At the end of President Joe Biden’s first two years in office, 3.3 million more U.S. residents had health insurance compared to 2019, according to a Capital & Main analysis of U.S. Census data with help from Thomas Data Consulting. This marked a 1.2% reduction in the national uninsured rate, bringing it to the lowest level in U.S. history.
In contrast, Donald Trump’s presidency saw a rise in uninsured individuals, with 2.3 million more people without coverage during his first three years, along with a 0.6% increase in the national uninsured rate.
Although health care affordability isn’t a dominant issue in the media during this year’s presidential campaigns, it remains critical for many Americans. A Pew Research Center survey from May found that 57% of Americans view it as a “very big problem.” Health care costs especially burden the approximately 27 million people who still lack insurance, increasing the likelihood they will delay or avoid medical treatment, resulting in worse health outcomes, according to a report by KFF.
Under Trump, 39 states experienced increases in uninsured rates, with more than 440,000 additional uninsured people across key battleground states such as Arizona, Georgia, Michigan, Nevada, North Carolina, Pennsylvania, and Wisconsin. In Biden’s first two years, nearly every state saw decreases in uninsured rates, with 580,000 fewer uninsured people in six of seven swing states.
Experts attribute these changes to the different health policy approaches taken by the two administrations. Trump worked to weaken the Affordable Care Act (ACA), introduced by former President Barack Obama to expand health coverage. Biden, on the other hand, aimed to expand and protect the ACA, reversing some of Trump’s policies and introducing executive orders.
The drop in the uninsured population during Biden’s tenure also resulted from pandemic-era policies initiated by both presidents. However, with some of these protections expiring in 2023 and more set to end by 2025, uninsured rates are expected to rise again unless further federal action is taken.
In 2016, Trump campaigned on repealing the ACA, coming close to achieving it in 2017. The repeal effort was blocked by a single vote from Senator John McCain, preserving the law. However, Trump’s administration diminished the ACA’s effectiveness.
Trump’s health care strategy involved limiting access to the ACA’s health insurance marketplace. The open enrollment period was halved, and promotional efforts were reduced, with the ACA’s advertising budget slashed by 90%. Additionally, the financial penalty for not having health insurance was removed, a move that Paulette Cha, health policy research fellow at the Public Policy Institute of California, described as making the mandate “toothless.” This change, according to a Congressional Budget Office estimate, raised premiums and contributed to millions more uninsured people.
Trump also expanded the public charge rule, making it easier for the government to deny green cards and visas to immigrants receiving public assistance, such as Medicaid. Census data showed states like Texas, Florida, and Arizona saw sharp rises in uninsured populations during Trump’s tenure.
However, the Trump administration temporarily shifted its approach during the pandemic. In 2020, Trump signed a bill that increased Medicaid funding to states, helping to maintain coverage during the federal health emergency.
In contrast, Biden focused on protecting the ACA from the start of his presidency. Eight days into his administration, Biden signed an executive order that extended the enrollment period for Medicaid and private insurance plans. He also reversed several of Trump’s orders that weakened the ACA, giving federal agencies more flexibility in maintaining the law.
Biden’s American Rescue Act, passed in 2021, expanded access to subsidies and tax credits for low- and middle-income individuals seeking health insurance through the ACA. The Inflation Reduction Act extended these provisions until 2025. Additionally, the administration fixed the “family glitch,” which had previously made employer-sponsored family health insurance unaffordable for over 5 million people.
As a result, the uninsured population dropped sharply, with Black and Latino communities seeing the largest gains in coverage. However, Paulette Cha points out that pandemic-related factors also played a role in these gains, complicating any analysis of policy impacts.
Although uninsured rates have fallen since 2019, recent data suggests that Biden’s historic coverage gains may be at risk. A CDC report indicated the uninsured rate rose from 7.7% in the first quarter of 2023 to 8.2% in the first quarter of 2024. This increase is partly due to Medicaid disenrollments following the expiration of pandemic-era protections. Although some individuals transitioned to ACA marketplace plans, the Congressional Budget Office predicts that 6 million more people will be uninsured by 2034 if current trends persist.
Trump has largely distanced himself from his 2016 campaign promises to repeal the ACA and has not proposed specific alternatives. His current platform, Agenda 47, promises to increase transparency, promote choice, and expand access to affordable healthcare, but lacks detailed policies.
The Heritage Foundation’s Project 2025, a conservative blueprint for the next Republican administration, calls for imposing lifetime caps on Medicaid benefits, a move that could threaten the coverage of over 18 million people, according to Natasha Murphy from the Center for American Progress. While Trump has praised the Heritage Foundation’s work, he has distanced himself from Project 2025.
Meanwhile, Vice President Kamala Harris announced an economic agenda in mid-August that includes expanding ACA subsidies and working with states to eliminate medical debt for millions of Americans.
Cha highlights that most of the progress in health coverage was made during the Obama administration, with the ACA reducing the uninsured population by nearly 20 million people. Going forward, the work will focus on closing remaining gaps in coverage.
