As ACA sign ups start, more Americans have health insurance than ever. Will it last?

More than 21 million Americans buy their health insurance through the Affordable Care Act, and open enrollment for next year’s Obamacare plans started Friday, Nov. 1.

People can shop for plans on Healthcare.gov, or their state-based marketplaces from Georgia Access to Covered California.

This year, premiums are still very affordable — for many people, premiums are $10 or less per month — and there are more plan options than ever. “I think this is really reflecting a turnaround in the ACA marketplaces,” says Cynthia Cox, who directs the Program on the Affordable Care Act for KFF, a nonpartisan health research organization.

Those low premiums and numerous plan options have spurred record high enrollment in ACA plans.

Most Americans get their insurance through their jobs or through a public program like Medicaid or Medicare. But still, this program has a big impact. As enrollment in the marketplaces set new records in the last few years, the number of uninsured Americans has dropped dramatically.

“Under President Biden and Vice President Harris, more Americans have access to a doctor, a hospital through their own health insurance than ever in the history of the country,” Secretary of Health and Human Services Xavier Becerra tells NPR. After this year’s open enrollment, he adds, “I have no doubt that we'll see another record set of Americans who have health care coverage.”

But this could be the high watermark for enrollment in these plans, depending on who is elected president and whether the next Congress acts to keep extra federal subsidies, which have made the health plans so affordable.

What’s new this year

One group that’s newly eligible for these subsidized marketplace plans is Deferred Action for Childhood Arrivals recipients, also known as Dreamers. Secretary Becerra says that an estimated 100,000 DACA recipients are expected to enroll.

“It's a good day for all these folks because for the longest time they've been working [and] paid taxes and not had a chance to get their coverage through the Affordable Care Act — that changes,” he says.

Camila Bortolleto is one of the Dreamers who’s been waiting for this. She came to the U.S. with her family from Brazil when she was nine. She’s now 36, living near Danbury, Ct., and uninsured, since her job with health benefits ended over the summer. That has meant, for example, paying out of pocket at urgent care when a dog bit her a few weeks ago.

“It is stressful,” she says. “I do need to get a checkup. I do need to go to the dentist now. And you never know when a random emergency's going to strike.” She planned to sign up as soon as enrollment opened on Friday.

Also new in 2025 is a rule that allows low income people to enroll in a marketplace health plan at any time of the year, not just during fall’s open enrollment period. That mirrors how enrollment works for Medicaid, the public health insurance program for people with low incomes.

Insurance companies will also have to follow new limits on how long patients should have to wait to get a doctor’s appointment.

“Some marketplace plans have very narrow networks — that means that there are very few doctors or hospitals that the insurance company will pay for you to see, so it could be harder to get an appointment,” Cox explains. “This is one step towards trying to make sure that having health coverage also means having access to health care.”

A consequential election for these health plans

Although health policy has not been a big focus of the presidential race, this whole picture could change depending on the outcome of the November election.

Former president Donald Trump has not campaigned as much — this time — on the problems with the Affordable Care Act, but he did say in the presidential debate he has the “concepts of a plan” for what could replace the law. Vice President Harris says she wants to preserve the law and improve on it.

The makeup of the next Congress could also play a big role in the future of these marketplaces. The extra federal subsidies that have made premiums so affordable will expire at the end of next year, unless lawmakers vote to extend them or make them permanent.

Important dates

Enrollment will be open until Jan. 15 in most states. To get coverage that is ready to go on Jan. 1, 2025, though, people need to sign up by Dec. 15. And Idaho has its own open enrollment period rolling from Oct. 15 to Dec. 15.

There are 17 states that run their own health insurance marketplaces, but everyone can start at HealthCare.gov to find out how to pick a plan in your state.