An estimated 26 million Americans, or 8 percent of the U.S. population, lacked health insurance in 2023. Although the United States still lags countries that have universal coverage, today’s uninsured rate represents a sea change from the years prior to the Affordable Care Act (ACA), when nearly twice as many people — 49 million, or 16 percent of the population — lacked health coverage.
But more work is needed to bring affordable, comprehensive coverage to all Americans. A pandemic-era boost to ACA marketplace subsidies will expire at the end of 2025, potentially causing premium spikes and coverage losses for an estimated 4 million people if Congress fails to extend the enhanced assistance. Ten states have not adopted the ACA’s Medicaid eligibility expansion, leaving 1.5 million very poor people uninsured. More than one of five working-age adults are underinsured, meaning they have coverage, but high deductibles and out-of-pocket costs leave them without adequate financial protection. Millions of Americans with insurance, including a large percentage of people in employer health plans, are burdened by medical debt and coping with medical billing errors or denials of coverage. And, in many states, there remain sharp disparities in coverage and access to care by income and by race and ethnicity.
The 2024 election presents a stark choice for voters: build on the coverage and affordability gains achieved in the last decade or return to policies that in the past have led to high uninsured rates, high premiums and out-of-pocket costs, and a serious risk of medical debt. Here’s what’s at stake for Americans’ health care coverage.
How could the election affect how many people have health insurance?
If elected president, Kamala Harris would likely continue efforts to reduce premiums and expand access to affordable, comprehensive coverage through the marketplaces and Medicaid. The enhanced marketplace premium tax credits, first passed by Congress and the Biden–Harris administration in 2021 and then extended in 2022, have dramatically lowered household premiums and led to a record 21.4 million people enrolled in the marketplaces in 2024. But the expanded tax credits are set to expire at the end of 2025, unless Congress extends them. The Urban Institute estimates that without these enhanced tax credits, annual premiums in 2025 would be $387 more for the lowest-income enrollees, who currently pay no premium costs, and nearly $3,000 more for people earning $60,240 or more. Four million more people would be uninsured without the enhanced credits. Harris supports extending them.
The Biden–Harris administration further boosted enrollment by restoring funds for outreach and enrollment assistance. It fixed the so-called “family glitch,” making it possible for more people in unaffordable employer plans to get covered in the marketplaces. It reinstated standardized plan options that the Trump administration had eliminated, allowing consumers to more easily select a marketplace plan. And the administration added a new special enrollment period for lower-income families to enroll in plans throughout the year.
A second Trump presidency, however, could once again pursue policies to reduce federal health spending that have historically made it more difficult for people to afford and access coverage on the marketplaces and Medicaid. When in office, Trump sought to repeal and replace the Affordable Care Act with plans that, according to projections, would increase the number of uninsured to more than 50 million and reopen the doors to preexisting condition denials and exclusions for people buying coverage on their own. His administration also nearly eliminated funding for outreach and enrollment assistance in the marketplaces. A second Trump administration might restart efforts to add work requirements to Medicaid, a policy that led to coverage losses.
Could the election affect consumers’ out-of-pocket costs and medical debt?
A Harris presidency could build on efforts to protect people from high out-of-pocket costs and medical debt. In April 2024, the Biden–Harris administration finalized a rule that reinstated limits on short-term health plans, reversing a Trump administration policy that left more people vulnerable to junk health insurance and on the hook for potentially high out-of-pocket costs. A Harris administration would likely retain these limits and further explore opportunities to prohibit medical debt information from appearing on consumer credit reports.
By contrast, a second Trump presidency could loosen insurance market regulations, like the expansion of short-term plans. These reforms are aimed at increasing choice for people but historically have spurred the creation of insurance plans that favor healthy people and raised premiums for sicker and older people. His administration could also build on earlier efforts to eliminate federal funding for cost-sharing subsidies that reduce deductibles and copayments for lower-income people in the marketplaces. The Trump campaign has not indicated it would pursue an extension of the enhanced premium tax credits, which would trigger premium spikes and coverage losses.
What might happen to efforts to promote health equity and reduce disparities?
Election results could determine the extent to which coverage policies prioritize equity in health care. A Harris presidency would likely continue to advance coverage policies to reduce disparities. For example, the Biden–Harris administration revised regulations that further the ACA’s goal of eliminating discrimination in health insurance and health care. Section 1557 of the law prohibits all insurers and health care providers that receive federal funds, like Medicare, from discriminating on the basis of race, color, national origin, sex, age, or disability. The Biden–Harris regulations also restored gender identity as part of the definition of sex discrimination, which the Trump administration had eliminated, and went further by adding sexual orientation.
The Trump administration weakened the ACA protections against discrimination by lifting Obama-era rules prohibiting insurers from using marketing and benefit designs intended to avoid higher-cost patients and from denying coverage of health services based on gender identity. A second Trump term might include similar efforts.
The Biden–Harris administration recently announced that, starting this November, it would allow young adult “Dreamers” — people who came to the United States as children and are protected against deportation by the Deferred Action for Childhood Arrivals (DACA) program — to gain coverage through the marketplaces. The Trump administration cancelled DACA in its entirety in 2017, although the Supreme Court later blocked the action and reinstated the program in 2020. It’s not clear if and how a second Trump administration might reexamine this issue.
What options does the next administration have to expand coverage and improve affordability?
To improve coverage and make care more affordable, the next administration and Congress could pursue several reforms:
- Permanently extend the enhanced marketplace premium tax credits set to expire in 2025. If Congress fails to extend these enhanced tax credits, marketplace premiums will spike and enrollment will fall, increasing the number of uninsured.
- Fill the Medicaid coverage gap. Congress could create a federal fallback option for Medicaid-eligible people in the 10 states that have yet to expand their program. Doing this could insure the estimated 1.5 million uninsured people in the coverage gap in those states.
- Create a longer period of continuous Medicaid eligibility. Disruptions in Medicaid coverage due to eligibility changes or administrative errors can leave people uninsured and unable to get care. Policymakers could apply the lessons of the COVID-19 pandemic and give states the option to maintain continuous enrollment eligibility for adults for 12 months, without the need to apply for a waiver.
- Create an auto-enrollment mechanism. Research shows that many uninsured people are eligible for Medicaid or subsidized marketplace plans. A system for automatically enrolling people in comprehensive insurance could move the nation closer to universal coverage.
- Lower deductibles and out-of-pocket costs in marketplace plans. Congress could extend cost-sharing reduction subsidies to middle-income people and change the benchmark plan in the ACA marketplaces from silver to gold, which offers better financial protection. These policies would save households $4.8 billion and decrease the number of uninsured by an estimated 1.5 million.
- Adjust premiums and cost sharing based on employee income in employer plans. In 2022, just 10 percent of employers with 200 or more employees had programs to reduce premium contributions for lower-wage workers; only 5 percent had similar programs to reduce cost sharing.
- Protect consumers from being financially ruined by medical debt. In June, the Biden–Harris administration released a new rule to prohibit medical debt information from appearing on consumer credit reports; earlier, it had taken steps to ensure greater scrutiny of providers’ bill collection tactics, among other actions. Many states have passed legislation to relieve medical debt, such as strengthening standards to ensure patients have access to hospital financial assistance programs, banning aggressive collection activities by hospitals, or prohibiting or capping interest on medical debt. North Carolina has implemented an innovative medical debt relief program that provides enhanced Medicaid reimbursements to participating hospitals.
- Reduce the relentless growth in health care costs that’s at the root of the nation’s medical debt and affordability crisis. Ultimately, private payers will need to do a better job of leveraging their purchasing power to slow cost growth in commercial markets. Federal and state policymakers could help by creating new public plan options.
By implementing policies to improve health insurance coverage in the U.S., policymakers could help ensure better access to affordable, comprehensive care for millions of people.
