The health insurance system is one of the most complex in the world. Since the adoption of Obamacare in 2010, officially called the Affordable Care Act (ACA), it has seen significant political and legislative developments. Both during his first term in 2017 and on his return to power in 2025, Donald Trump made the reform of the ACA a priority. ACA one of the pillars of its healthcare policy. For expatriates, international students and anyone living in or visiting the U.S., understanding these developments is a useful way of ensuring appropriate healthcare coverage.
- Obamacare (ACA) was signed into law in 2010, and this law has given over 20 million Americans access to health coverage, by requiring insurers to accept patients with pre-existing conditions.
- Structurally high medical costs. The ACA has not resolved the issue of pricing: drugs, fees and hospitalization remain among the most expensive in the world.
- The Trump reforms have reconfigured the market. Since 2017, several measures have relaxed ACA rules and encouraged the growth of alternative plans with more limited guarantees.
- More than 20 million people affected by rising premiums. The expiry of post-Covid subsidies has led to an average 114% increase for the beneficiaries concerned, many of whom are foreign residents.
- For expatriates, international insurance remains the most stable solution. Independent of domestic reforms, it guarantees continuous coverage in the United States and the rest of the world.
What is Obamacare (ACA)?
Obamacare or ACA (Affordable Care Act), is a law enacted in 2010 by Barack Obama with a central objective: to reduce the number of Americans without health coverage, which then reached nearly 50 million people. The law made health insurance compulsory for all Americans, with a few exceptions.
Its main measures to remember:
- The obligation for insurers to accept all customers, including those with pre-existing pre-existing medical conditions
- Framework for health-related bonuses
- Coverage for children under the parental contract up to age 26
- The creation of regulated insurance markets (exchanges) with subsidies for low-income households
- Expansion of the Medicaid program for the most disadvantaged households
In fifteen years, the law has enabled more than 20 million Americans to gain access to health coverage. For some policyholders, however, it has meant higher premiums and varying levels of reimbursement, depending on the contract.
The structural limits of ACA
The main limitation of Obamacare is that it has not resolved the issue of medical costs in the United States, which remain among the highest in the world. Several structural factors explain this reality:
- Drug prices set freely by pharmaceutical companies
- Medical fees without a price framework
- Increasing use of high-tech medical equipment
- Diagnostic practices often extensive prior to prescription
The question of how to pay for healthcare in the United States remains a subject of ongoing debate. Regardless of the laws in force. For expatriates or long-term travelers, the risk is concrete: a single hospitalization can generate a substantial bill. A international health insurance adapted to American standards remains the best protection before any extended stay in the country. Mondassur’s plans are designed to cover these amounts, with no unpleasant surprises when it comes to reimbursement.
Trump's first term (2017): the ACA's first developments
On January 20, 2017, Donald Trump signed an executive order to relax the ACA’s enforcement constraints. This text gave U.S. state health insurance agencies the possibility of waiving, delaying or granting exemptions to certain ACA rules. This orientation paved the way for greater flexibility in the design of American insurance contracts, at the cost of greater complexity for policyholders.
Attempts to completely replace the ACA in Congress in 2017 were unsuccessful, leaving the law largely in place.
Second Trump term (2025): new market developments
Since January 2025, a number of legislative and regulatory changes have altered the way the health insurance market.
1) Expiry of enhanced subsidies
The exceptional subsidies introduced during the Covid-19 pandemic expired at the end of 2025. Their non-renewal has resulted in an average 114% increase in the cost of insurance for over 20 million affected beneficiaries. This development mainly affects the self-employed, small business owners and people not eligible for Medicaid or Medicare programs.
2) New conditions of access to federal grants
Recipients of federal subsidies now have to verify their income upstream in order to access them, automatic renewal of contracts has been abolished and activity conditions have been introduced for some Medicaid beneficiaries.
3) The development of alternative insurance plans
New insurance contracts outside the ACA framework are developing. These plans, which are generally less costly, may offer more limited cover, notably for pre-existing conditions or certain benefits such as mental health and maternity. It is in this context that the term Trumpcare is used to refer to all these developments in the US healthcare market.
An impact that goes beyond American borders
These developments in the health insurance market are not limited to U.S. citizens. According to a study published in September 2025 by the Commonwealth Fund, some 4 to 5 million people could be affected: lose their coverage as of 2026. Among them were many foreign residents, expatriates posted to the U.S., international students and mobile workers who relied on ACA contracts as their local coverage solution.
For anyone living in the U.S. without a U.S. employer, this uncertainty makes it all the more important to take out international health insurance for the United States stable coverage, independent of domestic reforms, valid throughout the U.S. and the rest of the world.
Choosing health insurance in the United States
In a fast-changing market ACA and alternative plans each have their own advantages and limitations, depending on your profile. For expatriates and people moving to the United States, a international health insurance offers stability independent of domestic reforms, with coverage valid on U.S. territory and worldwide.
At Mondassur, we help you choose between ACA Compliant or international expatriate insurance in the USA depending on your status, your visa and your actual coverage needs.
Modified by Aleksander Siebert on 24/04/2026
