Black Book Market Research

WASHINGTON, April 26, 2025 (Newswire.com) - A national survey by Black Book Research indicates significant concerns and widespread opposition among Affordable Care Act (ACA) enrollees toward proposed healthcare policy changes under the current administration. Conducted between March 5 and April 20, 2025, the survey gathered insights from 1,000 ACA participants across 28 states (as of the 2025 plan year, these states utilize the Federally Facilitated Marketplace, accessing health insurance plans through HealthCare.gov) highlighting critical priorities and fears among American healthcare consumers.

Currently, approximately 24.2 million Americans rely on ACA Marketplace plans which is a historic enrollment peak largely driven by enhanced subsidies introduced by the American Rescue Plan Act (2021) and extended through 2025 by the Inflation Reduction Act. In total, over 45 million Americans depend on ACA-related coverage, including Medicaid expansion.

ACA enrollment is particularly substantial in traditionally Republican states, demonstrating the program's bipartisan appeal. Seven of the top ten ACA-enrolled states-Florida, Texas, Georgia, North Carolina, South Carolina, Tennessee, and Ohio-lean Republican and have experienced significant growth since 2020 due to improved affordability from federal subsidies.

As of April 2025, ten U.S. states have not expanded Medicaid under the Affordable Care Act (ACA): Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming. In these non-expansion states, many low-income adults fall into the "coverage gap," earning too much to qualify for traditional Medicaid but not enough to afford private insurance or qualify for ACA subsidies. The enhanced subsidies introduced through the American Rescue Plan and extended by the Inflation Reduction Act have made ACA Marketplace plans particularly attractive in these regions, leading to significant enrollment growth.

States with remarkable ACA enrollment growth since 2020 include:

Texas: Enrollment surged by 255%, the nation's highest increase.

Mississippi: Enrollment rose by 242%.

West Virginia and Louisiana: Each state experienced a 234% rise.

Georgia: Enrollment grew by 227%.

Tennessee: ACA sign-ups increased by 221%.

Key Survey Insights:

Awareness and Communication Gaps: Only 18% of respondents were aware of the proposed ACA changes upon receipt of this polling request, while 82% remained unaware, indicating critical communication shortfalls. Notably, the current administration has proposed a series of changes to ACA that could significantly impact how Americans access health insurance. The annual open enrollment period would be shortened to just 45 days, from November 1 to December 15, making it harder for some individuals to sign up for coverage. The administration also plans to end the monthly enrollment option for low-income individuals earning up to 150% of the federal poverty level, a move that could limit access to affordable insurance for many vulnerable populations. To tighten oversight, the proposal would require that at least 75% of new special enrollment applications be verified for eligibility, aiming to reduce improper enrollments. Additionally, the proposed rule would allow insurance plans to exclude coverage for gender-affirming care starting in 2026 by removing it from the list of essential health benefits. Another major change would restrict ACA coverage eligibility for Deferred Action for Childhood Arrivals (DACA) recipients, known as "Dreamers," reversing previous efforts to expand access. Together, these proposed changes reflect a broader effort to reduce federal involvement in healthcare while raising concerns about how the most vulnerable populations might be affected.

Concerns About Coverage Loss: An overwhelming 93% expressed serious concerns about potentially losing ACA coverage. The Trump administration's proposed changes to the Affordable Care Act (ACA) could result in an estimated 750,000 to 2 million people losing their health coverage if the rule is finalized. According to the Centers for Medicare & Medicaid Services (CMS), the coverage losses would be most concentrated in states like Alabama, Florida, Georgia, Mississippi, North Carolina, South Carolina, Tennessee, Texas, and Utah, although reductions are expected nationwide.While these measures are intended to reduce improper enrollments and promote program integrity, they could also disproportionately impact low-income individuals and vulnerable populations who currently rely on the flexibility and protections provided by the ACA.

Financial Stress and Potential Coverage Loss: 90% indicated premium increases would severely impact their finances. 59% reported they would likely discontinue their health insurance if premiums significantly increased. A notable 67% of respondents cited a threat of increased unemployment, specifically recent layoffs of federal workers from agencies such as the Department of Health and Human Services (HHS) and the Centers for Medicare & Medicaid Services (CMS), as substantially exacerbating their concerns about healthcare access and affordability.

Strong Opposition to ACA Changes: Only 9% supported the proposed ACA modifications, while 78% opposed the changes, citing affordability and coverage concerns. Surveys indicate that a substantial majority of Americans value programs like Medicaid, with 98% acknowledging its importance to their local communities and 86% considering it significant for their families. Even among Republican voters, including those who supported President Trump in 2024, there is notable support for maintaining or increasing Medicaid funding, reflecting the program's widespread reach and significance.

Respondents' Preferred Solutions: 68% favored expanding subsidies for ACA affordability. 33% supported introducing a public healthcare option. 20% suggested strengthening Medicaid expansion for low-income individuals. Given this landscape, the public is likely to endorse policy recommendations that focus on enhancing healthcare affordability and access without imposing stringent restrictions. Suggestions include extending open enrollment periods to provide more flexibility, maintaining continuous enrollment options for low-income individuals, and ensuring coverage for essential health benefits, including preventive and gender-affirming care.

There is strong public support for measures that address fraud and inefficiencies within the system, provided they do not compromise access to necessary services. Overall, 81% of the surveyed public favors a balanced approach that safeguards healthcare access while promoting program integrity.

Methodology

The survey employed rigorous methodology, utilizing stratified sampling to reflect diverse demographics including age, income, and geography. Data was collected via email and online platforms via a third party panel supported sample, achieving demographic accuracy with a 95% confidence level and a ±3% margin of error.

"These findings reveal a deep and growing anxiety among ACA enrollees about the potential loss of critical healthcare protections, particularly as political uncertainty intensifies," stated Doug Brown, founder of Black Book Research. "Respondents' strong opposition to potential rollbacks sends a clear signal: there is diminishing public patience for political maneuvering that risks healthcare affordability and access. The survey responses highlight the urgent need for policymakers to engage in transparent, consistent communication and prioritize actionable solutions, especially as economic pressures and unemployment fears escalate."

About Black Book Research

Black Book Research is an independent market research firm specializing in healthcare, technology and public opinion. Committed to delivering unbiased and insightful data, Black Book Research enables policymakers and organizations to make informed decisions that enhance healthcare outcomes and accessibility nationwide. Contact research@blackbookmarketresearch.com

Source: Black Book Research