For a few years, it was easy to forget that when the Affordable Care Act (ACA) took effect in 2014, it lifted the number of Americans with health insurance from 86.1 percent in 1990 to more than 92 percent—the highest in our nation's history. Our country still didn't have health insurance for everyone, but the ACA seemed like a big step in that direction.

In the years that followed, we started to take the benefits of the ACA* for granted. But now it seems we're going backwards: Some of those benefits are on the verge of being lost.

Thousands of people in our communities face a significant increase in the cost of their insurance—or the complete loss of health insurance.

Shifting Policies, Rising Costs

One in four Washington residents has government-subsidized insurance they bought on our state's exchange, which was established by the ACA. The exchange made health insurance a bargain, especially since a pandemic-era increase in the federal subsidy lowered costs for consumers even more than the ACA itself. That subsidy is set to expire at the end of December, which means costs will rise again—by a little for some people, and by a lot for others.

The ACA also allowed non-disabled, non-elderly, very low-income adults to enroll in Medicaid, a government-provided health plan. This was a major expansion of who could get Medicaid, and not all states agreed to participate. Fortunately, Washington state did. Now, 1.6 million Washingtonians rely on Medicaid.

But people who rely on Medicaid now face a welter of new restrictions that are scheduled to take effect over the next several years. Work requirements will be expanded to include people up to age 64, and will require more frequent reporting. This requirement alone is expected to eliminate many people from receiving Medicaid benefits.

‍Local Impacts, Local Resilience

At Mason General Hospital in Shelton, there are already two full-time employees whose sole job is to help people fill out Medicaid forms. Their work will expand dramatically.

Restrictions on both Medicaid and subsidized private insurance will also eliminate access to health insurance for several categories of legal immigrants. Refugees and Asylees who don't yet have green cards are excluded from Medicaid, CHIP, Medicare, and subsidized ACA marketplace plans. So are DACA recipients (people who were brought to the U. S. when they were children) and people with Temporary Protection Status who are from countries that are at war or exceptionally dangerous.

Currently, Washington state estimates that at the end of 2025, approximately 80,000 residents are likely to lose private health insurance they bought on the state's exchange because they can no longer afford it. About 250,000 people are likely to lose Medicaid coverage over the next handful of years.

This is a crisis for families, elders, and immigrants who are shocked to discover they can't rely on these programs. It is also a crisis for the clinics and hospitals that serve them.

Eric Moll, the CEO of Mason General Hospital in Shelton, estimates that these policy changes could eliminate 5,000 patients who would otherwise be served there. He and his team are working to find workarounds and adaptations to reduce that number.

"I was actually relieved to hear that the Medicaid cuts are being phased in slowly, not starting until the end of next year," he said. "This gives us a much longer runway to prepare."

There was widespread initial panic that Medicaid cuts would cause a wave of closures of rural hospitals. Since rural areas tend to be poorer, they have more patients on Medicaid, and Medicaid pays health care providers less—less than Medicare, less than private insurance, and less than the cost of care. Having to rely on Medicaid revenue for a significant percentage of its patients can bean extreme hardship for a struggling hospital or clinic.

Moll says 25 percent of Mason General's patients have Medicaid, and 80 percent of its hospital births are paid for by Medicaid. But Moll says he and his colleagues have carefully tended reserves and done enough mitigation planning to feel they are in no danger of closing.

Shelton (population 10,737) is a bustling metropolis compared to the town of Morton (population 1,089) in East Lewis County.

Morton, in east Lewis County, is not panicking either, for a different reason. Arbor Health, its local hospital, is a federally designated Critical Access Hospital that is paid a higher rate for Medicaid and Medicare patients. These Critical Access health care providers have 25 or fewer inpatient beds and provide outpatient care in locations that would otherwise be healthcare deserts. According to Eric Neil, CEO of Arbor Health in Morton, "serving East Lewis County with its small, widely spread out communities and lower income people would be impossible without it."

But even Critical Access status won't be enough to save small rural hospitals if many people lose Medicaid benefits and/or subsidized commercial insurance altogether. As Eric Moll, the CEO at Mason General, noted, "There will never be enough state funding for charity care to make up for that."

These changes—outlined in HR 1, a federal bill signed into law on July 4, 2025—mean that health care hardships will spread even into more urban areas with higher average incomes. Even people who rely on employer-paid private insurance will feel the pinch as insurance prices rise to keep health care providers in the black.

The Olympia Free Clinic is already planning for a rise in its caseload. This nonprofit organization is sustained by a corps of 120 volunteer doctors, nurses, and other health care providers and support staff, plus four paid staff. They have seen 537 patients so far this year. Patients are not asked about income, insurance, or immigration status.

What they see on the horizon—an unpredictable amount of increased demand for their services—has led them to form an alliance with CHOICE Regional Health Network and MultiCare to strategize and prepare.

Getting people the care they need when they need it is essential to keeping people out of Emergency Rooms.

That's an apt metaphor for the challenge of keeping our health care system out of the national policy emergency it's facing.

A System Under Strain

As these local challenges unfold, a national crisis adds new strain. When the federal government shut down on October 1, the ripple effects were immediate—even here in the South Sound. While essential programs like Medicare and Medicaid continue to operate, many of the administrative functions that keep them running smoothly have been suspended or slowed. Claims processing, customer service hotlines, and public outreach efforts have all been reduced. For Washington residents who rely on these systems, that means longer waits, delayed reimbursements, and uncertainty about coverage changes.

The shutdown also interrupted federal support for telehealth services and the "Hospital at Home" program—two innovations that had expanded access to care in rural and underserved areas during and after the pandemic. At the same time, enhanced federal subsidies that helped keep Affordable Care Act marketplace insurance affordable expired when Congress failed to reach a funding deal. As a result, thousands of Washingtonians who purchase insurance through the state's Health Benefit Exchange are expected to see their premiums rise sharply in the coming months. For families already managing tight budgets, this combination of policy inaction and administrative slowdown is creating new barriers to accessing timely, affordable care.

Right now, there is a faint but urgent hope that before the end of this year, Congress might extend the pandemic-era subsidy that kept exchange-based private insurance affordable.

In the new year, there will be time to reconsider the importance of Medicaid in keeping all Americans—and the American health care system—a source of national pride.

How We Move Forward, Together

Even as health systems strain under new pressures, the strength of our region has always come from the people who care—neighbors checking in, volunteers showing up, and community members giving what they can. Change begins here, in the South Sound, where local action can ease the weight of national challenges. Together, we can help ensure that everyone has access to the care they need to live healthy, connected lives.

As we shared in our recent story on The State of South Sound Nonprofits, even when challenges feel insurmountable, there is always something we can do. When we support one another, advocate for access, and strengthen the organizations that care for our neighbors, we remind ourselves that the heart of any health system isn't its policies—it's its people. Here are three ways you can make a difference:

• ‍Give something. Support local clinics, hospitals, and community networks. We highlighted three in this story, but many more are meeting this challenge in different ways across our region. You can also discover and support additional organizations during Give Local, happening November 10 – 21, 2025 at spsgives.org.
• Do something. Volunteer your time! Many health organizations rely heavily on volunteers, and the work is a rewarding way to build community by doing something tangible together. Reach out to organizations working to provide accessible health care in your community and ask how you can help.  
• Join something. Add your voice to state and national advocacy efforts to strengthen access to care in our systems. Great places to start include Health Care for All – Washington (HCFA – WA), Alliance for a Healthy Washington (AHW), the Washington Healthcare Access Alliance (WHAA), and the Washington State Public Health Association (WSPHA)—as well as national organizations like the American Academy of Family Physicians (AAFP) that advocate for equitable health access across the country.

Every system we rely on—food, health, housing, or otherwise—reflects the choices we make together. The future of care depends not just on policy, but on the people and communities who choose to keep showing up.

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*ACA provisions: no exclusion or extra cost for people with pre-existing conditions, insurance companies can't charge women more than men, kids can stay on parents' plans until 26, insurance policies must cover reproductive care, preventive services, mental health, no annual or lifetime limits on coverage