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.

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.

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.