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A series of policy changes in the so-called "big beautiful bill" are undermining the Affordable Care Act marketplace, in ways that may at first seem relatively subtle but which add up to a major change, health policy experts say.
That, in turn, has important implications for consumers and the broader health care system for years to come, they said.
The law — a multitrillion-dollar package that the Republican-led Congress passed in July — contains a series of administrative measures that make it harder or more expensive for many people to sign up for health insurance on the ACA marketplace, experts said.
Those policies concerning the marketplace would add about 3 million people to the ranks of the uninsured over the next decade, the Congressional Budget Office estimated in September.
Among them: ending automatic insurance renewals, removing certain financial protections for lower earners, tweaking annual enrollment periods, and barring many immigrants in the country legally from signing up for ACA marketplace insurance or accessing financial aid.
However, the administrative maneuvers — many of which are technical in nature and, on their face, may not seem consequential — have largely gone unnoticed by the public, experts said.
"A lot of things that are happening are kind of under the radar," said Jonathan Oberlander, a professor at the University of North Carolina and an expert in health-care politics and policy. "I'd describe the strategy as one of partial stealth," he said.
Other parts of the law — like more than $1 trillion of cuts to Medicaid, the public health program for lower earners — have garnered the bulk of public attention, experts said.
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Largest rollback of health insurance coverage
The Affordable Care Act, also known as Obamacare, established a health insurance marketplace where Americans could shop for private health plans.
The law, passed in 2010, also created premium tax credits and other assistance to make coverage more affordable for certain enrollees, and expanded access to Medicaid.
ACA marketplace enrollees are often small business owners, gig workers, freelancers and others who can't get health insurance elsewhere, such as via Medicaid, Medicare or coverage through an employer.
Obamacare helped drive down the U.S. uninsured rate to record lows in recent years, experts said.
However, health provisions in the "big beautiful bill" amount to the largest rollback of health insurance coverage in U.S. history, Oberlander said.
The share of the U.S. population without health insurance is expected to swell from 7.6% in 2025 to 10.4% by the end of the decade, according to the CBO.
Total enrollment in ACA marketplace health plans is expected to fall to 12.5 million by 2028, the CBO estimated in February. That would be about half of last year's enrollment and represent a near-erasure of all gains in marketplace sign-ups since 2021, when the enhanced subsidies took effect.
There are many potential downstream effects of this dynamic, according to health experts.
Millions of Americans becoming uninsured pose a serious financial risk to affected households, they said. Millions more will shift to plans with higher deductibles, reducing upfront premiums but leaving them exposed to big medical bills if they need to use their insurance.
I'd describe the strategy as one of partial stealth.Jonathan Oberlanderprofessor at the University of North Carolina
I'd describe the strategy as one of partial stealth.
professor at the University of North Carolina
There are also implications for the health care system at large. Hospitals with higher uninsured populations would likely face financial pressures, in turn impacting everyone who goes to the hospital by reducing resources available to treat people, Oberlander said.
"When individuals lose health insurance coverage, they ultimately turn to their local hospital when they need care," the American Hospital Association wrote in June. "This affects everyone, not only the uninsured, leading to overcrowded emergency departments, longer wait times and increased costs for care, which acts as a 'hidden tax' on all."
'Repeal and replace,' by a different name
The late Sen. John McCain (R-AZ) leaves the Senate Chamber after a vote on a stripped-down, or 'Skinny Repeal,' version of Obamacare reform on July 28, 2017 in Washington, DC. McCain was one of three Republican Senators to vote against the measure.
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Republicans have tried to dismantle the Affordable Care Act for years, partly due to ideological differences in health policy and increased partisan polarization, experts said.
Indeed, the ACA was passed into law in 2010 without a single Republican vote.
Health policy experts said the administrative policies in the "big beautiful bill" that aim to cripple the ACA amount to a less flashy version of "repeal and replace."
The term refers to previous Republican efforts to scrap large parts of the ACA and replace it with something new.
The GOP came close to fulfilling that goal during President Donald Trump's first term in office. However, the late Republican Sen. John McCain of Arizona cast a decisive thumbs-down vote in the Senate in 2017, scuttling legislation to repeal the health law.
President Trump has often said he dislikes the Affordable Care Act.
"The best thing we can do, politically speaking, is let Obamacare explode," he said in the White House in March 2017. "We'll end up with a truly great health care bill in the future after this mess known as Obamacare explodes," he added.
In October 2017, a few months after the effort to repeal the ACA failed in the Senate, he wrote on social media site X that "ObamaCare is a broken mess."
"Piece by piece we will now begin the process of giving America the great HealthCare it deserves!" he wrote.
Trump and congressional Republicans have said the ACA has contributed to rising costs for health care, such as insurance premiums. There is some debate on this point, though, and some experts point to other contributors to rising costs, such as consolidation among health care providers and physician billing practices.
Policies in the "big beautiful bill" — including cuts to Medicaid — and the expiration of enhanced premium tax credits will lead about 15 million people to lose health insurance, the CBO estimated in June when scoring the impact of the legislation.
"[That's] not far outside the scope of what some of the repeal-and-replace plans from 2017 would have done," said Cynthia Cox, director of the Affordable Care Act program at KFF, a nonpartisan health policy research group.
