Carley Calvi arrived on the second floor of a public library in suburban Milwaukee one morning this month, without health insurance to cover the anti-dizziness medication she needed. Worse still, she said, she didn’t have a doctor she trusted.

“I want someone to value me as the person I am,” said Ms. Calvi, a 35-year-old carpenter.

With about 110 options and the help of a health insurance navigator, she selected a plan with a steeply reduced monthly premium of $221, placing her among the 21.3 million people who have signed up for coverage on the Affordable Care Act markets for 2024. The total, announced Wednesday by the Biden administration, set a record for the third consecutive year and is nearly double the number of enrollments since 2020.

The increase in enrollment was driven by the continuation of more generous federal grants since the coronavirus pandemic.

President Biden and congressional Democrats extended the grants for two years as part of a pandemic relief package in 2021, and they later passed a three-year extension through 2025, meaning the Americans will be able to benefit from the strengthening of subsidies. assistance for an additional annual open enrollment period.

But what happens next will depend on the outcome of the November election and the resulting political environment.

Now in its second decade, the Affordable Care Act no longer faces an existential political threat. As former President Donald J. Trump, the front-runner for the Republican presidential nomination, recently renewed his opposition to the law, pressure to repeal the law known as Obamacare has lost steam. animating force among Republican candidates and voters. The law is also deeply ingrained in the American health care system.

“If we had this discussion in 1977 about Social Security or Medicare, I think most people would say, ‘Sure, improve it, but don’t repeat it,'” said Secretary Xavier Becerra to Health and Social Services. a meeting. “And if one of the things that has made it better for more Americans is making it more affordable through these subsidies, I doubt you’ll find many Americans who would say, ‘Go ahead, remove subsidies.”

But the Affordable Care Act remains closely tied to the nation’s political tides, in part because of the temporary nature of the enhanced subsidies. A Republican president or a Republican-controlled Congress could allow the subsidy expansion to expire, leading to higher premiums and potentially discouraging Americans from signing up for coverage. Such a move would also risk backlash from voters unhappy with higher costs.

“I had a low-level alarm go off in my brain,” said Sabrina Corlette, a research professor at the Center on Health Insurance Reforms at Georgetown University, referring to the possible expiration of increased subsidies. She added that “much of the sustainability of markets and enrollment growth will depend on the outcome of the 2024 elections.”

Subsidies are calculated on a sliding scale based on income. In addition to making aid more generous, the 2021 pandemic relief package made people with incomes above four times the federal poverty level, or $120,000, eligible for grants for the first time. for a family of four for those registered this year.

Behind the increase in total enrollment is what public health experts say is a notable trend with potential political ramifications: People signing up in large numbers for Obamacare plans in Republican-led states, in particularly those who did not expand Medicaid under the Affordable Care Act.

According to federal data released Wednesday on the open enrollment period for 2024, which ended last week in most states, 4.2 million people signed up for plans in Florida, 3.5 million in Texas and 1.3 million in Georgia, all states that have not adopted the expansion. Overall, more than half of enrollees were in one of the 10 states that did not expand Medicaid.

The subsidies have been a way to “cover people in non-expansion states who otherwise wouldn’t have done so,” said Chris Meekins, a health policy analyst at the financial services firm Raymond James and author of report released Tuesday describing the popularity of markets in red states.

More than 18 percent of Florida’s population is on an Obamacare plan, Mr. Meekins estimated in the report.

Markets also provided important support for Americans who lost Medicaid for the first time since the start of the pandemic, after a federal policy guaranteeing coverage expired in April and forced millions to seek new plans. Federal health officials said Wednesday that at the end of last year, 2.4 million registrations on, the federal marketplace, came from people who had already been enrolled in Medicaid or the health care program. health insurance for children.

More than a million poor Americans living in states that haven’t expanded Medicaid are estimated to still be in what’s known as the coverage gap, stuck with incomes too low to qualify for subsidized coverage. on the markets, but too high to qualify for Medicaid. But many low-income Americans benefit from the increased subsidies. Those whose incomes reach 150 percent of the federal poverty level, or $45,000 for a family of four, are eligible for free Obamacare plans with low deductibles.

Deanna Williams, a health insurance navigator who primarily helps rural residents in central Georgia, said many of those she enrolled in marketplace plans would struggle to afford even one fast food meal.

“These are people who can’t afford their medications,” she said.

The three-year extension of the most generous grants through 2025 had an estimated cost of $64 billion, according to the Congressional Budget Office. Conservative critics of the increased subsidies have argued that the cost to the federal government remains too high relative to the quality of plans in the marketplaces, and that deductibles and co-payments may still be too expensive for Americans of the middle class.

“When you talk to middle-class people and self-employed people, it’s not so much that they want a subsidy,” said Edmund F. Haislmaier, a health policy expert at the conservative Heritage Foundation. “They want lower deductibles and choice of provider.”

As Congress considers whether to extend the expanded subsidies, lawmakers will also grapple with the looming expiration of tax cuts passed by Republicans under Mr. Trump. Many provisions of that law are set to expire at the end of 2025, and Mr. Haislmaier said that timing could lead to horse-trading between the parties.

“There might be a possibility of reaching a compromise,” he said.

Mr. Trump’s campaign did not respond when asked whether he would support extending the increased subsidies beyond 2025. In a social media post in November, he wrote that he was “seriously studying alternatives” to the Affordable Care Act. took advantage of these comments to portray Mr. Trump as a threat to Americans’ health care.

Beyond the fate of increased subsidies, Mr. Trump could take other steps to weaken Obamacare if he returns to the White House. The Biden administration has rushed to provide grants to navigator groups that help people enroll in marketplace plans, and it has also spent a lot of money on advertising to promote The Trump administration has cut subsidies to browser groups and cut advertising spending.

Rep. Frank Pallone Jr. of New Jersey, the top Democrat on the Energy and Commerce Committee, said he could imagine a Trump-influenced campaign among congressional Republicans to let the enhanced subsidies in the part of a broader campaign to undermine the Affordable Care Act.

But people’s experience in the markets in recent years, he said, makes it much more difficult to weaken the law.

“When you ask people to participate in an affordable health insurance program and you tell them they’re going to take it away, I think that’s a much harder message to get out to the public,” he said. he declares.

Federal officials acknowledged that Obamacare plans may still be difficult to choose. Ms. Calvi chose one with a relatively low premium but a high deductible, a compromise she said reflects the infrequency of her doctor visits this year.

But the time it took him and a health care navigator to consider his options — more than an hour — reflected the complexity of the markets. The navigator who helped her, Nicholas Duke, said his consultations typically lasted nearly an hour, a sign of how important expert help is to those choosing their plans.

“It’s just nerve-wracking to choose,” Ms. Calvi said.

Audio produced by Parin Behrooz.

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