In his latest JAMA Forum column, KFF’s Larry Levitt explores how unaffordable health care is in the U.S. in the context of the debate over extending enhanced Affordable Care Act premium tax credits and an upcoming election where affordability will likely be front and center.

Note: This brief was updated on January 7, 2026 to incorporate new data on abortion statistics.

• In the three years since the Supreme Court ruling that overturned Roe v. Wade, the total number of abortions nationally has slightly increased. The most recent data from the Society for Family Planning’s #WeCount project show that the average monthly abortion volume during the first half of 2025 was higher than the monthly average in 2024. From January to June 2025, there have been more than 590,000 abortions compared to 1.14 million abortions in all of 2024 and 1.06 million abortions in 2023. For most of the decade prior to the Dobbs ruling, there was a steady decline in abortion rates nationally, with a slight uptick in the years just before the ruling.
• The upward trend in abortion volume is likely due to multiple reasons, including expanded telehealth capacity, the ability to mail medication abortion pills to patients, and the lower costs for telehealth abortions through virtual clinics compared to in-person care. Medication abortion via telehealth now accounts for 27% of all abortions.
• In contrast to the abortion bans, several states have passed laws to protect abortion access for their residents and expand access to people seeking abortions from other states which have contributed in part to the increased the number of abortions in those states compared to pre-Dobbs time frame. Twelve (12) states require state-regulated private plans to cover abortion, many without cost-sharing, and 20 Medicaid programs use state-only funds to cover nearly all medically necessary abortions. Twenty-three (23) states passed shield laws intended to reduce the legal risks for clinicians who provide abortion care to patients who live in states where abortion is banned or restricted.
• The upward trend in abortion volume can also be attributed to increased interstate travel. The travel rate for abortion care across state lines nearly doubled from 2020 to 2024, with Illinois, North Carolina, New Mexico, and Kansas experiencing the highest volume of out-of-state abortion patients last year.

Following the 2022 ruling in Dobbs v. Jackson Women’s Health Organization, it was generally expected that the abortion rate would drop due to the number of states that rapidly adopted abortion bans (13 states) and early gestational restrictions (6 states). There is no doubt these policies have made abortion access much more challenging or even impossible for those seeking abortion who live in restrictive states; yet, contrary to expectations, recent data show that the number of abortions in the U.S. overall has slightly increased in three years following the Supreme Court ruling. The combination of growth in telehealth availability for abortion care, lower telehealth costs, increased legal reproductive health care protections through state efforts, and higher rates of interstate travel, all likely contributed to the unexpected trajectory in abortion volume. However, the possibility of more state bans and restrictions combined with the ongoing legal challenges seeking to further restrict access may reverse this trend. Additionally, future actions that the Trump administration could take at the federal level could further limit abortion availability and access even in states that have enshrined the right to abortion, particularly if the administration restricts the distribution of medication abortion pills through the Comstock Act or targets the provision of telehealth abortions through regulatory revisions at the Food and Drug Administration.

This brief reviews the different sources of abortion data in the U.S., the factors that have affected abortion rates across the country before and after Dobbs, and what we may see as the Trump administration, Republican majorities in the House and Senate, and a conservative federal judiciary shape policy in the coming years.

How is abortion tracked at the state and federal level?

Three major organizations collect and report national and state-level data on abortion volume and rates: the federal Centers for Disease Control and Prevention (CDC), the Guttmacher Institute, and most recently, the Society of Family Planning through its (SFP) #WeCount project.

For decades, the federal CDC Abortion Surveillance System has requested data from the central health agencies of the 50 states, D.C., and New York City to document the number and characteristics of women obtaining abortions. Reporting to the CDC is voluntary and not all states participate in the surveillance system. Notably, California, Maryland, and New Hampshire have not reported data on abortions to the CDC system for years. Most states collect and report data on the demographic characteristics of patients, gestational weeks, and type of abortion procedure. CDC publishes data from the surveillance system annually, with the most recent data on abortions in 2022, reflecting a 2-year lag. Following the termination of federal staff from the agency’s the Reproductive Health Division, it was unclear whether the CDC would continue to update its Abortion Surveillance System which currently presents data from 2022 that was released in November 2024. It has been reported that the next Abortion Surveillance report is expected to be released during spring of 2026 with data from 2023.

Prior to the Dobbs ruling, the Guttmacher Institute, an independent research and advocacy organization, periodically conducted the Abortion Provider Census (APC), collecting data on abortion incidence, abortion facilities, and patient characteristics. Data from the APC are based primarily on questionnaires completed by known facilities that provide abortion in the country, information from state health departments, and Guttmacher estimates for a small portion of facilities. The most recent APC reports data from 2020. Following the Dobbs ruling, the Guttmacher Institute established an additional data collection initiative, the Monthly Abortion Provision Study, to track abortion volume within the formal U.S. health care system. This ongoing effort collects data on and provides national and state-level estimates on abortions while also tracking the changes in national abortion volume since 2020.

While the CDC and Guttmacher APC data differ in terms of collection methods, timeframe, and completeness, both have shown similar trends in abortion rates over the past decade. One notable difference is that Guttmacher’s survey has included continuous reporting from all states, which explains at least in part the higher abortion volume in their data.

Society of Family Planning’s (SFP) #WeCount is a newer national reporting initiative that measures changes in abortion access following the Dobbs ruling. The project provides semiannual reports on the monthly number of abortions by state and includes data on abortions provided through in-person health care settings and through telehealth. The #WeCount report started collecting data in April 2022 and has published two full years of abortion data since Dobbs.

How has the abortion rate changed over time?

For most of the decade prior to the Dobbs ruling, there was a steady decline in abortion rates nationally, but there was a slight increase in the years just before the ruling.

The most recent CDC data are from 2022, the same year as the Dobbs decision, and show that abortion rates declined from 2013 through 2017 and remained steady in the years leading up to the court decision (Figure 1). CDC reported 609,360 abortions in 2022 and a rate of 11.2 abortions per 1,000 women (excludes CA, DC, MD, NH, and NJ). In contrast, the Guttmacher Institute reported 930,160 abortions in 2020 and a rate of 14.4 abortions per 1,000 women. Guttmacher’s study showed a slight upward trend in abortion from 2017 to 2020 whereas CDC’s report showed a stable rate in abortions from 2017 to 2022 except for a slight uptick in 2019 and 2021.

Experts generally attribute the long-term decline in abortion rates to increased use of more effective methods of contraception. The slight increase in the years leading up to the Dobbs decision could be due to greater state-level coverage of Medicaid enrollees that made abortion access more affordable in some states as well as broader financial support from abortion funds to help individuals pay for the costs of abortion care.

Even prior to the Dobbs ruling, abortion rates varied widely between states.

National averages can mask local and more granular differences. Some of the variation in abortion volume and rates has been due to the wide differences in state policies that have shaped the availability of abortion, with some states historically placing restrictions on abortion (such as targeted regulations of abortion providers, requirements for multiple visits, and mandatory waiting periods), that constrained abortion access and availability. In some states, there were only one or two abortion providers even before Dobbs.

What has happened to abortion volume since Dobbs?

The SFP and Guttmacher Institute data both find that while the number of abortions in the U.S. dropped immediately following Dobbs, the total number of abortions nationally has increased two years following the ruling. However, the consistency observed at the national level obscures wide state-level variation and sharp declines in the number of abortions in states with bans and early gestational restrictions.

The latest SFP’s #WeCount data show that there were 591,770 abortions in the first half of 2025. In 2024, there were an estimated 1.14 million abortions, slightly up from 1.05 million in 2023. The monthly average number of abortions steadily increased from 88,180 abortions per month in 2023 to 95,250 abortions in 2024 to 98,630 in 2025 (January to June 2025)(Figure 3).

Why did the number of abortions increase after states instituted bans?

While it was not a total surprise that states without abortion bans had an increase in abortions following the Dobbs ruling, the reasons behind this increase are complex. The upward trend is likely due to a combination of increased interstate travel for abortion access by people coming from abortion ban states, the presence of state-level laws in states that protect providers who offer abortion services, lower costs associated with telemedicine medication abortions, and expanded virtual/telehealth capacity and the ability to mail medication abortions pills to patients among both bricks-and-mortar and telemedicine-only providers.

The Rise of Medication Abortion, Telehealth, and Virtual Clinics

While procedural abortions are only performed in a clinical setting, medication abortion can be provided either in a clinical setting or remotely via telehealth. Medication accounts for nearly two thirds (63%) of abortions nationally. Approved by the U.S. Food and Drug Administration (FDA) in 2000, medication abortion has a solid safety and effectiveness record regardless of whether the pills are dispensed in person by a clinician (either medical doctor or advanced practice clinician) or via telehealth and mailed or dispensed through a retail pharmacy. Medication abortion successfully terminates the pregnancy 99.6% of the time, with a 0.4% risk of major complications, and an associated mortality rate of less than 0.001 percent (0.00064%). The latest Guttmacher data show that in states without bans, medication accounted for the majority of abortions in 2023 (Figure 4). In five states (MT, WY, NE, GA, and VT), more than eight in ten abortions were medication abortions.

Access to medication abortion via telehealth had been historically limited by an FDA policy (Risk Evaluation Mitigation Strategy or REMS) that had permitted only physicians in a health care setting to dispense mifepristone in person. This resulted in a restriction on the ability to mail the pills or for retail pharmacies to dispense. In December 2021, the FDA revised this policy lifting the requirement that clinicians dispense the drug only in-person. This was done, in part, to alleviate the burden placed on the health care delivery system during the COVID-19 public health emergency. In January 2023, the FDA finalized a policy change that allows retail pharmacies to dispense medication abortion pills to patients with a prescription. These changes opened the door to greater use of telehealth for medication abortions.

The increase in telehealth abortions has also been driven in part by the rise in the number of virtual abortion clinics. The number of virtual clinics began to rise after the FDA revised its in-person dispensing requirement in 2021 and now accounts for a quarter (24%) of facilities that offer medication abortion services.

SFP’s #WeCount study breaks out monthly averages for telehealth abortions, and the most recent report shows that telehealth abortions accounted for 27% of all abortions in the second quarter of 2025 (Figure 5). The latest #WeCount reports distinguish between telehealth abortions provided by brick-and-mortar facilities from those provided under shield laws that give some legal protections to clinicians who provide abortion care via telehealth to people living in states with bans and restrictive policies. More than half of these telehealth abortions were performed under shield laws (56%), 6% of abortions were from online services offered by clinics that traditionally operate from physical locations (brick-and-mortar facilities), and four in ten (39%) were from virtual-only clinics. The provision of telehealth abortions varies widely across states, ranging from 8% of all abortions in some states and reaching 39% of all abortions in other states. Note: The counts for medication abortions, particularly those provided by mail, reflect the number of pills dispensed by providers, not necessarily complete abortions. 

Costs for Telemedicine Abortions

The median price of medication abortion offered through brick-and-mortar clinics increased from $580 in 2021 to $600 in 2023. In contrast, the median price of medication abortions via virtual clinics decreased from $239 in 2021 to $150 in 2023, which is 75% less than the cost of in-person care (Figure 6). Virtual clinics do not incur many of the costs of a physical clinic, such as building maintenance, meeting regulations for surgical centers, and security to handle protesters. The increased availability of telehealth and virtual clinics has lowered the costs of care and reduced financial barriers resulting from abortion services as well as travel and other related expenses.

Costs for some have also been offset by the availability of financial assistance and logistical support from national and local networks of abortion funds. Since Dobbs, these networks received a reported 39% more requests for abortion support and financially supported more than 100,000 individuals seeking abortion care. While donations to these networks increased immediately following Dobbs, the frequency of donations has slowed, and funds have begun to taper. Some organizations recently reported suspending operations altogether, signaling that abortion volume may consequently dwindle as demand outpaces donations.

State-Level Protections

Over the past several years, some of the states where abortion remains legal have passed laws to protect abortion access for their residents and expand access to people seeking abortions from other states. For example, residents in California are protected from civil liabilities for providing or receiving abortion services, and providers are protected from professional discipline. Policies that have been implemented include using state funds to cover abortions under Medicaid beyond federal limitations, raising Medicaid reimbursement rates for abortion services, requiring state-regulated private plans to cover abortion, and enacting shield laws to protect clinicians who provide abortions in their states either in person or via telemedicine.

Today, 12 states require state-regulated private plans to cover abortion, some without any cost-sharing (Figure 7).

State actions to use their own revenues to pay for abortions have also expanded access to abortion services. States are not restricted by the federal Hyde Amendment (which bans the use of federal funds for abortion in Medicaid, Medicare and other public programs unless the pregnancy is a result of rape, incest, or if it endangers the woman’s life) and have the option to use state-only funds to cover abortions under other circumstances for women on Medicaid, which 20 states do currently.

A growing number of states passed shield laws to reduce the legal risks for clinicians who provide abortion care to patients who live in states where abortion is banned or restricted. While the details of these laws vary state to state, some policies protect clinicians from professional discipline for offering health care that is criminalized in another state, and others protect clinicians who provide care to patients across state lines, such as by prescribing and mailing abortion pills via telehealth services to patients in their state of residence. Some states also passed broader shield laws to protect patients and people assisting with reproductive services from civil and criminal consequences. As of February 2025, 22 states and Washington D.C. have enacted shield laws, with 8 states extending explicit protections to clinicians regardless of patient location or state of residence (Figure 8).

Interstate Travel

The Guttmacher Institute Monthly Abortion Provision Study is the only data source so far to provide in-depth information on interstate travel pre- and post-Dobbs. Guttmacher estimates that prior to Dobbs, nearly one in ten people obtained an abortion by traveling across state lines in 2020. Even though abortion was legal, there were considerable restrictions in many states that made abortion access very limited, which led to the need for interstate travel for abortion care for some people. The latest data show that 155,000 patients traveled out of state for abortion care in 2024, a slight drop from 170,000 in 2023 but nearly double the number of travelers in 2020 (81,000). The states with the highest number of people traveling inbound for abortion care border at least one state where abortion is banned, including Illinois (36,920 patients), North Carolina (17,080 patients), Kansas (15,610 patients), and New Mexico (12,680 patients)(Figure 9).

The volume of interstate travel into Florida and North Carolina is especially notable as they were two of the last southern states in 2023 where abortion was legal beyond six weeks of gestation. However, the policies in these two states became more restrictive. North Carolina went from a 20-week ban to a 12-week ban in July 2023, and Florida’s 15-week ban changed to a 6-week ban in May 2024. The volume of interstate travel into Florida declined from 9,080 travelers in 2023 to 3,970 travelers in 2024 (data not shown). Conversely, the volume of interstate travel into North Carolina increased from 16,110 in 2023 to 17,080 in 2024 (data not shown). Virginia also had an increase in interstate travel for abortion, from 5,360 out-of-state travelers in 2023 to 9,410 travelers in 2024. This is largely due to Florida’s stricter gestational stage ban, which curtailed abortion access in the region and has resulted in patients in southern states having to travel elsewhere, such as to northern states, for abortion care.

While the data show that abortions slightly increased nearly three years after Dobbs, ongoing and impending legal challenges, state legislative efforts, and federal executive actions could further alter the reproductive care landscape and have impacts beyond abortion counts. A recent JAMA study, for instance, found that fertility rates have increased in states with complete or 6 week abortion bans, namely among populations with the greatest structural disadvantages and barriers to obtaining abortion care. A concurrent study showed infant mortality rates have also risen in these states, many of which are already experiencing some of the worst maternal, infant, and child health outcomes in the U.S. The findings from these studies underscore the widespread repercussions of policy efforts aimed at restricting abortion access.

On December 29, 2025, the Centers for Medicare & Medicaid Services (CMS) announced first-year state awards from the $50 billion Rural Health Transformation Program (the “rural health fund”), which is being administered by a new Office of Rural Health Transformation. The rural health fund was created as part of the July 2025 budget reconciliation law, sometimes called the One Big Beautiful Bill, to help offset the impact on rural areas of the law—which includes an estimated $911 billion in federal Medicaid spending reductions over ten years, including an estimated $137 billion in rural areas. All 50 states applied for the rural health fund, and each state received an award. CMS will distribute $10 billion each year from fiscal years 2026 through 2030, beginning this year.

State awards for 2026, the first of five years, average $200 million, ranging from $147 million in New Jersey to $281 million in Texas (Figure 1). Differences in total awards across states in the first year (and most likely in future years) are modest relative to large differences in rural populations and rural health needs more generally. For example, Texas has about thirty times as many rural residents as New Jersey (4.3 million versus about 140,000) but is only receiving about twice as much funding in the first year ($281 million versus $147 million). Differences in total awards across states are relatively modest primarily because half of the rural health fund (50%) is being distributed equally across approved states, regardless of need, as required by law. Because all states have been approved for funding, each is slated to receive $100 million from this half of the fund in 2026 and in each year from 2027 through 2030.

Texas, Alaska and California are receiving the largest total awards in the first year. While Texas and California have the largest and fourth-largest rural populations in the country, respectively, Alaska has the fifth smallest rural population. Alaska likely received a relatively large award at least in part because a portion of the fund was distributed to the five largest states based on land area. New Jersey, Connecticut, and Rhode Island are receiving the smallest awards in the first year. These are all states with relatively small rural populations.

Figure 1

First-year awards per rural resident vary widely across states, ranging from less than $100 in ten states to more than $500 in eight states according to KFF analysis (see Figure 2). State awards are partially, but not closely, tied to rural population, meaning that first-year awards per rural resident are generally relatively small among states with the largest rural populations. For example, Texas has the largest rural population in the country—and the largest total award in the first year—but will receive the smallest payment per rural resident ($66 in 2026). In contrast, states like Rhode Island, New Jersey, and Alaska, with far fewer rural residents, will receive substantially higher amounts per rural resident ($6,305, $1,069, and $990 respectively, with Rhode Island being an extreme outlier). Only a quarter of the $50 billion fund is being distributed exclusively based on measures of state need, with just 5% of the fund that is based on rural population. Other measures of need, according to CMS, include the number of rural facilities, land area, the share of hospitals receiving Medicaid disproportionate share hospital (DSH) payments, and other factors.

While lawmakers created the fund in part to help offset the impact on rural hospitals of cuts under the reconciliation law, CMS has made clear that funding is intended to benefit rural communities more broadly by transforming health care systems. Examples of state initiatives based on the subset of state applications available to the public and abstracts posted on CMS’s website include initiatives related to Make America Healthy Again (MAHA) (such as improving access to healthy foods and preventing and managing chronic conditions), expanding telehealth services and remote patient monitoring, rural workforce development programs, and supporting regional collaboration among providers.

CMS stipulates that payments to hospitals and others for patient care cannot exceed 15% of total funds, though providers could benefit in other ways, such as through investments in existing buildings and infrastructure (restricted to 20% of total funds). It is unclear how much of the money will benefit rural hospitals either directly or indirectly and the extent to which this will offset hospitals’ losses under the reconciliation bill. Moreover, it is not yet clear how much information will be available to the public to track the flow of dollars from states to rural providers and other entities and to evaluate the effectiveness of state initiatives.

The expiration of the Affordable Care Act’s enhanced premium tax credits, along with the passage of the budget reconciliation law, implementation of new Marketplace regulations, and other administrative changes, could bring significant changes to ACA Marketplace enrollment and affordability for the 2026 plan year and beyond. Anticipated increases in what enrollees pay for premiums and new standards for health savings accounts (HSAs) could lead some consumers to consider plan options with lower premiums in exchange for higher deductibles, such as catastrophic or bronze plans. This issue brief examines key features of bronze and catastrophic plans, recent policy changes, coverage and costs, and the complicated choices for consumers.

What are some key features of Marketplace bronze and catastrophic plans?

Affordable Care Act (ACA) qualified health plans (QHPs) are categorized into four “metal levels” based on the overall amount of cost sharing they require: bronze, silver, gold, and platinum, plus catastrophic plans, which are a separate tier of QHPs. Bronze and catastrophic plans offered through the Marketplaces must cover essential health benefits, limit the amount of annual cost sharing for covered benefits ($10,600 for an individual or $21,200 for a family in 2026), cover certain preventive services without cost sharing, and have other ACA-required consumer protections.

There are several notable differences between the characteristics of bronze and catastrophic plans (Table 1). Bronze plans usually have the lowest premiums of all metal levels, but the highest deductibles. Catastrophic plans often, but not always, have even lower premiums than bronze plans, but a higher level of cost sharing. In 2026, bronze plans have an average deductible of $7,476, while catastrophic plans have deductibles equal to the out-of-pocket maximum allowed under the ACA ($10,600 for an individual or $21,200 for a family in 2026).

Both bronze and catastrophic plans can be purchased on or off the Marketplaces, but premium tax credits are only available for metal level plans that are sold on the Marketplace, meaning they cannot be applied to any plans sold off the Marketplace, nor to catastrophic plans. (Cost-sharing reductions— which lower out-of-pocket costs for enrollees with income between 100% and 250% of the federal poverty level (FPL)—are only available for silver plans on the Marketplace.)

Actuarial value — the expected share of health care expenses a plan covers for a standard population — also differs between bronze and catastrophic plans. Bronze plans are currently required to have an actuarial value (AV) between 58% and 62%, though the AV for expanded bronze plans can be as high as 65%. (Regulations finalized in June 2025 would permit an AV as low as 56% for standard bronze plans, but a court ruling has temporarily blocked that provision (and others) from taking effect.) Catastrophic plans, on the other hand, are not required to meet minimum actuarial value targets, except that they must have a lower AV than bronze plans. However, due to the permitted range of bronze actuarial values, the “generosity” of these two types of plans can be similar.

Unlike metal level plans, which can be sold to anyone eligible for Marketplace coverage, catastrophic plans can only be sold to individuals under age 30 or individuals over 30 who qualify for a “hardship” or “affordability” exemption. Consumers may be eligible for the affordability exemption if their lowest cost coverage option available through a Marketplace or employer would cost more than 8.05% of their household income in 2026. A person may qualify for a hardship exemption if they experience one of several examples of financial or domestic circumstances, such as an unexpected natural or human-caused disaster, domestic violence, or bankruptcy.

What recent changes have been made to catastrophic plans and bronze plans?

In September 2025, the Trump administration issued guidance expanding the catastrophic plan hardship exemption to include consumers who are not eligible for premium tax credits or cost-sharing reductions due to their income, chiefly those with incomes below 100% FPL or above 250% FPL, beginning with the 2026 plan year. This change currently applies to individuals in all states except California, Connecticut, Maryland, and the District of Columbia.

Even though those below 100% FPL are ineligible for premium tax credits, they are generally eligible for Medicaid in states that have expanded Medicaid. With varied eligibility criteria in non-expansion states, this population may fall in the coverage gap. While they could theoretically buy a catastrophic plan, they would be unlikely to be able to afford the premium or the very high deductibles.

The administration has begun streamlining the application process for this hardship exemption through HealthCare.gov and its paper applications to make it easier for consumers to enroll in a catastrophic plan. Also, HealthCare.gov now automatically displays catastrophic plans (where available) for consumers age 30 and older if they enter an income above 400% FPL or below 100% FPL. These plans are not currently displayed for consumers with incomes between 250% FPL and 400% FPL.

In addition to the hardship exemption changes, the 2025 budget reconciliation law expanded the availability of health savings accounts (HSAs) on the Marketplace. Previously, only plans that met IRS rules related to minimum annual deductible amounts, out-of-pocket maximums, and other design features were eligible to be paired with an HSA. No catastrophic plans were HSA-eligible. Starting on January 1, 2026, all individual market bronze and catastrophic plans are considered HDHPs and eligible to be paired with an HSA even if the plan does not meet the minimum annual deductible requirement ($1,700 for individual coverage and $3,400 for family coverage in 2026) or the HSA out-of-pocket (OOP) maximum requirement ($8,500 for self-only coverage and $17,000 for family coverage in 2026) for an HDHP. New IRS guidance states that this change applies to all bronze and catastrophic plans, even those not purchased through a Marketplace (“off-exchange”). Other changes to HSA-eligible HDHPs include allowing pre-deductible coverage of telehealth and other remote care services, and allowing individuals covered by certain direct primary care arrangements to be eligible for an HSA.

Separately, congressional Republicans have recently proposed alternatives to continuing the enhanced premium tax credits that would further expand access to HSAs. While precise details vary, they generally propose directing funds to HSAs for eligible consumers enrolled in a catastrophic or bronze Marketplace plan to pay for out-of-pocket expenses. President Trump has also signaled his support for replacing tax credits with direct payments to consumers. None of these proposals has advanced.

What is the availability of and enrollment in bronze and catastrophic Marketplace plans?

An insurer selling QHPs on the Marketplace must offer at least one silver and one gold plan in all the areas where the insurer sells Marketplace coverage. Although Marketplace insurers in most states are not required to offer a bronze plan in all areas, only one county in the US does not have a bronze plan for sale for 2026; the availability of catastrophic plans is more limited. Where catastrophic plans are available, there tend to be fewer plan choices than there are for bronze plans.

In 2026, catastrophic plans are offered in 36 states and the District of Columbia—down from 40 states and the District of Columbia in 2025. The share of Marketplace enrollees with access to catastrophic plans fell from 87% to 76% over the same period.

In 2025 (without the new hardship exemption extension in effect), less than 1% of Marketplace enrollees chose a catastrophic plan, and 30% selected a bronze plan. The highest uptake of catastrophic plans was in the District of Columbia and Minnesota, where about 2% of Marketplace enrollees were in a catastrophic plan in 2025.

How do premiums for bronze and catastrophic plans compare?

In 2026, the average lowest-cost catastrophic Marketplace plan for a 27-year-old individual is $346 per month, a 29% increase from 2025. The average lowest-cost unsubsidized bronze plan (where catastrophic plans are also available) is $369 for a 27-year-old, a 19% increase from 2025. On average, the gap between premiums for unsubsidized bronze and catastrophic plans shrank by $19 per month for a 27-year-old individual from last year. (Differences in where catastrophic plans are offered may have contributed to this change.) The lowest-cost catastrophic Marketplace plans for 2026, where available, are, on average, $23 cheaper per month than the lowest-cost unsubsidized bronze plan for a 27-year-old individual. However, this varies a lot by county. For example, unsubsidized bronze plans offered in more than half of the counties in Oklahoma are over $200 cheaper per month than the cheapest catastrophic plan for a 27-year-old individual. Conversely, all counties in Connecticut have catastrophic plans around $200 a month cheaper than the lowest-cost unsubsidized bronze plan for a 27-year-old individual.

The Trump administration’s expansion of catastrophic plan hardship exemptions was not announced until September, after many insurers had already submitted their proposed rates for the 2026 plan year. As a result, its effect on pricing for bronze and catastrophic plans is unclear and may affect the relative pricing of bronze and catastrophic plans in future years, with more data on which to base premiums.

Even with the hardship exemption expansion, potential enrollees may have difficulty finding affordable coverage options in places where catastrophic plans are available. For a 27-year-old individual earning $45,000 a year (just under 300% FPL), expenditures on premiums would amount to 9% of income; a 50-year-old with the same income would spend 16% on premiums ($7,027 annually) on average.

One of the reasons catastrophic plans have lower premiums, on average, than bronze plans is that catastrophic plans tend to enroll younger and healthier consumers, thus lowering average claims costs per enrollee. Insurers may then be able to offer lower premiums, on average, compared to bronze plans, which may enroll an overall sicker (higher cost) population. Additionally, while all non-grandfathered individual market plans are part of the same general risk pool, for the purpose of the ACA’s risk adjustment program, which redistributes funds from plans with lower-risk enrollees to plans with higher-risk enrollees, catastrophic plans are treated as a separate risk pool from the metal level plans.

What is the outlook for consumers?

Recent policy changes could have wide-reaching implications for Marketplace coverage. As a result of the anticipated expiration of enhanced premium tax credits, out-of-pocket premiums in 2026 are estimated to more than double what subsidized enrollees currently pay annually for premiums, net of tax credits. To help offset these increases, some enrollees may switch to a plan with a higher deductible, while others, such as those with incomes above 400% FPL, who will lose subsidies altogether, may choose to exit the Marketplace.

Changes to HSA eligibility may also influence some Marketplace enrollees’ choice of plan. For plan year 2026, 35% of Marketplace plans sold on HealthCare.gov are HSA-eligible, compared to just 4% in plan year 2025. With all bronze and catastrophic plans now HSA-eligible, some consumers who were enrolled in a gold or silver plan, particularly those with enough income to set some aside into health savings accounts, may choose a bronze or catastrophic plan to take advantage of this change. HSAs offer a triple tax advantage: contributions are tax-deductible; withdrawals are tax-free if used to pay for qualified medical expenses; and investment earnings grow tax-free. Although more people will have access to HSA-eligible HDHPs starting in 2026, higher-income individuals typically have more disposable income to contribute to these accounts than those with lower incomes. Because they are in a higher tax bracket, higher-income enrollees save more money for every dollar contributed to their HSAs. The IRS’s interpretation of the budget reconciliation law’s expansion of HSA eligibility to include off-Marketplace catastrophic and bronze plans may also create new incentives for HSA vendors, who often charge fees for monthly account maintenance, making withdrawals, and other transactions, to market individual plans with HSAs outside the Marketplace.

Additionally, expanded hardship exemptions for catastrophic plans could increase uptake of these plans. The new HealthCare.gov display options for shoppers whose incomes make them ineligible for premium tax credits increase the visibility of catastrophic plans, and the streamlining of the hardship exemption process may make enrolling in these plans easier. More consumers choosing catastrophic plans could have implications for the Marketplace risk pool. To the extent that catastrophic plans pull enough healthy people out of metal level plans or off the Marketplace, premiums for these plans, which would be left with more sick people, could increase in the future.

In an already complex health insurance system, consumer awareness of these policy changes and their implications may be limited. The 2023 KFF Survey of Consumer Experiences with Health Insurance found that many individuals already have trouble understanding various aspects of health insurance. For example, 31% of Marketplace consumers reported difficulty comparing cost-sharing features, and 25% had trouble comparing premiums when presented with different coverage options. The barrage of marketing pitches consumers face during open enrollment (including through internet searches, telemarketing, and social media) can compound the challenges of making an informed decision. Some consumers could unknowingly be directed to off-Marketplace plans, which can be difficult to distinguish from on-Marketplace plans, as the websites can look very similar. While ACA-compliant plans may also be sold off-Marketplace, these websites often also sell non-ACA-compliant plans, which may make plan comparison more difficult for consumers and could result in consumers losing out on premium tax credits who would otherwise be eligible for them if they had purchased a plan on a Marketplace. With few impartial resources, shoppers may feel less confident choosing a plan that best meets their needs or be left with unanswered questions about their specific circumstances.

Lack of understanding of plan options can have far-reaching effects on consumer finances. Price-sensitive consumers shopping for bronze and catastrophic plans can face difficult tradeoffs. While these plans typically have lower premiums than other Marketplace plans, these plans come with higher deductibles. In addition, cost-sharing reductions are only available to enrollees in silver plans. Compared to a bronze plan, a silver plan with cost-sharing reductions often leads to a lower total health expenditure even with a higher premium. If an enrollee has a medical emergency or develops a serious illness, they may be on the hook for substantial out-of-pocket costs. Many Marketplace enrollees are already struggling to afford health care costs. According to a recent KFF poll, about six in ten (61%) Marketplace enrollees report having difficulty affording out-of-pocket costs for medical care. Considering that 37% of all U.S. adults reported that they would not be able to cover a $400 expense with cash or its equivalent—only 5% of the average bronze individual deductible or 4% of the catastrophic individual deductible—many consumers in plans with high deductibles could find themselves scrambling to pay for health care when they need it.

Methods

Premium information for 2026 come from the medical individual market file of the QHP landscape file from CMS for states using the federally-facilitated platform (HealthCare.gov) and from HIX Compare for all other states and the District of Columbia. Analysis of data from HIX Compare assume that all plans are available in all counties in their respective rating areas where the issuer offers at least one plan. To assess plan availability and differences in premiums, county data were weighted by the number of plan selections in 2025. Plan eligibility for health savings accounts was obtained from the plan attributes public use file, which is only available for plans offered on HealthCare.gov

On December 18, 2025, the Centers for Medicare and Medicaid Services (CMS) issued two proposed rules that would  further limit youth access to gender affirming care. One rule would change the hospital Conditions of Participation (CoPs) which would prohibit most Medicare and Medicaid enrolled hospitals from providing specified gender affirming medical care for youth (the proposed CoPs rule). The second proposed rule would prohibit federal Medicaid or CHIP funds from covering this care for youth (the proposed Medicaid rule). Despite gender affirming care being considered a best practice model of care and consisting of interventions recommended by major medical associations, if finalized and implemented, the proposed rules would have a sweeping impact, albeit for a small number of young people, significantly limiting their access to these services.  

The rules broadly align with a range of other administrative actions that take a multipronged approach to restrict this care. In particular, the proposed rules follow a January 2025 Executive Order that set a pathway for limiting youth access to gender affirming care and directed the Secretary of Health and Human Services (HHS) to “take all appropriate actions to end” gender affirming care for youth, including in Medicaid, and which specifically identified the CoPs as a possible vehicle for this. Additionally, on April 11, 2025, CMS sent a State Medicaid Director’s letter with the stated purpose of “reminding states of their responsibility to ensure that Medicaid payments are consistent with quality of care and that covered services are provided in a manner consistent with the best interest of recipients” and appearing to encourage states to take steps to limit gender affirming care for youth within their state Medicaid programs. Then, in May 2025, HHS sent a second letter to an unspecified group of providers, state medical boards, and health risk managers urging them to update treatment protocol to move away from provision of gender affirming medical care.

The proposed rules do not take effect immediately. Both have a 60-day comment period following their publication in the federal register. Then, following the comment period, CMS is tasked with considering the comments and could ultimately choose to finalize the proposed rule—either in amended form or as currently written—or elect not to do so. If finalized, both rules will likely face legal challenges, which could further slow implementation.

The Proposed Conditions of Participation (CoPs) Rule

If finalized, the proposed hospital CoPs rule would limit gender affirming care for youth, regardless of payer. The CoPs rule proposes to prohibit certain hospitals (i.e. those covered by section 42 CFR part 482) that accept payments from the Medicare or Medicaid programs from providing identified pharmaceutical and surgical services related to gender affirming care to young people under age 18. Prohibited services would include puberty blockers (which delay the onset of puberty), hormone therapy, and surgery (which is very rare among youth). While these services would be prohibited for the purposes of providing gender affirming care, the rule would permit hospitals to provide them to youth in some scenarios when the service is not intended to affirm a person’s gender.

The changes under the proposed CoPs rule represent a condition based on facility type (not payer) and therefore, if adopted, would prohibit hospitals from offering gender affirming services to all patients under 18 years old, regardless of payer, including youth with private insurance or other coverage and those paying cash, not just those covered by Medicare and Medicaid.  It does not prohibit other types of facilities (e.g. free standing clinics, primary care or specialist providers in other settings) from offering these services (there are a variety of CoPs for providers which are not affected by the proposed CoPs rule).

Hospital Conditions of Participation (CoPs) are currently used to regulate how services can be provided safely and with high quality, rather than prohibiting specific services from being offered altogether. There are a variety of CoPs across different provider types which set standards and requirements, primarily related to quality and safety of care that health care providers must generally meet to participate in and receive reimbursement from Medicare and Medicaid. Hospital CoPs regulate a variety of administrative functions and health care services, including a hospital’s responsibilities to its patients, obligations of the hospital’s governing body, requirements related to emergency preparedness and planning, staffing requirements, minimum medical record requirements, and processes to develop safety procedures and quality improvement plans.  While the proposed rule states that it is offering the revision to existing hospital CoPs regulations to address “the health and safety of children,” there is no medical consensus that gender affirming care represents a safety issue, and using hospital CoPs this way marks a departure from their current function of regulating how services can be performed (e.g., by licensed professionals, with equipment like defibrillators available during surgeries, etc.), rather than which services can be provided.  

Hospital compliance with the CoPs is monitored with detailed surveys conducted by state agencies or accredited organizations (like the Joint Commission on Accreditation of Hospitals). These surveys are conducted during onsite visits to the hospitals; CMS usually gives hospitals time to fix violations.  When hospitals are unwilling or unable to fix violations, CMS issues a termination notice, which happens relatively rarely. Medicare and Medicaid do not reimburse services rendered at terminated hospitals.

If finalized, the rule would apply to most hospitals in the United States. The proposed rule estimates there are a total of “4,832 Medicare/Medicaid certified hospitals” (covered by section 42 CFR part 482) that would be subject to its provisions. The restrictions would also apply to gender affirming care clinics and other clinics if they  operate as a part of a hospital, including at off-campus locations. In 2023, the American Hospital Association identified more than 6,000 hospitals nationwide and it is likely that the large majority of hospitals not covered in the proposed rule and not included in 42 CFR part 482 are facilities such as Critical Access Hospitals and Rural Emergency Hospitals which are small rural facilities that may be less likely to offer gender affirming care. Although the proposal would apply to the large majority of hospitals, it is not clear what share of hospitals currently offer gender affirming care services for youth and many systems have recently stopped offering such services and have cited growing concern about pressure from the federal government (e.g. Los Angeles Children’s cited the “complex and uncertain regulatory environment” and Children’s National the “escalating legal and regulatory risks,” among many other examples).

If the proposed CoPs rule were finalized, most hospitals would be prohibited from providing gender affirming care services for youth.  Although hospitals could in theory stop participating in Medicare and Medicaid to continue providing gender affirming services, it is very unlikely that they would do so given the financial challenges this would present. Nationally, nearly half (44%) of all spending on hospital care comes from Medicare and Medicaid payments. 

Although the rule would apply broadly to most hospitals, hospitals provide relatively few gender affirming care services and almost no gender affirming surgeries to youth. Accounting for states that already restrict youth access to gender affirming care, the proposed rule estimates the change would impact 8,570 young people. The Williams Institute estimates that there are approximately 724,000 trans identified youth (13-17) in the U.S. This suggests that approximately 1.2% of trans youth in the U.S. receive gender affirming medical services in hospitals and could be impacted by the proposal each year.  As with past research, the CMS finds that most of this care is pharmacologic with surgery being very rare among transgender youth. The proposed rule identifies 85 surgeries in facilities that would be impacted by the rule over the course of one year nationwide. This represents less than 0.0003% of youth under 18 in the United States (based on the denominator of people aged 12 to 18 being 29,600,770 as described in the proposed rule).

Although gender affirming services could still be provided outside of hospitals subject to the proposed CoPs rule, there would be fewer facilities available in a landscape where accessing this care has already become challenging. Many types of gender affirming care sought by young trans people (such as puberty blockers and hormone therapies) can be provided in outpatient settings and therefore received at non-hospital providers. However, patients may need to travel farther and pay more to receive the set of services they need. They may also face challenges finding a specialized pediatric gender clinic offering a cross-specialty integrated care experience as those clinics are often based in hospital settings. Indeed, the proposal states young people may face “difficulty in identifying in-network providers that have available space and longer commute times to these providers” and assumes that 4,285 youth (half of those estimated to be impacted by the proposed rule) would stop receiving care.

The Proposed Medicaid Rule

The proposed Medicaid rule would prohibit the use of federal Medicaid and CHIP funds to cover the specified gender-affirming care services, regardless of the site of care, limiting access for minors who are covered by these programs. The specified services are the same pharmaceutical and surgical services the CoPs proposed rule seeks to bar. Unlike the CoPs proposal, which seeks to limit access at the hospital level (regardless of coverage type), the Medicaid proposal seeks to limit funding for services for youth based on their coverage source (i.e. Medicaid or CHIP) and would therefore restrict reimbursement for care regardless of provider type (e.g. hospitals, primary care providers, endocrinologists, etc.). However, it does not prohibit providers from offering these services. Based on statutory definitions of “minor” the proposed rule would prohibit federal Medicaid reimbursement for this care to those under 18 years of age, while separately administered CHIP programs would limit reimbursement for people through age 18. (CMS is requesting comment on the feasibility of implementing the proposal with these age differences in Medicaid compared to CHIP.) As with the CoPs proposed rule, although Medicaid programs would be prohibited from covering the identified services for gender affirming care with federal funds, programs would be permitted to reimburse for these same services for youth when used for other purposes. Also, similar to the CoPs proposed rule, these health programs could cover other related services such as psychotherapy, which is a common part of gender affirming care services, especially for youth.

Although the proposed rule would prohibit states from using federal Medicaid or CHIP funds to cover gender affirming care, it would not restrict states from covering these services using state-only dollars. It is likely that different states will make different choices about whether or not to cover these services using state funds. Already, some states restrict coverage of gender affirming care in their Medicaid and CHIP programs.

The Medicaid proposed rule (unlike the CoPs proposal) does not offer an estimate on the number of individuals it would impact but it does find that only a very small share of Medicaid/CHIP funds are spent on gender affirming care, likely suggesting low utilization. Although the impact of the proposed Medicaid restrictions would be meaningful for individuals and families, only a very small amount of Medicaid funding is spent on services for which the Medicaid proposed rule would prohibit reimbursement. In the proposed rule, CMS estimates that Medicaid spent about $31 million on the specified services for enrollees aged 18 years and younger in 2023. This represents about 0.003% of all Medicaid spending that year (based on the proposed rule’s spending estimate and FY 2023 total Medicaid spending). Of this total ($31m), CMS finds most of the spending occurred on services provided to older teens, with two-thirds of identified spending (66%) occurring among those 15-18 years old. Notably, this includes some spending for 18-year-olds, some of whom would not be impacted by the proposal. Nonetheless, the agency’s analysis supports the conclusion of other researchers that utilization of gender affirming medical services is relatively rare among adolescents and most spending is nonsurgical. Ninety-two percent (92%) of spending on the specified services for enrollees aged 18 years and younger was nonsurgical and almost all surgical spending (98%) occurred among youth in the 15-18 age group. It is not possible to know how much of this was spent on eighteen-year-olds, a group not impacted by this policy, and the age of majority in most states.

KFF estimates 37% of people under 18 in the United States are covered by Medicaid or CHIP with variation across states. Applying state specific shares of youth enrolled in Medicaid to Williams Institute state level estimates of trans youth (and assuming the coverage distribution among trans youth is similar to youth in general), KFF estimates there to be approximately 270,000 trans youth covered by Medicaid or CHIP. We estimate that, approximately, 138,000 young trans people with Medicaid or CHIP live in a state without a state law prohibiting gender affirming care (and without a state-based Medicaid ban) and could face insurance limitations under the proposed Medicaid rule, if they sought gender affirming care. Notably, not all transgender youth would seek or desire access to the proposed restricted services, and the CoPs rule, along with other research, finds uptake of gender affirming medical services is low. Nonetheless, if finalized, the proposed rule could foreclose on their ability to receive covered care.

While young people with Medicaid and CHIP coverage could theoretically seek care outside of hospitals without using their insurance, the cost of doing so would likely be prohibitive. Families with children covered by Medicaid and CHIP have low to moderate incomes and would face difficulty paying for any uncovered care.

Looking Ahead

As noted earlier, the proposed rules do not take effect immediately. If finalized (following a 60-day comment period), these proposed rules taken together would lead to youth access to gender affirming care being further limited. Patients with the most financial and other supportive resources would have the greatest ability to navigate access (e.g., travel long distances to providers offering these services or have commercial insurance which might cover gender affirming care), whereas those with more limited resources and Medicaid/CHIP coverage, which is by definition insurance for low-income families, could find accessing services the most challenging. The rules would not limit other care for transgender young people.

Losing access to gender affirming care could have meaningful health implications for young people and their families.  Research has demonstrated that young transgender people’s mental health is negatively impacted when this care is denied, including leading to an increased risk of suicidality and that when care is received, well-being is improved. Hospitals with larger gender affirming care programs may also be conducting academic or clinical research on the experiences of and care for young transgender patients. If these hospitals close or limit their services, that may change or eliminate their ability to do this research.

Immediately following their release, the proposals faced criticism from the American Academy of Pediatrics which wrote, “these rules are a baseless intrusion into the patient-physician relationship” and that the association “remains committed to ensuring that all children — including gender-diverse youth and children covered by Medicaid — receive care that is backed by science, delivered with compassion, and offered without political interference.”

There has been significant litigation challenging efforts to limit gender affirming care at both the state and federal level and if finalized, lawsuits challenging these rules would be likely and could happen on multiple grounds (e.g., Constitutional, Administrative Procedure Act (APA), Section 1557 of the Affordable Care Act (ACA), and violations of Medicaid and Medicare statute and/or regulations, etc.). Indeed, the ACLU has already suggested a willingness to challenge these are regulations, stating that “if this administration moves forward with this attempt to enact a national ban on our medical care through coercion, the ACLU will see them in court.” Additionally, multiple state attorneys’ general have stated that they oppose the rule and plan to fight its implementation.

Beyond these two rules, also on December 18^th 2025, HHS Secretary Kennedy issued a declaration stating that the same pharmaceutical and surgical  procedures are “neither safe nor effective…and therefore, fail to meet professional recognized standards of health care” (the determination does not apply to these procedures when the service is not intended to affirm a person’s gender). It further noted the HHS Secretary has existing authority to exclude individuals or entities from participation in federal health programs, if the Secretary determines delivered services fail “to meet professionally recognized standards of health care.”  Unlike the two rules, the declaration is not limited to payer (as the Medicaid proposed rule is) or to a specific facility type (as the Conditions of Participation rule is).

On December 24, 2025, a lawsuit was filed in which nearly half of all states challenged the administration’s authority to issue the declaration, claiming it violates the Administrative Procedures Act and the Medicare and Medicaid statutes and that “the Secretary has no legal authority to substantively alter the standards of care and effectively ban, by fiat, an entire category of healthcare.”  On December 30^th, HHS announced it had referred at least one hospital to the Office of Inspector General based on the declaration.