Enrollment Growth in the ACA Marketplaces
ACA Marketplace enrollment has reached a record-high for a fourth year in a row, totaling 24.3 million people in 2025. Much of this growth can be attributed to the enhanced subsidies first made available by the American Rescue Plan Act (ARPA) in 2021 and later extended through the end of 2025 by the Inflation Reduction Act (IRA). Since 2020, enrollment in the Marketplaces has more than doubled, growing by 12.9M (a 113% increase) from 11.4M to 24.3M.
Where Have ACA Marketplaces Grown the Most?
Almost all states have seen increases in enrollment, but some have seen more growth than others. Enrollment has more than tripled in Texas (255% growth), Mississippi (242%), West Virginia (234%), Louisiana (234%), Georgia (227%), and Tennessee (221%). In total, 20 states since 2020 have seen their Marketplaces more than double.
A few states (New York, Oregon, and the District of Columbia) saw their Marketplaces shrink since 2020. These states are unusual because they have expanded programs (e.g. Basic Health Plan, high Medicaid eligibility). Low-income enrollees who would typically be part of the ACA Marketplace instead receive coverage from one of these expanded programs.
As of 2025, 88% of the total growth in the Marketplaces since 2020 (11.4M out of 12.9M new enrollees) is from states President Trump won during the 2024 election. On average, states that voted for President Trump have seen Marketplace enrollment grow by 157% while states that voted for former Vice President Harris saw a 36% increase in Marketplace enrollment.
The top 15 states with the most growth in the ACA Marketplace since 2020 were all won by President Trump in 2024. An earlier KFF analysis showed that states that had not expanded Medicaid and those that started off with high uninsured rates saw the most growth in ACA Marketplace enrollment. In states that currently have not expanded Medicaid, Marketplace enrollment has grown 188% from 2020 to 2025 compared to 65% growth in expansion states. In states where uninsured rates for children and adults under 65 were at least 10% in 2019, ACA Marketplace enrollment increased by 168% since 2020, whereas states with lower uninsured rates saw enrollment grow by 50%.
What is Next for the Enhanced Premium Tax Credits?
Enhanced tax credits, which have fueled much of the growth in the Marketplaces, are set to expire at the end of this year unless Congress votes to extend them. The enhanced tax credits have increased the affordability of coverage and newly extended financial assistance to middle-income enrollees making above 400% of poverty. Had it not been for the enhanced subsidies, annual premium payments for subsidized enrollees in 2024 would have been $705 (79%) higher, on average, up from $888 to $1,593.
The CBO estimates that the cost of permanently extending the enhanced subsidies would be $335 billion over a 10 year period. If the enhanced subsidies are not renewed, it is expected that 3.8 million more people would become uninsured. Additionally, CBO projects that the loss of enhanced subsidies would prompt healthy enrollees to leave the ACA Marketplace and, consequently, insurers to increase the sticker price of premiums.
