What was the impact of COVID relief on health insurance enrollment rates?

1. Pandemic relief’s clearest effect: big growth in the individual market

The American Rescue Plan Act (ARPA) and later extensions materially expanded advance premium tax credits and eligibility, and public-health relief measures coincided with a doubling of ACA marketplace enrollment from about 11 million in February 2021 to roughly 23–24 million by 2025 — a change reported and quantified by KFF and echoed by policy analysts ^{[1] [2] [3]}. That enrollment growth translated into a notable offset against job-loss-driven declines in employer coverage and helped push the uninsured rate down in 2020–2025, according to CMS and KFF reporting ^{[6] [2]}.

2. The math behind the shift: subsidies lowered costs and drew people in

ARPA’s subsidy enhancements reduced up‑front premium burdens by increasing advance premium tax credits and by removing the 400% FPL cliff for middle‑income people; the credits are advanceable and can be applied directly to monthly premiums, which made plans affordable enough for many previously uninsured or self‑insured workers to enroll ^{[7] [1]}. Analysts note that roughly 90%+ of marketplace enrollees received subsidies in recent years, underscoring how central the credits were to enrollment growth ^{[8] [5]}.

3. What happens if the enhanced relief expires: big price shock, likely enrollment declines

Multiple nonpartisan analyses and news outlets calculate a stark reversal if the enhancements lapse: KFF projected average premium payments for marketplace enrollees would rise about 114% (from $888 in 2025 to $1,904 in 2026) absent the enhanced credits, and federal and academic estimates foresee several million people losing coverage — commonly cited figures include roughly 3.8 million fewer insured people in CBO projections and similar estimates from the Urban Institute and other analysts ^{[1] [2] [4] [5]}. FactCheck and CBPP explain the mechanism: higher premiums push some enrollees — often younger and healthier people — out, which can worsen risk pools and prompt further rate increases ^{[5] [2] [4]}.

4. Distributional effects and political dynamics

Reporting highlights that enrollment growth was geographically and politically significant — concentrated in many Southern states and including people who voted for President Trump in 2024 — which complicates the political calculus around extending the credits ^{[8] [9]}. Policy writers note tradeoffs: making enhancements permanent would raise federal deficits (analyses estimate large ten‑year budget impacts) while preserving coverage gains, and the debate is framed through both fiscal and partisan lenses ^{[7] [2]}.

5. Other pandemic-era policies also affected public coverage and churn

Beyond marketplace subsidies, pandemic relief and statutory changes (e.g., continuous Medicaid enrollment protections tied to federal COVID funding) kept many people enrolled in Medicaid and CHIP longer than usual, cushioning uninsured rates despite employment shocks — CMS noted fewer uninsured in 2020 as Medicaid and marketplace gains offset employer coverage declines ^{[6] [10]}. Academic surveys also show people used multiple safety‑net programs during the pandemic, affecting overall enrollment dynamics ^[11].

6. Areas of uncertainty and limitations in current reporting

Available sources emphasize projections and model-based estimates that depend on behavioral responses: CBO, KFF, CBPP and others model how many will drop coverage, but actual outcomes depend on consumer reactions to price increases, outreach during open enrollment, and possible congressional action to extend credits ^{[1] [2] [4]}. Open questions left unaddressed in these pieces include exact short‑term churn rates when premiums rise and how state-level policies will moderate national effects — available sources do not mention precise, realized enrollment declines post‑expiration because those are projections rather than observed outcomes ^{[2] [1]}.

7. Bottom line for readers and policymakers

Pandemic-era premium tax credit enhancements clearly boosted marketplace enrollment and reduced the uninsured; if they expire, the prevailing estimates show large premium increases and multimillion‑person coverage losses, with broader spillovers for premiums and market stability ^{[1] [2] [4]}. Policymakers face a classic tradeoff between fiscal cost and coverage: extend the subsidies to preserve gains or allow expiration and accept sizable reversals in access and affordability documented in current analyses ^{[7] [2]}.