Affordable Care Act Turns 15 With Yet Another Wave of Attacks on Affordable Plans

March 23 marked the 15th anniversary of the Affordable Care Act (ACA). The law has had many enrollment successes since its passage, including a record 24.2 million individuals choosing Marketplace coverage for 2025 and record-low rates of people going uninsured.

Proposed Rule Revives Administrative ACA Wrangling

A new proposed rule from the Centers for Medicare & Medicaid Services (CMS), however, puts affordable ACA coverage at risk for many. During President Trump’s first term, Congress directly attacked the ACA, vowing to repeal and replace it. When that failed, his administration took steps to make it less effective—shortening timelines and eliminating some pathways for people to enroll and get help understanding their coverage, and promoting short-term and other non-ACA plans that did not protect consumers and left millions vulnerable to surprise bills and lack of coverage.

The Biden-Harris administration undid some of these changes by, for example, lengthening enrollment timelines, curtailing non-compliant plans, and adding funds to help people choose coverage.

But the restored policies may again prove temporary. The second Trump administration has restarted its campaign against the ACA by limiting funding to help people gain ACA coverage and attacking language access. Now the administration has come out with a proposed rule that would again limit enrollment timelines, as well as create new burdens on enrollees, plans, and states; impose discriminatory coverage policies; and bar Deferred Action for Childhood Arrivals (DACA) “Dreamers” from coverage.

Changes Target ACA Plan Access, Affordability, and Coverage

In part, the proposed rule would shorten the current ACA enrollment period from 75 to 45 days and prohibit states from having longer enrollment periods. In addition, the rule would eliminate a special enrollment period (SEP) for people with incomes under 150% of the federal poverty level and require applicants to submit documentation verifying their SEP eligibility pre-enrollment, rather than self-attest.

Troublingly, the rule would also start charging fees to people who are automatically reenrolled in coverage until they complete paperwork, a form of red tape that is likely to catch many low-income enrollees in its net, and block enrollment for those who have any past due premiums. Other changes would update the premium adjustment methodology in ways that are likely to make plans more expensive.

The rule would also create new sexually discriminatory policies by blocking coverage for “sex-trait modification” as an essential health benefit, a move designed to harm transgender enrollees. Of note, when he took office, President Trump also signed executive orders in an attempt to redefine sexual discrimination to exclude transgender, nonbinary, and intersex people and to ban medically necessary care for transgender individuals. Courts have already blocked enforcement of these orders, but the proposed rule nevertheless attempts to advance them.

Coverage for Millions Is at Risk

While CMS frames these changes as necessary to ensure “program integrity” and “protect consumers,” they will instead reduce program safeguards and access to care. CMS acknowledges in the proposed rule itself that that the fallout will be extensive, estimating that as many as 2 million people will lose ACA coverage next year alone.

Medicare Rights stands firm against attempts to dilute ACA protections and coverage or to otherwise limit access to care, whether that is through ACA plans, Medicare, or Medicaid. We call upon the administration and Congress to abandon this proposal and instead work together to build upon the successes of the ACA by further reducing the number of uninsured people and expanding access to high-quality, affordable care.

Further Reading

Read the proposed rule and analyses of the rule.

Read more about actions during Trump’s first term.

Read more about the importance of the ACA.