President Joe Biden in a campaign advertisement, May 8

President Joe Biden’s reelection campaign wants voters to contrast his record on health care policy with his predecessor’s. In May, Biden’s campaign began airing a monthlong, $14 million ad campaign targeting swing-state voters and minority groups with spots on TV, digital, and radio.

In the ad, titled “,” Biden assails former President Donald Trump for his past promises to overturn the Affordable Care Act, also known as Obamacare. Biden also warns of the potential effect if Trump is returned to office and again pursues repeal.

“That would mean over a hundred million Americans will lose protections for preexisting conditions,” Biden said in the ad.

Less than six months from Election Day, Trump narrowly leading Biden in a head-to-head race in most swing states. And voters trust Trump to better handle issues such as inflation, crime, and the economy by significant margins.

An of about 2,200 adults, released in early May, shows the only major policy issues on which Biden received higher marks than Trump were health care and abortion access. It’s no surprise, then, that the campaign is making to Biden’s pitch to voters.

As such, we dug into the facts surrounding Biden’s claim.

Preexisting Condition Calculations

The idea that 100 million Americans are living with one or more preexisting conditions is not new. It was the subject of a back-and-forth between then-candidate Biden and then-President Trump during their previous race, in 2020. After Biden cited that statistic in a , Trump responded, “There aren’t a hundred million people with preexisting conditions.”

A Ä¢¹½Ó°Ôº Health News/PolitiFact HealthCheck at the time rated Biden’s claim to be “mostly true,” finding a fairly large range of estimates — from 54 million to 135 million — of the number of Americans with preexisting conditions. Estimates on the lower end tend to consider “preexisting conditions” to be more severe chronic conditions such as cancer or cystic fibrosis. Estimates at the spectrum’s higher end include people with more common health problems such as asthma and obesity, and behavioral health disorders such as substance use disorder or depression.

Biden’s May ad focuses on how many people would be vulnerable if protections for people with preexisting conditions were lost. This is a matter of some debate. To understand it, we need to break down the protections put in place by the ACA, and those that exist separately.

Before and After

Before the ACA’s preexisting condition protections took effect in 2014, insurers in — people buying coverage for themselves or their families — could charge higher premiums to people with particular conditions, restrict coverage of specific procedures or medications, set annual and lifetime coverage limits on benefits, or deny people coverage.

“There were a number of practices used by insurance companies to essentially protect themselves from the costs associated with people who have preexisting conditions,” said , a co-director of the Center on Health Insurance Reforms at Georgetown University and an expert on the health insurance marketplace.

Insurers providing coverage to large employers could impose long waiting periods before employees’ benefits kicked in. And though employer-sponsored plans couldn’t discriminate against individual employees based on their health conditions, small-group plans for businesses with fewer than 50 employees could raise costs across the board if large numbers of employees in a given company had such conditions. That could prompt some employers to stop offering coverage.

“The insurer would say, ‘Well, because you have three people with cancer, we are going to raise your premium dramatically,’ and therefore make it hard for the small employer to continue to offer coverage to its workers because the coverage is simply unaffordable,” recalled , a research professor at Georgetown University’s McCourt School of Public Policy who researches public health insurance markets.

As a result, many people with preexisting conditions experienced what some researchers dubbed “.” People felt trapped in their jobs because they feared they wouldn’t be able to get health insurance anywhere else.

Some basic preexisting condition protections exist independent of the ACA. The 1996 , for example, restricted how insurers could limit coverage and mandated that employer-sponsored group plans can’t refuse to cover someone because of a health condition. Medicare and Medicaid similarly can’t deny coverage based on health background, though age and income-based eligibility requirements mean many Americans don’t qualify for that coverage.

Once the ACA’s preexisting condition protections kicked in, plans sold on the individual market had to provide a comprehensive package of benefits to all purchasers, no matter their health status.

Still, some conservatives say Biden’s claim overstates how many people are affected by Obamacare protections.

Even if you consider the broadest definition of the number of Americans living with such conditions, “there is zero way you could justify that 100 million people would lose coverage” without ACA protections, said , who was a Trump administration health policy adviser and is now a senior research fellow with the Paragon Health Institute and a senior fellow at the Manhattan Institute for Policy Research, a conservative think tank.

Joseph Antos, a senior fellow at the American Enterprise Institute, a conservative think tank, called the ad’s preexisting conditions claim “the usual bluster.” To reach 100 million people affected, he said, “you have to assume that a large number of people would lose coverage.” And that’s unlikely to happen, he said.

That’s because most people — about 55% of Americans, according to the most recent — receive health insurance through their employers. As such, they’re protected by the Health Insurance Portability and Accountability Act rules, and their plans likely wouldn’t change, at least in the short term, if the ACA went away.

Antos said major insurance companies, which have operated under the ACA for more than a decade, would likely maintain the status quo even without such protections. “The negative publicity would be amazing,” he said.

People who lose their jobs, he said, would be vulnerable.

But Corlette argued that losing ACA protections could lead to Americans being priced out of their plans, as health insurers again begin medical underwriting in the individual market.

Park predicted that many businesses could also gradually find themselves priced out of their policies.

“For those firms with older, less healthy workers than other small employers, they would see their premiums rise,” he told Ä¢¹½Ó°Ôº Health News.

Moreover, Park said, anytime people lost work or switched jobs, they’d risk losing their insurance, reverting to the old days of job lock.

“In any given year, the number [of people affected] will be much smaller than the 100 million, but all of those 100 million would be at risk of being discriminated against because of their preexisting condition,” Park said.

Our Ruling

We previously ruled Biden’s claim that 100 million Americans have preexisting conditions as in the ballpark, and nothing suggests that’s changed. Depending on the definition, the number could be smaller, but it also could be even greater and is likely to have increased since 2014.

Though Biden’s claim about the number of people who would be affected if those protections went away seems accurate, it is unclear how a return to the pre-ACA situation would manifest.

On the campaign trail this year, Trump has promised — as he did many times in the past — to with something better. But he’s never produced a replacement plan. Biden’s claim shouldn’t be judged based on his lack of specificity.

We rate Biden’s claim Mostly True.

our sources

ABC News/Ipsos Poll, “,” May 5, 2024

Avalere, “,” Oct. 23, 2018

Biden-Harris 2024 campaign email, “NEW AD: Biden-Harris 2024 Launches ‘Terminate’ Slamming Trump for Attacks on Health Care,” May 8, 2024

Center for American Progress, “,” Oct. 2, 2019

Census Bureau, “,” September 2023

CNN, “,” Oct. 22, 2018

Department of Health and Human Services, “,” Jan. 5, 2017

Department of Health and Human Services, “,” accessed May 15, 2024

Email exchanges with Biden-Harris 2024 campaign official, May 13-15, 2024

Email exchange with Karoline Leavitt, Trump 2024 campaign national press secretary, May 13, 2024

Ä¢¹½Ó°Ôº, “,” May 15, 2024

Ä¢¹½Ó°Ôº, “,” Feb. 6, 2024

Ä¢¹½Ó°Ôº Health News, “Drowning in a ‘High-Risk Insurance Pool’ — At $18,000 a Year,” Feb. 27, 2017

Ä¢¹½Ó°Ôº Health News and PolitiFact, “Biden’s in the Ballpark on How Many People Have Preexisting Conditions,” Oct. 1, 2020

The New York Times, “,” May 13, 2024

Phone interview and email exchanges with , a senior fellow at the Manhattan Institute and the director of the Private Health Reform Initiative at the Paragon Health Institute, May 14-15, 2024

Phone interview with , a research professor at Georgetown University’s McCourt School of Public Policy, May 22, 2024

Phone interview with , a co-director of the Center on Health Insurance Reforms at Georgetown University, May 14, 2024

Truthsocial.com, , Nov. 25, 2023

The Wall Street Journal, “,” Sept. 23, 2017

Work, Aging and Retirement, “,” Feb. 19, 2016

YouTube.com/@CSPAN, “,” Sept. 29, 2020

YouTube.com/@JoeBiden, “” campaign advertisement, May 10, 2024

Phone interview with Joseph Antos, a senior fellow at the American Enterprise Institute, June 5, 2024

Health Affairs, , Sept. 11, 2020

Ä¢¹½Ó°Ôº, , Dec. 12, 2016

PolitiFact, “,” June 3, 2024

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Ä¢¹½Ó°Ôº Health News contributor Andy Miller discussed Affordable Care Act subsidy changes on WUGA’s “The Georgia Health Report” on May 31.

• Read Miller’s “Presidential Election Could Decide Fate of Extra Obamacare Subsidies”

Ä¢¹½Ó°Ôº Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Ä¢¹½Ó°Ôºâ€”an independent source of health policy research, polling, and journalism. Learn more about .

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Customers often don’t discover the changes until they’re denied medical coverage or get stuck with a bill for ACA tax credits they have to repay.

Senate Finance Committee Chair Ron Wyden (D-Ore.) said he’ll propose legislation to allow the Centers for Medicare and Medicaid Services to hold fraudulent brokers “criminally responsible” for their actions. The agency, which oversees the ACA exchanges, can fine individuals up to $250,000 for submitting false information in an application for a health plan, but it hasn’t done so, Wyden said.

“I am disappointed these penalties have not yet been used to hold bad actors accountable,” Wyden wrote last week in a sharply worded letter to CMS Chief Chiquita Brooks-LaSure.

Jimmy Patronis, who oversees agencies including insurance regulators as Florida’s chief financial officer, called on Congress to push CMS to require two-factor authentication on and related platforms that agents use to sign people up for coverage. According to Patronis, the state has into problem enrollments.

“It’s far easier to prevent fraud from occurring in the first place than it is to ask state regulators to chase down these bad actors after the fact,” Patronis wrote.

The problem appears concentrated among the 32 states using the federal marketplace — — because, brokers say, it’s too easy for rogue agents to access policyholder information. All they need is a name, date of birth and state.

States that run their own insurance markets generally have additional security requirements.

CMS tallied 90,000 complaints about unauthorized sign-ups or plan switching in just the first quarter of 2024, out of more than 16 million enrollments.

Jeff Wu, acting director of the Center for Consumer Information and Insurance Oversight at CMS, has said his agency is preparing regulatory and technological fixes, investigating brokers and working to restore consumers to chosen plans.

But even with Wyden’s legislation on the way, Congress looks unlikely to act. Lawmakers are in the middle of an election year in which President Biden is trying to win votes for bolstering enrollment in ACA plans while knocking his opponent, former president Donald Trump, for his unsuccessful attempt to repeal the law.

Sabrina Corlette, who follows the ACA market as co-director of the Center on Health Insurance Reforms at Georgetown University, said the feds can do more, including coordinating better with state investigations.

But states like Florida should also regulate the marketplaces, she said.

“If there’s a lot of bad brokers in Florida, then Florida needs to look inward and maybe do a better job of policing brokers,” she said.

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Cox, 40, qualified for an Affordable Care Act marketplace plan with no monthly premium due to her relatively low income. And after she cut her hand severely, the 35 stitches she received in the ER led to an out-of-pocket expense of about $300, she said.

“I can’t imagine what the ER visit would have cost if I was uninsured,” she said.

Cox is among 1.3 million people enrolled in health coverage this year through the ACA marketplace in Georgia, which has seen a 181% increase in enrollment since 2020.

Many people with low incomes have been drawn to plans offering $0 premiums and low out-of-pocket costs, which have become increasingly common because of the enhanced federal subsidies introduced by President Joe Biden.

Southern states have seen the biggest enrollment bump of any region. Ten of the 15 states that more than doubled their marketplace numbers from 2020 to 2024 are in the South, according to a . And the five states with the largest increases in enrollment — Texas, Mississippi, Georgia, Tennessee, and South Carolina, all in the South — have yet to expand Medicaid under the Affordable Care Act, driving many residents to the premium-free health plans.

But with the federal incentives introduced by the Biden administration set to expire at the end of 2025, and the possibility of a second Donald Trump presidency, the South could be on track to see a significant dip in ACA enrollment, policy analysts say.

“Georgia and the Southern states generally have lower per-capita income and higher uninsured rates,” said Gideon Lukens, a senior fellow and the director of research and data analysis for the Center on Budget and Policy Priorities, a nonpartisan, Washington, D.C.-based research organization. If the enhanced subsidies go away, he said, the South, especially states that haven’t expanded Medicaid, will likely feel a bigger effect than other states. “There’s no other safety net” for many people losing coverage in non-expansion states, Lukens said.

When Cox was enrolling in Obamacare last fall, she qualified for premium tax credits that were added to two major congressional legislative packages: the American Rescue Plan Act in 2021, and the Inflation Reduction Act in 2022. Those incentives — which gave rise to many plans with no premiums and low out-of-pocket costs — have helped power this year’s record . The extra subsidies were added to the already existing subsidies for marketplace coverage.

The states that didn’t expand Medicaid and have high uninsured rates “got most of the free plans,” said Cynthia Cox, a Ä¢¹½Ó°Ôº vice president who directs the health policy nonprofit’s program on the ACA. Zero-premium plans existed before the new subsidies, she added, but they generally came with high deductibles that potentially would lead to higher costs for consumers.

A Trump presidency could jeopardize those extra subsidies. Brian Blase, a former Trump administration official who advised him on health care policy, said that eliminating the extra subsidies would bring the marketplace back to the ACA’s original intent.

“It’s not sustainable or wise to have fully taxpayer-subsidized coverage,” said Blase, who is now president of the Paragon Health Institute, a health policy research firm. People would still qualify for discounts, he said, but they wouldn’t be as generous.

Karoline Leavitt, a spokesperson for Trump, did not answer a reporter’s questions on the future of the enhanced subsidies under a new Trump administration. Despite his comments at the end of last year that he is “” to Obamacare, Leavitt said Trump is not campaigning to terminate the Affordable Care Act.

“He is running to make health care actually affordable, in addition to bringing down inflation, cutting taxes, and reducing regulations to put more money back in the pockets of all Americans,” she said.

While views on Obamacare may be divided, the wide support for subsidies crosses political lines, according to a released in May.

About 7 in 10 voters support the extension of enhanced federal financial assistance for people who purchase ACA marketplace coverage, the poll found. That support included 90% of Democrats, 73% of independents, and 57% of Republicans surveyed.

The enhanced assistance also allowed many people with incomes higher than 400% of the poverty level, or $58,320 for an individual in 2023, to get tax credits for coverage for the first time.

Besides the financial incentives, other reasons cited for the explosion in ACA enrollment include the end of continuous Medicaid coverage protections related to the covid public health emergency. About a year ago, states started redetermining eligibility, known as the “unwinding.”

of those who lost Medicaid coverage moved to the ACA marketplace, said Edwin Park, a research professor at the Georgetown University Center for Children and Families.

In Georgia, Republican political leaders haven’t talked much about the effect of the Biden administration’s premium incentives on enrollment increases.

Instead, Georgia Gov. Brian Kemp, among others, has , an online portal that links consumers directly to the ACA marketplace’s website or to an agent or broker. That agent link can create a more personal connection, said Bryce Rawson, a spokesperson for the state’s insurance department, which runs the portal. Employees from the agency and from consulting firms helped market the no-premium plans throughout the state, he said.

Yet Georgia Access didn’t become fully operational until last fall, during open enrollment for the marketplace. Republicans also credit a reinsurance waiver that, according to Rawson, increased the number of health insurers offering marketplace coverage in the state, leading to more competition.

Reinsurance is likely not a major reason for a state’s increased Obamacare enrollment, said Georgetown’s Park. And a found that Georgia’s reinsurance program had the unintended consequences of increasing the minimum cost of subsidized ACA coverage and reducing enrollment among individuals at a certain income level, .

The state’s insurance department said the study “does not accurately reflect the overall benefits the reinsurance program has brought to Georgia consumers.”

When asked whether the governor would support renewal of the enhanced subsidies, Garrison Douglas, Kemp’s spokesperson, said the matter is up to Congress to decide.

Another reason for the soaring ACA enrollment is the 2023 fix to the “family glitch” that had prevented dependents of workers who were offered unaffordable family coverage by employers from getting marketplace subsidies.

States that have run their own marketplaces, though, generally have not seen the same level of enrollment increases. Those 18 states, plus the District of Columbia, have expanded Medicaid. Georgia will join the list of states running their own exchanges this fall, making it the only state to operate one that has not expanded Medicaid.

The federal Centers for Medicare & Medicaid Services credits a national marketing campaign and more federal funding for navigators, the insurance counselors who provide education about marketplace health coverage and free help with enrollment.

That level of financial support for navigators may be in jeopardy if Trump returns to the White House.

The Biden administration injected nearly $100 million in funding for navigators in the enrollment period for coverage this year. The Trump administration, on the other hand, for navigators from 2018 to 2020.

The marketplace is usually “a transitional place” for people coming in and out of coverage, Ä¢¹½Ó°Ôº’s Cox said. “That marketing and outreach is pretty essential to help people literally navigate the process.”

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“We want the Centers for Medicare & Medicaid Services to hold these brokers criminally responsible for ripping people off this way,” he told Ä¢¹½Ó°Ôº Health News.

In a sharply worded letter sent to CMS Administrator Chiquita Brooks-LaSure, the Oregon Democrat expressed “outrage” over the practice, which nets unscrupulous agents commission payments while leaving consumers with a potential host of problems, from losing access to their regular doctors or treatments to higher deductibles and even owing taxes.

Noting that tens of thousands of Americans have been victimized, Wyden called on regulators to step up enforcement and be more proactive in notifying potentially affected consumers. He vowed to introduce legislation that would make participating in such schemes subject to criminal penalties.

“CMS must do more and you must do it now,” he wrote in his letter.

Complaints about such unauthorized enrollment schemes have grown in recent months. Ä¢¹½Ó°Ôº Health News has reported that unscrupulous brokers or agents can easily access policyholder information to change their coverage through private commercial platforms integrated with the federal Obamacare marketplace, healthcare.gov, which serves 32 states.

The challenge for federal regulators is to thwart the activity without reducing enrollment — a top priority for President Joe Biden’s administration.

CMS, which oversees the federal website, said it’s working on regulatory and technological fixes and can suspend or terminate problem agents’ access to healthcare.gov.

The agency will respond directly to Wyden, said Jeff Wu, acting director of CMS’ Center for Consumer Information & Insurance Oversight, in a written statement. He further noted that the agency is “consistently evaluating opportunities to identify and resolve issues sooner, including through outreach, technical assistance, and compliance actions.”

Ronnell Nolan, president and CEO of , whose group has been outspoken about the need for regulators to do more, welcomed Wyden’s involvement and the potential for criminal penalties for perpetrators.

“It’s a crime when a person’s insurance is taken from them when they’re in the middle of cancer treatment or on a transplant list and they’re put in a predicament where they might lose their life because of the fraudulent activity,” she said.

After initially declining to quantify the problem, CMS saying it had received more than 90,000 complaints in the first quarter of 2024 about unauthorized enrollments and plan switches. While the number of complaints represents a small percentage of the more than 16 million enrollments processed through healthcare.gov for this year’s coverage, it may understate the breadth of the problem, as complaints likely don’t reflect the magnitude of cases.

Although Wyden lauded CMS’ efforts to fix problems already encountered by consumers, he said in his letter that the agency needs to be more proactive about preventing them.

He urged regulators to contact potentially affected consumers instead of waiting to investigate only after a policyholder files a complaint, which sometimes doesn’t occur until weeks or months after a plan is switched.

It can be difficult for victims to recognize the changes. Rogue agents don’t obtain their consent, and many are signed up for plans that have no monthly premiums, so they don’t get a bill. Other consumers unknowingly enroll when they respond to misleading marketing promising gift cards, “government subsidies,” or other financial help.

Rather than wait for a consumer to complain, regulators could reach out directly when they see a policy submitted or changed by a broker or agency that has been found to be fraudulently enrolling others, Wyden wrote.

Wyden also said CMS should use its authority to impose civil penalties, up to $250,000, against “brokers who submit fraudulent enrollments.”

“I am disappointed these penalties have not yet been used to hold bad actors accountable,” he wrote.

Finally, he wants the agency to review private-sector platforms used by agents and brokers to enroll consumers in ACA plans. Those private companies are not used by 18 states and the District of Columbia, which run their own ACA marketplaces. The state-run marketplaces impose additional layers of identity-proofing and other security measures and have reported far fewer problems with unauthorized enrollment.

Dozens of private “enhanced direct enrollment” to integrate with healthcare.gov. Their involvement was expanded during the Trump administration, which also sharply reduced funding for nonprofits to help with outreach and enrollment.

The platforms were designed to be simpler to use than healthcare.gov. But they have drawn criticism from agents, who say the private websites make it too easy for unscrupulous brokers or others to access policyholder information and make changes. Currently, more than half of federal marketplace enrollments are assisted by agents or brokers, and most act legitimately, regulators and others say.

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“Folks, he’s coming for your health care, and we’re not going to let it happen,” Biden says of Trump in a out this month, part of a $14 million investment in the handful of states expected to decide the presidency in November.

The new ad draws on the popularity of the ACA among independent voters and alludes to Biden’s edge over Trump on health issues, which the current president hopes will help propel him to victory.

Swaying even a tiny percentage of voters could make a difference for Biden, said Kenneth Miller, an assistant professor of political science at the University of Nevada-Las Vegas.

“It will be so close,” he said. “Any little thing can be a deciding factor.”

Political experts say Biden is wise to draw attention to the ACA, which ended long-standing insurance practices denying coverage to people with preexisting conditions or charging them more — a change that is “popular across the partisan divide” and benefits about half of U.S. households, said Ashley Kirzinger, Ä¢¹½Ó°Ôº’s associate director of public opinion and survey research.

“Framing the ACA around those protections is a very smart move,” she said.

A new found Biden has an edge with independent voters when it comes to health care issues.

Independents trust Biden more than Trump to ensure access to affordable health insurance (47% to 22%) and maintain protections for people with preexisting conditions (47% to 23%).

Biden holds a smaller advantage over Trump in whom independents trust more to address high health care costs (39% to 26%). The survey also found the issue isn’t a slam dunk for either candidate: About a third of independent voters said they trust neither Biden nor Trump to address costs.

Democrats are fighting to extend higher government subsidies for most people with ACA coverage, which were increased during the pandemic and are set to expire in 2025. They’re also banking on outrage over the Supreme Court’s 2022 decision striking down Roe v. Wade, and strict abortion bans that have followed in many Republican-led states, to juice Democratic turnout.

The stakes “could not be higher for Americans who rely on the Affordable Care Act,” Biden campaign spokesperson Michael Tyler told reporters on a call this month.

The Trump campaign did not respond to a request for comment.

At least one Democratic-aligned super PAC is , including on Trump’s appointment of Supreme Court justices who helped overturn the constitutional right to an abortion.

Barry Burden, director of the Elections Research Center at the University of Wisconsin-Madison, said focusing on health care plays to Biden’s strengths.

“Biden has been mired by voter concerns about inflation and immigration, where Republicans are preferred,” he said. “Health care is more favorable territory where the Trump campaign does not have much of a defense to offer.”

in most battleground states, with voters expressing pessimism about the economy.

But Trump is vulnerable on health care, Miller said. He unsuccessfully tried to repeal the ACA as president and has alluded to trying again if he returns to the White House. In November, “Obamacare Sucks!” on social media, and in March he said he wants to improve the law without saying how.

“These ads are an effort to shake up the agenda,” Miller said. “Biden needs more work reminding Democrat-leaning independent voters who probably voted for him in 2020 that he is the better choice.”

Biden’s ad also claims his health care policies have helped save Americans $800 a year. The Biden administration that’s how much 13 million people buying coverage on ACA insurance marketplaces saved in 2022.

The ad’s primary claim, that 100 million people would be harmed if Trump eliminated preexisting condition protections, is misleading, said Robert Speel, director of the Public Policy Initiative at Penn State Behrend. That’s because many would retain the protections under their coverage, particularly those on Medicare and employer-sponsored insurance.

“The ad looks too generic to have a significant impact on the outcome of the election, though it may get through to enough of the small universe of swing voters to have at least some potential impact on who wins Pennsylvania,” Speel said.

The Ä¢¹½Ó°Ôº survey of 1,243 registered voters conducted April 23-May 1 had a margin of sampling error of plus or minus 4 percentage points.

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Fighting the problem presents tension for the administration: how to thwart the bad actors without affecting ACA sign-ups.

Complaints about these unauthorized changes — which can cause affected policyholders to lose access to medical care, pay higher deductibles, or even incur surprise tax bills — rose sharply in recent months, according to brokers who contacted Ä¢¹½Ó°Ôº Health News and federal workers who asked not to be identified.

Ronnell Nolan, president and CEO of the trade association Health Agents for America, said her group has suggested to the Centers for Medicare & Medicaid Services that it add two-factor authentication to healthcare.gov or send text alerts to consumers if an agent tries to access their accounts. But the agency told her it doesn’t always have up-to-date contact information.

“We’ve given them a whole host of ideas,” she said. “They say, ‘Be careful what you wish for.’ But we don’t mind going an extra step if you can stop this fraud and abuse, because clients are being hurt.”

Some consumers are pursued when they respond to misleading social media marketing ads promising government subsidies, but most have no idea how they fell victim to plan-switching. Problems seem concentrated in the 32 states using the federal exchange.

CMS about unauthorized ACA plan switches and enrollments in the first quarter of 2024, according to the agency.

The problem is big enough that CMS says it’s working on technological and regulatory solutions. Affected consumers and agents have filed a civil lawsuit in federal district court in Florida against private-sector firms allegedly involved in unauthorized switching schemes.

Biden has pushed hard to make permanent the enhanced subsidies first put in place during the covid pandemic that, along with other steps including increased federal funding for outreach, helped fuel the strong enrollment growth. Biden for the ACA with the stance of former President Donald Trump, who supported attempts to repeal most of the law and presided over funding cuts and declining enrollment.

Most proposed solutions to the rogue-agent problem involve making it more difficult for agents to access policyholder information or requiring wider use of identity questions tied to enrollees’ credit history. The latter could be stumbling blocks for low-income people or those with limited financial records, said Sabrina Corlette, co-director of the Center on Health Insurance Reforms at Georgetown University.

“That is the knife edge the administration has to walk,” said Corlette, “protecting consumers from fraudulent behavior while at the same time making sure there aren’t too many barriers.”

Jeff Wu, acting director of the Center for Consumer Information & Insurance Oversight, said in a statement that the agency is evaluating options on such factors as how effective they would be, their impact on consumers’ ability to enroll, and how fast they could be implemented.

The agency is also working closely, he wrote, with insurance companies, state insurance departments, and law enforcement “so that agents violating CMS rules or committing fraud face consequences.” And it is reaching out to states that run their own ACA markets for ideas.

That’s because Washington, D.C., and the 18 states that run their own ACA marketplaces have reported far fewer complaints about unauthorized enrollment and plan-switching. Most include layers of security in addition to those the federal marketplace has in place — some use two-factor authentication — before agents can access policyholder information.

California, for example, allows consumers to designate an agent and to “log in and add or remove an agent at will,” said Robert Kingston, interim director of outreach and sales for Covered California, the state’s ACA marketplace. The state can also send consumers a one-time passcode to share with an agent of their choice. Consumers in Colorado and Pennsylvania can similarly designate specific agents to access their accounts.

By contrast, agents can more easily access policyholder information when using private-sector websites that link them to the federal ACA market — all they need is a person’s name, date of birth, and state of residence — to enroll them or switch their coverage.

of such “enhanced direct enrollment” websites run by private companies, which are designed to make it easier and faster for agents certified to offer insurance through healthcare.gov.

last June requiring agents to get written or recorded consent from clients before enrolling them or changing their coverage, but brokers say they’re rarely asked to produce the documentation. If CMS makes changes to healthcare.gov — such as adding passcodes, as California has — it would need to require all alternative-enrollment partners to do the same.

The largest is San Francisco-based HealthSherpa, which assisted 52% of active enrollments nationally for this year, said CEO George Kalogeropoulos.

The company has a 10-person fraud investigation team, he said, which has seen “a significant spike in concerns about unauthorized switching.” They report problems to state insurance departments, insurance carriers, and federal regulators “and refer consumers to advocates on our team to make sure their plans are corrected.”

Solutions must be “targeted,” he said. “The issue with some of the solutions proposed is it negatively impacts the ability of all consumers to get enrolled.”

Most people who sign up for ACA plans are aided by agents or platforms like HealthSherpa, rather than doing it themselves or seeking help from nonprofit organizations. Brokers don’t charge consumers; instead, they receive commissions from insurers participating in state and federal marketplaces for each person they enroll in a plan.

While California officials say their additional layers of authentication have not noticeably affected enrollment numbers, the state’s recent enrollment growth than in states served by healthcare.gov.

Still, Covered California’s Kingston pointed to a decreased number of uninsured people in the state. In 2014, when much of the ACA was implemented, 12.5% of Californians were uninsured, , according to data compiled by Ä¢¹½Ó°Ôº. That year, the share of people uninsured nationwide was 8%.

Corlette said insurers have a role to play, as do states and CMS.

“Are there algorithms that can say, ‘This is a broker with outlier behavior’?” Insurance companies could then withhold commissions “until they can figure it out,” she said.

Kelley Schultz, vice president of commercial policy at AHIP, the trade association for large insurance companies, said sharing more information from the government marketplace about which policies are being switched could help insurers spot patterns.

CMS could also set limits on plan switches, as there is generally no legitimate need for multiple changes in a given month, Schultz said.

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A new regulation  allows states to include adult dental care as a benefit that health insurers must cover under the Affordable Care Act. Following , the proposal represents an election-year aspiration for the future of Obamacare: It doesn’t require states to do anything, even as it shows off President Biden’s intention to make the ACA a more robust safety net.

“It’s huge, really significant,” said Colin Reusch, director of policy at Community Catalyst, a health coverage advocacy group. He said the new Biden administration rule represents “one of the first real changes” to coverage provisions of the law since it passed in 2010.

But like so much in health care, expanding access to dental services is a lot more complicated than it sounds.

An estimated 68.5 million U.S. adults lacked dental insurance in 2023, according to the nonprofit CareQuest Institute for Oral Health. That’s more than 2.5 times the roughly 26 million Americans of all ages .

And millions of Americans lost dental coverage in the past year as part of the Medicaid “unwinding” that dropped low-income people who had been covered by the program during the pandemic.

At the same time,  more than $45 billion in lost productivity annually, according to the Centers for Disease Control and Prevention, and it’s linked to a long list of even more serious health problems, including heart disease and diabetes.

Still, efforts to expand U.S. dental coverage have long foundered on the shoals of cost. When people have dental insurance, they tend to use it. So including the coverage in a health insurance policy can raise overall premiums.

That’s one reason traditional Medicare coverage explicitly excludes most dental care. (Many private Medicare Advantage plans offer some dental coverage as an enticement for seniors to join.)

An effort to add a dental benefit to Medicare was stripped from Biden’s “Build Back Better” legislation before it was passed in 2022 as the Inflation Reduction Act. Instead, the administration in which Medicare can cover dental care. Any progress on oral health — including giving states the option to require coverage for adults — is seen by advocates as a victory. Dental coverage for children is already an essential benefit under the ACA.

But whether they actually get coverage depends on states affirmatively adding dental benefits to benchmark plans in the ACA’s insurance marketplaces. Those plans not only determine what services Affordable Care Act insurance has to cover, but also set parameters for state-employee and many private-employer health plans.

Reusch said a few states are considering the change, but it will be a while until anything is certain. States have until May 2025 to decide whether to add dental care to benchmark ACA plans; the benefit wouldn’t be effective until the 2027 plan year.

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According to the lawsuit, filed in U.S. District Court for the Southern District of Florida, two such call centers paid tens of thousands of dollars a day to buy names of people who responded to misleading advertisements touting free government “subsidies” and other rewards. In turn, sales agents used the information to either enroll them in ACA plans or switch their existing policies without their consent.

As a result, the lawsuit alleges, consumers lost access to their doctors or medications and faced financial costs, such as owing money toward medical care or having to repay tax credits that were paid toward the unauthorized coverage.

Some consumers were switched multiple times or had duplicative policies.

“We allege there was a plan that targeted the poorest of Americans into enrolling in health insurance through deceptive ads and unauthorized switching,” to gain compensation for the sign-ups or capture the commissions that would have been paid to legitimate insurance agents, said Jason Doss, one of two lawyers who filed the case following a four-month investigation.

Doss and Jason Kellogg, the other lawyer on the case, which was filed on behalf of several affected policyholders and agents, are seeking class action status.

Ä¢¹½Ó°Ôº Health News has in recent weeks reported on similar concerns raised by consumers and insurance agents.

Named as defendants are TrueCoverage and Enhance Health, which operate insurance call centers in Florida and other states; Speridian Technologies, a New Mexico-based limited liability company that owns and controls TrueCoverage; and Number One Prospecting, doing business as Minerva Marketing, which is also a lead-generating company. The lawsuit also names two people: Brandon Bowsky, founder and CEO of Minerva; and Matthew Herman, CEO of Enhance Health. Attempts to reach the companies for comment were unsuccessful.

According to the lawsuit, the call centers had access to policyholder accounts through “enhanced direct enrollment” platforms, including one called Benefitalign, owned by Speridian.

Such private sector platforms, which by the Centers for Medicare & Medicaid Services, streamline enrollment by integrating with the federal ACA marketplace, called healthcare.gov. The ones included in this case were not open to the public, but only to those call center agencies granted permission by the platforms.

One of the plaintiffs, Texas resident Conswallo Turner, signed up for ACA coverage in December through an agent she knew, and expected it to go into effect on Jan. 1, according to the lawsuit. Not long after, Turner saw an ad on Facebook promising a monthly cash card to help with household expenses.

She called the number on the ad and provided her name, date of birth, and state, the lawsuit says. Armed with that information, sales agents then changed her ACA coverage and the agent listed on it five times in just a few weeks, dropping coverage of her son along with way, all without her consent.

She ended up with a higher-deductible plan along with medical bills for her now-uninsured son, the lawsuit alleges. Her actual agent also lost the commission.

The lawsuit contains similar stories from other plaintiffs.

The routine worked, it alleges, by collecting names of people responding to online and social media ads claiming to offer monthly subsidies to help with rent or groceries. Those calls were recorded, the suit alleges, and the callers’ information obtained by TrueCoverage and Enhance Health.

The companies knew people were calling on the promise “of cash benefits that do not exist,” the lawsuit said. Instead, call center agents were encouraged to be “vague” about the money mentioned in the ads, which was actually the subsidies paid by the government to insurers toward the ACA plans.

The effort targeted people with low enough incomes to qualify for large subsidies that fully offset the monthly cost of their premium, the lawsuit alleges. The push began after March 2022, when a special enrollment period for low-income people became available, opening up a year-round opportunity to enroll in an ACA plan.

The suit asserts that those involved did not meet the privacy and security rules required for participation in the ACA marketplace. The lawsuit also alleges violations of the federal Racketeer Influenced and Corrupt Organizations Act, .

“Health insurance is important for people to have, but it’s also important to be sold properly,” said Doss, who said both consumers and legitimate agents can suffer when it’s not.

“It’s not a victimless crime to get zero-dollar health insurance if you don’t qualify for it and it ends up causing you tax or other problems down the road,” he said. “Unfortunately, there’s so much fraud that legitimate agents who are really trying to help people are also being pushed out.”

Ä¢¹½Ó°Ôº Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Ä¢¹½Ó°Ôºâ€”an independent source of health policy research, polling, and journalism. Learn more about .

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While the concern about unscrupulous brokers enrolling unsuspecting people in ACA coverage has simmered for years, complaints have risen in recent months as consumers discover their health insurance coverage isn’t what they thought it was.

Now such unauthorized enrollments are also causing tax headaches. Returns are getting rejected by the IRS and some people will have to pay more in taxes.

“It’s definitely gotten worse over the past year. We’ve helped three to four dozen people this year already,” said Erin Kinard, director of systems and intake for the Health and Economic Opportunity Program at in North Carolina, which helps low-income families enroll in ACA plans and get tax help.

Neither the IRS nor the Centers for Medicare & Medicaid Services, which oversees the federal Obamacare marketplace, responded to questions about the problem.

The IRS did, however, in February instructing consumers on what to do if their electronically filed returns are rejected because of ACA issues.

Unauthorized sign-ups can happen in several ways, Kinard and others said. Some rogue agents troll online enrollment portals that are accessible only to brokers but are integrated with the healthcare.gov website. When those agents open a new policy or switch an already enrolled policyholder to a different plan, they garner the associated monthly commissions. Other consumers unwittingly sign up when they respond to advertisements touting gift cards or government subsidies then are transferred to agents who enroll them in health coverage. It’s happening even after new requiring agents to get written or recorded consent from clients before making changes.

CMS has not released details on how many consumers have been affected or how many agents have been sanctioned for participating in such schemes.

There’s also no public tally of how many taxpayers are facing problems as a result. And the tax consequences can come as a surprise.

“Many people are finding out when they go to e-file their taxes and it bounces back and the IRS says it can’t accept your return,” said Christine Speidel, an associate professor and the director of the at Villanova University’s Charles Widger School of Law.

Returns are rejected if the IRS has information indicating the taxpayer has ACA coverage but the returns don’t include forms that help determine whether paid on the policyholder’s behalf to insurers were correct. If their income was misstated by the rogue broker who enrolled them, for example, they might not have qualified for the full amount paid. Or, if they had affordable employer coverage, they would not have been eligible for ACA subsidies at all.

Ashley Zukoski, an ultrasound technologist in Charlotte, North Carolina, had employer coverage but now faces a tax bill for an ACA plan she said she never signed up for. She reached out to Ä¢¹½Ó°Ôº Health News after it reported on such unauthorized plan enrollments.

Unbeknownst to her, she said, a broker in Florida enrolled her family in an ACA plan in late February 2023, even though Zukoski had coverage starting that January through her job. The broker listed an income that qualified the household for a full subsidy, so Zukoski never received a premium bill.

Her first inkling that something was amiss came early in 2024 when she received a special form, , which showed she had an ACA plan. After reporting the problem to the federal marketplace, she sought to get the 1095-A voided so she would not be liable for the plan’s premium subsidies paid by the government to the insurer.

But, because Zukoski’s pharmacy had billed the ACA plan instead of her job-based coverage, her request was denied. She plans to appeal.

In the meantime, the family has filed an extension on their taxes.

“Instead of getting a $4,100 refund, we now owe almost $700 in taxes based on the 1095-A and premium tax credit applied,” Zukoski said.

With the April 15 federal tax filing deadline upon us, there are some important steps for affected consumers to take, tax and insurance experts said.

First, because it could take weeks to get corrected forms, experts recommend filing for an extension to buy more time. When consumers file for that extension, they should also pay any taxes owed to avoid penalties and interest.

In general, consumers who at any point in the year think they are victims of an unauthorized enrollment or plan switch should report it immediately to the relevant federal or state ACA marketplace and request a corrected Form 1095-A. But move fast. Appeals to cancel coverage retroactively must be made within 60 days of discovering the fraudulent enrollment, Speidel said.

Consumers can ask for help filing a complaint with federal or state regulators by contacting their own insurance agents or seeking help from assisters or “navigator” programs, which are government-funded nonprofit groups that help people enroll or deal with insurance problems.

Navigators and assisters are fielding many such cases this year and can submit what are called “complex case forms,” which help federal officials investigate such complaints, said Lynn Cowles, program manager for , a navigator program in Texas.

Ä¢¹½Ó°Ôº Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at Ä¢¹½Ó°Ôºâ€”an independent source of health policy research, polling, and journalism. Learn more about .

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