This year, enrollment in Affordable Care Act (ACA) marketplaces reached historic highs, with more than 45 million nationwide now enrolled — a 46% increase since 2021 and more than three times the enrollment since the ACA’s early years in 2014. With a Republican trifecta in Washington and a conservative-majority Supreme Court, the ACA is on a path to repeal.
The program, known as Obamacare, has become an essential fixture in the U.S. health care system. “For decades, when it came to federal programs we could depend on to keep Americans covered, three were always top of mind — Medicare, Medicaid, and Social Security. But now it’s crystal clear that we need to add a fourth — the Affordable Care Act,” HHS Secretary Xavier Becerra said earlier this year.
The record enrollment has primarily been driven by enhanced subsidies, which were first enacted under the Biden administration in 2021 as part of the American Rescue Plan. The subsidies limit insurance costs to no more than 8.5% of a household’s income for many middle-income Americans, making coverage accessible for those previously unable to afford it.
However, the enhanced subsidies are only guaranteed through the end of 2025, and with Republicans newly in control of the Senate and House, the potential loss of these financial aids could spell trouble for millions of Americans who depend on the ACA.
“These historic enrollment numbers are a testament to the need for comprehensive, quality, affordable health insurance,” said Chiquita Brooks-LaSure, administrator for the Centers for Medicare and Medicaid Services. “Not only is demand for Marketplace insurance coverage at an all-time high, but the Marketplaces are delivering on the Affordable Care Act’s promise to provide the peace of mind that comes with having health insurance to millions of Americans.”
The states with the highest ACA enrollment rates in 2024 were largely conservative strongholds supporting Trump, including Florida with 4.2 million enrollees, Texas with 3.5 million, and Georgia with 1.3 million. These five states — Florida, Texas, California, Georgia and North Carolina — accounted for 55% of total ACA enrollment.
Each state uses the federal Healthcare.gov enrollment platform and has yet to expand Medicaid under the ACA, making the ACA subsidies particularly vital for affordable health care access.
The subsidies have also substantially impacted middle-income families, including those with incomes above 400% of the federal poverty level, or approximately $103,280 for a family of four. For this group, enhanced subsidies have capped insurance premiums at 8.5% of income; without the subsidies, premiums could exceed 20% of income, according to Kaiser Family Foundation.
If subsidies expire, middle-income enrollees would likely be hit the hardest, as many would be priced out of coverage entirely.
ACA enrollment has also surged in states like Texas and Mississippi, where growth rates have exceeded 200% since 2020. Notably, these states had some of the highest uninsured rates before introducing the enhanced subsidies. Without Medicaid expansion, the ACA marketplace has been the primary avenue for affordable insurance.
Enhanced subsidies, which reduce premiums for eligible enrollees by an average of 44%, or about $705 per year, have made health insurance more accessible than ever. However, if Congress fails to renew them, the Congressional Budget Office projects that ACA enrollment could fall from 22.8 million in 2025 to 15.4 million by 2030 as millions of Americans lose affordable options.
Without financial support, many of these individuals could be forced to go without insurance, leading to even higher rates of medical debt, which stood at $220 billion nationwide in 2021.
Health care policy experts and millions of Americans watch closely, hoping for a path forward that will secure affordable health care for all. The ACA continues to be a successful, popular and important federal program to millions of people and their families.
At least for now.
Stacy M. Brown is a senior writer for The Washington Informer and the senior national correspondent for the Black Press of America.