Feygele Jacobs, Kay Johnson, Sara Rosenbaum
June 2025
Alongside the expansion of Medicaid, the Affordable Care Act’s health exchanges or Marketplaces offered affordable insurance options, including subsidies or premium tax credits, for low-income people with no other coverage. Marketplace subsidies reduce the cost of enrollees’ insurance premiums, and in 2021, Congress made these Marketplace plans even more affordable by making the tax credits more generous. Subsidies are income-based, with the greatest subsidies available to people who earn the least, those with incomes between 100%-200% FPL.
Legislation now pending in the OBBBA, as well as HHS Marketplace integrity rules, will discontinue these enhanced subsidies and roll back changes made to simplify insurance enrollment and renewal — resulting in millions more people becoming uninsured. These policy changes will have the most adverse impact on the lowest-income Marketplace enrollees, many of whom receive their care at community health centers. The Urban Institute has estimated that the House bill provisions could result in 14% to 36% of Marketplace enrollees, on average, losing their coverage nationwide.
CBO’s recent analysis finds that together, the proposed Medicaid and Marketplace changes will increase the number of uninsured people by at least 16 million.
These reductions will land squarely on the patients and communities served by health centers. Approximately 5.2 million community health center patients were privately insured in 2023. A new analysis estimates the impact of proposed changes to Marketplace coverage on the number of privately insured adult community health center patients and associated health center revenue and net income. It finds that 826,000 to 2.1 million CHC patients are at risk of losing private insurance coverage, with resulting revenue shortfalls of $2.1 billion to $6.0 billion by 2028.
Capital Link’s Scenario Planner national snapshot and state -specific reports are available here.