This story by Elisabeth Rosenthal and Hannah Norman appeared on KFF Health News on August 11, 2025. We are sharing it in two parts.
More than half of Americans ages 18 to 29 have incurred medical debt in the past five years, a KFF Health News data investigation found. Few have the reserves to pay it off.
Out-of-pocket expenses have soared. Complex plans in the lightly regulated marketplaces featured rising premiums, high deductibles, and requirements that patients pay a significant portion of the cost of care, often 20% — a charge known as coinsurance.
The networks of doctors to choose from in these plans are often so limited that an insured person struggles to get timely appointments. It can even be hard to find the official websites amid an explosion of look-alikes operated by commercial brokers.
Sharing her contact information with one site that appeared legitimate left Lydia Herne, a social media producer in Brooklyn, “drowning” in texts and phone calls offering plans of uncertain and unregulated quality. “It never ends,” said Herne, 27.
Young Invincibles, an advocacy group representing young adults, runs its own “navigator” program to help young people choose health insurance plans.
“We hear the frustration,” said Martha Sanchez, the group’s former director of health policy and advocacy. “Twenty-six-year-olds have had negative experiences in a process that’s become really complex. Many throw up their hands.”
Elizabeth Mathis, 29, and Evan Pack, 30, a married couple in Salt Lake City, turned to the marketplaces two years ago, after Pack went uninsured for a “really scary” year after he turned 26.
“Every time he got in the car, I thought, ‘What if?’” Mathis said.
The couple pays more than $200 a month for a high-deductible health plan backed by a federal subsidy (the kind set to expire next year). It’s a significant expense, but they wanted to be sure they had access to contraception and an antidepressant.
But last year, Pack suffered serious eye problems and underwent an emergency appendectomy. Their plan left them $9,000 in debt, for medical care billed at over $20,000.
“Technically, we gambled in the right direction,” Mathis said. “But I don’t feel like we’ve won.”
The Affordability Problem
The ACA was supposed to help consumers find affordable, high-quality plans online. The legislation also tried to expand Medicaid programs, which are administered by states, to provide health insurance to low-income Americans.
But the Supreme Court ruled in 2012 that states could not be forced to expand Medicaid. Ten states, led mostly by Republicans, have not done so, leaving up to 1.5 million Americans, who could have qualified for coverage, without insurance.
Even where Medicaid is available to 26-year-olds, the transition has often proved precarious.
Madeline Nelkin of New Jersey, who was studying social work, applied for Medicaid coverage before her 26th birthday in April 2024 because her university’s insurance premiums were more than $5,000 annually.
But it was September before her Medicaid coverage kicked in, leaving her uninsured while she fought a chest infection over the summer.
“People tell you to think ahead, but I didn’t think that meant six months,” she said.
When Megan Hughes, 27, of Hartland, Maine, hit the cliff, she went without. An aide for children with developmental delays, she has a thyroid condition and polycystic ovary syndrome.
She looked for a health care plan but found it hard to understand the marketplace. (She didn’t know there were navigators who could help.) Now she can’t afford her medicine or see her endocrinologist.
“I’m tired all the time,” Hughes said. “My cycles are not regular anymore at all. When I do get one, it’s debilitating.” She is hoping a new job will provide insurance later this year.
Traditionally, most Americans with private health insurance got it through their jobs. But the job market has changed dramatically since the ACA became law, particularly in the wake of the pandemic, with the rise of a gig economy.
Over 30% of people ages 18 to 29 said in recent surveys that they were working or have worked in short-term, part-time, or irregular jobs.
The ACA requires organizations with 50 or more employees to offer insurance to people working 30 hours per week. This has led to a growing number of contract employees who work up to, but not past, the hourly limit.
Many companies, which say they can’t afford the rising costs of traditional insurance, offer their employees only a modicum of help, perhaps around $200 per month toward buying a marketplace plan, or a bare-bones company plan.
Young people juggling part-time jobs and insurance options face bumpy, daunting transitions.
In Oklahoma, Daisy Creager, 29, has had three employers over the past three years. Insurance was important to her, not least because her former husband had Type 1 diabetes.
As she left the first of those jobs, her husband’s endocrinologist helped the couple stockpile less expensive insulin from Canada, since they would be uninsured.
After a few months, they bought a marketplace plan, but it was expensive and “didn’t cover a lot,” she said.
When she found a new job, she dropped that plan, only to discover that her new insurance coverage didn’t start until the end of her first month of employment. The couple would be uninsured for a few weeks.
A few days later, she came home to find her husband unconscious on the floor, in a diabetic coma. After hovering near death in an intensive care unit for four days, he woke up and began to recover.
“I think I’ve done everything right,” Creager said. “So why am I in a position where the health insurance available to me doesn’t cover what I need, or I can barely afford my premiums, or worse, at times I don’t even have it?”
Kathryn Russell, 27, developed excruciating back pain two months before her 26th birthday. After extensive testing, doctors determined she needed a complex surgery, which her surgeon couldn’t schedule until after she would be off her family’s insurance plan.
Forget the pain and the fear of the operation, she said, it was insurance that kept her up at night. “There’s this impending terror of, ‘What am I going to do?’” she recalled.
(One day before she turned 26, her father’s company agreed to keep her on his plan for six more months, if he paid higher premiums.)
The idea that the ACA would offer a variety of good options for people turning 26 has not worked as well as the legislation’s authors had hoped. The “job lock” tying insurance to employment has long plagued the United States workforce.
Young adults need guidance on their options beforehand, said Sanchez of Young Invincibles. None of those interviewed for this story, for example, knew there were navigators to help them find insurance on the online marketplaces.
Experts agree that the marketplaces need stronger regulation.
In 2023, the federal government defined clearer standards for what plans in each tier of insurance should offer, such as better prescription drug benefits, defined copays for X-rays, or coverage for emergency room visits.
Certain types of basic care, such as primary care, should require just a small copay for at least a small number of initial visits. Each insurer must offer at least one plan that complies with these new standards for every level, known as an “easy pricing” option or a “standard plan.”
Most plans on the marketplaces don’t meet these criteria. Federal and state regulators had long planned to cull such “noncompliant” plans, gradually — fearing that doing so too quickly would scare insurers away from participating.
But with the priorities of the new Trump administration now in focus, and a Republican majority in Congress, it’s far from clear what course President Donald Trump, who sought to repeal the ACA outright in his first term, will take.
There are hints: Subsidies to help Americans buy insurance, adopted during the Biden administration, are set to expire at the end of 2025 unless the Republican-led Congress extends them.
If the subsidies expire, premiums are likely to rise sharply for plans sold on the marketplaces, leaving insurance out of reach for many more young adults.
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
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