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Upward of 44 million people, or 16.4% of the non-elderly U.S. population, have been covered by an Affordable Care Act initiative, including health plan enrollment and Medicaid expansion, finds a new KFF report.
In 2024, marketplace enrollment hit a record high of 21.4 million people (almost double the 11 million people enrolled in 2020), Medicaid expansion enrollment was 21.3 million (a 41% increase from 2020), and BHP enrollment in 2024 was 1.3 million (up from 880,000 in 2020).
KFF attributed much of the marketplace growth since 2020 to enhanced subsidies under the American Rescue Plan Act (ARPA) in 2021, which were renewed through 2025 by the Inflation Reduction Act. These subsidies, KFF said, reduced premium payments across the board for ACA Marketplace enrollees – including $0 monthly premiums for enrollees with incomes up to 150% of the federal poverty level (FPL) – and made some middle-income people who had previously been priced out of coverage newly eligible for financial assistance.
WHAT’S THE IMPACT
Medicaid expansion enrollment increased due to seven states implementing expansion in 2020 or later, as well as adoption of the continuous enrollment provision, a pandemic-era policy that prohibited states from disenrolling people from Medicaid in exchange for enhanced federal funding.
Even with the unwinding of the continuous enrollment provision starting April 1, 2023, enrollment in Medicaid expansion today is higher than it was in 2020, KFF found. The number of marketplace enrollees increased by 10 million people nationally, almost doubling between 2020 and 2024, and the number of Medicaid expansion enrollees increased by 6.2 million people. In 2024, marketplace consumers made up 49% of all people enrolled in ACA coverage compared to 42% in 2020.
At the same time, the uninsured rate hit a historic low in 2023 as coverage increased through the ACA and Medicaid. But KFF warned that these coverage gains might not last long – if enhanced subsidies are not renewed by Congress and are instead allowed to expire at the end of 2025, ACA enrollee premium payments are expected to increase by over 75% on average, and the Congressional Budget Office estimates that the number of people who are uninsured will increase by 3.8 million, on average, each year from 2026 to 2034.
Also, Congress may attempt to lower the Medicaid expansion match rate from the current 90% rate, which could reduce federal spending. But the analysis said this would shift costs to states and likely result in decisions by many states to terminate coverage.
About 4.3 million Medicaid expansion enrollees live in states with some type of trigger law that would end Medicaid expansion or require review of expansion coverage to mitigate increases in state costs if federal funding for the expansion is reduced, KFF said.
More than one in five non-elderly people in seven states (Louisiana, Oregon, Florida, New York, California, New Mexico and Vermont) and the District of Columbia had ACA coverage through Medicaid expansion, Marketplace or BHP in 2024. Meanwhile, fewer than one in 10 non-elderly residents of five states (Alabama, Kansas, Tennessee, Wisconsin and Wyoming) had coverage through one of these three ACA programs
Except for Florida, the states with the largest ACA enrollment as a share of population had adopted the Medicaid expansion. The five states with the lowest share of enrollment were Medicaid non-expansion states.
THE LARGER TREND
According to the Centers for Medicare and Medicaid Services, close to 24 million people have selected a health plan for 2025 during the Affordable Care Act open enrollment period.
The result is a historically low uninsured rate, CMS said.
Jeff Lagasse is editor of Healthcare Finance News.
Email: [email protected]
Healthcare Finance News is a HIMSS Media publication.
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