Enrollment on the Affordable Care Act's (ACA's) exchanges has more than doubled over the past several years, with much of that growth coming from red states, according to a new report.
Analysts at KFF found that enrollment in marketplace plans reached 24.3 million for 2025, up from 11.4 million in 2020. That's growth of 113% for those five years, the researchers said.
Almost all states have seen some level of increase since 2020, per the report. However, there are six states where enrollment more than tripled, and all were won by President Donald Trump in the 2024 election. The highest increases were in Texas and Mississippi, where enrollment grew by 255% and 242%, respectively.
In Louisiana and West Virginia, enrollment increased by 234%, while Georgia saw an increase of 227%. Enrollment rose in Tennessee by 221%.
Overall, the study found that enrollment grew by 157% on average in states won by Trump, while it it increased by an average of 36% in states carried by former Vice President Kamala Harris. Enrollment on the exchanges has more than doubled in 20 states since 2020, according to the report.
The likely largest contributing factor in increased enrollment is the enhanced premium subsidies, which were first rolled out in 2021 as part of the American Rescue Plan Act and were later extended through the Inflation Reduction Act.
Thanks to these tax credits, individuals earning up to 400% of the federal poverty level were eligible for financial assistance in securing plans through the ACA exchanges.
However, the fate of the enhanced subsidies is in limbo, as they are set to expire at the end of this year. Given the focus on cutting federal expending among Republicans on the Hill and in the White House, policy experts have expressed concern that this spells doom for the premium tax credits.
The Congressional Budget Office estimated that it would cost the feds $335 billion over the next 10 years to extend the subsidies permanently, according to the report. The agency projects that if the subsidies are not extended, 3.8 million people will become uninsured.
There are three outliers in the study that saw enrollment on their exchanges decline since 2020: New York, Oregon and the District of Columbia. The researchers said that these locales have other expanded programs, such as high Medicaid eligibility, that are likely siphoning off people who may have sought coverage on the individual market.