The Trump administration issued its first major set of proposed changes to the Affordable Care Act on Monday that federal officials said are intended to crack down on fraud in the program. Policy experts said they will make it harder for consumers to sign up for coverage, potentially reducing enrollment.
Details were released Monday after a draft press release was inadvertently posted earlier.
About 24 million Americans signed up for insurance plans sold under the ACA, known popularly as Obamacare, for 2025. The Biden administration achieved record enrollment levels after increasing premium subsidies for many lower-income people, which resulted in reducing the monthly cost of some plans to $0. It also made it easier for some very low-income people to sign up at any time of year, instead of waiting for an enrollment period each fall. But the program became plagued by fraudulent enrollment last year, generating about 274,000 consumer complaints through August, most focused on rogue insurance agents and other bad actors, to the Centers for Medicare & Medicaid Services.
The Trump administration said in a statement Monday that the new regulations include “critical and necessary steps to protect people from being enrolled in Marketplace coverage without their knowledge or consent, promote stable and affordable health insurance markets, and ensure taxpayer dollars fund financial assistance only for the people the ACA set out to support.”
Policy experts said the changes, though, will impose new paperwork burdens likely to hamper enrollment.
“Under this banner of trying to crack down on the bad actions of some insurance brokers, they are penalizing consumers, particularly low-income consumers, with more burdensome requirements and more limits on their access to coverage,” said Sabrina Corlette, a research professor and the co-director of the Center on Health Insurance Reforms at Georgetown University.
Among other new requirements, consumers would have to provide more information proving their eligibility for special enrollment periods and for premium subsidies when they enroll. The regulation would also shorten the annual enrollment period by a month. And it touches on social issues, limiting eligibility for “Dreamers” — a nickname for immigrants in the country illegally who were brought here as children, based on never-passed proposals in Congress called the DREAM Act.
The proposal would eliminate the year-round opportunity for a special enrollment period for people with very low incomes. But it would also set new requirements for the remaining special enrollment periods, which allow people to sign up after major life events, such as when their income changes, they lose their job-based coverage, or they get divorced, marry, or move. They would now have to provide evidence of their eligibility when applying under those special situations.
People auto-reenrolled into zero-premium plans during the regular enrollment period would be charged a small monthly payment until they confirm or update their information.
The ACA marketplaces, according to the proposal, would have to seek additional data from consumers, including the self-employed or gig workers, who estimate their income for the coming year but don’t have tax return data filed with the IRS for previous years.
The Biden administration made changes to reduce fraudulent enrollment last year including requiring three-way calls among insurance brokers, their clients, and the federal insurance marketplace, healthcare.gov, when certain sign-ups or coverage changes were made.
Some of the Trump administration’s proposed changes could help warn certain consumers that they’ve been unknowingly enrolled in an ACA plan, such as a requirement that some customers on even the least expensive plans receive a small, monthly premium bill.
However, the additional paperwork and other eligibility requirements “will probably have a downward effect on enrollment,” said Cynthia Cox, a vice president and the director of the Program on the ACA at KFF, a health information nonprofit that includes KFF Health News. “Some of that could be protecting enrollees who were fraudulently signed up or don’t realize they’re still signed up.”
Still, it could prove difficult for some people if they’re not able to document an expected change in income. “They might have a legitimate claim but have a hard time demonstrating it,” Cox said.
The annual open enrollment period would end Dec. 15, a month earlier than this year. The designated period is when most people sign up and is intended to prevent people from waiting until they get sick to enroll, a move that helps slow premium growth.
The Trump proposal also touches on social issues.
It would reverse the Biden administration policy that allows Dreamers to qualify for subsidized ACA coverage. That decision is already the subject of a court challenge brought by 19 states seeking to overturn it.
Also under the Trump proposal, gender-affirming care would not be considered part of the “essential health benefits” that all plans must cover.
According to an FAQ that accompanied the initial press release of the proposed regulations, the provision could “lead to increased out-of-pocket costs for individuals requiring sex-trait modification services, as they may need to seek plans that offer this coverage as a non-EHB or pay for services out-of-pocket.”
As a proposed rule, the measures now face a public comment period and potential revision before being finalized.
“None of it will go into effect right away,” said Katie Keith, director of the Center for Health Policy and the Law at Georgetown University. “The question is how much will apply in 2025 versus 2026.”
The FAQ acknowledged that some of the proposed changes, including ending year-round enrollment for very low-income people, “may increase the administrative burden for consumers associated with enrollment and verification processes or could deter some eligible low-income individuals from enrolling.”
But, it continued, “we believe that enhancing program integrity and reducing improper enrollments outweighs these potential impacts on access to coverage.”
Some lawmakers and conservative groups have pointed to the concerns about unauthorized enrollment and the role, if any, that ACA subsidies or enrollment periods have in fueling the problem.
The right-leaning Paragon Health Institute, for example, released a report in June that, among other things, called for the Biden administration’s expansion of the special enrollment period for low-income people to be reversed.
“There is substantial amounts of fraud and waste in the ACA exchanges and the Biden administration pursued the enrollment-at-all costs strategy, and was tolerant of the waste, fraud and abuse,” said Brian Blase, a former health aide during Trump’s first presidency who is president of the Paragon Health Institute and influential within the current Trump administration. “Clearly a different approach to protect legitimate enrollees and taxpayers is needed.”