What happened to ACA’s low-income special enrollment period? – Healthinsurance.org

Report on the Termination of the Low-Income Special Enrollment Period and its Impact on Sustainable Development Goals

Introduction: A Setback for SDG 3 (Good Health and Well-being)

Recent regulatory and legislative changes in the United States have resulted in the termination of the year-round special enrollment period (SEP) for health insurance, a critical access point for individuals with household incomes at or below 150% of the federal poverty level (FPL). This policy reversal presents a significant challenge to the advancement of Sustainable Development Goal 3, which aims to ensure healthy lives and promote well-being for all at all ages, particularly Target 3.8 concerning universal health coverage.

The Low-Income SEP: A Mechanism for Universal Health Coverage (SDG Target 3.8)

The low-income SEP was an institutional mechanism designed to reduce barriers to healthcare access for vulnerable populations, directly supporting the principles of SDG 3 and SDG 10 (Reduced Inequalities). Its key features and subsequent termination are outlined below.

• Establishment: Finalized in September 2021 by the U.S. Department of Health and Human Services (HHS), the SEP allowed subsidy-eligible applicants with household incomes up to 150% of the FPL to enroll in health coverage at any point during the year.
• Initial Framework: The SEP was initially linked to the American Rescue Plan’s (ARP) subsidy enhancements, which made benchmark plans available at zero premium for this income bracket.
• Functionality: Eligible individuals could enroll in an ACA-compliant plan through the Health Insurance Marketplace, with coverage effective the following month. This flexibility was crucial for ensuring continuous health coverage, a cornerstone of universal health systems.
• Termination: As of August 25, 2025, this enrollment pathway is no longer available, restricting low-income individuals to the annual open enrollment period or a special enrollment period triggered by a qualifying life event. This curtails progress towards achieving universal health coverage.

Legislative Impact on SDG 1 (No Poverty) and SDG 10 (Reduced Inequalities)

The elimination of the low-income SEP was codified through a series of institutional actions that directly impact goals related to poverty reduction and equality. The lack of accessible health insurance is a primary driver of financial hardship and can push households into poverty (SDG 1). The removal of a program specifically targeting low-income groups exacerbates existing health and economic disparities (SDG 10).

1. HHS Rule Change (June 2025): HHS finalized a rule that temporarily eliminated the low-income SEP nationwide from August 25, 2025, through the end of 2026.
2. Enactment of the “One Big Beautiful Bill Act” (OBBBA) (July 2025): This legislation permanently altered the landscape by prohibiting Marketplace subsidies for any individual enrolling through an income-based SEP not linked to a specific qualifying life event.
3. Permanent Elimination: The OBBBA provision effectively makes the low-income SEP unviable in the future. Even if an exchange were to offer it post-2026, enrollees would not be eligible for the subsidies necessary to make coverage affordable, thereby undermining the program’s purpose and failing to protect vulnerable populations from financial catastrophe due to health shocks.

State-Level Mitigation Efforts Aligned with SDG Principles

While federal policy has created a significant gap, some states maintain programs that offer alternative pathways to year-round health coverage for low-income residents, reflecting localized commitment to the principles of SDG 3 and SDG 10.

• Oregon and Minnesota: These states operate Basic Health Programs (BHPs) providing year-round enrollment for individuals with incomes up to 200% of FPL.
• New York: Offers a program with year-round enrollment for those with incomes up to 250% of FPL.
• Massachusetts: The ConnectorCare program is available year-round to newly eligible individuals with incomes up to 500% of FPL.
• Connecticut: The Covered Connecticut program provides coverage for adults with incomes up to 175% of FPL.

Conclusion and Forward-Looking Strategies

The termination of the nationwide low-income SEP represents a regression in efforts to achieve universal health coverage and reduce inequality in the United States. While income-based subsidies remain, their accessibility has been severely limited for the most economically vulnerable populations. To continue progress toward SDGs 1, 3, and 10, affected individuals must leverage the annual open enrollment period and remain vigilant for qualifying life events that grant temporary enrollment access. Policymakers and health advocates should look to existing state-level models as potential frameworks for designing inclusive and accessible health systems that leave no one behind.

1. Which SDGs are addressed or connected to the issues highlighted in the article?

The article discusses issues related to health insurance access for low-income populations, which directly connects to several Sustainable Development Goals (SDGs). The primary SDGs addressed are:

• SDG 1: No Poverty

  The article focuses exclusively on individuals with household incomes not exceeding 150% of the federal poverty level (FPL). The special enrollment period (SEP) and the associated subsidies are social protection mechanisms designed to alleviate the financial burden of healthcare for this vulnerable group, which is a core objective of SDG 1.

• SDG 3: Good Health and Well-being

  The entire article revolves around access to health insurance coverage through the Affordable Care Act (ACA) Marketplace. Ensuring access to affordable health services is a fundamental component of achieving good health and well-being for all. The discussion about enrollment periods, subsidies, and state-based programs like Medicaid and Basic Health Programs (BHPs) directly relates to the goal of universal health coverage.

• SDG 10: Reduced Inequalities

  The low-income SEP was a policy specifically created to reduce inequality in healthcare access by providing a pathway to coverage for those with the lowest incomes. The article details how the creation, and subsequent elimination, of this policy affects a specific economic group, highlighting the role of policy in either reducing or exacerbating inequalities in access to essential services.

2. What specific targets under those SDGs can be identified based on the article’s content?

Based on the article’s discussion of health insurance policies for low-income individuals, the following specific SDG targets can be identified:

• Target 1.3: Implement nationally appropriate social protection systems and measures for all, including floors, and by 2030 achieve substantial coverage of the poor and the vulnerable.

  The ACA Marketplace, premium tax credits (subsidies), and the special enrollment period are all components of a national social protection system aimed at providing health coverage. The article’s focus on individuals with incomes up to 150% of the FPL directly addresses the target of achieving substantial coverage for the poor and vulnerable.

• Target 3.8: Achieve universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.

  The article is centered on mechanisms for achieving health coverage. The low-income SEP was designed to expand access. The mention of premium tax credits and “$0 premium benchmark plan” for applicants with low incomes directly relates to providing financial risk protection and making healthcare affordable, which are key components of universal health coverage.

• Target 10.4: Adopt policies, especially fiscal, wage and social protection policies, and progressively achieve greater equality.

  The article analyzes specific fiscal and social protection policies. The American Rescue Plan’s (ARP) subsidy enhancements and the “One Big Beautiful Bill Act” (OBBBA) are examples of fiscal and legislative policies that directly impact equality in healthcare access. The creation and elimination of the low-income SEP is a clear example of a social protection policy being adopted and then changed, with direct consequences for low-income groups.

3. Are there any indicators mentioned or implied in the article that can be used to measure progress towards the identified targets?

Yes, the article mentions or implies several indicators that can be used to measure progress:

• Indicator for Target 1.3: Proportion of population covered by social protection floors/systems, by sex, distinguishing children, unemployed persons, older persons, persons with disabilities, pregnant women, newborns, work-injury victims and the poor and the vulnerable.

  The article provides a specific metric for this indicator: the number or proportion of individuals with household incomes up to 150% of the FPL who are enrolled in health coverage through the Marketplace. The availability of a year-round SEP for this group was a direct measure of the robustness of this social protection system.

• Indicator for Target 3.8: Proportion of population with health coverage.

  The core issue of the article is the ability of low-income individuals to enroll in health plans. An implied indicator is the enrollment rate for subsidy-eligible individuals with incomes up to 150% of FPL. The elimination of the year-round SEP is expected to impact this rate. Furthermore, the mention of “$0 premium benchmark plan” serves as an indicator of financial protection and affordability within the health coverage system.

• Indicator for Target 10.4: Existence and implementation of policies that promote equality and non-discrimination.

  The article directly discusses the existence, terms, and eventual elimination of a specific policy: the “special enrollment period for individuals with income up to 150% of the federal poverty level.” The status of this policy (active, temporary, or eliminated) serves as a direct indicator of policy measures aimed at promoting health access equality for a specific economic group. The legislative changes, such as the “One Big Beautiful Bill Act” (OBBBA), are also concrete indicators of policy shifts affecting this group.

4. Create a table with three columns titled ‘SDGs, Targets and Indicators” to present the findings from analyzing the article.

Source: healthinsurance.org