By Robert Applebaum
When the Affordable Care Act, also known as the ACA or Obamacare, was enacted in 2010, lawmakers hoped it would help reduce the number of uninsured Americans. That year, an estimated 48.2 million people – about 18% of the U.S. population under age 65 – did not have health insurance.
By 2023, the number of uninsured Americans had dropped by nearly 50%, to 25.3 million people under 65, or 9.5% of the total population.
I’m a gerontologist who studies the U.S. health care system. ACA health care subsidies are at the center of a now monthlong U.S. government shutdown that could become the longest in U.S. history. So I looked at the available data about ACA marketplace plan usage in Florida to understand how the debates in Washington could affect access to health care in the Sunshine State going forward.
How the ACA expanded access to health insurance
The ACA implemented a three-pronged strategy to expand access to affordable health insurance.
One was the use of fines. The government fined anyone – until 2018 – who chose not to get health insurance. The government also fined businesses with 50 or more full-time employees that didn’t offer their employees affordable health care plans. The idea was to offer incentives for healthy people to get insurance to lower costs for everyone.
Ultimately, the fines had little impact on the number of insured Americans, with one notable exception: The employer-required expansion allowed young adults ages 19 to 25 to remain on their parents’ health insurance plan. For this group, the uninsured rate dropped from 31.5% in 2010 to 13.1% in 2023.
Second, the ACA allowed for Medicaid to be expanded to low-income Americans who were employed but working in low-wage jobs. The expansion of Medicaid to low-income workers at 138% of the federal poverty level was originally required nationwide. But a 2012 Supreme Court ruling allowed states to choose whether they would participate in Medicaid expansion.
As of 2025, 16 million Americans are covered by the expansion. However, 10 states, including Florida, have opted out.
The third way the ACA changed the health insurance system is that it established health insurance subsidies that the government can provide. Those subsidies are for low- and moderate-income Americans who do not receive health insurance through their employers and aren’t eligible for Medicaid, Medicare or any other government-operated health insurance program.
This established a private health insurance marketplace that would include federal subsidies to make insurance more affordable. As of October 2025, more than 24 million Americans currently get their health insurance through the subsidized marketplace.
Florida and the ACA marketplace
The number of people insured under the ACA in each state varies. But the state with the largest number of residents on marketplace insurance plans is Florida. About 4.7 million Florida residents are covered through these plans, representing 27% of the state’s under-65 population, compared to the national average of 8.8%. Of those on marketplace plans, 98% receive a subsidy at some level.
There are several reasons why this rate is so much higher in Florida than elsewhere.
First, only 40% of Sunshine State residents are covered by an employer-based health insurance plan, compared to 49% for the nation as a whole.
This is the lowest rate in the country. A contributing factor is that Florida ranks fifth in the proportion of workforce that is self-employed, with 1.3 million Floridians in this category.
The state’s lower rate could also be related to the high number of seasonal and part-time workers in the tourism industry.
Another reason is that the state has relatively few people enrolled in Medicaid, the federal program that provides mainly low-income people with health insurance coverage. Among Floridians ages 44 to 64, only 11% are enrolled in Medicaid, compared to 17% for the nation overall.
Florida hasn’t expanded Medicaid, and it’s also more restrictive than most states about who can enroll in the program.
States set their own Medicaid eligibility criteria, and they determine what services Medicaid will cover and at what cost. Florida has the second-lowest Medicaid expenditures per enrollee in the nation, and it ranks last on Medicaid expenditures for adults under 65.
An uncertain path ahead
Because Florida residents rely heavily on marketplace plans, ending ACA subsidies would have a big effect on Floridians.
Unless Congress reverses course and preserves the insurance subsidies that have not been renewed, the average marketplace plan premium is predicted to increase by more than 100%, from $74 to $159 per month. An American earning $28,000 annually – $13.50 per hour – would see a fivefold increase, from $27 to $130 per month. And a worker making $35,000 per year would see their premium increase from $86 to $217 per month.
At 13.4%, Florida already has the third-highest proportion of uninsured residents under 65. It is safe to assume that if the federal marketplace subsidies disappear and health insurance premiums become unaffordable for more people, the result will be more uninsured Floridians. And if healthy, younger people can’t afford insurance, premiums are likely to go up for everyone else with insurance.
The path to resolve the ongoing debate is uncertain. In my view, however, it is clear that states such as Florida, Texas and Georgia, which haven’t expanded Medicaid and rely heavily on the marketplace plans, will be dramatically affected by cuts to federal subsidies.
Robert Applebaum is Senior Research Scholar at the Scripps Gerontology Center, Miami University.
Shark says
No Problem – They can switch over to that beautiful trump care that was promised in January 2017 !!!!
Welcome aboard yall says
As a working uninsured person I welcome those to the club, ha! While the loss of benefits is nothing to celebrate, it’s fun to watch the repubs unwind this country into the mess it’s becoming. Lavish parties with caviar wrapped in gold at 1600 Penn Ave paid fully by tax payer money soon to come! ;)
Greg says
I’m so tired of hearing about providing cash to reduce Obamacare costs. My wife don’t make $28000 a year on social security and pays $186 a month, and soon going to I think $206 a month. I barely make over that amount and pay the same. I hear NOBODY in Congress crying to reduce our costs. It just pisses you off
The seniors are loosing their asses every year and I never hear congresss offer to help. The 2.8% SS raise for next year and inflation up 3%, so we lose more. Tired of the crying for the few.
Al says
You are exactly correct, why do the Medicare rates go up and the demand don’t care. Before subsidies are even considered there needs to be a purging of the illegals from the ACA. Next people over 28 are adults and shouldn’t be on their parents policy, we were adults at 18 not 25.
With all the people getting free insurance the doctors are filled up 3 months in advance. Drop the abortion and drug rehabilitation programs.
Deborah Coffey says
FACT: There are no “illegals” on the ACA. There are NO people over 28 on their parents’ policy. America doesn’t have enough doctors and Trump won’t let new ones into the country, not to mention those he deported. Medicare rates go up because Republicans continue to give tax cuts to billionaires. Sounds like you might have voted the very things you despise, Al.
Al says
There’s a skinny little jerk and a big nose buffoon in Washington that have said there are illegals on the ACA. They said it’s not enough to worry about and they need the votes so who cares. Get your facts correct. That whole article was written without any reference to where the author got his facts. You agreed with his facts so why question the made up percentages. What I was commenting on was that 2 people on SS pay 400 a month for medical while a family of 4 is burdened by having to pay 100 a month, go figure.
Ray W. says
Hello Deborah Coffey.
It appears accurate that in “mixed status” families, meaning American citizens or those lawfully present in the country who live with an undocumented immigrant spouse, or with children, the individuals who are citizens or lawfully present in the country can qualify for ACA medical coverage, but the undocumented immigrant family members cannot.
In some states, supplemental medical care benefits can be made available to the undocumented immigrants residing in those states, using state dollars to subsidize the medical care benefits.
Of course, undocumented immigrants can purchase on their own medical care coverage through insurance providers outside of ACA coverage, but these undocumented immigrants do not qualify for any federal premium subsidy.
Under the federal Emergency Medical Treatment and Labor Act (EMTALA), undocumented immigrants can present at emergency rooms and receive federally subsidized health care for “stabilizing” treatment.
Undocumented immigrants can qualify for non-emergency primary care and prescription drugs, based on a sliding scale of ability to pay, through “federally qualifiied health centers” and “free clinics.”
But the undocumented among us do not directly qualify for ACA Marketplace health benefits or other form of federal subsidy.
I appreciate that the issue is complex and politically divisive. I appreciate the pressure some people place on themselves to distort the issue for political gain.
Can it be argued ironic that a FlaglerLive commenter who exhorted you to get your facts straight before you comment didn’t take the time to get the facts straight before commenting?
Oy vey! (yiddish slang, broader in meaning than the Hebrew phrase, for woe is me or woe to us all)
R.S. says
The philosophy of insurance is wrong in this country. Many people see in insurance a delayed purchase plan of services one may or may not need. However, health insurance had its beginning with shared-cost systems: Blue Cross having begun as a collaboration of faculty at Baylor University and Blue Shield having begun as a collaboration of lumberjacks in the 1920s and 30s. When one shares the cost of healthcare, we all benefit. Insurance companies should be non-profits with most of the inflow of cash going to the prime purpose of the insurer: helping pay health cost! Making a profit off disease is sick and demented indeed. England and Canada have it right; from each according to ability; to each according to need. A good dose of genuine Christian love of neighbor would really improve the “greed is good” crowd here, I’d think.
Joe D says
As a Master’s prepared Clinical Nurse Specialist and Certified Nurse Case Manager with 43 years of Nursing experience, I FULLY agree that heath insurance companies should be NON-PROFIT.
HOWEVER, just because the parent company is “NONPROFIT” doesn’t prevent them from trying to bully medical providers and Hospitals into signing contracts with such low reimbursement rates, that treatment programs were shut down and increased NON EMERGENCY treatment scheduling times resulted.
The East Coast University Teaching and Specialty Hospital I worked at, told #1 BC several years ago they would no longer participate with BC unless there were improved contract conditions. Patients who were in specialized treatment programs and Pediatric Cancer services, DROPPED BC coverages and switched to other insurance coverage in such numbers that BC had to return to the negotiating table to increase the payment level to a reasonable level.
They just did the same thing with #2 United Healthcare (a PRIVATE for profit insurance company) this fall 2025. The hospital challenged the high level of payment denials and the unnecessary hoops Programs and Doctors had to jump through with PREAUTHORIZATION requirements to get patients approved for medically necessary treatments and procedures. That dispute was not resolved, so UHC patients are now considered “out of network” ( much higher copays, or not able to be approved for treatment there at all)
PS: if you think there is a shortage of doctors now, wait a few years after the new Trump’s ONE BIG BEAUTIFUL BILL cuts in Student loan maximums which won’t cover tuition at almost ANY US medical school. We will go back to the days 100 years ago, when the only students who went to medical school, were those that had families who could afford to pay for medical school out of pocket!
R.S. says
Correct, John Doe; however, why defeat small steps toward progress by pointing out that perfection won’t be reached?
The dude says
MAGAs whining about helping our neighbors and fellow citizens, while at the same time cheering the bailout of Argentina at taxpayer expense is peak MAGA and totally on brand.
Why do they hate America?
celia pugliese says
Undocumented on Medicare…? This is the most ridiculous thing I ever heard! The reality I experince is so different, as an example my child as an independent contractor her highest bill is her medical insurance that she manages to fund while thinking about those making the minimum pay “all americans, no illegals”, that can’t afford it, while working without benefits”. Another example an old dear friend working for these couple gynecologist medical practice without medical isurance provided by her employers and sick with cancer not affording her second round of expensive surgery, scans, radiation treatments as was max out her deductible with Obamacare, is alive and still fighting for the next 5 years ,thanks to a loan I gave her from my savings, so she could afford her deductible and is still be alive. Now with current administratioin plans she is concerned again if she will loose the remaining Obamacare that still paying her cancer treatment. Also the backwards thinking of some here not having compassion for their fellow Americans when it comes to afford preventive medical care insurance system. Medical care is a need like food, without it we die! One more case I have seeing here in Fl, a young father had to choose between his kids providing and his costly health insurance. He chose his kids and he, stricken with a a flesh eating desease over delayed medical assistance because lack of funds, he ended up loosing a leg and months of life saving hospitalization, and now disability for this young father. We all ended up anyway paying for it all! Would not have been less costly to us all if he could have had affordable subsidized medical insurance other than and life long tragic disability? Do we ever take in account all those contributors to social security and medicare, some of them millionaires contributed all their lives, like Steve Jobs and millions of others that died young and never lived to collect one penny of SS or Medicare…? Where are those numbers logged? I know how costly healtcare insurance for independent contractors is, like when we owed our own businesses to provide ourselves and 50% of our employees back then in the nineties and 2000’s, last bill was $1000/month each with Florida Health Care, before 65 y/o until retirement took over. Maybe all of the above makes me realistically care for our young fellow American to afford preventive medical insurance cleared of any fraud, perception of undeserving and “conspiracies”.
R.S. says
Al, do the math first! How many undocumenteds are on Medicare, pray tell! How much does that impact the Medicare budget? That is the problem: Shooting from the hip without doing the research. Playing intuition against knowledge and insisting that that process is just as good as someone who has done the research. What a dumbing down of the society! Next thing you’ll try to tell me is that the Ballroom is being built by illegals and that SNAP has to be cut out because only undocumented folk benefit from it. Oh Geeez! If only ignorance were to inflict pain on people, there’d be such screaming around this place!
Al says
Do your research and you’ll see I’m correct. Auto correct put 28 where I typed 25 and it was supposed to say democrats not demand. If your kid is 25 and still living home they have emotional problems. Families like mine pay the taxes while you complain about how you don’t get enough.
celia pugliese says
RS can you please request and provide the real figures of how many of your ” undocumenteds are on Medicare”? and while you are at it, can you also request the numbers of our young contibutors including some millionaires like Steve Jobs/Conrad Hilton Jr. and millions more that died before collecting a penny of their lives contributions?
Those non conspiracy numbers will be greatly appreciated…
R.S. says
Celia, that’s just my point: Insurance is a matter of all of us sharing the cost; it’s not a prepaid purchase plan where we must get out what we paid in. If it were a prepaid purchase plan, we might as well put our money in a healthcare CD and use it instead of feeding a big company. From a financial turn-around of $400 billion, United Healthcare made a PROFIT [money that’s going into their own pockets to feed shareholders and CEOs] of $14 billion in ’24. I don’t approve of killing anyone, but I do understand Luigi Mangione’s reaction, born of frustration.
Al says
The word was democrats not demand and 18 not 28. Spell check sucks.
Joe D says
It’s not SPELL CHECK that is causing you the problem, it’s AUTO COMPLETE!! The part of the software that “anticipates” what it THINKS you are going to type from a category of most probable words. Sometimes you wonder HOW that was the WORD, The AUTO COMPLETE picked? You still need to do your own MANUAL spell check too.
R.S. says
Here you go:
Undocumented immigrants in the United States do not have a single, reliable national count for how many receive government-funded health care. Most federal public insurance programs are legally restricted by immigration status, leading to sparse enrollment in standard Medicaid and reliance on emergency-only or state-limited alternatives. Recent studies estimate that Emergency Medicaid is available in many states, but it covers only acute or emergent services, leaving routine care largely uncovered.
[From an AI research of the web.]
I would submit that the thinking about sharing medical cost is wrong in this country: The way Bluecross and Blueshield started, they were non-profits where a group of people [faculty at Baylor University (Blue Cross) and Northwest Lumberjacks (Blue Shield) started to share medical cost. From all according to income [a percentage of income]; to all according to need [full payment]. When wealthy folk pulled out of the Affordable Care system, the onus of cost fell on all the low- and mid-income people and the contributions had to rise. If we had some true Christian love for one another, none of this would be onerous at all. But we’re fighting other needy people when actually the wealthy walk off with the goods. The thinking in our culture is too dismal to believe.
Sherry says
Thank you RS. . . that’s what I read as well.
What’s ridiculous to me is that Maga posts Fox BS “talking points” about how those immigrants are to blame for almost everything, like the costs of healthcare. BUT, they seem to have no problem with trump’s bail out of his friend in Argentina to the tune of 20 BILLION of our hard earned tax dollars!
Or, trump’s tax cuts that benefit his billionaire friends. . . who use loopholes to “pay” little or no taxes themselves!
Skibum says
Our nation’s emergency medical treatment law which allows hospitals to accept and give basic, life sustaining care to undocumented non-citizens is not something that republi-cons in Congress should be yelling and upset about! It makes no difference in the law whether the hospital is giving this emergency medical care to someone who crossed over the border without documentation or a tourist from a foreign country who has a visa and is on vacation when they have a life threatening medical episode requiring hospitalization. This is what countries with good citizenry should do for people, and what ethical, compassionate medical treatment standards should require!
Yet here we are, with right-wing, extremist, maga pea brains complaining about. One of them, Mike Johnson… hmm, isn’t he a minister? A man of faith? How would he stand before Jesus and try to justify withholding EMERGENCY medical care from an injured or ill human being based on extremist political ideology???