Shorter enrollment periods. More paperwork. Higher premiums. The sweeping tax and spending bill pushed by President Donald Trump includes provisions that would not only reshape people\u2019s experience with the Affordable Care Act but, according to some policy analysts, also sharply undermine the gains in health insurance coverage associated with it.<\/p>\n
The moves affect consumers and have particular resonance for the 19 states (plus Washington, D.C.) that run their own ACA exchanges.<\/p>\n
Many of those states fear that the additional red tape \u2014 especially requirements that would end automatic reenrollment \u2014 would have an outsize impact on their policyholders. That\u2019s because a greater percentage of people in those states use those rollovers versus shopping around each year, which is more commonly done by people in states that use the federal healthcare.gov marketplace.<\/p>\n
\u201cThe federal marketplace always had a message of, \u2018Come back in and shop,\u2019 while the state-based markets, on average, have a message of, \u2018Hey, here\u2019s what you\u2019re going to have next year, here\u2019s what it will cost; if you like it, you don\u2019t have to do anything,\u2019\u201d said Ellen Montz, who oversaw the federal ACA marketplace under the Biden administration as deputy administrator and director at the Center for Consumer Information and Insurance Oversight. She is now a managing director<\/a> with the Manatt Health consulting group.<\/p>\n Millions \u2014 perhaps up to half of enrollees in some states \u2014 may lose or drop coverage as a result of that and other changes in the legislation combined with a new rule<\/a> from the Trump administration and the likely expiration at year\u2019s end of enhanced premium subsidies put in place during the covid-19 pandemic. Without an extension of those subsidies, which have been an important driver of Obamacare enrollment in recent years, premiums are expected to rise 75% on average next year<\/a>. That\u2019s starting to happen already, based on some early state rate requests<\/a> for next year, which are hitting double digits.<\/p>\n \u201cWe estimate a minimum 30% enrollment loss, and, in the worst-case scenario, a 50% loss,\u201d said Devon Trolley, executive director of Pennie, the ACA marketplace in Pennsylvania, which had 496,661 enrollees<\/a> this year, a record<\/a>.<\/p>\n Drops of that magnitude nationally, coupled with the expected loss of Medicaid coverage for millions more people under the legislation Trump calls the \u201cOne Big Beautiful Bill,\u201d could undo inroads made in the nation\u2019s uninsured rate, which dropped by about half from the time most of the ACA\u2019s provisions went into effect in 2014, when it hovered around 14% to 15% of the population, to just over 8%, according to the most recent data<\/a>.<\/p>\n Premiums would rise along with the uninsured rate, because older or sicker policyholders are more likely to try to jump enrollment hurdles, while those who rarely use coverage \u2014 and are thus less expensive \u2014 would not.<\/p>\n After a dramatic all-night session, House Republicans passed the bill, meeting the president\u2019s July 4 deadline. Trump is expected to sign the measure on Independence Day. It would increase the federal deficit by trillions of dollars and cut spending on a variety of programs, including Medicaid and nutrition assistance, to partly offset the cost of extending tax cuts put in place during the first Trump administration.<\/p>\n The administration and its supporters say the GOP-backed changes to the ACA are needed to combat fraud. Democrats and ACA supporters see this effort as the latest in a long history of Republican efforts to weaken or repeal Obamacare. Among other things<\/a>, the legislation would end several changes put in place by the Biden administration that were credited with making it easier to sign up, such as lengthening the annual open enrollment period and launching a special program for very low-income people that essentially allows them to sign up year-round.<\/p>\n In addition, automatic reenrollment, used by more than 10 million people<\/a> for 2025 ACA coverage, would end in the 2028 sign-up season. Instead, consumers would have to update their information, starting in August each year, before the close of open enrollment, which would end Dec. 15, a month earlier than currently.<\/p>\n That\u2019s a key change to combat rising enrollment fraud, said Brian Blase, president of the conservative Paragon Health Institute, because it gets at what he calls the Biden era\u2019s \u201clax verification requirements.\u201d<\/p>\n He blames automatic reenrollment, coupled with the availability of zero-premium plans for people with lower incomes that qualify them for large subsidies, for a sharp uptick in complaints from insurers, consumers, and brokers about fraudulent enrollments in 2023 and 2024. Those complaints centered on consumers\u2019 being enrolled in an ACA plan, or switched from one to another, without authorization, often by commission-seeking brokers.<\/p>\n In testimony to Congress on June 25<\/a>, Blase wrote that \u201cthis simple step will close a massive loophole and significantly reduce improper enrollment and spending.\u201d<\/p>\n States that run their own marketplaces, however, saw few, if any, such problems, which were confined mainly to the 31 states using the federal healthcare.gov.<\/p>\n The state-run marketplaces credit their additional security measures and tighter control over broker access than healthcare.gov for the relative lack of problems.<\/p>\n \u201cIf you look at California and the other states that have expanded their Medicaid programs, you don\u2019t see that kind of fraud problem,\u201d said Jessica Altman, executive director of Covered California, the state\u2019s Obamacare marketplace. \u201cI don\u2019t have a single case of a consumer calling Covered California saying, \u2018I was enrolled without consent.\u2019\u201d<\/p>\n Such rollovers are common with other forms of health insurance, such as job-based coverage.<\/p>\n \u201cBy requiring everyone to come back in and provide additional information, and the fact that they can\u2019t get a tax credit until they take this step, it is essentially making marketplace coverage the most difficult coverage to enroll in,\u201d said Trolley at Pennie, 65% of whose policyholders were automatically reenrolled this year, according to KFF data<\/a>. KFF is a health information nonprofit that includes KFF Health News.<\/p>\n Federal data shows<\/a> about 22% of federal sign-ups in 2024 were automatic-reenrollments, versus 58% in state-based plans. Besides Pennsylvania, the states that saw such sign-ups for more than 60% of enrollees include California, New York, Georgia, New Jersey, and Virginia, according to KFF.<\/p>\n States do check income and other eligibility information for all enrollees \u2014 including those being automatically renewed, those signing up for the first time, and those enrolling outside the normal open enrollment period because they\u2019ve experienced a loss of coverage or other life event or meet the rules for the low-income enrollment period.<\/p>\n \u201cWe have access to many data sources on the back end that we ping, to make sure nothing has changed. Most people sail through and are able to stay covered without taking any proactive step,\u201d Altman said.<\/p>\n If flagged for mismatched data, applicants are asked for additional information. Under current law, \u201cwe have 90 days for them to have a tax credit while they submit paperwork,\u201d Altman said.<\/p>\n That would change under the tax and spending plan before Congress, ending presumptive eligibility while a person submits the information.<\/p>\n A white paper<\/a> written for Capital Policy Analytics<\/a>, a Washington-based consultancy that specializes in economic analysis, concluded there appears to be little upside to the changes.<\/p>\n While \u201ctighter verification can curb improper enrollments,\u201d the additional paperwork, along with the expiration of higher premiums from the enhanced tax subsidies, \u201cwould push four to six million eligible people out of Marketplace plans, trading limited fraud savings for a surge in uninsurance,\u201d wrote free market economists Ike Brannon and Anthony LoSasso.<\/p>\n \u201cInsurers would be left with a smaller, sicker risk pool and heightened pricing uncertainty, making further premium increases and selective market exits [by insurers] likely,\u201d they wrote.<\/p>\n KFF Health News<\/a> is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF\u2014an independent source of health policy research, polling, and journalism. 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