Who's Paying for Healthcare in the Future?

The US healthcare coverage model is being rewritten. Traditional group insurance is losing ground to self-insured employer models and ACA marketplaces, while economic uncertainty could push millions into the ranks of the uninsured.

At the center of this shift: a new funding paradigm, employer-led, consumer-directed, and increasingly digitally powered.

Self-insured employers take the lead

Enrollment is expected to grow from 117.1 million (2025) to 122.2 million (2032). Employers are bypassing traditional insurers to invest in data-driven care, wellness and mental health services. The future of health coverage is enterprise-built ecosystems, not passive plans.

Group commercial insurance is in decline

Coverage is projected to shrink from 60 million to 54 million by 2032, driven by hybrid work, gig employment and cost pressures. Traditional insurance models are no longer aligned with workforce realities.

Marketplace plans gain traction

ACA marketplaces are expanding access, especially for young, price-sensitive, digital-first consumers, validating the consumer-as-purchaser model, though subsidies remain critical to sustainability.

The uninsured rate is climbing

If ACA subsidies expire, many may lose coverage, and Medicaid funding changes could reverse decades of equity progress. Without intervention, there's a risk of a coverage cliff.