Obamacare sets record sign-up total again. Will it last?

Fate of expanded subsidies unclear after 2025

NEW BERLIN, Wis. — 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 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 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 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 US health care system.

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 subsidies 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 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.