One of the clearest success stories in US healthcare over the past 20 years has been the dramatic decline in the number of Americans without health insurance. In 2010, the year the Affordable Care Act was enacted, 16 percent of the population lacked coverage. By 2025, according to estimates from the US government, that figure was cut nearly in half, to 8.3 percent.
The increase in coverage hasn’t been a panacea; even people with an insurance card can struggle to afford their medical bills or to secure a doctor’s appointment. But with the US standing alone among its international peers in its failure to offer universal healthcare, it represented significant progress toward ensuring every American had a basic level of access to routine medical services.
Now, however, those gains are about to be reversed.
Last year, when drafting their One Big Beautiful Bill, Republicans had a chance to strike a blow against the ACA — a law they’d vilified for years — 15 years after its passage and eight years after failing to repeal the law in President Donald Trump’s first term. They established work requirements to target the people covered by the ACA’s Medicaid expansion and allowed subsidies that had helped millions of people to buy private coverage on the ACA marketplaces to lapse.
As a result, millions of Americans are dropping their health insurance this year, and millions more are expected to lose their coverage in the years to come.
The uninsured rate has spiked before, but it’s usually the byproduct of an economic crisis; people lose their jobs, and they lose their coverage. What makes the current turmoil different is that it is entirely a matter of policy choices.
Now, millions of Americans will pay the price.
“I don’t think there’s any historical precedent for the rollback in federal support for health coverage coming with the cuts in Medicaid plus the expiration of enhanced ACA premium subsidies,” Larry Levitt, executive vice president for health policy at the healthcare think tank KFF, told me. “The expected effects of OBBBA on coverage are self-inflicted and dwarf even the historical losses due to changes in the economy.”
One of the major ways that the ACA expanded health insurance coverage was by setting up insurance marketplaces where individuals and families could purchase private health plans with the help of government subsidies.
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Enrollment in those marketplaces has ballooned — particularly since 2021, when Democrats in Congress approved an expansion of the ACA’s financial aid that made more people eligible for assistance. Prior to 2021, there had been a strict cutoff at 400 percent of the federal poverty level (about $64,000 for an individual in 2026, or $132,000 for a family of four). Anybody who made a higher income was ineligible for aid. After 2021, anybody could qualify for ACA subsidies, and their insurance premiums were capped at a percentage of their income. (The subsidies were initially authorized for two years and, then, were extended to 2026 through the Inflation Reduction Act.)
It seemed to have plugged one of the obvious holes in the healthcare law: While many people below 400 percent of the poverty level had enjoyed both mandated comprehensive coverage and new government subsidies that offset any increases in costs, people above that threshold had been subjected to significant premium hikes since the ACA passed. Now, they were able to access the same subsidies, and sign-ups boomed. Marketplace enrollment grew from 9.8 million Americans in 2019 to 22.3 million in 2025.
But, to keep down the cost of their legislation and get it passed with a narrow Senate majority, Democrats allowed the new subsidies to expire in 2026. Then, Trump won the 2024 presidential election, and Republicans took control of Congress. The GOP decided not to extend the subsidies, despite some bipartisan efforts to pull together a plan. When people went to sign up for their health insurance for 2026, many of them no longer had access to financial aid. I spoke last year with some of those people. One family was preparing to allow one parent and child to become uninsured so they could afford a health plan for the other parent who has an autoimmune disease. A young man with asthma also expected to go without coverage after his previous plan ($100 per month and no deductible) was no longer available, and the cheapest replacement he could find was $282 per month with a $10,000 deductible. He told me he was banking on being able to pay for his medication out of pocket or getting it through a charity service.
So, we knew some people would drop their insurance as a result of the expired subsidies, but it was hard to be sure how many. Now, we’re starting to get hard data, and it does not look good. Based on KFF’s preliminary analysis of enrollment data and premium payments, about 4.7 million fewer people will actually end up being enrolled in an ACA marketplace plan in 2026 compared to 2025 — a 21 percent drop in a single year.
The ACA’s other major coverage provision was the expansion of Medicaid eligibility to any American with an income at or below 133 percent of the poverty level (about $21,000 for an individual in 2026, or $44,000 for a family of four). It replaced the preexisting patchwork system for eligibility that created significant differences across states — in particular, millions of childless adults, some of whom were living in deep poverty but had been left out of the program in many states before the ACA, now qualified for Medicaid.
As of June 2025, more than 16 million Americans who became newly eligible for Medicaid through the ACA had been enrolled in the program, making up nearly a quarter of all Medicaid enrollees.
Republicans in Congress had been sharply critical of Medicaid expansion, even as many GOP-led states adopted it, and 2025’s OBBBA gave them a chance to roll it back. They approved, for the first time, national work requirements for Medicaid, targeted to expansion-eligible enrollees, and made several other technical changes to constrain states’ Medicaid financing. People on the program will be required to work or perform other approved activities for at least 80 hours per month or show they should be exempted from the requirement. Otherwise, they could lose their benefits.
And based on what we know from historical precedent, many of the coverage losses won’t be because people are actually ineligible for Medicaid, but because of the administrative burden of complying with these new requirements, even if you are working, or if you are someone — like a pregnant person — who is supposed to be exempted. Arkansas is the only state to implement Medicaid work requirements prior to the OBBBA, and only a fraction of the people required to submit work activities to the state actually did so; many of the people who lost coverage lost it because they failed to turn in paperwork.
The Medicaid population is, by nature, hard to reach. This group is lower-income and might work irregular hours, move around more, or have less access to the internet. It’s easy for people to fall through the cracks.
The OBBBA’s requirements go into effect nationally in January 2027 (after this year’s midterm elections), but some states are instituting them early. Nebraska implemented work requirements on May 1, Montana and Arkansas are starting theirs on July 1, and Iowa will adopt the requirements on December 1. Then, starting on January 1, 2027, they will apply in every state.
The coverage losses are difficult to project, and they could take time to accrue, but they are expected to be sizable. The nonprofit research group RAND estimated Medicaid enrollment will drop by 7.6 million people by 2034.
And they, much like those people dropping ACA coverage, will lose more than just their insurance card. Health insurance, even with its shortcomings, does a lot to help people. Americans with health insurance accrue less medical debt. They are more likely to go to routine medical appointments and receive routine screenings. Prior research on Medicaid expansion’s effects has estimated that it saved tens of thousands of lives.
In other words, the coming increase in the uninsured rate will do more than change some percentage points on a spreadsheet; it will make it harder for millions of Americans to stay healthy and stay alive.
If you’ve ever used an online patient portal to message your doctor in the middle of the night, you won’t be surprised to learn that responding to those messages takes an increasingly big bite out of clinicians’ workdays.
So in recent years, hospitals have begun adopting an AI tool that can draft responses for them. The tool was supposed to make a time-consuming task go more quickly and smoothly, said Philip Barrison, an MD-PhD student at the University of Michigan Medical School who studies AI in healthcare.
Instead, the tool has given doctors and nurses a new to-do list. First they have to read the AI-generated response and decide if it “is actually something that they think they would say,” Barrison said. Humans are suggestible, and looking at something and deciding whether you would have thought of it on your own is a cognitively complex task.
Even if the message looks correct, the clinician still needs to “edit it to the point where they think it’s acceptable” to send to a patient, Barrison said. The AI tool introduces a totally new set of complicated judgment calls into what used to be a relatively straightforward process. As a result, many clinicians have chosen not to use it at all.
They’re fortunate to have the choice. Buoyed by expectations of cost savings and skyrocketing productivity, companies are increasingly asking (and sometimes requiring) employees to use AI to make their work more efficient. Meta, for example, last year instructed some workers to use AI to “go 5X faster by eliminating the frictions that slow us down.” The CEO of Shopify told employees they’d need to prove they “cannot get what they want done using AI” before the company would approve new hires. Some companies are even evaluating or ranking employees based on how much they use AI tools.
Workers in some sectors have found major time savings from AI. But for others, the tools just change the work rather than making it faster. Workers might be spending less time writing patient portal messages, for example, but more time editing the releases the AI tool writes.
At best, this mismatch between employer expectations and employee reality can be an annoyance. In other cases, however, it can result in workers being laid off for failing to meet unrealistic efficiency demands. Some critics say the overzealous adoption of AI in high-stakes settings like healthcare even puts people’s lives at risk. Now workers, unions, and experts are increasingly calling for guardrails to protect employees from inflated expectations around AI — and customers, students, patients, and the general public from mistakes that can happen when managers put AI adoption above all else.
Corporations are increasingly presenting employees with a choice: Use AI to be more productive or “you’re going to be automated out of a job,” said Aiha Nguyen, director of the labor futures program at the research organization Data & Society.
But the effects of AI on productivity aren’t as straightforward as some CEOs have claimed. In one 2025 study, software developers believed AI made them faster, but in fact they took 19 percent longer to complete tasks. (The researchers tried to repeat the experiment this year but had trouble recruiting developers who would agree to work without AI.) And in a recent survey of 5,000 white-collar workers, 40 percent of rank-and-file employees said AI saved them no time at all.
Workers across heavily AI-exposed fields point to hidden timesucks that come with using the technology. Julie, an art teacher, wrote in a response to a Vox reader survey that her school’s administrators routinely suggest using AI for lesson-planning, emails, and progress report comments. She’s tried AI-generated lesson plans, but they don’t account for the fact that kids may work through an activity at different speeds.
“First, I am checking what AI suggests, then I am editing them. Why add a step I can accomplish on my own?”
Julie, an art teacher who wrote in response to a Vox reader survey
“First, I am checking what AI suggests, then I am editing them,” she said. “Why add a step I can accomplish on my own?”
For an employee at an East Coast communications agency, an internal AI tool was supposed to speed up the process of drafting press releases and other documents about the pharmaceutical industry.
“The goal is, I think, to be able to plug and chug into this machine and be able to turn a lot of materials around a lot quicker than we already do,” said the employee, who asked to remain anonymous for fear of career repercussions.
But when the employee tried to use it for basic research, it made too many mistakes. Double-checking its work erased any time savings. When the employee tried using it for communications with clients, its people-pleasing tendencies became a problem, as the tool put a “weird happy spin” even on messages warning of bad news.
“Part of the reason we take a human speed to turn things around is because there is so much nuance behind everything that we do,” the employee told me. “AI is just not going to be able to catch it.”
It’s not just that AI makes errors. With the advent of agentic AI, workers are increasingly being asked to edit and oversee the output of multiple AI tools, a new kind of work that can have unexpected costs.
One recent study of 1,488 workers across industries, for example, found that excessive oversight of AI agents could lead to what the researchers called “AI brain fry,” a kind of cognitive fatigue. “Participants described a ‘buzzing’ feeling or a mental fog with difficulty focusing, slower decision-making, and headaches,” the researchers wrote in Harvard Business Review. Brain fry was also associated with an increased number of errors and an increased desire to quit one’s job.
The researchers also found that while using one or two AI tools increased productivity, adding additional tools produced diminishing returns, and after four tools, productivity actually declined.
Despite such findings, companies continue to pressure employees to use AI, and to cite AI investment as a rationale for layoffs, even as companies that try to link staff reductions to AI adoption tend to struggle on the stock market.
Some workers and organizations, however, are beginning to push back. National Nurses United, the country’s largest nurses’ union, has criticized the use of AI tools in hospitals to estimate staffing needs or to recommend treatment protocols for patients.
There’s no guarantee that these tools will take into account a patient’s individual profile, including underlying medical conditions, the way human clinicians can, Cathy Kennedy, the union’s president, told me. AI is supposed to “help us do our work more efficiently, but at the end of the day, it makes it even more burdensome,” she said.
Hospitals need to evaluate, with nurses at the table, whether AI tools really work as advertised, Kennedy said. “We have to stop — we have to go back and really see if this is truly doing what it needs to do,” she said.
The same is true across industries, Barrison, the healthcare researcher, told me. “Organizations need to be prepared to say when, if they were seeking a return on investment, if they were seeking value in a technology — how do you define what that value is? And if there’s not value there anymore, how do you turn it off?”
Some workers have found ways that AI actually helps them do their work — just not the ones management expected. Julie, the art teacher, likes to use Claude to learn more about topics she’s less familiar with, like kiln-firing ceramics.
Meanwhile, researchers have found that AI can actually reduce employee burnout, if it’s used to complete tasks employees find burdensome. “Everybody in every job has a list of things that they procrastinate on,” said Julie Bedard, a managing director and partner at Boston Consulting Group who led the AI brain fry study. “Those are the places I get, unsurprisingly, a lot of enthusiasm to try AI with.”
But employers won’t find out what those burdensome tasks are unless they listen to rank-and-file employees. “Worker standards and worker rights should continue to be at the heart of all of this,” Nguyen said, “rather than just focusing too much on the AI.”
I turned 48 this week, which meant it was time for my annual physical. After the usual battery of questions from my doctor — How much did I drink? Was I exercising? How was I sleeping? — it was my turn to ask a question. I had one prepared: Should I get the shingles vaccine?
According to standard medical guidance, the answer would be no. The shingles vaccine is only recommended by the government for people 50 years or older; the only exceptions are adults whose immune systems are weakened by disease or treatment. And despite the way my back feels when I get out of bed each morning, I wasn’t there quite yet. Our immune systems weaken as we age, but at 48, I was probably still capable of beating back the varicella-zoster virus that causes shingles (and chickenpox).
And yet my doctor was open to the idea for the same reason that I was asking about it: because there is early but growing evidence that the shingles vaccine may be protective against neurodegenerative diseases like dementia. For someone my age, with more time behind me than in front of me, the possibility of developing those diseases — and the desire to do anything to prevent them — is suddenly looming large.
I’m far from alone. Dementia already afflicts more than 6 million Americans today, and a 2025 study in Nature Medicine estimated that the lifetime risk of developing dementia after age 55 is 42 percent, with higher figures for women, Black adults, and those who carry the APOE ε4 allele genetic variant, which is known to increase the risk for Alzheimer’s. That same study projected new US cases of dementia would double by 2060, from 514,000 a year in 2020 to more than 1 million annually, due largely to population aging.
Behind those figures is a universe of suffering. Nearly everyone reading this has watched, or will watch, someone they love succumb to dementia. And once you get to my side of your 40s, that risk starts to feel less abstract and a lot more personal.
Yet the frightening story of the rise in dementia cases as the US population ages obscures real progress that is already being made to prevent it — and the even greater progress that could follow. Dementia may feel inevitable, a cruel side effect of longer life. But it doesn’t have to be.
The Nature study is about incidence — new cases, not the total number of people living with dementia. Separate CDC estimates project nearly 14 million older Americans living with Alzheimer’s disease, the most common form of dementia, by 2060.
But the rate hasn’t been holding steady — it’s been dropping. A 2020 study that drew on data from six countries across Europe and North America found that age-specific dementia incidence for people of European ancestry had fallen about 13 percent per decade since the late 1980s, and around 16 percent per decade for clinical Alzheimer’s. A 2016 study tracked five-year dementia rates across four periods between the late 1970s and the early 2000s and found them steadily falling, ultimately dropping 44 percent by the most recent period. The authors of the 2020 study project that if the decline in incidence remains steady in the future, 15 million fewer people might develop dementia by 2040 across high-income countries than if the incidence of the disease remained unchanged.
That good news may not be shared by everyone. The 2016 study found that the decline only showed up among people with at least a high school diploma — more on that below — and even then, it wasn’t evenly shared. And the sheer increase in older people means that a continually dropping incidence only blunts the coming dementia wave, rather than blocking it. One study of older adults in England actually found dementia incidence falling through 2008 and then creeping back up; the researchers also found that when you account for the fact that people headed toward dementia tend to die earlier, the drop gets much harder to see. What’s fallen before can rise again.
But what this likely means in practice is that a person turning 80 today is meaningfully less likely to have dementia than a person who turned 80 a generation ago. And it’s reasonable to hope the same will hold for whoever turns 80 next — like, say, me.
The question, though, is why.
Here’s a veteran health journalist tip: if anyone ever asks you why something is improving in public health, just attribute it to the decline in smoking. There’s a decent chance you’ll be right.
While Alzheimer’s is a brain disease, and dementia is the umbrella term for several kinds of cognitive decline, there is a growing consensus that they are deeply driven by vascular health — meaning what damages your heart and blood vessels is ultimately what damages your mind. Thanks to the development of blood pressure and cholesterol-lowering medicines, better heart disease and stroke management, and perhaps most of all, drastic reductions in smoking, cardiovascular health has been improving. Even with the rise of obesity and diabetes, most vascular risk factors have decreased over the same time that dementia and Alzheimer’s prevalence fell.
The rise in education over the same time period may play a role as well. Americans turning 80 today went to school during a great mid-century expansion in education, while their parents were schooled — or rather, not schooled — in the 1920s and ’30s. In 1940, only 24.5 percent of Americans 25 and older had a high school diploma, and just 4.6 percent had completed a bachelor’s degree or more. By 2017, high school completion had reached 90 percent, and the share of people with a bachelor’s or more had hit 34 percent. And researchers have correlated higher education attainment with lower dementia and Alzheimer’s rates.
Now repeat after me: correlation is not causation. Researchers don’t really know why more years of schooling seem to be associated with a lower risk of dementia, though there are theories that education might boost the brain’s “cognitive reserve.” But the hopeful take is that the decline in incidence is largely driven by behaviors and life conditions we can change. And one of the most unexpected and promising acts is something as simple as routine vaccination.
Last April, I wrote about what I called “one of the brightest spots in an otherwise dark field”: a study in Wales that found that older adults who received a vaccine against shingles were 20 percent less likely to develop dementia in the seven years following vaccination than those who did not receive it. It wasn’t a randomized trial, but it was stronger than the usual observational association: the study harnessed a natural experiment in Wales, where vaccine eligibility turned on a birthday cutoff, meaning it was less likely that the results were because vaccinated people were simply healthier.
Earlier this year, a study in Canada looked at hundreds of thousands of people over the age of 70 and, like the Welsh study, found that those who had taken the shingles vaccine were less likely to develop dementia. And a new analysis from late 2025 of the data in the Welsh study found that the vaccine was associated with benefits that went beyond prevention — it also seemed to slow the disease for those with dementia and reduced deaths attributable to it.
The shingles vaccine in the Welsh study was an older, live-virus version; the current vaccine is a newer recombinant form that can’t accidentally cause shingles, and another study found it was associated with even greater protection from dementia.
These findings are promising but still leave plenty of questions. The Welsh live-vaccine study found a larger apparent benefit in women, who also suffer higher rates of dementia. But the pattern is not settled: the newer recombinant-vaccine study found an association in both men and women, though stronger in women. Shingles may be connected to dementia, though the evidence is still messy: A large 2025 health-records study found recurrent shingles was associated with a modestly higher dementia risk than a single episode, while earlier evidence has been more mixed.
Shingles occurs when the dormant varicella zoster virus — the same virus that causes chickenpox — reactivates. It’s possible that the resulting neural inflammation may feed dementia. A randomized controlled trial published in December tested a related herpes-virus idea, treating 120 adults with early Alzheimer’s or mild cognitive impairment — all with evidence of prior herpes simplex infection — with a medication called valacyclovir. After 18 months, researchers found no significant advantage over a placebo, dampening hopes that herpes antivirals could be an effective Alzheimer’s treatment.
That’s a real strike against the simplest version of the theory that the virus itself is rotting the brain. But it could mean that the shingles vaccine’s possible protective effects don’t come from shingles at all. A 2025 study found that the newer shingles vaccine and an RSV vaccine that share the same AS01 immune-boosting adjuvant were each associated with lower 18-month dementia risk compared with flu vaccination, and researchers did not find a statistically significant difference between the two AS01 vaccines. The implication is that the benefit might come from giving an aging immune system a jolt, rather than from any one bug it’s aimed at.
But as the vaccine science sorts itself out, there are lifestyle changes you can make to help protect yourself without getting a shot. A 2024 Lancet commission found that, in principle, up to 45 percent of dementia cases could be prevented or delayed by addressing 14 risk factors, including not smoking; lowering high LDL cholesterol in midlife; treating hearing loss, especially from midlife on; and limiting obesity. The key period here is midlife, which the commission defined (rather widely in my opinion) as 18-65. Which, for someone my age, means there’s no better time to focus on prevention.
I don’t know whether I’ll go ahead and try to get the shingles vaccine early, and to be clear, I’m not telling anyone they should. The science is still uncertain, and I am, obviously, not a medical doctor. But the lifestyle factors that have been shown to protect against dementia — which are largely the same ones that help cardiovascular health — can be adopted by everyone, for their health now and in the future.
No one knows for sure what the future holds, for me or for you. What’s certain is that, barring a medical miracle, the sheer number of dementia cases will continue to rise as our population ages, and that some of us will be in that number. But that doesn’t mean we’re helpless.
A version of this story originally appeared in the Good News newsletter. Sign up here!
Ontario has established a regulatory body for the province’s 100,000 personal support workers. But they are not represented on the body which the workers call fundamentally flawed. Plus the LabourStart report about union events. And singing: ‘Hold That Line.”
Music credit: Robin Roberts (vocals) Peter Hicks and Geoff Francis (Lyrics). Used with permission.
RadioLabour is the international labour movement’s radio service. It reports on labour union events around the world with a focus on unions in the developing world. It partners with rabble to provide coverage of news of interest to Canadian workers.
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