The outcome of the presidential election in November could jeopardize coverage for millions, experts warn, even as a record number of people in the United States are signing up for health insurance coverage through the Affordable Care Act, also known as Obamacare.

Former President Donald Trump has renewed his threat to get rid of the health law if he wins a second term. What’s more, if Republicans gain control of Congress, experts say they would likely let expire the discounts that make Obamacare more affordable for millions of people.

“This election has huge health impacts,” said Chris Meekins, a health policy research analyst at the investment firm Raymond James.

Worries about health care costs are a major reason for negative views of the U.S. economy, a KFF poll released Wednesday found. Nearly three-quarters of adults fear they won’t be able to pay for their medical bills. And 50% of people in the U.S., including almost a quarter of Republicans, actually want the next president and Congress to expand what the ACA does. Only a third of adults support scaling back the law (14%) or repealing it entirely (18%), the new poll found.

As of Jan. 24, more than 21 million people had signed up for 2024 health insurance plans through Obamacare, according to the latest data from the Department of Health and Human Services — already surpassing the 16 million total sign-ups during the 2023 enrollment period.

While some of that surge in sign-ups is due to people losing Medicaid coverage, a large portion of  it is in response to the government-backed subsidies passed through the Inflation Reduction Act, Meekins said.

The subsidies, which significantly lower the cost of monthly premiums, are offered to individuals or families who would otherwise pay more than 8% of their annual income on Obamacare coverage. (A 50-year-old couple with an annual income of $70,000, for example, could pay around $430 per month in premiums, down from $1,333 per month without the subsidies, according to KFF, a nonpartisan group that studies health policy issues.) 

Where Obamacare sign-ups have increased since 2020

Southern states saw the largest jump in Affordable Care Act enrollment from 2020 to 2024.

The subsidies were originally passed and put in place for two years, as part of the 2021 Covid relief bill, the American Rescue Plan Act. They were extended for three years under the Inflation Reduction Act in 2022. 

These discounts, however, are set to expire at the end of 2025, unless Congress extends them once more, a prospect unlikely under a Republican-controlled Congress or presidency, Meekins said.

“If there’s a Republican president, it is pretty unlikely you would see those expanded subsidies continue,” he said. 

More than 3 million Americans could become uninsured if Congress fails to extend the subsidies, said Lawrence Gostin, director of the O’Neill Institute for National and Global Health Law at Georgetown University, adding that the lower premiums have helped people in Republican-led states, such as Florida and Texas, where sign-ups have notably increased in the past decade. 

There are already signs that Obamacare or provisions that bolster the health law could be in danger, said Drew Altman, president and CEO of KFF. 

Trump, the likely Republican presidential nominee for the 2024 election, is threatening to repeal the health law once again, Altman said. In November, Trump said on social media that “Obamacare Sucks!!!” and that “I want to REPLACE IT with MUCH BETTER HEALTHCARE.” 

While a full repeal of Obamacare is unlikely, “it’s difficult to see the subsidies continue if Republicans control every branch of government and Trump is president,” Altman said. 

Without the subsidies, people who get their insurance through Obamacare plans could potentially pay hundreds of dollars more each month, making it increasingly difficult to afford their insurance coverage, he said.