ACA Enrollment Is at a Record High. Here’s How It’s Changed Over the Years.

The number of people who signed up for health insurance through the Affordable Care Act’s marketplaces hit a record high this season for the third year in a row, with the latest figures released by the Biden administration Wednesday showing more than 21 million people selected a plan between Nov. 1 and mid-January.

The total for the latest open enrollment period marks a 30% increase from a year ago, based on past enrollment figures published by the health policy research organization KFF. It’s also an 87% rise from the number of people who signed up in 2020, which saw the lowest enrollment total aside from the first year the marketplaces were up and running in 2014.

“For decades, when it came to federal programs we could depend on to keep Americans covered, three were always top of mind – Medicare, Medicaid, and Social Security, but now it’s crystal clear that we need to add a fourth – the Affordable Care Act,” Department of Health and Human Services Secretary Xavier Becerra said in a statement. “Once again, a record-breaking number of Americans have signed up for affordable health care coverage through the Affordable Care Act’s Marketplace, and now they and their families have the peace of mind that comes with coverage.”

The latest data reflects people who selected coverage for 2024 in the 32 states using the federal HealthCare.gov platform, with a deadline for enrollment last week. Also included are plan selections in the 18 states and the District of Columbia that operate their own marketplaces, some of which have sign-up deadlines at the end of the month, meaning the overall enrollment number still could grow.

Officials said the figures include 5 million new signups and more than 16 million people with 2023 ACA plan coverage.

Some of the biggest increases in enrollment tied to the health care reform law known as Obamacare occurred in states that have yet to expand Medicaid to more low-income people. Texas had the largest increase in enrollees from 2023 to 2024 at nearly 1.1 million, followed by Florida with an increase of more than 986,000 people signing up for coverage. West Virginia, which has expanded Medicaid, saw the largest percentage increase in enrollment at 80%.

“Marketplace coverage is very important to those in those states whose incomes are under 138% of poverty,” says Sara Collins, vice president for health care coverage and access and tracking health system performance for The Commonwealth Fund. “It is a reflection of the lack of Medicaid expansion in those states.”

An analysis by KFF notes ACA health plan enrollment has increased each year during the Biden administration. Under former President Donald Trump, meanwhile, the number of total signups decreased by 10% in 2020 to 11.4 million compared with 12.7 million in 2016, the year Trump took office.

KFF report co-author Cynthia Cox, director of the organization’s program on the ACA, says the increase in demand is in line with a trend seen over the past few years and is thanks in part to enhanced subsidies provided through the American Rescue Plan Act and Inflation Reduction Act that lowered the cost of marketplace plan premiums. The Biden administration also put an emphasis on outreach, including by investing more than $98 million during the 2023 open enrollment period to support navigators who could help people find health coverage.

At the same time, Cox says the biggest factor that likely led to the sharp rise in 2024 signups was the loss of health coverage for millions of people with the end of continuous Medicaid enrollment last year.

Her analysis notes that enrollment in the individual health insurance market, which includes ACA marketplaces, grew by 5.7% between April and September 2023, amounting to growth of about 1 million enrollees.

“When (continuous enrollment) came to an end in April 2023, we can see it corresponding with an increase in marketplace signups in the middle of the year last year even before the open enrollment period started,” Cox says. “That’s really unusual because in a normal year you see the market shrinking during those months, and this year we actually saw it growing.”

With the enhanced subsidies set to expire at the end of 2025, Collins says any continued increases in enrollment in the coming years will depend heavily on whether lawmakers opt to keep such benefits in place.

“If those subsidies were not renewed, then I think you would see a gradual waning of some of the gains that we have made,” Collin says.

The 2024 presidential election also holds likely ramifications for future enrollment. GOP front-runner and former President Donald Trump has again expressed his desire to “replace” Obamacare – something Republicans were unable to accomplish during his last tenure in office. The previous Trump administration also cut back on outreach aimed at helping people enroll, among other maneuvers.