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| Thanks to a court order, you can still attest to an income over 100% FPL |
It’s good to see the fight over renewal or nonrenewal of the expiring enhanced ACA marketplace subsidies sitting at the center of the current political agenda.
The enhanced summaries created by the American Rescue Plan Act (ARPA) in March 2021 are plainly the main driver of a doubling of ACA marketplace enrollment from OEP 2021 to OEP 2025 (from 12 million to 24 million). The enhanced subsidies gave the ACA a credible claim to fulfilling the mission embodied in its name, offering affordable to care to all who lack access to other affordable insurance (excepting perhaps two million in the coverage gap created by red state refusal to enact the ACA Medicaid expansion).*
Renewal or nonrenewal of ARPA subsidies will determine the basic size and shape of the ACA marketplace in 2026 and who-knows-how-many years beyond. Even if the subsidies were renewed without strings today, however, other changes to the marketplace triggered by Trump’s CMS, the Republican Congress, and political uncertainty generated by their assaults on the law are likely to inhibit 2026 enrollment substantially.
To get a working sense of how some (not all) of these restrictions function, it’s important to recognize that the majority of enrollments in the ACA exchanges are executed by brokers. Brokers played an important role in the marketplace from the beginning, but their ranks swelled from 49,000 in 2019 to 83,000 in 2024 (as CMS told me by email) - spurred first by encouragement and facilitation by the first Trump administration, and then by the increasing attractiveness of offerings and ease of enrollment when the ARPA subsidy schedule kicked in. By OEP 2024, brokers accounted for almost 80% of active enrollments in the states using HealthCare.gov, which account for about three quarters of all enrollment — up from 44% in OEP 2019. Brokers execute a large share of enrollments in most state-based exchanges as well (e.g., 56% of California’s 2 million enrollments in 2025).
The mass influx of brokers into the marketplace over the past few years has been, I believe, a mixed blessing. On the one hand, Americans are endemically ignorant of what the marketplace has to offer (and, often, until they need it, of its existence), and broker outreach, often stimulated by ads, has probably been a key factor in reaching low-income people in red states (enrollment at 100-150% FPL has nearly tripled since OEP 2021, most of it concentrated in states that have not expanded Medicaid). A good broker is priceless, and many are devoted, detail-oriented types who will slog with clients through baffling enrollment barriers and help navigate narrow networks and coverage denial.
On the other hand, the availability of zero-premium coverage at low incomes, coupled with year-round enrollment at incomes up to 150% FPL, the ease of broker access to accounts in commercial “enhanced direct enrollment” (EDE) platforms, and weak oversight, spurred a major outbreak of broker fraud in 2023-2024 in particular (CMS started to crack down in advance of OEP 2025, with results as yet I think undetermined). In addition to outright fraud, the low-hanging fruit — enrollees eligible year-round for zero-premium coverage, easily enrolled on the EDEs — seems to have stimulated a proliferation of high-volume call centers, taking leads from misleading and sometimes outright fraudulent ads, and doubtless often providing dubious guidance at best.
All that said, many of the enrollment barriers thrown up by Trump’s CMS and the Republican megabill, along with market turmoil generated in large part by regulatory and legislative turmoil (as in 2017, when ACA repeal was looming) directly affect brokers and their participation. While the clampdown on brokers’ easy access to all enrollees’ accounts - -a necessary security measures — may drive out bad actors, a raft of new documentation requirements and limits on Special Enrollment Periods outside of OEP will drive some prospective enrollees out of the market and make brokers’ lives more difficult — though a court-imposed stay on some of the new restrictions will limit the effects this year.
With that too-long prelude, here is a rundown of new marketplace factors other than the enhanced premium subsidies that may affect enrollees and brokers.
Restrictions on Immigrant Enrollment - The Republican megabill ended eligibility for ACA premium subsidies for most lawfully present noncitizens who do not have a green card (with exceptions for certain classes of Cubans and Pacific Islanders) — stripping coverage from refugees, asylees, trafficking victims, and people with DACA status, among others. CBO estimated that this ban would increase the uninsured population by 1 million. The bill also stripped eligibility for lawfully present noncitizens with income under 100% FPL who are subject to the federal 5-year waiting period for Medicaid eligibility (imposed in 1996). CBO estimated that this measure would increase the uninsured population by 300,000. In CBO estimates, the numbers becoming uninsured are generally smaller than the number who lose marketplace eligibility. So, somewhere north of 5% of current marketplace enrollees (or their replacement by similarly situated immigrants) will be cut out. The immigrant cuts could affect agent/brokers in Miami/Dade, the county with the highest concentration of enrollees in the U.S., where a storefront broker industry has been rooted since at least 2015; and in California, Texas, and other states where immigrants are heavily concentrated (especially nonexpansion states like Texas, where more than half of enrollees have incomes below 200% FPL).
Insurer exits from the marketplace - In every plan year, insurers enter and exit the ACA exchanges, entirely or in select states and counties. In 2016 and 2017, Aetna, Humana and UHC exited the marketplace, with Aetna and Humana completing full withdrawals in early 2017, when the threat of ACA repeal was at its peak. Those exits and others left many states to scramble (successfully) to ensure that at least one insurer was offering plans in every rating area. The prospect of collapse in some or all markets apparently induced Trump to abruptly cut off reimbursement of insurers for the Cost Sharing Reduction (CSR) subsidies they are obliged by statute to provide to low-income enrollees in silver plans in October 2017 — and boast immediately afterward that he had killed “Obamacare.” That didn’t happen, as Trump pulled the trigger too late to spook insurers, and state regulators allowed insurers to price CSR into premiums (and in most cases into silver premiums only, boosting subsidies). Enrollment and premiums stabilized, and in the Biden years the ARPA subsidy boosts triggered new market entries. Now, for 2026, insurer exits are on the rise again. Aetna is exiting in full for the second time, leaving more than 1 million enrollees to seek coverage from other insurers. Charles Gaba has tracked full and partial exits nationwide, tallying a total of about 1.6 million enrollees who will have to switch carriers. (For perspective, Louise Norris tracks new entries as well as exits.) While exits to this point are far from catastrophic, failure by year’s end to extend the ARPA subsidies could trigger a larger exodus. The ailing giant UnitedHealth Group has floated the possibility of a full ACA exit.
Cuts to broker commissions - The ACA did not mandate broker commissions or set levels, and commissions in the marketplace have always been low compared to commissions in Medicare Advantage or the lightly regulated short-term market (which the first Trump administration sought to boost as a competing parallel market to the ACA marketplace, with Trump’s current CMS following suit). Commissions have ebbed and flowed with insurer participation, and improved in the ARPA subsidy era. Plan Year 2026 is bringing new cutbacks, though I don’t have good information as to how prevalent they are. Molina, a cut-rate insurer with 690,000 marketplace enrollees in 2025, is ending commissions for new enrollments in ten of the thirteen states in which it will offer plans: Florida, New Mexico, Texas, South Carolina, Illinois, Michigan, Wisconsin, Connecticut, Washington and Ohio. In Texas, brokers report that several insurers with hundreds of thousands of enrollments among them — Baylor Scott & White, Sendero, and (per above), Molina — have cut off broker commissions for 2026.
Regulatory hurdles - In June 2025, CMS finalized a raft of “program integrity” rules — ostensibly to clamp down on fraud, but also imposing regulatory hurdles likely to crimp enrollment. These included requiring that income and immigration status be verified before tax credits could be credited; requiring documentation proving that an enrollee outside of Open Enrollment qualifies for a Special Enrollment Period (e.g., by proving loss of coverage from an employer) before enrollment is effectuated; imposing a $5/month premium surcharge for enrollees who allow passive re-enrollment, i.e., do not update their prior-year applications; requiring low-income enrollees whose tax data or other data indicates an income below the 100% FPL eligibility threshold to document a qualifying income; and ending year-round monthly SEPs for enrollees with income below 150% FPL. Some of these measures have been stayed by a court order, including the $5 surcharge for auto re-enrollment, the verification requirement for those whose incomes may be below 100% FPL; and proof of SEP eligibility prior to enrollment effectuation (as opposed to in a waiting period following enrollment). Others rules were codified in the Republican megabill — including requiring income/immigration status documentation before granting tax credits and ending the monthly SEP for those with income below 150% FPL. The provisions that remain standing or codified will inhibit enrollment to some degree and force some enrollees to go without coverage or pay full premium if the verification process takes a long time (as it may, with the Trump administrations massive personnel cuts in CMS). But the court stay will take much of the regulatory pressure off in 2026. Voiding the requirement that low-income enrollees prove an income above 100% FPL (in one sense impossible, as the income declaration on the ACA application is a future estimate) is a particularly important bit of relief, as enrollment in the 100-150% FPL income bracket accounts for most of the doubling of enrollment in the ARPA years. People in that income bracket often work uncertain hours, rely on tips, are self-employed, do gig work, work multiple jobs or change jobs often. Estimating a full year’s income is difficult, and the unavailability of government support for coverage at incomes below 100% FPL is a travesty produced by states’ cruel and stupid refusal to enact the ACA Medicaid expansion.
In sum, the ARPA subsidy enhancements are the big enchilada. At this point, it seems likely that if Congress extends them, they won’t get the job done until after the beginning of OEP on November 1, which will cause some chaos and likely drive out people who see premium quotes prior to the extension. Regulatory changes may drive bad brokers out of the market — excessive as the new measures are, they do make acting without enrollee consent all but impossible (the most important change, enacted by the Biden administration, requires verifiable client consent before a broker can act on an application on an EDE). Those changes may also drive out some good brokers, or marginally acceptable high-volume brokers, and so inhibit enrollment. Massive cuts to federally funded nonprofit enrollment assistance — a reprise of the first Trump administration’s 90% cuts — will also have an effect, perhaps more on Medicaid enrollment than on marketplace. The end of the year-round SEP for low-income enrollees will indeed inhibit fraud (it should never have been a monthly SEP, enabling serial unauthorized plan-switching), but also legitimate enrollment.
Finally, the denial of subsidy eligibility to lawfully present immigrants who lack a green card and to those whose income would qualify them for Medicaid if they were not subject to the five-year bar is a gratuitously cruel piece of legislative demagoguery that will worsen the risk pool and degrade public health as well as causing suffering to more than a million individuals.
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* The ACA — and the marketplace in particular — have many flaws, but under the ARPA-enhanced subsidy schedule, a health plan that can credibly be called “affordable” and comprehensive has been available since March 2021 to any citizen or lawfully present noncitizen who lacks access to other affordable insurance (again excepting those with income under 100% FPL in the nonexpansion states). Since the passage of Republicans’ megabill on July 4, cross off that list lawfully present noncitizens who lack green cards or aren’t in certain privileged classes of Cuban or Pacific Islander immigrants.
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