By the conclusion of Joe Biden’s initial two years in office, there were 3.3 million additional Americans with health insurance compared to 2019. This finding, based on a Capital & Main review of U.S. Census data with support from Thomas Data Consulting, resulted in a 1.2% drop in the national uninsured rate, marking the lowest number of uninsured individuals in U.S. history.

In contrast, during the first three years of Donald Trump’s presidency, there was an increase of 2.3 million uninsured individuals, leading to a 0.6% rise in the national uninsured rate.

While discussions about the affordability of healthcare may not be as prominent in this year’s presidential campaigns, a Pew Research Center survey from May revealed that 57% of Americans consider it a “very big problem.”

Healthcare affordability is especially critical for approximately 27 million individuals currently without insurance. Those without coverage are more inclined to postpone or avoid seeking medical care, which can result in poorer health outcomes, according to a KFF report.

Trump Administration Sees Surge in Uninsured in Key States

During Trump’s presidency, 39 states experienced rises in their uninsured rates. In seven crucial battleground states—Arizona, Georgia, Michigan, Nevada, North Carolina, Pennsylvania, and Wisconsin—over 440,000 more individuals became uninsured. In contrast, in Biden’s first two years, all but three states reported declines in uninsured rates, with six out of seven swing states seeing 580,000 fewer uninsured individuals.

Experts link these changes in coverage to differing healthcare policies. Trump aimed to diminish the Affordable Care Act (ACA), originally implemented by former President Barack Obama, which expanded coverage and required insurance to lower healthcare costs.

In contrast, Biden emphasized the expansion and safeguarding of the ACA, even issuing executive orders to reverse Trump’s policies. The decrease in uninsured individuals during Biden’s term was also a result of COVID-19-era policies enacted by both administrations. However, some of these protections ended in 2023, with more set to expire in 2025, prompting concerns that uninsured rates might rise once again without federal intervention.

Trump campaigned in 2016 on a platform to repeal and replace the ACA, nearly achieving this goal in 2017. However, a critical “no” vote by Republican Senator John McCain ultimately preserved the law. Despite failing to repeal the ACA, Trump managed to weaken its effectiveness while serving.

As Natasha Murphy, director of health policy at the Center for American Progress, remarks, Trump’s approach involved “a mix of both undermining and attacking the ACA, along with efforts against the Medicaid program.”

These efforts included making it more difficult to access coverage through the ACA’s marketplace, which was designed to help individuals find and enroll in insurance plans. Under Trump, the open enrollment period was reduced by half, promotional campaigns were halted, and the ACA’s advertising budget was cut dramatically by 90%.

Additionally, Trump removed the monetary penalty for not obtaining health insurance, rendering the insurance mandate ineffective, as noted by Paulette Cha, a health policy research fellow at the Public Policy Institute of California. The Congressional Budget Office had previously projected that removing this penalty would lead to increased premiums and millions more uninsured individuals.

Finally, Trump expanded the public charge rule, which allowed the government to refuse green cards and visas to immigrants receiving public assistance, such as Medicaid.

Enrollment in ACA Marketplace Dropped Prior to Biden’s Presidency

The enrollment in the ACA marketplace declined annually from 2016 to 2020.

During Trump’s time in office, Texas’s uninsured population surged by nearly 700,000; Florida’s increased by over 240,000; and Arizona’s by almost 130,000 from 2016 to 2019, according to census data.

When the COVID-19 pandemic began affecting American lives in 2020, the Trump administration temporarily shifted its strategy regarding Medicaid. Trump endorsed a Democrat-sponsored bill that provided states with additional funds to maintain Medicaid coverage until the federal health emergency concluded, allowing individuals to remain covered instead of losing their eligibility prematurely.

Murphy notes, “That was a policy that really made a huge difference in ensuring access to much-needed COVID treatment, testing, and later, vaccines.” Indeed, estimates from the Centers for Disease Control and Prevention highlighted a decrease in the uninsured rates in 2020 compared to 2019. However, these rates still surpassed the figures when Trump assumed office.

Biden’s Campaign Promised to Expand and Support the ACA

Unlike Trump, Biden ran for president in 2020 on a commitment to enhance and safeguard the ACA. Just eight days after his inauguration, he issued an executive order aimed at simplifying enrollment in Medicaid and private insurance plans, providing individuals with extended timeframes to secure coverage. Additionally, he rolled back some of Trump’s executive measures that had undermined the ACA by restoring protections.

Federal agencies have been given significant leeway to modify, postpone, or overlook parts of the law they find to be financially taxing.

Moreover, in March 2021, Biden enacted the American Rescue Act which increased the subsidies and tax credits available to low- and middle-income individuals looking for health insurance via the ACA. His landmark legislation on climate and health, the Inflation Reduction Act, extended these benefits until 2025.

By introducing a revised tax law, the Biden administration successfully addressed the “family glitch.” This term refers to an IRS interpretation of the ACA that left many employer-sponsored family health insurance plans unaffordable for over 5 million individuals. Thanks to this adjustment, family members could access federal subsidies if the employer’s coverage was deemed too expensive.

These measures contributed to a significant reduction in the number of uninsured individuals.

Black and Latino Communities Saw Notable Increases in Coverage

Historically, Black and Latino communities have had lower insurance coverage rates than their white counterparts, but they have shown some of the most substantial improvements in coverage.

However, linking all of these coverage increases directly to Biden’s policies might not capture the complete picture, as Cha suggests.

According to Cha, “In the past four years, separating the impact of policy from the realities of a pandemic and its aftermath has been very challenging.”

Even with a notable drop in the uninsured rate since 2019, recent reports indicate that Biden’s achievements regarding expanded coverage might be at risk.

A CDC report released this month estimated that the uninsured rate increased from 7.7% in early 2023 to 8.2% in early 2024. This spike has been attributed mostly to states removing individuals from Medicaid after pandemic-specific protections ended, as outlined by the Congressional Budget Office.

Not everyone affected is without coverage now; some might have enrolled in health plans through the ACA marketplace, which has reached high enrollment numbers, while others may have found alternative insurance. However, if current trends continue, the budget office predicts that the uninsured population could rise by roughly 6 million by 2034.

During this election season, Trump has shifted from his previous commitment to abolish the ACA but has yet to present clear alternate policies. His official campaign platform, known as Agenda 47, lacks detailed policy proposals but asserts that Republicans “will enhance transparency, promote choices and competition, and broaden access to affordable healthcare.”

The project named Project 2025, devised by the conservative Heritage Foundation as a roadmap for the next Republican administration, advocates for the implementation of lifetime caps on Medicaid benefits. Murphy estimates this measure could threaten healthcare for over 18 million individuals.

Although Trump has distanced himself from Project 2025, reports indicate that numerous individuals associated with the project have been part of his team, and he has commended the Heritage Foundation for shaping the groundwork for future governance.

In mid-August, Vice President Kamala Harris presented her economic initiatives, which included a plan to extend subsidies for ACA plans and collaborate with states to “eliminate medical debt for millions of Americans.”

Cha notes that a substantial portion of the advancements in coverage rates occurred during the Obama administration with the introduction of the ACA, which decreased the number of uninsured people by nearly 20 million during his presidency. What remains, according to Cha, involves the often unexciting efforts of closing loopholes and ensuring that all those who are eligible have access.