The Trump administration has proposed a shortening of the ACA enrollment period and the implementation of eligibility verification checks under fully subsidized plans each year.
Enrollment in the ACA marketplace reached a record high of 23.6 million in 2025, spurred by increased federal subsidies, reducing the cost of premiums for most beneficiaries. The enhanced subsidies are set to expire at the end of 2025. In the first quarter of 2024, CMS said it received 40,000 complaints of customers being enrolled in ACA plans, or switched into a new plan, without their knowledge.
In February, the Trump administration slashed funding for the ACA Navigator program, which helps beneficiaries enroll in ACA plans. According to CMS, navigators enrolled fewer than 1% of ACA beneficiaries during the open enrollment period, despite receiving $98 million in funding.
Becker’s sat down with NCD CEO Sam Melamed and Chief Strategy Officer Bret Voith on the Payer Issues Podcast to discuss the latest proposed reforms, and upcoming opportunities for insurers offering coverage on the marketplace. NCD offers ancillary benefits such as dental and vision.
Editor’s note: This is an excerpt from the podcast. Responses are lightly edited for length and clarity.
Question: How should health plans be preparing for these possible regulatory shifts under the ACA?
Sam Melamed: These are the first ACA regulations from the Trump administration, and they weren’t much of a surprise. The previous administration seemed to focus on growing the ACA at all costs under the idea that growing the program would make it a public good. The new regulations are focused more on cleanup and integrity. Many people assumed that the Trump administration would look to hurt the market or get rid of the ACA, but they’ve been clear that wasn’t their intent. You can start to see that now with these new regulations. Yes, we might see growth slow or even shrinkage, but their focus is more on making the marketplaces economically viable and removing waste, fraud, and abuse. The big debate now in D.C. is about the extension of premium subsidies, which really grew the ACA more than anything. The new regulations, which wouldn’t take effect until 2026 (when the subsidies end), seem to be designed around tweaking elements of those subsidized members.
Bret Voith: One of the things we track closely is the interplay between dental and other supplemental benefits in the ACA market. For example, last year, the Biden administration allowed states for the first time to include adult dental as an essential health benefit for plan years as early as 2027. While this is a big change, there are still many complicated questions about how it will be administered, such as what a reference plan will look like. Will the interplay of dental and ACA offerings play out, or will the administration change directions?
Q: What notable year-over-year trends have you seen in ACA enrollment?
BV: The market is now at an all-time high, with over 20 million Americans enrolled in the ACA. What’s most notable is that states running their own exchanges have seen the greatest growth. Even more surprising, states that typically vote Republican in presidential elections have also seen the strongest growth in recent years. We’re seeing early indications that the Trump administration is focusing on issues like risks with auto enrollment. While it’s hard to be certain, we expect that growth will likely slow and could even see enrollment decline in the upcoming year.
SM: We clearly saw that some broker enforcement rules were put in place in response to fraud linked to easy additions to the ACA since the premium subsidies were created. This shifted where there was less new business on healthcare.gov, but the total number of enrollees still grew due to auto enrollment. One interesting part of the new regulatory proposal is the $5 fee for anyone who had no cost share previously but hadn’t affirmed their enrollment in a new plan. This could help reduce fraud or show that people didn’t realize they had a plan or perhaps qualify for Medicaid. If this leads to people being dropped, it could impact the MLR. Health plan executives need to consider how to project their MLR and price plans properly for 2026.
With the growth in red states and the subsidies’ popularity, it’s hard to imagine a wholesale change that harms those being subsidized right now. I believe the premium subsidies may be extended, possibly with tweaks like work requirements. It doesn’t seem like the goal is to undermine the ACA, but rather to focus on waste reduction and fraud prevention.
Q: How should marketplace plans be repositioning themselves for long-term success?
BV: For ACA-focused plans, there are carriers and distributors who have built their business around the ACA market. Our view is that now is the time for these ACA distributors to add resiliency through diversification. They should expand beyond being just ACA distributors and start thinking about how to serve their clients’ broader needs by offering related ancillary health products, like dental and vision. By diversifying their book of business, they can create more value for their clients and strengthen their relationships by solving a greater range of needs. There’s a broad opportunity for ACA participants to think about other products and how to bring them to clients in the coming months.
