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Congressional District Interactive Map: How Much Will ACA Premium Payments Rise if Enhanced Subsidies Expire?



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Enhanced Affordable Care Act (ACA) subsidies were first made available as part of the American Rescue Plan Act in 2021 and were extended through the end of 2025 by the Inflation Reduction Act. The enhanced subsidies build on the ACA’s original tax credits by increasing the amount of premium assistance lower-income enrollees receive, and by making middle- and higher-income enrollees (with incomes over four times poverty) newly eligible for financial assistance to buy health insurance. These enhanced subsidies will expire at the end of this year unless Congress further extends them and President Trump signs it into law. In 2024, 56% of ACA Marketplace enrollees live Congressional Districts represented by Republicans and 76% of enrollees are in states won by President Trump in the 2024 election.

If the enhanced subsidies expire, monthly premium payments for the vast majority of Marketplace enrollees will increase sharply starting January 1, 2026. Among subsidized enrollees living in states that use Healthcare.gov (where data are available), premium payments would have been an average of 93% higher in 2024 without the enhanced tax credits. If these enhanced subsidies expire, the Congressional Budget Office (CBO) projects that there will be an average of 3.8 million more uninsured people each year. Unsubsidized premiums will also likely rise as healthier enrollees drop their coverage. While some state-based Marketplaces offer additional premium financial assistance for certain enrollees, the amount of and availability of these state subsidies would not be enough to fully replace the federal enhanced subsidies.

The interactive map below illustrates how much premium payments would rise without the enhanced subsidies, net of tax credits, at the congressional district level. The tool presents average net premium increases (for states that use Healthcare.gov, where data are available) and two hypothetical scenarios (in all states): one of an older couple who would lose subsidy eligibility due to their income exceeding four times poverty and another for a single individual with a $31,000 income (206% of poverty). A KFF calculator allows users to evaluate zip-code specific changes in premium payments with and without enhanced subsidies for other income and family scenarios.

Because enhanced tax credits decrease premium payments across the board for people receiving a tax credit, all subsidized Marketplace enrollees will experience increases in their monthly premium payments if the enhanced subsidies expire. However, how much each enrollee’s premium payment increases will vary widely and will depend on their family size, location, and income.

Average Increases in Premium Payments Among Subsidized ACA Enrollees

In some congressional districts, there is both a large share of the population enrolled in ACA Marketplace coverage and an expectation of very high average increases in premium payments without the enhanced tax credits. Among states that use Healthcare.gov (where average enhanced tax credit data are available), there are 39 congressional districts where at least 10% of the population is enrolled in the ACA Marketplaces and where 2024 average premium payments would have been double or more had it not been for the enhanced subsidies (Table 1). While these 39 districts are politically split (19 are represented by Democrats and 20 are represented by Republicans), these districts are mostly concentrated in a few red states. Twenty of these 39 districts are in Texas, 7 are in Florida, and 3 are in Georgia. These states are among those that have seen ACA Marketplace enrollment grow the most since the enhanced subsidies went into effect. Since 2020, ACA Marketplace enrollment has more than doubled in Florida and more than tripled in Texas and Georgia.

Increases in Premium Payments for An Older Couple on the “Subsidy Cliff”

The expiration of the enhanced premium tax credits would mean that people with incomes over four times the poverty level are no longer eligible for financial assistance. Prior to the availability of enhanced subsidies, ACA Marketplace premium assistance eligibility capped at 400% of poverty (which is $60,240 for a single person or $81,760 for a couple in 2025). If enhanced subsidies expire, Marketplace enrollees making just above 400% of poverty will encounter the “subsidy cliff” and would face the full price of a Marketplace plan. If the enhanced subsidies expire, a 60-year-old couple making $82,000 (401% of poverty) would see their premium payment for the benchmark silver plan, on average, at least double in the vast majority of congressional districts. The benchmark silver premium for a 60-year-old couple at this income would triple or more, on average, in 328 congressional districts.

Premium Increases for Lower-Income Enrollees

A 40-year-old Marketplace enrollee in the contiguous U.S. making $31,000 (206% of poverty) would see monthly premium payments in 2025 rise by $95 (a 165% increase) from $58 to $153. (Alaska and Hawaii have different poverty guidelines). Nationally, there are 75 congressional districts where at least 10% of the population is enrolled in the Marketplace. For a 40-year-old making $31,000, premium payments would at least double on average in all 75 districts. 62 of these districts are in Florida, Georgia and Texas. 38 of these 62 districts are represented by Republicans while 24 are represented by Democrats.

Under the enhanced phase out caps, Marketplace enrollees with incomes up to 150% of poverty currently pay zero (or near zero) dollars for a benchmark silver plan. Should the enhanced subsidies expire, enrollees in this income group will be on the hook for some of the cost of their premiums if they want to keep a silver plan. Before the enhanced subsidies went into effect, Marketplace enrollees at this income group paid about 2-4% of their income for a benchmark plan. A sizeable portion of the Marketplace population benefits from zero dollar premiums, with 42% of HealthCare.gov enrollees in 2024 paying nothing for Marketplace coverage (up from 14% of HealthCare.gov enrollees in 2021).

Methods

These maps visualize the 119th Congressional District boundaries in place for 2025-2026, as of September 2024. County to Congressional District designations are taken from the Missouri Census Data Center GeoCorr 2022 data.

Premium changes displayed for the average scenario are calculated using CMS data on subsidized HealthCare.gov enrollees in 2024. Average premiums by congressional district for income-specific scenarios are calculated using 2025 county-level premiums weighted by 2024 county-level plan selections, which are taken from a combination of CMS files, state-provided data, or estimated using plan selections from prior years when otherwise not available. When a county is part of multiple congressional districts, an allocation factor from the GeoCorr tool is used to apportion county-level plan selections among the congressional districts based on the 2020 decennial census. 2025 county-level premiums are collected from a combination of insurer rate filings, state regulatory authorities, or state shopping tools. Hypothetical premium payments without enhanced subsidies are calculated using indexed required contribution percentages provided by CBO. Premiums used in this map do not account for state-based premium assistance and may not reflect non-essential health benefits.

Enrollment by Congressional District displayed for HealthCare.gov states is taken from CMS data, while estimates are displayed for state-based Exchanges using plan selections for each county allocated to Congressional District using the GeoCorr allocation factor. To calculate the share of people in each Congressional District enrolled in the ACA Marketplace, total Marketplace enrollment is divided by Census estimates of population for the 119th Congressional Districts. For non-HealthCare.gov states, the share of population enrolled in an ACA Marketplace plan may differ from the estimate if population growth diverge from the proportions recorded in the Census.



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A Look at Federal Health Data Taken Offline



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On Friday January 31, 2025, several federal government datasets went offline. The datasets taken down included some widely used, large-scale national health surveys, indices, and data dashboards that inform research, policy making, and media coverage about health care and public health. For example, several Centers for Disease Control and Prevention (CDC) surveys and datasets were offline Friday and Saturday, with messages simply saying the page “was not found.” The homepage of the United States Census displayed an error message, but data.census.gov – where many datasets can be downloaded – was functioning.

By Sunday February 2, 2025, some of the landing pages started to come back online – now with a warning message: “CDC’s website is being modified to comply with President Trump’s Executive Orders,” suggesting there could be future changes. In some cases, survey data files are back online and appear to be intact, but the survey documentation (questionnaires and codebooks), which researchers use to analyze the data files, remained offline. Some related reports also remained offline. It is not yet clear whether all the datasets and their documentation that went offline will come back or remain online, and if they do, what changes, if any, will be made. It also remains to be seen what changes may be made to future data collection efforts.

The removal or modification of these data sources appears to be in response to executive orders issued by President Trump on his first day in office outlining the administration’s perspectives and approach to sex and gender and on racial equity and diversity equity and inclusion (DEI), as well as a pause on foreign assistance. An Office of Personnel Management (OPM) memorandum on the first EO directed departments and agencies to “take down all outward facing media (websites, social media accounts, etc.) that inculcate or promote gender ideology” and “withdraw any final or pending documents, directives, orders, regulations, materials, forms, communications, statements, and plans that inculcate or promote gender ideology.” Another OPM memorandum similarly directed departments and agencies to “Take down all outward facing media (websites, social media accounts, etc.) of DEIA offices”. None of these executive orders nor the OPM memos specifically mention datasets or survey data.

Federal surveys play a key role in the health surveillance system, which helps direct initiatives to address some of the most pressing health conditions and problems facing the country. For example, one of the affected datasets is CDC’s Behavioral Risk Factor Surveillance System (BRFSS), which is one of the most widely used national health surveys and has been ongoing for about 40 years. Datafiles for all years were temporarily offline and as of this writing have been reposted, but without questionnaires or codebooks. BRFSS is described on one federal website as a source of state-level “information about health risk behaviors, preventive health practices, and health care access primarily related to chronic disease and injury.” The survey has been used for decades to inform policymakers, the media, and the public on a wide range of health topics, such as obesity rates, access to breast cancer screenings, vaccination rates, and the share of people with pre-existing conditions. With sampling in every state, BRFSS data are particularly helpful for understanding health issues in low-population states and rural areas.

In reviewing KFF’s archives of the BRFSS core questionnaire, it did not include detailed questions about sexual orientation or gender identity. However, in recent years, BRFSS offered an optional module on sexual orientation and gender identity, which was implemented in most states. This supplemental data has been used by KFF to show that adults who identify as transgender are more likely than cisgender adults to be uninsured, experience depression, and report being in poor health. At the time of this writing, the BRFSS data file is back online and appears to be intact, including the question about gender identity, though the survey documentation is not online.

Another of the datasets taken offline was CDC’s Youth Risk Behavior Survey (YRBS), which, since 1990, has tracked high school students’ behaviors that can influence health and social outcomes, like smoking, drug and alcohol use, and dietary and exercise habits. Like BRFSS, the landing page and associated materials were offline but, as of the time of this writing, have returned without questionnaires or codebooks. This survey is particularly useful because it asks questions to teenagers directly, rather than surveying their parents, who may be unable or unwilling to answer questions accurately. KFF analysis of YRBS data has shown that large shares of teenagers experience persistent sadness and hopelessness, and that teenage girls experienced a sharp rise in suicidal ideation during the pandemic. Recently, the YRBS has asked respondents about their sexual orientation and gender identity, and the data has been used to highlight substantial mental health disparities among LGBTQ+ high school students, compared to their non-LGBTQ+ peers.

Several of the other datasets taken down (at least temporarily) relate to HIV/AIDS in the U.S. as well as global health efforts around the world in low and middle-income countries, including but not limited to:

  • CDC AtlasPlus: an interactive database with about 15 years of surveillance data for HIV, viral hepatitis, STD, and TB, as well as data on the social determinants of health. (Data pertaining to the Ryan White HIV/AIDS Program also remain offline as of this writing, including reports and databases.)
  • PEPFAR Data Dashboards: PEPFAR, the U.S. global HIV/AIDS Program’s comprehensive, up-to-date online data portal of program budgets and expenditures by country and service category, among other variables.
  • Demographic and Health Surveys (DHS) databases: an ongoing set of nationally representative household surveys with population, health, HIV, and nutrition data from more than 90 countries, data downloads.
  • Foreignassitance.gov: The U.S. government’s website with all foreign assistance data by country, budget, expenditure, program, going back more than two decades and created to increase aid transparency (this website is now back online).

Other federal dashboards and indices were also offline, at least temporarily, including but not limited to: Area Health Resource Files (a resource of data on health professionals, hospitals, and economic indicators), CDC’s Social Vulnerability Index (Census-based socioeconomic data used for disaster planning, response and recovery), and the Environmental Justice Index (Census tract-level data used to identify populations facing negative environmental, social and health factors).

While not the focus of this brief, other health information intended for the public has also been removed or changed, which could have implications for access to and receipt of services and other interventions.



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How Does U.S. Life Expectancy Compare to Other Countries?



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Between 2019 and 2022, the U.S. experienced a sharper decline and a slower rebound in life expectancy than peer countries, on average, due to increased mortality and premature death rates in the U.S. from the COVID-19 pandemic. Updated life expectancy estimates in this chart collection show that in 2023, life expectancy in the U.S. returned to pre-pandemic levels, but remains lower than that of comparable countries.

This chart collection examines how life expectancy in the U.S. compares to that of other similarly large and wealthy countries in the Organisation for Economic Co-operation and Development (OECD). The countries included in the comparison are Australia, Austria, Belgium, Canada, France, Germany, Japan, Netherlands, Sweden, Switzerland, and the United Kingdom.

The analysis is available through the Peterson-KFF Health System Tracker, an information hub dedicated to monitoring and assessing the performance of the U.S. health system.



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How Does the Department of Health and Human Services (HHS) Impact Health and Health Care?



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With President Trump now in office, his cabinet nominees continue to testify at congressional hearings as part of the nomination process. Robert F. Kennedy Jr. is the nominee to be the secretary of the Department of Health and Human Services (HHS), and his nomination hearings will spotlight a range of HHS activities but may not touch on the full scope of the department’s responsibilities. To better understand HHS’s impact on the health care system and the American people’s coverage, public health, safety, and well-being, what follows is an overview of the activities of the department.

Overview of HHS

The Department of Health, Education, and Welfare was established in 1953 and evolved into the Department of Health and Human Services in 1980 after the Department of Education was established as an independent entity. A relatively new department of the 15 current executive branch departments, HHS has a Fiscal Year (FY) 2024 budget funding estimated at $1.7 trillion, and the department’s budget is about a quarter of the total FY 2024 U.S. federal budget. It has the largest budget of any federal agency and is the largest grant-making agency.

Most federal executive branch health policy is implemented and managed within HHS, though the White House typically plays a major role in policymaking. The department has 13 operating divisions, most of which have a health focus in areas of coverage, research, regulation, resource delivery, and training. Others are focused on social assistance and support for families and communities in need. More than 80,000 HHS employees are located across the U.S. and the world and half of the workforce is outside the greater Washington, D.C. area.

The Public Health Service (PHS) predates HHS and now exists across ten of the 13 operating divisions within the department:

  • The Administration for Strategic Preparedness and Response (ASPR)
  • The Advanced Research Projects Agency for Health (ARPA-H)
  • The Agency for Healthcare Research and Quality (AHRQ)
  • The Agency for Toxic Substances and Disease Registry (ATSDR)
  • The Centers for Disease Control and Prevention (CDC)
  • The Food and Drug Administration (FDA)
  • The Health Resources and Services Administration (HRSA)
  • The Indian Health Service (IHS)
  • The National Institutes of Health (NIH)
  • The Substance Abuse and Mental Health Services Administration (SAMHSA)

Led by the Assistant Secretary of Health and the U.S. Surgeon General, the more than 6,000 United States Public Health Service Corps work across HHS and several other federal departments in everyday roles involving their health expertise, but they are also the country’s frontline workers for emergency response including public health emergencies.

Health Care Coverage and Affordability

The largest division of HHS is the Centers for Medicare and Medicaid Services (CMS), responsible for administering or overseeing health insurance coverage for Medicare, Medicaid, the Children’s Health Insurance Program, and the Affordable Care Act’s Health Insurance Marketplaces. Together, these programs provide health coverage access to 170 million Americans—more than half the population. However, the impact of HHS on the nation’s health insurance system goes well beyond the programs it administers, as it is heavily involved in the federal regulation of private health insurance, including employer-sponsored health insurance covering more than 150 million people, in conjunction with the Departments of Labor and the Treasury.

Beyond the core health insurance programs CMS administers, HHS also supports access to health care services in several other ways. Community health centers provide primary care and some additional services to low-income and uninsured populations and often serve special populations, e.g., people experiencing homelessness, migratory agricultural workers, and rural residents. HHS has a central role in setting standards and providing significant funding through various sources. HHS also provides medical and public health care to American Indians and Alaskan Natives through a network of providers run or contracted by the Indian Health Service. It has programs addressing the needs of specific populations, including the Ryan White HIV/AIDS program, refugee health, mental health and substance use treatment programs, and maternal and child health, to name a few.

Public Health and Disease Control

The public health role of HHS has been in the spotlight due to the COVID-19 pandemic, but its role during the crisis was based on pre-existing infrastructure and routine activities that adapt to the needs of the day. The department has a long-standing role in monitoring, preventing, and reducing the spread of infectious and non-communicable diseases. Its role encompasses a wide range of responsibilities, including research, screening, policy development and guidance, public education, treatment, and funding for state and local health departments.

Aside from COVID-19, HHS has been active in addressing infectious disease outbreaks of H5N1 avian flu, mpox, and hepatitis A in the past five years and works on long-term challenges like the HIV/AIDS epidemic. The role of HHS in vaccination dates back to the 1950s polio vaccine and it continues to have a substantial role in influencing the country’s vaccine policy.

Emergency Preparedness and Response

The routine health activities of HHS often merge with its role in addressing the health impacts of public emergencies and disasters. Events like the September 11, 2001, terrorist attacks, the opioid epidemic, the Flint, Michigan water crisis, natural disasters of hurricanes, tornadoes, and wildfires, and disease outbreaks have all triggered an HHS response in conjunction with other federal agencies.

HHS has provided emergency coordination and strategic planning to set up shelters for acute medical care and mental health support, sometimes utilizing the National Disaster Medical System, accessed stockpiles of critical equipment and medicine, led investigations and expanded on testing and monitoring activities, and assisted with survivor and community recovery including continuity of health care services.

Food and Drug Safety

Arguably, the broadest touch point for HHS’ impact on Americans’ daily lives is its role in food safety. The Food and Drug Administration (FDA) oversees most food safety aside from meat and poultry and shares responsibility for egg products with the Department of Agriculture. It also regulates the information about dietary supplements provided to consumers, though it does not have authority to approve them for safety and effectiveness. Among the activities related to food safety are conducting inspections of facilities, labeling requirements, issuing food recalls and alerts, and ensuring imported food meets U.S. standards. However, the FDA isn’t the only HHS agency that plays a significant role in food safety, as the Centers for Disease Control’s broad role of monitoring and responding to disease outbreaks also includes those related to consuming contaminated food.

HHS has a major role in regulating medical drugs and devices, mainly through the FDA. This includes pre-market testing for the safety and effectiveness of a product’s intended use, monitoring of approved products for any harm to consumers, and regulations for producing and labeling such products.

Scientific Research and Innovation

HHS, primarily through the National Institutes of Health, is the world’s largest public funder of health research. While the research often conducted can center on the basics of science and biomedicine, it has led to breakthroughs like the first successful polio vaccine, treatments for cancer and HIV/AIDs, the development of MRI technology, and the ability to personalize medicine because of the mapping of the human genome.

Supporting Families and Communities

The health of individuals can be impacted by several non-medical factors often categorized as social determinants of health. HHS has a range of social service programs that may not be typically considered health services, but usually factor in the stability of individual and family lives.

Financial assistance for low-income families with children has long been a federal program, and Temporary Assistance for Needy Families (TANF) is the primary cash assistance program for this population. TANF is administered by the HHS Administration of Children and Families (ACF) which also has programs related to child support enforcement, foster care, adoption, and child care. It also promotes early childhood development in low-income children under the age of five through Head Start.

One element of the department’s support services that has gained significant attention over the past decade, particularly as refugee resettlement submissions to the U.S. have sharply increased, is the array of services offered by the Office of Refugee Resettlement (ORR). Established 45 years ago, ORR aims to integrate individuals, including unaccompanied minors, and families into American society and provide a pathway to self-sufficiency. Services offered include financial assistance, housing, medical care, and employment services.



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Can a new President make health policy changes on ‘Day One?’



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When a new Commander in Chief takes office – and their party also controls both chambers of Congress – how quickly can they make changes to health policy? Is it realistic to think that policy changes can happen on “Day One” of a new administration?

The short answer is that administrations can set changes in motion starting on Day One. But government processes and regulations – including federal rulemaking protocols, court actions, and the legislative process – slow the process of implementing changes and may delay them for months or even years.

If you’re among the more than 24 million people who enrolled in 2025 Marketplace coverage during open enrollment, nothing will change about your coverage or premiums this year, since benefit and premium changes happen at the start of a plan year – January 1 for individual market coverage (barring unforeseen circumstances such as the mid-year carrier exit we saw in a few states in 2023).

How can a President start making changes on ‘Day One?’

An incoming President can sign executive orders, proclamations, and administrative orders starting on their first day in office. In January 2017, President Trump signed four executive orders during his first week in office, and in 2021, President Biden signed 24 executive orders during his first week in office.

These documents do not require the support of Congress or federal agencies, but they can be blocked by the courts. Presidents often use these tools “to set a policy direction. For example, President Trump issued an executive order in 2020 directing the Department of Health and Human Services (“HHS”) and Congress to reach a solution to protect consumers from surprise balance billing, and legislation addressing that matter was enacted later that year. But executive orders are also much easier to undo than legislation, since they can be reversed by an incoming president just as easily as they were implemented.

An example of a health policy presidential proclamation is the immigrant health coverage proclamation that President Trump signed in 2019, although this was blocked by a court before it took effect and later revoked by President Biden.

Executive orders can be used to guide federal agencies, and are often cited by those agencies when they issue proposed rulemaking.

How quickly can a President make policy changes through federal rulemaking?

A president’s administration may also make policy changes through federal rulemaking, which plays an important role in setting health policy in the United States. For example, numerous sections of the Affordable Care Act (ACA) direct the Secretary of Health & Human Services to set rules and guidelines for the implementation of its provisions. These rules can evolve over time, as we’ve seen with ACA Section 1557 implementation.

But federal rulemaking is not an overnight process. Federal agencies must publish proposed rulemaking in the Federal Register and accept public comments for at least 30 days before considering those comments and then publishing a final rule.

The Centers for Medicare & Medicaid Services (CMS), which oversees Medicare, Medicaid, and Marketplace health coverage, typically keeps the comment period open for at least 60 days. And the effective dates for final rules must be at least 30 days after they’re finalized (at least 60 days after finalization for “significant” and “major” rules).

This is why it’s not a quick process for administrations to make regulatory changes. For example, consider the changes we’ve seen over the years regarding short-term health insurance:

  • The Obama administration proposed new short-term coverage rules in June 2016, finalized them in October 2016, and they took effect in January 2017, with enforcement delayed until April 2017 – more than 10 months after the proposal.
  • The Trump administration proposed new short-term coverage rules in February 2018, finalized them in August 2018, and they took effect in October 2018 – more than seven months after they were proposed.
  • The Biden administration proposed new short-term coverage rules in July 2023, finalized them in March 2024, and they took effect in September 2024 – over a year after the proposal.

What types of health insurance policy changes are possible via rulemaking?

One important aspect of federal rulemaking related to the ACA happens each year, with the annual Notice of Benefit and Payment Parameters (NBPP).

The NBPP, which is hundreds of pages long, can be used for a wide range of changes that affect the health insurance Marketplaces. These include the length of open enrollment, access to special enrollment periods, user fees that insurers are charged to offer coverage via HealthCare.gov, rules for enhanced direct enrollment entities, setting guidelines for 1332 waiver proposals, rules and duties for Navigators, and many others.

Here’s a summary of some of the changes implemented by the 2025 NBPP.

The Biden administration published the proposed 2026 NBPP in October 2024, and finalized it in January 2025, in the waning days of the administration. But the incoming administration may make additional changes.

We saw this in 2021, with the 2022 NBPP: The outgoing Trump administration published the 2022 NBPP in January, finalizing some aspects of their proposed rule. Then the Biden administration issued a “Part Two” 2022 NBPP a few months later, and subsequently proposed additional rulemaking for 2022, which was finalized in September 2021.

Separate invoices for coverage of abortion. The federal rulemaking process could be used to require Marketplace insurers to issue separate premium invoices for abortion coverage. A rule requiring this was finalized under the first Trump administration, but later overturned by a judge and repealed by the Biden administration.

DACA eligibility for Marketplace enrollment. The federal rulemaking process could also be used to make changes to the Biden administration’s May 2024 rule that allowed DACA recipients to begin using the health insurance Marketplace in November 2024. This rule has already been challenged in court and DACA recipients are unable to use the Marketplace in the 19 states that challenged the rule.

Additional legal challenges are possible, but a change to the federal rule itself is also possible under a new administration.

It’s also important to note that even after the federal rulemaking process is complete, the resulting rules can also be challenged in court. During the first Trump administration, there were 246 legal challenges to federal regulations, guidance documents, and agency memoranda. More than three-quarters of these cases resulted in either the court ruling against the federal agency, or the agency withdrawing the action due to the lawsuit.

Funding for cost-sharing reductions (CSR). In October 2017, the Trump administration announced that they were cutting off funding for Marketplace cost-sharing reductions (CSR), effective immediately. The immediate effective date was unusual, but this stemmed from a lawsuit in which GOP lawmakers had argued that Congress had never allocated CSR funding.

Federal funding for CSR did cease immediately, but eligible Marketplace enrollees continued to receive CSR benefits. Insurers in most states added the cost of CSR to the premiums for Silver plans (CSR benefits are only available on Silver plans). Premium subsidy amounts are based on the cost of the second-lowest-cost Silver plan, so the increased Silver plan premium resulted in larger premium subsidies for most enrollees, and this continues to be the case.

Medicaid waivers. Medicaid waivers, including 1115 waivers, allow states to customize their Medicaid programs within various requirements and guardrails set by the federal government.

Medicaid waiver proposals are approved by CMS on a case-by-case basis, and the last two presidential administrations have taken very different approaches to this.

Examples of Medicaid changes that could be made with a new administration’s approach to 1115 waivers include work requirements or premiums for some enrollees. But just like federal rule changes, the Medicaid waiver approval process includes a public comment period and a federal review period, so these are not changes that could be put into effect overnight.

Is it possible for Congress and a President to overturn a predecessor’s rule quickly?

In most cases, a new administration has to go through the regular notice-and-comment rulemaking process to undo a regulation put in place by a previous administration. As described above, the evolving rules for short-term health insurance are an example of this.

But the Congressional Review Act (CRA) gives Congress and the President the ability to overturn a rule within 60 days of it being published in the Federal Register.

So a CRA resolution passed by Congress and signed by the President could be used to overturn rules that were finalized in the last several weeks of the Biden administration. The CRA, enacted in 1996, has previously been used to overturn 20 rules.

How can one-party control of the White House and Congress speed policy changes?

With one-party control of the White House and Congress, legislative action on health policy is certainly possible. In addition to the aforementioned CRA process for overturning federal agency rules, the regular legislative process could be used to make changes to existing laws or enact new laws.

This would be necessary, for example, to make sweeping changes to the ACA, or to change the Inflation Reduction Act’s provisions regarding Medicare drug coverage.

Members of the newly sworn-in Congress have circulated a “menu of potential spending reductions for members to consider,” which includes Medicaid per-capita caps and work requirements, repealing the ACA’s Prevention and Public Health Fund, funding cost-sharing reductions (as noted above, de-funding CSR has resulted in higher government spending on premium subsidies), and repealing “major Biden health care rules.”

But significant healthcare legislation would tend to have an effective date months or even years in the future, to give insurers, patients, and medical providers time to adapt. For example, consider the American Health Care Act (AHCA), a partial ACA repeal bill that passed the House in 2017 but failed in the Senate.

The AHCA would have ended the enhanced federal funding that states get for Medicaid expansion under the ACA, but not until 2020. And it would also have replaced the ACA’s income-based Marketplace premium tax credits with age-based fixed dollar tax credits, but not until 2020.

In summary, a new administration and Congress can make numerous changes to health policy. But while the process can begin immediately, the implementation of changes will generally be delayed by months or even years, depending on the policy.


Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org.





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As Congress Looks to Reduce Federal Spending, Medicare and Medicaid Remain Broadly Popular, and At Least Twice as Many People Want to Increase Spending Rather Than Cut It



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With the incoming Trump administration and Republican-led Congress looking to ways to reduce federal spending, a new KFF Health Tracking Poll finds that the Medicare and Medicaid programs remain broadly popular, and more people favor more spending on those programs than less spending.

About eight in 10 Americans overall view Medicare (82%) and Medicaid (77%) favorably. This includes majorities across partisans, including most Republicans (75% view Medicare favorably and 63% view Medicaid favorably).

About half (46%) of the public say the federal government doesn’t spend enough on Medicaid, more than twice the share (19%) who say the government spends “too much.” The gap is even larger for Medicare, with half (51%) of the public saying the government doesn’t spend enough compared to 15% who say the government spends too much.

The Affordable Care Act (ACA), sometimes called Obamacare, also remains popular, with nearly two thirds (64%) of the public holding favorable views, though with more of a partisan divide. Most Democrats and independents hold favorable views of the ACA, while about three quarters of Republicans (72%) hold unfavorable views.

Large majorities also say they are “very” or “somewhat” worried that people covered by each of the three programs in the future won’t get the same benefits available today. This includes 81% who say so about Medicare, 72% who say so about Medicaid, and 70% who say so about the ACA marketplaces. Republicans are less worried than other partisans about Medicaid and the ACA.

Ahead of President Trump’s inauguration, the poll also assesses how the public prioritizes 11 potential actions on health that the new administration and Congress could take.

About six in 10 say that boosting price transparency rules (61%) and limiting chemicals in the food supply (58%) are both a “top priority.” This includes majorities of Republicans, independents and Democrats.

During his first administration, President Trump issued federal regulations establishing price transparency requirements for hospitals and insurers, and Robert F. Kennedy Jr., his pick to head the U.S. Department of Health and Human Services, has long advocated against chemicals in food.

In contrast, few among the public rank several other health policies associated with President Trump and his allies as top priorities.

For example, about one in seven say that reducing federal spending on Medicaid (13%) or limiting access to abortion (14%) is a top priority, while much larger shares say each of these “should not be done” (44% and 51%, respectively). Other low-ranking priorities include cutting funding to schools that require students to get vaccinated (15%), encouraging communities not to add fluoride to their water supply (23%), and repealing and replacing the ACA (27%).

Among other health priorities:

  • Medicare drug price negotiations. More than half (55%) of the public say it is a top priority to expand the number of prescription drugs subject to Medicare drug price negotiations, including most Democrats (65%) and about half of Republicans (48%). Only 3% say this shouldn’t be done.
  • Regulating insurance claim denials. Most people (55%) say more closely regulating insurers’ decisions to approve or deny claims for health services or prescription drugs should be a top priority. This includes most Democrats (61%) and independents (59%), along with nearly half (45%) of Republicans. Overall, just 5% oppose this.
  • Enhanced ACA subsidies. About a third (32%) say that extending the expanded financial assistance that helps make ACA marketplace health insurance affordable should be a top priority. This includes half of Democrats (50%) but few Republicans (16%). Only 7% say this shouldn’t be done.

The incoming Trump administration has established a new “Department of Government Efficiency,” or DOGE, charged with developing plans to cut federal spending and reduce regulations.

Most Americans (73%) say that reducing fraud and waste in government health programs would lead to “major” or “minor” reductions in federal spending overall. This includes most Republicans (80%), independents (72%), and Democrats (68%).

At the same time, more than half (55%) of the public also say that reducing fraud and waste would lead to reductions in the benefits that people receive from government health programs. At least half of Republicans (60%), Democrats (55%), and independents (51%) hold this view.

Other findings include:

  • Most of the public say the government is not spending enough on the prevention of chronic diseases (60%) or prevention of infectious diseases and preparing for future pandemics (54%). Much smaller shares say the government spends “too much” on each of these.
  • More than half (57%) of the public say they expect health care to become less affordable for their families over the next few years. This includes most (54%) Trump voters and half (51%) of Republicans despite the campaign’s emphasis on addressing rising costs, including in health care.

Designed and analyzed by public opinion researchers at KFF. The survey was conducted Jan. 7-14, 2025, online and by telephone among a nationally representative sample of 1,310 U.S. adults in English and in Spanish. The margin of sampling error is plus or minus 3 percentage points for the full sample. For results based on other subgroups, the margin of sampling error may be higher.



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KFF Health Tracking Poll: Public Weighs Health Care Spending and Other Priorities for Incoming Administration



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Key Findings

  • Both Medicare and Medicaid continue to be viewed favorably by large majorities of the public, including majorities of Republicans, Democrats, and independents. While lawmakers are discussing changes to Medicaid and Medicare including possible spending cuts, about half of the public think the federal government isn’t spending enough on each of these programs. Half (51%) say the federal government spends “not enough” on Medicare, and nearly half (46%) say the same about the Medicaid program. Across both programs, the share of the public who say the government isn’t spending enough is more than twice the share who say the government is spending “too much.”
  • The latest KFF Health Tracking Poll also shows bipartisan consensus for some health policy priorities for the new presidential administration and Congress, especially around oversight and regulation. Majorities of the public – including about half or more across partisans – say boosting health care price transparency rules (61%), setting stricter limits on chemicals found in food supply (58%), and more closely regulating the process used by health insurance companies when they approve or deny services or prescription drugs (55%) should be a “top priority” for the incoming administration and Congress. Expanding the number of prescription drugs that the federal government negotiates the Medicare price on is also ranked as a “top priority” by a majority of the public including two-thirds of Democrats, 54% of independents, 48% of Republicans and three-fourths of people who are currently enrolled in Medicare.
  • While the public is largely in-line with some of the administration’s potential health care priorities, other possible policy actions are seen as lower priorities, and in some cases, larger shares of the public say they “should not be done.” The public is divided on whether the administration should prioritize recommending against fluoride in local water supplies, with the same share saying it should be a “top priority” (23%) as say it “should not be done” (23%). In addition, less than one in eight adults (including fewer than a quarter of Republicans) say reducing federal funding to schools that require vaccinations (15%), limiting abortion access (14%), or reducing federal spending on Medicaid (13%) should be a “top priority,” while at least four in ten say each of these “should not be done.”
  • Nearly two-thirds of adults (64%) hold a favorable view of the 2010 Affordable Care Act (ACA), but views on the future of the law are still largely partisan. Four in ten Republicans (40%) say repealing the legislation should be a top priority, while half of Democrats (50%) say extending the enhanced subsidies for people who buy their own coverage should be a top priority. Overall, most of the public is worried about the level of benefits for people who buy their own coverage through the ACA marketplaces including nearly nine in ten Democrats (86%), nearly eight in ten independents (78%), and nearly half of Republicans (47%).
  • Overall, about three-fourths (73%) of the public thinks that reducing fraud and waste in government health programs could lead to reductions in overall federal spending – which is the goal of Trump’s newly formed government efficiency program, but many also think it will result in a reduction of benefits. More than half of the public say reducing fraud and waste could lead to reductions in the benefits people receive from the Medicaid and Medicare programs.

Public’s Health Care Priorities

As President-elect Trump takes office on January 20th with Republican majorities in both chambers of Congress, the public is sending mixed messages on how they prioritize key components of the Trump administration’s health agenda. While Americans across partisanship largely embrace prioritizing increased regulation and oversight such as boosting price transparency rules and setting stricter limits on chemicals in the food supply, there are other aspects of the Republican agenda the public does not support – most notably, reducing federal funding to Medicaid.

When asked about a variety of health care proposals, including those put forth by Republican and Democratic lawmakers, about six in ten say boosting price transparency rules to ensure health care prices are available to patients (61%) should be a “top priority,” and a similar share say the same about setting stricter limits on chemicals found in the food supply (58%). A majority (55%) also say more closely regulating the process used by health insurance companies when they approve or deny services or prescription drugs is a top priority. Overall, while health care ranks lower than other policy areas such as immigration, foreign policy, and the economy; majorities of the public – including half or more across partisanship – say each of these should be a “top priority” for Congress and the new Trump administration.

When it comes to proposed changes to two key health care legislations: the Inflation Reduction Act’s provisions to allow the federal government to negotiate the Medicare price of prescription drugs as well as the 2010 Affordable Care Act (ACA), larger shares of the public support actions to expand or strengthen these laws rather than repealing them. More than half of the public (55%) say expanding the number of prescription drugs subject to Medicare price negotiation should be a top priority, twice the share who prioritize rolling back this provision (28%). On the ACA, about a third (32%) prioritize extending the enhanced subsidies for people who buy their own health coverage while a quarter of the public (27%) say repealing and replacing the ACA is a top priority.

Other health care issues, many of which may be the focus of the Trump administration, are seen as even lower priorities for the incoming administration with substantial shares of the public saying they “should not be done.” Less than a quarter of the public think changing recommendations for fluoride in local water supplies (23%) should be a “top priority,” which is identical to the share who say it should not be done. Less than one in eight say reducing federal funding to schools that require vaccinations (15%), limiting abortion access (14%), and reducing federal funding on Medicaid (13%) should be top priorities. At least four in ten of the public say each of these “should not be done” by Congress or the Trump administration.

Some Bipartisan Agreement on Health Care Priorities, but Views on ACA Are Highly Partisan

Robert F. Kennedy Jr., President Trump’s choice for head of the Department of Health and Human Services has long touted the need for a complete overhaul of U.S. food policy including cracking down on ultra-processed foods and food dyes. This focus on limiting chemicals in the public’s food supply is echoed in the public’s list of top health care priorities, with majorities across partisans saying it should be a top priority for the new Trump administration and Congress. More than half of Republicans (61%), independents (56%), and Democrats (55%) say setting stricter limits on chemicals in the food supply should be a “top priority” for Congress or the Trump administration.

Majorities of Democrats and independents also say oversight – both boosting price transparency rules to ensure health care prices are available to patients and more closely regulating health insurance companies’ approval or denial of care – should be a top priority for lawmakers. This increased oversight on hospital pricing and insurance companies is also seen as a priority among large shares Republicans (56% and 45%, respectively). Partisans also hold similar views on whether expanding the number of drugs subject to Medicare price negotiation should be a priority, with about half of Republicans (48%) saying this should be a “top priority,” as do nearly two-thirds of Democrats (65%).

There is also bipartisan agreement on what shouldn’t be a top health care priority for lawmakers. Few Democrats, independents, or Republicans think the incoming administration should prioritize changing recommendations for fluoride in local water supplies, reducing federal funding to schools that require vaccinations, limiting abortion access, or reducing federal funding for Medicaid.

On the other hand, views on the future of the 2010 Affordable Care Act continue to be partisan. Repealing the ACA continues to rank as a priority for Republicans (40% say it is a “top priority” in the most recent tracking poll), but it has dropped as priority among the total public (down 10 percentage points), and among Republicans specifically (down 23 percentage points), since the start of the first Trump administration. Democrats, on the other side of the political aisle, are more likely to prioritize extending the Biden-era enhanced ACA marketplace subsidies. Half of Democrats say this should be a “top priority” compared to just about one in six Republicans.

Many Americans Expect Their Health Costs To Continue Increasing

Throughout the 2024 presidential campaign, voters consistently said they were most interested in electing a candidate who could reduce their health care costs. President Trump largely capitalized on voters’ economic concerns and his own record to convince voters that he was the candidate most adept at taking on the high cost of health care. Yet, few Americans now expect health care costs for them and their family members to become more affordable over the next few years. In fact, more than half (57%) of the public – including 54% of Trump voters – say they expect the cost of health care to become “less affordable.” Majorities of Democrats (60%), independents (59%), as well as half of Republicans (51%) all expect health care costs for them and their family members to become less affordable in the coming years.

Public Largely Holds Favorable Views of Government Health Programs

With the Trump administration’s focus on tax cuts and border security, House Republicans have been coming up with plans to pay for these which may include reducing spending on government health programs such as Medicare, Medicaid, and the Affordable Care Act. Yet, changes to these programs may run up against public sentiment according to the latest KFF Tracking Poll.

KFF has asked the public about their attitudes about both Medicaid and Medicare for more than two decades, and these two programs continue to be overwhelmingly popular among the public. In the most recent poll, about eight in ten (82%) Americans hold favorable views of Medicare and more than three-fourths (77%) hold favorable views of Medicaid.

Medicare, the federal government health insurance program for adults 65 and older and some younger adults with disabilities, has maintained favorability among eight in ten adults for nearly a decade. In the January KFF Health Tracking Poll, the share who say they view the program favorably includes three-fourths of Republicans (75%) and more than eight in ten independents (84%), and Democrats (90%). This also includes 94% of the individuals who are currently enrolled in the Medicare program.

Similarly, Medicaid, the federal-state government health insurance program for certain low-income individuals and long-term care program, is also very popular with three-fourths of adults (77%) holding favorable views, including six in ten Republicans (63%), and at least eight in ten independents (81%) and Democrats (87%). Medicaid is also popular among those enrolled in the program with 84% saying they view the program favorably.

Notably, both programs are also viewed favorably by a majority of voters who say they voted for President Trump in the 2024 election.

While lawmakers are discussing changes to these programs including significant cuts to Medicaid, about half of the public actually think the federal government isn’t spending enough on either of these programs. About half of the public (51%) say the federal government spends “not enough” on Medicare, while one-third say the government spends “about the right amount” and about one in seven (15%) say the government spends “too much.” A majority of Democrats (60%) and pluralities of independents (49%) and Republicans (43%) say the federal government doesn’t spend enough on Medicare.

Nearly half (46%) say the federal government doesn’t spend enough on the Medicaid program, with another third saying it spends “about the right amount” and around one in five (19%) saying it spends “too much.” While most Democrats (62%) say the federal government doesn’t spend enough, Republicans are a bit more divided with about similar shares of Republicans saying the government spends “too much” (34%), “not enough” (32%), or “about the right amount” (33%) on Medicaid.

The Affordable Care Act, the Obama-administration health insurance program that was a frequent target of the first Trump administration, also continues to be popular – although to a somewhat lesser degree than Medicaid or Medicare. Nearly two-thirds of the public (64%) view the 2010 ACA favorably while less than four in ten (36%) say they hold an unfavorable view of the law. The share of the public who views the law unfavorably continues to be largely made up of Republicans, with about three-fourths (72%) saying they have an unfavorable view. ACA favorability increased substantially during the 2017 repeal efforts, and has maintained majority support throughout the past four years of the Biden administration.

With possible changes to all three government health programs, the public is worried that people covered by each of these programs in the future will not be able to get the same level of benefits that are available today. About eight in ten (81%) say they are either “very worried” or “somewhat worried” that Medicare enrollees will not get the same level of benefits in the future. This includes more than eight in ten (82%) individuals who are currently covered by the program as well as about nine in ten adults (88%) who will be eligible for the program in the coming years, those between the ages of 50 and 64.

In addition, seven in ten are worried about the level of benefits that will be available to people covered by Medicaid (72%) and people who buy their own coverage through the ACA marketplaces (70%). Both Medicaid and the ACA have repeatedly been discussed as possible focuses of the incoming Trump administration and Congressional Republicans.

Many Think Federal Government Isn’t Spending Enough on Public Health

As the Trump administration is balancing spending priorities, the public thinks the government isn’t spending enough on many facets of public health, including both the priorities of RFK Jr, Trump’s pick to lead HHS, and the priorities of Congressional Republicans.

Most of the public says the government is spending “not enough” on the prevention of chronic diseases (60%) or prevention of infectious diseases and preparing for future pandemics (54%). More than four in ten said the government was spending “not enough” (45%) on biomedical research, while 38% said it was spending “about the right amount.” Smaller shares say the federal government is spending “too much” on each of the key health priorities asked about.

Public Thinks Government Efficiency Could Decrease Federal Spending, but Worries Efforts May Reduce Benefits

One of the Trump administration’s promises has been to cut excessive government spending, including reducing fraud and waste across various sectors of the government. As the newly-formed “Department of Government Efficiency” or DOGE begins work, the public is concerned about the impact that government efficiency efforts will have on people who get their health insurance through Medicare or Medicaid.

Overall, the public thinks that reducing fraud and waste in government health programs could lead to reductions in overall federal spending – which is the goal of the government efficiency program, but many also think it will result in a reduction of benefits. Four in ten say reducing fraud and waste in government health programs could lead to “major reductions” in federal spending with an additional third (32%) saying it could lead to “minor reductions.” This includes majorities across partisans (80% of Republicans, 68% of Democrats, and 72% of independents) who say reducing fraud and wasted could reduce overall federal spending.

Yet, more than half (55%) of the public also say reducing fraud and waste could lead to reductions in the benefits people receive from the programs. More than a quarter (28%) of the public say that reducing fraud and waste will lead to “major reductions,” with an additional quarter who say it will lead to “minor reductions” in benefits. Once again, more than half across partisans (60% of Republicans, 55% of Democrats, and 51% of independents) say that reducing fraud and waste will lead to reduced benefits.

The public is largely divided on whether the incoming Trump administration’s proposed efforts to improve government efficiency will have a negative or positive impact on people who get health coverage through Medicare or Medicaid. Similar shares say the impact will be “mostly negative” (43%) and “mostly positive” (41%), while 15% say there won’t be any impact. Views of the impact are highly partisan, with large majorities of Democrats (78%) saying there will be a mostly negative impact, and most Republicans (80%) say there will be a mostly positive impact. Independents are more divided, but a larger share say there will be a mostly negative impact (43%).



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How sunsetting ARP’s subsidy enhancements would affect ACA subsidy amounts



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What will happen to Marketplace health insurance subsidy availability – and subsidy size – when the subsidy enhancements instituted under the American Rescue Plan (ARP) and extended by the Inflation Reduction Act (IRA) sunset after 2025? It’s a question that health reform experts and media who cover health reform have been asking as political control of the White House and Congress is about to shift in 2025.

To get an idea of how sunsetting the subsidy enhancements would impact subsidy eligibility and subsidy size, we looked at states with the highest average pre-subsidy Marketplace premiums, which in turn have among the largest subsidies. We found some examples of how premium subsidy amounts would decrease or be eliminated entirely when the ARP’s subsidy enhancements expire at the end of 2025 – unless Congress acts to further extend the enhancements.

How have ARP’s subsidy enhancements affected eligibility for Marketplace premiums?

Enrollment in the health insurance Marketplaces hit an all-time high for plan year 2024, with more than 21 million people signing up for private Marketplace plans during the open enrollment period for 2024 coverage. The record high enrollment, along with earlier record highs set in 2022 and 2023, was driven in part by the premium subsidy enhancements that were put in place by the American Rescue Plan and extended through 2025 by the Inflation Reduction Act (IRA).

Of the nearly 21 million people who had effectuated Marketplace coverage as of early 2024, 93% were receiving advance premium tax credits (subsidies) that offset some or all of their monthly premiums. The federal government noted that as a result of the IRA’s extension of the ARP’s subsidy enhancements for an additional three years, four out of five people who enrolled through HealthCare.gov had access to plans with after-subsidy premiums of $10 or less per month in 2024.

But the ARP subsidy enhancements are scheduled to sunset at the end of 2025 unless they’re extended again by Congress. When the subsidy enhancements end, Marketplace subsidy amounts will decrease for everyone who receives them – and will disappear altogether for some enrollees. Let’s take a look at why this would happen, and how enrollees in some states would be affected:

ACA subsidy rules prior to ARP

When the subsidy enhancements sunset at the end of 2025, the rules will revert – starting in 2026 – to the subsidy rules set by the ACA. Here’s how the ACA premium subsidy rules worked prior to the ARP:

  • Subsidies were available if household income was at least 100% of the federal poverty level (FPL), or more than 138% FPL in states that had expanded Medicaid eligibility under the ACA. However,
  • Subsidies were not available if household income was more than 400% FPL, regardless of the percentage of income a household would have to spend to buy coverage. This resulted in a subsidy cliff at 400% FPL.
  • For subsidy-eligible enrollees, the subsidy amount was based on the enrollee having to pay a certain percentage of their household income for the benchmark plan (second-lowest-cost Silver plan). That percentage varied with household income, and ranged between roughly 2% and 9.5% of household income. (This is called the “applicable percentage” and the range was indexed each year by the IRS.)

Temporary subsidy enhancements under the ARP and IRA

Now let’s take a look at how the ARP temporarily changed these rules, and how the IRA extended those changes through 2025:

  • The lower income threshold for premium subsidy eligibility did not change.
  • But the 400% FPL cap on subsidy eligibility was temporarily eliminated, so we haven’t had a subsidy cliff for the last few years. Instead, people with household income over 400% FPL are eligible for subsidies if the cost of the benchmark plan is more than 8.5% of their household income. (This assumes they meet other subsidy eligibility requirements, including not having access to Medicaid, premium-free Medicare Part A, or an employer’s plan that’s considered affordable and provides minimum value.)
  • For subsidy-eligible enrollees, the percentage of household income that the enrollee has to pay for the benchmark Silver plan has been reduced across the board. Instead of ranging from 2% to 9.5% of household income, it now ranges from 0% to 8.5% of household income. And again, that now applies to households with income above 400% FPL.

So the ARP subsidy enhancements, extended by the IRA, had two major effects:

  • They allow Marketplace enrollees with household income above 400% FPL to potentially qualify for premium subsidies.
  • They reduced the percentage of income that people pay for the benchmark plan at all income levels.

For example, under the original ACA rules, a person earning 150% FPL would pay 4% of their income for the benchmark plan, and their subsidy would cover the rest.

But under ARP rules, a person earning 150% FPL pays 0% of their income for the benchmark plan. Their subsidy covers the entire cost of the premium.

We won’t know the 2025 FPL numbers (used to determine subsidy eligibility in 2026) until early 2025. And we also don’t yet know what the exact applicable percentage range would be for the 2026 plan year when the ARP subsidy enhancements sunset, as the IRS will have to calculate and publish those numbers. But it will be roughly in the range of 2% to 9.5%, with subsidies ending altogether at above 400% FPL. (To clarify: from 2015 through 2020, the range had increased four times and decreased twice. As of 2020, it stood at 2.06% to 9.78%.)

Subsidies disappear for people with household incomes over 400% FPL

The return of the subsidy cliff would be particularly significant for older enrollees, since full-price premiums are based on age. (In almost all states, a 53-year-old will pay roughly twice as much as a 21-year-old, and a 64-year-old will pay three times as much as a 21-year-old.)

It would also be particularly significant in areas where health insurance is more expensive than average. since the full premium would have to be paid by enrollees if their household income is over 400% FPL. (The national average pre-subsidy Marketplace premium in 2024 was about $603/month, but as we’ll discuss in a moment, some states have much higher averages.)

To illustrate this, let’s look at the ten states where average full-price Marketplace premiums were the highest for plan year 2024. We’ll consider a 55-year-old in each of those states, earning 405% of the 2024 FPL, which is used to determine subsidy eligibility for 2025. These enrollees are eligible for significant premium subsidies in 2025, as shown in the table below:

State Avg. 2024 premium for people enrolled in Marketplace plans Total enrollment 400% FPL enrollment % of enrollees above 400% FPL 2025 subsidy for 55-year-old based on ZIP, earning 405% FPL ZIP code for largest population in state Avg. 2024 net premiums across all Marketplace enrollees in state Net 2025 premium for benchmark plan (age 55 earning 405% FPL),,,,
WV $1,122 51,046 5,068 10% $1,204/month 25301 $108 $432
AK $972 27,464 5,192 19% $1,229/month 99501 $222 $557
WY $939 42,293 7,691 18% $1,001/month 82001 $108 $431
CT $896 129,000 26,500 21% $863/month 06601 (Fairfield) $230 $435
VT $874 30,027 5,637 19% $844/month 05401 $237 $431
DE $725 44,842 6,901 15% $500/month 19801 $188 $431
NY $721 288,681 40,992 14% $449/month 10001 $422 $432
ME $714 62,586 9,811 16% $477/month 04019 $223 $433
LA $714 212,493 12,681 6% $392/month 70032 $82 $432
AL $706 386,195 13,787 4% $600/month 35649 $64 $432

When the ARP subsidy enhancements sunset at the end of 2025, these individuals would not be eligible for any premium subsidies starting in 2026, assuming their 2026 household income is more than 400% of the 2025 FPL. So they could potentially go from receiving hundreds of dollars per month in subsidies in 2025 to receiving no subsidies at all in 2026. To continue to have coverage, they would have to pay the full premium amount.

These enrollees are not hypothetical. Across all Marketplace enrollees nationwide, the 55-64 age group has the highest total enrollment, with 5.1 million enrollees in 2024. And the next-closest age group is 45-54, with 4.1 million enrollees.

And out of the 21.4 million people who selected Marketplace plans during the open enrollment period for 2024 coverage, 1.5 million reported incomes above 400% FPL. The chart above illustrates the percentage of enrollees in each state whose income is over 400% FPL. In eight of the ten states, this population accounts for at least 10% of Marketplace enrollment.

For everyone else, subsidies would get smaller

In addition to the return of the subsidy cliff for households earning more than 400% FPL, it’s important to understand that a return to the pre-ARP ACA subsidy rules would also result in smaller subsidies for everyone who continues to be subsidy-eligible. This is because at all income levels, people would have to pay a larger percentage of their income to purchase coverage.

Let’s consider a 45-year-old in Chicago who earns about $45,000 in 2025, or about 300% FPL. If this person enrolls in 2025 Marketplace coverage under the current enhanced subsidy rules, they will qualify for a subsidy of $227/month, and will have to pay $224/month in after-subsidy premiums to purchase the benchmark Silver plan. Their after-subsidy premiums amount to about 6% of their household income, as called for in the ARP applicable percentage table.

But if the pre-ARP ACA subsidy rules were in place for 2025 instead, this person would have to pay roughly 9.5% of the household income for the benchmark plan. (Without the ARP subsidy enhancements extended by the IRA, the applicable percentage would have been indexed by the IRS, but it would have been close to 9.5%.) That would have amounted to about $356/month in after-subsidy premiums, instead of the $224/month that the aforementioned Chicagoan is paying under the ARP subsidy enhancements.

The Biden-Harris administration has noted that the ARP subsidy enhancements, and their extension by the IRA, resulted in not only record-high enrollment, but also an increase in the number of people who upgraded their Marketplace coverage from Bronze to a higher metal level. This makes sense, since the larger subsidies allowed people to buy more expensive coverage without increasing their net premiums.

Without the ARP subsidy enhancements, the Congressional Budget Office projects that Marketplace enrollment will drop from 22.8 million in 2025 to 18.9 million in 2026. And while millions of people will continue to have Marketplace coverage, it stands to reason the plan upgrades in response to the subsidy enhancements could reverse, with people opting to downgrade their coverage to keep the premiums affordable.

Will the subsidy enhancements sunset?

Unless new legislation is enacted, the APR subsidy enhancements will sunset at the end of 2025. Insurers will submit their proposed 2026 rates and plans to state and federal regulators starting in the spring of 2025. So Congress would need to act before then – likely before March 31, 2025 – to avoid a scenario in which insurers are basing their rates on the lower enrollment and less-healthy risk pool that would be expected when the subsidy enhancements sunset.

The Congressional Budget Office projects that without the ARP subsidy enhancements, gross premiums for the benchmark (second-lowest-cost Silver) plan would increase by an average of 4.3% in 2026.


Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org.





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How has U.S. Spending on Health Care Changed Over Time?



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This chart collection explores National Health Expenditure (NHE) data from the Centers for Medicare and Medicaid Services (CMS). These data offer insights into changes in health spending over time in the U.S., as well as the driving forces behind spending growth. The data specifically show how healthcare spending changed in 2023. A related interactive tool contains more of the latest NHE data.

The slideshow is part of the Peterson-Kaiser Health System Tracker, an online information hub dedicated to monitoring and assessing the performance of the U.S. health system.



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National Health Spending Explorer | KFF



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Now updated with 2023 data, the National Health Spending Explorer on the Peterson-KFF Health System Tracker provides up-to-date information on U.S. health spending by federal and local governments, private companies, and individuals. It was developed by KFF using data from the National Health Expenditure Account and will be updated annually with each data release.

A short video tutorial provides instructions for the tool.

A partnership of KFF and the Peterson Center on Healthcare, the Peterson-KFF Health System Tracker is an online information hub dedicated to monitoring and assessing the performance of the U.S. health system.



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