Why Some Walked Away From Health Insurance — And May Not Be Coming Back

Rhode Island’s shrinking marketplace may reflect a deeper shift in how people access care.

Rhode Island policymakers are facing a familiar question after federal pandemic-era health insurance subsidies expired: should the state step in and replace them?

Roughly 13,000 fewer people enrolled in HealthSource RI this year after those federal subsidies ended. Now two approaches are being debated at the State House. Governor Dan McKee has proposed spending about $20 million annually to partially replace the lost tax credits, targeting residents with incomes below 200 percent of the federal poverty level. Some lawmakers have proposed going much further, restoring the entire $60 million in federal subsidies that had been helping Rhode Islanders pay their premiums.

Both proposals assume the same thing: that the people who left the marketplace should be brought back.

But what if some of them simply aren’t coming back?

Over the past decade, the way people access healthcare has quietly changed. Patients who once relied almost entirely on primary care doctors now have a growing range of alternatives: urgent care centers, telehealth visits, pharmacy clinics, and retail clinics such as CVS MinuteClinic. In lower-income neighborhoods, free and sliding-scale community health clinics have also become widely available.

For many residents, especially those who are relatively healthy, these options can handle most day-to-day medical needs.

At the same time, Rhode Island faces a well-documented shortage of primary care physicians. Many practices are not accepting new patients, and existing patients can wait weeks or even months for routine appointments. Recordings tell patients in urgent need, many in the evening or weekend hours to go to their emergency room at a local hospital. When something urgent happens — a sudden illness, an injury, or severe pain — patients often discover that their doctor cannot see them quickly.

Urgent care clinics, by contrast, will.

During the COVID-19 pandemic, those habits accelerated. People avoided doctors’ offices out of concern about exposure and turned instead to telehealth visits, urgent care centers and retail clinics. Many discovered they could handle most routine issues without the traditional cycle of scheduled office visits and referrals, a cumbersome process, often leaving a patient with unacceptable wait times or hoops to go through. Some left – and never went back.

Technology has added yet another layer to this shift. Increasingly, people are turning to online symptom checkers and AI-powered tools to get quick guidance about medical questions before deciding whether they even need to see a doctor.

For relatively healthy adults, the calculation can start to look different. If telehealth can answer questions, urgent care can treat sudden problems, community clinics provide low-cost care, and online tools offer basic medical guidance, the value of paying a monthly insurance premium may feel less obvious — especially when those premiums rise sharply.

The insurance marketplace

This year many marketplace premiums doubled after federal subsidies expired. Someone who had been paying $40 or $50 per month might suddenly face a $100 or $150 premium.

That increase feels dramatic. But it also reflects another shift in expectations.

Years ago, before the Affordable Care Act created insurance marketplaces, workers who lost employer-sponsored coverage often had to rely on COBRA. Those premiums could easily exceed $1,000 per month because employees were suddenly paying the full cost of their insurance after an employer subsidy disappeared. The experience revealed the real price of health coverage — something many workers had never seen before. People often took jobs that provided healthcare – just because it provided healthcare.

After years of subsidies pushing marketplace premiums down to $40 or $50 for some households, today’s $100 premium can feel unreasonable. In reality, the system may simply be reverting closer to what insurance has always cost.

Uncompensated care… Free care…

Another factor shaping public perception is the complicated way healthcare prices actually work. Hospitals frequently negotiate bills with uninsured patients, offer charity-care programs for lower-income households, and provide emergency treatment regardless of insurance status. The latter is the law. Many Americans have learned that the price on a hospital bill is often not the final price.

Rightly or wrongly, this has led some people to believe that the financial risk of going without insurance may not be as catastrophic as policymakers assume.

Many Americans also feel that the healthcare system works best at the extremes. If you are very poor, public programs and charity-care policies often cover most of the cost of care. If you are wealthy, premium insurance and personal resources make it easier to navigate the system and absorb costs that insurance does not cover. It is the middle — people earning too much to qualify for assistance but not enough to comfortably pay rising premiums and deductibles — who often feel squeezed.

A changing demographic

Rhode Island’s changing population may also influence how care is accessed. In many immigrant families, particularly those newer to the United States, the “emergency room” can become the most familiar entry point into the healthcare system. When a grandparent develops a respiratory infection or a child spikes a fever, families sometimes go together to the hospital rather than navigating a complicated network of primary care providers, insurance plans and referrals. Language barriers can add another layer of complexity, and it is not uncommon for younger family members to help translate for older relatives during medical visits.

That pattern places additional pressure on hospital emergency departments, but it also reflects how confusing the American healthcare system can be for families trying to access care quickly.

Visit Miriam Hospital on a busy night. With the closure of Memorial Hospital, the demographics have dramatically changed for this East Side of Providence hospital – groups coming in together are more the norm than the exception. The well-honed clinic model at Memorial may not have been a good business model in the end, but it adapted to the population it served.

Of course, the real dangers of being uninsured remain serious. Cancer, heart disease and other major illnesses can produce staggering medical costs. Insurance still provides protection against those catastrophic events and often offers patients more options for specialists and hospitals.

But for many residents, especially those who rarely use healthcare services, the system may appear to function well enough without comprehensive coverage.

The Rhode Island decision

That leaves Rhode Island lawmakers facing a difficult policy question.

Should the state spend tens of millions of dollars trying to restore federal subsidies that Washington chose to end? Or is the healthcare system itself changing in ways that government programs may not fully reverse?

Over the past decade Americans have quietly built a new healthcare ecosystem around themselves — urgent care clinics, telehealth visits, retail clinics, community health centers, and now even AI tools that offer instant medical guidance. It is not the system policymakers originally designed, but it is increasingly the one patients use.

And once people learn how to navigate that system, convincing them to return to a traditional insurance marketplace may be harder than lawmakers expect.

The debate in Rhode Island may ultimately come down to more than dollars and subsidies.

It may hinge on a deeper question: whether some residents have already decided they are not coming back to the insurance marketplace — no matter how much the state spends trying to bring them there.

This debate is about more than adding people back onto the rolls of the insured. Patients have adapted — and they’ve been educated, in many cases by the system itself. Over the past decade, and especially during the pandemic, people have learned how to navigate urgent care, telehealth, community clinics, and even the realities of medical pricing. They know more now about their options than they did before, and they are making different choices. The challenge is no longer just restoring the old model, but recognizing that many people may not be willing to return to it.

And if those choices continue, it raises a larger question: what happens to a system that depends on broad participation to remain financially stable? If enough people decide they no longer need traditional insurance, the implications go beyond enrollment numbers. Rising costs, shrinking risk pools, and increasing pressure on providers could follow — forcing a deeper rethink of how healthcare is funded in the first place.