Illustration: Sarah Grillo/Axios
States that President Trump carried last year had the biggest growth in Affordable Care Act marketplace coverage, largely thanks to enhanced premium tax credits that are due to expire at the end of this year, per a new KFF report.
Why it matters: The findings give Republicans another data point to consider as they decide whether to let the subsidies expire and face constituents' coverage losses before the midterms.
What's inside: KFF studied ACA open enrollment data going back to 2020.
- As of 2025, 88% of the total growth in marketplaces since 2020 was in states that Trump won in the 2024 election.
- On average, states that voted for Trump in 2024 increased enrollment 157%, while states that voted for former Vice President Kamala Harris had only a 36% increase.
- This is the fourth year in a row with record-high ACA enrollment, with 24.3 million people having marketplace coverage. And enrollment in the ACA marketplace has more than doubled since 2020.
Zoom in: KFF also found that the 15 states with the most growth in ACA enrollment since 2020 were also states that Trump won in 2024.
- The six states where enrollment more than tripled since 2020 were Texas, Mississippi, West Virginia, Louisiana, Georgia and Tennessee.
State of play: So far, only two Republican senators, Lisa Murkowski and Thom Tillis, have publicly endorsed extending the enhanced ACA subsidies past 2025, citing concerns over the affordability of insurance in their states.
- Tillis is facing reelection next year in what's likely to be a competitive Senate race. North Carolina's ACA enrollment rose 93% from 2020 to 2025.
- Trump hasn't weighed in on his thoughts around the ACA subsidies, though he slammed the health insurance program on the campaign trail.
