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ACA Marketplaces support care access for kids, parents

With enhanced premium tax credits at risk, families that rely on ACA Marketplace coverage could lose access to healthcare services.

Sara Heath
By
Published: 05 Nov 2025

The Affordable Care Act Marketplaces have been essential to providing insurance coverage to families, and as a result, have closed the gap in healthcare access between insured and uninsured people, according to an assessment from the Urban Institute.

These findings come as Congress debates expansion of enhanced premium tax credits (PTCs), which subsidize Marketplace plans for low- and middle-income people.

"If enhanced PTCs expire at the end of 2025, millions of Marketplace enrollees, including parents and children, are projected to lose coverage, with most becoming uninsured," Jennifer Haley, principal research associate at Urban, said in an emailed statement. "Parents in non-expansion states, who are concentrated in the South, would be especially likely to be affected, given their high rates of reliance on Marketplace coverage and large increases in Marketplace coverage under the enhanced PTCs."

The ACA Marketplaces were established in 2014 to give individuals without employer-sponsored health insurance the opportunity to purchase private health insurance. This has been particularly important for adults who are not eligible for Medicaid, as well as their kids who might not qualify for coverage under the Children's Health Insurance Plan (CHIP).

Marketplace plan access expanded even further under the American Rescue Plan Act of 2021, which created Marketplace subsidies via enhanced premium tax credits. The Inflation Reduction Act of 2022 extended those subsidies through the end of 2025, resulting in record Marketplace enrollment.

But reliance on Marketplace plans among parents and children could come to an end, as the enhanced premium tax credits that made these plans more affordable are slated to sunset at the end of the year.

Using data from the 2019-2024 National Health Interview Survey (NHIS) and the 2019-2025 Current Population Survey (CPS) Annual Social and Economic Supplement, the Urban Institute assessed how families rely on the ACA Marketplaces and the impact Marketplace coverage has had on their healthcare access. They found that Marketplace coverage was critical for ensuring affordable access to healthcare, closing the gap that could've emerged had they gone without insurance at all.

Exploring Marketplace coverage trends

Although employer-sponsored insurance plans remain the most common type of insurance coverage in the United States, the role the ACA Marketplaces play in covering families can't be overlooked.

Between 2019 and 2025, the share of parents and children relying on Marketplace coverage increased by 33% and 48%, respectively, per the CPS. Between 2019 and 2024, the proportion of parents and children relying on Marketplace coverage increased by 48% and 59%, respectively, according to the NHIS.

That shakes out to 4.8% of parents and 3.4% of children having Marketplace coverage in 2025 and 5.9% of parents and 3.1% of children having Marketplace coverage in 2024. According to the researchers, narrower eligibility parameters for Medicaid versus CHIP contributes to the difference in parents and children covered by Marketplace plans.

Notably, living in a state that has expanded Medicaid influenced reliance on Marketplace plans.

Parents who live in states that did not expand Medicaid were 7.1% more likely to have Marketplace coverage than those living in expansion states, indicating that the ACA Marketplaces -- and the subsidies in place to make these plans affordable -- are valuable in these states. To that end, Marketplace plan reliance was more concentrated in the South, Midwest and West.

Marketplace enrollment drives healthcare access

According to the researchers, enrollment in a Marketplace plan helps individuals access healthcare services much more affordably than if they went uninsured. Unsurprisingly, individuals without insurance coverage face cost barriers to healthcare, among other issues.

Marketplace plans offer insurance access to those who otherwise wouldn't qualify for Medicaid, making it easier for them to afford healthcare they might otherwise forego.

For people with incomes between 100% and 400% of the federal poverty level, access to care and healthcare utilization rates for those with Marketplace plans was about the same as individuals with employer-sponsored health insurance. In other words, Marketplace plans close the care access gap between folks with and without employer-sponsored health plans.

Dental care served as one exception, likely because Marketplace plans do not cover dental and many employers offer dental insurance.

"Although fewer parents and children have Marketplace coverage compared with other coverage types like [employer-sponsored insurance] and Medicaid/CHIP, these findings show that the importance of Marketplaces has risen steeply over recent years for families with children, particularly for parents, especially those in non-expansion states," the researchers wrote.

According to the researchers, the increased reliance on Marketplace plans -- enabled by premium tax credits -- and the more affordable healthcare access that comes with it, should be top-of-mind for policymakers.

"As Congress considers whether to extend the enhanced PTCs, and 4.8 million people are projected to become uninsured if they are discontinued, this analysis suggests that the resulting coverage losses would increase unmet health care needs and out-of-pocket spending burdens among parents and children," the researchers concluded.

Sara Heath has reported news related to patient engagement and health equity since 2015.

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