After years of growth, advocates fear Affordable Care Act is going backward

A doctor takes the blood pressure of a pregnant patient. The Affordable Care Act has expanded the number of people with access to health insurance and health care, but advocates say changes being made since President Donald Trump took office could lead people to lose access. (Getty Images)
Federal fallout
As federal funding and systems dwindle, states are left to decide how and whether to make up the difference.Read the latest >
Months away from 2026, Amanda Sherman worries often about how the new year will change her health care.

Sherman, a broker’s assistant in a real estate office, buys her health insurance through the federal health insurance marketplace, HealthCare.gov. Her coverage has helped her through a chronic illness and critical health setbacks.
Her health plan costs her $300 a month. Without it, she says she couldn’t afford the weekly shots that she gets for lupus — a chronic autoimmune disorder she was diagnosed with five years ago.
HealthCare.gov was established in 2014 as part of the Affordable Care Act (ACA). “It’s been there as a great resource when I haven’t been able to get insurance at work,” Sherman says.
In 2026, however, Sherman expects the cost of her health insurance to skyrocket. An enhanced federal subsidy that helped her afford the coverage is set to disappear at the end of this year. When that happens, she isn’t sure what she’ll do.
In the last few years, record numbers of Americans, including record numbers of Wisconsin residents, have been signing up for coverage that the ACA has made possible.
“When we look back over the last decade, the number of uninsured people in our state has dropped by over 200,000 thanks to the Affordable Care Act,” Wisconsin Commissioner of Insurance Nathan Houdek tells the Wisconsin Examiner. “So we’ve seen a lot of success in terms of more people getting health insurance coverage and being able to access the health care they need as a result.”
Advocates warn that that is about to change under policies coming from the administration of President Donald Trump and the Republican majority in Congress.
“It’s going to take apart a lot of the advances that have been made to extend coverage to more people,” says Bobby Peterson, executive director of ABC for Health, which provides nonprofit legal services and advocacy for people caught up in medical debt.
Obamacare and HealthCare.gov
The ACA was enacted in 2010 during then-President Barack Obama’s first term and phased in over four years.
Nicknamed Obamacare — by detractors at first but later by its supporters — the law made changes that affected health coverage for everyone. It prevented insurers from rejecting coverage or hiking the premium cost because of a pre-existing health condition, for example.
We've seen a lot of success in terms of more people getting health insurance coverage and being able to access the health care they need as a result.
– Nathan Houdek, Wisconsin Commissioner of Insurance
The ACA also created a first-ever national marketplace where people without health insurance could buy coverage for themselves and their families: HealthCare.gov. And the law set standards for the policies sold in the marketplace.
In addition, the law established a nationwide navigator system — nonprofit agencies that help people who buy coverage at HealthCare.gov review their policy options and assess what might best fill their needs.
Dr. Jill McMullen, a family practitioner in Tomah, says she saw “a big improvement in people having access to care and the consistency of care since the Affordable Care Act went in place.”
The ACA required insurers to cover preventive care visits, for example.
“We could predict what was covered regardless of what insurance a patient was signed up with,” McMullen says. “That just makes it a lot easier for patients to get their care” — and also reduces the chance that providers would not get paid for their services.
To make insurance more affordable, the ACA included tax credit subsidies tied to the consumer’s income and available for people with household incomes up to 400% of the federal poverty guidelines. Those subsidies reduce, but don’t eliminate, the HealthCare.gov premium cost and reduce the annual out-of-pocket deductible that the patient has to pay.
Program improvements, record enrollments
In 2021, after President Joe Biden took office, Congress passed and Biden signed the American Rescue Plan Act (ARPA), legislation to provide economic relief in the aftermath of the COVID-19 pandemic. ARPA included a provision that supercharged the premium tax credits and lowered patients’ out-of-pocket costs.
For the first time, subsidies were available to people with incomes more than four times the poverty guideline, according to the nonpartisan health research organization KFF. The 2022 Inflation Reduction Act extended those enhanced subsidies through the end of 2025.

The Biden administration increased funding for navigator agencies and extended the annual ACA open enrollment period to run from Nov. 1 to Jan. 15.
Those changes helped produce higher-than-ever HealthCare.gov enrollments in Wisconsin in the last few years, Houdek says.
For 2025 alone, a record 313,579 people signed up for coverage at HealthCare.gov. National marketplace enrollment for 2025 also reached a record, 24 million, according to KFF.
Since taking office President Donald Trump and his administration have made or proposed changes in how HealthCare.gov works.
In June the Trump-appointed administration at the federal Centers for Medicare & Medicaid Services (CMS) filed a new administrative rule governing Healthcare.gov enrollment that also would add roadblocks for the premium subsidies and shorten the open enrollment period for HealthCare.gov in future years.
On Friday, however, a federal judge in Maryland issued an injunction halting several provisions in the rule pending the outcome of a lawsuit to overturn it.
Even if the new rule doesn’t get enacted, experts say other Trump administration changes to the ACA are almost certain to make health insurance more expensive for people who buy their own coverage.
Navigator cutbacks, mega-bill changes
The administration has cut back support for the nonprofit health care navigators.
Wisconsin’s navigator agency is Covering Wisconsin, part of the University of Wisconsin Extension. Over the course of 2024, the agency’s 41 navigators helped with 100,000 coverage issues, says Covering Wisconsin Director Allison Espeseth.
Those include about 10,000 people who needed assistance through the full process of enrollment at Healthcare.gov, she says. But navigators up to now have helped people with other related needs, such as getting people who qualify enrolled in Medicaid, called BadgerCare in Wisconsin.
“The role of the navigator is to be that hub,” Espeseth says. “To be that one person who understands the health system, hospitals, health plans, understands government.”

In May, Covering Wisconsin received word from the federal government that, like navigator programs across the country, the Wisconsin program would lose 90% of its federal funding, Espeseth says. The cutback took effect Wednesday, Aug. 27.
Espeseth said that will reduce the number of Covering Wisconsin navigators from 41 to 17. With just one-third the number of navigators, “it’s going to make it more difficult for sure to see as many consumers as we have in the past,” she says.
Espeseth says Covering Wisconsin is connecting with insurance agents and brokers who can help with HealthCare.gov marketplace enrollment. The nonprofit is also coordinating with county agencies that qualify and enroll people in Medicaid and other safety net programs.
During the Healthcare.gov open enrollment period, “Typically we help anybody with any coverage issue that comes up, not just for the marketplace,” Espeseth says. “But this year, we need to prioritize. So we’re going to be really focusing as much as we can on marketplace consumers [who] need to renew or find a plan [or] don’t have coverage.”
The tax-cut and spending cut reconciliation bill that Republicans in Congress passed this summer and Trump signed on July 4 includes new limits on who can qualify for the ACA’s premium tax credit subsidies.
Meanwhile, Trump and the congressional Republicans rejected appeals to keep the ARPA enhanced subsidies in place after 2025.
“The federal reconciliation bill is the biggest change to health care in this country since the passage of ACA, and it goes in the wrong direction,” says William Parke-Sutherland, government affairs director for Kids Forward, an advocacy organization for families and children.
The ARPA enhanced subsidies “made health insurance way more affordable for people under 250% of the federal poverty level,” he says — and also made it possible for middle class families who previously had no support to get “a little bit of support to help pay for the cost of their health insurance.”
KFF reported earlier in August that insurers on the ACA marketplace on average plan to increase premiums 18% for 2026. But without the enhanced subsidies, consumers’ out-of-pocket expenses for health coverage could increase by 75%, the research organization calculates.
“You could see 50,000 or more Wisconsin residents lose their ACA coverage because of some of the changes related to not extending the enhanced premium tax credits, increasing the maximum out-of-pocket cost for consumers, shortening the open enrollment period, reducing funding for navigators,” Houdek says.
“All of these things are going to have a negative impact on people’s ability to access coverage through the Affordable Care Act.”
Next: The threat to coverage and widespread consequences
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