The unprecedented cuts to Medicaid in President Donald Trump’s tax bill rightfully garnered headlines in recent months. After all, the latest estimates from the Congressional Budget Office predict some 10 million people eventually will lose their public insurance.

But attention now should turn to the less visible ways his policies are undermining the Affordable Care Act.

Instead of the full-blown attack on the ACA waged in his first term, when Trump tried — and failed — to repeal the law, he is letting crucial parts of it wither on the vine, and millions of Americans will be affected while potentially not even realizing who is to blame.

Some will log in to sign up for care in 2026, only to discover their plan has gotten a lot more expensive — and an estimated 4.2 million of them will risk going uninsured because of it. Others will never know they could have had affordable insurance, because the government will make far less of an effort to advertise its existence.

“It's a stealth sabotage,” says Benjamin Sommers, a physician and health economist at the Harvard T.H. Chan School of Public Health. “Many folks won't even see the small print that led to that outcome.”

Enrollments for marketplace plans soared under the Biden administration. That was largely due to two things: enhanced subsidies, which made insurance more affordable for a broader swath of the population, and an incredible outreach effort to help people find and enroll in policies. Both helped bring the number of uninsured people in the U.S. to an all-time low in 2023, and by the end of Biden’s term, a record-breaking 24.2 million people bought coverage through the government.

That’s more than twice the number of people who accessed plans under Trump’s last watch. This time around, his administration is quickly unraveling both factors underpinning that progress. The biggest impact will come from an anticipated spike in the cost of federal or state-run marketplace plans as the government takes away extra subsidies that make them affordable.

The ACA has always included tax credits that vary based on someone’s income, but they got a lot more generous under the Biden administration. Since 2021, those additional benefits made it cheaper for people to buy insurance while also expanding the number of people who qualified for help. Coverage was suddenly within reach for many more Americans — in fact, four out of five enrollees qualified for a plan that cost as little as $10 per month.

Trump’s new tax bill allows those subsidies to expire at the end of this year. A recent analysis by the nonpartisan health care group KFF gives a snapshot of what that could mean for consumers. It found that out-of-pocket premiums will go up on average by 75% — and people in at least a dozen states could see those fees double or more. Retaining marketplace insurance will cost a typical family of four living on $65,000 per year an additional $2,400, according to an analysis by the Center on Budget and Policy Priorities.

While the overall burden on families is rising, insurers themselves are also going to charge more for their plans. Just how much more is starting to come into view as marketplace providers begin to publish their proposed rates, which they file to state regulators each summer. KFF found that among the insurers reporting to states, expiration of the enhanced tax credits is attributed to an average 4% increase in premiums next year. That would primarily raise costs for the people who buy marketplace coverage, but don’t qualify for subsidies, Sommers explains.

The insurers’ reasoning? Without subsidies, they say fewer healthy people will sign up for plans, leaving them to cover a larger proportion of sicker people (who ostensibly use more health care).

The likely expiration of the enhanced benefits isn’t the only way that the Trump administration is undermining Obamacare accessibility. The president is also making it harder to know about and sign up for a marketplace plan. Within weeks of taking office, he slashed the budget for navigators, the ACA experts who help the public wrestle with their insurance options, by 90%. Meanwhile, he has shortened the window during which people can sign up for coverage and is expected to repeat a trick from his last term, when he decimated the budget for advertising the open enrollment period.

Those aren’t just nice-to-haves. Sommers led a recent study published in the National Bureau of Economic Research that found affordability is not enough — people need to be able to easily sign up for a plan, too. He found that the same subsidy offered under the Biden administration resulted in a 30% greater decrease in the uninsured population compared to the Trump regime. The difference? A federal push to help people understand when they are eligible and guide them through the process of finding coverage.

There’s still time to fix this. Congress could act to renew the subsidies (it recently kicked the decision to the fall). And while Republicans seem determined to get rid of them, they might want to remember that unlike the Medicaid cuts, the impact of which won’t be felt until after the midterms, these ACA changes will hit consumers next year. If lawmakers don’t act, then hopefully the public will connect the dots back to who made their health care more expensive.

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This column reflects the personal views of the author and does not necessarily reflect the opinion of the editorial board or Bloomberg LP and its owners.

Lisa Jarvis is a Bloomberg Opinion columnist covering biotech, health care and the pharmaceutical industry. Previously, she was executive editor of Chemical & Engineering News.

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