Health disparities and health access-related challenges persist among the LGBTQ+ community.  While there have been various state and federal efforts over the last several years to address equity in the LGBT+ community, including with respect to health care access, nondiscrimination, and data collection, recent Trump Administration policy actions could reverse these developments. Additionally, potential changes in the health policy landscape could lead to insurance coverage losses, which could stand to exacerbate existing access challenges. In particular, efforts to restrict access to gender affirming care, including for adults, could lead to more medical mistrust, and reduce willingness to engage in the health system.

This brief presents key data points on the health care experiences of LGBT+ women from the KFF Women’s Health Survey, a nationally representative survey of women in the United States conducted from May 13 – June 18, 2024. This online and by telephone survey includes a sample of 3,901 women of reproductive age (18-49). Respondents were asked about their gender and sexual orientation. The LGBT+ sample (n = 676) in this brief includes respondents who identified as women and also identified as non-binary or transgender and/or said their sexual orientation was lesbian or gay, bisexual, or something else. The non-LGBT+ sample are respondents who identified as other women, those who are cisgender and heterosexual.

1. One in six (17%) women of reproductive age identify as LGBT+, with the largest share of LGBT+ women identifying as bisexual.

One in six (17%) women of reproductive age identify as lesbian, gay, bisexual, transgender, non-binary or something else (LGBT+) (Figure 1). Women ages 18 to 35 are twice as likely to identify as LGBT+ compared to women ages 36 to 49 (23% vs. 9%).

2. LGBT+ women are more likely to be younger than non-LGBT+ women but are similar in other demographic indicators.

Three in four reproductive age LGBT+ women are age 35 and younger (77%) compared to 53% of non-LGBT+ women (Figure 2). Nearly six in ten reproductive age LGBT+ women are White and nearly one in five are Hispanic, which is not significantly different than non-LGBT+ women. LGBT+ women are less likely to be Asian and more likely to identify as another race/ethnicity compared to non-LGBT+ women. Four in ten reproductive age LGBT+ women have household incomes below 200% of the federal poverty level (FPL), similar to non-LGBT+ women. Nine in ten live in an urban/suburban area, which is higher than non-LGBT+ women. A quarter of LGBT+ women are the parent or guardian of children under the age of 18, which is half the share of non-LGBT+ women (27% vs. 52%).

3. While the majority of reproductive age LGBT+ women have a regular health care provider, three in ten do not (31%). LGBT+ women are less likely to go to a private doctor’s office for care than non-LGBT+ women, but a higher share rely on clinics or do not have a place to go.

Despite being a younger population overall, LGBT+ women are more likely to report fair or poor health (Figure 3) than non-LGBT+ women. One in four reproductive age LGBT+ women (26%) describe their health as fair or poor compared to one in six non-LGBT+ women (16%). Most LGBT+ women have a usual site of care to go to when they are sick or need advice about health (92%), while only 8% say they do not have a place to go. LGBT+ women are less likely than non-LGBT+ women to go to a private doctor’s office for care, and a higher share do not have a place to go compared to non-LGBT+ women. While the majority of LGBT+ women have a regular doctor or health care provider (69%), three in ten do not (31%).

4. Similar shares of LGBT+ and non-LGBT+ women say they have received HIV and STI tests, but fewer report receiving a Pap test than non-LGBT+ women. One in seven (15%) LGBT+ women say they have never seen a doctor or nurse for an OBGYN exam.

Similar shares of LGBT+ women say they have received an HIV test (37% vs. 36%) and STI test (44% vs. 39%) compared to non-LGBT+ women in the past two years (Figure 4). However, a smaller share of LGBT+ women compared to non-LGBT+ women report receiving a Pap smear or Pap test to test for cervical cancer in the past two years. One in seven (15%) reproductive age LGBT+ women say they have never seen a doctor or nurse for an OBGYN exam, which was higher than non-LGBT+ women (10%).

5. One in five reproductive age LGBT+ women report having a disability, twice the rate of non-LGBT+ women.

While a younger population, among reproductive age LGBT+ women report who report a disability, one in ten have more than one disability (15%) (Figure 5). The largest share say they have a disability related to a mental health condition, which is significantly higher than non-LGBT+ women (16% vs. 4%). Just over one in ten (15%) LGBT+ women report having a developmental disability, such as a learning disability, compared to 2% of non-LGBT+ women. One in ten (11%) LGBT+ report having a physical disability compared to 6% of non-LGBT+ women. A similar share of LGBT+ and non-LGBT+ women report having a sensory condition, such as being visually impaired or deaf (1%).

6. About four in ten LGBT+ women (43%) report that they have been treated unfairly or with disrespect by a doctor or health care provider, especially based on their age, weight, or gender.

Nearly twice as many LGBT+ women (aged 18-49) compared to non-LGBT+ women (43% vs. 24%) the same age have felt that a doctor, health care provider or other staff treated them unfairly or with disrespect at some point in the past 2 years (Figure 6). They cite weight, gender, and age as the top reasons they were treated unfairly or with disrespect. Compared to non-LGBT+ women, a larger share of LGBT+ women say there was a time in the past 2 years when a health provider ignored a direct request they made or a question they asked (34% vs. 20%), assumed something about them without asking (32% vs. 19%), didn’t believe they were telling the truth (32% vs. 16%), suggested they were personally to blame for a health problem they were experiencing (29% vs. 13%), and refused to prescribe pain medication they thought they needed (15% vs. 9%). Eight percent (8%) of LGBT+ women say they have been treated unfairly or with disrespect because of their sexual orientation during a health care visit in the past 2 years.

7. Many LGBT+ women report experiencing mental health challenges. Half of reproductive age LGBT+ women describe their mental health as fair or poor compared to a quarter of non-LGBT+ women, and many say they have not gotten mental health services in the past year.

Half of LGBT+ women (aged 18-49) describe their mental health or emotional wellbeing as fair or poor compared to a quarter of non-LGBT+ women (50% vs. 27%) (Figure 7). While half of LGBT+ women say they have received mental health services from a doctor, counselor, or other mental health professional (51%), about half also say there was a time in the past 12 months when they thought they might need mental health services or medication, but didn’t get them (54%).

8. LGBT+ women report experiences with intimate partner violence at almost double the rate of non-LGBT+ women.

Over one in three reproductive age LGBT+ women say they have experienced intimate partner violence in the past 5 years, compared to 20% of non-LGBT+ women (Figure 8). Rates of all aspects of IPV asked about in the survey are twice as high in LGBT+ women compared to non-LGBT+ women. Approximately one in five LGBT+ women said that in the past five years, a current or former partner has made them fear for their or their family and friends’ safety (21%), tried to control most or all of their daily activities (23%), hurt them physically (19%), or forced them into sexual activity (21%).

9. Similar shares of sexually active LGBT+ and non-LBGT+ reproductive age women say they used contraception in the past year.

Eight in ten (81%) sexually active LGBT+ women report using contraception in the past year, similar to the share among non-LGBT+ women (81%). One in ten (10%) sexually active LGBT+ women say they were not using contraception. While a younger group, smaller shares of sexually active LGBT+ women report being pregnant or trying to conceive compared to non-LGBT+ women (5% vs. 9%). The shares of LGBT+ and non-LGBT+ women report being unable to conceive was the same (4%). One in ten LGBT+ women say they or their partners use contraception solely for reasons outside of preventing pregnancy, which is significantly higher than non-LGBT+ women (11% vs. 5%) (Figure 9).

10. Over a third (38%) of LGBT+ women have been pregnant including nearly one in ten (9%) who report having have had an abortion, both shares considerably lower rates than non-LGBT+ reproductive age women.

A larger share of reproductive age LGBT+ women say they have never been pregnant compared to non-LGBT+ women (62% vs. 35%) (Figure 10). About one in ten (11%) LGBT+ women say they or their partner have ever needed fertility assistance, including medical advice, testing, services or medication to help an individual or their partner become pregnant or prevent a miscarriage, which is similar to the 14% of non-LGBT+ women who have needed fertility assistance.

The One Big Beautiful Bill passed by the House is projected by the Congressional Budget Office to reduce federal Medicaid spending by $793 billion over the next 10 years, a cut that could lead to 10.3 million fewer people enrolled in Medicaid in 2034. The Senate Finance Committee’s draft reconciliation includes similar provisions. Medicaid currently provides health care coverage to 1 in 10 veterans (1.6 million people), and for some, it is their only source of coverage, especially if they do not qualify for military health benefits such as care provided by the Department of Veterans Affairs (VA health care), or TRICARE, the health insurance program administered by the Department of Defense for eligible active-duty service members, retirees, and their families.

The Department of Veterans Affairs operates a nationwide health care system, but access is not guaranteed. Eligibility for VA health care depends on a veteran’s service history, discharge status, income, and whether a health condition is connected to their military service. As a result, about half of veterans are enrolled in VA health care. TRICARE, meanwhile, is generally limited to active-duty members and military retirees.

Medicaid helps fill gaps in coverage for veterans who are low-income, have disabilities, or are otherwise ineligible for military health benefits. Many veterans use Medicaid alongside Medicare or VA health care, particularly as they age and their health needs increase. Veterans enrolled in Medicaid have complex health conditions, including high rates of disability, mental illness, and substance use disorders. Medicaid ensures regular access to care for these veterans, helping them manage chronic conditions, access a broader range of providers outside the VA system, and pay for services not covered by VA health care, such as different forms of long-term care. It also reduces out-of-pocket costs that can pose a barrier to care. This brief presents key facts about veterans enrolled in Medicaid and examines how proposed changes could affect their coverage and access to care.

1. Over the past decade, the number of veterans has declined, but the percent of veterans with Medicaid has increased.

In 2023, there were approximately 16 million veterans ages 19 and older in the United States. The veteran population is both aging and shrinking: nearly half of all veterans are 65 and older, and the total number has declined by 7 million over the past decade, from 23 million in 2013, as older veterans from World War II, the Korean War, and the Vietnam War have passed away, and fewer individuals have entered military service in the recent years.

As the veteran population changes, so too have the pathways to coverage. The Affordable Care Act (ACA) created a new pathway to coverage for veterans who might otherwise have been uninsured by expanding Medicaid eligibility to nearly all adults with incomes up to 138% of the Federal Poverty Level ($21,597 for an individual in 2025). Medicaid expansion covers adults who are parents of dependent children whose income is above the eligibility limit for parent coverage and adults who do not have dependent children and who were previously not eligible for Medicaid. Forty-one states, including DC, have adopted Medicaid expansion, and nearly seven in ten (69%) veterans ages 19 and older who have Medicaid coverage live in a state that has expanded Medicaid.

Since the implementation of Medicaid expansion, the share of veterans with Medicaid, either as their sole source of coverage or in combination with other insurances, has increased, and the share of those who are uninsured has dropped. Between 2013 and 2023, Medicaid enrollment among all veterans increased from 8% to 10% (Figure 1), representing 1.6 million veterans in 2023. However, the share of veterans enrolled in Medicaid varies across states, ranging from as low as 6% to as high as 15% (Appendix Table ). In 2023, 11% of veterans in Medicaid expansion states were enrolled in Medicaid, compared to 9% in non-expansion states. Over the 2013-2023 period, the uninsured rate for veterans fell by more than half, dropping to 2% from 6% (Figure 1). Studies link Medicaid expansion to increased coverage, improved access to care, greater healthcare affordability, and better health .

2. Medicaid often supplements coverage for an aging veteran population.

Among those 1.6 million veterans with Medicaid coverage, most had additional forms of insurance. While some rely on Medicaid as their only source of coverage, it more often supplements other types of insurance by covering services that other payers may not, such as long-term care. For veterans who are also enrolled in Medicare, Medicaid can help cover both premiums and cost-sharing responsibilities, reducing out-of-pocket costs for services like doctor visits, hospital stays, and prescription drugs.

Only 17% of veterans with Medicaid were covered by Medicaid alone. The remaining 83% had at least one other source of coverage. The most common combination was Medicaid and Medicare, which accounted for 60% of all veterans with Medicaid (some of whom were also enrolled in VA health care). This high share reflects the aging veteran population; half of all veterans with Medicaid were 65 and older. Many of today’s veterans served during the Vietnam and Gulf Wars. Smaller percentages of veterans were also enrolled in VA health care (17%), or another other form of insurance coverage, such as TRICARE or employer-sponsored insurance (6%).

3. Veterans with Medicaid have higher disability rates than those who are not covered by Medicaid.

Nearly half (49%) of veterans covered by Medicaid, either as their only source of coverage or in combination with other insurance, report having a disability, compared to fewer than three in ten (29%) veterans who are not covered by Medicaid (Figure 3). A person is considered to have a disability if they experience difficulty with hearing, vision, cognitive function, mobility, self-care, or independent living. While disability rates increase with age among all veterans, the difference in the rates between those with Medicaid and those not covered by Medicaid are especially pronounced in their working-age years. Among veterans ages 27 to 49, 33% of those with Medicaid reported a disability, compared to 17% of those with other coverage. The gap is even wider among veterans ages 50 to 64, with 51% of Medicaid enrollees reporting having a disability compared to 20% of those with other coverage. Veterans 65 and older have the highest disability rates of any age group, but even among this group, a higher percentage of veterans with Medicaid have a disability (55%) compared to those without (40%).

4. Medicaid supports regular access to care for veterans who have high rates of chronic conditions.

Veterans covered by Medicaid often have complex health needs. Nearly half (45%) of veterans with Medicaid describe their health as fair or poor, more than twice the share among those not covered by Medicaid (18%) (Figure 4). All veterans have high rates of chronic conditions (82% for those with Medicaid and 79% for those without), but some conditions are more common among veterans with Medicaid. Specifically, behavioral health conditions affect a larger share of veterans with Medicaid, with 46% reporting any form of mental illness and 26% reporting substance use disorder (SUD), compared to 17% and 13%, respectively, among those without Medicaid. Medicaid provides access to care, including mental health and SUD care for veterans. Among veterans covered by Medicaid, 41% received mental health or SUD treatment in the past year, nearly twice the share of those without Medicaid (21%).

5. Nearly seven in ten working-age veterans with Medicaid are working, but work varies by age, disability, and parental status.

Nearly seven in ten (68%) working-age veterans (ages 19 to 64) enrolled in Medicaid are working, excluding those who receive Supplemental Security Income or Social Security Disability Insurance, or are dually enrolled in Medicare (Figure 5). The share of veterans in this age group varies by state (Appendix Table 2). Veterans who are older (ages 50 to 64), have a disability, or do not have dependent children are less likely to be working:

• The share of veterans who are working declines with age: 79% of those ages 19 to 26 are working, compared to 59% of those ages 50 to 64.
• While 75% of veterans without a disability are working, that share drops to 51% among those with a disability.
• Parents are more likely to be in the workforce than veterans without dependent children (78% vs 60%), likely reflecting their relatively younger age and lower rates of disability.

Proposed changes to Medicaid that would impose work and reporting requirements as a condition of eligibility could negatively affect veterans and lead to coverage loss among those who are unable to work or those unable to report or document work or exemption criteria.

Appendix Tables

People in lower-income families with employer coverage spend a greater share of their income on health costs than those with higher incomes, and the cost of employer sponsored health insurance—including premiums, deductibles, and other out-of-pocket costs—has risen steadily over time. Low-income workers offered health insurance through their employer are typically not eligible for subsidies on the Affordable Care Act (ACA) Marketplaces, even if they would face lower costs to buy coverage and with reduced cost sharing.

This analysis uses information from the 2024 Annual Social and Economic Supplement (ASEC) to the Current Population Survey to look at the share of family income people with employer-based coverage pay toward their premiums and out-of-pocket payments for medical care. It considers non-elderly people living with one or more family members who are full-time workers and have employer-based coverage.

The analysis is available through the Peterson-KFF Health System Tracker, an online information hub dedicated to monitoring and assessing the performance of the U.S. health system.

This analysis was updated on July 11, 2025, to reflect enactment of the 2025 budget reconciliation law, which was signed into law on July 4, 2025, and the changes it makes to ACA Marketplace standards.

Rooting out fraud has been one of the primary reasons given for changes to ACA Marketplace enrollment and eligibility standards included in the Trump administration’s final Marketplace integrity and affordability rule (“final regulation”), and in the recently enacted budget reconciliation law. In the final regulation, the Centers for Medicare and Medicaid Services (CMS) points to “dramatic levels of improper enrollment” in Marketplace plans that CMS says have involved fraudulent actions by some agents, brokers, and web brokers. The final regulation and the budget reconciliation law seek to address alleged fraud by instituting new standards for consumers to enroll in Marketplace coverage, from additional paperwork requirements to “verify” a consumer’s estimated household income to obtain advanced premium tax credits (APTC) to significant new administrative steps and new payments for consumers to continue Marketplace coverage. Few changes are made in the final regulation concerning oversight of entities alleged to have engaged in fraudulent activities, and none are included in the budget reconciliation law.

This brief explains what is known about fraud and improper enrollment in ACA Marketplace plans and what the final regulation and budget reconciliation law will do to change current Marketplace enrollment and eligibility standards.

1. The Affordable Care Act (ACA) gives the federal government broad authority to combat Marketplace fraud, alongside existing state oversight of private health insurance.

The Affordable Care Act (ACA) gives the Secretary of the Department of Health and Human Services (HHS) the authority to determine appropriate activities to reduce fraud and abuse in the administration of Marketplaces and to investigate Marketplace activity, “in coordination with” the Inspector General (OIG) of HHS. The HHS Secretary oversees these functions through the Center for Medicare and Medicaid Services (CMS), with at least two CMS offices involved in combating ACA fraud—the Center for Consumer Information and Insurance Oversight (CCIIO) and the Center for Program Integrity (CPI). These agencies, along with the HHS OIG, have a role in protecting the financial and program integrity of ACA programs. The Department of Justice litigates civil and criminal actions involving alleged health care fraud and abuse.

Fraud oversight is just one part of these agencies’ program integrity functions. These agencies are charged with protecting government resources, as well as program beneficiaries (consumers), by making sure that enrollment and required government payments are accurate and provided without delay. This involves ongoing audits of actors involved in the administration of Marketplaces and oversight of all individuals involved in ACA Marketplace enrollment and eligibility—from the agencies that run the program, to consumers and insurers, as well as those who assist in enrolling consumers, from agents and brokers to Navigators.

Improper enrollment or improper government payments of federal subsidies are fraudulent only if there is an intentional act to deceive or misrepresent facts in order to enroll or receive these benefits. The ACA does not have its own definition of “fraud” specific to Marketplace plans, but agencies can look to existing definitions that have been part of Medicare and Medicaid program integrity standards for some time.

In addition to this broad authority to oversee program integrity in the Marketplace, the ACA provides that if an applicant for Marketplace coverage or subsidies “knowingly and willfully” provides false or fraudulent information, the applicant may be subject to a civil penalty of up to $250,000 (smaller penalties apply where a consumer negligently provides false information in applying for Marketplace coverage). The civil penalty extends to “any person,” including an agent or a broker that directly provides false or incorrect information related to a Marketplace enrollment. In addition, any person who receives information from a Marketplace applicant in order to apply for coverage is subject to a civil penalty if they do not keep this information confidential.

The ACA also states that any payments made in connection with Marketplaces are subject to the False Claims Act if these payments include any federal funds. The False Claims Act is a century-old law that is designed to prevent and punish any individual or organization that defrauds the federal government. This could include circumstances where an individual intentionally presents, or causes to be presented, a false or fraudulent claim to the federal government. The ACA increased the penalties available for False Claims Act violations.

Marketplaces were created by the ACA as a platform for individuals to enroll in private insurance coverage and to apply for income-based federal subsidies. While the coverage is private—making it different from the public programs like Medicare and Medicaid, Marketplaces rely on federal dollars to (1) pay for and administer advance premium tax credits (APTCs) and cost-sharing reductions (CSRs) that help most enrollees pay for coverage, and (2) fund the agency, CMS, that runs the federally-facilitated Marketplace (FFM) (HealthCare.gov) for the states that elect not to operate their own Marketplace. CMS, along with the Internal Revenue Service (IRS) (part of the Treasury Department), set up a complex process to determine who is eligible for Marketplace coverage and financial assistance.

Oversight of these processes and the extent of each federal agencies’ authority to police the program at the federal level is still developing, as federal regulators and enforcers interpret and implement existing requirements. Recent federal activity in this area is discussed below.

The federal government functions exist alongside state oversight. States are the primary regulators of the private insurance coverage available in the Marketplaces and 20 states run their own Marketplace. As a result, each state has its own parallel authority to oversee the integrity of the programs they run and have their own fraud and abuse authority to deal with bad actors in the system, including insurers and those that sell insurance for these insurers, such as agents and brokers. As discussed below, states license the agents and brokers that sell Marketplace coverage.

2. Improper enrollment in Marketplace coverage and subsidies is not the same as fraud.

The ACA contains a unique structure for determining eligibility for Marketplace coverage and for eligibility for financial assistance (APTCs and CSRs). Eligibility is largely determined based on the projected household income of a consumer for the coming year—not on the consumer’s past or current income. Specifically, at open enrollment in the fall before the January 1 coverage year, the consumer is asked to estimate what their household income will be in the coming year.

In addition to open enrollment, there are limited special opportunities for individuals to enroll in Marketplace plans during the coverage year. These “special enrollment periods,” or SEPs, allow individuals to enroll in Marketplace coverage and obtain APTCs during the year if they meet specific criteria. Determining eligibility for SEPs also requires consumers to make an educated guess (estimate) about what their total annual household income will be at the end of the year.

Consumers, especially those with low incomes, often face difficulty predicting future income. KFF analysis found that individuals, especially those with low wages and unstable work, experience significant swings in income throughout the year. For those near poverty, predicting annual income may be especially difficult. Many people with incomes just above poverty at the beginning of the year end up below the federal poverty level (FPL) by the end of the year, and conversely, many who start out with incomes below poverty end up with incomes above poverty. Three in five (61%) people with starting incomes below poverty end the year with an income more than 20% different than their income during the first three months of the year. People with incomes below poverty ($15,060 for a single person in 2025) are not eligible for premium tax credits.

In setting up the Marketplace enrollment structure, Congress recognized that an individual’s annual income might end up being higher or lower than what they estimated when they applied for coverage. This difference could mean that a consumer appears to be “improperly enrolled” in Marketplace coverage or “improper payments” of Marketplace subsidies are paid by the federal government, even though the consumer did not intend to deceive or misrepresent their income. Recognizing this possibility, Congress provided for a process to “reconcile” APTC payments at the end of the year, once a consumer’s actual household income is known.

This is how the process works now: If a consumer is eligible for an APTC, these payments are made by the IRS directly to the insurer of the Marketplace plan that the consumer selects. The consumer does not directly receive these APTCs. If an individual’s actual household income at the end of the year was higher than the consumer estimated, the IRS may have paid too much money on behalf of the consumer to the insurer for APTCs. As a result, the consumer must “repay” the IRS the excess premium tax credit when the consumer files their income tax. Congress included provisions in the ACA that prohibit the federal government from requiring individuals below certain income levels to pay the full amount of excess premium tax credits (often referred to as “repayment limits or caps”). The example below illustrates how this works under current law:

In this example, although Carla’s insurer received more APTC amounts than it should have, Carla did not intentionally underestimate her expected income (engage in fraud) in order to gain undue tax credits. She made an estimate that was reconciled at the end of the year when her actual household income was known, following the process Congress created in the ACA. The budget reconciliation law eliminates the repayment limits.

3. To date, allegations of fraud related to Marketplace enrollment have primarily focused not on the actions of consumers, but on agents, brokers, web brokers and/or third parties that assist these entities in generating business.

 Agents and brokers are state-licensed professionals who sell health insurance and assist consumers with selecting and enrolling in a health plan. Agents and brokers generally receive commissions from health insurance companies for enrolling individuals in health plans. A “web broker” is an individual or group of agents, brokers or business entities registered with the federal Marketplace that “develops and hosts” a non-Marketplace website that interfaces with the Marketplace to assist consumers with direct enrollment in Marketplace plans. Accusations of fraud have involved actions by these entities to fraudulently enroll consumers in Marketplace coverage in order to obtain commission payments from insurance companies. These fraudulent enrollments typically involve one of the following scenarios:

• Unauthorized Enrollment: Enrolling an individual in Marketplace coverage without their consent
• Unauthorized Switching: Switching an individual already enrolled in a Marketplace plan to another Marketplace plan without their consent

Between January 2024 and August 2024, CMS received 183,553 complaints of unauthorized enrollments, and 90,863 complaints of unauthorized switching of plans sold on the FFM (HealthCare.gov). CMS suspended 850 brokers for reasonable suspicion of fraudulent or abusive behaviors related to unauthorized plan switches and unauthorized enrollments between June and October 2024. Some of the entities suspended were web brokers approved and registered by CMS to host an application for Marketplace coverage on their own websites through processes called direct enrollment (DE) and enhanced direct enrollment (EDE). These functions are discussed below.

CMS took action to resolve the complaints, putting safeguards into place to protect consumers from broker fraud. For example, CMS announced that starting in July 2024, it would block agents and brokers from modifying a consumer’s HealthCare.gov enrollment unless the agent or broker has already assisted the consumer with enrollment in the past. Also, agents and brokers must enter into a three-way call with consumers and the Marketplace Call Center when trying to make changes to an account they are not already associated with.

Fraud allegations brought wide-ranging reactions from Congress in the summer of 2024. Some House Republican leaders called for further investigation, alleging that recent legislative and regulatory changes made to Marketplace rules (specifically, enhanced APTCs and Biden-era regulations aimed at reducing barriers for consumers signing up for Marketplace coverage) created incentives that encouraged Marketplace fraud. Democratic Congressional leaders, on the other hand, introduced legislation aimed at improving oversight and accountability for agents, brokers and marketing entities that engage in fraud.

Consumers sued brokers alleging fraudulent enrollment. In April 2024, consumers (and some brokers) brought class action litigation against specific brokers, web brokers, and marketing companies that generate sales leads (called “lead generators”) alleging, among other things, that the unauthorized switching and enrollment were part of a widespread scheme to obtain broker commissions that resulted in harm to enrollees and to brokers that originally placed an enrollee in coverage before the switch. While the case has since been dismissed, the plaintiffs alleged that the parties involved “created, sold, purchased and/or financed the purchase of leads that deceived consumers into thinking that they would receive cash cards and other cash benefits.” Leads include information such as consumer names and contact information that agents and brokers use to generate business. Many individuals and groups are in the business of lead generation and are not themselves licensed as agents and brokers. They sell or provide this information to those licensed to sell insurance.

How the alleged scheme worked: The complaint alleged a complicated scheme involving multiple parties. Marketing agencies and other individuals developed social media ads that falsely offered free cash rewards. Consumers that clicked on the ad were brought to a landing page where they were asked to provide specific information with the promise of cash. This information was captured and sold to agents and brokers who, using an enhanced direct enrollment platform, enrolled consumers in Marketplace coverage without their knowledge or switched their existing coverage to another plan.

Some brokers involved in the case brought an action against the federal government. In August 2024, TrueCoverage, LLC and Benefitalign LLC, two of the entities that had been sued in the April 2024 litigation and that had been suspended from the ACA Marketplaces, sued HHS and CMS after they were blocked for engaging in conduct that “compromised and placed consumers’ personally identifiable information (“PII”) and the integrity of the Exchanges at risk.” The case was dropped by the plaintiffs in October 2024, following a court decision denying the plaintiffs’ request for emergency relief. The court found that current regulation permits CMS to suspend direct enrollment entities based on “circumstances” that pose a “risk” that is “unacceptable.” Proof that systems have been compromised is not required.

Many suspended brokers were reinstated in 2025, according to CMS. It was reported that by March 2025, CMS had reinstated at least some of the brokers that had been suspended. It is not clear whether the reinstated brokers had demonstrated to HHS that they had remedied the cause of the suspension, as required in a regulation finalized by the Biden administration in January 2025. In June 2025, CMS released a Frequently Asked Questions (FAQs) document related to the removal of more than 1,000 brokers from its agent/broker suspension and termination list.

While these fraud allegations received nationwide attention in 2024, federal investigations of agents and brokers date back to at least 2018 (before the availability of enhanced APTCs and the Biden administration’s enrollment changes). Law enforcement action against agents and brokers include allegations of activity as far back as 2018. For example:

• The Justice Department, in February 2025, charged two individuals with intentionally enrolling consumers in fully subsidized Marketplace plans between 2018 and 2022 that they were not eligible for in order to obtain commission payments. The indictment alleges that the individuals used misleading and deceptive sales tactics that targeted low-income individuals and provided false addresses and social security numbers. The trial is scheduled for later this year.
• Another recent Justice Department indictment alleges similar activity dating back to 2019.
• Annual HHS/DOJ reports on health fraud and abuse enforcement note investigations of agents and brokers going back to 2019. For example, the annual report on fraud enforcement activity for FY 2019 noted that CMS “reviewed cases of agent and broker misconduct and took administrative actions including terminating CMS’s agreements with agents and brokers and imposing civil monetary penalties on those agents and brokers who were found to have engaged in misconduct.” An FY 2023 report stated that CMS had received over 73,000 consumer complaints involving such misconduct as consumers being enrolled in federal Marketplace policies without their consent. That year, CMS “conducted over 80 investigations of outlier and high-risk agents and brokers, and made recommendations for administrative action, including suspension and termination of an agent’s and/or broker’s registration to sell policies on the FFM.”

4. Agents and brokers (including web brokers) who assist in Marketplace enrollment are regulated by both the federal government and states. 

Clearing the pathway to allow brokers to assist consumers to enroll in Marketplace plans aligns with an ACA goal to increase consumer access to comprehensive health coverage. However, the history of broker-related fraudulent enrollment activity points to the importance of oversight of these entities. This not only protects consumers but also ensures that brokers operating in good faith with adequate control and accountability for the third parties that assist them can still provide enrollment help for Marketplace consumers. Both the federal government and states have authority to regulate agents and brokers.

Federal Marketplace oversight related to brokers’ conduct has developed over time aimed at protecting consumers from fraud, as well as preventing deceitful marketing practices and other potentially harmful conduct. The ACA requires the Secretary of HHS to establish procedures where States may allow agents and brokers to enroll individuals in Marketplace plans and assist them in applying for Marketplace subsidies. With this authority, CMS has developed and continues to update requirements agents and brokers must meet in order to assist consumers to enroll in Marketplace coverage. CMS has developed a framework that is different from CMS agent and broker requirements for Medicare Advantage plans. In Medicare Advantage, the insurers have a legal responsibility to ensure agents and brokers comply with federal (and state) requirements. For Marketplace plans, CMS has set standards to regulate agents and brokers directly, without accountability flowing through the insurers that hire them.

In the early years of ACA Marketplace regulation, rules largely included in annual CMS regulations added a range of requirements including a process for broker termination and suspension, standards for the display of Qualified Health Plan (QHP) information and disclaimers that must be posted when certain QHP information is not available, and standards of conduct for agents and brokers selling plans on the FFM.

New technology allows more consumers to enroll in Marketplaces but raises new concerns. “Direct Enrollment” (DE) is a process that allows insurers and web brokers to enroll consumers in coverage directly from their websites. Initially, the direct enrollment pathway allowed the consumer to start the process on a web broker’s own website, but then had to be redirected back to HealthCare.gov to complete the eligibility application before returning to the web broker site to select a plan. Improved technology has added new enrollment pathways that allow agents and brokers to complete the entire eligibility application and enroll consumers in coverage on their own third-party website platforms, without being redirected to HealthCare.gov. This process is known as “Enhanced Direct Enrollment” (EDE).

Although EDE was praised for its potential to increase HealthCare.gov enrollments, as with any new technology, there are and continue to be concerns about privacy and security of consumer information, the potential for fraud, and the possibility that EDE could lead to consumers receiving inaccurate or misleading information that might affect eligibility determinations and consumer choice. In March 2016, CMS announced its intent to implement this new enrollment pathway in the federally-facilitated Marketplace but delayed implementation of the EDE pathway until 2018 and added new safeguards, including a process for HHS-approved third-party entities to periodically monitor and audit agents and brokers using the DE or EDE pathways.

Use of EDE begins and grows; CMS makes further changes to agent and broker standards. The Trump administration expanded the use of the EDE pathway for the federal Marketplace with CMS’s approval of its first Enhanced Direct Enrollment partner, HealthSherpa, in December 2018.

• CMS reported that DE and EDE pathways were utilized for 37% of all active HealthCare.gov plan selections during 2021 open enrollment, up from 29% during 2020 open enrollment, attributing its growth to increased use of the EDE pathway. The EDE process has historically only been available in HealthCare.gov states; however, in 2024, Georgia became the first state-based Marketplace (SBM) to partner with EDE entities.
• HealthSherpa reported that more than 95% of total EDE enrollments came through its EDE implementations during the 2021 open enrollment.
• CMS implemented Help On Demand, a referral service allowing consumers using HealthCare.gov to request enrollment assistance from licensed agents and brokers.
• CMS added new requirements specific to issuers, agents, and brokers as direct enrollment grew. In 2019, the Trump administration rescinded a requirement that only HHS-approved auditors conduct third-party audits of these entities, allowing issuers, agents, and brokers to choose their own auditors.

Continuing consumer complaints of unauthorized agent and broker enrollment resulted in further changes to agent and broker oversight. Regulations issued during the Biden administration updated agent and broker oversight requirements, including:

• In 2023, to address enrollments done without consumer consent, CMS established new requirements that require agents, brokers, and web brokers in the federal Marketplace to verify that the eligibility application information they collected has been reviewed and confirmed by the consumer before submission. Receipt of the consumer’s consent has to be documented by agents, brokers, and web brokers.
• To clarify the reach of federal enforcement against agents and brokers, standards finalized in January 2025 allow CMS to hold “lead agents”—typically executives or others in leadership of broker agencies –accountable for misconduct or noncompliance that they direct or oversee.
• CMS clarified its authority to take immediate action to suspend a broker’s or agent’s access to the DE and EDE pathways and their ability to transmit information to the Marketplace when circumstances pose an “unacceptable risk” to enrollees, the accuracy of the Marketplace’s eligibility determinations, or the Marketplace’s information technology systems.

States also oversee insurance agents and brokers. Agents and brokers are required to be licensed in every state where they sell health insurance and are also required to complete the CMS Agent and Broker Federally-facilitated Marketplace (FFM) registration to sell Marketplace plans. To further combat fraud and other deceptive practices, the National Association of Insurance Commissioners (NAIC) reports that every state and the District of Columbia (DC) has made insurance fraud a crime for at least some lines of insurance, and 42 states and DC have insurance fraud bureaus that investigate claims of illegal insurance activities and work to prosecute insurance fraud. The NAIC’s model state law, Unfair Trade Practices Act (Model 880), which describes activities considered “unfair or deceptive acts or practices” in the insurance industry, has been adopted in some form by 45 states and the District of Columbia.

States that operate their own Marketplaces currently have considerable flexibility to establish additional policies and procedures in their Marketplaces for agents and brokers. States can go beyond the requirements set out in federal regulations for oversight. For example, Idaho’s SBM stated that its online platform requires multi-factor authorization and only consumers can add an agent to their account. Massachusetts’s SBM does not use brokers nor does it permit EDEs to enroll consumers. California’s SBM requires that agents be specifically added by the consumer through their consumer portal (or consent can be verified through a three-way call), and consumers can edit and remove permissions on that portal.

Some states have been proactive in law enforcement actions related to Marketplace agent and broker fraud. For example, Massachusetts and California took action related to fraudulent Marketplace enrollments concerning a scheme involving substance use disorder treatment centers a few years ago. Although there have been allegations of Marketplace broker fraud in Florida in recent years, information on recent enforcement activity by the state is not available.

5. Final regulation and budget reconciliation law introduce new paperwork and other enrollment requirements for Marketplace consumers but make few changes to broker oversight.

In the final Marketplace Integrity and Affordability rule, released on June 20, 2025, CMS says that Marketplace fraud occurred due to the widespread availability of zero-dollar out-of-pocket premium plans following the implementation of enhanced premium tax credits and enrollment policy changes during the Biden administration. The final regulation introduces many significant changes to Marketplace enrollment standards, verification processes, and documentation requirements. Some of these changes apply to both the federal Marketplace and state-based marketplaces and many will expire at the end of the 2026 plan year. The 2025 budget reconciliation law includes some related provisions (without an expiration date) as well as some additional enrollment and eligibility changes.

The final regulation addresses concerns about fraud in the Marketplace primarily by implementing stricter consumer-facing verification and eligibility procedures as well as by limiting enrollment opportunities. Some examples of the provisions include:

• Requiring Marketplaces to generate a data matching inconsistency if a consumer estimates that their income will be between 100% and 400% of the FPL (between $15,650 and $62,600 for a single person in 2025), but IRS data or other data sources show their past income was below 100% of the FPL. Takes effect in August 2025 and expires at the end of the 2026 plan year.
• No longer requiring Marketplaces to accept an applicant’s or enrollee’s estimate of projected household income when tax return data is unavailable. Under the regulation, Marketplaces will be required to confirm income with other data sources and require that applicants submit documentation that confirms their income. Takes effect in August 2025 and expires at the end of the 2026 plan year.
• Removing the low-income SEP that allows low-income consumers to enroll in a Marketplace plan during the year if their estimated income is no more than 150% of the FPL ($23,475 for a single person in 2025). Takes effect in August 2025 and expires at the end of the 2026 plan year (see similar, permanent provision below). 
• Requiring consumers in FFM states who are automatically re-enrolled in a $0-premium plan (because tax credits fully cover their premium) to confirm or update their eligibility during Open Enrollment or face a $5 monthly charge. Applies to the 2026 plan year only and does not apply to SBM states.
• Shortening the Open Enrollment period so that, for all Marketplaces, Open Enrollment must begin no later than November 1 and end no later than December 31. Begins with the 2027 Open Enrollment period and does not expire. 

Although there are some related provisions in the final regulation and the budget reconciliation law, the law contains several additional provisions related to eligibility and enrollment, which do not expire. For example, the law:

• Removes APTC repayment limits and requires all enrollees, including those with low incomes, to repay the entirety of any excess premium tax credits that were paid to their insurer. Begins with the 2026 plan year.
• Prohibits eligibility for APTCs for Marketplace consumers who qualify for special enrollment periods based solely on their income relative to the poverty level, beginning with the 2026 plan year.
• Eliminates eligibility for APTCs for certain low-income, lawfully present immigrants by excluding individuals such as refugees, asylees, and survivors of human trafficking. Begins in 2027.
• Establishes new requirements for consumers to verify specific information before they can receive APTCs. This provision could effectively end automatic re-enrollment for most Marketplace consumers. Consumers will still be permitted to enroll in a health plan while awaiting confirmation of eligibility, but they will not receive APTCs until after their eligibility is verified. Begins with the 2028 plan year. 

See this KFF analysis for additional details on the ACA-related provisions in the 2025 budget reconciliation law.

Changes include few reforms to agent and broker oversight. There is only one provision in the final rule that specifically addresses agents and brokers. The final regulation clarifies the standard that CMS must prove to terminate a broker contract as the “preponderance of the evidence” standard of proof. The rule defines “preponderance of the evidence” as proof by evidence that, when compared to opposing evidence, leads to the conclusion that the fact at issue is more likely true than not. This provision appears to be aimed at providing more transparency to agents and brokers about the standard the government will use to determine whether they have breached their contract with CMS or other standards of conduct agents and brokers are required to meet. No reforms to broker and agent oversight are included in the budget reconciliation law.

On June 27, 2025, the U.S. Supreme Court issued the most recent opinion in a long history of challenges to different elements of the Affordable Care Act (ACA). In this case, Kennedy v. Braidwood Management, the Court ruled (6-3) that the ACA requirement that most private insurers and Medicaid expansion programs cover preventive services recommended by the United States Preventive Services Preventive Task Force (USPSTF) with no cost-sharing is constitutional. This means that these services continue to remain available without cost-sharing to most individuals with private coverage. About 100 million privately insured people get preventive services each year without cost-sharing under the ACA’s requirement.

In this case, the only question before the Court was whether the process for appointing USPSTF members by the Secretary of Health and Human Services violated the Constitution’s Appointments Clause in Article II, which provides that “officers of the United States” may only be appointed by the president, subject to the advice and consent of the Senate. The respondents (Braidwood et al.) contended it did while the petitioners (Health and Human Services Agency) claimed the opposite. The court writes, “that question turns on whether the Task Force members are principal officers or inferior officers.” Inferior officer the Court writes, “are those ‘whose work is directed and supervised at some level by others who were appointed by Presidential nomination with the advice and consent of the Senate.’”

In its ruling, the Supreme Court held that the structure of the USPSTF does not violate the Constitution’s appointment clause. The Court agreed with the federal government, finding that the HHS Secretary has the power to remove USPSTF members at will and to review the recommendations they issue. The court writes “The Secretary of HHS has the power to appoint (and has appointed) the Task Force members… and no statute restricts removal of Task Force members. Therefore, ‘there can be no doubt’ that the Secretary may remove Task Force members at will.”

While the Court’s decision upholds the current ACA USPSTF coverage requirements, it will likely not be the final word on the preventive services that the ACA requires plans to cover free of cost-sharing. The Trump administration could change the membership of the USPSTF in ways that may significantly alter the recommendations it issues or ask the USPSTF re-consider earlier recommendations that it disagrees with. If members were removed and no new members appointed, this could delay review of new services or updates to existing services which would have implications for access under the ACA provision and for providers who look to USPSTF recommendations as clinical guidance.

In their briefs, the Trump administration also raised that they have the authority to indefinitely delay the implementation of recommendations issued by USPSTF and that the Secretary may have additional authority to supervise and veto Task Force recommendations, something that no prior administrations has ever done. In their brief, the administration stated, “In addition to removing Task Force members at will, the Secretary may supervise and review their recommendations directly.”

Demonstrating this authority earlier this month, albeit for a separate but somewhat similar body, Secretary Kennedy fired all 17 ACIP members and appointed eight new committee members. In a very short time, the newly formed committee has begun to not only review the recommendations for new and updated immunizations, it has said it will also re-evaluate the long-standing childhood vaccine schedule and reconsider its approval of vaccines that have been recommended for decades, and in the case of a type of flu vaccine, already has done so.

In this case, the Supreme Court narrowly considered whether the structure of the USPSTF violates the Appointments Clause, but did not review the litigants’ other claims about ACIP or HRSA. The federal district court will now resume briefing on the consideration of the plaintiffs’ claim that the Secretary of Health and Human Services’ ratification of HRSA and ACIP recommendations violates the Administrative Procedure Act. In addition, the original plaintiffs prevailed in the lower court on their claims that the requirement to cover PrEP violated their religious rights. While the Supreme Court did not review the religious claims brought by the original plaintiffs in this case, the Court has ruled in other cases brought on religious grounds challenging the ACA’s contraceptive coverage requirement, a recommendation from HRSA’s preventive services for women. In those cases, the Supreme Court ruled that exceptions are needed to accommodate employers with religious objections to contraception. Given the ongoing litigation in the lower courts and the Trump administration’s recent actions on vaccine recommendations, the Braidwood case is not likely to be the last word on the ACA preventive services coverage requirements.

Note: An analysis of how the Senate-passed bill’s Medicaid cuts could affect rural areas is available here.

Approximately 66 million people – about 20% of the U.S. population – live in rural areas, where Medicaid covers 1 in 4 adults (a higher share than in urban areas) and plays large part in financing health care services. In rural communities, Medicaid covers nearly half of all births and one fifth of inpatient discharges. The Congressional Budget Office (CBO) estimates that the Medicaid changes in the House-passed budget reconciliation bill—the One Big Beautiful Bill Act—will reduce federal Medicaid spending by $793 billion, decrease Medicaid enrollment by 10.3 million people, and increase the number of uninsured people by 7.8 million. Senators from both parties have raised concerns about potential impacts on rural hospitals and other providers, particularly given the ongoing trend of rural hospital closures.

To address those concerns, Senate Republicans have proposed adding a rural health fund to the reconciliation bill. Initial reports have pegged the size of the fund at $15 billion, though some Republican Senators have argued it should be bigger. The fund would provide $3 billion per year in fiscal years 2027 through 2031, with half distributed equally across all states and half to be distributed by the Centers for Medicare and Medicaid Services (CMS) based at least in part on states’ rural populations, percent of providers located in rural areas, and the situation of hospitals who serve low-income patients. It is unclear how the funds will be distributed across hospitals, other providers, and various state initiatives and whether the funds would be enough to offset any losses for providers under the bill.

This policy watch estimates how the House-passed reconciliation bill would affect federal Medicaid spending in rural areas and the number of rural Medicaid enrollees.

Building on KFF’s earlier estimates of state-by-state Medicaid cuts, this analysis estimates that Medicaid spending in rural areas could decrease by $119 billion over 10 years (Figure 1). The analysis allocates each state’s estimated spending reductions from the earlier analysis of the One Big Beautiful Bill Act to urban and rural areas using the percentage of Medicaid spending that paid for services used by rural enrollees within each state.

Overall, federal Medicaid spending in rural areas could decrease by 15% ($119 billion), which is far more than the $15 billion that has been suggested for the rural health fund. These estimates may underestimate the effects on rural areas because they do not account for the full change in total Medicaid spending, which would include the federal spending reductions and the associated reduction in state Medicaid spending stemming from lower enrollment. The estimates also do not account for the 8.2 million people who are expected to be uninsured because of changes in the Affordable Care Act. Those coverage losses stem from $268 billion in cuts to Affordable Care Act (ACA) Marketplace coverage from the reconciliation bill, the expiration of enhanced ACA subsidies that were enacted during the COVID-19 pandemic, and the impact of proposed Marketplace integrity rules. Federal spending cuts and coverage losses could have implications for rural hospitals and other providers, including increases in uncompensated care. While providers could potentially offset some of the cuts, financial pressure on hospitals and other providers could lead to layoffs of staff, more limited investments in quality improvements, fewer services, or additional rural hospital closures.

Over half of the spending reductions in rural areas are among 12 states that have large rural populations and have expanded Medicaid under the ACA, each of which could see rural federal Medicaid spending decline by $4 billion or more. Those states include Kentucky, North Carolina, Ohio, Illinois, Virginia, Michigan, New York, Washington, Pennsylvania, Oklahoma, Louisiana, and Arkansas. Kentucky would experience the largest rural Medicaid spending reduction, with an estimated drop of over $10 billion over 10 years. Larger effects in expansion states reflect the fact that expansion states would experience spending reductions under the House-passed reconciliation bill equal to 13% of their projected Medicaid spending, compared with only 6% in non-expansion states. Over half of the estimated federal spending cuts stem from provisions that only apply to states that have adopted the ACA expansions, including work requirements, more frequent eligibility determinations, and new cost sharing requirements. As a result, the effects of the reconciliation bill in rural areas will be larger for expansion than non-expansion states. The $119 billion decline in federal spending does not account for any changes in states’ Medicaid spending.

Building on KFF’s earlier estimates of state-by-state Medicaid enrollment declines, an estimated 1.5 million fewer people could be covered by Medicaid in rural areas under the reconciliation bill in 2034. The analysis allocates each state’s estimated enrollment loss from the earlier analysis of the One Big Beautiful Bill Act to urban and rural areas using the percentage of Medicaid enrollees in rural areas within each state. The same 12 states with the largest spending reductions account for over half of the estimated enrollment losses, each of which could experience enrollment declines of 50,000 or more rural enrollees in 2034. Currently, the uninsured rate is lower in expansion states than in non-expansion states, but it’s unclear whether that could change if the reconciliation bill passes. Research consistently links health coverage to improved health and to reduced mortality. The 1.5 million people who lose Medicaid in rural areas does not account for other increases in the uninsured rate stemming from reconciliation provisions affecting the number of people with coverage purchased through the ACA Marketplaces. It also does not account for the expiration of enhanced premiums tax credits, which were temporarily established during the COVID-19 pandemic, and the impact of proposed Marketplace integrity rules.

On June 26^th, 2025, the Supreme Court of the United States issued its decision in Medina v. Planned Parenthood South Atlantic, finding that Medicaid enrollees cannot seek relief in federal court to enforce Medicaid’s “free-choice of provider provision.” This provision allows Medicaid enrollees to seek care from any provider that is qualified and willing to participate in the program. South Carolina’s policy barring Medicaid patients from obtaining care from clinics that provide abortion care is part of broader efforts by anti-abortion policymakers to exclude Planned Parenthood clinics from the Medicaid program, and ultimately, eliminate all federal payments to Planned Parenthood centers. Medicaid pays health care providers, including Planned Parenthood, for the delivery of health care services, but the program does not pay for abortion care except under very limited circumstances (abortions for pregnancies resulting from rape, incest or that are life-threatening).

This decision means that people enrolled in Medicaid in South Carolina, and in other states that exclude Planned Parenthood going forward, will not be able to use their Medicaid coverage to obtain any preventive services, such as contraceptive care, STI treatment and cancer screenings, at Planned Parenthood clinics. Medicaid is a major source of revenue for Planned Parenthood clinics. The loss of this revenue could result in the closure of many sites or scaling back service hours or staff and affect access for all patients, not only Medicaid enrollees. Nationally, one in three (32%) women and one in ten men (11%) have received health services from a Planned Parenthood clinic.

This case stems from a 2018 executive order issued by South Carolina’s governor that prohibited any clinic that provides abortion care from participating in the state’s Medicaid program. Planned Parenthood South Atlantic, which operates two clinics in South Carolina, and Julie Edwards, a patient who wanted Planned Parenthood to be her provider, challenged this decision to block Medicaid patients from having Planned Parenthood as their provider. The Court ruled that the “free-choice of provider” provision does not create a right enforceable by individuals under the civil right statute Section 1983 because the statute does not clearly confer an individual right. The majority opinion distinguished this case from the Court’s 2023 Talevski decision, which found a private right of action for nursing home residents, because the Federal Nursing Home Reform Act (FNHRA) includes explicit language giving residents’ rights. Without the word “right” in the Medicaid “free choice of provider” provision, the Court concluded that the provision is about states’ duties under Medicaid, but it does not confer individual rights to Medicaid enrollees to sue to get services from the participating provider of their choice.

Justice Jackson wrote a dissent, joined by Justices Kagan and Sotomayor, criticizing the majority and contesting their conclusion that because the word “right” does not appear in the free choice of provider provision, the section does not confer individual rights.

Enforcement of Free-Choice of Provider is Now Limited

The Court states that Planned Parenthood could challenge their exclusion from South Carolina’s Medicaid program through South Carolina’s administrative process and then appeal to state courts and ultimately seek review at the Supreme Court. However, the administrative process at the state level could be prolonged, and in the meantime, patients enrolled in Medicaid would not be covered for care at Planned Parenthood clinics. As a result, the clinics would likely close or reduce the scope or availability of services before the administrative process concludes.

How will this impact access to care for Medicaid patients across the country?

Many states have tried to exclude Planned Parenthood clinics from their Medicaid program, largely due to opposition to including a health care provider that also provides abortion. In the past decade, at least 14 states (AL, AR, AZ, FL, IA, ID, KS, LA, MO, MS, OK, SC, TN, TX) have used state-level policies or sought federal permission to block the provider from participating in their state Medicaid programs, though they have often been blocked by court action, until this ruling (Figure 1).

While the high court’s ruling opens the door for South Carolina and other states to disqualify Planned Parenthood from their Medicaid program, the House-approved reconciliation bill could have an even broader impact if passed by the Senate. It would ban federal health care payments by Medicaid for any services to Planned Parenthood and other providers who also offer abortion care (which is currently not covered by Medicaid) in every state. The Senate Parliamentarian is still reviewing the provision to see whether it can be included in the final Senate version of the bill or whether it runs afoul of the “Byrd Rule” and would therefore require 60 votes to pass. Regardless of the outcome, as a result of the Medina case, patients who rely on Planned Parenthood sites for their contraceptive, STI, and preventive care will be likely in some states to find themselves with fewer or no options to get that care, especially in rural or medically underserved communities where there are far fewer providers.

Marketplace enrollment has grown substantially in recent years, increasing from 11.4 million people in 2020 to 24.3 million in 2025. Insurance coverage is a key determinant in accessing health care services, including mental health services. However, several pending policy changes, such as the One Big Beautiful Bill Act (OBBBA) and the expiration of enhanced premium tax credits, may lead to an additional 8.2 million people losing their Marketplace coverage and becoming uninsured by 2034, according to the Congressional Budget Office (CBO). This potential coverage loss raises concerns about access to mental health care services. One in five Marketplace enrollees report that their mental health is “fair” or “poor”, based on a KFF survey. This brief estimates the number of current Marketplace enrollees with a mental health diagnosis – identified as individuals with a health care claim that included at least one mental health diagnosis – to understand what changes in enrollment may mean for access to services, using 2022 health care claims data from the Center for Medicare and Medicaid Service.

Among Marketplace enrollees, more than 1 in 6 (18.2%) had at least one mental health diagnosis on a health care claim in 2022 (Figure 1). However, the share of Marketplace enrollees with a mental health condition is likely higher. This estimate only captures diagnoses for people with a mental illness diagnosis recorded in their medical claims. This estimate does not account for enrollees with only prescription drug claims for a mental health condition, enrollees with undiagnosed mental health conditions, enrollees in remission from mental health conditions, or those who did not seek treatment for their mental health conditions. Additionally, not all individuals are screened for mental illness, and diagnoses are not always recorded on healthcare claims. Prevalence rates estimated through surveys are generally higher than the prevalence rates observed in claims data. A prior KFF analysis found that among adults – regardless of insurance status – reporting moderate or severe symptoms of anxiety and/or depression, 39% did not receive treatment.

Among the 24.3 million Marketplace enrollees in 2025, over 4.4 million individuals are estimated to have at least one mental health diagnosis on a health care claim (Figure 2). Given that 18.2% of Marketplace enrollees had a health care claim with a mental health diagnosis in 2022, approximately 4.4 million enrollees may seek services associated with a mental health diagnosis in 2025. These mental health diagnoses include, but are not limited to, anxiety disorders (3.0 million), depression disorders (2.0 million), trauma and stressor related disorders (0.9 million), and bipolar disorders (0.3 million). Further, mental health conditions often co-occur. Among Marketplace enrollees with at least one mental health diagnosis, 39% will have health care claims that include two or more mental health diagnoses.

Among Marketplace enrollees, mental health diagnoses were most common among adults ages 26-34 and females (Figure 3). Female Marketplace enrollees were more likely to have a health care claim that included a mental health diagnosis than males (22.8% vs. 12.8%). A prior KFF analysis found that men with moderate to severe symptoms of anxiety and/or depressive disorder were more likely than women to not receive mental health treatment, and as a result not receive a mental health diagnosis in the year. Over one-in-five enrollees ages 26-34 (21.6%) had a health care claim that included a mental health diagnosis, followed by enrollees ages 35-49 and 50-64 (19.5% and 19.2% respectively).

The Congressional Budget Office estimates that up to 8.2 million more people will be uninsured in 2034 as a result of changes to Marketplace coverage, which may affect many enrollees with mental health conditions. Several aspects of Marketplace plans created under the Affordable Care Act have allowed for improved access to mental health and substance use services, including classifying these services as essential health benefits, providing coverage for individuals with pre-existing conditions, including mental health conditions, and parity protections. Access to these Marketplace plans has increased with record enrollment in recent years driven in part by enhanced premium tax credits that lowered costs for most enrollees, as well as policy changes that made it easier to sign up for coverage. However, several pending policy changes, including the OBBBA, recently passed by the House, along with the expiration of enhanced premium tax credits, and provisions in a new CMS Marketplace Integrity and Affordability rule may lead to an additional 8.2 million people losing their Marketplace coverage and becoming uninsured by 2034. This would mean if enrollees with mental health conditions lose coverage at a similar rate as other Marketplace enrollees, over one million more people with a mental health diagnosis could be uninsured in 2034. Separately, CBO estimates that changes to Medicaid via the OBBBA would further increase the number of uninsured people by 7.8 million. Medicaid plays a large part in coverage and treatment of behavioral health conditions, covering nearly one-third of all adults with mental health disorders.

Health care expenditures for those with mental health conditions are higher than those without, making insurance an important part of affording treatment for people with mental health conditions. Insured adults with moderate to severe symptoms of anxiety and/or depression are significantly more likely to receive mental health care compared to their uninsured counterparts (64% vs. 38%) in 2019, highlighting the key role insurance coverage plays in linking individuals to mental health care. Among privately insured individuals, those with anxiety and/or depression face higher out-of-pocket costs annually than their peers without a mental health diagnosis ($1,501 vs. $863 in 2021). Reflecting these financial burdens, a 2023 KFF survey found that 43% of insured adults with “fair” or “poor” mental health said they didn’t get needed mental health care because they couldn’t afford the cost. Loss of insurance coverage would further exacerbate the financial burden of seeking mental health treatment.

On May 22, the House passed the One Big Beautiful Bill Act, which the Congressional Budget Office (CBO) estimated would reduce federal Medicaid spending by $793 billion over 10 years. Almost 10% of those savings came from a provision that would limit state-directed payments to hospitals and nursing facilities in future years. State-directed payments (SDPs) require managed care organizations (MCOs) to make certain types of payments to health care providers, generally aimed at increasing provider payment rates to increase access to or quality of care (see Box 1). The House reconciliation bill would require future SDPs for hospitals and nursing facilities to be limited to 100% of Medicare rates in expansion states and 110% of Medicare rates in non-expansion states but would allow existing SDPs to remain at current rates. The Senate Finance Committee’s draft reconciliation language expands on the SDP provision by reducing existing SDPs 10% each year until they reach the statutory limits applicable to new SDPs.

If Congress passes the reconciliation bill with the Finance Committee’s requirements for SDPs, the required payments to hospitals or nursing facilities would likely decrease in 29 states, and possibly, in more than 31. KFF identified the potentially affected states by reviewing SDP arrangements that have been approved by the Centers for Medicare and Medicaid Services (CMS). Although the focus of this issue brief is payments to hospitals or nursing facilities, which combined account for a major source of Medicaid spending, payment rates for other providers could be affected, and some SDPs apply to multiple provider types but set different payment limits for different types of providers. Payments to other providers are included in this analysis when they are included in an SDP that also targets hospitals and/or nursing facilities (see Methods). Further, this analysis does not consider whether affected states would have to reduce payments to hospitals, nursing facilities, or both. This analysis also does not attempt to project the effects of the provision that will limit any future SDPs to levels that are lower than today’s or for the proposed limits on provider taxes which are one of the ways that SDPs can be funded and the new limits could prompt states to reduce SDPs.

Most states that have SDPs for hospitals or nursing facilities use average commercial rates to benchmark at least one state-directed payment (Figure 1).  The pre-approval documents states submit to CMS before implementing SDPs (“preprints”) generally require states to indicate the payment level required of comprehensive managed care organizations (MCOs), which is sometimes described as a benchmark. Benchmarks are generally established using Medicare or Medicaid fee-for-service rates, or commercial rates and a state can use one or more of these when establishing SDPs. Benchmarks are generally established for specific types of providers and specified categories of services. State-directed payments are often higher than the levels that would be permissible under the reconciliation bill: 24 states have at least one SDP which raises reimbursement to more than 90% of average commercial rates. One state (North Carolina) benchmarks against average commercial rates but its specific rates are only disclosed in attachments to its preprints that are not publicly available. About one fifth (11) of states have at least one payment rate benchmarked to Medicare (half of those payment rates are benchmarked to at least 92% of Medicare rates with one as high as 202%), and relatively few (3) states have at least one payment benchmarked to Medicaid fee-for-service rates.

Tying payments to average commercial rates was intended to ensure access to adequate provider networks and increase the use of value-based payment methods. A 2024 rule on Medicaid managed care codified CMS’ previously informal practice that the maximum payment rate on total payments after accounting for SDPs for hospital services, nursing facility services, and qualified practitioner services at academic medical facilities was the average commercial payment rate (ACR). There is no upper payment limit on SDPs for other types of services, but CMS indicated that it would use the average commercial rate as a standard when considering states’ applications for approval. The change was intended to help Medicaid compete with commercial insurers and to ensure robust access to Medicaid enrollees. Base rates paid to hospitals by Medicaid, without accounting for supplemental payments like SDPs, are often quite low.

Average commercial rates tend to be higher than Medicaid or Medicare rates and SDPs have been a driver of increased federal spending. There have been numerous proposals to restrain commercial prices for hospital care, which have contributed to higher premiums and reduced wage growth, among other effects.  The Congressional Budget Office (CBO) updated its Medicaid spending projections for 2025-2034 to reflect a 4% (or $267 billion) increase with half of the increase attributed to expected growth in directed payments in Medicaid managed care (driven in part by the rule change allowing states to pay at the average commercial rates). The Government Accountability Office noted that the rapid spending growth suggested the need for enhanced oversight and transparency.

Most states would likely need to reduce payments to hospitals or nursing facilities to comply with the Senate Finance Committee’s proposed caps on state-directed payments (Figure 2). The list of potentially affected states includes any state with an SDP benchmark that exceeds 100% of Medicare fee-for-service rates in expansion states, and 110% of Medicare rates in non-expansion states. For SDPs that benchmark rates to commercial payment rates, KFF converted those rates to a percentage of Medicare rates using data from RAND about the relationship between commercial and Medicare payment rates for hospitals (see Methods).

Among the 42 states with comprehensive managed care plans, 36 states had SDPs starting on January 1, 2024 or later, of which 33 states had SDPs targeting hospitals or nursing facilities (in addition to Vermont’s SDP which is through their All-Payer Accountable Organization Model). Among those 34 states:

• 29 states would likely be affected because they have at least one SDP benchmarked to Medicare or average commercial rates that are estimated to be higher than the proposed caps (see Methods). Eleven of these states (Georgia, Iowa, Kentucky, Minnesota, Nevada, Oklahoma, Oregon, South Carolina, Tennessee, Washington, and New Mexico) have at least one SDP raising payments to 100% of average commercial rates.
• Two states, North Carolina and Wisconsin, could possibly be affected by the proposed caps. North Carolina benchmarks some SDPs to commercial rates but does not document the adjusted rate within the preprint. For other SDPs, North Carolina benchmarked payment rates between 146% of Medicaid fee-for services rates (hospital outpatient laboratory services) and 256% of Medicaid rates (for inpatient hospital services). There are no publicly available data to compare states’ Medicaid rates to Medicare rates, so it’s difficult to discern whether benchmarks above 100% of Medicaid rates would also be above the new Medicare-based statutory limits specified in the reconciliation bill. Wisconsin has an SDP that benchmarks payment rates against providers’ costs (up to 124%), which is also difficult to compare to Medicare rates.
• Three states (Indiana, Missouri, and Vermont) have SDPs that would likely not be affected because their SDP rates are estimated to be below the proposed caps.

Among the remaining states, 3 states (Nebraska, Utah, and West Virginia) have SDPs that do not target hospitals or nursing homes, and 13 states and DC do not have any SDPs in this time period.

Reduced payments to hospitals or nursing facilities could potentially lead to reduced access to or quality of care. Increased payments through SDPs are permitted under federal law, with the goal to help ensure sufficient access to care and promote improved quality. They can help support hospitals serving a large percentage of Medicaid patients and rural hospitals, which are more likely to have negative operating margins and could face larger financial challenges with cuts to Medicaid financing and increasing the number of people without health insurance by nearly 11 million. These reductions could also have implications for nursing facilities because Medicaid is the primary payer for over 6 in 10 residents, paying for nearly half of the total spending on institutional long-term care. For both types of providers, they may have to offer fewer services or reduce the quality of care to work with the reduced payment rates expected under the bill, and in some cases, may be unable to remain open.

The effects of limiting SDPs in the reconciliation bill will amplify the effects of limiting provider taxes, a mechanism that many states use to help fund hospital and nursing facility payment rates. Both the House and Senate reconciliation language establishes a moratorium on provider taxes that is expected to save money in future years by limiting the amount of future Medicaid spending growth (some health care provisions of the Senate bill have been ruled out of order by the Senate parliamentarian and may need to be revised or removed from the legislation to pass with a simple majority). That provision is similar to the House’s proposed SDP limits that apply to new SDPs but permit existing SDPs to remain in place. In both cases, the Senate Finance Committee’s language makes deeper Medicaid cuts: by limiting existing SDPs and by reducing existing provider taxes in states that adopted the Medicaid expansion if they exceed new limits. KFF estimates that 22 states would be required to cut provider taxes on hospitals or managed care organizations under the Finance Committee language, which would exacerbate the effects of cutting existing SDPs for the states that are jointly affected. Because provider taxes often fund SDPs, even states with SDPs below permissible levels could be forced to cut their provider payment rates if they are affected by the lower provider tax thresholds.

The budget reconciliation bill (the “One Big Beautiful Bill”) being debated in Congress makes significant changes to the Medicaid program, including requiring states to impose cost sharing on certain adults enrolled through the ACA Medicaid expansion. This requirement marks a departure from current rules that permit, but do not require, states to impose cost sharing on certain populations within limits designed to protect Medicaid enrollees from high out-of-pocket costs. These protections were put in place based on evidence showing that cost sharing, even nominal amounts, can pose barriers to accessing needed care for individuals with low incomes. Cost sharing, such as copays required at point of service, is associated with reduced use of care, worse health outcomes, and increased financial burden. Other research finds that cost sharing often has limited state savings and often means a reduction in reimbursement for providers.

The bill would, for the first time, require states to impose cost sharing of up to $35 per service on Medicaid expansion adults with incomes between 100% and 138% of the federal poverty level (FPL; the federal poverty level is $15,650 for a single adult in 2025). Some services, including primary care, mental health and substance use disorder (SUD) treatment, family planning, emergency care provided in a hospital emergency department, and institutional long-term care, would be exempt from cost sharing. Additionally, cost sharing for prescription drugs would remain at nominal levels as specified by current rules. While $35 is the upper cost sharing limit per service (with the exception of non-emergency services provided in an emergency room, for which cost sharing can exceed $35), states can choose to charge less. As under current rules, states can allow providers to require payment of any cost sharing prior to providing services, which could lead to denial of services if an enrollee is unable to pay.

Under current rules, states are permitted to impose cost sharing on adults enrolled through the Medicaid expansion, though federal rules limit what states can charge given enrollees’ limited ability to pay out-of-pocket costs. Maximum allowable cost sharing varies by type of service and income. Total out-of-pocket costs are limited to no more than 5% of family income, and states are required to establish a process for tracking incurred cost sharing that does not rely on enrollee documentation and stops cost sharing once a family meets the cap, which the bill would maintain. Prior to the start of the COVID-19 pandemic in January 2020, over half of states that had adopted the Medicaid expansion charged cost sharing on some services for adults enrolled in the expansion. Most of these states imposed cost sharing regardless of income, though three states limited cost sharing to adults with income at or above 100% FPL. States were prohibited from imposing new cost sharing or increasing existing cost sharing from January 2020 through December 2023 in exchange for enhanced federal Medicaid funding. States could impose new cost sharing starting in January 2024, though some states have since eliminated all cost sharing.

Because the bill only addresses cost sharing for a limited group of expansion enrollees, it does not appear to affect existing cost sharing policies states have in place. States that currently impose cost sharing on the expansion population will likely maintain that cost sharing, though they may be required to apply the cost sharing to a wider range of services for expansion adults with incomes 100%-138% FPL. If a state has a cost sharing requirement above $35 per service, they will likely have to reduce the amount for the specified expansion adult population. Cost sharing on populations other than the specified expansion adults will likely be able to remain in place as long as it complies with existing rules.

This brief uses 2021 Medicaid claims data to examine utilization among Medicaid expansion adults and estimate how much cost sharing these enrollees could be required to pay under the new requirement if all states imposed the maximum cost sharing amounts. This is an illustrative analysis intended to describe which enrollees may be subject to the most cost sharing under the new provisions rather than estimate exactly what expansion enrollees may actually pay. The estimates are based on utilization among all adults enrolled through the expansion (income data to identify adults with income 100%-138% FPL are not available) who had utilization that would be subject to the cost sharing and assumes cost sharing of $35 per non-exempt service. The $35 represents the upper bound of what states could charge for most services, though not all states would be expected to impose cost sharing at this amount on all services. It does not, however, include cost sharing for prescription drugs, which the bill mandates must be limited to nominal amounts. Many states currently charge nominal cost sharing for prescription drugs. See methods for more details and limitations of this analysis.

Under the proposed cost sharing rules, the average expansion enrollee could pay $542 in a year if maximum cost sharing amounts were imposed on non-exempt services (Figure 1). Overall, 31% of Medicaid expansion enrollees would not be subject to the cost sharing requirements either because they did not use any services in the year or they only used services, such as primary care, mental health treatment, or family planning services, that would be exempt from the cost sharing requirements. Among the remaining expansion enrollees in the 2021 claims data who used services potentially subject to cost sharing, the average enrollee received 15.5 services and could pay up to $542 annually for those Medicaid services.

Expansion adults who are older or who have multiple chronic conditions could face a much higher cost sharing burden than the average enrollee. Copayments that are required at the point of service have a greater impact on enrollees with higher health care needs who use more services. Compared to younger enrollees and those with fewer chronic conditions, adults ages 50-64 and those with multiple chronic conditions utilize more health care services and, therefore, are subject to higher cost sharing. Adults ages 50-64 could pay, on average, $736 per year or one-third more than the average enrollee and more than twice the $349 that younger adults ages 19-26 could pay (Figure 1). Medicaid enrollees with three or more chronic conditions would have the highest average cost sharing and could pay up to $1,248 per year, or more than twice what the average expansion enrollee could pay, and more than five times what Medicaid enrollees with no chronic conditions could pay.

Because of higher utilization, average cost sharing for single Medicaid expansion enrollees ages 50-64 and those with multiple chronic conditions who have income at 100% FPL could come close to exceeding or could exceed the cap of 5% of family income on out-of-pocket costs. While the required cost sharing for many Medicaid enrollees would not exceed 5% of family income, some expansion enrollees with particularly high utilization could face cost sharing amounts that would exceed the cap. Average cost sharing could amount to 4.7% of income for single Medicaid expansion enrollees ages 50-64 with income at 100% FPL, which is close to the 5% cap. For single enrollees with three or more chronic conditions, average cost sharing could be 8% of income at 100% FPL, exceeding the cap by three percentage points.