Background
The Affordable Care Act, sometimes known as ACA or Obamacare, ushered in the largest shakeup to the U.S. healthcare system in decades—and those changes are still evolving. Even now, with the law marking its 15-year anniversary in March 2025, the issues of healthcare costs and coverage are a major part of the national conversation, especially during federal elections.
While the number of uninsured Americans has decreased, owing in part to pandemic relief measures and the expansion of Medicaid programs nationwide, the cost of health insurance has continued to climb.
In 2023, the average annual health insurance premium was $23,968 for family coverage and $8,435 for single coverage, according to the Kaiser Family Foundation. The study showed that the average family premium has increased 22 percent since 2018 and 47 percent since 2013. Both family and single coverage premiums increased by 7 percent in 2023 alone.
For people without access to health insurance through W-2 employment, subsidized Medicaid plans or other government programs, the cost
of insurance is an undeniable burden. The
increasing number of workers shifting to
1099 independent contractor status as part of
the “gig economy” could exacerbate the problem, because these jobs rarely include health insurance benefits. The expiration of funding
for expanded subsidies on ACA exchange plans
in 2025 may have a similar impact.
In 2023, the average annual health insurance premium was $23,968 and Single Coverage was $8,435.
Since 2018,
22% increase
Since 2013,
47% increase
Source: KFF Employer Health Benefits Survey, 2023
by Plan Type
| HMO |
|
| PPO |
|
| POS |
|
| HDHP/SO |
|
Source: KFF Employer Health Benefits Survey, 2023
“If the enhanced subsidies expire, almost all ACA Marketplace enrollees will experience steep increases in premium payments in 2026,” Kaiser reported.
In theory, competition has always been a central tenet of controlling costs under the Affordable Care Act, but this has not played out in practice.
In 2017, the White House issued Executive Order 13813, directing the Department of Labor to expand access to large group health plans under ERISA, the Employee Retirement Income Security Act of 1974, which regulates health coverage for the vast majority of working-age Americans. This was supposed to give many more people options beyond signing up for individual and small-group plans, which have little ability or incentive to control costs. The department issued a new Association Health Plan (AHP) rule in 2018, but it failed to generate enough activity to have any meaningful impact on costs. In 2019, a federal court struck down the rule.
