The Trump administration’s most recent actions have made it harder than ever for Americans to get good health insurance. This week, the administration proposed regulations that will govern how Americans get health insurance in the Affordable Care Act (ACA) marketplaces in 2027. The news isn’t good: the administration projects that these changes will reduce enrollment by 1.2 million to 2 million people. These losses are on top of 2026 changes that are expected to leave 7.5 million people uninsured.
In its first term, the Trump administration attempted to repeal the ACA but failed to pass the necessary legislation. However, it has, with the help of Republicans in Congress, inflicted damage to the ACA marketplaces. Last year, despite support by a majority of the public for the enhanced ACA premium tax credits, Republicans did not pass legislation to extend them, which led to average annual premium increases of $750 to $4,035, depending on income. H.R. 1, the legislation that passed on a party-line vote with nearly all Republicans supporting and all Democrats voting against, cut millions of legal immigrants and asylees from coverage and imposed new income verification requirements. In addition, the Trump administration’s marketplace rule for 2026 increased out-of-pocket costs, eliminated special-enrollment periods for low-income people, and placed new restrictions on autoenrollment. Insurers raised premiums for the marketplaces by more than 20 percent, in an effort to protect themselves against healthier customers dropping coverage, leaving only sicker (and more costly) people in the market. The bulk of the increase was attributable to the recent policy changes.
When an administration proposes new rules, the public has a right to provide input. In this way, regulations can be improved and better reflect the nation’s preferences. Past administrations have given the public 45 days to comment on proposed marketplace rules. Last year, the Trump administration allowed just 30 days for comments on its 2026 proposed marketplace rule; the same is true for the 2027 proposal. Nevertheless, in 2025, 24,000 individuals and organizations submitted comments. These became the basis of two lawsuits against the final rule, one of which resulted in a judge placing stays on several major provisions in the final rule. This meant that they didn’t go into effect this year.
The administration includes some of those provisions again in the 2027 proposed rule. Despite evidence to the contrary that was cited in the judge’s decision, the administration continues to maintain that many people with incomes under the poverty level (that is, $15,650 for an individual and $32,150 for a family of four) who are ineligible for Medicaid in the 10 states without expanded programs are fraudulently misrepresenting their income and getting covered in the marketplaces. For this alleged reason, the Trump administration eliminated special-enrollment periods for low-income people last year and maintains it needs to scrutinize enrollees with incomes near the poverty line again this year.
For people too poor to be eligible for marketplace subsidies in states that have not expanded Medicaid and those with incomes that make them ineligible for cost-sharing subsidies, the administration suggests “catastrophic” health plans. Such plans cover catastrophic medical costs but leave people paying for most routine health care, after an allowance of three primary care visits and preventive care mandated by the ACA. The administration is also proposing that these plans be permitted to only cover health care expenses beyond these allowances after a person has spent more than $15,000 on health care. This amount is roughly equivalent to the total annual income of a person living at or below the poverty level.
The administration also loosens physician network requirements for health plans and proposes that health insurers be allowed to offer “nonnetwork” plans. In nonnetwork plans, all providers are out of network. Instead of negotiating rates with a network of providers, plans will pay a set amount of the cost of a covered benefit; the enrollee is responsible for paying the difference between that cost and what providers charge.
The proposed rule continues to restrict Americans’ access to health care. Fewer people will have health insurance. Many who have insurance have plans with high deductibles and copayments. This reality runs counter to an ever-expanding body of evidence that shows that being uninsured or underinsured significantly reduces people’s access to health care, substantially increases the risk of medical debt, and leads to poorer health and shorter lives, particularly among households with middle or low incomes. The administration’s actions demonstrate a disconnect from the reality of our extremely costly health care system. From the perspective of patients, comprehensive health insurance is not the only thing that matters to get good health care, but it is the first thing that matters.
