The president’s domestic policy law will cause millions of people to lose health coverage they held through Medicaid and the marketplaces; millions more will lose insurance because of new Trump administration regulations. Many of these losses will be driven by intentional inefficiencies, additional steps, and administrative burdens that hinder and prohibit individuals and families from enrolling in and maintaining marketplace coverage. The changes will be particularly harmful to certain communities, including people of color, immigrants, and transgender and nonbinary individuals, but will also be felt broadly, hampering access to affordable health insurance for all current and potential marketplace customers.
How Do Administrative Burdens Affect Enrollment?
Burdens associated with enrolling in a public program can substantially depress take-up among eligible individuals. The more time-consuming it is for a person to learn how and when to apply for coverage, the more steps they must take to enroll, the more challenging it is to complete application paperwork and submit documentation, and the more frequently enrollees must repeat these tasks to reestablish eligibility — the less likely it is that people will have coverage, even though they are eligible.
This is a problem for people who, if uninsured, face poorer health outcomes and greater financial risk. However, the harm extends to all marketplace enrollees. Administrative barriers disproportionately reduce enrollment of younger and healthier people, making the risk pool sicker and more costly to insure, and ultimately causing premiums to rise for everyone.
Making Access Harder Again
The law and rules will impose a host of new administrative barriers to marketplace enrollment.1 These include:
- Eliminating streamlined coverage renewals. Since 2015, marketplace consumers have had the option to automatically reenroll in coverage for a subsequent year; most returning consumers renew this way. For the 2026 open-enrollment period (OEP), the administration will effectively eliminate auto-reenrollment for low-income individuals eligible for $0 insurance premiums with advance premium tax credits (APTCs) by imposing a punitive $5 monthly fee until they reconfirm their APTC eligibility. Beginning with the 2028 OEP, automatic reenrollment will end altogether, denying marketplace consumers an option typical in employer-sponsored insurance.
- Mandating more paperwork. Marketplace consumers have been able to attest to eligibility information, such as projected household income and immigration status. Then, this information is verified against trusted data sources. If the data do not match, the consumer has limited time to submit documentation that allows the marketplace to verify eligibility. The administration will now require millions more consumers to submit additional paperwork and has reduced by two months the amount of time consumers have to do so.
- Withholding financial assistance during paperwork processing. Marketplaces have historically treated consumers as provisionally eligible for PTCs while resolving data-matching issues. The new law largely eliminates provisional eligibility. Beginning with the 2028 OEP, a consumer and their entire household will be ineligible for PTCs until data issues are resolved. Until then, they will be able to enroll only if they can afford to pay the full, unsubsidized premium.
- Restricting enrollment opportunities. Currently, the annual marketplace OEP runs for at least 11 weeks. In addition, low-income consumers otherwise eligible for PTCs can access coverage outside OEP via special-enrollment opportunities. The new federal policies will mandate a shorter OEP and terminate the special enrollment period for low-income consumers.
- Making tax rules more onerous. Marketplace enrollees whose actual income turns out to be higher than they estimated must repay the excess PTCs they received during the year when they file taxes. Previously, the federal government capped repayment obligations for low- and middle-income consumers. New policies eliminate this cap, increasing consumers’ financial exposure for underestimating future income.
- Prohibiting people snared by Medicaid red tape from accessing affordable private coverage. Starting in 2027, the federal government will require Medicaid enrollees to meet work reporting requirements as a condition of eligibility. States that previously required work reporting saw Medicaid enrollment suffer due to complex administrative processes, and millions are expected to lose coverage because of the forthcoming federal requirements. In addition, those denied Medicaid under the new reporting regime will also be barred from accessing federal subsidies in the marketplace, even if they are otherwise eligible.
Wide and Disproportionate Impacts
Anyone relying on marketplace coverage may be negatively affected by the changes, but certain communities will bear the brunt. Marketplaces have been a vital source of coverage for many non-white populations who are less likely to be enrolled in employer-sponsored insurance. Administrative burdens disproportionately affect vulnerable populations, such as people with limited English proficiency or disabilities who may have extra difficulty navigating the less user-friendly system. Shorter time frames to resolve data-matching issues may disproportionately affect transgender and nonbinary individuals when state-issued documentation with name and gender identity does not match the information on record with the Social Security Administration.
Looking Ahead
Enrolling in health insurance can be challenging; the new law and regulation make the process far harder. The administration previously cut funding for outreach and enrollment assistance, ensuring that consumers will have far less help navigating the new administrative barriers. Meanwhile, Congress’s refusal to extend tax credit enhancements for marketplace consumers means marketplace coverage will soon be far more expensive. These choices will leave millions of people uninsured.
