Jan 31, 2022 - Health

ACA enrollment soars, and faces a perilous fall

Illustration of the US Capitol building with a caduceus on top.

Illustration: Shoshana Gordon/Axios

Democrats are touting record Affordable Care Act enrollment, but a lot of those gains will be wiped away next year unless Congress takes action.

Why it matters: Millions of Americans have taken advantage of the enhanced ACA subsidies Congress passed into law last year, with many enrolling in health insurance for the first time. But under the status quo, that more generous coverage is going to expire at the end of 2022 — and people will be notified right before the midterm elections.

The big picture: When Democrats' coronavirus response bill last year expanded the amount of ACA premium subsidy assistance available to millions of low-income Americans, it also made more middle-income Americans eligible for premium help.

  • That led to a 21% spike in enrollment year over year, totaling 14.5 million. If you include other special ACA plans in New York and Minnesota, total enrollment is closer to 15.5 million people, according to marketplace tracker Charles Gaba.

State of play: An extension of the enhanced subsidies was included in Democrats' Build Back Better legislative package. But that's stalled in the Senate, and it's unclear which pieces — if any — will make it into law.

  • Unlike the other health care components of the package, the subsidy extension prohibits the loss of a benefit and, subsequently, higher costs for Americans. The other pieces were designed to provide new benefits or lower costs.
  • That makes inaction on the subsidies sting worse for enrollees — and a big political risk for Democrats.

Between the lines: This isn't exactly the taste Democrats want in voters' mouths as they head to the polls.

  • "Democrats would be facing all kinds of negative news about their signature domestic achievement of the last decade," said KFF's Larry Levitt. "President Biden has successfully reinvigorated the ACA, as he promised to do. But, that success will be sustained only if the extra premium help continues."

The bottom line: As Democrats try to salvage their reconciliation package, preserving the larger ACA subsidies is likely to be a top priority.

  • The subsidy extension "has a two-way motivation to pass," said Democratic strategist Chris Jennings.
  • "First, to avoid a significant increase in premiums and decrease in coverage," he said. "And second, to secure an affordability legacy and policy sustainability of the law for the Biden administration and the Democratic Congress."
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