Behind the tense dialogue between actors in the foreground of the season three trailer for the HBO Max award-winning series, “The Pitt,” patients on gurneys line the hallway.
Scenes of overcrowded, hot, uncomfortable emergency department waiting areas are not just the stuff of fiction. In real life, emergency department visits have risen in California, for example, boarding is up, and anyone could get stuck in the hallway for hours waiting for care.
As more people go uninsured or avoid care due to rising costs, they’re less likely to see primary care physicians like me, who take care of them in clinic and follow up on their health progress with the goal to help keep them out of the ER.
A new report from the State Marketplace Network reveals that since the beginning of this year, enrollment in Marketplace plans continues to decline as people faced their first and subsequent monthly bills. This news comes as health insurers are gearing up for open enrollment, when people will choose their health insurance plan for next year. Or they decide to forego coverage.
This year, driven by rising monthly premiums, many Americans switched into Marketplace plans with higher out-of-pocket costs. As a result, Insurance companies and states must redouble their efforts to educate all people who remain covered to ensure that they take advantage of the benefits that they have.
Health insurers may not see the immediate payoff for pushing people to get preventive care, an investment which may be even less certain for those who pay lower premiums. But there is a disastrous risk to the U.S. healthcare system if they don’t collectively shift focus.
This year, 36% of enrollees, or over 560,000 people, in California’s ACA Marketplace are in Bronze plans, up from just 23% in 2025. This is significant because people in Bronze plans are responsible for paying 40% of their total healthcare costs while their insurance company pays 60%.
This can be a lot of money out-of-pocket, over $1,000 for a single episode of care, depending on what type of visit or service they need. Silver, Gold, and Platinum plans offer increasing levels of coverage.
Critically, though, all plans (including Bronze plans) are required to cover preventive care and screening tests with $0 out-of-pocket. This means that people in Bronze plans, who are usually responsible for paying for a big portion of their care, can get many services at no added cost. Blood pressure checks, cancer screenings, annual preventive visits, and much more are free. But they’re less likely to happen.
Despite the availability of free preventive care, members enrolled in Bronze plans receive screening tests like mammograms at significantly lower rates than other members and have fewer doctor visits for preventive care. Whether it’s because people don’t know about these benefits, the system is difficult to navigate, or they’re concerned about unanticipated costs, there’s less prevention happening for these individuals.
This pattern of less prevention now sends an alarming signal about the impact of shifting enrollment on health outcomes in the future. Fewer primary care visits may mean worsening control of chronic conditions. Fewer cancer screenings—that happened during the COVID-19 pandemic— mean more late-stage diagnoses and deaths.
For example, a patient who first came to see me in his late-50s on his initial visit, told me that he knew something was seriously wrong. He had smoked for decades and for about a year had a bad feeling in his lungs, felt more tired, and was coughing more than usual.
He hadn’t seen a doctor regularly for almost 20 years; had health insurance on and off but didn’t really use it. He was diagnosed with metastatic lung cancer.
If this patient had used his health insurance to get care before he felt sick, he might have had a CT scan to screen for lung cancer. Because this test is considered essential preventive care, he would have gotten it without being charged a copay.
Maybe then there would have been a smaller mass in his lung, before it had spread. And maybe he could have avoided the discomfort, fatigue, and burden of his treatment course.
Because people typically enrolled in Bronze plans seek less preventive care, they may eventually seek care elsewhere, when they’re sicker, in already overwhelmed emergency departments for conditions that could have been managed in a clinic. The cost of an emergency room visit has been increasing since 2012, now costing anywhere from over $1,000 to over $5,500 for a single visit, and it often represents one of the more expensive places to go for care.
The data is not available yet on how these shifts in enrollment will play out as more people choose health plans with higher out-of-pocket costs in exchange for lower monthly premiums. In the meantime, it may take months or years to see the health and cost impact, as less preventive care is already happening.
Healthcare leaders, administrators, state governments, and insurance companies must act now. Though people enrolled in Bronze plans pay lower premiums to their health insurance company, it is worth the investment to ensure they get care now.
Focused outreach, messaging, and navigation to preventive care is critical to their future health and the efficiency of the healthcare system in saving lives—and not just a story line for a TV show.