what it did not include: a renewal of enhanced premium tax credits that help millions of Americans afford marketplace coverage.
When the ACA first became law, Congress set up premium tax credits for people making between 100% and 400% of the federal poverty level, and in 2021, in an effort to address the effects of the COVID-19 pandemic, lawmakers introduced enhanced credits that increased the value of the credits and expanded eligibility beyond 400% of the poverty level.
The expansion of the credits meant that enrollment in marketplace health coverage more than doubled, from 11.4 million people in 2020 to 24.3 million in 2025. Without them, enrollees could see an average 75% increase in premium costs, according to a joint report issued last month by KFF and the Peterson Center on Health Care.
Fernando Wilson, the director of the Matheson Center for Health Care Studies at the University of Utah, said in an interview that the credits are “something that Congress may or may not revisit later, separately,” though most people expected that if Congress were to renew the credits, they would do so during the budget reconciliation process.
At least one Senate Republican, Sen. Thom Tillis of North Carolina, has said he would like to work across the aisle to pass a separate bill extending the enhanced tax credits. But Tillis, who recently announced he will not run for reelection and voted against the megabill, hardly speaks for the Republicans who control both chambers of Congress.
Members of Utah’s congressional delegation — which includes Sens. Mike Lee and John Curtis and Reps. Blake Moore, Mike Kennedy, Celeste Maloy and Burgess Owens — did not respond or declined to comment on whether they would support legislation to extend the enhanced credits before they expire.
And while there still is time for lawmakers to address that expected increase, the fact that Congress did not renew the credits under the “Big Beautiful Bill” is already having ripple effects, as insurers set rates for the coming year.
“All 23 insurers from D.C. and the three states that have posted their proposed rates reference the expiration of the enhanced premium tax credits. Over half of the insurers stated that the expiration of enhanced tax credits will cause premiums to increase,” the KFF and the Peterson Center on Health Care report read.
Wilson noted that healthy people dropping out of the marketplace will put pressure on insurers to raise costs to cover a less healthy group that can’t afford to drop their coverage.
“We don’t know if it’s a significant risk or substantial risk,” he said, “but that also affects planning if you’re insurer in terms of, ‘Well, how do I compensate for that risk?’”
A big hit to small businesses
(Francisco Kjolseth | The Salt Lake Tribune) A steady flow of traffic moves past businesses on Main Street in Heber City on Thursday, Jan. 9, 2025.
The expiration of the enhanced tax credits could hit small businesses particularly hard, as many small businesses across the country rely on the ACA marketplace — and the help of the enhanced tax credits — to provide coverage for their employees, as providing private insurance for small organizations can be prohibitively expensive.
“Small business owners and entrepreneurs, they’re disproportionate users of the ACA marketplace,” Wilson said. That means changes in the bill, he said, including more frequent eligibility checks, the elimination of auto-renewals, and the expected premium increases, will disproportionately impact small businesses and self-employed people.
Additionally, for many self-employed Utahns, estimating expected income can be difficult, and another change under the megabill could make that particularly expensive for self-employed people.
The effect of these changes could be particularly intense in Utah, where the small business community is dense: According to a 2022 report from the U.S. Small Business Administration’s Office of Advocacy, 99.3% of businesses in the state are small businesses.
Rae pointed to a hypothetical situation where a husband and wife own a business together and use the marketplace to enroll themselves and their two children, estimating that their income will be 395% of the poverty level, but instead it turns out to be 405%.
“They could be on the hook for repaying $30,000, depending on their state,” Rae said. “These are not ridiculously wealthy people to face massive, massive potential tax increases. And this is compounded, I think, by the fact that if you don’t make this repayment, then you’re blocked out of all future access to subsidies.”
An environment of uncertainty
Last week, Utah’s Office of Legislative Research and General Counsel released a report assessing the possible effects of the megabill on Utahns, but the section dedicated to ACA changes had little solid information.
Regarding changes to special enrollment periods, new eligibility verifications for tax credits and excess tax credit repayments, the report concluded that not enough information was available to determine how the changes could affect Utahns.
It also addressed changes to ACA access for immigrants, but said, again, that the impact was hard to quantify. Currently, marketplace health care is available to U.S. citizens and all lawfully present immigrants, but the megabill limits eligibility, stripping individuals here as asylum seekers, refugees and people with temporary protected status of their access to the marketplace.
The report did not address the possible expiration of the enhanced premium tax credits.
In a statement shared with The Salt Lake Tribune, Aundrea Peterson, a spokesperson for the Utah Senate, said lawmakers would be working closely with the legislative research office and fiscal analysts, as well as the Department of Health and Human Services, to review the bill and determine next steps.
“Utah consistently ranks as the top state in the nation, and senators remain committed to building on that and putting Utahns first,” Peterson said.
Alexa Musselman, a spokesperson for the Utah House, said House leaders and the speaker are continuing to “carefully review the bill and its implications for Utahns.”
“Our top priority remains serving our constituents and ensuring Utah remains the best place to live, work, and raise a family,” Musselman said.
Utah Republican Gov. Spencer Cox acknowledged the predicted health coverage losses at a news conference earlier this month and said he would be working with the state Legislature to understand the scale.
“I think everybody’s trying to figure out what that means and what the impact is,” Cox said. But, he added, he was concerned about the wide-ranging effects of mass losses.
“Helping people get onto private insurance is going to be really important,” he said. “We end up paying for this one way or another. If [people] don’t have health care coverage, and end up going to the emergency room — which is where you get the most expensive care — all that does is raise rates for everybody else in the state.”
Despite the uncertainty, Wilson said it’s clear “what direction things are going.”
“We have to see [if] the state legislature gets involved and see what happens at that level,” he said. “And then we have to see people’s responses to these legislative changes. It’s really like a dynamic system that’s hard to predict.”
Rae agreed, but said that if states want to step in to address losses, they are already running out of time.
“The scary part is these plans are legally required to have their rates filed [in the coming weeks],” he said. “People have to start enrolling in coverage in four months … so if states are going to do something that they’ve got to do it, otherwise those plans aren’t gonna be able to adjust in time.”
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