The unraveling of pandemic-era protections threatens coverage gains and raises stakes for millions in the November election.
In Tuesday’s debate, former President Donald Trump criticized the Affordable Care Act, labeling it “lousy” and saying he’d like to replace it, though he admitted he only had “concepts of a plan” in mind.
Newly released data from the U.S. Census Bureau’s annual American Community Survey underscored the degree to which the now broadly popular legislation has helped people gain health insurance across the country.
In 2023, the number of people without health insurance reached a record low, marking the third consecutive year of decline. Experts attributed the reduction to efforts by President Joe Biden’s administration to bolster the Affordable Care Act, along with pandemic-era policies that temporarily expanded Medicaid enrollment and increased subsidies for private insurance.
Three years into the Biden administration, the number of uninsured U.S. residents dropped by nearly 3.5 million compared to 2019, the last year health insurance statistics were collected during the Trump administration. Across the key battleground states of Arizona, Georgia, Michigan, Nevada, North Carolina, Pennsylvania and Wisconsin, more than 630,000 fewer people lacked health insurance three years into Biden’s term, according to census data analyzed by Capital & Main with support from Thomas Data Consulting. A total of 46 states saw reductions in the number of uninsured in that time.
In contrast, three years into Trump’s presidency, the uninsured population increased in 39 states, with 2.3 million more people lacking health insurance. More than 440,000 of those additional uninsured people came from the seven swing states alone, according to the census data reviewed by Capital & Main.
Biden’s coverage gains may already be eroding, though. The pandemic-era rule that kept people enrolled in Medicaid during the pandemic, even if they no longer qualified, ended in 2023, and more protections are set to expire next year. Absent federal action, the number of uninsured, which was about 26 million last year, could rise by millions more over the next decade.
Most U.S. respondents in a recent survey by the Pew Research Center viewed health care affordability as a “very important” issue, and both Trump and his Democratic presidential rival Vice President Kamala Harris are courting voters by promising to improve access to health insurance. But their approaches — and the effect on the uninsured rate — would likely be significantly different, according to experts.
In the official Republican Party campaign platform, Trump’s party promises to “increase Transparency, promote Choice and Competition, and expand access to new Affordable Healthcare.”
During Tuesday’s debate, however, Trump seemed unsure what course he would take if he won a second term. “If we come up with something, and we are working on things, we’re going to do it and we’re going to replace [the Affordable Care Act],” Trump said.
As president, Trump unsuccessfully sought to repeal the Affordable Care Act, and his administration undermined the law’s effectiveness. He has both praised and distanced himself from Project 2025, the Heritage Foundation’s plan for the next Republican administration. The plan includes a long list of proposals to weaken the law and calls for ending pandemic-era subsidies for private insurance and implementing lifetime caps on Medicaid.
On Tuesday’s debate stage, Harris promised to “maintain and grow” the Affordable Care Act. Her recently unveiled policy platform backs making the enhanced subsidies, which help individuals buy private insurance through the ACA marketplace, permanent. On average, those enhanced subsidies saved enrollees $700 in 2024, according to the Center on Budget and Policy Priorities, helping drive record marketplace enrollment.
Even if Harris is elected, however, she will need support from Congress to renew the Biden-era health insurance subsidies. “If Democrats have a majority in Congress, they’d be more likely to renew [them] than Republicans,” said Bradley Corallo, senior policy analyst with KFF’s Program on Medicaid and the Uninsured.
Though the recently released 2023 census data showed the share of residents without insurance at a record low of 7.9%, the actual state of coverage in the United States is somewhat more complicated, according to Corallo.
After some pandemic protections ended last year, states began disenrolling ineligible Medicaid recipients in a process the Brookings Institution called the “Great Unwinding.” Since the American Community Survey is conducted throughout the year, some who lost insurance in 2023 were still counted as insured.
Corallo expects the long-term effect of unwinding to be a rise in the uninsured rate. He also said that the magnitude of that rise will depend on whether the increased Biden-era subsidies for private insurance are allowed to expire at the end of 2025. Republicans in Congress have called for ending those enhanced subsidies.
“There is definitely a possibility that hinges on the election whether those subsidies are renewed or not. If they are not renewed, and people lose that support, I wouldn’t be surprised if more people became uninsured,” Corallo said.
Copyright 2024 Capital & Main.
Jeremy Lindenfeld is a California Local News Fellow.
This story has been updated to provide a more precise explanation of the methodology used in the U.S. Census Bureau’s recently released American Community Survey.