Midterm Election Update: The Affordable Care Act Marketplaces

More people than ever got coverage through the Affordable Care Act (ACA) Marketplaces in 2025, but the expiration of enhanced premium tax credits has driven up what people pay and contributed to declining enrollment in 2026. Law and regulatory changes also tightened ACA eligibility and enrollment requirements, including for some lawfully present immigrants. Public opinion of the ACA remains generally favorable, although views remain divided along partisan lines.

Overview

The Affordable Care Act (ACA) Marketplaces, sometimes called Obamacare markets, allow individuals and families who don’t get coverage from other sources to buy their own insurance, often with the help of federal tax credits based on income to make comprehensive coverage more affordable.

Effectuated enrollment – that is, the number of people who paid their premiums – climbed to a record 21.8 million in 2025 in large part due to more generous temporary enhanced premium tax credits. These enhanced tax credits reduced premium payments for lower and middle-income Marketplace enrollees and also made some upper-middle class and higher-income enrollees newly eligible for financial assistance. The enhanced tax credits were first passed as part of a relief package during the COVID-19 pandemic and later extended temporarily by the Inflation Reduction Act.

The expiration of those temporary tax credits at the end of 2025 sharply increased what people have to pay out of pocket toward premiums. The total cost of marketplace insurance also is on the rise, with insurers seeking a median premium increase of about 15% for 2027. While the remaining tax credits will protect most enrollees from the full impact of next year’s premium hikes, those with higher incomes who are no longer eligible for financial assistance would have to pay the full costs.

There are also concerns about how shrinking enrollment and rising prices will affect the marketplace’s stability going forward. Some insurers cite a deteriorating risk pool as a factor in rate increases as healthier enrollees drop coverage rather than paying more, and some insurers plan to leave some ACA markets.

Key Developments

As part of the 2025 reconciliation law, sometimes called “the One Big Beautiful Bill,” Congress created new pre-enrollment verification requirements, which could effectively end autorenewals  starting in 2028; required enrollees who underestimated their incomes at the start of the year to fully repay any excess tax credits; and prohibited many lawfully present immigrants from receiving ACA tax credits.

The Trump administration also finalized stricter enrollment and eligibility procedures, including additional verification of income, household information, immigration status, and other eligibility details. Many of these requirements, as well as other changes included in a 2026 regulation, are on hold due to pending litigation but could lead to further enrollment decline if implemented.

The reconciliation law enacted in July 2025 did not address the expiring enhanced premium tax credits. Late last year, Republicans in Congress blocked efforts by Democrats to extend the tax credits before they expired, arguing that they were so generous that they allowed insurers to charge more and encouraged improper or fraudulent enrollment.

The Trump administration also is working to make it easier for consumers to enroll in alternatives to ACA Marketplace coverage, such as short-term limited duration health plans. Unlike Marketplace insurance, short-term plans can reject consumers based on their medical history. Enrollees are also not eligible for any of the ACA’s premium tax credits, meaning they have to pay the full cost themselves regardless of their income.

In September, the Trump administration announced it would send $500 check to nearly 1 million ACA Marketplace enrollees in 30 states – a small share of current enrollees. Enrollees who won’t get rebates include those in mostly blue states that run their own Marketplace and those who receive premium tax credits, even though what they’re paying has gone up. The Administration also announced it would cancel coverage for more than 760,000 people it says were improperly enrolled and did not respond to a request for more information within 30 days. That process likely resulted in some legitimately enrolled consumers losing their coverage.

Recent Issues and Looking Ahead

After the temporary tax credits expired, what people would have to pay in premiums after accounting for tax credits increased by 114% or more than $1,000 annually to stay in the same plan in 2026. Facing higher premium payments, some dropped coverage, while some others switched to lower-premium plans with higher deductibles. On net, premium payments increased 58% on average (as opposed to 114%), but deductibles increased by 37% or about $1,000 more per person due to many people buying down to lower levels of coverage. Eight in ten of those who chose to remain in the marketplace say their health care costs went up, and more than half said they were cutting back on other expenses to afford the increases.

Effectuated enrollment in Marketplace plans fell for the first time in seven years, from 21.8 million last year to 19.2 million in 2026.  Enrollment dropped in every state except New Mexico, which offered state subsidies to replace the expired tax credits. Enrollment is expected to drop further this year, potentially as low as 17.5 million, as consumers wrestle with higher premium payments.

Looking ahead, the Congressional Budget Office projected that the reconciliation law’s ACA provisions alone would increase the number of uninsured by 2.1 million by 2034. Combined with the law’s Medicaid changes and the expiration of the enhanced tax credits, the estimated increase in the uninsured by 2034 topped 14 million people.

The Public’s Views

Most of the public views the ACA favorably as it has since 2017, when congressional Republicans failed to repeal the law during the first Trump administration. As of March, 61% of the public hold favorable views, while 38% hold unfavorable views. Views diverge by political party, with nine in ten Democrats and nearly two thirds of independents (64%) viewing the law favorably, while two thirds of Republicans (67%) hold unfavorable views.

Support for extending the ACA’s enhanced tax credits was also strong throughout 2025. Earlier this year, two thirds of the public (67%), including strong majorities of Democrats and independents, said that Congress did the wrong thing by failing to extend the tax credits. Most Republicans (63%) said Congress did the right thing.