When Kathy Cox of Bainbridge, Georgia, ended up in the emergency room in January, she was thankful for the Obamacare insurance she had recently selected for her 2024 coverage.
Cox, 40, has a relatively low income and can get an Affordable Care Act marketplace plan without paying monthly premiums. She said she cut her hand so badly that she needed 35 stitches in the emergency room, which resulted in her out-of-pocket expenses of about $300.
“I can't imagine how much an emergency room visit would have cost if I didn't have insurance,” she said.
Cox is one of 1.3 million people who have signed up for health insurance through Georgia's ACA marketplace this year, a 181% increase in enrollment since 2020.
No-premium and low-deductible plans have become increasingly common thanks to increased federal subsidies put in place by President Joe Biden, attracting many lower-income people.
(Read more: Tennessee hits record number of Obamacare subscribers as President Trump renews calls to repeal ACA)
Southern states will see the largest enrollment growth of any region: Ten of the 15 states that will more than double the number of markets between 2020 and 2024 are in the South, according to a KFF policy brief. And the five states with the largest enrollment growth (Texas, Mississippi, Georgia, Tennessee and South Carolina, all in the South) have yet to expand Medicaid under the Affordable Care Act, shifting many residents to premium-free health insurance plans.
But with federal incentives put in place by the Biden administration set to expire at the end of 2025 and the possibility of President Donald Trump being re-elected, policy analysts say the South could see a big drop in ACA enrollment.
“Georgia and Southern states in general have lower per capita incomes and higher rates of uninsurance,” said Gideon Lukens, senior fellow and director of research and data analysis at the Center on Budget and Policy Priorities, a nonpartisan research institute based in Washington, D.C.
He said states in the South, especially those that haven't expanded Medicaid, are likely to be hit harder than others when the increased funding runs out.
Lukens said that for many people who lose insurance in non-expansion states, “there's no other safety net.”
When Cox signed up for Obamacare last fall, she was eligible for premium tax credits added to two major congressional bills: the American Rescue Plan Act of 2021 and the Combat Inflation Act of 2022. These incentives led to a slew of plans with no premiums and low out-of-pocket costs, helping to boost the number of people enrolled in Obamacare to a record 21 million this year. The extra subsidies were on top of existing subsidies for Marketplace insurance.
States that didn't expand Medicaid and have high uninsured rates “got most of the free plans,” said Cynthia Cox, vice president who directs the ACA program at health policy nonprofit KFF. She added that zero-premium plans existed before the new subsidies but typically came with high copayments that could lead to higher costs for consumers.
With President Donald Trump in office, those extra subsidies could be in jeopardy. Eliminating the extra subsidies would return the markets to the original intent of the ACA, said Brian Blades, a former Trump administration official who advised him on health policy.
“A taxpayer-funded, all-insurance system is neither sustainable nor prudent,” said Mr. Blades, now president of the health policy research firm Paragon Health Institute. People will still be eligible for discounts, but they probably won't be as big as they were before, he said.
Trump spokeswoman Caroline Levitt declined to answer reporters' questions about the future of the enhanced subsidies under a Trump administration. Despite saying late last year that the administration was “seriously looking at alternatives” to Obamacare, Levitt said Trump was not campaigning to repeal it.
“He's running to not only lower inflation, cut taxes and reduce regulations to put more money back in the pockets of all Americans, but to actually make health care affordable,” she said.
(Read more: Southern lawmakers reconsider opposition to Medicaid expansion)
Opinion on Obamacare may be divided, but broad support for the subsidies cuts across political lines, according to a KFF Health Tracking poll released in May.
The poll found that roughly 70% of voters support extending enhanced federal financial support for people who buy insurance through the ACA markets, including 90% of Democrats, 73% of independents and 57% of Republicans surveyed.
The increased assistance means that many people earning more than 400% of the poverty level — $58,320 for an individual in 2023 — can get a tax credit for insurance for the first time.
Besides financial incentives, another cited reason for the ACA enrollment surge is the end of continued Medicaid coverage protections related to the COVID-19 public health emergency. About a year ago, states began redetermining eligibility, a process known as “unfreezing.”
About a quarter of people who lost Medicaid insurance moved into the ACA marketplaces, said Edwin Park, a research professor at Georgetown University's Center for Children and Families.
In Georgia, Republican political leaders have not said much about the effect the Biden administration's premium incentives will have on increasing enrollment.
Instead, Georgia Gov. Brian Kemp and others have touted the work of Georgia Access, an online portal that links consumers directly to ACA marketplace websites, agents and brokers. The agent links can create a more personal connection, said Bryce Lawson, a spokesman for the state Insurance Department, which runs the portal. Staff from the department and consulting firms have helped promote the premium-free plans across the state, he said.
But Georgia Access wasn't fully operational until the marketplace enrollment period last fall. Republicans also credited the reinsurance waiver with increasing the number of health insurers offering marketplace insurance in the state, which has led to more competition. Lawson said the waiver has increased the number of health insurers offering marketplace insurance in Georgia, which has led to more competition.
Georgetown's Park said reinsurance likely isn't the main reason for the state's increase in Obamacare enrollment, and a study in Health Affairs magazine recently reported that Georgia's reinsurance plan had the unintended consequence of raising the minimum cost of subsidized ACA coverage and reducing enrollment among people at certain income levels, as reported by The Atlanta Journal-Constitution.
The state's Insurance Department said the study “does not accurately reflect the overall benefits the reinsurance program has provided to Georgia consumers.”
Asked whether the governor would support renewing the funding, Kemp's spokesman, Garrison Douglas, said the issue was up to the Legislature to decide.
Another reason for the surge in ACA enrollment is that the “family glitch” will be fixed in 2023, which meant that dependents of workers who were offered expensive family coverage by their employers were not able to receive marketplace subsidies.
(Read more: Tennessee becomes first state to provide free diapers to Medicaid recipients)
But states that run their own marketplaces generally haven't seen the same levels of enrollment growth. These 18 states and the District of Columbia have expanded Medicaid. Georgia will join the list of states that run their own exchanges this fall, becoming the only state that runs an exchange that hasn't expanded Medicaid.
The federal Centers for Medicare & Medicaid Services is evaluating a national marketing campaign and increased federal funding for navigators, insurance counselors who provide free education about and help people sign up for health insurance on the insurance marketplace.
This level of financial support for mariners could be in jeopardy if President Trump returns to the White House.
The Biden administration has pumped about $100 million into navigators over the course of the insurance enrollment period this year, compared with the Trump administration, which provided just $10 million per year to navigators from 2018 to 2020.
KFF's Cox said the marketplace is typically a “transitional space” for those who join and leave insurance, and “marketing and outreach are really important to help people literally navigate that process.”
KFF Health News is a core operating program of KFF, a national newsroom producing in-depth journalism on health issues and an independent source of health policy research, polling and journalism. Learn more about KFF here.
