How does a worker's health insurance status affect workers' comp claim costs?

Health insurance status doesn't appear in the workers' comp system directly, but it shapes what happens when an injury occurs. Workers without coverage are more likely to have untreated chronic conditions like diabetes and hypertension. When they get hurt on the job, those conditions complicate recovery, extend disability duration, and increase medical costs on the WC claim. NCCI's 2026 data shows comorbidities can drive two to four times the medical utilization on a single claim.

Will the ACA subsidy expiration raise my experience modification rate?

Not directly or immediately. The ACA subsidy expiration won't change your current mod, which is calculated from claims already in your three-year experience period. But if your workforce loses health coverage and chronic conditions go untreated, future workplace injuries may generate costlier claims. Those higher claim values flow into your mod calculation when they enter the experience window. The effect is gradual, not a sudden spike.

What percentage of construction workers are uninsured?

Roughly 31% of construction workers lack health insurance, about three times the national average for all workers (UC Berkeley Labor Center, 2022). The rate varies by region and trade. Workers in residential framing, roofing, and concrete tend to have lower coverage rates than those in commercial mechanical and electrical trades. The ACA subsidy expiration is projected to widen this gap in 2026.

What is a comorbidity in workers' compensation?

A comorbidity is a pre-existing health condition that exists alongside the workplace injury. Common examples include diabetes, hypertension, obesity, and degenerative joint conditions. In workers' comp, comorbidities matter because they extend healing time, increase medical treatment intensity, and lengthen disability duration. NCCI's 2026 research shows claims involving comorbidities can require two to five times the medical utilization of claims without them.

Field ReportMay 28, 2026 · 4 min read

ACA Subsidy Cliff Hits Workers' Comp Through the Back Door

NCCI's 2026 comorbidity data shows diabetes quadruples medical costs on WC claims. With 4.8 million losing ACA coverage, construction's uninsured gap is about to hit your mod.

By TraciThe Orson Group

Field Report

Medical utilization for WC claims with diabetes comorbidity

NCCI AIS 2026

At a glance

When construction workers lose ACA marketplace coverage, chronic conditions like diabetes and hypertension go untreated. NCCI's 2026 data shows diabetes drives 4x medical utilization in workers' comp claims, extending disability and inflating costs. With 4.8 million projected to lose coverage (KFF, May 2026) and construction workers 3x more likely to be uninsured, the added cost flows through your experience mod.

What if the biggest threat to your workers' comp costs in 2026 isn't a fall or a trench collapse, but a health insurance policy your employee just lost?

NCCI (the National Council on Compensation Insurance) put a number to something auditors have seen for years. At its 2026 Annual Issues Symposium, they showed that injured workers with diabetes generate four times the medical utilization of workers without comorbidities (NCCI, May 2026). Four times. Now pair that with a policy shift: the ACA's enhanced premium tax credits expired at the end of 2025. That's 4.8 million people projected to lose marketplace coverage in 2026 (KFF, May 2026). Construction feels it most. Workers in the trades are already three times more likely to be uninsured than the national average (UC Berkeley, 2022).

Your workers' health insurance status doesn't appear on your NCCI worksheet. The claims it generates do.

The ACA Coverage Gap Construction Already Had

Before the subsidies expired, construction had the worst uninsured rate of any major industry. Not by a little. Roughly 31% of construction workers lacked health insurance, triple the rate for all workers nationally (UC Berkeley Labor Center, 2022). The subsidies helped. Enhanced premium tax credits introduced under the American Rescue Plan in 2021 and extended through 2025 narrowed the gap, and subsidized marketplace enrollment more than doubled between 2020 and 2024, from 9.2 million to 19.3 million (CRS, December 2024).

Those credits expired January 1, 2026. The fallout is already measurable. Effectuated enrollment is projected to drop from 22.3 million to 17.5 million, a loss of 4.8 million covered lives (KFF, May 2026). Average net premiums for remaining enrollees jumped 58%. Deductibles surged 37% to $3,786 (KFF, May 2026). Bronze plan enrollment spiked from 30% to 40% of selections, meaning workers who kept coverage bought plans with far higher out-of-pocket costs.

The hit concentrates on workers earning between 200% and 400% of the federal poverty level. In construction, that pay range covers a wide swath of laborers, helpers, and apprentices.

Untreated Conditions Become Workers' Comp Claims

A worker with unmanaged diabetes who tears a rotator cuff doesn't just have a shoulder claim. It's a shoulder claim complicated by impaired healing, elevated infection risk, and extended disability. The coverage gap matters. What went untreated because he lost his plan in January makes his July injury far more expensive.

NCCI put numbers to this at the 2026 AIS in Orlando. Claims involving diabetes show roughly four times the medical service utilization of claims without comorbidities (NCCI, May 2026). Hypertension drives three times the utilization. The baseline for a comorbidity-free claim is about 9,300 medical utilization units. With diabetes, that figure approaches 37,000.

Disability duration tells the same story. A claim without comorbidities averages about 40 days of temporary disability and 130 days of medical treatment. Add a comorbidity, and those figures stretch to roughly 90 and 210 days (NCCI AIS 2026). Construction already leads all industries in per-claim medical utilization. The sector's physically demanding work and limited access to preventive care put it at the front of this problem.

How Comorbidity Costs Reach Your EMR

The Experience Modification Rate (EMR, also called "the mod") doesn't distinguish between a routine claim and one inflated by a comorbidity. It sees dollars. A $12,000 medical-only claim that would have closed at $4,000 with proper chronic-disease management hits your worksheet at the actual incurred value.

The mod formula compares your actual losses to expected losses for your classification and payroll size. When comorbidities inflate those costs, the actual-to-expected ratio widens. Your mod goes up.

Severity is where this bites hardest. The formula splits losses into primary and excess components, and larger claims push more dollars into the excess layer. One comorbidity-inflated lost-time claim can keep your mod elevated for three full rating years. We see this in our reviews of Southeast contractor worksheets. A handful of claims carry incurred values wildly out of proportion with the injury itself. That gap? It's almost always a comorbidity the claim file never documented.

What an Audit Would Check

An audit examines whether the claims on your worksheet carry reserves and incurred values that reflect the actual workplace injury. Not figures inflated by unrelated chronic conditions. It looks at carrier medical management on complex claims and checks whether open reserves inside your experience period have drifted from what the underlying injury supports.

If your workforce's health coverage shifted this year, claims from 2026 forward may look different than prior years. Send us your NCCI worksheet and we'll show you what the numbers say.