Various provisions in President Donald Trump's budget reconciliation bill threaten to undermine the strides that states have made in recent years to increase health insurance coverage for residents under the Affordable Care Act (ACA). Shorter enrollment periods, more documentation requirements, no automatic reenrollment, and higher premiums are likely to affect consumers.
Analysts expect that these changes will hit particularly hard in the 19 states and Washington, D.C., that operate their own ACA exchanges. In those states, a greater percentage of residents rollover their coverage through automatic reenrollment instead of shopping for a new plan, which is more common in those states that use the federal marketplace at healthcare.gov.
Between restrictions in the budget bill and the likely expiration of enhanced premium subsidies at the end of the year — which is expected to drive up premiums by as much as 75% — millions of people, including as many as half the enrollees in some states, may lose or drop their ACA coverage. Furthermore, the Trump administration recently issued a new rule that would require enrollees to provide new and additional information to enroll, shorten the annual enrollment period, eliminate year-round enrollment for people with the lowest income, and set new restrictions on the remaining special enrollment periods. The rule also would eliminate coverage for gender-affirming care and bar Deferred Action for Childhood Arrivals (DACA) recipients from coverage eligibility.
The anticipated loss of 30–50% of enrollees from ACA coverage, combined with the expected loss of Medicaid coverage for millions of people, threatens to reverse recent gains in reducing the number of uninsured Americans.
While the Trump administration touts the changes as necessary to crack down on unauthorized enrollment, the increased administrative burden is likely to decrease the number of legitimate enrollees. Still, some point to an increase in the number of complaints from insurers, consumers, and brokers about fraudulent enrollments in 2023 and 2024. Most of the complaints centered on brokers working on commission, enrolling consumers in an ACA plan, or switching them to a different plan without authorization. According to the Trump administration, these changes will target Obama's poor verification procedures.
Still, states running their exchanges see very few unauthorized enrollments, largely due to tighter security measures and control over broker access. Therefore, unauthorized enrollment issues appear to be limited to the 31 states using the federal marketplace.
Furthermore, rollovers are common not only in state marketplaces but also in other forms of health insurance, such as employer-sponsored coverage. Only about 22% of federal marketplace plan enrollees in 2024 were automatic reenrollments, compared to 58% on average in state marketplace plans. Some states reported even higher numbers. Moreover, states do check eligibility requirements for all enrollees, even when they automatically reenroll. For instance, in one state, if the state system flags an enrollee for mismatched data, then the enrollee has 90 days to maintain coverage with the tax credit subsidy while they submit additional paperwork. However, under the new federal requirements, presumptive eligibility, while providing more information, would no longer be an option.
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