ACA Under Siege: Is the American Dream of Affordable Healthcare Officially Dead?

Access to healthcare isn’t just a policy issue; it’s a lifeline. For millions of Californians, the Affordable Care Act has meant the difference between seeing a doctor and skipping care due to cost. Nearly 1.8 million people in the state rely on ACA plans, a number that reflects years of hard-won progress. Yet, a new set of proposed federal rules from the U.S. Department of Health and Human Services aims to unravel this foundation, threatening to leave countless Americans without coverage and drive up costs for those who manage to keep it.

California Attorney General Rob Bonta, joined by 21 other state attorneys general, has sounded the alarm. Their recent comment letter lays bare the stakes: these changes would shorten enrollment periods, exclude Deferred Action for Childhood Arrivals recipients from ACA eligibility, and block gender-affirming care as a required benefit. Each move chips away at the ACA’s core mission to expand coverage and make care affordable. The coalition’s stance isn’t just about legal technicalities; it’s about protecting people who can’t afford to lose access to doctors, prescriptions, or peace of mind.

This fight feels personal because it is. When bureaucracy threatens to dictate who gets care and who doesn’t, it’s not abstract. It’s the single parent juggling bills, the young adult managing a chronic condition, the transgender person seeking dignity in treatment. These rules aren’t neutral; they’re a deliberate step backward, and they demand a response.

Consider the proposal to shorten the ACA’s open enrollment period from 75 days to just 45. Data from Pennsylvania’s marketplace shows that 40% of enrollees sign up in the final month, often because they need time to navigate options or get help. Cutting this window risks leaving people uninsured, especially those already stretched thin by work or family demands. California’s own marketplace, Covered California, has thrived on flexibility, historically extending enrollment to boost sign-ups. A rigid, truncated period ignores how real people make complex decisions.

Then there’s the plan to bar DACA recipients from ACA coverage. These are people who contribute to our communities, pay taxes, and work in critical fields like healthcare and education. In 2024, an estimated 11,000 DACA recipients gained ACA plans after eligibility expanded, with thousands more poised to benefit. Reversing this would not only disrupt their care but also strain emergency rooms and safety-net providers as uninsured numbers climb. The economic ripple effects hit everyone, from local businesses to state budgets.

Perhaps most troubling is the push to exclude gender-affirming care from essential health benefits. This isn’t just about insurance; it’s about equality. Major medical associations affirm that gender-affirming care is evidence-based and life-saving, yet the proposed rule dismisses this consensus. It violates the ACA’s anti-discrimination protections and the Equal Protection Clause, as Bonta’s coalition argues. For transgender individuals, particularly youth, losing access to care means heightened risks to mental health and well-being. Denying them coverage isn’t neutrality; it’s harm.

Some might claim these changes streamline the system or cut costs. But efficiency that leaves millions uninsured or underinsured isn’t progress; it’s regression. Higher premiums and out-of-pocket costs, as the coalition warns, would hit hardest those least equipped to absorb them. The argument for fraud prevention falls flat when the result is less comprehensive coverage and more barriers to enrollment. These aren’t solutions; they’re obstacles dressed up as reform.

California’s track record shows what’s possible when access is prioritized. Since the ACA’s start, the state’s uninsured rate has plummeted from 17% to under 7%. Expanded Medicaid and robust outreach through Covered California made that happen. But with federal subsidies set to expire in 2025, premiums could spike by 72% for some, threatening these gains. Bonta’s legal efforts, from defending DACA recipients’ coverage to challenging restrictive executive orders, aim to hold the line against policies that prioritize ideology over people.

The ACA isn’t perfect, but it’s a foundation that has changed lives. California’s 1.8 million ACA enrollees are proof of its impact, as are the millions nationwide who no longer fear medical debt or untreated illnesses. The proposed rules don’t just tweak the system; they undermine its purpose. Shortened enrollment, excluded communities, and restricted care aren’t minor adjustments. They’re a retreat from the idea that healthcare is a right, not a privilege.

Bonta and his allies aren’t standing still. Their legal challenges, from amicus briefs to motions to intervene, show a commitment to fight for every person’s access to care. This isn’t about politics; it’s about ensuring that no one falls through the cracks because of where they were born or who they are. The path forward lies in defending what works and pushing for better, not tearing down progress for the sake of change.