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Policies Designed to Strengthen ACA Marketplaces Succeed, But Are Under Threat
More people are getting their health insurance through the Affordable Care Act (ACA) marketplaces than ever before. Enrollment more than doubled over the past four years, from 12 million people in 2021 to 24.1 million people in 2025. The marketplace serves people across a wide range of incomes, and the gains in coverage have been broad across all racial and ethnic groups. The greatest gains have been among Black people and Latino people, for whom combined marketplace plan selections roughly tripled between 2020 and 2024, and among people with incomes between 100 and 200 percent of the federal poverty level, whose enrollment more than doubled during the same period. Small business and self-employed workers also account for a large and growing proportion of marketplace enrollees, a recent analysis from the Treasury Department finds.
The recent enrollment gains are no accident. Policies from the first Trump Administration, deliberately designed to undermine the ACA, caused enrollment to decline between 2017-2020. Starting in 2021, the Biden Administration began implementing a series of purposeful federal policies, many reversing the Trump Administration’s policies, to make coverage more affordable, simplify the enrollment process, and improve transitions from other coverage programs.
The Biden-era policies should be preserved. These policies have made it possible for millions to gain coverage and have reduced health care costs for millions more people, a welcome help to families who have faced higher prices for many goods and services over the last several years. These policies include:
Making coverage more affordable. More than 90 percent of marketplace enrollees receive a premium tax credit (PTC), a subsidy that covers a portion, or in some cases all, of their monthly premium. Since 2021, premium tax credit amounts have been larger because of changes in the American Rescue Plan Act and the Inflation Reduction Act designed to make coverage more affordable. People are saving an extra $59 per month on average with the higher premium tax credit. For each of the years between 2022 and 2025, 4 out of 5 HealthCare.gov enrollees could find a plan for $10 or less per month after taking the premium tax credit into account.
The federal government also finalized a rule to more realistically determine what’s considered an “affordable” offer of employer coverage for an employee’s family members. This has allowed millions of people who lack an affordable offer of employer coverage to enroll in ACA marketplace coverage with a premium tax credit.
- Investing in outreach and enrollment assistance. Advertising and outreach campaigns (like this $50 million federal campaign in 2021) and individual enrollment help are critical so that people know they can get coverage and can successfully complete the enrollment process. Over the past four years, Navigators, who conduct outreach and provide free, unbiased application and enrollment help, received robust federal funding in the states with a federally operated marketplace: $82 million in 2021, nearly $99 million per year in 2022 and 2023, and $100 million in 2024. This came after four years of extreme federal funding cuts to Navigator programs, which received just $36 million in 2017 and $10 million per year between 2018-2020. Navigators often help people who face the greatest barriers to enrollment — including Limited English Proficiency and more limited access to internet/technology needed to enroll online — complete the process.
Making it easier to enroll. The Biden Administration extended the length of open enrollment from an unreasonably short 44 days (which also overlapped with the busy end-of-year holiday season) to a 75-day minimum (many states that run their own marketplaces give people even more time). The Biden-era regulations also simplified the process of enrolling. They reduced paperwork verification requirements, which create unnecessary barriers to enrollment, and restored standardized plans, which make it easier for people to compare plans. Another policy automatically moves people to plans with lower deductibles and cost sharing when they qualify.
Importantly, the Biden Administration also created an option for marketplaces to allow people with very low incomes (less than 150 percent of poverty) to enroll in marketplace coverage or change plans at any time throughout the year, which has spurred increased enrollment among the lowest income people eligible for marketplace financial help.
- Improving transitions from other coverage. The unwinding of the pandemic-related Medicaid continuous coverage protection in 2023 and 2024 resulted in many people losing eligibility for Medicaid or Children’s Health Insurance Program (CHIP) coverage and becoming eligible for marketplace coverage with a subsidy. The Biden Administration created a temporary Special Enrollment Period to allow people losing Medicaid or CHIP to enroll in marketplace coverage without having to wait for open enrollment. Many people who lost Medicaid eligibility during the unwinding period did successfully enroll in marketplace coverage, analyses of CMS data show.
The new Trump Administration, in a recent executive order, said it wants to “defeat the cost of living crisis” and “increase the prosperity of the American worker.” However, its first action related to the ACA marketplaces — slashing federal Navigator funding by 90 percent — directly mirrors the Trump Administration’s approach to Navigator funding during its first term. Defunding these critical programs will lead to loss of coverage, reduced enrollment, and could erode the individual market risk pool. Meanwhile, health policies under consideration by House Republicans would make marketplace coverage more expensive and harder to enroll in, and they would increase the number of people who are uninsured. As the last four years demonstrated, policies make a significant difference in how many people can get affordable coverage through the ACA marketplaces. These early signals suggest a reversal in course that is likely to lead to coverage loss among people with the lowest incomes who face the greatest obstacles to enrollment.