The Rise and Fall of Affordable Care

Since the Obama administration and its Affordable Care Act (ACA) the number of Americans without medical insurance has been cut in half. Current actions (and non-actions) by the Trump administration and by the Republican majorities in both houses of Congress threaten to undo that progress.

The graph below plots the number (in millions) of Americans without health insurance between 2010 and 2023. During this period, the number dropped from 46.5 million to 25.3 million, based on calculations by KFF using Census Bureau survey data.

The next chart compares where residents of Wisconsin under age 65 got their health insurance in 2010 and 2023. Although employers are by far the largest source of health insurance, their share of the total has shrunk.

Two sources have grown in recent years, so-called “non group,” which includes insurance purchased on the ACA marketplace, and Medicaid. In the case of Wisconsin, the state turned down the available expansion money. Instead, it excluded people with incomes over the poverty line from Medicaid, in the expectation that those people could get insurance through the ACA marketplace. This opened spaces for childless adults and other low-income people.

The next graph summarizes the history of people purchasing health insurance through the ACA Marketplace, from 2014, when the major elements of the law took effect, to 2023. In 2016, enrollment peaked at 12.68 million, only to drift down during the first three years of the Trump administration.

In 2020, the COVID-19 pandemic hit. To avoid a possible recession, the American Rescue Plan Act, followed by the Inflation Reduction Act, introduced substantially increased tax credits for plans purchased through the marketplace. These included 100% premium subsidies for the lowest income enrollees and made some middle income people newly eligible for financial assistance.

Who were the new enrollees? The next chart gives a hint of the answer. The chart is a scatter plot of the states. The horizontal axis shows the vote for president in the 2024 election, with Democratic states to the right and Republican states to the left. The vertical yellow line separates the two parties.

The vertical axis shows the percentage increase in each state’s enrollment through the Marketplace between 2020 and 2025. Wisconsin is shown with the large red dot and growth just over 50%.

Given the opposition to the ACA among Republican politicians, there is a fair amount of irony associated with this graph. The states with the biggest growth of ACA insurance all vote Republican, including Texas (with 255% growth), Mississippi (242%), West Virginia and Louisiana (both 234%), Georgia (227%) and Tennessee (221%).

While ironic, this pattern is understandable. The very hostility towards expanded Medicaid coverage in these states makes alternatives to the private marketplace unavailable.

The red circles indicate the ten states that refused to accept the ACA offer of a higher federal match for expanding Medicate. Eight of these states were among those with particularly growth in marketplace enrollment.

The future is likely to see increases in the number of people with no access to medical coverage. The main threat to Medicaid is contained in Donald Trump’s “One Big Beautiful Bill.” This act requires states and enrollees to take a number of steps to prove that enrollees are employed or fit in a category that is exempted from this requirement.

This requirement is widely expected to lead to a substantial share of enrollees failing to submit the required documents, leading to a decline in Medicaid enrollment and government spending on this, partially offsetting the costs of Trump’s tax reduction skewed towards the wealthiest members of our society. Effectively, this is an example of the upward redistribution of wealth.

KFF (formerly the Kaiser Family Foundation) is a non-profit, non-partisan organization that provides independent, in-depth information and analysis on health policy and health care issues; it points out that the threat to the Marketplace has received much less attention than the threat posed by Trump’s big bill. The extended tax credits that made health coverage more affordable to many people are scheduled to expire at the end of this year. Unless Congress agrees to extend the credits this will likely make health care coverage unaffordable to millions of people who previously discovered that the credits made coverage affordable.

A letter to Congress members from the Congressional Budget Office, entitled “Re: The Effects of Not Extending the Expanded Premium Tax Credits for the Number of Uninsured People and the Growth in Premiums.”

CBO expects that not extending the credit will increase the number of people without health insurance and raise the average gross benchmark premiums for plans purchased through the marketplaces.

The CBO conclusion is summarized in the next graph. The number of additional uninsured people in millions is shown with the blue columns and the left-hand axis. CBO estimates that in the long run almost 4 million people would lose their coverage. The orange line and right hand scale show the expected increase in the premium. As the price of insurance rises, the most healthy people are most likely to drop insurance, thus raising the cost of the people who remain.

All things considered, we may look back at this year as the time when the number of people with no health insurance hit bottom, only to begin rising again.