ACA Marketplace Enrollment Has More Than Doubled Since 2020, with the Fastest Growth Occurring in States Won by President Trump in 2024

Enrollment in Affordable Care Act (ACA) Marketplace health plans reached a record 24.3 million people, more than double the total in 2020, with most of the growth occurring in states won by President Trump in the 2024 election, a new KFF analysis finds. 

Almost all states have seen increases in enrollment since 2020, including six states where enrollment has more than tripled: Texas (up 255%), Mississippi (up 242%), West Virginia (up 234%), Louisiana (up 234%), Georgia (up 227%), and Tennessee (up 221%). Only New York (down 19%), Oregon (down 4%) and the District of Columbia (down 3%) experienced enrollment declines over the past five years.

The growth in enrollment since 2020 has been concentrated in states that President Trump carried in the 2024 election. Those 31 states accounted for 88% of the increase in enrollment during the past five years. Put another way, since 2020, enrollment grew by an average of 157% in states carried by President Trump but only 36% in states carried by former Vice President Harris. 

Much of the enrollment growth stems from the enhanced premium aid first made available in 2021 that helped to make Marketplace coverage more affordable for many people. The extra assistance is set to expire at the end of this year unless Congress acts to extend it.