Photo courtesy KFF Health News
This story by Elisabeth Rosenthal and Hannah Norman appeared on KFF Health News on August 11, 2025. We are sharing it in two parts.
Amid the challenges of adulthood, one rite of passage is unique to the United States: the need to find your own health insurance by the time you turn 26. That is the age at which the Affordable Care Act declares that young adults generally must get off their family’s plan and figure out their coverage themselves.
When the ACA was voted into law in 2010, what’s known as its dependent coverage expansion was immediately effective, guaranteeing health insurance to millions of young Americans up to age 26 who would otherwise not have had coverage.
But for years, Republicans have whittled away at the infrastructure of the original ACA. Long gone is the requirement to buy insurance. Plans sold in the ACA’s online insurance marketplaces have no stringent quality standards. Costs keep rising, and eligibility requirements and subsidies are moving targets.
The erosion of the law has now created an “insurance cliff” for Americans who are turning 26 and don’t have a job that provides medical coverage.
Some, scared off by the complexity of picking a policy and by the price tags, tumble over the edge and go without insurance in a health system where the rate for an emergency room visit can be thousands, if not tens of thousands, of dollars.
Today, an estimated 15% of 26-year-olds go uninsured, which, according to a KFF analysis, is the highest rate among Americans of any age.
If they qualify, young adults can sign up for Medicaid, the federal-state program for Americans with low incomes or disabilities, in most but not all states. Otherwise, many buy cheap subpar insurance that leaves them with insurmountable debt following a medical crisis. Others choose plans with extremely limited networks, losing access to longtime doctors and medicines. They often find those policies online, in what has become a dizzyingly complicated system of government-regulated insurance marketplaces created by the ACA.
The marketplaces vary in quality from state to state; some are far better than others. But they generally offer few easily identifiable, affordable, and workable choices.
“The good news is that the ACA gave young people more options,” said Karen Pollitz, who directed consumer information and insurance oversight at the Department of Health and Human Services during the Obama administration.
“The bad news is the good stuff is hidden in a minefield of really bad options that’ll leave you broke if you get sick.”
Publicly funded counselors called “navigators” or “assisters” can help insurance seekers choose a plan. But those programs vary by state, and often customers don’t realize that the help is available. The Trump administration has cut funding to publicize and operate those navigator programs.
In addition, changes to Medicaid eligibility in the policy bill recently passed by Congress could mean that millions more ACA enrollees lose their insurance, according to the Congressional Budget Office.
Those changes threaten the very viability of the ACA marketplaces, which currently provide insurance to 24 million Americans.
In dozens of interviews, young adults described the unsettling and devastating consequences of having inadequate insurance, or no insurance at all.
Damian Phillips, 26, a reporter at a West Virginia newspaper, considered joining the Navy to get insurance as his 26th birthday approached. Instead, he felt he “didn’t make enough to justify having health insurance” and has reluctantly gone without it.
Ethan Evans, a 27-year-old aspiring actor in Chicago who works in retail, fell off his parents’ plan and temporarily signed up for Medicaid. But the diminished mental health coverage meant cutting back on visits to his longtime therapist.
Rep. Maxwell Frost, a Florida Democrat and the first Gen Z member of Congress, was able to quit his job and run for office at 25 only because he could stay on his mother’s plan until he turned 26, he said. Now 28, he is insured through his federal job.
“The ACA was groundbreaking legislation, including the idea that every American needs health care,” he said. “But there are pitfalls, and one of them is that when young adults turn 26, they fall into this abyss.”
Why 26?
Back in 2010, the decision to make 26 the cutoff age for staying on a parent’s insurance was “kind of arbitrary,” recalled Nancy-Ann DeParle, deputy chief of staff for policy in the Obama White House. “My kids were young, and I was trying to imagine when my child would be an adult.”
Before that time, children were often kicked off family plans at much younger ages, typically 18.
The Obama administration’s idea was that young adults were most likely settling into careers and jobs with insurance by 26. If they still didn’t have access to job-based insurance, Medicaid and the ACA marketplaces would offer alternatives, the thinking went.
But over the years, the courts, Congress, and the first Trump administration eviscerated provisions of the ACA. By 2022, a shopper on a federal government-run marketplace had more than 100 choices, many of which included expensive trade-offs, presented in a way that made comparisons difficult without spreadsheets.
Jack Galanty, 26, a freelance designer in Los Angeles, tried to plan for his 26th birthday by seeking coverage on the California insurance marketplace that would ensure treatment for his mild cerebral palsy and for HIV prevention.
“You’re scrolling for what feels like years, looking at 450 little slides, at the little bars, and trying to remember, ‘Was the one I liked No. 12 or 13?’” he recalled. “It feels like it’s nearly impossible to make a good choice in this scenario.”