Carley Calvi came to the second floor of a public library in suburban Milwaukee one morning this month without health insurance to cover the vertigo medication she needed. Worse, she said, was not having a doctor she trusted.
“I want somebody to value me as the person I am,” said Ms. Calvi, a 35-year-old woodworker.
With roughly 110 options and the help of a health insurance navigator, she selected a plan with a steeply discounted $221 monthly premium, placing her among the 21.3 million people who have signed up for coverage on the Affordable Care Act’s marketplaces for 2024. The sign-up total, announced by the Biden administration on Wednesday, set a record for the third year in a row and amounted to almost double the number of sign-ups from 2020.
Driving the surge in enrollment has been the continuation of more generous federal subsidies that date to the coronavirus pandemic.
President Biden and Democrats in Congress expanded the subsidies for two years as part of a pandemic relief package in 2021, and they later enacted a three-year extension that runs through 2025, meaning that Americans will be able to take advantage of the beefed-up assistance for one more annual open enrollment period.
But what happens after that will depend on the outcome of November’s elections and the political environment that results.
Now in its second decade, the Affordable Care Act no longer faces an existential political threat. While former President Donald J. Trump, the front-runner for the Republican presidential nomination, has recently renewed his broadsides against it, the push to repeal the law known as Obamacare has faded away as an animating force among Republican candidates and voters. The law has also become deeply embedded in the U.S. health care system.
“If we were having this discussion in 1977 about Social Security or Medicare, I think most people would say, ‘Sure, make it better, but don’t repeal it,’” Xavier Becerra, the health and human services secretary, said in an interview. “And if one of the things that has made it better for more Americans is making it more affordable through these subsidies, I doubt you’re going to find many Americans who say, ‘Go ahead and strip the subsidies.’”
But the Affordable Care Act remains intertwined with the nation’s political currents, in part because of the temporary nature of the enhanced subsidies. A Republican president or a Republican-controlled Congress could allow the expansion of the subsidies to expire, which would cause premiums to rise and potentially discourage Americans from signing up for coverage. Such a move would also risk drawing a backlash from voters unhappy about the higher costs.
“I’ve had a low-level alarm going off in my brain,” said Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms, referring to the possible expiration of the increased subsidies. She added that “so much of the sustainability of the marketplaces and the enrollment growth will hinge on the outcome of the 2024 election.”
The subsides are calculated on a sliding scale based on income. In addition to making the assistance more generous, the 2021 pandemic relief package made people with incomes higher than four times the federal poverty level, or $120,000 for a family of four for those enrolled this year, eligible for subsidies for the first time.
Behind the rising enrollment total is what public health experts say is a notable trend with potential political ramifications: People are signing up for Obamacare plans in large numbers in Republican-led states, particularly those that have not expanded Medicaid under the Affordable Care Act.
According to federal data released on Wednesday about the open enrollment period for 2024, which concluded last week in most states, 4.2 million people signed up for plans in Florida, 3.5 million in Texas and 1.3 million in Georgia, all states that have not adopted the expansion. Overall, more than half of those signing up were in one of the 10 states that have not expanded Medicaid.
The subsidies have been a way to “get people covered in nonexpansion states that otherwise wouldn’t have done it,” said Chris Meekins, a health policy analyst at the financial services firm Raymond James and the author of a report published on Tuesday outlining the popularity of the marketplaces in red states.
More than 18 percent of Florida’s population had signed up for an Obamacare plan, Mr. Meekins estimated in the report.
The marketplaces have also been important backstops for Americans who lost Medicaid for the first time since the onset of the pandemic, after a federal policy guaranteeing coverage expired in April and forced millions of people to hunt for new plans. Federal health officials said on Wednesday that as of the end of last year, 2.4 million sign-ups on HealthCare.gov, the federal marketplace, were by people who had previously been enrolled in Medicaid or the Children’s Health Insurance Program.
More than a million poor Americans in states that have not expanded Medicaid are estimated to still be in the so-called coverage gap, stuck with incomes too low for subsidized coverage through the marketplaces but too high to qualify for Medicaid. But many low-income Americans are benefiting from the increased subsidies. Those with incomes up to 150 percent of the federal poverty level, or $45,000 for a family of four, are eligible for free Obamacare plans with low deductibles.
Deanna Williams, a health insurance navigator who helps mostly rural residents in central Georgia, said that many of those whom she enrolled in marketplace plans would struggle to afford even a fast-food meal.
“These are people who can’t afford their medications,” she said.
The three-year extension of the more generous subsidies through 2025 came with an estimated price tag of $64 billion, according to the Congressional Budget Office. Conservative critics of the enhanced subsidies have argued that the cost to the federal government remains too high for the quality of plans on the marketplaces, and that deductibles and co-pays can still be too expensive for middle-class Americans.
“When you talk to people who are middle class and self-employed, it’s not so much that they want a subsidy,” said Edmund F. Haislmaier, a health policy expert at the conservative Heritage Foundation. “They want lower deductibles and a choice of provider.”
When Congress considers whether to extend the expanded subsidies, lawmakers will also be grappling with the impending expiration of tax cuts that Republicans passed under Mr. Trump. Many provisions from that law are set to lapse at the end of 2025, and Mr. Haislmaier said that timing could lead to horse-trading between the parties.
“There might be an ability to come to a compromise,” he said.
Mr. Trump’s campaign did not respond when asked whether he would support extending the increased subsidies past 2025. In a social media post in November, he wrote that he was “seriously looking at alternatives” to the Affordable Care Act. Mr. Biden’s campaign quickly seized on the comments to cast Mr. Trump as a threat to Americans’ health care.
Beyond the fate of the expanded subsidies, Mr. Trump could take other steps to weaken Obamacare if he returns to the White House. The Biden administration has been eager to provide grants to navigator groups that help people sign up for marketplace plans, and it has also spent significantly on advertising to promote HealthCare.gov. The Trump administration slashed grants for navigator groups and cut back on ad spending.
Representative Frank Pallone Jr. of New Jersey, the top Democrat on the Energy and Commerce Committee, said he could imagine a Trump-influenced campaign among congressional Republicans to let the enhanced subsidies expire as part of a broader push to undermine the Affordable Care Act.
But the experience of people in the marketplaces in recent years, he said, makes it much more difficult to undermine the law.
“When you’re actually having people participate in an affordable health insurance program and you tell them they’re going to take it away — I think that’s a much harder message to sell to the public,” he said.
Federal officials have acknowledged that Obamacare plans can still be difficult to choose. Ms. Calvi selected one with a relatively low premium but a high deductible, a trade-off that she said reflected how infrequently she planned to see a doctor this year.
But the time it took her and a health care navigator to sift through her options — more than an hour — reflected the complexity of the marketplaces. The navigator who helped her, Nicholas Duke, said his consultations typically lasted close to an hour, a sign of the importance of expert help for those picking plans.
“It’s just nerve-racking to choose,” Ms. Calvi said.