Introduction

Recent and forthcoming policy changes may have important implications for American Indian or Alaska Native (AIAN) people and could widen existing disparities in health and health care. This brief provides an overview of recent policies affecting health and health care for AIAN people and their potential impacts. It draws on data from KFF’s Key Data on Health and Health Care for American Indian or Alaska Native People and KFF analysis of recent laws and policy changes. AIAN people are identified as a racial and ethnic group. However, AIAN is also a political and legal classification. This status recognizes over 570 AIAN Tribes as sovereign nations, establishing a government-to-government relationship that dictates the federal government’s trust responsibility, including the provision of health care to AIAN people in federally recognized Tribes.  Key takeaways include the following:

• The 2025 reconciliation law makes large cutbacks in federal Medicaid spending that could negatively impact AIAN people and communities. The Congressional Budget Office (CBO) estimates that the law will reduce federal Medicaid spending over the next decade by an estimated $911 billion and increase the number of uninsured people by 10 million due to changes to Medicaid and other programs, including the ACA Marketplace. Medicaid is the primary source of health coverage for Native communities, with over one in three (35%) AIAN individuals under age 65 enrolled in Medicaid or the Children’s Health Insurance Program (CHIP), including 52% of AIAN children. Medicaid and CHIP are also the largest source of third-party funding for the Indian Health Service (IHS) and Tribal health facilities, and one of the main ways the federal government upholds its trust responsibility. To replace reductions in federal funding, states will need to increase spending or make program reductions, which could lead to eligibility and benefit cutbacks that might reduce coverage for low-income people overall, including AIAN people, and reduce funding available to IHS and other Tribal providers. Further, although the law provides exemptions for most AIAN people from new work requirements and more frequent eligibility determinations, AIAN people may face challenges documenting their eligibility for such exemptions and may experience coverage losses.
• Similarly, changes to the ACA Marketplace may erode coverage for AIAN people. Enhanced premium tax credits are set to expire at the end of 2025, which would make coverage unaffordable for many, including AIAN people. Estimates show that as many as 40% of AIAN people enrolled in the Marketplace with tax credits will lose their coverage if these credits expire.
• Continued underfunding of the IHS, broad reductions in federal funding and equity initiatives, and shifts in vaccination policy and attitudes may also negatively impact health and health care access for AIAN people. Despite proposed increases, FY 2026 funding for the IHS falls short of levels estimated to fully meet health care needs and fulfill the federal trust responsibility. Further, while Executive Orders focused on eliminating Diversity, Equity, and Inclusion (DEI) initiatives largely exempt Tribes, broader federal budget cuts and rollbacks to equity initiatives may reduce resources available to Tribal communities, including for data, public health surveillance, and outreach. Recent declines in vaccination rates, rising misinformation about vaccines, and shifts in federal vaccine policy may increase the risk of preventable disease outbreaks in AIAN communities, including recent measles outbreaks in the U.S.

Health Care for AIAN People

Under treaties and laws, the U.S. has a unique trust responsibility to provide health care to AIAN people. The IHS is the primary federal agency through which the federal government fulfills its trust responsibility for members of federally recognized Tribes, who make up approximately 2.8 million AIAN people from 574 federally recognized Tribes nationwide. Members of federally recognized Tribes, as well as certain other eligible AIAN individuals, can receive IHS-funded services through a network of IHS- and Tribally-run hospitals and clinics, along with Urban Indian Organizations (UIOs). AIAN people receiving services through IHS providers are not charged or billed for the cost of their services. However, the IHS has long been underfunded and lacks the resources needed to fully meet the health care needs of AIAN people. Services available through the IHS are primarily limited to primary care, although the IHS does provide some ancillary and specialty services. When care is not available within IHS or Tribal facilities, the Purchased/Referred Care (PRC) Program may fund services from outside providers. Yet, the funding for PRC has historically been insufficient and does not extend to UIOs. As a result, access to care through the IHS varies widely by location, and AIAN individuals who rely solely on the IHS often face significant barriers to obtaining needed services.

AIAN people can access health coverage through Medicaid, CHIP, and the Affordable Care Act (ACA) Marketplace, with certain unique benefits and protections. Tribal members enrolled in these programs can continue receiving care from IHS, Tribal, or UIO providers at no cost and additionally have access to a broader network of services than those available solely through IHS since they can access care through any provider participating in Medicaid and are covered by the comprehensive Medicaid benefit package. Medicaid offers specific protections for Tribal members, including exemptions from out-of-pocket costs. For the ACA Marketplace, Tribal members eligible for premium tax credits can enroll in zero or limited cost-sharing Marketplace plans and have other specific protections. For example, AIAN individuals with incomes between 100% and 300% of the federal poverty level who enroll in zero cost-sharing plans pay no out-of-pocket costs for covered services. Additionally, AIAN Marketplace enrollees have access to a Special Enrollment Period, allowing them to enroll in or switch plans once per month, beyond the standard open enrollment window that is available for other eligible people.

Health coverage improves access to care for AIAN people and strengthens Tribal health systems. Given the limitations of IHS funding and service availability, health coverage through Medicaid and the Marketplace enhances access to care for AIAN people since they can access covered care through a broader network of providers and have coverage for a comprehensive set of benefits. In addition to improving individual access to care, Medicaid is also an important source of funding for IHS and Tribal facilities and is one of the primary ways the federal government upholds its federal trust responsibility to provide health care to AIAN people. Medicaid is the largest third-party payer for the IHS, accounting for $1.3 billion out of the total almost $1.8 billion in third-party collections in fiscal year 2025. Further, unlike other Medicaid costs, which are typically shared between the federal government and states, the federal government covers 100% of the cost for services provided to AIAN Medicaid enrollees through the IHS or Tribally operated facilities whether operated directly by the IHS or on its behalf by a Tribe. Importantly, in contrast to IHS funding, Medicaid funding is not subject to annual appropriations and is provided on a continuous, claims-based basis throughout the year. As a result, Medicaid revenues are a vital funding stream that help facilities cover operational costs, pay providers, and invest in infrastructure development.

Due to a combination of lower coverage rates, additional access barriers, and historical and ongoing discrimination, AIAN people continue to face significant disparities in health and health care. AIAN people have shorter life expectancies relative to their White counterparts (70.1 vs 78.4 years at birth), higher rates of chronic diseases such as diabetes and asthma, and higher rates of suicide deaths and substance use disorder. About a quarter (26%) of AIAN adults report having fair or poor health status compared to 17% of White adults. Additionally, AIAN people face greater risks during pregnancy, including higher rates of preterm births and infant mortality. Among those under age 65, AIAN people are three times more likely to be uninsured (21%) compared to White people (7%).

Recent and Proposed Policies Related to AIAN Health and Health Care

Since President Trump took office in January 2025, the Administration and Congress have made significant health policy changes. While in some cases AIAN people have been specifically exempted or protected from new requirements or cutbacks, many changes may have significant impacts on health and health care for AIAN people that could exacerbate the large disparities they already face in health and health care.

Medicaid and ACA Marketplace Changes

The 2025 reconciliation legislation makes large cutbacks in federal Medicaid spending that could negatively impact low-income people overall, including AIAN people and communities. CBO estimates that the law will reduce federal Medicaid spending over the next decade by an estimated $911 billion and increase the number of uninsured people by 10 million due to changes to Medicaid and other programs, including the ACA Marketplace. Medicaid is the primary source of health coverage for Native communities with one in three (35%) AIAN individuals under age 65 enrolled in Medicaid or the Children’s Health Insurance Program (CHIP), including 52% of AIAN children. As noted, Medicaid is also the largest source of external funding for IHS and Tribal health facilities, accounting for roughly two-thirds of their third-party revenue and providing a stable funding source to support operations. To replace reductions in federal funding, states will need to increase spending or make program reductions, which could lead to broad eligibility and benefit cutbacks that might reduce coverage for low-income people overall, including AIAN people and reduce funding available to IHS and other Tribal providers.

The law imposes an array of new requirements on Medicaid enrollees but largely exempts AIAN people from these changes. The law will require more frequent Medicaid eligibility determinations (every six months), adds a new work requirement, and imposes increased cost sharing for adults enrolled in the ACA Medicaid expansion. The law exempts AIAN people from these new requirements. However, it is unclear how state Medicaid programs will verify AIAN people’s Tribal citizenship. Some AIAN people may face challenges documenting their exemption status. While states are required to use available data to verify exemption status, some AIAN people who need to document their Tribal citizenship may face challenges to submitting documents, including long distances to post offices and limited internet access, as seen during the recent unwinding of Medicaid continuous enrollment.

While the 2025 reconciliation law exempts AIAN people from changes to Marketplace coverage, the pending expiration of enhanced Marketplace subsidies could lead to declines in coverage for AIAN people. Without renewal of the enhanced tax credits, premium payments for individuals enrolled in the Marketplace are expected to more than double on average. Estimates suggest that a substantial share of AIAN people currently enrolled in a Marketplace plan could lose coverage if the enhanced premium tax credits expire, particularly in states that have not expanded Medicaid to adults.

Funding for IHS

Congressional appropriations bills for Fiscal Year (FY) 2026 increase funding for the IHS compared to prior years but still fall far short of the funding levels to fulfill the federal trust responsibility to AIAN communities. In late July 2025, both the House and Senate Appropriations Committees passed their respective FY 2026 bills, each proposing increased funding for the IHS. The House bill allocates $8.41 billion, while the Senate bill allocates $8.1 billion, both above the FY 2025 enacted level of $6.96 billion. These increases are expected to support expanded primary care, behavioral health, and preventive services, as well as help offset inflationary pressures that threaten to erode service capacity. The House bill also includes $105.99 million for Urban Indian Health and $6.05 billion in advance appropriations for FY 2027. Following the most recent government shutdown, the deadline to pass FY 2026 appropriations bills has been extended through the end of January, during which time IHS continues to operate at FY 2025 funding levels. While these bills increase funding, they fall short of estimated needs. The Tribal Budget Formulation Work Group, led by Tribal leaders across all IHS regions, has recommended full funding at $73 billion for the IHS and $1.09 billion for Urban Indian Health to meet health care needs and fill service gaps. The group has identified several areas that would benefit from increased funding including workforce shortages, Infrastructure improvement, and targeted public health initiatives, such as mental health, substance use and opioid treatment programs, efforts to eliminate HIV and hepatitis C, and culturally tailored chronic disease management through the Special Diabetes Program for Indians.

Federal Cutbacks to Staff, Diversity Initiatives, Data, and Research

Although Tribes have largely been exempted from recent reductions in DEI initiatives, broader federal program and budget cutbacks that eliminate staff and programs focused on health equity may still undermine efforts to address longstanding disparities affecting AIAN communities. While Health and Human Services (HHS) Secretary Robert F. Kennedy Jr. has suspended layoffs at IHS, Tribal leaders caution that deep cuts at other federal health agencies are causing widespread disruption. These reductions are impacting many programs Tribal communities rely on, including public health surveillance, data systems, and community outreach efforts. Tribes report that staffing losses in key federal health agencies have led to gaps in data collection, weakened communication, and delayed implementation of essential programs. Maintaining strong health data infrastructure and partnerships with Tribal communities is key for tracking health inequities and targeting resources effectively. One notable loss is the Centers for Disease Control and Prevention’s (CDC) Healthy Tribes Program, which previously provided roughly $32.5 million annually to support culturally grounded approaches, such as community gardens and incorporation of traditional wellness practices, but has now been effectively dismantled. Broader restructuring across the HHS has also affected Indian country. Tribal representatives, including the National Indian Health Board, have expressed concerns that dismantling equity-focused initiatives threatens to reverse gains addressing disparities affecting AIAN people.

Changes in Vaccine Policy

Shifts in vaccine policy, misinformation about vaccine safety, and declines in childhood vaccination rates may lead to a rise in outbreaks of once eradicated diseases with disproportionate impacts for AIAN people. HHS Secretary Kennedy, known for his longstanding opposition to vaccines and for spreading vaccine misinformation, has recently spearheaded initiatives to review the federal childhood vaccination schedule, overhaul the membership of the Advisory Committee on Immunization Practices (ACIP), and limit both COVID-19 vaccines and mRNA vaccine research. Additionally, the Trump administration has released a report advocating for a new vaccine policy framework, which includes revisiting the childhood vaccine schedule and focusing on vaccine-related injuries. Since the COVID-19 pandemic, childhood vaccination coverage has declined nationwide. Gaps in immunization are higher in AIAN communities, increasing their susceptibility to disease resurgence. Among children born in 2020, only 57% of AIAN children were fully immunized by age two, compared to 71% of non-Hispanic White children. Additionally, roughly 76% of AIAN children have received their first MMR dose, falling short of the 95% coverage required to achieve herd immunity. AIAN adults were also 30% less likely to receive a flu shot than their non-Hispanic White counterparts during the 2023–2024 season. These declines have contributed to the most severe measles outbreak in the U.S. in more than three decades. Recent measles clusters in Tribal communities, especially in the Northern Plains and Southwest, have disrupted health care access and led to temporary clinic closures. In response, IHS, Tribal, and Urban health facilities have implemented mobile vaccination units, walk-in clinics, and multilingual public health campaigns tailored to meet local needs.

At the same time, misinformation about vaccine safety continues to circulate widely. KFF polling data shows that a majority of Americans have read or heard the false claim that the MMR vaccine causes autism in children. About one-third have heard that getting the measles vaccine is more dangerous than becoming infected with measles, and 34% believe the debunked claim that MMR vaccines cause autism. Among parents, about one in ten (9%) believe the MMR vaccine can cause autism, and roughly one in six (16%) say they have ever skipped or delayed at least one childhood vaccine for any of their children. Additionally, while formally supportive of the MMR vaccine’s effectiveness, Senator Kennedy has amplified anti-vaccine narratives including debunked claims linking the MMR vaccine to autism, creating confusion and reducing clarity on vaccine safety. Beyond the existing mistrust of the health care system due to historical trauma and abuse, some Tribal leaders warn that skepticism and mistrust of the health care system among AIAN people is increasing. Together, the increased skepticism among the public about the safety and effectiveness of measles vaccines and a decline in trust of health authorities in general, have contributed to lower vaccination rates and complicated outreach and communication efforts to combat preventable disease outbreaks.

Health care affordability has been a longstanding concern in the U.S., including among older adults, many of whom have relatively low incomes and modest assets to help cover the cost of premiums and medical bills. Medicare offers important financial protection by providing health insurance coverage to 69 million people in the U.S., including adults age 65 or older and younger adults with long-term disabilities. However, Medicare-covered benefits are subject to cost-sharing requirements and exclude some commonly needed services, like dental and vision care.  Additionally, traditional Medicare does not include a cap on out-of-pocket costs.

To help with cost sharing for Medicare-covered services and fill the gaps in Medicare benefits, most Medicare beneficiaries supplement traditional Medicare with additional coverage, such as Medigap, for which policyholders pay an average of $2,600 annually in premiums. More than half of people with Medicare are currently enrolled in Medicare Advantage, which offers extra benefits not available in traditional Medicare and caps annual out-of-pocket costs. Medicare beneficiaries may also have employer- or union-sponsored coverage or Medicaid coverage in addition to Medicare. But some people on Medicare lack additional coverage and face the risk of incurring high out-of-pocket costs if they need expensive medical care.

This analysis documents the different sources of coverage among people with Medicare and examines variation in beneficiary characteristics by source of coverage. The analysis draws on data from the Centers for Medicare & Medicaid Services (CMS) March 2025 Medicare Advantage enrollment files and the 2023 Medicare Current Beneficiary Survey (see Methods for details).

Key Facts

• More than half of all people with Medicare Part A and Part B (54% or 34.1 million in 2025) are enrolled in a Medicare Advantage plan, while 46% (28.7 million) are in traditional Medicare.
• Among traditional Medicare beneficiaries, most (87%) had additional coverage that supplements Medicare benefits in 2023, but 3.5 million beneficiaries (13%) lacked additional coverage, leaving them at risk of facing high out-of-pocket costs for medical care.
• Overall, 14.1 million beneficiaries (23% of all Medicare beneficiaries) had employer or union sponsored coverage in 2023, either as a supplement to traditional Medicare or through group Medicare Advantage plans, another 12.2 million (20%) had Medicaid in addition to traditional Medicare or Medicare Advantage, and the same number, 12.2 million (20%) had a Medicare supplemental insurance (Medigap) policy to supplement traditional Medicare.

• The number and share of Medicare beneficiaries with Medicaid (dual eligible individuals) were substantially higher in Medicare Advantage (68%) than traditional Medicare (32% in 2023).
• Compared to traditional Medicare beneficiaries, Medicare Advantage enrollees were more likely to be Black or Hispanic, have incomes below $20,000 per person, and self-report fair or poor health.

More than Half of All People with Medicare Are Enrolled in Medicare Advantage

In 2025, Medicare Advantage covered more than half (54%) of Medicare beneficiaries with both Medicare Parts A and B, or 34.1 million out of about 62.8 million people. Of the total number of Medicare Advantage enrollees in 2025, most (62%) are enrolled in individual plans available to all Medicare beneficiaries. One in five (21%) are in Special Needs Plans (SNPs) and 17% are enrolled in employer- or union-sponsored group plans, where employers or unions contract with an insurer and Medicare pays the insurer a fixed amount per enrollee to provide benefits covered by Medicare. (These estimates are based on March 2025 Medicare Advantage plan enrollment data and therefore differ from those discussed below and shown in Figure 1, which are based on the 2023 Medicare Current Beneficiary Survey (MCBS)).

Compared to traditional Medicare beneficiaries, Medicare Advantage enrollees were more likely to be Black or Hispanic, have incomes below $20,000 per person, and self-report fair or poor health, based on KFF analysis of the 2023 MCBS (Figure 2, Appendix Table 1).

Most Medicare Beneficiaries in Traditional Medicare Have Additional Coverage that Supplements Medicare Benefits

In 2023, most (87%) people in traditional Medicare had some form of additional coverage, either through Medigap (43%), employer coverage (29%), Medicaid (14%), or another source (1%),based on estimates from the MCBS.But 3.5 million Medicare beneficiaries in traditional Medicare (13%) had no additional coverage. A more detailed discussion of these types of coverage and the characteristics of people with each coverage type is below.

Nearly a Quarter of Medicare Beneficiaries Have Employer Coverage, Either through Group Medicare Advantage Plans or in Addition to Traditional Medicare

In total, 14.1 million Medicare beneficiaries – nearly a quarter (23%) of Medicare beneficiaries overall – had some form of employer or union-sponsored health insurance coverage in 2023 in addition to Medicare Part A and Part B. Of this total, 8.2 million beneficiaries had employer coverage in addition to traditional Medicare (29% of beneficiaries in traditional Medicare), while 5.9 million beneficiaries were enrolled in Medicare Advantage employer group plans. Most people with both Medicare Part A and Part B and employer- or union-sponsored coverage are retirees with Medicare as their primary source of health insurance coverage.

Compared to traditional Medicare beneficiaries overall in 2023, beneficiaries with employer or union-sponsored coverage in addition to traditional Medicare were more likely to have higher incomes ($40,000 or greater per person), a bachelor’s degree or higher, self-report excellent or good health, and were less likely to be under age 65 (Figure 3, Appendix Table 1).

Separately, in 2023, an estimated 5.8 million Medicare beneficiaries had Part A only, a group that primarily includes people who were active workers (either themselves or their spouses) and had primary coverage from an employer plan and Medicare as a secondary payer. People with Part A only cannot enroll in a Medicare Advantage plan, so people with coverage through Medicare Advantage employer group plans are likely to be retired.

Four in 10 People in Traditional Medicare Have a Medigap Supplemental Policy

Medicare supplement insurance, also known as Medigap, covered 2 in 10 (20%) Medicare beneficiaries overall, or 43% of those in traditional Medicare (12.2 million beneficiaries) in 2023. Medigap policies, sold by private insurance companies, fully or partially cover Medicare Part A and Part B cost-sharing requirements, including deductibles, copayments, and coinsurance. Medigap limits the financial exposure of Medicare beneficiaries and provides protection against catastrophic medical expenses. However, Medigap premiums can be costly and can rise with age, among other factors, depending on the state in which they are regulated.

Compared to all traditional Medicare beneficiaries in 2023, beneficiaries with Medigap were more likely to be White, have higher annual incomes (above $20,000 per person), self-report excellent, very good, or good health, and have a bachelor’s degree or higher (Figure 3, Appendix Table 1).

In contrast, a smaller share of traditional Medicare beneficiaries under age 65 have a Medigap policy than traditional Medicare beneficiaries ages 65 and older (1% versus 9%). Federal law provides a 6-month guarantee issue protection for adults ages 65 and older when they first enroll in Medicare Part B if they want to purchase a supplemental Medigap policy, but these protections do not extend to adults under the age of 65 with disabilities, and most states do not require insurers to issue Medigap policies to beneficiaries under age 65.

One in Five People with Medicare Also Have Coverage from Medicaid, with More Covered Under Medicare Advantage than Traditional Medicare

Medicaid, the federal-state program that provides health and long-term services and supports coverage to low-income people, was a source of supplemental coverage for 12.2 million Medicare beneficiaries with low incomes and modest assets in 2023, or 20% of all Medicare beneficiaries. A larger number and share of Medicare beneficiaries with Medicaid (known as dual-eligible individuals) were enrolled in a Medicare Advantage plan (8.3 million, or 68% of all dual-eligible individuals) than in traditional Medicare (4.0 million, or 32%) (Appendix Table 1). For these beneficiaries, Medicaid typically pays the Medicare Part B premium and may also pay a portion of Medicare deductibles and other cost-sharing requirements. Most dual-eligible individuals are also eligible for full Medicaid benefits, including long-term services and supports.

Compared to traditional Medicare beneficiaries overall in 2023, dual-eligible individuals were more likely to have low incomes and relatively low education levels, self-report fair or poor health, identify as Black or Hispanic, and be under the age of 65 (Figure 3, Appendix Table 1).

3.5 Million Traditional Medicare Beneficiaries Lack Supplemental Coverage

In 2023, 3.5 million Medicare beneficiaries – 6% overall –and 13% of beneficiaries in traditional Medicare – had no supplemental health insurance coverage. Traditional Medicare beneficiaries with no additional coverage are fully exposed to Medicare’s cost-sharing requirements, which would mean paying a $1,736 deductible for a hospital stay in 2026, daily copayments for extended hospital and skilled nursing facility stays, and a $283 deductible plus 20% coinsurance for physician visits and other outpatient services. (These costs are in addition to the standard Part B premium amount of $203 per month in 2026). Beneficiaries in traditional Medicare without additional coverage also face the risk of high annual out-of-pocket costs because there is no cap on out-of-pocket spending for Part A and B services in traditional Medicare, unlike in Medicare Advantage plans.

Beneficiaries in traditional Medicare without any form of additional coverage were more likely to have modest incomes (between $20,000 and $40,000 per person) compared to all traditional Medicare beneficiaries in 2023 (Figure 3, Appendix Table 1). Medicare beneficiaries with modest incomes have limited ability to afford Medigap premiums and are unlikely to qualify for Medicaid because their income and assets are not low enough to meet eligibility guidelines.

The number and share of traditional Medicare beneficiaries without any form of supplemental coverage has steadily declined in recent years. Between 2018 and 2023, the number of traditional Medicare beneficiaries without supplemental coverage declined from 5.6 million beneficiaries (10% of the total Medicare population, or 17% of those in traditional Medicare) to 3.5 million (6% of the total Medicare population, or 13% of those in traditional Medicare). This decline likely reflects the increase in Medicare Advantage enrollment over time, which has increased from 20 million in 2018 to 34 million in 2025.

Appendix

The 2025 reconciliation law could have major implications for nearly 15,000 federally certified nursing facilities and the more than 1.2 million people living in them. Nursing facilities provide medical and personal care services for older adults and people with disabilities. In 2023, Medicaid paid for 44% of long-term institutional care costs; 37% of long-term institutional care costs were paid for out-of-pocket; and the remaining 18% was covered by other public and private payers. Although provisions in the reconciliation law do not directly limit or reduce nursing facility services, changes to the Medicaid program could result in reduced payments from Medicaid for nursing facility care and may result in fewer people having Medicaid coverage of nursing facility care (see Box 1 for more on the 2025 reconciliation law.)

This data note discusses the impact of the 2025 reconciliation law on nursing facilities and examines the characteristics of nursing facilities and the people living in them with data from Nursing Home Compare, a publicly available dataset that provides a snapshot of information on quality of care in each nursing facility, and CASPER (Certification and Survey Provider Enhanced Reports), a dataset that includes detailed metrics collected by surveyors during nursing facility inspections. State-level data are also available on State Health Facts, KFF’s data repository with downloadable health indicators. Key takeaways from July 2025 data include:

• There are 14,742 nursing facilities certified by CMS and about 1.24 million residents living in these certified nursing facilities (Figure 1).
• Nursing facility residents receive, on average, about 3.85 hours of nursing care per day from licensed practical nurses (LPN/LVN), registered nurses (RNs), and nurse aides (Figure 2).
• On average, nursing facilities receive 9.5 deficiencies over the course of a survey cycle (Figure 3).
• While nearly all facilities receive at least one deficiency over the course of a survey cycle, 27% of facilities receive serious deficiencies for actual harm or jeopardy posed to a resident (Figure 3).

As of July 2025, there are 14,742 nursing facilities certified by CMS (Figure 1). The number of nursing facilities certified by CMS decreased by 6% between July 2015 and July 2025. There has generally been a steady decline during that time period. In order to receive payment under the Medicare and/or Medicaid programs, nursing facilities are required to follow certain regulations and be certified by CMS. The decreased number of nursing facilities reflects the net change in the number of certified facilities after accounting for newly-certified facilities and facilities that are no longer certified, including facilities that closed.

There are about 1.24 million residents living in certified nursing facilities (Figure 1). Since 2021, the number of nursing facility residents has gradually increased from 1.10 million to 1.24 million. However, between 2015 and 2025, the number of residents living in nursing facilities decreased by 9%, with most of that coming from a steep decline between 2020 and 2021, reflecting the effects of the COVID-19 pandemic. Prior to the pandemic, the number of residents was relatively steady, although it declined from 1.37 million in 2015 to 1.32 million in 2020. COVID-19 exacerbated the decrease in nursing facility residents—in part because nursing facility residents and staff incurred so many deaths during the pandemic.

Residents receive an average of 3.85 hours of nursing care per day, including 0.87 hours of LPN care, 0.68 hours of RN care, and 2.3 hours of nurse aide care (Figure 2). While staffing levels have gradually slightly increased overtime since 2022, the average hours of nursing care that nursing facility residents received declined by 7%, from 4.13 hours to 3.85 hours per resident each day, between July 2015 and July 2025. The decrease was driven by a 19% decline in registered nurse (RN) hours and a 7% decline in nurse aide hours. Licensed practical nurse (LPN) hours increased by 5% in this same time period. The 2024 rule would have required nursing facilities to meet minimum standards in staff hours for RNs and nurse aides but did not include any requirements for LPNs. A Texas judge overturned key elements of the rule in April 2025, the 2025 reconciliation law delayed all provisions of the rule until October 2034 (Box 1), and the Trump Administration rescinded the rule in December 2025. Previous KFF analysis show that just 19% of nursing facilities met the standards at the time of the rule’s passing.

The total hours of nursing care per resident decreased between 2015 and 2025, but rose briefly in 2021. The relatively higher staffing hours per resident in 2021 reflected the fact that the number of residents declined more quickly than the number of total nursing staff hours did between 2020 and 2021. In 2021, the number of staffing hours was 12% lower than in 2020 (data not shown). These lower staffing levels in the last several years align with data as of March 2024 showing that the number of workers employed at long-term care facilities continues to remain below pre-pandemic levels.

Nursing facilities receive an average of 9.5 deficiencies over the course of a survey cycle and 27% of facilities receive deficiencies for actual harm or jeopardy (Figure 3, Box 3). While nearly all facilities receive at least one deficiency during a survey cycle, this analysis focuses on the share with serious deficiencies since there is wide variation in the types of deficiencies a facility may receive. Both the average number of deficiencies and the share of facilities with serious deficiencies have increased over time, which could reflect increased oversight and low staffing levels that lead to staffing-related deficiencies. Between 2015 and 2025, the average count of deficiencies per nursing facility increased from 6.8 to 9.5, an increase of 40%. The increase was generally steady overtime, except for two stable periods: 1) between 2020 and 2022 and 2) between 2024 and 2025 (though 2024 and 2025 reported the highest number deficiencies during the 10-year period). The share of facilities reporting serious deficiencies between 2015 and 2025 increased from 17% to 27%, with a slight decrease between 2024 and 2025. A 2023 report on nursing home staffing by Abt Associates found that better-staffed nursing homes are typically cited for fewer deficiencies or violations of federal regulations, suggesting there may be a relationship between the increase in deficiencies and the general decrease in staffing levels over the 10-year time period.

Medicaid is the primary payer for 63% of nursing facility residents; Medicare for 14% of residents; and the remaining 23% of residents have another primary payer (ex. out-of-pocket) (Figure 4). The share of residents by primary payer has stayed relatively stable over time. Medicare does not generally cover long-term care but does cover up to 100 days of skilled nursing facility care following a qualifying hospital stay. KFF polling shows that four in ten adults overall incorrectly believe that Medicare is the primary source of insurance coverage for low-income people who need nursing facility care. 

Nearly three-quarters (73%) of nursing facilities are for-profit, one-fifth (20%) are non-profit, and the remaining seven percent are government-owned (Figure 5). The share of facilities by ownership type has also stayed relatively stable over time but there was increasing scrutiny over the 73% of facilities that are for-profit during the prior Administration. Despite little change in the type of ownership, there have been reports of private equity firms purchasing nursing facilities and changing operations to increase profits, resulting in lower-quality care. The GAO estimates that about 5% of nursing facilities had private equity ownership in 2022.

The Biden Administration issued a final rule in November 2023 on nursing facilities (separate from the April 2024 staffing rule that was delayed by the 2025 reconciliation law and then rescinded by the Trump Administration in December 2025). The 2023 nursing facility rule requires nursing homes enrolled in Medicare or Medicaid to disclose detailed information regarding their owners, operators, and management, including:

• Anyone who exercises any financial control over the facility;
• Anyone who leases or subleases property to the facility, including anyone who owns 5% or more of the total value of the property; and
• Anyone who provides administrative services, clinical consulting services, accounting or financial services, policies or procedures on operations, or cash management services for the facilities.

Facilities must also disclose whether any of the owning or managing entities are a private equity company or real estate investment trust (REIT). Facilities began self-reporting this data to CMS in early 2024 and the data is now available to the public. However, these data may be incomplete for now as fewer than 100 facilities report private equity ownership and just over 300 facilities report REIT ownership. Other research estimates those counts to be higher. 

The Trump administration has made several recent changes to federal routine vaccination recommendations. Specifically, under the auspices of Secretary Kennedy, who has long questioned the safety and efficacy of vaccines and stated his intention to review vaccine schedules, the CDC’s Advisory Committee on Immunization Practices (ACIP) has recommended changes (including to age group, type of vaccine, and/or clinical decision-making process) to seven vaccine usage recommendations in the United States: Meningococcal; RSV for adults; RSV for children; influenza; COVID-19; Measles, Mumps, Rubella and Varicella (MMRV); and Hepatitis B. These recommendations, which have been adopted by the HHS Secretary or Acting CDC Director, have raised questions about the implications for insurance coverage, since most insurers are required to cover ACIP/CDC recommended vaccines at no-cost, either due to requirements of the Affordable Care Act or other federal statutes.

Below, we provide an overview of each of these changes and what they mean for coverage requirements. As the table indicates, of the seven recent changes, two have no implications for coverage, two removed the coverage requirement, and three expanded the requirement. When a coverage requirement is removed, an insurer could still choose to cover a vaccine at no cost. In fact, AHIP, the trade association for the health insurance industry whose members cover more than 200 million Americans, announced that health plans will continue to cover all ACIP-recommended immunizations that were recommended as of September 1, 2025 with no cost-sharing for patients through the end of 2026. When a coverage requirement is expanded, insurers (with limited exception) must cover the vaccine at no-cost. The insurance requirement extends to vaccines with “individual decision-making” (also known as “shared clinical decision-making”) recommendations as well, which are those “individually based and informed by a decision process between the health care provider and the patient or parent/guardian”.

In addition to federal requirements for coverage, states have the authority to require state-regulated health insurers (employer plans that are fully insured and individual and small-group marketplace plans) to cover vaccines beyond minimum federal requirements (and not necessarily linked to current ACIP/CDC recommendations). As of December 2025, eight states have moved to do so (and one state authorizes the state Commissioner of Insurance to do so). Still, states cannot impose coverage requirements on self-insured employer plans, which cover most (67%) people with employer coverage.

Additional changes to ACIP-recommended vaccine schedules are likely, as President Trump has issued a Presidential Memorandum calling on HHS and CDC to begin a “process to align U.S. core childhood vaccine recommendations with best practices from ‘peer, developed countries’”. Beyond their implications for insurance coverage, changes to vaccine recommendations, particularly those that narrow or limit access, are likely to have other implications, such as driving down already falling vaccine coverage rates in the United States.

Changes to Vaccine Recommendations and Insurance Coverage

Notes:
See KFF, ACIP, CDC, and Insurance Coverage of Vaccines in the United States, for coverage criteria by payer.
*While Medicare Part B is required to cover influenza vaccine by statute, not linked to ACIP/CDC, this change will result in the removal of the multi-dose vaccine from the market.
**CDC has not changed its recommendations for adult hepatitis B vaccinations, which are that adults aged 19–59 years, and adults aged 60 years and older with risk factors for hepatitis B or without identified risk factors but seeking protection, receive the vaccine if they had not been previously vaccinated. See CDC Hepatitis B Vaccine Administration.

Sources:

• https://www.cdc.gov/acip/vaccine-recommendations/index.html
• https://www.cdc.gov/acip/vaccine-recommendations/index.html#:~:text=RSV%20Vaccines%20%2D%20Adults
• https://www.hhs.gov/press-room/acip-recommends-covid19-vaccination-individual-decision-making.html 
• https://www.hhs.gov/press-room/thimerosal-mercury-removed-from-us-flu-vaccines-acip.html
• https://www.hhs.gov/press-room/cdc-immunization-schedule-individual-decision-covid19-standalone-chickenpox-toddlers.html
• https://www.hhs.gov/press-room/acip-recommends-chickenpox-vaccine-for-toddlers.html
• https://www.hhs.gov/press-room/acip-recommends-individual-based-decision-making-hepatitis-b-vaccine-birth-dose-infants-born-women-test-negative-virus.html
• https://www.hhs.gov/press-room/cdc-adopts-individual-based-decision-making-for-hepatitis-b-immunization-for-infants-born-to-women-who-test-negative-for-the-hepatitis-b-virus.html

On January 20, 2025, the first day of his second term, President Trump issued an executive order on “gender ideology” outlining how his administration would view sex and gender and incorporate these concepts into government. This executive order has had widespread implications across government and for federal grantees. One area that has been impacted is the federal government’s data collection efforts. This includes changes to questions about sexual orientation and gender identity (SOGI) in multiple federal surveys, and retreating from plans to incorporate SOGI questions in surveys of the U.S. population by the Census Bureau. While data collection on both sexual orientation and gender has been scaled back or modified, measures relating to gender identity have been more specifically targeted for deletion.

Although several national surveys and data sets have been affected by changes to SOGI data collection and availability, this brief focuses specifically on changes in three national surveys that are representative of these efforts: the National Health Interview Survey (NHIS), the Medicare Current Beneficiary Survey (MCBS), and the National Crime Victimization Survey (NCVS). These surveys are central to the federal government’s efforts to understand the health and well-being of the U.S. population overall (NHIS) and people with Medicare (MCBS) and to understand people’s experiences with criminal victimization (NCVS), and had the potential to meaningfully expand the knowledge base in these areas as they relate to the nearly 14 million U.S. adults who identify as LGBT, and particularly the over 2 million adults who identify as transgender. Limiting SOGI data collection in these and other federal surveys moving forward will present challenges for understanding and assessing the needs and experiences of the LGBTQ population in the U.S.

Overview of Surveys Examined and Adoption of SOGI Metrics

The NHIS, MCBS, and NCVS offer unique opportunities to better understand the experiences of people’s health and well-being. While not the only federal sources that have historically collected SOGI data, these three surveys represent distinct and policy-relevant opportunities for the collection and use of LGBTQ data. The NHIS has included SOGI measures that enable analyses of broad population health measures, including insurance coverage patterns and overall health status. The MCBS could offer rare insight into LGBTQ older adults—a population that is typically difficult to sample due to its relatively small size (just 1.8% of adults over 65 identify as LGBT, but this share is likely to grow larger over time). SOGI data were only recently added to MCBS. Finally, the NCVS has provided SOGI data that is particularly valuable for examining experiences of violence and discrimination, areas where disparities between LGBTQ and non-LGBTQ people have been well documented.

The National Health Interview Survey (NHIS), administered by the National Center for Health Statistics within the U.S. Centers for Disease Control and Prevention, is the largest and oldest national health survey in the U.S. and collects information on a broad range of topics including demographics, socioeconomic factors, health status, health care access, and health coverage. NHIS data provides in depth information across the population, and its size allows for comparisons across groups, including LGBT people.

Questions about sexual orientation were added to NHIS in 2013 and questions related to gender identity were added to the survey in 2022 on an experimental basis to develop a methodology. On adding a sexual orientation variable to the survey (at the time referred to as sexual identity) HHS wrote, “The objective of asking a question on sexual identity in the NHIS is to fill the tremendous gap that exists regarding knowledge of general health behaviors, health status, and health care utilization of LGBT persons.”

The Medicare Current Beneficiary Survey (MCBS), administered by the Centers for Medicare & Medicaid Services (CMS), is the government’s long-running, comprehensive, nationally representative survey of people with Medicare. The MCBS includes questions about beneficiaries’ health care use, health status, cost and payment issues, demographic and housing characteristics, experiences with care, and other domains.

Questions about sexual orientation and gender identity were added to the survey in 2023 to provide the opportunity to gain new knowledge about LGBTQ older adults and people with disabilities covered by Medicare. According to CMS at the time, “Including sexual orientation and gender identity questions on the MCBS will provide nationally representative data on topics such as the accessibility and utilization of health care services by the Lesbian, Gay, Bisexual, and Transgender (LGBT) populations and the resulting health disparities that impact this community. … In no instance have we identified another source of data that would be an effective substitute for the MCBS.” CMS also added an item asking Medicare beneficiaries about their experiences with discrimination from health care providers based on eight demographic factors, including race, language or accent, gender or gender identity, sexual orientation, age, culture or religion, disability, and medical history. This measure, according to CMS, would allow the agency “to capture the most actionable and impactful information about health care experiences that directly influence health outcomes and will provide CMS with additional measures for assessing health equity and fair treatment for underserved populations.”

The National Crime Victimization Survey (NCVS), administered by the Bureau of Justice Statistics within the U.S. Department of Justice, provides nationally representative data on criminal victimization, including frequency, characteristics, and consequences. Data are collected on both crimes reported to the police and crimes not reported. Demographic data is also collected from respondents along with experiences with the criminal justice system.

Questions about sexual orientation and gender identity were added to the survey in 2016. The NCVS included questions asking respondents about their sexual orientation, sex assigned at birth, gender identity, and a clarifying question used when there was a conflict between a respondent’s reported sex assigned at birth and gender identity.¹ Two additional questions were asked among those who had been victimized about whether they believed it was due to “prejudice or bigotry” relating to gender identity or sexual orientation. In support of including these measures, DOJ wrote that they were “identified in other research as subgroups of interest to key stakeholders and, correlates to victimization. For example, sexual orientation and gender identity are recognized in the 2013 reauthorized Violence Against Women Act (VAWA). Additionally, the inclusion of these items will allow researchers to better understand the relationships between these variables and experiences with criminal victimization.”

Why Were SOGI Questions Added to Federal Surveys?

The inclusion of SOGI questions to federal surveys aligned with a range of efforts by the federal government to improve data collection related to sexual orientation and gender identity. Top of Form

The move to collect SOGI data within the federal government was recommended in a National Academies of Sciences Report: Understanding the Well-Being of LGBTQI+ Populations and received support from a number of researchers and advocates. Other activities that led to wider collection of this data include:

• Support in Healthy People 2010, 2020 and 2030 to increase collection of sexual orientation and gender identity data in population surveys.
• In 2016, the Office of Management and Budget (OMB) convened a Federal Interagency Working Group on Improving Measurement of Sexual Orientation and Gender Identity in Federal Surveys “to begin addressing the dearth of data for these populations and the issues surrounding methodological issues in collecting such data.”
• In 2022, pursuant to a Biden administration executive order, the OMB released a report on the best practices for sexual orientation and gender identity data collection in federal surveys.
• In 2023, the Biden administration developed a Federal Evidence Agenda on Lesbian, Gay, Bisexual, Transgender, Queer, and Intersex (LGBTQI+) Equity, a “roadmap for opportunities for the Federal Government to continue to build evidence and leverage data to advance equity for LGBTQI+ people.”
• Efforts within NIH to “Encourage data collection related to SGM [sexual and gender minority] populations in research and the health research workforce.” (Note the webpage for the NIH Sexual & Gender Minority Research Office hasbeen removed under the Trump Administration, likely also a part of broad efforts to align with the Executive Order discussed here).

How SOGI Data Collected in NHIS, MCBS, and NCVS Has Been Used

NHIS

The NHIS data on gender identity and sexual orientation has been used to track insurance coverage among LGBTQ people, including by KFF. Additionally, NHIS SOGI measures have allowed researchers to explore population level disparities among sexual minorities including: examining substance use and sleep problems by sexual orientation and assessing food insecurity, mental health, and health care access, as well as experiences with intersectional disparities.

MCBS

SOGI questions were added to the MCBS in 2023 and were initially released to researchers with approved data use agreements who purchased an “early release” version of the 2023 MCBS Survey File in the fall of 2024 from CMS – about 9 months before the full year of 2023 MCBS Survey File data were made available in July 2025. As such, SOGI data collected in the MCBS have not yet been widely utilized by researchers. Additionally, KFF found that the number of Medicare beneficiaries who identified as transgender in the early release file (the only file to include this data) was too small to generate a reliable estimate. Without data on gender identity in future years, researchers will be unable to pool multiple years of data to produce a more robust sample, as is sometimes done in research with LGBTQ groups in other contexts when necessitated by limited sample sizes.

NCVS

NCVS data has been used to understand the victimization experiences of teens and adults, including LGBTQ people. NCVS has been used to provide representative estimates on transgender people’s experiences specifically. Research has examined the forms of violence experienced by gender identity and sexual orientation. Experiences of victimization among LGBT people have also been examined to assess intersecting factors such as age, race/ethnicity, and relationship to the assailant, alongside comparison to non-LGBT people.

Recent Changes to SOGI Data in Federal Surveys

The Trump administration’s January 2025 Executive Order (EO) 14168 on “gender ideology” required federal agencies to “remove all statements, policies, regulations, forms, communications, or other internal and external messages that promote or otherwise inculcate gender ideology.” With these actions, the Trump administration sought to promote a view of sex as a binary biological concept and to disavow the notion of gender identity – the internal sense and experience of being male, female, transgender, non-binary or something else. Operating under this directive, the federal government undertook an effort to remove gender-identity related content from federal surveys and modify certain content related to sexual orientation and sex in early 2025.

The federal agencies responsible for administering NHIS, MCBS, and NCVS specifically cited EO 14168 in their rationale when requesting changes from the Office of Management and Budget. The changes made to these variables in NHIS, MCBS, and NCVS are as follows (see Table 1 for full question wording, changes, and sources):  

NHIS

Modifications were made to the gender identity question but not the sexual orientation question. The specific changes include:

• removing a question asking about the respondent’s gender identity
• removing the follow-up question where a respondent who selected “something else” could provide a verbatim response to describe their gender identity in their own words

MCBS

Changes were made to the series of SOGI questions, including:

• removing a question asking about the respondent’s gender identity,
• removing a question asking respondents to report their sex assigned at birth on their original birth certificate and replacing it with a question asking the respondent to report their sex (without providing additional information on how to consider the question),
• removing “something else” as a response option to a question about the respondent’s sexual orientation,
• removing the follow-up question where a respondent who selected “something else” could provide a verbatim response to describe their sexual orientation in their own words, and
• removing a question related to the respondent’s experiences with unfair or insensitive treatment from health care providers based on several demographic factors, including their sexual orientation and their gender or gender identity.

NCVS

Modifications were made to most of the gender identity questions but not the sexual orientation questions, including:

• removing a question asking about the respondent’s gender identity,
• removing a question asking respondents to report the sex assigned at birth on their original birth certificate,
• removing a question seeking clarification related to gender identity (asked when sex assigned at birth and gender identity do not align),
• temporarily pausing and then reinstating a question related to whether respondents who had been victimized believed it was due to prejudice or bigotry relating to gender identity, and
• removing training material information on the above questions.

Implications of the Survey Changes

Deleting and modifying questions related to sexual orientation and gender identity from federal surveys will leave gaps in researchers’ ability to understand and analyze the experiences of LGBTQ people, including the challenges they face and their health problems; diminish the ability of policymakers to identify and address health discrimination and equity issues for the population; and limit the information available to health care provider trying to improve care for LGBTQ people and eliminate barriers to care. Limiting data collection related to LGBTQ people and experiences with violence and victimization may also lead to challenges with addressing unmet need in that area. As LGBTQ people face persistent disparate experiences with stigma, discrimination, and victimization, as well as health (including mental health) disparities, across the lifespan, losing access to this federal data is particularly notable.

Because transgender people make up a very small share of the U.S. population overall, it may be difficult for the private and nonprofit sectors to make up for the loss of data from large federal surveys in non-governmental nationally representative surveys, which rarely have a large enough sample size to be able to pull out the experiences of this group. National surveys, with large sample sizes, had started to fill some of that gap. The challenge is especially acute when trying to understand the experiences of a segment of the transgender community. For example, given that only a small share of older adults identifies as LGBTQ and an even smaller share identify as transgender, maintaining the gender identity variable in the MCBS would have provided an opportunity to understand the experiences of a population that would otherwise be very difficult and/or very costly to sample through traditional surveys.  

The Trump administration’s rolling back of data collection related to gender identity, and to some extent sexual orientation, marks a decline in the capacity of the federal government to measure the experiences of LGBTQ people. The full implications for data users, providers, policymakers, and communities will continue to unfold, and ongoing assessment could help clarify the effects of deleted or modified SOGI measures in federal surveys.

1. Asking about both biological sex assigned at birth and gender identity provides a method for identifying people who might identify as male or female rather than as transgender, but who were assigned a different sex on their original birth certificate. This two-step approach to measuring gender identity is a recommended best practice. ↩︎

Commercial health insurance markets remain highly concentrated across coverage types. However, the individual market, which consists mostly of the ACA Marketplaces, has attracted more insurers and witnessed greater insurer competition across a variety of measures since the implementation of the enhanced premium tax credits in 2021, according to a new Healthy System Tracker analysis.

For example, from 2020 to 2023, the average market share of the largest insurer in each state’s individual market declined from 60% to 53%, corresponding with enrollment growth in the ACA Marketplaces driven by the enhanced premium tax credits. By contrast, fully insured employer-sponsored health insurance markets have become less competitive in the past decade. The analysis presents 2013-2023 enrollment and market competition data for fully insured and individual plans both nationally and on a statewide basis.

The full analysis and other data on health costs are available on the Peterson-KFF Health System Tracker, an online information hub dedicated to monitoring and assessing the performance of the U.S. health system.