Nearly 53 million people of all ages in the United States live in households that experience food insecurity, meaning they are unable to access adequate food due to lack of money or other resources. The Supplemental Nutrition Assistance Program (SNAP) was established in 1964 as a federal aid program to address food insecurity among low-income households by providing a monthly benefit to help participants purchase food.

The GOP’s House and draft Senate budget reconciliation bill, known as the One Big Beautiful Bill Act, is working its way through Congress and would reduce federal spending on SNAP by $287 billion over 10 years. Cuts to SNAP would produce budgetary savings but could produce higher rates of food insecurity and poorer health outcomes in the long run. Several studies indicate that individuals who receive SNAP benefits have better health and lower rates of food insecurity than similar people who are eligible but not receiving these benefits. Food insecurity is associated with multiple chronic conditions, poorer self-reported health status, higher health care utilization, and lower rates of medication adherence.

In addition to SNAP cuts, the reconciliation bill would cut federal health program spending by more than $1 trillion over the next decade, including $793 billion from Medicaid and $268 billion from the ACA Marketplaces – the largest cuts to federal support for health programs in the nation’s history. According to Congressional Budget Office (CBO), the bill will increase the number of uninsured by 10.9 million within ten years. The combination of federal spending reductions on SNAP and health programs would mean many people are at risk of losing both food assistance and health coverage, primarily those enrolled in Medicaid.

This analysis, based on the U.S Census Bureau’s 2023 Survey of Income and Program Participation (SIPP), examines the distribution of SNAP recipients and rates of food insecurity, by source of coverage.

The majority (78%) of people who received SNAP benefits in 2022 were covered by Medicaid, including 18% who were covered by both Medicaid and Medicare.

Nearly 30 million of the 38.3 million people receiving SNAP benefits in 2022 were enrolled in Medicaid (Figure 1). The overlap between the two programs reflects similar eligibility requirements for Medicaid and SNAP, though rules vary by state. Among Medicaid enrollees receiving SNAP benefits, 23.3 million were solely covered under Medicaid, while 6.7 million were also covered by Medicare (otherwise known as dual-eligible individuals). Medicaid was the primary source of coverage for children receiving SNAP, covering 88% of kids with SNAP, or approximately 13 million children.

A total of 9.2 million Medicare beneficiaries received food assistance benefits under SNAP, accounting for one in four (24%) SNAP recipients. Most Medicare beneficiaries with SNAP benefits (18% or 6.7 million) had supplemental coverage under Medicaid. In 2023, one in four Medicare beneficiaries lived on incomes below $21,000 per person.

Over 500,000 people who purchase health insurance coverage directly (mostly from ACA Marketplaces) received SNAP benefits in 2022. In addition, 2.4 million SNAP recipients were uninsured in 2022.

Some Medicaid enrollees who receive food assistance benefits from SNAP could lose both health insurance coverage and financial resources to supplement their food budgets as a result of the reconciliation bill.

Proposed changes in eligibility rules in both SNAP and Medicaid may jeopardize some people’s access to both adequate food and health care if various provisions of the bill take effect, in part because there is a significant overlap in eligibility requirements for Medicaid and SNAP across states. Four in 10 (40%) Medicaid enrollees receive SNAP benefits, compared to only 3% of those without Medicaid.

Recent KFF polling shows a majority of the public is worried about the consequences of significant reductions in federal Medicaid spending, and half of low-income adults reported their households having difficulty affording necessities, including food.

A CBO analysis of the House version of the reconciliation bill estimates that households in the lowest income decile could see a 4% decrease in resources by 2034, primarily due to changes in Medicaid and SNAP, while the highest income decile households would see a 2% increase in resources as a result of proposed tax cuts.

Many people enrolled in the programs slated for cuts in the reconciliation bill, including Medicaid and those receiving SNAP benefits, already experience food insecurity.

People living in households with and without SNAP report that they had problems affording food over the prior year. Overall, 52.8 million people lived in a household with food insecurity in 2022, including 30% of people enrolled in Medicaid (22.4 million), 13% of Medicare beneficiaries (8.7 million people), 26% of the uninsured, and 12% with coverage they purchased directly, including from ACA Marketplaces (Figure 2). A total of 14.6 million children lived in a household that experienced food insecurity in 2022.

Many households already struggling with food insecurity may be at risk of reduced SNAP benefits, or losing eligibility, at the same time they face new eligibility restrictions or higher costs for their healthcare. 22.4 million people enrolled in Medicaid experienced food insecurity, including 9.3 million children. Nearly 2 million people enrolled in direct purchase coverage in 2022 lived in a household experiencing food insecurity. Many of these households will face higher premium costs if Marketplace enhanced premium tax credits expire at the end of this year, increasing demands on some household budgets. Almost half of ACA Marketplace enrollees have incomes below 150 percent of the federal poverty level, $23,475 for an individual in 2025.

Among the 52.8 million people who reported food insecurity in their households in 2022, more than two-thirds (73%, or 38.6 million) were not receiving SNAP benefits. At the same time, even SNAP participants can experience food insecurity. Among the 38.3 million people receiving SNAP benefits in 2022, 37% (14 million) reported being unable to access adequate food due to lack of money or other resources.

Proposed cuts to SNAP could increase the number of people experiencing food insecurity and worsen affordability challenges for those already struggling to access food, as well as for those at risk of losing health insurance due to other changes in the legislation.

The Trump Administration and Congress are moving quickly to pass legislation that could have significant implications for health coverage of older Americans. The House-passed reconciliation bill awaiting action by the full Senate, known as the One Big Beautiful Bill, includes several provisions that would affect health insurance coverage and well-being of older adults ages 50 and older, including those who are covered by Medicare.

The House-passed reconciliation bill includes an estimated $793 billion in federal Medicaid spending cuts over the next 10 years, including several provisions expected to increase costs or eliminate coverage for Medicaid beneficiaries, with similar provisions in the draft Senate bill. Collectively, these provisions could affect the 22 million people ages 50 and older with coverage under the Medicaid program by reducing the number of people with Medicaid and reducing access to health and long-term care services for people who remain enrolled in the program. The House bill and draft Senate language also include changes that are expected to reduce the number of people with ACA Marketplace coverage, including among 50-64 year olds.

According to KFF’s most recent poll, one third (34%) of adults ages 50 and older said they have a favorable view of the tax and budget bill moving rapidly through Congress, with stronger support among Republicans (61%) than Independents (23%) or Democrats (9%). After hearing that the bill would increase the number of uninsured by 10 million people, the share of adults ages 50 and older with favorable views drops from 34% to 24% and from 61% to 39% among Republicans. Among older adults who self-identify as MAGA, support for the bill drops from 70% to 45%. Support drops by a similar amount when people are told that the bill would decrease funding for local hospitals (see Figure 1 below).

Below are six health-related provisions to watch as the reconciliation bill works its way through the Congress. 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 eliminated for the legislation to pass with a simple majority.

1. New Medicaid Work Requirements. The largest source of federal Medicaid spending cuts would come from new work requirements that would be imposed on the Medicaid expansion population. The Congressional Budget Office (CBO) estimates that the work requirements in the House-passed bill would reduce Medicaid spending by $344 billion and cause nearly 5 million people to become uninsured. If passed, the bill would require adults ages 50-64 to meet new work and reporting requirements if they are enrolled through the ACA expansion. Most Medicaid enrollees ages 50-64 are working or could be exempt from the work requirements because of a disability or caregiving responsibility, but they would still need to comply with reporting requirements, putting them at risk of risk losing Medicaid coverage. According to a new KFF analysis, fewer than half of adults ages 50-64 would meet the work requirements through either employment or school, compared with 72% of adults ages 19-27 and 66% of adults ages 27-49. Those who do not qualify for an exemption could also face greater challenges reentering the workforce because of their age and physical limitations.

2. Changes to ACA Marketplaces. An estimated 5.5 million adults ages 55 to 64 get health insurance from ACA Marketplaces in 2025. The House-passed bill and Senate draft bill make changes to the ACA Marketplaces that would increase the number of people who are uninsured, including older people ages 50-64. The legislation in its current form, combined with the Trump administration Marketplace integrity rules, would shorten the open enrollment period, impose new documentation and pre-enrollment verification of eligibility requirements, and make other changes that would affect enrollment. Overall, the outcome would be loss of health insurance coverage for an estimated 4 million people by 2034, including older adults.

Further, because the bill in its current form does not extend enhanced ACA premium tax credits for Marketplace coverage that are set to expire at the end of this year, an additional 4.2 million people (including older adults) are estimated to lose coverage by 2034. Without enhanced premium tax credits, enrollees with incomes over four times poverty would lose subsidy eligibility and those with incomes between 100 and 400% of poverty will receive a smaller tax credit. Over half of individual market enrollees with incomes above four-times the poverty threshold are between the ages of 50 and 64.

Health insurance premiums are higher for people in their 50s and early 60s than for younger adults choosing the same plan in the same area. If the enhanced premium tax credits expire, enrollees currently receiving a subsidy could face higher costs to enroll, particularly if their incomes are about or above 400% of poverty. For example, according to the KFF calculator, a 59 year old single widow living in Jackson, Missouri earning $62,000 (just above 400% of the poverty level) would pay $5,270 for her silver Marketplace plan in 2025, but without enhanced premium tax credits, she would pay $14,213 in premiums, which amounts to 22.9% of her income for the same health insurance policy. It’s not hard to see why she and others like her might give up their Marketplace plans, given the cost relative to their income.

3. Blocking Implementation of the Medicare Savings Program and Medicaid Eligibility and Enrollment Rules. Older adults are also at risk of losing coverage due to provisions in the House-passed bill and the Senate Finance Committee language that would block implementation of two Biden-era rules that were intended to streamline the enrollment process for Medicaid, especially for older adults and people with disabilities. The second largest source of federal reductions in Medicaid spending stems from these two provisions, which are collectively estimated to reduce federal Medicaid spending by $167 billion.

Both rules aim to reduce barriers to enrolling in and maintaining Medicaid coverage. They are expected to disproportionately affect enrollment among older adults and people with disabilities because there are specific requirements related to streamlining enrollment among Medicare beneficiaries, and to facilitating smoother enrollment for people who are eligible for Medicaid because they have a disability, are ages 65 and older, or use long-term care.

CBO estimates that the reconciliation language would result in 1.3 million low-income Medicare beneficiaries losing Medicaid coverage. A separate KFF analysis shows that the loss of these benefits would result in a someone with an income of $967 per month paying $185 per month in Medicare premiums, or about 20% of income, without accounting for other non-trivial out-of-pocket costs, including Medicare cost-sharing requirements and the loss of Medicaid benefits.

4. Reducing Spending for Long-Term Care Services. If signed into law, the House-passed bill and the draft Senate legislation would reduce federal funds for nursing facilities and would likely lead to reductions in spending for other long-term care services. The bill would reduce federal Medicaid spending by $23 billion over 10 years by prohibiting implementation of a Biden Administration rule on nursing facility staffing. The rule aims to help address long-standing concerns about inadequate staffing and the quality of care, locking into place a federal judge’s ruling to overturn key elements of the rule.

The reconciliation bill could also reduce Medicaid funds available to nursing facilities through a moratorium on provider taxes (in place for nursing facilities in 46 states) and new limits on some payments to nursing facilities (known as state-directed payments). In the House bill, those provisions jointly account for $161 billion in reduced federal Medicaid spending over 10 years, although they would also affect hospitals and other providers. The Senate Finance language would also reduce existing state-directed payments to 100% of Medicare rates in states that have adopted the ACA expansion and 110% of Medicare rates in states that have not.

If past predicts future, substantial cuts to federal Medicaid spending could lead to reduced spending for home care, which includes long-term care provided in people’s homes and the community (and is sometimes referred to as home- and community-based services or HCBS). During the last major reduction in federal spending, all states reduced spending on home care by serving fewer people (40 states) or by benefits or cutting payment rates (for long-term care providers) (47 states). As a significant source of Medicaid spending comprised of optional services for which there are already waiting lists, home care may be especially vulnerable.

5. Prohibiting Medicare Coverage for People with Lawful Immigrant Status. Under current law, undocumented immigrants are not eligible for Medicare. Medicare coverage is restricted to people who are citizens or permanent legal residents. Both the House-passed reconciliation bill and draft Senate legislation include a provision that would prevent defined groups of individuals who are lawfully present in the U.S. from becoming eligible for Medicare benefits. The legislation would also terminate Medicare coverage for currently eligible beneficiaries who are not U.S. citizens, green card holders, certain immigrants from Cuba, and people residing under the Compacts of Free Association within a year of enactment of the legislation. Individuals affected by this provision and their employers would continue to be required to pay Medicare payroll taxes. This would be the first time that Congress has taken away coverage from potentially eligible legally residing individuals.

The Senate parliamentarian has ruled that this provision, as currently drafted, would require 60 votes to pass.

6. Adding Work Requirements and Cutting Spending for Supplemental Nutritional Assistance Program (SNAP). The House-passed reconciliation bill and draft Senate bill includes nearly $300 billion in cuts to SNAP benefits. Reductions of this magnitude, coupled with work requirements, are likely to affect the health of older adults, particularly given the strong ties between health and nutrition. As noted above, work requirements, even with exemptions, pose administrative hurdles for older adults that put them at risk for losing SNAP benefits. An estimated 9.2 million Medicare beneficiaries received SNAP benefits to help cover the costs of food and groceries in 2022, according to KFF analysis. The SNAP work requirements may particularly exacerbate financial challenges for older Medicaid enrollees ages 50 and older who are two and a half times more likely to experience food insecurity than other older adults not enrolled in Medicaid (28% compared to 10%).

Originally published on June 2, this Policy Watch has been updated to reflect subsequent developments related to the reconciliation bill.

The House of Representatives recently passed a budget reconciliation bill that would appropriate funding for cost-sharing reductions that insurers are required to provide to low-income enrollees in the Affordable Care Act marketplace. The Congressional Budget Office (CBO) has estimated that this action will reduce the deficit by $31 billion and increase the number of people without health insurance by 300,000 through 2034. This provision was ruled out of order by the Senate parliamentarian (Byrd rule) on June 26, 2025 and may need to be revised or eliminated for the legislation to pass with a simple majority.

This brief explains what these cost-sharing reductions are, how they relate to federal spending, and how appropriating funding impacts premiums and the uninsured rate.

What are cost-sharing reductions?

The Affordable Care Act (ACA) has two types of financial assistance for lower-income enrollees: assistance with monthly premiums (“premium tax credit”) and assistance with out-of-pocket expenses when people get medical care or fill a prescription (“cost-sharing reductions”).

The ACA requires insurers to offer plans with reduced patient cost-sharing (e.g., deductibles and copays) to marketplace enrollees with incomes between 100 and 250% of the poverty level (an annual income of $15,650 to $39,125 for a single person in the contiguous U.S.). The reduced cost-sharing is only available in silver level plans, and the premiums are the same as standard silver plans.

The cost-sharing reductions (CSRs) significantly lower deductibles in these plans: for plans where there is a combined deductible for medical care and prescription drugs, the average deductible is reduced for those with incomes below 150% of poverty from $4,902 to $87; for those with incomes between 150% and 200% of poverty, the average deductible is reduced to $682; and for enrollees with incomes between 200% and 250% of poverty, the average deductible is $3,620.

During the Obama administration, from the start of ACA implementation in 2014, the federal government paid insurers directly to offset the cost-sharing reductions. To compensate for the added cost to insurers of the reduced cost-sharing, the federal government was making 7 billion dollars in annual payments directly to insurance companies by 2017.

In 2016, a federal district judge ruled that direct CSR payments without explicit congressional appropriation were illegal, but stayed the ruling after it was appealed by the Obama administration. However, in October 2017, the Trump administration stopped the appeals process and chose to end the CSR payments, saying at the time the ACA was “dead.”

What is silver loading?

In response to the federal government ending cost-sharing reduction payments, most insurers raised silver premiums substantially to compensate for the loss of CSR payments. Most states either allowed or encouraged insurers to “load” the cost of CSRs onto silver premiums only (not onto other metal levels), since silver plans are the only plans where cost-sharing reductions are available. The practice of increasing silver plan premiums to compensate for the loss of federal CSR payments is known as “silver loading.” From 2017 to 2018, average benchmark silver plan premiums rose by about 17 percentage points more than bronze premiums did.

In August 2018, the Trump administration issued guidance encouraging state regulators to allow insurers to increase only the premium on silver plans offered on-exchange, so that off-exchange silver plans could be priced lower. The 2026 Notice of Benefit and Payment Parameters (issued by the Biden Administration in January 2025) codified the practice of silver loading so long as it is permitted by the state regulator and the insurer does not receive other reimbursements for cost-sharing reductions.

What is the cost of silver loading to the federal government?

While the federal government saved money by no longer making CSR payments, those savings were offset by higher payments for premium tax credits that result from silver loading. That is because the ACA’s premium tax credits are based on the premium for a benchmark plan in each area: the second-lowest-cost silver plan in the marketplace. The premium tax credit is calculated as the difference between the premium for that benchmark plan and a premium cap calculated as a percent of the enrollee’s household income. Any systematic increase in premiums for benchmark silver plans increases the amount of premium tax credits.

The increased tax credits completely cover the increased premium for subsidized enrollees covered through the benchmark silver plan. Enrollees who apply their tax credits to other plans (e.g., bronze, gold, or other silver plans) would also receive increased premium tax credits even if they do not qualify for reduced cost-sharing and even if the underlying premiums in their plans might not have increased at all. After 2017, increased premium tax credits allowed many more individuals to purchase bronze – and sometimes even gold – plans with zero out-of-pocket premium costs.

For this reason, ending federal payments for cost-sharing reductions ended up costing the federal government more money than if the cost-sharing reduction payments had continued. Additionally, subsequent research has pointed to the practice of silver loading having an upward effect on ACA Marketplace enrollment.

An August 2017 CBO report projected that ending CSR payments would increase the federal deficit by $6 billion in 2018, $21 billion by 2020 and $26 billion by 2026, and added that after taking premium tax credits into account, most enrollees would pay similar or lower premiums than they had been paying before.

What does the House reconciliation bill do with CSR funding?

The budget reconciliation bill passed by the House in May 2025 appropriates funding for cost-sharing reductions, returning to the pre-2017 federal payment system practice. The bill does not explicitly ban silver loading, but if insurers receive federal CSR payments, they will no longer have a justification to silver load under current regulations.

The bill also bans federal CSR payments to insurers for Marketplace plans that include coverage for abortion, which will raise conflicts with state laws in a dozen states requiring abortion coverage. It is not yet clear how those states will respond (e.g., whether they will restrict abortion coverage in ACA marketplace plans and allow insurers in their state to receive federal cost-sharing reduction payments).

Although the federal government would resume CSR payments to insurers, this is expected to reduce the federal deficit by effectively ending silver-loading, thus lowering benchmark silver plan premiums, which in turn reduces the dollar amount of premium tax credits paid out to subsidized enrollees.

What might be the effect on premiums and enrollment?

Premiums for silver plans – before accounting for premium tax credits – are expected to decrease as silver-loading would no longer be necessary if funding for CSRs is appropriated. Given that silver premiums rose by about 17 percentage points more than bronze plans did in 2018, it is likely there could be a similar drop in gross premiums for silver plans if this legislation passes. Meanwhile, funding CSRs is likely to have little or no effect on what insurers charge for bronze and gold premiums (before accounting for the premium tax credit).

However, the vast majority of ACA Marketplace enrollees receive a premium tax credit and therefore do not pay the gross premium. Generally speaking, subsidized enrollees who pick a silver level plan may see no difference in their monthly out-of-pocket premium payments resulting from the funding of CSRs. Meanwhile, enrollees who pick a bronze or gold level plan will likely pay more for their monthly premium. This is because bronze and gold gross premiums would be unaffected, while the total amount of the premium tax credit is smaller, resulting in people in those plans paying more than they would have with silver loading.

Because enrollees in bronze and gold plans would face higher premium payments if CSRs are appropriated, it’s likely some of these enrollees would drop their coverage, thus having an upward effect on the uninsured rate. The enrollees who drop their coverage as a result of CSR appropriation are likely to be middle-income people (those making between two and four times the poverty level).

However, the appropriation of CSRs is just one of many changes the reconciliation package makes to the ACA Marketplaces. Other provisions of the budget reconciliation, as well as expiring enhanced subsidies, will have separate effects on premiums and the amount of financial assistance enrollees receive.

Approximately 66 million people in the United States live in rural areas – about 20% of the population. Individuals living in rural areas may experience unique health care challenges compared to individuals living in urban areas. They report poorer physical and mental health, and have lower incomes and higher rates of poverty than individuals living in urban areas. Additionally, individuals in rural areas may have less access to health care services due, in part, to provider shortages in rural areas, and many rural hospitals have closed or are at risk of closure.

Evidence suggests that Medicaid helps mitigate some of these challenges. Medicaid covers nearly half of all births in rural areas and one-fifth of inpatient discharges in rural hospitals. Studies have shown that the Affordable Care Act (ACA) Medicaid expansion is associated with improved hospital financial performance and lower likelihood of hospital closure, particularly for rural hospitals; significant increases in the number of visits to providers for services such as mammograms and substance use disorders in rural areas; and higher staffing levels in rural community health centers.

The One Big Beautiful Bill passed by the House is projected to reduce federal Medicaid spending by $793 billion over 10 years, based on Congressional Budget Office (CBO) estimates, which could have a significant impact on rural communities and individuals living in rural areas who rely on Medicaid for health care coverage. The Senate finance committee’s draft reconciliation language includes similar provisions as the House, but with potentially more significant funding cuts for hospitals, particularly in states that have adopted the ACA expansion. Polling data show that among both parties, most people living in rural areas say Medicaid is “very important” for people in their local community and that they or a family member has received help from Medicaid at some point. Many are worried about the effects of the federal spending reductions to their communities. Furthermore, researchers estimate that more than 300 rural hospitals might be at risk of closure if the federal Medicaid spending cuts as outlined in the House bill are enacted.

1. Nearly 1 in 4 people in rural areas have Medicaid coverage.

Medicaid is the second largest source of health care coverage in both rural and urban areas. However, Medicaid covers a somewhat higher share of people (including those who have both Medicaid and Medicare coverage) in rural areas compared to urban areas, 24% and 21%, respectively. Employer-sponsored insurance is the largest source of health care coverage in rural and urban areas but covers a lower share of people in rural areas (42%) compared to urban areas (50%). Rates of uninsurance are similar across both rural and urban areas.

States have wide variation in their rates of Medicaid coverage in rural areas and in their shares of Medicaid enrollees who are living in rural areas (Appendix Table 1). In six states, at least half of Medicaid enrollees are living in rural areas – Vermont, Wyoming, South Dakota, Mississippi, Montana and Kentucky (Appendix Table 1).

2. People living in rural areas in expansion states have higher rates of Medicaid coverage and lower rates of uninsurance compared to non-expansion states.

States that expanded Medicaid have a somewhat larger share of individuals enrolled in Medicaid (including those dually enrolled in Medicaid and Medicare) in rural areas (25%) than states that did not expand Medicaid (22%). This contributes to a lower uninsured rate in rural areas – in expansion states, 7% of people are uninsured compared to 11% in states that did not expand Medicaid. Expansion and non-expansion states have similar rates of employer-sponsored health insurance coverage in rural areas (42% vs 41%).

Research shows that Medicaid enrollees, in general, have substantially better access to care than people who are uninsured and are less likely to postpone or go without needed care due to cost, as federal rules generally limit out of pocket Medicaid costs. A study focused specifically on rural Medicaid enrollees found that gaining Medicaid coverage significantly increased the likelihood that rural residents felt their health care needs were addressed from when they were uninsured.

3. Children and expansion adults represent over half of rural Medicaid enrollees.

In rural areas, children are the largest Medicaid eligibility group, constituting 36% of enrollees, followed by expansion adults who represent 20% of rural Medicaid enrollees. When looking only at Medicaid enrollees who live in the most rural areas (i.e. rural areas not adjacent to metropolitan areas), the share of expansion adults increases to 24% of enrollees (Appendix Figure 1). In expansion states, the share of rural Medicaid enrollees who are eligible through the ACA expansion jumps to 30% (data not shown), a group that is more at risk of losing Medicaid coverage given the targeting of federal spending reductions to expansion states. A majority (63%) of rural enrollees are White, with smaller shares of Black (12%) and Hispanic (10%) enrollees. This is a notably different demographic make-up compared to urban enrollees, where only one-third of urban enrollees are White (data not shown).

4. Nearly 4 in 10 rural Medicaid enrollees under age 65 have a diagnosed chronic condition.

Chronic conditions are conditions that last at least one year and require ongoing medical care or limit daily activities (e.g. heart disease, diabetes, cancer, mental illness, etc.). Thirty-eight percent of rural Medicaid enrollees under age 65 and not dually enrolled in Medicare have at least one diagnosed chronic condition. Of those with at least one chronic condition, approximately one-quarter have three or more chronic conditions (data not shown). The most diagnosed chronic conditions for these rural Medicaid enrollees are physical (which include high blood pressure, obesity and high cholesterol), with 24% of rural Medicaid enrollees having at least one diagnosed physical health condition. Behavioral health conditions, which include mental health and substance use conditions, are diagnosed in 22% of rural Medicaid enrollees and 5% of rural Medicaid enrollees have a diagnosed cognitive impairment condition, including dementia and intellectual and developmental disabilities, which often cause functional limitations that require long-term care.

Rates of diagnosed chronic conditions are calculated from Medicaid claims data, which reflect only diagnoses recorded during medical visits in 2021 and do not measure overall prevalence. Prevalence rates from surveys are generally higher than claims-based estimates because not everyone is screened, treated, or has a recorded diagnosis for their chronic conditions in claims data in any given year. The numbers exclude Medicaid enrollees who also have Medicare (since Medicare is the primary payer for outpatient and acute care services), as well as enrollees ages 65 and older, nearly all of whom also have Medicare coverage (see Methods for more details).

5. A higher percentage of rural Medicaid enrollees used care in expansion states than in non-expansion states.

Eighty-two percent of Medicaid enrollees living in rural areas in expansion states had at least one health care claim in the year compared to 74% of rural Medicaid enrollees in non-expansion states. Enrollees living in urban areas in expansion states also utilized care at higher rates than those living in non-expansion states, although by a smaller margin than rural enrollees, 80% to 74%, respectively (data not shown).

Appendix

On May 22, the House passed a budget reconciliation bill that makes significant changes to the Medicaid program, including adopting a national work requirement for certain people covered by Medicaid. The new requirements would apply to adults eligible through the Medicaid expansion and would require them to work 80 hours or more per month, engage in work-related activities, or be in school half time. Certain individuals, including parents of dependent children and individuals who are “medically frail,” (defined as those who have a physical, intellectual, or developmental disability, a substance use disorder or “disabling” mental disorder, and those with “serious or complex” medical conditions), would be exempt from the requirements.

Under the House-passed bill, whether an individual is meeting the work requirements would be assessed at application and at renewal. Adults applying for Medicaid would have to meet the requirements or qualify for an exemption at least in the month preceding their application and could be required at state option to meet the requirements for more than one consecutive month. Adults enrolled in Medicaid expansion coverage would have to meet the requirements for at least one month between 6-month eligibility determinations, or more frequently at state option.

Text of the Senate version of the reconciliation bill, released on June 16, also includes a Medicaid work requirement similar to the provisions in the House bill, though it makes some changes to who is exempt from the requirement, notably narrowing the exemption for parents to those whose children are ages 14 and younger.

The Congressional Budget Office estimates the Medicaid work requirement provisions in the House bill would reduce federal spending by $344 billion over ten years, and increase the number of people without health insurance by 4.8 million. Based on experience with work requirements in Arkansas, where 18,000 enrollees lost Medicaid coverage following implementation of work requirements, many adults are expected to lose coverage because of difficulty navigating the reporting requirements and proving they worked the required hours or qualified for an exemption.

This analysis builds on prior analysis of the work status of Medicaid enrollees and uses data from the Survey of Income and Program Participation (SIPP) to model the impact of the work requirements in the House-passed bill. It includes adults on Medicaid who are not receiving disability income, are not also enrolled in Medicare, and are not parents of dependent children in states that had adopted the Medicaid expansion as of December 2021, as these adults are likely to be subject to the new requirements. Specifically, the analysis examines the work status of these Medicaid adults to assess whether they would meet the 80+ hours per month requirement and identify the reasons why individuals may not be meeting the requirement. It also examines work status throughout the year for this group to determine whether adults who meet the work requirement by working 80 or more hours in one month continue to meet the requirement in subsequent months.

Monthly Work Status

Among Medicaid adults who would be subject to the work requirements in the House-passed reconciliation bill, nearly eight in ten either met the requirement to work at least 80 hours or did not meet the requirement for a reason that would likely qualify them for an exemption. Over half (53%) worked at least 80 hours in the month analyzed (June 2022) and 9% were attending school (Figure 1). Nearly one in five (17%) of adults did not work 80 or more hours because of illness or disability (15%) or caregiving responsibilities (2%), reasons that could qualify them for an exemption from the requirement. However, about one in five (21%) Medicaid adults were not working or did not work enough hours to meet the requirement for reasons, including the inability to find work or to work more hours, retirement, or having been laid off, that would put them at particular risk for losing coverage if the new requirements go into effect.

The share of adults who would meet the new requirements or qualify for an exemption varies by age. Over seven in ten (72%) of young adults ages 19-27 were working 80 or more hours (48%) or were in school (24%) and would have met the requirements, the highest share of any age group. An additional 7% reported having an illness or disability (Figure 2). A slightly smaller share (66%) of adults ages 27-49 would have met the requirements while one in five would have qualified for an exemption based on health limitations or caregiving responsibilities. Adults ages 50-64 were least likely to meet the requirements, with less than half (48%) working 80 or more hours in the month. However, nearly a quarter (24%) of these adults were not meeting the requirements for reasons that would likely qualify them for an exemption.

Adults ages 50-64 are at greater risk of losing Medicaid coverage for not meeting the new requirements. Adults who are not working 80 or more hours in the month and who do not appear to qualify for an exemption because they cite an inability to find work, retirement, or other reasons for why they are not working are at the greatest risk of losing coverage if the work requirements are implemented. Nearly three in ten (29%) Medicaid adults ages 50-64 are not meeting the work requirements and do not appear to qualify for an exemption (Figure 2). While similar shares of adults ages 50-64 compared to other age groups cited being unable to find work or other reasons for not meeting the work requirements, over one in ten (11%) said they had retired. Among adults who said they retired, 28% reported having a disability. Because of their age and physical limitations, these adults may face particular challenges trying to reenter the workforce, if they don’t meet reporting requirements to qualify for an exemption.

Work Status Throughout the Year

About 10% of Medicaid adults who meet the requirement to work 80+ hours in a month do not continue to meet the requirement for all of the following six months. Under the requirements in the House-passed bill, states must confirm that individuals meet the work requirements at application and every 6 months when eligibility is redetermined (or more frequently at state option). States would be required to “look back” at least one month between 6-month eligibility periods and could choose to “look back” more consecutive or non-consecutive months to verify compliance. While 44% of Medicaid adults who met the requirement to work 80+ hours in June continued to meet the requirement in all six months from July to December, 4% met the requirement for 4 or 5 months and 5% met the work requirement for only 1, 2, or 3 months during the 6-month period from July to December. Depending on how states operationalize the “look back” period, the month-to-month volatility in hours worked could lead to increased coverage loss, but even individuals who continue to meet the requirement could still lose coverage if states require monthly verification.

Similar to previous analyses, this analysis shows that a majority of Medicaid expansion adults who would be subject to the work requirements in the reconciliation bill are working 80 or more hours in a month, and most are working those hours consistently over a six-month period. Many adults who do not meet the work requirements are attending school or have an illness or disability that limits their ability to work and would, therefore, appear to qualify for an exemption from the work requirements. Nevertheless, these adults are at risk of losing coverage if they are unable to navigate reporting requirements established by their state. Expansion adults ages 50-64 may be at greater risk of losing coverage under the new requirements because they are less likely to work 80 or more hours in a month or to qualify for an exemption.

This resource provides data on global health funding awards by U.S. state and congressional district in FY 2024. Data were obtained from USAspending.gov, the official source of spending across the U.S. government. While the resource allows users to see how much funding for global health projects was channeled to organizations in the U.S., it only provides information on the prime awardee of funding, not sub-awardee, and should not be used to assess how much funding ultimately went to other countries (other analyses¹  show that most funding does go to support health activities in recipient countries). Rather, the analysis can be used to indicate that some funding goes to U.S.-based organizations and companies who in turn work on behalf of the U.S. government on global health.

Some key take-aways are as follows:

• In FY 2024, the U.S. obligated more than $10 billion for global health activities.
• Most of this funding (75% or $7.9 billion) was designated for work primarily to be performed in other countries, whether or not the prime awardee was a U.S. or foreign implementer.
• U.S.-based prime awardees received $4.6 billion (44%) of FY 2024 global health funding (foreign implementers received $5.9 billion or 56%).
• Of the $4.6 billion provided to U.S.-based implementers:
  • Funding was provided to organizations in 45 states and the District of Columbia and 151 of 436 congressional districts.² 
  • The top 10 states accounted for $4.5 billion, or 97%. D.C.-based organizations received the largest amount of funding ($2 billion), primarily because the global health supply chain contractor is based on D.C., followed by Maryland ($661 million), North Carolina ($555 million), Virginia ($386 million), Massachusetts ($294 million), New York ($283 million), Washington ($217 million), Georgia ($61 million), Tennessee ($43 million), and California ($37 million).
  • The top 10 congressional districts accounted for $4.2 billion, or 90%. Again, D.C. received the largest amount of funding ($2 billion), followed by NC-04 ($553 million), MD-08 ($384 million), MD-07 ($274 million), WA-07 ($188 million), VA-08 ($188 million), VA-11 ($180 million), NY-13 ($157 million), MA-05 ($142 million), and MA-08 ($141 million).

Detailed data are provided below.

States

Congressional Districts

1. See: Center for Global Development, “No, 90 Percent of Aid Is Not Skimmed Off Before Reaching Target Communities,” https://www.cgdev.org/blog/no-90-percent-aid-not-skimmed-reaching-target-communities; WLRN Public Radio and Television, “PolitiFact FL: Does as little as 10% of USAID go to help people in need? What that claim gets wrong,” https://www.wlrn.org/government-politics/2025-02-07/politifact-florida-usaid; PEPFAR, “PEPFAR 2022 Country and Regional Operational Plan (COP/ROP) Guidance for all PEPFAR-Supported Countries”, https://modern.kff.org/wp-content/uploads/2022/02/PEPFAR-2022-COP-ROP-Guidance-Final.pdf#page=97; Washington Post, “Vance, Rubio peddle fiction that 88 percent of foreign aid doesn’t go overseas,” https://www.washingtonpost.com/politics/2025/06/11/usaid-vance-rubio-fact-checker/. ↩︎
2. Excludes congressional districts in U.S. territories; includes D.C.’s congressional district. ↩︎

Most people with Medicare are required to pay a monthly premium for enrollment in Medicare Part B, which provides coverage for physician visits and other outpatient services. In 2025, the standard Part B premium is $185 per month, up from $174.70 in 2024. People with relatively low incomes and limited financial resources can qualify for the Medicare Savings Programs, through which state Medicaid programs provide financial assistance with Medicare premiums and cost sharing. However, provisions in the GOP’s budget reconciliation bill currently moving through Congress would make it harder for people to enroll in these programs. The Congressional Budget Office estimates 1.3 million Medicare beneficiaries would lose access to these Medicaid benefits, meaning some low-income Medicare beneficiaries would lose Part B premium assistance. Many people with Medicare are facing a relatively high financial burden associated with paying Part B premiums, and the reconciliation bill could drive that number higher.

Over one in ten (12% or 7.4 million) of the 61 million Medicare beneficiaries enrolled in Part B in 2024 spent more than 10% of their annual per capita income on Part B premiums. Another 5 million spent between 8% and 10% of their income on Part B premiums, meaning that altogether, over one in five (21% or 12.5 million) people with Medicare Part B spent more than 8% of their annual per capita income on Part B premiums in 2024 (Figure 1). For roughly half of Medicare beneficiaries enrolled in Part B in 2024 (30.7 million), the Part B premium accounted for a smaller share of their annual per capita income – 6% or less. These estimates, which are based on income data from the Dynamic Simulation of Income Model (DYNASIM), highlight the burden of Part B premiums for the many Medicare beneficiaries living with modest means.

The monthly Part B premium imposes a relatively large financial burden on lower-income Medicare beneficiaries who are not enrolled in the Medicare Savings Programs. The 7 million beneficiaries who spent at least 10% of their annual income on Part B premiums in 2024 by definition had per capita income of $21,000 or less per person, based on the 2024 monthly Part B premium of $174.70 (or $2,100 for the year). An individual with income of this amount would have been just above the upper threshold to qualify for the Medicare Savings Programs in 2024, which was around $20,600 (135% of the federal poverty guidelines that year).

Delaying implementation of the rules intended in part to streamline enrollment in the Medicare Savings Programs, as proposed in the House-passed budget reconciliation bill, or prohibiting their implementation, as proposed by the Senate, would result in the loss of valuable financial protections under Medicaid for some low-income Medicare beneficiaries, who would then be responsible for paying Part B premiums (and possibly also Medicare deductibles and cost sharing). These costs would represent a relatively substantial share of their income, as illustrated in another KFF analysis showing that in 2025, the $185 monthly Part B premium would represent nearly 20% of the monthly $967 Supplemental Security Income (SSI) benefit for a low-income Medicare beneficiary receiving SSI. This individual would be automatically enrolled in a Medicare Savings Program under the federal rule proposed for delayed implementation in the reconciliation bill.

Factoring in Medicare cost-sharing requirements, such as the annual Part A and Part B deductibles ($1,676 and $257 in 2025), the same individual, if they paid those full cost-sharing amounts, would have costs consuming at least one-third or more of their SSI benefit for the year. With Medicare Part B premiums projected to increase to nearly $2,500 in 2026 and more than $4,000 by 2034, the financial burden on Medicare beneficiaries associated with paying for Part B coverage is likely to grow.

Changes to Marketplace plans recently finalized by the Centers for Medicare and Medicaid Services (CMS) may incentivize insurers to make their plans less generous. With less generous plans, consumers could face higher out-of-pocket costs. However, these changes could also lower premiums for those who don’t qualify for premium assistance (roughly 8% of Marketplace enrollees). Plans sold on the Affordable Care Act (ACA) Marketplaces and sold in the small group market are grouped into metal tiers—bronze, silver, gold, and platinum—based on their actuarial value (AV), or the average share of health care costs the plan covers for a standard population. Bronze plans require the highest cost sharing, paying only 60% of expected costs, followed by silver plans (70%), gold plans (80%), and platinum plans (90%). “Expanded” bronze plans have a somewhat higher actuarial value and are required to cover some services before the deductible is met.

Issuers are given flexibility in meeting these actuarial value targets. In rules issued in effect from the 2023 plan year, standard on-exchange bronze (except expanded bronze), silver, gold, and platinum plans are required to be within +2/-2 percentage points of their AV targets, a range known as the de minimis range. Individual market standard silver plans have an allowable range of +2/0 percentage points; silver plans offered with cost-sharing reductions for lower-income enrollees are required to have a narrower range (+1/0 percentage points).

CMS has finalized expanding the de minimis range as part of a broader Program Integrity Rule starting in plan year 2026. The finalized rule reverts to the range used between 2018-2022 and gives issuers more flexibility to lower the AV of plans while maintaining their metal level. Individual and small-group market plans may vary from the target AV by up to +2/-4 percentage points (except for expanded bronze plans). For silver plans that include cost-sharing reductions, the allowable range is expanded to +1/-1 percentage points. The One Big Beautiful Bill Act, as passed by the House of Representatives, would codify these ranges into law.

An illustrative silver plan can be used to illustrate the potential impacts of widening the allowable range of AVs. Under current rules, a silver plan with 15% coinsurance for enrollees across all services and a $4,000 combined medical and drug deductible has an actuarial value of 70%. That calculation is based on the actuarial value calculator issued by the federal government. Under the new finalized rule, a plan with a deductible $1,750 higher or a coinsurance 25 percentage points higher could still be classified as silver, with an AV of just over 66%. How much more any given consumer would pay out-of-pocket would depend on their use of services.

Insurers may choose to configure plan designs in this wider range by some combination of increased copays, coinsurance, maximum out-of-pocket amounts, or cost sharing for specific services to decrease the AV. Many Marketplace plans currently have AVs near the lower end of the allowed range: In 2025, the average AV for silver plans was 70.3%.

Standardized plans (designated “easy pricing” plans on HealthCare.gov) were created to simplify cost-sharing arrangements and allow consumers to easily compare plans. For the 2026 plan year, standardized plans have an actuarial value of 70.0% in most states. Allowing a wider range of actuarial values to be classified as the same metal level may increase the challenges of shopping. If insurers choose to offer non-standardized plans with lower AVs, consumers may have difficulty identifying the decreased coverage provided by these plans compared to standardized ones.

While insurers are not required to lower AVs, the finalized rule could create an incentive to do so—effectively reducing the value of coverage for Marketplace enrollees. The finalized rule cites increased cost sharing as a potential benefit, lowering overall premiums, and encouraging more people without a subsidy to purchase coverage. However, those who are eligible for premium tax credits – which make up the vast majority of Marketplace enrollees – would not pay lower premiums and may face higher cost sharing.

The House recently passed a budget reconciliation bill that includes national Medicaid work requirements for adults in the Affordable Care Act (ACA) expansion group, which the Congressional Budget Office (CBO) estimates would reduce federal Medicaid spending by $344 billion over ten years and increase the number of people without health insurance by 4.8 million. On June 16, the Senate Finance committee released proposed reconciliation language with some substantive changes to the Medicaid work requirement provisions, but this language may change as the Senate debates the bill. Under the House-passed bill, adults enrolled through ACA Medicaid expansion must complete 80 hours of work (or other qualifying activities) per month or meet specific exemption criteria (such as having a substance use disorder (SUD) or “disabling” mental disorder). States must verify compliance (at least) at application, renewal, and every six months thereafter, starting no later than December 31, 2026 or individuals could be denied or disenrolled from coverage. For additional details about this process, see KFF’s explainer.

Medicaid plays a large part in coverage and treatment of behavioral health conditions, covering nearly one-third of all adults with mental health disorders and one-fifth of all adults with substance use disorders; among Medicaid expansion enrollees specifically, 24% have a diagnosed behavioral health condition. Continuous Medicaid coverage supports ongoing treatment for mental health and substance use disorders, and disruptions may negatively affect individuals’ mental and physical health. Additionally, many adults with mild or moderate conditions already work or engage in qualifying activities but rely on Medicaid-covered medications and treatments to maintain steady employment. This brief describes key challenges that Medicaid work requirements may pose for adults with mental health or substance use disorders.

Medicaid expansion is the primary coverage pathway for people with mental health or substance use disorders. Among Medicaid-covered adults diagnosed with a substance use disorder, 59% qualify through ACA expansion, similar to those with opioid use disorders (61%), any mental health disorder (51%), and serious mental illness (45%, defined here as schizophrenia, other psychotic disorders, and bipolar disorders). These shares are higher when limited to ACA Medicaid expansion states (Figure 1). Others qualify for Medicaid by receiving Supplemental Security Income (SSI) for a disability, as a low-income parent, or pregnant/postpartum individual. Although certain serious mental illness diagnoses may qualify for SSI, the disability determination process is lengthy and complex, and overall two-thirds of Medicaid enrollees with disabilities qualify through non-disability pathways, such as Medicaid expansion. Substance use disorders alone do not qualify individuals for SSI.

The House-passed bill (and language proposed by the Senate Finance Committee) specifies exemptions for individuals with substance use disorders or “disabling” mental disorders from Medicaid work requirements under the “medically frail” designation. Participation in a SUD treatment program is also listed as an exemption in the bill. However, the bill does not explicitly define which diagnoses constitute “disabling” mental disorders. Mental health disorders that substantially impair daily functioning—such as schizophrenia, other disorders involving psychosis, or bipolar disorder—might be among those considered “disabling” mental disorders under the medically frail designation. However, the exact diagnoses qualifying for this exemption have not yet been clarified and will depend on forthcoming federal guidance and state decisions.

Federal and state decisions about implementing work requirements may be particularly impactful for adults with mental health or substance use disorders. However, the extent of the impact may depend heavily on how these requirements are defined and operationalized, and many details currently remain unclear. Upcoming federal guidance may provide some clarification, but processes could still vary by state. For example, the House bill does not specify how states would be expected to identify individuals who are exempt or whether/when individuals may be required to self-report or provide documentation to confirm they meet exemption criteria. Potential challenges include:

• The House bill does not specify states will be required to use available data to automatically verify exemptions, and even states using data may miss some individuals due to data limitations. While states could cross-reference Medicaid enrollment records with other data sources, such as Medicaid claims, to identify exemption-qualifying conditions like substance use disorders or certain mental disorders, there is often a delay of weeks or months between a service being delivered and claims being fully processed. The length of this delay may also differ by state and Medicaid managed care organization, the primary way most enrollees receive care. Claims further delayed due to disputes, denials, or bundling with other services can further obscure specific diagnoses. These data limitations could leave some exempt individuals unidentified, requiring them to initiate and navigate the state’s exemption process. States with outdated or less integrated data systems may face additional challenges, potentially increasing reliance on manual reporting—particularly difficult for individuals with mental health or substance use disorders. For example, when Arkansas implemented Medicaid work requirements, data-matching identified about two thirds of enrollees, exempting them from reporting work hours or exemption status. Among those who had to actively report, about 70% did not obtain an exemption or report compliance with the work requirements, ultimately resulting in over 18,000 people losing coverage. Arkansas is among a subset of states that already makes “medically frail” determinations because they opt to provide an “alternative benefit package” to ACA expansion adults, enrolling them in Marketplace health plans (while individuals designated “medically frail” may receive the “traditional” Medicaid benefit package). As a result, the state may be better positioned to conduct data matching for exemptions relative to other states; but still Arkansas highlighted (in its new waiver request) that limitations with “data matching” led to some individuals with medical conditions or disabilities that prevented them from working to “fall through the cracks” when the state implemented its work policies in 2018.

Common behavioral health symptoms would make it more challenging for individuals with these conditions to self-report work or exemption status. Behavioral health symptoms can include challenges with concentration, planning, energy levels, anxiety, feelings of overwhelm, and difficulties managing stress, all of which may make it harder for enrollees to understand requirements, navigate complex submission processes, and troubleshoot issues that arise. Individuals experiencing severe or acute behavioral health symptoms may find it particularly difficult to provide documentation, especially for those whose disorders are compounded by unstable employment, housing instability, or homelessness—which is more common among those with serious mental health disorders or severe substance use disorders. Therefore, mental health and substance use disorders themselves could increase the risk of Medicaid coverage loss under proposed requirements. Provider burden may increase if provider documentation is required to obtain an exemption. Under New Hampshire’s work requirement waiver, adults who self-attested to being medically frail were still required to obtain certification from a medical professional of their medical frailty exemption, which was reportedly difficult for enrollees to navigate and complicated for providers.

• Mild and moderate mental health disorders may not qualify adults for exemptions from work requirements; however, symptoms could lead to employment gaps, making compliance with new requirements more difficult. People with mild or moderate disorders can experience episodic symptoms, such as depressive episodes or severe anxiety, which can disrupt consistent employment. The House bill allows states to provide short-term hardship exceptions, such as during inpatient psychiatric stays; however, these exceptions are not federally required and must be requested by the enrollee. Additionally, variation in work requirement implementation could further affect compliance. For instance, states that require verification of work history over three consecutive preceding months may present greater compliance challenges compared to states with less stringent criteria.

• Individuals with new or undiagnosed behavioral health disorders may struggle to qualify or maintain Medicaid coverage without sufficient work history or formal diagnoses. Adults experiencing sudden symptoms, such as a first episode of psychosis, may face significant difficulties navigating exemption processes quickly, particularly at the onset of a disorder, which can be confusing and difficult in itself. Additionally, many adults have undiagnosed behavioral health disorders, an issue especially common among people with substance use disorders. If enrollees are required to submit an official diagnosis to receive an exemption, individuals without an official diagnosis remain subject to work and reporting requirements, potentially leading to coverage loss if symptoms disrupt employment. Even in states that use Medicaid claims data to identify exemptions, there is typically processing time between service dates and when the visit appears in claims data, which can delay states’ identification of individuals with new diagnoses. In addition, applicants with recent employment gaps due to mental health or substance use symptoms may face additional barriers documenting compliance or exemption status at enrollment. For example, Georgia—the only state currently requiring work compliance at Medicaid application—experienced significantly lower enrollment than anticipated due to these requirements, though it did not allow any exemptions.

Being in poor health is associated with an increased risk of job loss, while access to affordable health supports obtaining and maintaining employment. Regular access to care, including mental health and substance use disorder treatment, can help stabilize behavioral health symptoms. However, disruptions or losses in coverage can interrupt treatment, exacerbating these conditions. For instance, stopping medication for opioid use disorder significantly increases mortality risk, with individuals facing a six-fold greater risk of death in the four weeks immediately following treatment discontinuation.