In a sweeping overhaul of the Affordable Care Act’s implementation, the Trump administration on Friday finalized a rule that shortens the annual enrollment period, ends federal health coverage for certain immigrants known as “Dreamers,” and imposes stricter eligibility checks aimed at curbing what officials claim is rampant fraud.
The changes mark a stark reversal of policies under the Biden administration, which had expanded access to ACA health plans, resulting in record-high enrollment numbers. According to Trump officials, that expansion also triggered a surge in questionable enrollments that burdened taxpayers.
Shorter Enrollment Period
The most immediate change will be a compressed open enrollment period for federally run exchanges, now set to run from November 1 to December 31, trimming two weeks from the current deadline of January 15. The administration argues the shortened window aligns better with private market practices and reduces the risk of consumers taking advantage of late sign-ups without qualifying reasons.
States that operate their own ACA marketplaces will still have flexibility but must cap their enrollment periods to no more than nine weeks between November and December.
End of Coverage for Dreamers
In one of the rule’s most controversial provisions, the administration is eliminating ACA eligibility for immigrants brought to the U.S. illegally as children—commonly referred to as Dreamers. This reverses a Biden-era policy that had allowed an estimated 147,000 Dreamers to access subsidized health plans.
The Biden rule had been partially blocked in 19 states due to ongoing litigation, but the Trump administration's move now aims to fully dismantle the provision. Immigrant advocacy groups condemned the decision, warning that thousands of law-abiding individuals who contribute to the economy could lose access to essential care.
Gender-Affirming Care Coverage Cut
Starting in plan year 2026, the rule also prohibits ACA plans from treating “sex-trait modification” procedures—which includes gender-affirming care—as an essential health benefit. This change targets five states that currently mandate such coverage and extends to all federally regulated ACA plans, even in states without explicit protections.
Supporters argue the move aligns with a narrower interpretation of federal health law, while critics view it as a direct attack on transgender individuals’ access to healthcare.
Stricter Verification, Temporary Measures
The final rule introduces a series of temporary enforcement measures, set to expire in one year, unless Congress moves to codify them. These include:
More stringent income and eligibility verification for those enrolling in subsidized plans.
A $5 monthly premium charge for individuals automatically re-enrolled until they confirm or update their information.
Elimination of a monthly special enrollment window for individuals earning below 150% of the federal poverty line—a policy CMS says has been exploited for unauthorized plan switches.
Republicans in Congress are expected to pursue legislation to make the changes permanent and use the projected savings to help finance a forthcoming party-line tax and spending bill.
Fiscal Justification and Projected Savings
According to the Centers for Medicare and Medicaid Services (CMS), the new rule could save taxpayers up to $12 billion in 2026, largely by reducing improper subsidies and tightening enrollment eligibility.
“By reining in wasteful federal spending and restoring integrity to the enrollment process, we are refocusing on making health insurance markets more affordable and sustainable for hardworking American families,” CMS said in a statement.
Political Outlook
While the Trump administration frames the overhaul as a necessary fix to a bloated system, Democrats and healthcare advocates argue the changes will increase the number of uninsured Americans, especially among low-income individuals and marginalized groups.
Legal challenges are expected, particularly around the rollback of Dreamer coverage and gender-affirming care. Meanwhile, Republican lawmakers are preparing to lock the changes into law, setting up a broader election-year fight over the future of U.S. healthcare policy.
Key Dates to Know:
New Open Enrollment Period: Nov. 1 – Dec. 31 (starts 2025)
Gender-Affirming Care Exclusion: Starts plan year 2026
Temporary Measures Expire: End of 2026, unless codified by Congress
