A new government report shows that the number of Americans with a direct stake in the Affordable Care Act and what happens to it after Novembers election is bigger than you might think.

Nearly 50 million people have gotten private health insurance through the Affordable Care Act marketplaces in the decade since they first began operating, according to calculations the U.S. Treasury Department released Tuesday morning. Thats roughly 1 in 7 Americans.

Thats also about 2 times the number of people getting coverage through the marketplaces today. The reason the 10-year total is so much higher is that over an extended period of time, people will get insurance from different sources as their circumstances change.

They might, for example, leave a job that provides health benefits to work for themselves and then start buying individual coverage through one of the marketplaces, such as HealthCare.gov , where they would be eligible for the financial assistance that the health care law makes available.

The number is important because the future of the 2010 law likely depends on what happens in the election.

Republican nominee Donald Trump is a longtime critic of the program, which has come to be known as Obamacare because it was the signature legislative accomplishment of former President Barack Obama.

Trump spent years attacking the program and then, upon entering the Oval Office in 2017, tried desperately to repeal it. He failed, but last year he suggested on social media that he remained interested in repeal, saying the law sucks and that Republicans should never give up on trying to terminate it.

When those posts provoked criticism from the laws defenders, he said he merely wanted to replace it with MUCH BETTER HEALTHCARE. It was a version of the same promise he made repeatedly during his 2016 campaign, before taking office and pushing to pass repeal bills that would have taken insurance away from millions.

The Political Outlook For The Health Care Law

Given staunch Democratic Party support for the law, Trump would almost certainly need a Republican Congress to pass repeal in a second term. And even then it could be a tough sell with lawmakers, given the ACAs popularity nowadays and the political backlash Republicans suffered the last time they tried to get rid of it.

But a determined Trump administration and even somewhat compliant Congress could find ways to roll back the law that would fall short of full repeal.

They could try to cut or limit funding for the laws Medicaid expansion, which has probably reached even more people than the marketplace coverage has. Two prominent conservative policy publications the Heritage Foundations Project 2025 and the House Republican Study Committees proposed 2024 budget endorsed versions of this idea.

Trump and his Republican allies could also try to block renewal of a major but temporary boost to the Affordable Care Acts financial assistance that President Joe Biden and Democrats put in place.

Because of that boost, 15 million Americans now buying insurance through the marketplaces are saving an average of $800 a year, according to calculations by the Department of Health and Human Services.

That boost is among the reasons that marketplace enrollment has gone up substantially in the last few years and that the nations uninsured rate that is, the proportion of the population without coverage has hit historic lows .

The extra assistance expires after 2025. Democrats , including Vice President Kamala Harris, the Democratic presidential nominee, have said they want to extend it into the future.

Neither Trump nor Republicans have had much to say on the topic. But they are likely to oppose renewal in no small part because of the expense, which the Congressional Budget Office recently estimated at $335 billion over 10 years. That money would have to come from somewhere.

But without renewal, private insurance through the marketplaces would become more expensive, forcing would-be buyers to pay more for policies or drop coverage altogether. And over time that would affect a significant portion of the population, as Tuesdays new report shows.