The workers’ compensation industry may soon feel the reverberations of sweeping changes to America’s health insurance landscape, according to Dr. Benjamin Sommers, who delivered the opening keynote address at the 2026 Workers’ Compensation Research Institute (WCRI) Issues and Research Conference here in Boston today.
Dr. Sommers, the Huntley Quelch Professor of Health Care Economics at the Harvard T.H. Chan School of Public Health and a practicing primary care physician, drew on his extensive research portfolio and experience as a former Deputy Assistant Secretary at the U.S. Department of Health and Human Services to outline what he described as a partial unraveling of the coverage gains achieved under the Affordable Care Act — and what that could mean for employers, injured workers, and the workers’ compensation system.
His message was clear: when millions of Americans lose health insurance or shift to plans with significantly higher out-of-pocket costs, workers’ compensation becomes an increasingly attractive avenue for medical care. The industry needs to be paying attention.
Sommers opened by walking the audience through a decade of health coverage expansion. The Affordable Care Act, he explained, achieved its coverage gains through two primary mechanisms: expanding Medicaid eligibility to adults earning up to 138 percent of the federal poverty level, and creating health insurance marketplaces with premium tax credits that made private coverage affordable for millions who didn’t have access through their employers. By late 2022 and into 2023, the national uninsured rate had reached its lowest point in American history — roughly 8 percent of the population, or about 26 million people. Some 40 million Americans had coverage directly attributable to ACA-related programs.
“We are really the only high-income country that has tens of millions of people without health insurance,” Sommers noted, providing international context. “But this was the lowest it had ever been.”
That progress, he argued, is now at risk. Sommers identified several converging policy changes — some legislative, some administrative — that are poised to reverse a significant share of those coverage gains.
The most immediate impact came from the expiration of enhanced premium tax credits at the end of 2025. Originally passed during the pandemic in 2021 and extended through the end of that year, these subsidies had made marketplace coverage dramatically more affordable for many people. Under the enhanced credits, roughly 60 percent of uninsured Americans who qualified could find a plan for zero dollars per month. Notably, Sommers did not discuss the amount of money being paid to insurance companies on the behalf of those people.
Congress, however, failed to extend the credits, despite a prolonged government shutdown in which the issue was central to negotiations. Sommers estimated that 3 to 4 million people could lose their insurance and become uninsured as a result of the premium increases that have already begun taking effect in 2026.
Beyond the subsidy expiration, the second Trump administration has taken several administrative actions that don’t require congressional approval. Federal spending on marketplace outreach and advertising has been cut dramatically — navigator programs that helped people understand their options and enroll saw a 90 percent funding reduction. The open enrollment period has been shortened. And a proposed rule would expand access to high-deductible catastrophic plans, previously available only to young adults, to people of all ages. Some of these plans could carry deductibles in the tens of thousands of dollars, offering little practical coverage unless a person becomes catastrophically ill.
Sommers also presented findings from his ongoing research with MIT economist Jonathan Gruber showing that the same law, without any change from Congress, can be significantly more or less effective at covering people depending on who controls the executive branch and how aggressively states pursue enrollment. He noted that marketplace subsidies were roughly twice as effective at reducing uninsured rates in states that established their own marketplaces compared to those relying on the federal healthcare.gov platform.
On the Medicaid side, Sommers outlined the major provisions of the One Big Beautiful Bill Act, passed last year, which introduces the first federal work requirement for Medicaid beneficiaries in the program’s history. Under the new law, adults enrolled through Medicaid expansion in 40 states will need to demonstrate 80 hours per month of work, community service, education, or other qualifying activity to maintain their coverage. The requirement is set to take effect at the end of 2026, though some states have discussed earlier implementation.
While acknowledging that work requirements poll well with the general public across party lines, Sommers presented evidence suggesting the policy is unlikely to achieve its stated goals of increasing employment and self-sufficiency. He pointed to a natural experiment in Arkansas, which implemented a similar work requirement in 2018 with federal permission. Within months, 18,000 people were removed from the program for noncompliance. The result was a substantial increase in uninsured rates with no measurable change in employment. A third of those subject to the policy reported they had never even heard of it.
The underlying math, Sommers explained, tells the story. In Arkansas, roughly 40 percent of the affected Medicaid population was already working. Another large segment had health-related limitations preventing employment. Only about 3 to 4 percent were neither working nor had an obvious qualifying exemption. The policy, in effect, required 97 percent of beneficiaries to navigate paperwork proving they already met the criteria, and many couldn’t get through the process. Based on this and similar evidence, analysts have estimated that 5 to 6 million people could lose Medicaid coverage due to the administrative burden of work requirements, while the Congressional Budget Office has projected essentially no impact on actual employment.
Sommers bolstered this concern by showing data from the post-pandemic Medicaid “unwinding,” when states had to redetermine eligibility for everyone who had been continuously enrolled during the public health emergency. Some 24 million people lost coverage during that process, and the variation across states was staggering. In states like Maine and Oregon, fewer than 10 percent of enrollees were removed. In Utah and Oklahoma, the figure approached 40 to 50 percent — and the vast majority of those losses were not because people were found ineligible, but because they couldn’t understand the overly complex process or complete the paperwork.
The legislation also introduces twice-yearly eligibility redeterminations for expansion enrollees starting in early 2027, increased cost-sharing for those above the poverty level, and new restrictions on how states can use provider taxes to finance their share of Medicaid spending — a change that will put particular financial pressure on the 40 expansion states.
So what does all of this mean for workers’ compensation? Sommers connected the dots directly. Research has consistently shown that when people gain health insurance from other sources, workers’ comp claims shift. A study from Massachusetts found that coverage expansion produced a 5 to 10 percent reduction in workers’ compensation paid claims for emergency department and inpatient services. Conversely, when young adults age off their parents’ insurance at 26, workers’ comp claims increase in that age group. And when coverage doesn’t disappear but simply becomes less generous — through higher deductibles and cost-sharing — workers gravitate toward using their comp benefits for treatment they might otherwise have sought through their health plan. Studies cited by Sommers found that the growth of high-deductible plans in the employer market has already contributed to 1 to 3 percent increases in workers’ comp spending.
The implications are straightforward: as millions of Americans face higher premiums, lose subsidies, get dropped from Medicaid through work requirements or complex red tape, or shift to catastrophic plans that cover very little, the workers’ compensation system should expect to absorb some of that displaced demand.
Sommers closed by emphasizing that state-level decisions will matter enormously in determining how these changes play out. States that invest in automated data matching and behind-the-scenes eligibility verification will retain far more of their eligible Medicaid populations than those that place the reporting burden on enrollees. The variation during the pandemic unwinding proved that administrative capacity — not just policy design — drives real-world outcomes.
The presentation set a serious tone for the two-day conference, underscoring that the workers’ compensation industry does not operate in a vacuum. Changes to the broader health insurance landscape will inevitably ripple into comp, and the magnitude of those ripples will depend on decisions being made right now in Washington and in state capitals across the country.
