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Achieving Universal Coverage



Why One in Ten Americans Will Feel the Pain of ACA Repeal Without an Effective Replacement

people health insurance

The idea that 20 million Americans could suffer if the Affordable Care Act (ACA) is repealed without careful replacement has become accepted wisdom. But it’s wrong. The number is higher than 30 million—or one in ten Americans. And that’s an estimate that’s important to keep in mind as the U.S. House of Representatives prepares to vote on a repeal bill, given that replacement proposals will likely cover far fewer Americans than the ACA.

There are now more than 20 million fewer uninsured people in the United States than there were in 2010, when the ACA was signed into law.1 But there are millions more Americans who currently have insurance because of the law’s provisions—or have coverage that is affected by the law—and would feel the effects of repeal-and-replace proposals. Here’s a breakdown of all the people who have benefited in different ways from the ACA:

  • 12 million Americans signed up for insurance this year through the federal and state marketplaces (Exhibit 1).2
  • 7 million people are estimated to have purchased coverage in the individual market outside the marketplaces, where insurers must comply with the same regulations that apply to the marketplaces.3
  • More than 17 million working-age adults are insured through a small employer that must buy coverage in the small-group market with the same regulations and consumer protections that apply to individuals.4
  • Roughly 7 million young adults ages 19–25 have employer-based health insurance through a parent’s health plan.5
  • About 11 million people are insured through expanded eligibility for Medicaid.6



All told, more than 30 million people are therefore currently insured as a result of the ACA’s insurance tax credits, expanded Medicaid eligibility, state and federal outreach efforts, and market regulations in both the individual and small-group markets.



If policymakers in Washington, D.C., decide to pass the bill repealing the ACA, they might keep this in mind. Walk down any American street. Count 10 people. One of them is at risk of having either no insurance, less affordable insurance, or less valuable insurance if the law is repealed without a replacement that does as well as or better than the ACA in assuring access to needed health care services.

The authors thank Sophie Beutel and Munira Gunja for research assistance.



1 M. E. Martinez, E. P. Zammitti, and R. A. Cohen, Health Insurance Coverage: Early Release of Estimates from the National Health Interview Survey, January–September 2016 (National Center for Health Statistics, Feb. 2017).

2 Centers for Medicare and Medicaid Services, “Biweekly Enrollment Snapshot: Weeks 12 through 14, Jan. 15–Jan. 31, 2017,” News release (CMS, Feb. 3, 2017); and National Academy for State Health Policy, Latest Data on SBEs & SBM-FPs Enrollment (NASHP, n.d.).

3 Office of the Assistant Secretary for Planning and Evaluation, About 2.5 Million People Who Currently Buy Coverage Off-Marketplace May Be Eligible for ACA Subsidies, ASPE Data Point (ASPE, Oct. 4, 2016).

4 Analysis of the Commonwealth Fund Biennial Health Insurance Survey, 2016.

5 Analysis of the Commonwealth Fund Biennial Health Insurance Survey, 2016.

6 R. Rudowitz, S. Artiga, and K. Young, What Coverage and Financing Is at Risk Under Repeal of the ACA Medicaid Expansion? (Kaiser Commission on Medicaid and the Uninsured, Dec. 2016).

Publication Details



David Blumenthal, President, The Commonwealth Fund

[email protected]


D. Blumenthal and S. R. Collins, “Why One in Ten Americans Will Feel the Pain of ACA Repeal Without an Effective Replacement,” To the Point, The Commonwealth Fund, March 8, 2017.