Sign-ups in Affordable Care Act marketplaces reach record 14.5 million

About 14.5 million Americans have signed up to get health coverage this year through Affordable Care Act insurance marketplaces, eclipsing the previous record enrollment by nearly 2 million.

The popularity of ACA health plans is a substantial slice of good news for President Joe Biden, who has made expanding access to affordable health insurance one of his principal domestic policy aims, while some approaches he favors to achieve that goal have stalled on Capitol Hill.

The enrollment figure is the heart of a report to be released Thursday by the Department of Health and Human Services. The White House rushed out a statement from the president in advance, in which Biden said he was proud that the sign-ups are “the highest numbers ever produced in an open enrollment period.”

The tally is not quite final, so it probably will be higher in the end.

The 14.5 million figure includes a final count of 10 million consumers who chose health plans during the most recent open-enrollment window through HealthCare.gov, the federal insurance marketplace on which 33 states rely. For 17 states and the District of Columbia, which run their own insurance marketplaces under the ACA, the data being released Thursday includes their roughly 4.5 million sign-ups through Jan. 15, the deadline for the federal open enrollment.

Five state-run marketplaces plus the District’s are still open for consumers to buy health coverage for 2022. And three states and the District have created special enrollment periods that will allow uninsured residents longer to sign up for ACA coverage.

The ACA is a sprawling health care law, pushed through a Democratic Congress in 2010, that has become a source of partisan warring ever since.

The insurance marketplaces created under the law began offering coverage in 2014.

The health plans are intended for consumers who cannot get affordable benefits through a job, meaning they must buy plans on their own - a part of the U.S. insurance industry that was especially dysfunctional in the past, with companies charging high prices for such individual coverage and rejecting many people with medical conditions. The ACA stopped the practice of spurning or overcharging people with preexisting conditions and for the first time provided federal subsidies to most people buying marketplace plans.

President Donald Trump was a vehement foe of the law. During his administration, he and a Republican Congress repeatedly tried to repeal large parts of it but didn’t succeed. Trump and his health care aides nevertheless took aim at the insurance marketplaces, slashing federal money for advertising and other outreach activities, as well as for “navigators” who serve as community-level enrollment coaches.

Biden’s arrival in the White House a year ago marked a striking turnabout. The president moved swiftly to rehabilitate the law as the main tool to expand the number of Americans with insurance coverage and to make health plans more affordable. It had been a central campaign goal but assumed greater significance as the coronavirus pandemic cost millions of people their jobs and health benefits - and as the virus laid bare the importance of being able to get appropriate care when sick.

ACA open-enrollment periods typically run for several weeks starting mid-fall for the coming year. A week into his presidency, Biden announced an unprecedented special enrollment period for eligible people to buy an ACA health plan if they needed coverage because of the pandemic. The period eventually stretched six months and attracted 2.8 million people to sign up for plans.

The coronavirus relief law Congress adopted in March contained the first expansion of federal subsidies for ACA health plans in the program’s history. The law, known as the American Rescue Plan, increases tax credits for monthly insurance payments and allows people with higher incomes to qualify for such help.

And the administration reversed its predecessor’s cuts in funding for outreach and navigators, putting more money into those activities than in the past. Federal health officials also extended the open-enrollment period a month longer than it had been in recent years.

The number of people who sign up for an ACA health plan typically dips somewhat as bills from insurance companies arrive. People secure coverage only if they pay whatever share of the monthly premiums they owe after taking into account the subsidy that most consumers get.

Still, even without being final, the new sign-up figure is 21% greater than the final enrollment - 12 million - in federal and state marketplaces a year ago. The previous record was nearly 12.7 million sign-ups for 2016, the marketplaces’ third year. Even during the Trump years, ACA enrollment never fell below 11 million, and it increased slightly for 2021, during the pandemic.

The marketplaces’ increased popularity contrasts with the fate of other health policies Biden espouses.

Congress has never seriously considered some of his campaign positions, such as creating a public insurance alternative to compete with private health plans. Other goals, such as adding Medicare benefits and helping insure more low-income people in states that have not expanded Medicaid under the ACA, have become bogged down in friction among Democrats over the social spending bill that proponents call Build Back Better.