160 million Americans get insurance at work, but the rest face a web of risky alternatives

Approximately 160 million Americans receive health coverage through their employers, a group that health economists Thomas Buchmueller and Helen Levy say is fortunate. For the rest of the population, securing affordable health insurance has become increasingly difficult and confusing as federal subsidies for Affordable Care Act plans shrink.

The reduction in subsidies caused large premium increases for millions of people in 2025, leading many to drop their coverage. With premiums expected to rise further and new Medicaid work requirements set to begin in January 2027, many Americans are now searching for lower-cost options. These alternatives often appear attractive but carry specific risks that are not always immediately obvious.

Before the ACA took effect in 2014, insurers could charge higher premiums based on health status or deny coverage for preexisting conditions. The law eliminated this practice and required plans to cover 10 essential benefits and all preventive care. It also introduced income-based subsidies for marketplace plans. Low-cost plans available outside these marketplaces largely resemble the insurance landscape from before 2014.

Short-term, limited-duration plans are designed for temporary gaps in coverage, such as periods between jobs. These plans can be purchased for up to six months and are cheaper than marketplace coverage because they are not subject to ACA rules. They often exclude maternity care and may not have an annual limit on out-of-pocket costs, leaving policyholders responsible for large unexpected expenses.

These short-term plans can also deny coverage based on health status. By screening out higher-cost consumers, insurers keep premiums low. However, people with preexisting conditions may struggle to find an insurer willing to sell them a plan. Five states have banned these plans due to concerns that they destabilize the market by siphoning off healthy consumers.

Healthcare sharing ministries offer another affordable option for consumers with common religious beliefs. These groups agree to share medical expenses but are not regulated as insurance companies. Their websites often mimic insurance products but avoid standard terms like "premium" or "deductible." There is no guarantee that a ministry will cover a submitted claim, and they may deny coverage based on health history or limit total benefits.

Farm bureau health coverage is available in 14 states and is limited to members of the state’s farm bureau. Enrollment does not require working in agriculture, but the plans are not subject to federal or state insurance regulations. Like other low-cost options, they can screen out high-cost consumers and may lack certain benefits required by the ACA. Unlike short-term plans, farm bureau coverage has no limit on how long a person can hold the policy.