President Donald Trump during his first administration promised to repeal and replace the Affordable Care Act, often called Obamacare, but fell short.
While there’s less chatter about the repeal, during Trump’s second administration the One Big Beautiful Bill Act might deliver on the years-old promise.
Although cuts to the Medicaid and supplemental nutrition assistance programs (SNAP) are grabbing the headlines, Florida health care advocates worry that the changes to the ACA may be even more damaging.
Florida leads the nation in Obamacare enrollment in 2025, with 4.7 million people enrolled in the marketplace, U.S. Centers for Medicare & Medicaid Services (CMS) data show. A key feature of the ACA is the marketplace through which people can use advanced premium tax credits to purchase subsidized health insurance.
By contrast, there are 4.17 million people enrolled in Medicaid in Florida, the safety net program for the poor, elderly, and disabled.
During COVID, Congress agreed to make the premium tax credits more generous than those in the original law. The enhanced credits allow people who earn more money to qualify for the subsidies. Under the U.S. House version of the budget reconciliation act, these enhanced advance tax credits are slated to expire at the end of the year, although the original credits contained in the ACA will remain intact.
Advocates warn it’s not just the elimination of the enhanced advanced premium tax credits that will hurt people.
The House reconciliation bill also shortens the Obamacare open-enrollment periods, eliminates special enrollment periods for low-income individuals, and requires people to show upfront significant documents such as passports, birth certificates, marriage certificates, and income tax records to qualify for the advanced premiums tax credits.
Florida Health Justice legal director Lynn Hearn said the changes will blunt the progess the ACA has shown in providing people access to affordable health insurance.
Florida Health Justice Project Legal Director Lynn Hearn“This time, Congress might not be calling it an outright repeal of the ACA, as it did in 2017, but a program that is inaccessible or unaffordable is as good as repeal,” Hearn said during a panel discussion on the ACA, Medicaid, and SNAP cuts in the One Big Beautiful Bill Act.
The Florida Health Justice Project and 76 other entities across the state sent a letter Tuesday to Florida Sens. Rick Scott and Ashley Moody expressing concerns with the ACA changes as well as the proposed cuts to Medicaid and SNAP.
“Floridians in every county across the state will experience a devastating loss of essential health care coverage and food assistance if Congress follows through with the current proposal,” the letter reads. “In Florida, over 4 million people are enrolled in Medicaid, most of whom are children, older adults, or people with disabilities.”
The letter was sent as the Kaiser Family Foundation released a poll that showed the budget reconciliation bill is viewed unfavorably by large majorities of Democrats (85%) and independents (71%), but favorably by six in 10 Republicans (61%).
A breakdown of Republicans and Republican-leaning independents who self-identify as supporters of the Make America Great Again (MAGA) movement (72%) view the bill favorably. By contrast, 66% of Republicans and Republican-leaning independents who don’t identify with the MAGA movement view the bill unfavorably.
The Florida Policy Institute coordinated a press conference with Florida Health Justice and others to highlight the letter and discuss the cuts more in depth. FPI is dedicated to advancing policies and budgets that improve the economic mobility and quality of life for all Floridians.
President of the SEIU Florida State Council Martha Baker has been a registered nurse for more than 45 years and spent the last 35 years working at Jackson Health System in Miami. The system, she said, should be a role model for the nation.
“Jackson’s mission has been since the beginning of time for one single high standard of care to all residents regardless of your ability to pay. Dade County citizens have endorsed that with tax donations for the last 100 years. And again, this is an example of how healthcare should be delivered in the richest country on Earth.”
Limiting access to the marketplace health insurance policies and cutting Medicaid “is only going to be penny wise and dollar foolish, as they say,” she said.
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Since its inception, the ACA has included advanced premium tax credits to help offset the costs of the policies for people with incomes between 100% and 400% of the federal poverty level, which in 2025 was $126,800 for a family of four.
During the COVID-19 pandemic in 2021, Congress increased the subsidies and included a provision that allowed people who earn more than 400% of the poverty level to qualify for them. Congress the following year extended the enhanced tax credits through 2025.
Centers for Medicare & Medicaid Services March data show that of the 4.7 million Florida residents with an Obamacare plan in 2025, 4.6 million receive advanced premium tax credits.
Because of those credits, 2.3 million enrollees pay less than $10 a month for their health insurance. On average, the CMS data show, the monthly Obamacare premium in Florida is $67.
Only Alabama, Mississippi, and Texas (all of which have lower Obamacare enrollment) have lower average monthly premiums.
Hearn said that allowing the enhanced advanced premium tax credits to expire could lead to a 75% increase in health insurance costs for ACA enrollees in families who earn more than 400% of the poverty level. That means a family of four earning more than $126,000 could wind up with a $9,000 a year premium increase, Hearn said.
“So obviously, this is going to make it unaffordable for many people,” Hearn said.
And those rates could increase even more, she said, if paperwork requirements for annual open enrollment aren’t removed.
The paperwork requirement is more than inconvenient, Hearn said, noting that they could have a deleterious effect on premiums. She worries that healthy people, who may not rely on health insurance on a daily basis, will find the requirements burdensome and won’t enroll.
But people with medically complex conditions who routinely tap into their health insurance benefits will take pains to ensure they comply.
If healthy people leave and sick people who have higher-than-average healthcare costs remain, premiums will increase and the market becomes less stable.
“So, it’s a race to the bottom,” Hearn said.
And that, she contends, will hurt small businesses — the same companies the Legislature said it wanted to help by permanently eliminating the business rent tax in the recently passed tax relief plan.
“In Florida, many of the enrollees tend to be small-business owners and employees and their families. Businesses where the employer isn’t obligated to offer health insurance because of its size, or it does offer health insurance but it’s unaffordable for either the employee themselves or their extended family,” Hearn said.