By Rachel Swindle, Jalisa Clark, Christine Monahan and Justin Giovannelli
The Affordable Care Act (ACA) marketplaces are a critical source of health coverage for millions of people. Marketplaces help connect individuals and families to comprehensive individual market policies and, for many, federal financial assistance to significantly reduce their premiums. They also can serve as an access point for the Medicaid program for those who are eligible.
Marketplaces have been particularly beneficial for communities of color. Black, Hispanic, and American Indian/Alaskan Native (AI/AIN) populations historically and still today are less likely to be enrolled in employer-sponsored insurance and thus are more dependent on individual market coverage. With implementation of the ACA marketplaces, we’ve seen the uninsured rate drop and marketplace enrollment surge for these communities, and racial disparities narrow.
Yet the role of the marketplaces in the coverage landscape fluctuates greatly in response to the priorities of the president and members of Congress. After trying and failing to repeal the ACA in 2017, the Trump Administration instead sought to undermine the law through funding cuts, neglect, and rule changes. These actions corresponded with an increase in the uninsured rate and a decrease in the number of Black enrollees in the ACA’s federal marketplace. By contrast, under the current Biden-Harris administration, the uninsured rate has fallen considerably (from 10.3% in 2020 to 7.7% in 2023); the number of Latino enrollees in the marketplaces increased 185 percent, and the number of Black enrollees grew 204 percent. Enrollment among AI/AN communities also doubled.
| Coverage Affordability and Take-Up Have Increased Substantially Since the Federal Government Recommitted to the Marketplaces: Key Data from States with Racially Diverse Populations | ||||
| State | Percent Change in Federal Navigator Funding, 2020-2024 | Total Annualized Value of Expanded Premium Tax Credits Received by State Residents in 2024 | Average Reduction in Consumer Premiums Due to Expanded Premium Tax Credits in 2024 | Percent Change in Marketplace Plan Selections, 2020-2024 |
| Alabama | 1,176% | $227,000,000 | 48% | 141% |
| Alaska† | 1,540% | $43,000,000 | 56% | 55% |
| Arizona | 1,000% | $238,000,000 | 46% | 127% |
| Delaware† | 1,493% | $48,000,000 | 41% | 87% |
| Florida | 1,189% | $2,163,000,000 | 47% | 120% |
| Georgia | 362%* | $659,000,000 | 46% | 181% |
| Hawaii† | 195% | $20,000,000 | 33% | 10% |
| Illinois† | 1,335% | $367,000,000 | 38% | 36% |
| Louisiana† | 1,134% | $156,000,000 | 50% | 142% |
| Michigan† | 1,184% | $310,000,000 | 41% | 59% |
| Mississippi | 583% | $138,000,000 | 62% | 190% |
| North Carolina†† | 1,252% | $659,000,000 | 51% | 103% |
| Ohio† | 558% | $343,000,000 | 45% | 143% |
| South Carolina | 217% | $322,000,000 | 50% | 167% |
| Tennessee | 1,303% | $284,000,000 | 50% | 177% |
| Texas | 999% | $1,531,000,000 | 54% | 212% |
| Notes: The table includes all HealthCare.gov states in which, as of 2022, the share of residents who identified as Black, Hispanic, or Asian exceeded the national average. Federal navigator funding is awarded on a multi-year (but non-guaranteed) basis with 12-month budget periods that typically run from late August of one year to late August of the next. The percent change in federal navigator funding shown here reflects the difference between a) the total value of all navigator agreements for the given state for the 12-month budget period that included open enrollment for the 2024 plan year, with b) the total value of all such agreements for the 12-month budget period that included open enrollment for the 2020 plan year.
† State implemented the ACA’s Medicaid expansion prior to 2020. Sources: Authors’ analysis of population distribution data derived from the American Community Survey by KFF; authors’ analysis of CMS Marketplace Open Enrollment Public Use Files for 2020 and 2024; authors’ analysis of CMS Navigator Cooperative Agreement Awards for 2019-20, 2021-22, and 2023-24; Ortaliza J. et al., Inflation Reduction Act Health Insurance Subsidies: What Is Their Impact and What Would Happen if They Expire? KFF, July 26, 2024; CMS Health Insurance Marketplaces 2024 Open Enrollment Report. |
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The winners of the 2024 Presidential and Congressional elections will have a significant impact on health insurance coverage, particularly for communities of color. Below are some of the key policies at stake.
Expanded Federal Subsidies
Expanded federal premium tax credits (PTCs) are due to expire after 2025, and must be extended by Congress soon to avoid significant disruption. The Harris-Walz campaign supports making the policy permanent, while members of the Trump campaign and key advisors to the former president have repeatedly called for expanded PTCs to end.
Federal financial assistance for marketplace plans was a core part of the ACA’s framework. The 2021 expansion made the original PTCs far more generous and widely available, which drove up enrollment. Marketplace plan selections increased by 88 percent nationwide from 2020 to 2024, by which time 70 percent of consumers using HealthCare.gov selected a plan for which they owed a monthly premium of $50 or less with PTCs.
Coverage gains have been especially large among people of color. Recent analysis suggests that Black enrollment increased 79 percent and Hispanic enrollment increased 61 percent nationally due to the PTC expansion (compared to a 42 percent increase among white enrollees). These trends are more pronounced in states that have not expanded Medicaid – several of which have large numbers of Black residents.
States have built on expanded federal financial assistance by investing state funds in new marketplace affordability programs, many of which have helped further close the coverage gap. Enrollees through Maryland’s Young Adult Subsidy program in Maryland, for example, are more likely to be Black or Hispanic compared to marketplace enrollees in the same age cohort who are not eligible for the subsidy. The success of state programs like the one in Maryland is inextricably linked to and dependent on an ongoing federal commitment to coverage affordability, including the expanded PTC.
Outreach and Assistance
The Navigator program was designed to reach out to and support underserved and vulnerable communities who have disproportionately lacked access to health coverage and health care, including rural communities, individuals with HIV, and immigrant populations, on behalf of marketplaces. They fill a critical gap left by brokers and agents, who are paid commissions by insurance companies to enroll people and employers in coverage, but do not reach everyone. For example, Navigators are more likely than brokers to assist people who are currently uninsured or are enrolled in Medicaid. They also more frequently serve individuals who identify as Hispanic, need help with immigration issues, or require language assistance.
Despite the important and unique role Navigators play, the Trump administration reduced funding for the federal Navigator program by 85 percent, lowering it from $63 million in 2016 to a shocking $10 million in 2018 through 2020. After the funding announcement, many community organizations scaled back operations, while others ended services entirely.
The fallout of the Trump administration’s decision fell disproportionately on people of color and immigrant communities. For example, in response to the cuts, most Navigators reported they were likely to reduce services to consumers with limited English proficiency (LEP). Subsequent research has found that defunding the Navigator program was associated with a significant decrease in health coverage among low-income adults, Hispanic adults, and the LEP population.
The Biden-Harris administration took a far different approach, reinvesting in Navigators and emphasizing the role they play in reaching and assisting underserved communities. In July 2024, the administration announced $500 million in funding allocated to the Navigator program over the next five years. While a Harris presidency can be expected to maintain this commitment, there can be little doubt a second Trump administration would return to its past practices.
Eligibility, Enrollment, and Nondiscrimination Policies
The Biden-Harris administration has taken numerous other steps to expand marketplace coverage and improve affordability that are at stake this election:
Looking Forward
Political threats to the ACA and its marketplaces this election season could lead to sizable coverage losses and decreased access to care across the country, and these deleterious impacts will disproportionately hit communities of color. Both Congress and the new president will determine whether the expanded PTCs should continue after 2025, and the executive branch’s administration of the law will play a major role in how ACA marketplaces work for consumers. Consistent federal commitment from both is key to sustaining and building on the progress made to date. Whether that comes to fruition will depend on who voters choose.
Support for this work was provided by the Commonwealth Fund. The views expressed here do not necessarily reflect the views of the Fund.
