Senior Lecturer of History, Auburn University
Zachary W. Schulz does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.

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A few years ago, a student in my history of public health course asked why her mother couldn’t afford insulin without insurance, despite having a full-time job. I told her what I’ve come to believe: The U.S. health care system was deliberately built this way.
People often hear that health care in America is dysfunctional – too expensive, too complex and too inequitable. But dysfunction implies failure. What if the real problem is that the system is functioning exactly as it was designed to? Understanding this legacy is key to explaining not only why reform has failed repeatedly, but why change remains so difficult.
I am a historian of public health with experience researching oral health access and health care disparities in the Deep South. My work focuses on how historical policy choices continue to shape the systems we rely on today.
By tracing the roots of today’s system and all its problems, it’s easier to understand why American health care looks the way it does and what it will take to reform it into a system that provides high-quality, affordable care for all. Only by confronting how profit, politics and prejudice have shaped the current system can Americans imagine and demand something different.
My research and that of many others show that today’s high costs, deep inequities and fragmented care are predictable features developed from decades of policy choices that prioritized profit over people, entrenched racial and regional hierarchies, and treated health care as a commodity rather than a public good.
Over the past century, U.S. health care developed not from a shared vision of universal care, but from compromises that prioritized private markets, protected racial hierarchies and elevated individual responsibility over collective well-being.
Employer-based insurance emerged in the 1940s, not from a commitment to worker health but from a tax policy workaround during wartime wage freezes. The federal government allowed employers to offer health benefits tax-free, incentivizing coverage while sidestepping nationalized care. This decision bound health access to employment status, a structure that is still dominant today. In contrast, many other countries with employer-provided insurance pair it with robust public options, ensuring that access is not tied solely to a job.
In 1965, Medicare and Medicaid programs greatly expanded public health infrastructure. Unfortunately, they also reinforced and deepened existing inequalities. Medicare, a federally administered program for people over 64, primarily benefited wealthier Americans who had access to stable, formal employment and employer-based insurance during their working years. Medicaid, designed by Congress as a joint federal-state program, is aimed at the poor, including many people with disabilities. The combination of federal and state oversight resulted in 50 different programs with widely variable eligibility, coverage and quality.
Southern lawmakers, in particular, fought for this decentralization. Fearing federal oversight of public health spending and civil rights enforcement, they sought to maintain control over who received benefits. Historians have shown that these efforts were primarily designed to restrict access to health care benefits along racial lines during the Jim Crow period of time.
Today, that legacy is painfully visible.
States that chose not to expand Medicaid under the Affordable Care Act are overwhelmingly located in the South and include several with large Black populations. Nearly 1 in 4 uninsured Black adults are uninsured because they fall into the coverage gap – unable to access affordable health insurance – they earn too much to qualify for Medicaid but not enough to receive subsidies through the Affordable Care Act’s marketplace.
The system’s architecture also discourages care aimed at prevention. Because Medicaid’s scope is limited and inconsistent, preventive care screenings, dental cleanings and chronic disease management often fall through the cracks. That leads to costlier, later-stage care that further burdens hospitals and patients alike.
Meanwhile, cultural attitudes around concepts like “rugged individualism” and “freedom of choice” have long been deployed to resist public solutions. In the postwar decades, while European nations built national health care systems, the U.S. reinforced a market-driven approach.
Publicly funded systems were increasingly portrayed by American politicians and industry leaders as threats to individual freedom – often dismissed as “socialized medicine” or signs of creeping socialism. In 1961, for example, Ronald Reagan recorded a 10-minute LP titled “Ronald Reagan Speaks Out Against Socialized Medicine,” which was distributed by the American Medical Association as part of a national effort to block Medicare.
The health care system’s administrative complexity ballooned beginning in the 1960s, driven by the rise of state-run Medicaid programs, private insurers and increasingly fragmented billing systems. Patients were expected to navigate opaque billing codes, networks and formularies, all while trying to treat, manage and prevent illness. In my view, and that of other scholars, this isn’t accidental but rather a form of profitable confusion built into the system to benefit insurers and intermediaries.
Even well-meaning reforms have been built atop this structure. The Affordable Care Act, passed in 2010, expanded access to health insurance but preserved many of the system’s underlying inequities. And by subsidizing private insurers rather than creating a public option, the law reinforced the central role of private companies in the health care system.
The public option – a government-run insurance plan intended to compete with private insurers and expand coverage – was ultimately stripped from the Affordable Care Act during negotiations due to political opposition from both Republicans and moderate Democrats.
When the U.S. Supreme Court made it optional in 2012 for states to offer expanded Medicaid coverage to low-income adults earning up to 138% of the federal poverty level, it amplified the very inequalities that the ACA sought to reduce.
These decisions have consequences. In states like Alabama, an estimated 220,000 adults remain uninsured due to the Medicaid coverage gap – the most recent year for which reliable data is available – highlighting the ongoing impact of the state’s refusal to expand Medicaid.
In addition, rural hospitals have closed, patients forgo care, and entire counties lack practicing OB/GYNs or dentists. And when people do get care – especially in states where many remain uninsured – they can amass medical debt that can upend their lives.
All of this is compounded by chronic disinvestment in public health. Federal funding for emergency preparedness has declined for years, and local health departments are underfunded and understaffed.
The COVID-19 pandemic revealed just how brittle the infrastructure is – especially in low-income and rural communities, where overwhelmed clinics, delayed testing, limited hospital capacity, and higher mortality rates exposed the deadly consequences of neglect.
Change is hard not because reformers haven’t tried before, but because the system serves the very interests it was designed to serve. Insurers profit from obscurity – networks that shift, formularies that confuse, billing codes that few can decipher. Providers profit from a fee-for-service model that rewards quantity over quality, procedure over prevention. Politicians reap campaign contributions and avoid blame through delegation, diffusion and plausible deniability.
This is not an accidental web of dysfunction. It is a system that transforms complexity into capital, bureaucracy into barriers.
Patients – especially the uninsured and underinsured – are left to make impossible choices: delay treatment or take on debt, ration medication or skip checkups, trust the health care system or go without. Meanwhile, I believe the rhetoric of choice and freedom disguises how constrained most people’s options really are.
Other countries show us that alternatives are possible. Systems in Germany, France and Canada vary widely in structure, but all prioritize universal access and transparency.
Understanding what the U.S. health care system is designed to do – rather than assuming it is failing unintentionally – is a necessary first step toward considering meaningful change.
Copyright © 2010–2025, The Conversation

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You do it 20,000 times a day—but are you doing it right?
If you’ve ever been told to “take a deep breath” during a stressful moment, know that this advice isn’t merely a platitude—it’s backed by science.
Research shows conscious breathing comes with a host of immediate and long-term benefits that include improved heart health, reduced anxiety, boosted mood, improved cognitive function, and better sleep quality.
“Breathwork is one of the simplest and profoundly effective tools we have for calming the nervous system and boosting physical and mental resilience,” says Guy Fincham, founder of the breathwork lab at Brighton & Sussex Medical School in England and co-author of breathwork research. “And yet, precisely because it’s so accessible, its power is often underestimated.” 
Here’s why mindful inhaling and exhaling can be so good for you, plus which breathing techniques are best and how to ensure you’re doing them safely and effectively. 
Emerging science suggests that how you breathe—day in and day out—can influence everything from heart health and mood to memory and sleep.
One of the clearest examples comes from the cardiovascular system. Diaphragmatic, or “belly,” breathing stimulates the vagus nerve. This nerve originates in the brainstem and extends down through the neck into many branches of the large intestine and other vital organs. When this nerve is activated through deep breathing, it sends calming signals throughout the body, helping to regulate heart rate, lower blood pressure, and improve circulation.
(Here’s how better posture can improve your overall health.)
Adjusting your breathing pattern can also subtly shift your body’s internal chemistry. “When you slow your breathing and gently take in less air, carbon dioxide levels in the lungs and blood rise slightly,” says Patrick McKeown, an advisor of the International Academy of Breathing and Health and the author of The Breathing Cure: Develop New Habits for a Healthier, Happier, and Longer Life. This is a good thing, he explains, as carbon dioxide is not just a waste gas but “acts as a natural vasodilator by opening up blood vessels and allowing more oxygen-rich blood to reach the brain and the heart.”
Since the vagus nerve is part of the parasympathetic nervous system—the system that counteracts the body’s fight-or-flight response by triggering a “rest and digest” response—breathing slower and consciously can also ease symptoms of stress, anxiety, and depression. In fact, the longer and slower your breath, “the more you activate the calming effects of this system,” says Raj Dasgupta, a pulmonary and sleep medicine physician at Huntington Memorial Hospital in California.
Fincham agrees, as he has co-authored a meta-analysis demonstrating the positive effects conscious breathing has “on stress, anxiety, and depressive symptoms.”
(Does meditation actually work? Here’s what the science says.)
In 2017, Stanford researchers similarly identified a cluster of neurons in the brainstem that links the breathing control center with the brain’s arousal system. “This neural pathway explains how slow, controlled breathing can further induce a state of calm,” says McKeown.
That sense of calm isn’t only good for easing frazzled nerves—it’s also been shown to reduce cravings for food and addictive substances, suggesting a wider reach of breathwork’s regulatory power.
Reduced pain and muscle tension are additional benefits of intentional breathing techniques because doing so triggers the body’s endogenous opioidergic system, which is critically involved in the cognitive modulation of pain. That’s one reason deep breathing has long been encouraged during labor, athletic exertion, and military training: it’s an accessible, nonpharmacological tool for managing discomfort.
Similarly, breathwork can even reduce migraine frequency, muscle tension, and pain severity, says Helen Lavretsky, director of integrative psychiatry at the David Geffen School of Medicine at UCLA. 
Improved cognitive function occurs as well as breathing techniques such as coherent breathing “improve communication between the right and left hemisphere of the brain and increase oxygen levels so the brain works better,” says Patricia Gerbarg, clinical assistant professor of psychiatry and behavioral sciences at New York Medical College and a co-author of dozens of prominent breathwork studies.
Recent research even hints at breathwork’s potential role in detecting or influencing neurodegenerative conditions. One 2025 study showed how breathing impacts brain structures like the amygdala and hippocampus, both associated with focus and memory. It’s a connection that explains how “breathing patterns can directly influence cognitive function,” says McKeown. 
(You’ve heard of forest bathing. Now try forest therapy.)
Another recent study found that people with Alzheimer’s disease breathe significantly faster at rest than more cognitively healthy individuals. This elevated respiratory rate “may reflect underlying neurovascular dysfunction that could serve as an early biomarker for Alzheimer’s-related brain changes,” says McKeown.
Better sleep also occurs, Dasgupta notes, as breathing calms the nervous system and promotes the relaxation needed to release the sleep-inducing hormone melatonin. Breathing through your nose while you fall asleep and throughout the night has also been shown, both in recent and older research, to provide a better night’s rest. “Nasal breathing during sleep reduces snoring, improves sleep quality, and supports healthy breathing rhythms overnight,” says McKeown.
So, what kind of breathing works best? That depends on what you need—a quick mental reset, support during physical effort, or a few minutes of deeper relaxation.
One of the fastest ways to calm the body is the physiological sigh. It’s performed as a double nasal inhale (the first inhale longer, immediately followed by a shorter second one on top of the first one), before exhaling through the mouth. “This technique can shift you out of fight-or-flight in seconds,” says Fincham. “It’s a rapid and reliable reset that’s also useful before a big test or speech or anything that’s got you nervous.”
(Quieting your mind to meditate can be hard. Here’s how sound can help.)
The pursed-lip technique is another exercise to turn to for quick calming or to push through physical exertion, such as lifting weights. It’s done by inhaling through your nose, then exhaling slowly through pursed lips, “as though blowing out through a straw,” Dasgupta explains.
If you have more time, several meditative styles can help shift your body into a more relaxed state. These include box breathing (sometimes called square breathing), coherent, quiet, and diaphragmatic (belly) breathing.
Box breathing controls your inhales, exhales, and breath holds for specific periods. “Breathe in slowly through your nose for a count of four, hold your breath for four, exhale through your mouth for four, and count to four again before repeating,” says Dasgupta. Note that the amount of time doesn’t matter, so long as the ratios are equal. “You could start with a 3-3-3-3 repetition but extend each second count out until you’re reaching a yogic one-breath-per-minute,” says Lavretsky.
(How stressed are you? Answer these 10 questions to find out.)
Coherent breathing is similar to box breathing, but without the breath holds. Inhale through the nose for six seconds, then exhale through the nose for six seconds. “The key is a conscious, connected rhythm with no pauses between inhale and exhale, just a smooth flow,” advises Fincham. Gerbarg agrees and calls coherent breathing “the safest, most useful, and most adaptable breath practice.” 
Quiet breathing is another option and is done by taking a soft, quiet breath in through your nose, “followed by an even softer, silent breath out through your nose,” says McKeown. “The goal is to breathe so lightly that it feels as if you’re hardly breathing at all—you should even feel a slight air hunger, which signals the exercise is working.” 
Diaphragmatic breathing can be performed in five- to 10-minute sessions, two or three times daily. It’s done by inhaling deeply and slowly through your nose, “allowing your abdomen to expand as you fill your lungs with air,” says Dasgupta. “Then exhale through your mouth as you allow your belly to contract.” Beginners should try this one lying on their back with their knees bent and hands over the belly to better feel each breath expand their stomach.
Dasgupta recommends practicing breathwork in a peaceful environment where you can relax fully before trying to employ the techniques in school, work, or gym settings. “If you feel dizzy or uncomfortable while doing breathwork, stop and return to normal breathing,” he advises.
Also, remember that “breathing should never be forced or strained,” ​adds Fincham. “The aim is to remove layers of stress, not create more.” 
Copyright © 1996-2015 National Geographic SocietyCopyright © 2015-2025 National Geographic Partners, LLC. All rights reserved

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Court documents are shedding new light on the murder of United Healthcare CEO Brian Thompson. New York state prosecutors say Luigi Mangione had a diary where he wrote about his plans to kill the healthcare executive months before Thompson was shot and killed in New York City.
NEW YORK (FOX 9) – Prosecutors say, to Mangione, Thompson and UnitedHealthcare were symbols of the healthcare industry and what the 27-year-old considered a deadly greed-fueled cartel.
What we know:
When Luigi Mangione was arrested by police in Altoona, Pennsylvania, last December, prosecutors say they recovered a red notebook he used as a diary among his possessions.
They say the diary includes several entries that explain Mangione's intent and motive to deliberately assassinate Brian Thompson, the CEO of United Healthcare, the country's largest health insurance company.
The backstory:
Prosecutors say an entry in August 2024 reads, "I finally feel confident about what I will do. The details are coming together. And I don't feel any doubt about whether its right/justified."
He goes on to write, "The target is insurance. It checks every box."
Then, in October of last year, about a month and a half before Thompson was shot and killed outside the midtown Manhattan hotel where United Healthcare's annual investors conference was scheduled to be held, Mangione writes: "The investor conference is a true windfall. It embodies everything wrong with our health system, and – most importantly — the message becomes self-evident."
Prosecutors say Mangione references Ted Kaczynski, saying the Unabomber made some good points, but he crossed the line from anarchist to terrorist by indiscriminately mail bombing innocent people.
In his diary, prosecutors say Mangione writes "…instead of carrying out a bombing, one should "wack" the CEO at the annual parasitic bean counter convention. It's targeted, precise and doesn't risk innocents."
"The point is made in the news headline 'Insurance CEO killed at annual investors conference.'"
What they’re saying:
In the filing, prosecutors wrote, "If ever there were an open and shut case pointing to defendant's guilt, this case is that case. Simply put, one would be hard-pressed to find a case with such overwhelming evidence of guilt as to the identity of the murderer and the premeditated nature of the assassination."
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A Community Health Worker (CHW) is a frontline public health worker who connects individuals to health care, social services, and community resources. CHWs help people navigate complex systems, understand their options, and access programs that meet their unique needs. By connecting people with the right support, CHWs help reduce disparities, improve health outcomes, and strengthen community well-being.
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Fifty-two Alabama organizations urged Ivey to oppose cuts to Medicaid and the Affordable Care Act, warning of harm to families and healthcare access.
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Published on June 6, 2025 at 7:56 am CDT
On Wednesday, 52 organizations from across Alabama sent a letter to Gov. Kay Ivey and the members of Alabama’s state legislature urging them to contact members of Congress and express concerns about the U.S. House’s budget reconciliation bill — also known as the “One Big Beautiful Bill Act.” Specifically, the letter highlights the cuts which the Republican budget proposal would make to Medicaid and the Affordable Care Act and the harmful impact these cuts would have on Alabama families.
The organizations behind the letter are members of Cover Alabama, a self-described “nonpartisan alliance of community partners, consumer groups, health care providers and faith groups advocating for Alabama to provide quality, affordable health coverage to its residents and implement a sustainable health care system.”
“We are writing to raise serious concerns about the budget reconciliation bill under consideration in Congress,” the groups’ letter reads. “If passed, this legislation would undermine Alabama’s ability to manage its Medicaid program, limit our future options and increase barriers to coverage for families across our state.”
In its current form, the budget reconciliation bill would strip Alabama of $619 million in extra federal funding set aside to help the state cover the first two years of its much-needed Medicaid expansion. As the organizations note in their letter, that funding was created to offset the fact that Alabama and the nine other states who have yet to expand their Medicaid programs did not benefit from the original 100 percent federal match rate offered when the option to expand Medicaid was first introduced under the ACA. 
The organizations also point out that the new Medicaid work requirements and eligibility redeterminations outlined in the bill could strip coverage away from Alabamians who are currently eligible for Medicaid. Additionally, they note that the bill’s reduction of retroactive Medicaid coverage from three months to one month would “put many Alabamians at financial and medical risk — particularly pregnant women.” 
“This is especially concerning given Alabama’s recent step forward in establishing presumptive eligibility for pregnant women,” they write. “Reducing retroactive Medicaid coverage would directly undermine the intent of that policy, creating unnecessary delays in prenatal care and risking poorer health outcomes for mothers and babies.”
All told, nonpartisan health policy organization KFF estimates that over the next ten years Alabama would lose a baseline of $3 billion in federal spending and would experience a Medicaid enrollment loss of 42,000 individuals if the “One Big Beautiful Bill” passes in its current form.
The bill would also prevent Alabama from expanding its own state funding of Medicaid by freezing provider taxes at current levels, preventing increases even in response to inflation, changes in service demand, or new health care priorities.
As for the Affordable Care Act, the current Republican budget would allow enhanced ACA tax credits to expire, only adding to the number of Alabamians who would lose access to healthcare by making Marketplace plans less affordable.
“This would result in coverage losses and higher uninsured rates, especially among working families who don’t qualify for Medicaid but can’t afford full-price private plans,” the organizations note. “Letting enhanced tax credits expire would cost the state an estimated $1.14 billion in lost GDP and 10,000 jobs by 2026. This would worsen economic distress in rural communities and stall local economic growth precisely where it is most needed.”
KFF estimates that the expiration of these tax credits compounded with the bill’s cuts to Medicaid spending could result in around 170,000 Alabamians losing access to healthcare.
“This legislation doesn’t just threaten health coverage for low-income families. It also would strip Alabama of the tools, flexibility and funding we need to manage our own Medicaid program in the way that works best for our state,” the organizations concluded. “We urge you to contact members of Congress and make clear your concerns about this bill and its impact on Alabama. Alabama needs solutions that expand access to care, support our health care providers and respect our state’s decision-making — not more red tape and bureaucratic constraints. Thank you for your time and continued service.”
Alabama Arise, the ACLU of Alabama, the Alabama Chapter of the American Academy of Pediatrics, Communications Workers of America, the North Alabama Area Labor Council, the American Cancer Society Cancer Action Network and the American Lung Association are among the organizations behind the letter.
Alex Jobin is a freelance reporter. You can reach him at [email protected].
Alabama could lose billions with cuts to Medicaid, straining rural hospitals and reducing care access for vulnerable residents.
The statewide anti‐poverty group warns the House’s “Big Beautiful” omnibus budget will shift $300 million in SNAP costs to Alabama and slash Medicaid funding.
Trump’s “One Big Beautiful Bill” would cut safety net programs in Alabama for thousands.
This session delivered some major wins on taxes, healthcare, workforce support, and public safety.
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The independent source for health policy research, polling, and news.
The independent source for health policy research, polling, and news.
Alice Burns, Jared Ortaliza, Justin Lo, Matthew Rae, and Cynthia Cox
Published: Jun 06, 2025
Note: KFF’s analysis was updated on June 6 to reflect new estimates from the Congressional Budget Office (CBO) on the increase in the number of people who would be without health insurance because of changes to Medicaid and the ACA in the One Big Beautiful Bill Act.
House Republicans have passed a reconciliation package (the “One Big Beautiful Bill Act”) that would make significant changes to Medicaid and the Affordable Care Act (ACA) Marketplaces. The Congressional Budget Office (CBO) estimates that the bill would increase the number of people without health insurance by 10.9 million, because of changes to Medicaid and the ACA. Additionally, these legislative changes come at a time when enhanced premium tax credits for ACA Marketplace enrollees are set to expire later this year. When combining the reconciliation bill’s effects with that of the expected expiration of the ACA’s enhanced premium tax credits, CBO expects 16.0 million more people will be uninsured in 2034 than would otherwise be the case.
This analysis apportions the increase in the number of uninsured across the 50 states and the District of Columbia and shows that number as a percentage of each state’s population. The number of newly uninsured as a percent of the population is equivalent to the percentage point increase in the 2034 uninsured rate. Nationally, CBO projected an uninsured rate of under 10% in 2034 under current law, which assumed the enhanced ACA premium tax credits would expire. The analysis here includes two maps: one showing the effects of the House reconciliation package, and another showing those effects combined with expiration of the ACA enhanced premium tax credits and full impact of the program integrity rule.
Anticipating how states will respond to changes in Medicaid policy is a major source of uncertainty in CBO’s cost estimates. Instead of making state-by-state predictions about policy responses, CBO estimates the percentage of the affected population that lives in states with different types of policy responses. For example, in the reconciliation bill, Medicaid work requirements account for nearly half of the federal savings on Medicaid, suggesting they may contribute to the largest loss of insurance coverage in CBO’s estimates. However, different states might choose to implement a work requirement with reporting requirements that are easier or harder for enrollees to comply with. Reflecting the uncertainty, this analysis illustrates the potential variation by showing a range of enrollment effects in each state, varying by plus or minus 25% from a midpoint estimate.
The interactive table at the end is sortable by state and size of coverage loss.
The One Big Beautiful Bill Act would result in increases in the uninsured rates of 3 percentage points or more in 16 states (Washington, Oregon, Louisiana, New York, Kentucky, Florida, California, Illinois, New Mexico, Rhode Island, Connecticut, Arizona, New Jersey, West Virginia, Arkansas and Alaska) and District of Columbia. These increases are attributable to the One Big Beautiful Bill Act alone and do not include the effect of the expiration of the enhanced premium tax credits nor the full impact of the proposed Marketplace integrity rule.
In terms of increases in the number of uninsured people, California and Florida are the top two states (1.7M and 990k, respectively). New York, Texas, and Illinois would follow at 920K, 770k, and 500k, respectively.
The combined effects of the House reconciliation package with the expiration of the ACA enhanced tax credits, compared to a scenario where the enhanced subsidies are in place and the proposed integrity rule was not in effect, results in the greatest uninsured increases in Florida, Georgia, Louisiana, Texas, Mississippi, Washington, and the District of Columbia, where the uninsured rate is expected to increase by at least 5 percentage points. Thirty-five states and the District of Columbia may see an increase in their uninsured rates of 3 percentage points or more.
About half (48%) of the 16 million more people who would be uninsured in this scenario live in Florida (2.3M), Texas (1.9M), California (1.8M), New York (920k), and Georgia (750k). The largest growth in ACA Marketplace enrollment since 2020, the year before the enhanced premium tax credits became available, occurred in Texas (2.8M), Florida (2.8M), and Georgia (1.0M).
Changes in Medicaid: CBO estimates that changes in Medicaid from the House reconciliation bill are expected to trigger two types of health insurance loss. First, an estimated 10.3 million people are expected to lose Medicaid. Second, an estimated 1.4 million people are expected to lose coverage provided to immigrants regardless of immigration status through programs financed entirely by the states. KFF uses the ratio of those numbers to first allocate the newly uninsured population (7.8 million) to Medicaid or state-funded coverage categories.
This analysis allocates the newly uninsured population stemming from a loss of Medicaid across the states proportionally to each state’s estimated federal funding loss. In a prior analysis, KFF estimated how the federal Medicaid cuts would be allocated across the states using prior modeling work and state-level data. Data sources include:
The analysis allocates the newly uninsured stemming from a loss of state-funded coverage across the states proportionally to the federal spending reductions resulting from the new penalty on ACA expansion states that offer state-funded coverage.
Changes in the ACA Marketplaces: Increases in the uninsured population are taken from Congressional Budget Office estimates. Impacts of individual provisions within the Energy and Commerce and Ways and Means sections of the One Big Beautiful Bill Act are broken out in detail and separately apportioned to calculate state-level estimates.
Because the policy changes in the Trump administration’s proposed program integrity rule have already been proposed through regulation, CBO assigned half of the effect of codifying the proposed rule (900,000 increase in uninsured) to the reconciliation legislation while the other half is accounted for in the baseline. Therefore, this analysis considers only half of the estimated state-level impact from the proposed rule for Figure 1 (900,000), and the whole effect in Figure 2 (1.8 million). Due to rounding in the CBO estimates, increases in the uninsured due to individual provisions have been scaled to sum up to the totals provided by CBO. Downward scaling was subsequently applied to all provisions other than program to account for the interaction effects within the reconciliation package.
Population Estimates: Decennial state-level population projections from the Weldon Cooper Center for Public Service are used to interpolate the population in 2034 assuming compound population growth. The percentage point increase of the uninsured population per state reflects the estimated increase in the uninsured as a share of the projected population. The total impact from all changes were aggregated then rounded to two significant figures, with the percentage point increase in the uninsured population rounded to the nearest whole number.
KFF Headquarters: 185 Berry St., Suite 2000, San Francisco, CA 94107 | Phone 650-854-9400
Washington Offices and Barbara Jordan Conference Center: 1330 G Street, NW, Washington, DC 20005 | Phone 202-347-5270
www.kff.org | Email Alerts: kff.org/email | facebook.com/KFF | twitter.com/kff
The independent source for health policy research, polling, and news, KFF is a nonprofit organization based in San Francisco, California.

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