Credits

With most patient care provided on the second and third levels, generators on the fourth level, and utility lines underground, the hospital is expected to remain operational after a natural disaster.

Thorsen said an earthquake and tsunami threaten not only vast flooding , in which the ground loosens and causes structures above it to collapse. Deep foundations, thick slabs, and other structural supports are expected to protect the new hospital and tsunami structure against such failure.

Through the years, hospital administrators and civic leaders in Astoria have sought other locations for Columbia Memorial. But relocation wasn’t economical. Columbia Memorial committed to invest in a new hospital and tsunami shelter to protect not only patients and staff but also nearby residents.

“Your community should count on your hospital to be a safe haven in a natural disaster,” Thorsen said.

Fighting To Restore Funds

The estimated construction budget for Columbia Memorial’s expansion is $300 million, mostly financed through new debt from the hospital. The tsunami shelter is budgeted at about $20 million, for which FEMA’s BRIC program , with a $6 million matching grant from the state, which has maintained its support.

The shelter and the building’s structural protections — featuring reinforced steel, deeper foundations, and thicker slabs — are integral to the design and cannot be removed without compromising the rest of the structure, said Michelle Checkis, the project architect.

“We can’t pull the TVERS [tsunami vertical evacuation refuge structure] out without pulling the hospital back apart again,” she said. “It’s kind of like, if I was going to stack it up with Legos, I would have to take all those Legos apart and stack it up completely differently.”

Columbia Memorial has sought help from Oregon’s congressional delegation. In to Department of Homeland Security Secretary Kristi Noem and former FEMA acting administrator David Richardson, the lawmakers demanded that the agencies restore the hospital’s grant.

The hospital’s leadership is seeking other grants and philanthropic donations to make up for the loss. As a last resort, Thorsen said, the board will consider removing “nonessential features” from the building, though he added that there is little fat to trim from the project.

The in July alleged that FEMA lacks the authority to cancel the BRIC program or redirect its funding for other purposes.

The states argued that canceling the program and undermined projects underway.

In their response to the lawsuit, the Trump administration said repeatedly that the defendants “deny that the BRIC program has been terminated.”

The lawsuit cites examples of projects at risk in each state due to FEMA’s termination of the grants. Oregon’s first example is Columbia Memorial’s tsunami shelter. “Neither the County nor the State can afford to resume the project without federal funding,” the lawsuit states.

In response to questions about the impact of canceling the grant on Astoria and the surrounding community, DHS spokesperson Tricia McLaughlin said BRIC had “deviated from its statutory intent.”

“BRIC was more focused on climate change initiatives like bicycle lanes, shaded bus stops, and planting trees, rather than disaster relief or mitigation,” McLaughlin said. DHS and FEMA provided no further comment about BRIC or the Astoria hospital.

Preparing for a Tsunami Disaster

Located near the end of the Lewis & Clark National Historic Trail, Astoria sits on a peninsula that juts into the Columbia River near the Pacific Ocean.

Much of the city is not in the tsunami inundation area. But Astoria’s downtown commercial district — where gift shops, hotels, and seafood restaurants line the streets — is nearly all an evacuation zone.

Two hospitals — Ocean Beach Health in nearby Washington, and Providence Seaside Hospital in Oregon — are about 20 miles from Columbia Memorial. Both are 25-bed hospitals, and neither is designed to withstand a tsunami.

Ocean Beach Health regularly conducts drills for mass-casualty and natural disasters, said Brenda Sharkey, its chief nursing officer.

“We focus our planning and investments on areas where we can make a real difference for our community before, during, and after an event — such as maintaining continuity of care, ensuring rapid triage, and coordinating with regional emergency partners,” Sharkey said in an email.

Gary Walker, a spokesperson for Providence Seaside, said in a statement that the hospital has a “comprehensive emergency plan for earthquakes and tsunamis, including alternative sites and mobile resources.”

Walker added that Providence Seaside has hired “a team of consultants and experts to conduct a conceptual resilience study” that would evaluate the hospital’s vulnerabilities and recommend ways to address them.

Oregon’s emergency managers advise residents and visitors in coastal communities to immediately seek higher ground after a major earthquake — and not to rely on tsunami sirens, social media, or most technology.

“There may not even be cellphone towers operating after an event like this,” said Jonathan Allan, a coastal geomorphologist with the Oregon Department of Geology and Mineral Industries. “The earthquake shaking, its intensity, and particularly the length of time in which the shaking persists, is the warning message.”

The stronger the earthquake and the longer the shaking, he said, the more likely a tsunami will head to shore.

A tsunami triggered by a Cascadia zone earthquake could strike land in , according to state estimates.

Many of Oregon’s seaside communities are near high-enough ground to seek safety from a tsunami in a relatively short time, Allan said. But he estimated that, to save lives, Oregon would need about a dozen vertical tsunami evacuation shelters along the coast, including in seaside towns that attract tourists and where the nearest high ground is a mile or more away.

Willis Van Dusen’s family has lived in Astoria since the mid-19th century. A former mayor of Astoria, Van Dusen stressed that tsunamis are not a hypothetical danger. He recalled seeing one in Seaside in 1964. The wave was only about 18 inches high, he said, but it flooded a road and destroyed a bridge and some homes. The memory has stayed with him.

“It’s not like … ‘Oh, that’ll never happen,’” he said. “We have to be prepared for it.”

Ñî¹óåú´«Ã½Ò•îl Health News correspondent Brett Kelman contributed to this report.

The investigation found heightened flood risks at large trauma centers, small rural hospitals, children’s hospitals, and long-term care facilities that serve older and disabled patients. At least 21 are critical access hospitals, with the next-closest hospital 25 miles away, on average.

Flooding threatens dozens of hospitals in coastal areas, including in Florida, Louisiana, Texas, and New York. Farther inland, flooding of rivers or creeks could envelop other hospitals, particularly in Appalachia and the Midwest. Even in the sun-soaked cities and arid expanses of the American West, storms have the potential to surround some hospitals with several feet of pooling water, according to Fathom’s data.

These findings are likely an undercount of hospitals at risk because the investigation overlooked pockets of potential flooding at some hospitals. It excluded facilities like stand-alone ERs, outpatient clinics, and nursing homes.

“The reality is that flood risk is everywhere. It is the most pervasive of perils,” said Oliver Wing, the chief scientific officer at Fathom, who reviewed the findings. “Just because you’ve never experienced an extreme doesn’t mean you never will.”

Dresser, the ER doctor, said even a small amount of flooding can shut down an unprepared hospital, often by interrupting its power supply, which is needed for life-sustaining equipment like ventilators and heart monitors. He said the most vulnerable hospitals would likely be in rural areas.

“A lot of rural hospitals are now closing their pediatric units, closing their psychiatry units,” Dresser said. “In a financially stressed situation, it can be hard to prioritize long-term threats, even if they are, for some institutions, potentially existential.”

Urban hospitals can face dangerous flooding, too. Fathom’s data predicts 5 to 15 feet of water around neighboring hospitals — Kadlec Regional Medical Center and Lourdes Behavioral Health — that straddle a tiny creek in Richland, Washington.

By Fathom’s estimate, a 100-year flood could cause the nearby Columbia River to spill over a levee that protects Richland, then loosely follow the creek to the hospitals. Some of the deepest flooding is estimated around Lourdes, which was built on land the U.S. Army Corps of Engineers set aside in 1961 as a “ponding and drainage easement.”

At the time, this land was supposed to be capable of storing enough water to fill at least 40 Olympic-size swimming pools, according to obtained through the Freedom of Information Act. A mental health facility has occupied this spot since the 1970s.

Both Kadlec and Lourdes said in statements that they have disaster plans but did not answer questions about flooding. Tina Baumgardner, a Lourdes spokesperson, said government flood maps show the hospital is not in a 100-year flood plain.

This is not uncommon. Of the more than 170 hospitals with significant flood risk identified by Ñî¹óåú´«Ã½Ò•îl Health News, one-third are located in areas that FEMA has not designated as flood hazard zones.

Sometimes the difference is stark. For example, at Ochsner Choctaw General in Alabama — the only hospital for 30 miles in any direction — FEMA maps suggest a 100-year flood would overflow a nearby creek but spare the hospital. Fathom’s data predicts the same event would flood most of the hospital with 1 to 2 feet of water, including the ER and the helicopter pad.

Ochsner Health did not answer questions about flooding preparations at Choctaw General.

FEMA flood maps were launched in the ’60s as part of the National Flood Insurance Program to determine where insurance is required and building codes should include flood-proofing. According to a FEMA statement, the maps show only a “snapshot in time” and are not intended to predict where flooding will or won’t happen.

FEMA spokesperson Geoff Harbaugh said the agency intends to modernize its maps through the Future of Flood Risk Data initiative, which will enable the agency to “better project flood risk” and give Americans “the information they need to protect their lives and property.”

The program was launched by the first Trump administration in 2019 but has since received sparse public updates. Harbaugh declined to provide a detailed update or timeline for the program.

Chad Berginnis, executive director of the Association of State Floodplain Managers, said it is unknown whether FEMA is still trying to upgrade its maps under Trump, as the agency has cut off communications with outside flooding experts.

“There has been not a single bit of loosening of what I’m calling the FEMA cone of silence,” Berginnis said. “I’ve never seen anything like it.”

Floods are expected to worsen as a warming climate fuels stronger storms, drenching areas that are already flood-prone and bringing a new level of flooding to areas once considered lower risk.

The National Oceanic and Atmospheric Administration has said that 2024 was the warmest year on record — more than 2 degrees Fahrenheit higher than the 20th-century average. Scientists across the globe that each degree of global warming correlates to a 4% increase in the intensity of extreme rainfall.

“Warmer air can hold more moisture, so this leads us to experience heavier downpours,” said Kelly Van Baalen, a sea level rise expert at the nonprofit . “A 100-year flood today could be a 10-year flood tomorrow.”

Intensifying storms raise concerns about Peninsula Hospital, which has operated for decades mere feet from the Tennessee River but has no known history of flooding.

Peninsula spokesperson Josh Cox said the river is overseen by the Tennessee Valley Authority, which uses dams to manage water levels and generate electricity. Estimates provided by the TVA suggest the dams could keep Peninsula dry even in a 500-year flood.

Fathom, however, said its flood simulation accounts for the dams and stressed that a large enough storm could drop more rain than even the TVA could control. These predictions are echoed by another flood modeling firm, , which also says an intense storm could cause more than 10 feet of flooding in the area around Peninsula.

“It’s a hospital right on the banks of a major American river,” said Wing, the Fathom scientist. “It just isn’t conceivable that such a location is risk-free.”

Jack Goodwin, 75, a retired TVA employee who has lived next to Peninsula for three decades, said he was confident the dams could protect the area. But after reviewing Fathom’s predictions, Goodwin began to research flood insurance.

“Water can rise quickly and suddenly, and the destruction is tremendous,” he said. “Just because we’ve never seen it here doesn’t mean we won’t see it.”

‘All the Elements of a Real Disaster’

One year ago, as Hurricane Helene carved a deadly path across Southern Appalachia, Angel Mitchell was visiting her ailing mother at Unicoi County Hospital in the tiny town of Erwin, Tennessee.

Swollen by Helene, the nearby Nolichucky River spilled over its banks and around the hospital, which was built in a flood plain. Staff tried to bar the doors, Mitchell said, but the water got in, trapping her and others inside. The lights went out. People fled to the roof, where the roar of rushing water nearly drowned out the approach of rescue helicopters, Mitchell said.

Ultimately, 70 people from the hospital, including Mitchell and her mother, were airlifted to safety on Sept. 27, 2024. The hospital remains closed, and the company that owns it, Ballad Health, has said its .

“Why allow something — especially a hospital — to be built in an area like that?” Mitchell told CBS News. “People have to rely on these areas to get medical help, and they’re dangerous.”

Beyond Unicoi, Ñî¹óåú´«Ã½Ò•îl Health News identified 39 inland hospitals — including 16 in Appalachia — that Fathom predicts could flood when nearby rivers, creeks, or drainage canals overspill their banks, even in storms far less intense than Helene.

For example, in the Cumberland Mountains of southwestern Virginia, a 100-year flood is projected to cause Slate Creek to engulf Buchanan General Hospital in more than 5 feet of water.

Near the Great Lakes in Erie, Pennsylvania, LECOM Medical Center and Behavioral Health Pavilion could become flooded by a small drainage creek that is less than 50 feet from the front door of the ER.

Neither Buchanan nor LECOM responded to questions about flooding or preparations.

And in West Virginia’s capital of Charleston, where about 50,000 people live at the junction of two rivers in a wide and flat valley, a single storm could potentially flood five of the city’s six hospitals at once, along with schools, churches, fire departments, and other facilities.

“I hate to say it,” said Behrang Bidadian, a flood plain manager at the , “but it has all the elements of a real disaster.”

At the largest hospital in Charleston, CAMC Memorial Hospital, Fathom predicts that the Kanawha River could bring as much as 5 feet of flooding to the ER. Across town, the Elk River could surround CAMC Women and Children’s Hospital, cutting off all exits.

And in the center of the city, where the overflowing rivers are predicted to merge, Thomas Orthopedic Hospital could be besieged by more than 10 feet of water on three sides.

WVU Medicine, which owns Thomas Orthopedic Hospital, did not respond to requests for comment.

CAMC spokesperson Dale Witte said the hospital system is aware of its flood risk and has prepared by elevating electrical infrastructure and acquiring flood-proofing equipment, like a deployable floodwall. CAMC also regularly revises and drills its disaster plans, Witte said, although he added that hospitals there have never been tested by a real flood.

Shanen Wright, 48, a lifelong Charleston resident who lives near CAMC Memorial, said many in the city have little worry about flooding in the face of more immediate problems, like the opioid epidemic and the decline of manufacturing and mining.

Tugboats and coal barges sail past his neighborhood as if they were cars on his street.

“It’s not to say it’s not a possibility,” he said. “I’m sure the people in Asheville and the people in Texas, where the floods took so many lives, they probably didn’t see it coming either.”

‘The Water Is Coming’

Despite wide scientific consensus that climate change fuels more dangerous weather, the Trump administration has that concerns about global warming are overblown. In a speech to the United Nations in September, Trump called climate change “the greatest con job ever perpetrated on the world.”

The Trump administration has made deep staff and funding cuts to FEMA, NOAA, and the National Weather Service. At FEMA, the cuts prompted 191 current and former employees to in August warning that the agency is being dismantled from within.

Daniel Swain, a University of California climate scientist, said the administration’s rejection of climate change has left the nation less prepared for extreme weather, now and in the future.

“It’s akin to enforcing malpractice scientifically,” Swain said. “Imagine making a medical decision where you are not allowed to look at 20% of the patient’s vital signs or test results.”

Under Trump, FEMA has also taken actions critics say will leave the nation more vulnerable to flooding, specifically:

• FEMA disbanded the Technical Mapping Advisory Council, which had to modernize its flood maps to estimate future risk and account for the impacts of climate change.
• FEMA canceled its program, which provided grants to help communities and vital buildings, including hospitals, protect themselves from floods and other natural disasters.
• And after stopping enforcement early this year, FEMA the Federal Flood Risk Management Standard, which was designed to harden buildings against future floods and save tax dollars in the long run.

Berginnis, of the Association of State Floodplain Managers, said the administration’s unwillingness to prepare for climate change and worsening storms would result in a dangerous and costly cycle of flooding, rebuilding, and flooding again.

“The president is saying we are closed for business when it comes to hazard mitigation,” Berginnis said. “It bugs me to no end that we have to have reminders — like people dying — to show us why it’s important to make these investments.”

FEMA did not answer specific questions about these decisions. In the statement to Ñî¹óåú´«Ã½Ò•îl Health News, spokesperson Llargués touted the administration’s response to flooding in Texas and New Mexico and said FEMA had provided billions of dollars to help people and communities recover and rebuild. He did not mention any FEMA funding for protecting against future floods.

Few hospitals understand this threat more than the former Coney Island Hospital in New York City, which has suffered catastrophic flooding before and has prepared for it to come again.

Superstorm Sandy in 2012 forced the hospital to evacuate hundreds of patients. When the water receded, fish and a sea turtle were found in the building.

Eleven years later, the facility reopened as Ruth Bader Ginsburg Hospital, transformed by a FEMA-funded $923 million reconstruction project that added a 4-foot floodwall and elevated patient care areas and utility infrastructure above the first floor.

It is now likely one of the most flood-proofed hospitals in the nation.

But, so far, no storm has tested the facility.

Svetlana Lipyanskaya, CEO of NYC Health+Hospitals/South Brooklyn Health, which includes the rebuilt hospital, said the question of flooding is “not an if but a when.”

“I hope it doesn’t happen in my lifetime,” she said, “but frankly, I’d be surprised. The water is coming.”

Methodology

CBS News correspondent David Schechter, photojournalist Chance Horner, and producer Aparna Zalani contributed to this report.

Publicly funded counselors called “navigators” or “assisters” can help insurance seekers choose a plan. But those programs vary by state, and often customers don’t realize that the help is available. The Trump administration has cut funding to publicize and operate those navigator programs.

In addition, changes to Medicaid eligibility in the policy bill recently passed by Congress could mean that millions more ACA enrollees , according to the Congressional Budget Office.

Those changes threaten the very viability of the ACA marketplaces, which currently provide insurance to 24 million Americans.

In dozens of interviews, young adults described the unsettling and devastating consequences of having inadequate insurance, or no insurance at all.

Damian Phillips, 26, a reporter at a West Virginia newspaper, considered joining the Navy to get insurance as his 26th birthday approached. Instead, he felt he “didn’t make enough to justify having health insurance” and has reluctantly gone without it.

Ethan Evans, a 27-year-old aspiring actor in Chicago who works in retail, fell off his parents’ plan and temporarily signed up for Medicaid. But the diminished mental health coverage meant cutting back on visits to his longtime therapist.

Rep. Maxwell Frost, a Florida Democrat and the first Gen Z member of Congress, was able to quit his job and run for office at 25 only because he could stay on his mother’s plan until he turned 26, he said.

Now 28, he is insured through his federal job.

“The ACA was groundbreaking legislation, including the idea that every American needs health care,” he said. “But there are pitfalls, and one of them is that when young adults turn 26, they fall into this abyss.”

Why 26?

Back in 2010, the decision to make 26 the cutoff age for staying on a parent’s insurance was “kind of arbitrary,” recalled Nancy-Ann DeParle, deputy chief of staff for policy in the Obama White House.

“My kids were young , and I was trying to imagine when my child would be an adult.”

Before that time, children were often kicked off family plans at much younger ages, typically 18.

The Obama administration’s idea was that young adults were most likely settling into careers and jobs with insurance by 26. If they still didn’t have access to job-based insurance, Medicaid and the ACA marketplaces would offer alternatives, the thinking went.

But over the years, the courts, Congress, and the first Trump administration eviscerated provisions of the ACA. By 2022, a shopper on a federal government-run marketplace had more than 100 choices, many of which included expensive trade-offs, presented in a way that made comparisons difficult without spreadsheets.

Jack Galanty, 26, a freelance designer in Los Angeles, tried to plan for his 26th birthday by seeking coverage on the California insurance marketplace that would ensure treatment for his mild cerebral palsy and for HIV prevention.

“You’re scrolling for what feels like years, looking at 450 little slides, at the little bars, and trying to remember, ‘Was the one I liked No. 12 or 13?’” he recalled. “It feels like it’s nearly impossible to make a good choice in this scenario.”

Out-of-pocket expenses have soared. Complex plans in the lightly regulated marketplaces featured rising premiums, high deductibles, and requirements that patients pay a significant portion of the cost of care, often 20% — a charge known as coinsurance.

More than half of Americans ages 18 to 29 have incurred medical debt in the past five years, a Ñî¹óåú´«Ã½Ò•îl Health News data investigation found. Few have the reserves to pay it off.

The networks of doctors to choose from in these plans are often so limited that an insured person struggles to get timely appointments. It can even be hard to find the official websites amid an explosion of look-alikes operated by commercial brokers.

Sharing her contact information with one site that appeared legitimate left Lydia Herne, a social media producer in Brooklyn, “drowning” in texts and phone calls offering plans of uncertain and unregulated quality. “It never ends,” said Herne, 27.

Young Invincibles, an advocacy group representing young adults, runs its own “navigator” program to help young people choose health insurance plans.

“We hear the frustration,” said Martha Sanchez, the group’s former director of health policy and advocacy. “Twenty-six-year-olds have had negative experiences in a process that’s become really complex. Many throw up their hands.”

Elizabeth Mathis, 29, and Evan Pack, 30, a married couple in Salt Lake City, turned to the marketplaces two years ago, after Pack went uninsured for a “really scary” year after he turned 26.

“Every time he got in the car, I thought, ‘What if?’” Mathis said.

The couple pays more than $200 a month for a high-deductible health plan backed by a federal subsidy (the kind set to expire next year). It’s a significant expense, but they wanted to be sure they had access to contraception and an antidepressant.

But last year, Pack suffered serious eye problems and underwent an emergency appendectomy. Their plan left them $9,000 in debt, for medical care billed at over $20,000.

“Technically, we gambled in the right direction,” Mathis said. “But I don’t feel like we’ve won.”

The Affordability Problem

The ACA was supposed to help consumers find affordable, high-quality plans online. The legislation also tried to expand Medicaid programs, which are administered by states, to provide health insurance to low-income Americans.

But the Supreme Court ruled in 2012 that states could not be forced to expand Medicaid. Ten states, led mostly by Republicans, have not done so, leaving up to 1.5 million Americans, who could have qualified for coverage, .

Even where Medicaid is available to 26-year-olds, the transition has often proved precarious.

Madeline Nelkin of New Jersey, who was studying social work, applied for Medicaid coverage before her 26th birthday in April 2024 because her university’s insurance premiums were more than $5,000 annually.

But it was September before her Medicaid coverage kicked in, leaving her uninsured while she fought a chest infection over the summer.

“People tell you to think ahead, but I didn’t think that meant six months,” she said.

When Megan Hughes, 27, of Hartland, Maine, hit the cliff, she went without. An aide for children with developmental delays, she has a thyroid condition and polycystic ovary syndrome.

She looked for a health care plan but found it hard to understand the marketplace. (She didn’t know there were navigators who could help.) Now she can’t afford her medicine or see her endocrinologist.

“I’m tired all the time,” Hughes said. “My cycles are not regular anymore at all. When I do get one, it’s debilitating.” She is hoping a new job will provide insurance later this year.

Traditionally, most Americans with private health insurance got it through their jobs. But the job market has changed dramatically since the ACA became law, particularly in the wake of the pandemic, with the rise of a gig economy.

Over said in recent surveys that they were working or have worked in short-term, part-time, or irregular jobs.

The ACA requires organizations with 50 or more employees to offer insurance to people working 30 hours per week. This has led to a growing number of contract employees who work up to, but not past, the hourly limit.

Many companies, which say they can’t afford the rising costs of traditional insurance, offer their employees only a modicum of help, perhaps around $200 per month toward buying a marketplace plan, or a bare-bones company plan.

Young people juggling part-time jobs and insurance options face bumpy, daunting transitions.

In Oklahoma, Daisy Creager, 29, has had three employers over the past three years. Insurance was important to her, not least because her former husband had Type 1 diabetes.

As she left the first of those jobs, her husband’s endocrinologist helped the couple stockpile less expensive insulin from Canada, since they would be uninsured.

After a few months, they bought a marketplace plan, but it was expensive and “didn’t cover a lot,” she said.

When she found a new job, she dropped that plan, only to discover that her new insurance coverage didn’t start until the end of her first month of employment. The couple would be uninsured for a few weeks.

A few days later, she came home to find her husband unconscious on the floor, in a diabetic coma. After hovering near death in an intensive care unit for four days, he woke up and began to recover.

“I think I’ve done everything right,” Creager said. “So why am I in a position where the health insurance available to me doesn’t cover what I need, or I can barely afford my premiums, or worse, at times I don’t even have it?”

Kathryn Russell, 27, developed excruciating back pain two months before her 26th birthday. After extensive testing, doctors determined she needed a complex surgery, which her surgeon couldn’t schedule until after she would be off her family’s insurance plan.

Forget the pain and the fear of the operation, she said, it was insurance that kept her up at night. “There’s this impending terror of, ‘What am I going to do?’” she recalled.

(One day before she turned 26, her father’s company agreed to keep her on his plan for six more months, if he paid higher premiums.)

The idea that the ACA would offer a variety of good options for people turning 26 has not worked as well as the legislation’s authors had hoped. The “job lock” tying insurance to employment has long plagued the United States workforce.

Young adults need guidance on their options beforehand, said Sanchez of Young Invincibles. None of those interviewed for this story, for example, knew there were navigators to help them find insurance on the online marketplaces.

Experts agree that the marketplaces need stronger regulation.

In 2023, for what plans in each tier of insurance should offer, such as better prescription drug benefits, defined copays for X-rays, or coverage for emergency room visits.

Certain types of basic care, such as primary care, should require just a small copay for at least a small number of initial visits. Each insurer must offer at least one plan that complies with these new standards for every level, known as an “” option or a “standard plan.”

Most plans on the marketplaces don’t meet these criteria. Federal and state regulators had long planned to cull such “noncompliant” plans, gradually — fearing that doing so too quickly would scare insurers away from participating.

But with the priorities of the new Trump administration now in focus, and a Republican majority in Congress, it’s far from clear what course President Donald Trump, who sought to repeal the ACA outright in his first term, will take.

There are hints: Subsidies to help Americans buy insurance, adopted during the Biden administration, are set to expire at the end of 2025 unless the Republican-led Congress extends them.

If the subsidies expire, for plans sold on the marketplaces, leaving insurance out of reach for many more young adults.

Credits

Credits

With most patient care provided on the second and third levels, generators on the fourth level, and utility lines underground, the hospital is expected to remain operational after a natural disaster.

Thorsen said an earthquake and tsunami threaten not only vast flooding , in which the ground loosens and causes structures above it to collapse. Deep foundations, thick slabs, and other structural supports are expected to protect the new hospital and tsunami structure against such failure.

Through the years, hospital administrators and civic leaders in Astoria have sought other locations for Columbia Memorial. But relocation wasn’t economical. Columbia Memorial committed to invest in a new hospital and tsunami shelter to protect not only patients and staff but also nearby residents.

“Your community should count on your hospital to be a safe haven in a natural disaster,” Thorsen said.

Fighting To Restore Funds

The estimated construction budget for Columbia Memorial’s expansion is $300 million, mostly financed through new debt from the hospital. The tsunami shelter is budgeted at about $20 million, for which FEMA’s BRIC program , with a $6 million matching grant from the state, which has maintained its support.

The shelter and the building’s structural protections — featuring reinforced steel, deeper foundations, and thicker slabs — are integral to the design and cannot be removed without compromising the rest of the structure, said Michelle Checkis, the project architect.

“We can’t pull the TVERS [tsunami vertical evacuation refuge structure] out without pulling the hospital back apart again,” she said. “It’s kind of like, if I was going to stack it up with Legos, I would have to take all those Legos apart and stack it up completely differently.”

Columbia Memorial has sought help from Oregon’s congressional delegation. In to Department of Homeland Security Secretary Kristi Noem and former FEMA acting administrator David Richardson, the lawmakers demanded that the agencies restore the hospital’s grant.

The hospital’s leadership is seeking other grants and philanthropic donations to make up for the loss. As a last resort, Thorsen said, the board will consider removing “nonessential features” from the building, though he added that there is little fat to trim from the project.

The in July alleged that FEMA lacks the authority to cancel the BRIC program or redirect its funding for other purposes.

The states argued that canceling the program and undermined projects underway.

In their response to the lawsuit, the Trump administration said repeatedly that the defendants “deny that the BRIC program has been terminated.”

The lawsuit cites examples of projects at risk in each state due to FEMA’s termination of the grants. Oregon’s first example is Columbia Memorial’s tsunami shelter. “Neither the County nor the State can afford to resume the project without federal funding,” the lawsuit states.

In response to questions about the impact of canceling the grant on Astoria and the surrounding community, DHS spokesperson Tricia McLaughlin said BRIC had “deviated from its statutory intent.”

“BRIC was more focused on climate change initiatives like bicycle lanes, shaded bus stops, and planting trees, rather than disaster relief or mitigation,” McLaughlin said. DHS and FEMA provided no further comment about BRIC or the Astoria hospital.

Preparing for a Tsunami Disaster

Located near the end of the Lewis & Clark National Historic Trail, Astoria sits on a peninsula that juts into the Columbia River near the Pacific Ocean.

Much of the city is not in the tsunami inundation area. But Astoria’s downtown commercial district — where gift shops, hotels, and seafood restaurants line the streets — is nearly all an evacuation zone.

Two hospitals — Ocean Beach Health in nearby Washington, and Providence Seaside Hospital in Oregon — are about 20 miles from Columbia Memorial. Both are 25-bed hospitals, and neither is designed to withstand a tsunami.

Ocean Beach Health regularly conducts drills for mass-casualty and natural disasters, said Brenda Sharkey, its chief nursing officer.

“We focus our planning and investments on areas where we can make a real difference for our community before, during, and after an event — such as maintaining continuity of care, ensuring rapid triage, and coordinating with regional emergency partners,” Sharkey said in an email.

Gary Walker, a spokesperson for Providence Seaside, said in a statement that the hospital has a “comprehensive emergency plan for earthquakes and tsunamis, including alternative sites and mobile resources.”

Walker added that Providence Seaside has hired “a team of consultants and experts to conduct a conceptual resilience study” that would evaluate the hospital’s vulnerabilities and recommend ways to address them.

Oregon’s emergency managers advise residents and visitors in coastal communities to immediately seek higher ground after a major earthquake — and not to rely on tsunami sirens, social media, or most technology.

“There may not even be cellphone towers operating after an event like this,” said Jonathan Allan, a coastal geomorphologist with the Oregon Department of Geology and Mineral Industries. “The earthquake shaking, its intensity, and particularly the length of time in which the shaking persists, is the warning message.”

The stronger the earthquake and the longer the shaking, he said, the more likely a tsunami will head to shore.

A tsunami triggered by a Cascadia zone earthquake could strike land in , according to state estimates.

Many of Oregon’s seaside communities are near high-enough ground to seek safety from a tsunami in a relatively short time, Allan said. But he estimated that, to save lives, Oregon would need about a dozen vertical tsunami evacuation shelters along the coast, including in seaside towns that attract tourists and where the nearest high ground is a mile or more away.

Willis Van Dusen’s family has lived in Astoria since the mid-19th century. A former mayor of Astoria, Van Dusen stressed that tsunamis are not a hypothetical danger. He recalled seeing one in Seaside in 1964. The wave was only about 18 inches high, he said, but it flooded a road and destroyed a bridge and some homes. The memory has stayed with him.

“It’s not like … ‘Oh, that’ll never happen,’” he said. “We have to be prepared for it.”

Ñî¹óåú´«Ã½Ò•îl Health News correspondent Brett Kelman contributed to this report.

The investigation found heightened flood risks at large trauma centers, small rural hospitals, children’s hospitals, and long-term care facilities that serve older and disabled patients. At least 21 are critical access hospitals, with the next-closest hospital 25 miles away, on average.

Flooding threatens dozens of hospitals in coastal areas, including in Florida, Louisiana, Texas, and New York. Farther inland, flooding of rivers or creeks could envelop other hospitals, particularly in Appalachia and the Midwest. Even in the sun-soaked cities and arid expanses of the American West, storms have the potential to surround some hospitals with several feet of pooling water, according to Fathom’s data.

These findings are likely an undercount of hospitals at risk because the investigation overlooked pockets of potential flooding at some hospitals. It excluded facilities like stand-alone ERs, outpatient clinics, and nursing homes.

“The reality is that flood risk is everywhere. It is the most pervasive of perils,” said Oliver Wing, the chief scientific officer at Fathom, who reviewed the findings. “Just because you’ve never experienced an extreme doesn’t mean you never will.”

Dresser, the ER doctor, said even a small amount of flooding can shut down an unprepared hospital, often by interrupting its power supply, which is needed for life-sustaining equipment like ventilators and heart monitors. He said the most vulnerable hospitals would likely be in rural areas.

“A lot of rural hospitals are now closing their pediatric units, closing their psychiatry units,” Dresser said. “In a financially stressed situation, it can be hard to prioritize long-term threats, even if they are, for some institutions, potentially existential.”

Urban hospitals can face dangerous flooding, too. Fathom’s data predicts 5 to 15 feet of water around neighboring hospitals — Kadlec Regional Medical Center and Lourdes Behavioral Health — that straddle a tiny creek in Richland, Washington.

By Fathom’s estimate, a 100-year flood could cause the nearby Columbia River to spill over a levee that protects Richland, then loosely follow the creek to the hospitals. Some of the deepest flooding is estimated around Lourdes, which was built on land the U.S. Army Corps of Engineers set aside in 1961 as a “ponding and drainage easement.”

At the time, this land was supposed to be capable of storing enough water to fill at least 40 Olympic-size swimming pools, according to obtained through the Freedom of Information Act. A mental health facility has occupied this spot since the 1970s.

Both Kadlec and Lourdes said in statements that they have disaster plans but did not answer questions about flooding. Tina Baumgardner, a Lourdes spokesperson, said government flood maps show the hospital is not in a 100-year flood plain.

This is not uncommon. Of the more than 170 hospitals with significant flood risk identified by Ñî¹óåú´«Ã½Ò•îl Health News, one-third are located in areas that FEMA has not designated as flood hazard zones.

Sometimes the difference is stark. For example, at Ochsner Choctaw General in Alabama — the only hospital for 30 miles in any direction — FEMA maps suggest a 100-year flood would overflow a nearby creek but spare the hospital. Fathom’s data predicts the same event would flood most of the hospital with 1 to 2 feet of water, including the ER and the helicopter pad.

Ochsner Health did not answer questions about flooding preparations at Choctaw General.

FEMA flood maps were launched in the ’60s as part of the National Flood Insurance Program to determine where insurance is required and building codes should include flood-proofing. According to a FEMA statement, the maps show only a “snapshot in time” and are not intended to predict where flooding will or won’t happen.

FEMA spokesperson Geoff Harbaugh said the agency intends to modernize its maps through the Future of Flood Risk Data initiative, which will enable the agency to “better project flood risk” and give Americans “the information they need to protect their lives and property.”

The program was launched by the first Trump administration in 2019 but has since received sparse public updates. Harbaugh declined to provide a detailed update or timeline for the program.

Chad Berginnis, executive director of the Association of State Floodplain Managers, said it is unknown whether FEMA is still trying to upgrade its maps under Trump, as the agency has cut off communications with outside flooding experts.

“There has been not a single bit of loosening of what I’m calling the FEMA cone of silence,” Berginnis said. “I’ve never seen anything like it.”

Floods are expected to worsen as a warming climate fuels stronger storms, drenching areas that are already flood-prone and bringing a new level of flooding to areas once considered lower risk.

The National Oceanic and Atmospheric Administration has said that 2024 was the warmest year on record — more than 2 degrees Fahrenheit higher than the 20th-century average. Scientists across the globe that each degree of global warming correlates to a 4% increase in the intensity of extreme rainfall.

“Warmer air can hold more moisture, so this leads us to experience heavier downpours,” said Kelly Van Baalen, a sea level rise expert at the nonprofit . “A 100-year flood today could be a 10-year flood tomorrow.”

Intensifying storms raise concerns about Peninsula Hospital, which has operated for decades mere feet from the Tennessee River but has no known history of flooding.

Peninsula spokesperson Josh Cox said the river is overseen by the Tennessee Valley Authority, which uses dams to manage water levels and generate electricity. Estimates provided by the TVA suggest the dams could keep Peninsula dry even in a 500-year flood.

Fathom, however, said its flood simulation accounts for the dams and stressed that a large enough storm could drop more rain than even the TVA could control. These predictions are echoed by another flood modeling firm, , which also says an intense storm could cause more than 10 feet of flooding in the area around Peninsula.

“It’s a hospital right on the banks of a major American river,” said Wing, the Fathom scientist. “It just isn’t conceivable that such a location is risk-free.”

Jack Goodwin, 75, a retired TVA employee who has lived next to Peninsula for three decades, said he was confident the dams could protect the area. But after reviewing Fathom’s predictions, Goodwin began to research flood insurance.

“Water can rise quickly and suddenly, and the destruction is tremendous,” he said. “Just because we’ve never seen it here doesn’t mean we won’t see it.”

‘All the Elements of a Real Disaster’

One year ago, as Hurricane Helene carved a deadly path across Southern Appalachia, Angel Mitchell was visiting her ailing mother at Unicoi County Hospital in the tiny town of Erwin, Tennessee.

Swollen by Helene, the nearby Nolichucky River spilled over its banks and around the hospital, which was built in a flood plain. Staff tried to bar the doors, Mitchell said, but the water got in, trapping her and others inside. The lights went out. People fled to the roof, where the roar of rushing water nearly drowned out the approach of rescue helicopters, Mitchell said.

Ultimately, 70 people from the hospital, including Mitchell and her mother, were airlifted to safety on Sept. 27, 2024. The hospital remains closed, and the company that owns it, Ballad Health, has said its .

“Why allow something — especially a hospital — to be built in an area like that?” Mitchell told CBS News. “People have to rely on these areas to get medical help, and they’re dangerous.”

Beyond Unicoi, Ñî¹óåú´«Ã½Ò•îl Health News identified 39 inland hospitals — including 16 in Appalachia — that Fathom predicts could flood when nearby rivers, creeks, or drainage canals overspill their banks, even in storms far less intense than Helene.

For example, in the Cumberland Mountains of southwestern Virginia, a 100-year flood is projected to cause Slate Creek to engulf Buchanan General Hospital in more than 5 feet of water.

Near the Great Lakes in Erie, Pennsylvania, LECOM Medical Center and Behavioral Health Pavilion could become flooded by a small drainage creek that is less than 50 feet from the front door of the ER.

Neither Buchanan nor LECOM responded to questions about flooding or preparations.

And in West Virginia’s capital of Charleston, where about 50,000 people live at the junction of two rivers in a wide and flat valley, a single storm could potentially flood five of the city’s six hospitals at once, along with schools, churches, fire departments, and other facilities.

“I hate to say it,” said Behrang Bidadian, a flood plain manager at the , “but it has all the elements of a real disaster.”

At the largest hospital in Charleston, CAMC Memorial Hospital, Fathom predicts that the Kanawha River could bring as much as 5 feet of flooding to the ER. Across town, the Elk River could surround CAMC Women and Children’s Hospital, cutting off all exits.

And in the center of the city, where the overflowing rivers are predicted to merge, Thomas Orthopedic Hospital could be besieged by more than 10 feet of water on three sides.

WVU Medicine, which owns Thomas Orthopedic Hospital, did not respond to requests for comment.

CAMC spokesperson Dale Witte said the hospital system is aware of its flood risk and has prepared by elevating electrical infrastructure and acquiring flood-proofing equipment, like a deployable floodwall. CAMC also regularly revises and drills its disaster plans, Witte said, although he added that hospitals there have never been tested by a real flood.

Shanen Wright, 48, a lifelong Charleston resident who lives near CAMC Memorial, said many in the city have little worry about flooding in the face of more immediate problems, like the opioid epidemic and the decline of manufacturing and mining.

Tugboats and coal barges sail past his neighborhood as if they were cars on his street.

“It’s not to say it’s not a possibility,” he said. “I’m sure the people in Asheville and the people in Texas, where the floods took so many lives, they probably didn’t see it coming either.”

‘The Water Is Coming’

Despite wide scientific consensus that climate change fuels more dangerous weather, the Trump administration has that concerns about global warming are overblown. In a speech to the United Nations in September, Trump called climate change “the greatest con job ever perpetrated on the world.”

The Trump administration has made deep staff and funding cuts to FEMA, NOAA, and the National Weather Service. At FEMA, the cuts prompted 191 current and former employees to in August warning that the agency is being dismantled from within.

Daniel Swain, a University of California climate scientist, said the administration’s rejection of climate change has left the nation less prepared for extreme weather, now and in the future.

“It’s akin to enforcing malpractice scientifically,” Swain said. “Imagine making a medical decision where you are not allowed to look at 20% of the patient’s vital signs or test results.”

Under Trump, FEMA has also taken actions critics say will leave the nation more vulnerable to flooding, specifically:

• FEMA disbanded the Technical Mapping Advisory Council, which had to modernize its flood maps to estimate future risk and account for the impacts of climate change.
• FEMA canceled its program, which provided grants to help communities and vital buildings, including hospitals, protect themselves from floods and other natural disasters.
• And after stopping enforcement early this year, FEMA the Federal Flood Risk Management Standard, which was designed to harden buildings against future floods and save tax dollars in the long run.

Berginnis, of the Association of State Floodplain Managers, said the administration’s unwillingness to prepare for climate change and worsening storms would result in a dangerous and costly cycle of flooding, rebuilding, and flooding again.

“The president is saying we are closed for business when it comes to hazard mitigation,” Berginnis said. “It bugs me to no end that we have to have reminders — like people dying — to show us why it’s important to make these investments.”

FEMA did not answer specific questions about these decisions. In the statement to Ñî¹óåú´«Ã½Ò•îl Health News, spokesperson Llargués touted the administration’s response to flooding in Texas and New Mexico and said FEMA had provided billions of dollars to help people and communities recover and rebuild. He did not mention any FEMA funding for protecting against future floods.

Few hospitals understand this threat more than the former Coney Island Hospital in New York City, which has suffered catastrophic flooding before and has prepared for it to come again.

Superstorm Sandy in 2012 forced the hospital to evacuate hundreds of patients. When the water receded, fish and a sea turtle were found in the building.

Eleven years later, the facility reopened as Ruth Bader Ginsburg Hospital, transformed by a FEMA-funded $923 million reconstruction project that added a 4-foot floodwall and elevated patient care areas and utility infrastructure above the first floor.

It is now likely one of the most flood-proofed hospitals in the nation.

But, so far, no storm has tested the facility.

Svetlana Lipyanskaya, CEO of NYC Health+Hospitals/South Brooklyn Health, which includes the rebuilt hospital, said the question of flooding is “not an if but a when.”

“I hope it doesn’t happen in my lifetime,” she said, “but frankly, I’d be surprised. The water is coming.”

Methodology

CBS News correspondent David Schechter, photojournalist Chance Horner, and producer Aparna Zalani contributed to this report.

Publicly funded counselors called “navigators” or “assisters” can help insurance seekers choose a plan. But those programs vary by state, and often customers don’t realize that the help is available. The Trump administration has cut funding to publicize and operate those navigator programs.

In addition, changes to Medicaid eligibility in the policy bill recently passed by Congress could mean that millions more ACA enrollees , according to the Congressional Budget Office.

Those changes threaten the very viability of the ACA marketplaces, which currently provide insurance to 24 million Americans.

In dozens of interviews, young adults described the unsettling and devastating consequences of having inadequate insurance, or no insurance at all.

Damian Phillips, 26, a reporter at a West Virginia newspaper, considered joining the Navy to get insurance as his 26th birthday approached. Instead, he felt he “didn’t make enough to justify having health insurance” and has reluctantly gone without it.

Ethan Evans, a 27-year-old aspiring actor in Chicago who works in retail, fell off his parents’ plan and temporarily signed up for Medicaid. But the diminished mental health coverage meant cutting back on visits to his longtime therapist.

Rep. Maxwell Frost, a Florida Democrat and the first Gen Z member of Congress, was able to quit his job and run for office at 25 only because he could stay on his mother’s plan until he turned 26, he said.

Now 28, he is insured through his federal job.

“The ACA was groundbreaking legislation, including the idea that every American needs health care,” he said. “But there are pitfalls, and one of them is that when young adults turn 26, they fall into this abyss.”

Why 26?

Back in 2010, the decision to make 26 the cutoff age for staying on a parent’s insurance was “kind of arbitrary,” recalled Nancy-Ann DeParle, deputy chief of staff for policy in the Obama White House.

“My kids were young , and I was trying to imagine when my child would be an adult.”

Before that time, children were often kicked off family plans at much younger ages, typically 18.

The Obama administration’s idea was that young adults were most likely settling into careers and jobs with insurance by 26. If they still didn’t have access to job-based insurance, Medicaid and the ACA marketplaces would offer alternatives, the thinking went.

But over the years, the courts, Congress, and the first Trump administration eviscerated provisions of the ACA. By 2022, a shopper on a federal government-run marketplace had more than 100 choices, many of which included expensive trade-offs, presented in a way that made comparisons difficult without spreadsheets.

Jack Galanty, 26, a freelance designer in Los Angeles, tried to plan for his 26th birthday by seeking coverage on the California insurance marketplace that would ensure treatment for his mild cerebral palsy and for HIV prevention.

“You’re scrolling for what feels like years, looking at 450 little slides, at the little bars, and trying to remember, ‘Was the one I liked No. 12 or 13?’” he recalled. “It feels like it’s nearly impossible to make a good choice in this scenario.”

Out-of-pocket expenses have soared. Complex plans in the lightly regulated marketplaces featured rising premiums, high deductibles, and requirements that patients pay a significant portion of the cost of care, often 20% — a charge known as coinsurance.

More than half of Americans ages 18 to 29 have incurred medical debt in the past five years, a Ñî¹óåú´«Ã½Ò•îl Health News data investigation found. Few have the reserves to pay it off.

The networks of doctors to choose from in these plans are often so limited that an insured person struggles to get timely appointments. It can even be hard to find the official websites amid an explosion of look-alikes operated by commercial brokers.

Sharing her contact information with one site that appeared legitimate left Lydia Herne, a social media producer in Brooklyn, “drowning” in texts and phone calls offering plans of uncertain and unregulated quality. “It never ends,” said Herne, 27.

Young Invincibles, an advocacy group representing young adults, runs its own “navigator” program to help young people choose health insurance plans.

“We hear the frustration,” said Martha Sanchez, the group’s former director of health policy and advocacy. “Twenty-six-year-olds have had negative experiences in a process that’s become really complex. Many throw up their hands.”

Elizabeth Mathis, 29, and Evan Pack, 30, a married couple in Salt Lake City, turned to the marketplaces two years ago, after Pack went uninsured for a “really scary” year after he turned 26.

“Every time he got in the car, I thought, ‘What if?’” Mathis said.

The couple pays more than $200 a month for a high-deductible health plan backed by a federal subsidy (the kind set to expire next year). It’s a significant expense, but they wanted to be sure they had access to contraception and an antidepressant.

But last year, Pack suffered serious eye problems and underwent an emergency appendectomy. Their plan left them $9,000 in debt, for medical care billed at over $20,000.

“Technically, we gambled in the right direction,” Mathis said. “But I don’t feel like we’ve won.”

The Affordability Problem

The ACA was supposed to help consumers find affordable, high-quality plans online. The legislation also tried to expand Medicaid programs, which are administered by states, to provide health insurance to low-income Americans.

But the Supreme Court ruled in 2012 that states could not be forced to expand Medicaid. Ten states, led mostly by Republicans, have not done so, leaving up to 1.5 million Americans, who could have qualified for coverage, .

Even where Medicaid is available to 26-year-olds, the transition has often proved precarious.

Madeline Nelkin of New Jersey, who was studying social work, applied for Medicaid coverage before her 26th birthday in April 2024 because her university’s insurance premiums were more than $5,000 annually.

But it was September before her Medicaid coverage kicked in, leaving her uninsured while she fought a chest infection over the summer.

“People tell you to think ahead, but I didn’t think that meant six months,” she said.

When Megan Hughes, 27, of Hartland, Maine, hit the cliff, she went without. An aide for children with developmental delays, she has a thyroid condition and polycystic ovary syndrome.

She looked for a health care plan but found it hard to understand the marketplace. (She didn’t know there were navigators who could help.) Now she can’t afford her medicine or see her endocrinologist.

“I’m tired all the time,” Hughes said. “My cycles are not regular anymore at all. When I do get one, it’s debilitating.” She is hoping a new job will provide insurance later this year.

Traditionally, most Americans with private health insurance got it through their jobs. But the job market has changed dramatically since the ACA became law, particularly in the wake of the pandemic, with the rise of a gig economy.

Over said in recent surveys that they were working or have worked in short-term, part-time, or irregular jobs.

The ACA requires organizations with 50 or more employees to offer insurance to people working 30 hours per week. This has led to a growing number of contract employees who work up to, but not past, the hourly limit.

Many companies, which say they can’t afford the rising costs of traditional insurance, offer their employees only a modicum of help, perhaps around $200 per month toward buying a marketplace plan, or a bare-bones company plan.

Young people juggling part-time jobs and insurance options face bumpy, daunting transitions.

In Oklahoma, Daisy Creager, 29, has had three employers over the past three years. Insurance was important to her, not least because her former husband had Type 1 diabetes.

As she left the first of those jobs, her husband’s endocrinologist helped the couple stockpile less expensive insulin from Canada, since they would be uninsured.

After a few months, they bought a marketplace plan, but it was expensive and “didn’t cover a lot,” she said.

When she found a new job, she dropped that plan, only to discover that her new insurance coverage didn’t start until the end of her first month of employment. The couple would be uninsured for a few weeks.

A few days later, she came home to find her husband unconscious on the floor, in a diabetic coma. After hovering near death in an intensive care unit for four days, he woke up and began to recover.

“I think I’ve done everything right,” Creager said. “So why am I in a position where the health insurance available to me doesn’t cover what I need, or I can barely afford my premiums, or worse, at times I don’t even have it?”

Kathryn Russell, 27, developed excruciating back pain two months before her 26th birthday. After extensive testing, doctors determined she needed a complex surgery, which her surgeon couldn’t schedule until after she would be off her family’s insurance plan.

Forget the pain and the fear of the operation, she said, it was insurance that kept her up at night. “There’s this impending terror of, ‘What am I going to do?’” she recalled.

(One day before she turned 26, her father’s company agreed to keep her on his plan for six more months, if he paid higher premiums.)

The idea that the ACA would offer a variety of good options for people turning 26 has not worked as well as the legislation’s authors had hoped. The “job lock” tying insurance to employment has long plagued the United States workforce.

Young adults need guidance on their options beforehand, said Sanchez of Young Invincibles. None of those interviewed for this story, for example, knew there were navigators to help them find insurance on the online marketplaces.

Experts agree that the marketplaces need stronger regulation.

In 2023, for what plans in each tier of insurance should offer, such as better prescription drug benefits, defined copays for X-rays, or coverage for emergency room visits.

Certain types of basic care, such as primary care, should require just a small copay for at least a small number of initial visits. Each insurer must offer at least one plan that complies with these new standards for every level, known as an “” option or a “standard plan.”

Most plans on the marketplaces don’t meet these criteria. Federal and state regulators had long planned to cull such “noncompliant” plans, gradually — fearing that doing so too quickly would scare insurers away from participating.

But with the priorities of the new Trump administration now in focus, and a Republican majority in Congress, it’s far from clear what course President Donald Trump, who sought to repeal the ACA outright in his first term, will take.

There are hints: Subsidies to help Americans buy insurance, adopted during the Biden administration, are set to expire at the end of 2025 unless the Republican-led Congress extends them.

If the subsidies expire, for plans sold on the marketplaces, leaving insurance out of reach for many more young adults.

Credits