Obamacare sign-ups for 2019 fell to 11.4 million people, down from 11.8 million the year before, after the Trump administration made changes to the law that experts blame for the decrease. Trump removed the individual mandate, cut the ACA advertising budget, allowed healthy consumers to stay on "skimpy" insurance plans and shortened the enrollment period for consumers to sign up.
Enrollment has been slowly decreasing since its peak of 12.6 million sign-ups in 2016.
Still, about 30 million people, either covered by Medicaid expansion or plans sold on the Obamacare exchanges, would lose their health insurance if the Affordable Care Act is repealed with no replacement plan.
The law, which sought to expand access to insurance, increase consumer protections and reduce health-care costs, initially required most Americans to purchase health insurance. If nonexempt Americans weren't covered, they faced a tax penalty of $695 per adult or 2.5 percent of household income, whichever was higher. The idea was to force younger, healthier consumers to sign up to mitigate the costs of covering older and sicker Americans. The mandate incensed conservatives who viewed it as a symbol of government overreach.
Consumers can now opt out of purchasing health insurance without facing a penalty since the Trump administration reduced the individual mandate to $0. But the Obamacare exchanges are still available to the public. Consumers in all 50 states and the District of Columbia have access to exchanges, either federal or state run.
Twenty-eight states use federally run marketplaces, while 12 states use their own state-based marketplaces. Eleven states use either federally supported state marketplaces or marketplaces that are run by a partnership between the federal government and the state.
In 2017, insurance companies began to abandon the Obamacare exchanges as they worried about potential changes a Republican administration would make to the Affordable Care Act. But insurers have since started offering plans in more states or expanding in states they already operate in as they started making profits in the individual market, giving customers more options.
Obamacare also expanded Medicaid eligibility to uninsured children or adults at or below 138 percent of the federal poverty level. It also made many people with mental illnesses eligible for coverage.
According to the Kaiser Family Foundation, 36 states and D.C. have adopted Medicaid expansion and 14 states have not. Medicaid enrollment increased by 16 million people since Obamacare went into effect, with 13.6 million living in Medicaid expansion states.
Critics of Medicaid expansion claim it is a financial burden on states, which have budgets that are already dominated by the cost of Medicaid. The federal government initially covered all the costs of expansion, but states were eventually expected to pick up 10 percent of the tab.