ACA Turns 16 as Megabill’s Anti-Immigrant Stance Sets Path to End Coverage Gains Among People With Lawful Immigration Status

The Affordable Care Act (ACA) envisioned a nation where everyone had access to affordable, high-quality health coverage. An important aspect of the new law was to address long-time inequity that kept people with lawful immigration status in low-income households from being able to access the Medicaid program due to long-standing harsh immigration-related eligibility restrictions.

The ACA significantly increased health coverage access among people who immigrated to the United States. In 2013, 36 percent of immigrants below the age of 65 were uninsured and by 2024, 21 percent were uninsured, according to CBPP analysis of American Community Survey data.

But these coverage gains are expected to disappear, as provisions from the harmful Republican megabill, enacted in July 2025, begin to materialize. Approximately 900,000 people will become uninsured by 2034 due to the megabill taking away ACA premium tax credits from many people with lawfully present immigration statuses, including children, according to the Congressional Budget Office (CBO). People were already required to have a lawfully present immigration status to purchase health insurance plans through the ACA marketplaces and to obtain premium tax credits (which help people afford the premiums for these plans) prior to the megabill’s enactment. The megabill further restricts which categories of immigrants can receive premium tax credits, starting January 1, 2027. This new, narrow group is limited to:

• citizens and nationals of the United States;
• lawful permanent residents (also known as green card holders);
• Cuban-Haitian entrants, who meet specific criteria as defined in the Refugee Education Assistance Act of 1980; and
• people from the Federated States of Micronesia, Republic of the Marshall Islands, or Republic of Palau who live and work in the United States under Compacts of Free Association (COFA), often referred to as COFA migrants.

These new megabill restrictions take away this assistance from numerous groups of immigrants living lawfully in the U.S., including:

• people granted asylum;
• refugees;
• children who have applied for or received Special Immigrant Juvenile status due to abuse, abandonment, or neglect by one or both parents;
• temporary protected status holders;
• those granted humanitarian parole (based on a determination that their urgent humanitarian needs cannot be met in their home countries); and
• certain victims of domestic violence, labor or sex trafficking, and other serious crimes.

At the start of this year, the megabill terminated premium tax credit eligibility for lawfully present people with incomes below the poverty line who were ineligible for Medicaid due to its very restrictive immigration-related rules. The ACA included a provision that allowed people in these groups to qualify for premium tax credits and cost-sharing reductions even if their incomes are below the poverty level (about $16,000 for an individual), but the megabill ended this provision, starting January 1, 2026. As a result, approximately 300,000 more people will become uninsured by 2034, according to the CBO.

The megabill will also apply the same narrow immigration-related eligibility restrictions that were imposed on ACA premium tax credits (described above) on people with lawful immigration status enrolled in Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP), meaning even more people will lose health coverage. These changes will result in approximately 200,000 more people becoming uninsured by 2034 according to CBO estimates.

Turning away from the ACA’s efforts to improve access to comprehensive, affordable health coverage will leave more people unable to afford to meet their medical needs and more likely to accrue medical debt. It will also harm our health system, which will see rises in uncompensated care. Research shows that states with lower levels of uninsurance due to the ACA Medicaid expansions have decreased uncompensated care costs. Rather than strip people with lawful immigration status of their health coverage, our nation should be working towards further reducing the number of uninsured people and ensuring that everyone is able to access the health care they need to thrive.