Fewer than Half of the Public Are Aware of Mifepristone Prevalence and Safety

 About half (53%) of the public say they have heard of mifepristone, one of the two medications used in most abortions in the U.S., including just over half (56%) of women of reproductive age (ages 18 to 49). Public awareness of mifepristone  has increased over the years as it has become the focal point for lawsuits following the overturning of Roe v. Wade. However, the public is still largely unaware that most abortions in the U.S. are done by taking abortion pills. About one in four (24%) adults correctly say that most abortions in the U.S. are medication abortions, while three in ten (29%) incorrectly believe that most abortions are done procedurally, and nearly half (47%) say they are not sure.

Larger shares of women of reproductive age, Democrats, and adults who identify as “pro-choice” are aware that most abortions in the U.S. are performed using abortion pills, but about one-third or fewer of each of these groups are aware of this. In fact, at least four in ten adults across key demographic groups say they are “not sure” how most abortions in the U.S. are conducted.

The public is also largely unaware of the medication’s long-established safety record. Twenty-five years of mifepristone’s availability in the U.S. has shown the medication is safe when taken as directed by a doctor or other health care provider. However, the latest polling from KFF shows that the public is not entirely aware of this. While more than twice as many adults say the medication is “safe” (42%) than say it is “unsafe” (18%), an additional four in ten adults are not sure. The results are similar among women of reproductive age, with about four in ten saying abortion pills are safe (41%), about one in five (21%) saying they are unsafe, and nearly four in ten (37%) saying they are not sure.

Perceptions of the safety of mifepristone safety diverge by partisanship. Nearly two-thirds (63%) of Democrats say medication abortion pills are at least “somewhat” safe compared to four in ten independents and just a quarter of Republicans (26%). Larger shares of Republicans (47%) and independents (44%) compared to Democrats (26%) say that they are “not sure” whether abortion pills are safe.

While a plurality of adults view abortion pills as very or somewhat safe when taken as directed by a health care provider, this share has declined since May 2023. About four in ten (42%) now say that abortion pills are safe when taken as directed, compared to a majority (55%) two years ago. At the same time, there have been slight increases in the shares saying abortion pills are “unsafe” (18% now, up from 9% in 2023) and that they are “not sure” (40% now, up from 35% in 2023).

Similarly, among women of reproductive age, the share viewing the pills as safe decreased from 59% to 41%, while larger shares now view the pills as unsafe (from 12% in 2023 to 21% now) or say they are not sure if abortion pills are safe (from 29% to 37% now).

Perceptions of safety are somewhat higher when the public is told that the FDA has determined the medication is safe when taken as directed by a health care provider. Just over half of the public (54%) – including a similar share of women of reproductive age – say they are confident in the FDA’s determination that mifepristone is safe, while about a quarter are “not too” or “not at all confident” (27%) and one in five are unsure (19%).

Confidence in the FDA’s determination of mifepristone’s safety is largely partisan. About three-quarters (74%) of Democrats and just over half (55%) of independents are at least somewhat confident in the FDA’s determination that mifepristone is safe when taken as directed by a health care provider, compared to about one-third (35%) of Republicans. Just under half (46%) of Republicans say they are “not too” or “not at all confident” in the FDA’s determination, and about one in five say they are not sure.

Public Awareness of Recent FDA Review of Mifepristone Is Low

In late September, HHS Secretary Kennedy and FDA Commissioner Makary wrote a letter to Republican state attorneys general announcing a review of mifepristone’s safety by the FDA. They cited the need to examine alleged complications and policies related to dispensing mifepristone, a move prompted by a flawed report from an anti-abortion advocacy group questioning the pill’s safety.

Most of the public say they have heard “a little” (27%) or “nothing at all” (47%) about this move from Secretary Kennedy and the FDA. One in five adults have heard “some,” and few (6%) report hearing “a lot.” Democrats are more likely than independents or Republicans to say they have heard at least “some” about this decision, but at least two-thirds across partisans report hearing little or nothing about it.

Once they are made aware of Secretary Kennedy’s decision to have the FDA review the safety of mifepristone, the public is split in assessing its intention, with just over half saying it is mostly to make it more difficult to access abortion pills (53%), and slightly fewer saying it is mostly to protect the health and safety of women (46%). Just over half (54%) of women of reproductive age say that the review of the safety of mifepristone is mostly to make abortion pill access more difficult.

Partisans have very different assessments of the intention behind this review. Eight in ten Democrats (81%) say the move is mostly intended to make access to abortion pills more difficult, while about three in four Republicans (73%) say it is mostly to protect the safety of women. Independents are split with about half saying the move is to make access more difficult (53%), and half (46%) saying it is to protect the safety of women.

A Majority of the Public Oppose Policy Proposals Aimed at Restricting Medication Abortion Access

Overall, at least two thirds of the public oppose policies aimed at restricting or banning medication abortion asked about in this survey. This includes two-thirds of adults who oppose banning the use of medication abortion, nationwide (68%) and a similar share who oppose making it a crime for health care providers to mail abortion pills to patients in states where abortion is banned (65%).

Support for these proposals varies by partisanship, with large shares of Democrats and independents opposed and Republicans more evenly split. A slim majority of Republicans support making it a crime for health care providers to mail abortion pills to patients in states where abortion is banned (55%), while about four in ten (44%) oppose this. Among Republicans, similar shares support (52%) or oppose (46%) banning mifepristone nationwide.

Republican and Republican-leaning supporters of the Make America Great Again (MAGA) movement are also split, with half saying they support banning mifepristone nationwide (50%) and half opposing this (48%). When it comes to mailing abortion pills to patients in states where abortion is banned, MAGA-supporting Republicans are more likely to say they support (58%) criminalizing health care providers than they are to oppose this (41%).

Most of the Public Oppose the Medicaid Funding Ban on Clinics that also Provide Abortions

In July 2025, President Trump signed a spending law that ended federal Medicaid reimbursement to certain clinics for services they provide to patients if the clinics also offer abortions. Abortions, however, were and are not paid for using federal Medicaid funds other than the Hyde Amendment exceptions for pregnancies that are life threatening or result from rape or incest. The law blocks federal reimbursements for other services, including preventive care, contraceptives, and STI treatment. Some states have redirected their own funds to compensate for the loss of these federal reimbursements, and at least twenty Planned Parenthood clinics have closed since the law took effect in July 2025.

About two-thirds (65%) of the public oppose the current law banning clinics that provide abortions from receiving federal Medicaid payments for other services they provide, while about one-third (35%) support this.

Partisans are split on this, with majorities of Democrats (83%) and independents (65%) opposing banning clinics from receiving these funds, while Republicans are more divided. Just over half (55%) of Republicans say they support a law banning clinics that provide abortions from receiving Medicaid payments for other services, while 45% oppose this. MAGA-supporting Republicans and Republican-leaning independents are more likely to support this ban (58%) than oppose it (42%).

This KFF Health Tracking Poll was designed and analyzed by public opinion researchers at KFF. The survey was conducted October 27-November 2, 2025, online and by telephone among a nationally representative sample of 1,350 U.S. adults in English (n=1,274) and in Spanish (n=76). The sample includes 1,031 adults (n=63 in Spanish) reached through the SSRS Opinion Panel either online (n=1,007) or over the phone (n=24). The SSRS Opinion Panel is a nationally representative probability-based panel where panel members are recruited randomly in one of two ways: (a) Through invitations mailed to respondents randomly sampled from an Address-Based Sample (ABS) provided by Marketing Systems Groups (MSG) through the U.S. Postal Service’s Computerized Delivery Sequence (CDS); (b) from a dual-frame random digit dial (RDD) sample provided by MSG. For the online panel component, invitations were sent to panel members by email followed by up to three reminder emails.

Another 319 (n=13 in Spanish) adults were reached through random digit dial telephone sample of prepaid cell phone numbers obtained through MSG. Phone numbers used for the prepaid cell phone component were randomly generated from a cell phone sampling frame with disproportionate stratification aimed at reaching Hispanic and non-Hispanic Black respondents. Stratification was based on incidence of the race/ethnicity groups within each frame. Among this prepaid cell phone component, 143 were interviewed by phone and 176 were invited to the web survey via short message service (SMS).

Respondents in the prepaid cell phone sample who were interviewed by phone received a $15 incentive via a check received by mail. Respondents in the prepaid cell phone sample reached via SMS received a $10 electronic gift card incentive. SSRS Opinion Panel respondents received a $5 electronic gift card incentive (some harder-to-reach groups received a $10 electronic gift card). In order to ensure data quality, cases were removed if they failed two or more quality checks: (1) attention check questions in the online version of the questionnaire, (2) had over 30% item non-response, or (3) had a length less than one quarter of the mean length by mode. Based on this criterion, one case was removed.

The combined cell phone and panel samples were weighted to match the sample’s demographics to the national U.S. adult population using data from the Census Bureau’s 2024 Current Population Survey (CPS), September 2023 Volunteering and Civic Life Supplement data from the CPS, and the 2025 KFF Benchmarking Survey with ABS and prepaid cell phone samples. The demographic variables included in weighting for the general population sample are gender, age, education, race/ethnicity, region, civic engagement, frequency of internet use and political party identification. The weights account for differences in the probability of selection for each sample type (prepaid cell phone and panel). This includes adjustment for the sample design and geographic stratification of the cell phone sample, within household probability of selection, and the design of the panel-recruitment procedure.

The margin of sampling error including the design effect for the full sample is plus or minus 3 percentage points. Numbers of respondents and margins of sampling error for key subgroups are shown in the table below. For results based on other subgroups, the margin of sampling error may be higher. Sample sizes and margins of sampling error for other subgroups are available on request. Sampling error is only one of many potential sources of error and there may be other unmeasured error in this or any other public opinion poll. KFF public opinion and survey research is a charter member of the Transparency Initiative of the American Association for Public Opinion Research.

Key Takeaways

• Marketplace enrollees largely see health insurance as very important to their ability to access care, to their financial well-being, and to their peace of mind; however, if the enhanced premium tax credits are not extended, many of the twenty-four million adults in the U.S. who currently buy their own insurance through the ACA Marketplace may consider changes to their current coverage. When asked what they would do if the amount they pay for health insurance each month doubled, one in three enrollees (32%) say they are very likely to shop for a lower-premium plan (with higher deductibles and out-of-pocket costs) and one in four (25%) say they would be very likely to go uninsured.
• Notably, with Congress potentially voting on extending the premium tax credits in December and recent discussions about a Republican health care proposal, the vast majority of enrollees (89%) expect to make a decision about the 2026 coverage by the end of the year, including many enrollees who say they have already made their decision.
• Many Marketplace enrollees are already struggling with health care costs. Six in ten adults (61%) who buy their health coverage on the ACA Marketplace say it is very or somewhat difficult to afford their deductibles and out-of-pocket costs for medical care and half (51%) say it is difficult to afford the cost of health insurance premiums each month. In addition, nearly six in ten Marketplace enrollees say they would not be able to afford an annual increase of $300 in health care expenses without significantly disrupting their household finances.
• The enhanced premium tax credits allow most Marketplace enrollees to pay less than the full price of their health insurance premiums, and the poll finds bipartisan support among Marketplace enrollees for Congress to extend these tax credits even as the political parties in Congress disagree about the way forward. More than eight in ten (84%) Marketplace enrollees – including nearly all Democrats and about seven in ten Republicans – say Congress should extend the tax credits. If the tax credits are allowed to expire, most enrollees who want to see the credits extended think either President Trump (41%) or Congressional Republicans (35%) deserve most of the blame.
• Following the longest federal government shutdown in U.S. history, which ended without an extension of the enhanced premium tax credits, about two-thirds of Marketplace enrollees say they have either “not much” or “no confidence” in President Trump, nor in Congressional Republicans, to address health care costs for people like them. Congressional Democrats fare slightly better, but still more than half of enrollees say they lack confidence in Congressional Democrats to address this issue.
• Regardless of whether Marketplace enrollees decide to continue with their current Marketplace plan, switch to a lower-premium but higher-deductible plan, or go uninsured in 2026, many will face higher health care expenses next year and many say this increased financial burden will impact how they approach the 2026 midterm election. A slight majority (54%) of enrollees who are registered to vote say if their health care expenses increase by $1,000 next year, it would have a major impact on whether they will vote in the 2026 elections and about half (52%) say it would have a major impact on which party’s candidate they will support.

Most Enrollees Are Wary About Expiring Enhanced Premium Tax Credits

Open enrollment for the ACA Marketplace began on November 1^st amid a government shutdown as Congress debated extending the tax credits. The survey, conducted in the first weeks of open enrollment and as Congress passed a short-term spending bill, finds that the focus on the enhanced premium tax credits has resonated with most Marketplace enrollees. At the time the survey was fielded in mid-November, about six in ten Marketplace enrollees say they’ve heard “a lot” (27%) or “some” (32%) about the enhanced premium tax credits. However, four in ten enrollees say they have heard “a little” (22%) or “nothing at all” (19%) about the enhanced premium tax credits. In most states, open enrollment for ACA Marketplace plans ends on January 15^th, 2026.

As of mid-November, a slight majority (56%) of enrollees say they have looked for, sought out, or received any information about what the cost of their health insurance will be in 2026. Enrollees in states that use the federal ACA Marketplace platform are more likely than those in states that have a state-run Marketplace to say they have looked for or received information about the cost of their health insurance for next year (62% vs. 49%).

More than half of Marketplace enrollees (54%) expect that the cost of their health insurance coverage for next year will “increase a lot more than usual.” A further one in four (26%) expects it to increase a “little more than usual,” while fewer expect their health insurance costs to “increase about the same as usual” (12%) or to “not increase at all” (8%). Enrollees with higher incomes are somewhat more likely than those with lower household incomes to expect their costs to increase “a lot more than usual.” Notably, Marketplace enrollees with an income just above 400% of the federal poverty level (FPL), who currently pay no more than 8.5% of their income in monthly insurance premiums, would have to pay full price for their insurance coverage if the enhanced premium tax credits are allowed to expire.

Half or more across partisans and geographies expect the cost of their health insurance for next year to increase “a lot more than usual,” including 60% of Democrats, 52% of Republicans, 54% of independents, 53% of enrollees living in states that have expanded Medicaid, and 56% of enrollees living in states that have not expanded Medicaid.

About nine in ten (89%) Marketplace enrollees say they will make a decision about their coverage for 2026 this year, including one in four (26%) who say they have already made a decision about their health insurance coverage for next year and 28% who planned to make a decision sometime in November. Enrollees must generally select a plan or be automatically reenrolled by December 15 for coverage to start on January 1, 2026. About a third (35%) of enrollees say they plan to make their health insurance decision in December, while one in ten (11%) say they plan to decide in early January.

Most Enrollees See Health Insurance as Very Important – Particularly Those Ages 50 and Older

Even with the current financial help provided by the enhanced premium tax credits, many Marketplace enrollees are already struggling to afford health care costs. About six in ten (61%) Marketplace enrollees say it is very difficult or somewhat difficult for them to afford out-of-pocket costs for medical care, and about half (51%) say they already have difficulty affording their health insurance premiums. Out-of-pocket costs for medical care ranks as the top household budget item that Marketplace enrollees find difficult to afford – ranking ahead of rent or mortgage, food and groceries, utilities, and housing costs.

Yet, health insurance is a clear priority for Marketplace enrollees. More than three in four say having health insurance is “very important” for their ability to get the health care they need (77%) and for their peace of mind (78%). About seven in ten (69%) say it is “very important” for their financial well-being. Notably, enrollees between the ages of 50 and 64 – a group that does not yet qualify for Medicare but may have additional age-related health care needs – are more likely than younger enrollees to say that health insurance is very important to accessing needed health care, to their financial well-being, and to their peace of mind. A majority of Marketplace enrollees, regardless of partisanship, say that health insurance is “very important” to their financial wellbeing, their peace of mind, and their ability to access health care.

Expiring Premium Tax Credits May Make Coverage Unaffordable for Most Marketplace Enrollees

Nine in ten Marketplace enrollees (90%) expect that the expiration of the enhanced premium tax credits will have an impact on the amount they pay monthly for their health insurance, including seven in ten (69%) who say it will have a “major impact.” KFF analysis has found that if the enhanced premium tax credits for adults who purchase their own insurance through the ACA Marketplace are not extended, the annual amount that enrollees pay for their premiums for 2026 will more than double on average.

The KFF 2025 Marketplace Enrollees Survey finds that this type of increase could have a significant impact on the household finances of the millions of adults who purchase their own insurance through the ACA Marketplaces. Nearly six in ten enrollees (58%) say they would not be able to afford an increase of just $300 per year in the amount they pay for insurance without significantly disrupting their household finances. Those with lower incomes are likely to see smaller dollar increases in their premium payments, yet notably seven in ten (70%) enrollees with household incomes under 200% FPL say they wouldn’t be able to afford a $300 increase in the amount they pay each year, which is the approximate increase for a low income person to keep a “silver plan” if the enhanced premium tax credits expire.

If enrollees said they could afford an annual increase of $300, they were then asked about their ability to afford larger annual increases. A further 20% of enrollees say they would be unable to afford an increase of $1,000 per year, the average projected increase, without significant financial disruption. Only one in eight Marketplace enrollees (13%) say they could afford an increase of $2,000 or more (which some people would face).

Younger adults are less likely to be able to afford any increase, including two-thirds (67%) of adults ages 18 to 29 who say they would not be able to afford a $300 annual increase without disrupting their household finances. ACA Marketplace insurers have expressed concern that the expiring tax credits will lead to younger, healthier people disproportionately dropping their coverage, and are therefore raising premiums more than they otherwise would.

About half of Marketplace enrollees (53%) say it would be “very difficult” for them to find another source of health insurance they could afford if their current coverage became unaffordable, and a further 36% say it would be “somewhat difficult.” Majorities of enrollees, regardless of their household income or age, say it would be at least somewhat difficult to find another source of health insurance coverage.

Marketplace enrollees may respond to a projected increase in premiums in different ways. If the monthly amount enrollees pay for their health insurance doubled (or increased by $50 for those who currently do not pay a premium), about a third (32%) say they would be “very likely” to look for a different Marketplace plan with a cheaper premium, but higher deductibles and co-pays. A quarter of enrollees (25%) say they would be “very likely” to go without health insurance. About one in seven (15%) say they would be “very likely” to look for a different job that provides health insurance that meets their needs and only 10% say they are “very likely” to stay with their current insurance plan if their monthly premium payments doubled.

Notably, about three in ten (28%) Marketplace enrollees from states with current Republican governors say they are “very likely” to go uninsured if the monthly amount they pay for health insurance doubles, as expected on average, if the tax credits are not extended. Among Marketplace enrollees in states that have not expanded Medicaid coverage under the ACA, where more people with incomes just above the poverty level are eligible to enroll in Marketplace coverage with premium tax credits, three in ten (31%) say they are very likely to go uninsured if faced with a doubling of their monthly health insurance premiums.

How a $1,000 Annual Increase Would Affect Marketplace Enrollees

Regardless of what they decide to do about their health insurance coverage for next year, the vast majority of current Marketplace enrollees are likely to face an increase in their overall health care expenses in 2026. Those who choose to stay with their current insurance plan may face substantial premium payment increases, those who switch to a lower-premium plan will likely face increased out-of-pocket costs through higher deductibles and co-pays, and those who go uninsured may face costly medical bills if they need care.

If faced with an annual increase of $1,000 in health care expenses, most Marketplace enrollees (67%) say they are very or somewhat likely to cut back spending on food, clothing, or basic household items in order to cover additional health care costs. More than half (54%) say they would be very or somewhat likely to try to find an extra job or work more hours to cover an increase in health care expenses. About four in ten (41%) say they would skip or delay paying other bills and about a third (34%) say they would take out a loan or increase their credit card debt for day-to-day expenses if faced with an increase of $1,000 in health care expenses.

Assessing the Political Implications of Failing To Extend the Tax Credits

On October 1^st, the federal government was shut down when Democratic senators attempted to negotiate a vote for continued government funding in exchange for the extension of the enhanced premium tax credits for adults who purchase their own insurance through the ACA Marketplace. As part of a deal to end the recent federal government shutdown, Republican Congressional leaders have promised Democrats a vote on the ACA Marketplace enhanced premium tax credits in December.

More than eight in ten (84%) Marketplace enrollees say that Congress should extend the enhanced tax credits, while one in six (16%) think they should let the tax credits expire. Majorities across partisanship want to extend the enhanced premium tax credits, including nearly all Democrats (95%), about eight in ten independents (84%), and about seven in ten Republicans (72%) enrolled in Marketplace plans. About seven in ten (72%) Republicans or Republican-leaning independents who support the MAGA movement and get insurance through the Marketplaces want to extend the credits, while about three in ten (28%) want to let them expire. Majorities of Marketplace enrollees, regardless of where they live, including those living in states that haven’t expanded their Medicaid programs or living in states with Republican governors, want to see Congress extend these tax credits.

If the enhanced premium tax credits are not extended, those who want to see them extended are most likely to blame Republican leaders, including President Trump. Four in ten of those who support extending the premium tax credits say that if they are not extended, President Trump deserves most of the blame (41%, or 34% of all Marketplace enrollees) and about a third (35%, or 29% of all enrollees) say Republicans in Congress deserve most of the blame. A smaller share (23%, 19% of all enrollees) says Democrats in Congress deserve most of the blame for not extending the credits.

Unsurprisingly, partisans are most likely to say the other party deserves the blame if Congress doesn’t extend the enhanced premium tax credits. However, four in ten Republican enrollees who want to see the tax credits extended say they will either place most of the blame on President Trump (21%) or Republicans in Congress (21%). Even among the most ardent supporters of President Trump, 14% of MAGA supporters say he will deserve most of the blame if the tax credits are not extended, and an additional one in five MAGA supporters (19%) say Republicans will deserve most of the blame.

Overall confidence that Congress and President Trump can address the cost of health insurance is low. About two-thirds of Marketplace enrollees say they have “not too much” or no confidence in President Trump (66%) nor in Republicans in Congress (67%) to address health insurance costs for people like them. Congressional Democrats fare only slightly better. Just over half (53%) of enrollees say they have not much or no confidence in Democrats in Congress to address the cost of health insurance for people like them. About half (47%) of Marketplace enrollees express at least some confidence in Congressional Democrats to address insurance costs. About a third say the same about President Trump (34%) and Republicans in Congress (33%).

Unsurprisingly, partisans are more likely to express at least some confidence in lawmakers from their own party. For example, about three in four (73%) Democrats with Marketplace insurance say they have at least some confidence in Democrats in Congress to address the cost of insurance for people like them. On the other hand, about three-quarters of Republicans with Marketplace coverage say they have at least some confidence in Congressional Republicans (73%) and in President Trump (75%) to address the cost of health insurance. Nearly eight in ten (78%) Democrats and nearly half (48%) of independents say they have “no confidence” in President Trump to address the cost of health insurance for people like them.

Large shares of Republicans and Republican-leaning independents with Marketplace coverage who support the MAGA movement express at least some confidence in President Trump (83%) and in Republicans in Congress (77%) to address health insurance costs; yet notably, about one in four MAGA supporters (23%) do say they have “a lot” or “some” confidence in Democrats in Congress to address this issue.

Increases in Health Care Expenses May Impact How Enrollees Approach the 2026 Elections

If current Marketplace enrollees are faced with increased health care expenses next year, there may also be some notable political implications. More than a third of Marketplace enrollees (37%) say President Trump would deserve most of the blame if their personal health care expenses increased by $1,000 next year. A third (33%) say the Republicans in Congress would be most to blame, while about three in ten (29%) place most of the blame on Democrats in Congress.

Democrats with Marketplace insurance say they would largely blame Republicans in Congress (46%) or President Trump (49%) if their health care expenses increase by $1,000 next year. Among independents, more than four in ten (44%) would blame the President, while about a third (32%) would blame Congressional Republicans, and about one in four (23%) would put most of the blame on Democrats in Congress.

Though most Republicans (65%) would blame Congressional Democrats if their health care costs increased by $1,000 next year, about a third say they would blame either Republicans in Congress (20%) or President Trump (14%). Among MAGA supporters, 17% say they would blame Republicans in Congress and a further 9% would blame President Trump if their health care expenses increase by $1,000 next year.

Additionally, for some Marketplace enrollees, an increase in health care expenses may affect how they approach the 2026 midterm elections. If their overall health care expenses, including co-pays, deductibles, and premiums, increased by $1,000 next year, about half of Marketplace enrollees who are registered to vote say it would have a “major impact” on their decision to vote in the 2026 midterm elections (54%) or which party’s candidate they will vote for (52%). About one in five say an increase in their expenses would have a “minor impact” on their decision to vote (17%) or which party they vote for (17%).

Democratic voters with Marketplace coverage are much more likely to say that a $1,000 increase in their health expenses would have a major impact on the 2026 midterm elections, both in terms of turnout and candidate choice, compared with Republican and independent voters with Marketplace coverage. Seven in ten Democrats (70%) and just over half of independents (54%) say an increase in their health care expenses would have a “major impact” on their decision to vote, as do about four in ten (39%) of Republicans. In addition, about two-thirds of Democrats (65%) as well as a slight majority of independents (55%), say an increase of $1,000 in their health care expenses next year would have a “major impact” on which party’s candidate they would support, compared to about a third of Republicans (35%). Four in ten MAGA Republican enrollees who are registered to vote say that if their health care expenses increased by $1,000 next year, it would have “no impact at all” on which party’s candidate they support in the 2026 midterm elections (40%) or whether they vote (41%).

This KFF 2025 Marketplace Enrollees Survey was designed and analyzed by public opinion researchers at KFF. The survey was conducted November 7-15, 2025, online and by telephone among a nationally representative sample of 1,350 U.S. adults ages 18-64 who are covered by a plan purchased through the Affordable Care Act Marketplace, in English (n=1,301) and in Spanish (n=49). To qualify for the survey respondents needed to indicate that they were 18-64 years old, covered by health insurance purchased directly from an insurance company, health insurance broker or a state or federal marketplace and not covered by COBRA extension of employer-based health insurance. The sample includes 972 adults (n=24 in Spanish) reached through the SSRS Opinion Panel either online (n=944) or over the phone (n=28). The SSRS Opinion Panel is a nationally representative probability-based panel where panel members are recruited randomly in one of two ways: (a) Through invitations mailed to respondents randomly sampled from an Address-Based Sample (ABS) provided by Marketing Systems Groups (MSG) through the U.S. Postal Service’s Computerized Delivery Sequence (CDS); (b) from a dual-frame random digit dial (RDD) sample provided by MSG. For the online panel component, invitations were sent to panel members by email followed by up to three reminder emails.

An additional 350 adults ages 18-64 who are currently covered by direct-purchase insurance were reached through the IPSOS Knowledge Panel online in English (n=325) and in Spanish (n=25). The IPSOS Knowledge Panel is a nationally representative probability-based panel where panel members are recruited randomly through invitations mailed to respondents randomly sampled from an Address-Based Sample (ABS) through the U.S. Postal Service’s Computerized Delivery Sequence (CDS). Another 28 adults ages 18-64 currently covered by direct-purchase insurance that were previously recruited to complete the KFF Health Tracking Polls in 2024-2025 were reached via their prepaid cell phone number. Among this prepaid cell phone component, 11 were interviewed by phone and 17 were invited to the web survey via short message service (SMS).

Respondents in the prepaid cell phone sample who were interviewed by phone received a $15 incentive via a check received by mail. Respondents in the prepaid cell phone sample reached via SMS received a $10 electronic gift card incentive. SSRS Opinion Panel respondents received a $5 electronic gift card incentive (some harder-to-reach groups received a $10 electronic gift card). Ipsos operates an incentive program that includes raffles and sweepstakes with both cash rewards and other prizes to be won. An additional incentive is usually provided for longer surveys. In order to ensure data quality, cases were removed if they failed two or more quality checks: (1) attention check questions in the online version of the questionnaire, (2) had over 30% item non-response, or (3) had a length less than one quarter of the mean length by mode. Based on this criterion, there were no cases removed.

The combined cell phone and panel samples were weighted to match the sample’s demographics to the national U.S. adult population 18-64 who are currently covered by direct-purchase insurance using data from the Census Bureau’s 2025 Current Population Survey (CPS). The demographic variables included in weighting are gender, age, education, census region, number of adults in household, and home tenure. The sample was also weighted to match the proportion of responses by individuals living in a Medicaid expansion state. Additionally, the weights account for differences in the probability of selection for each sample type (prepaid cell phone, IPSOS Knowledge Panel, and SSRS Opinion Panel). This includes adjustment for ownership of a prepaid cellphone and the design of the panel-recruitment procedure (IPSOS Knowledge Panel and SSRS Opinion Panel).

The margin of sampling error including the design effect for the full sample is plus or minus 3.3 percentage points. Numbers of respondents and margins of sampling error for key subgroups are shown in the table below. For results based on other subgroups, the margin of sampling error may be higher. Sample sizes and margins of sampling error for other subgroups are available on request. Sampling error is only one of many potential sources of error and there may be other unmeasured error in this or any other public opinion poll. KFF public opinion and survey research is a charter member of the Transparency Initiative of the American Association for Public Opinion Research.

The 2025 reconciliation law imposes significant new restrictions on states’ ability to generate Medicaid provider tax revenue, including prohibiting all states from establishing new provider taxes or from increasing existing taxes as well as reducing existing provider taxes for states that have adopted the Affordable Care Act (ACA) Medicaid expansion. Medicaid is jointly financed by the federal government and the states, with the federal government guaranteeing states federal matching payments with no pre-set limit. In federal fiscal year (FFY) 2024, the federal government paid 65% and states paid 35% of total Medicaid costs. States are permitted to finance the non-federal share of Medicaid spending through multiple sources, including state general funds, health-care related taxes (referred to as “provider taxes” throughout this brief), and local government funds.

States are now facing a more tenuous fiscal climate due to slowing revenue growth, increasing spending demands, and growing fiscal uncertainty, due in part to the 2025 reconciliation law. The Medicaid provisions in the new law, including new provider taxes restrictions, are estimated to reduce federal Medicaid spending by $911 billion (or by 14%) over a decade, with wide variation in how the effects will be felt across the states. The cuts to Medicaid coupled with other changes in the 2025 reconciliation law and changes to the ACA marketplace coverage could increase the number of people by 14.2 million when everything is fully implemented. Those that support the new limits on provider taxes say that providers and states receive federal matching funds without expending their own money, which can “inflate a state’s Medicaid match.” However, provider taxes are a key source of Medicaid funding and limiting them could exacerbate existing state budget challenges and result in lower provider payment rates or reductions in Medicaid coverage, potentially compounding the effects associated with increases in the number of people without health insurance.

This issue brief uses data from KFF’s 2025-2026 survey of Medicaid directors to describe states’ current provider taxes, explore how the 2025 reconciliation law changed the federal rules governing provider taxes, and summarize potential impacts of the changes across states.

1. All states but Alaska use provider taxes to help finance the state share of Medicaid spending. 

States have considerable flexibility in determining how to finance the state (or non-federal) share of Medicaid payments, within certain limits. While most of the state share of Medicaid spending comes from state general funds, there is considerable variation in how much states rely on other non-federal share funding sources. KFF’s 2025 Medicaid budget survey found that general funds accounted for a median of 70% of the non-federal share in state fiscal year (FY) 2026 enacted budgets, while provider taxes accounted for 18% and funds from local governments or other sources accounted for 6% (this is relatively similar to 2018 data on non-federal share funding sources reported by the Government Accountability Office (GAO) and 2024 data on general fund spending from the National Association of State Budget Officers (NASBO)). 

All states but Alaska finance part of the state share of Medicaid funding through at least one provider tax and 41 states have three or more provider taxes in place (Figure 1). Medicaid provider taxes are defined as those for which at least 85% of the tax burden falls on health care items or services or entities that provide or pay for health care items or services (see Social Security Act, Section 1903(w)(3)(A)). Provider taxes may be imposed as a percentage of provider revenues or using an alternative formula such as a flat tax on the number of facility beds or inpatient days. States use provider tax revenues to fund Medicaid “base” rates and supplemental payments; to finance eligibility expansions, including the ACA Medicaid expansion; or to more generally support the Medicaid program. Over time, states have increased their reliance on provider taxes, with expansions often driven by economic downturns or a desire to fund eligibility expansions or provider reimbursement increases. Beyond helping finance the state share of Medicaid, permissible tax arrangements may have potential financial benefits for providers who are subject to the tax and serve a high volume of Medicaid patients.

2. Provider taxes are most common for institutional providers.

Provider taxes fall on a wide range of provider types but are most common for institutional providers including hospitals (47 states), nursing facilities (45 states), and intermediate care facilities for people with intellectual or developmental disabilities (33 states, Figure 2). Provider tax revenues often finance supplemental payments to institutional providers, which may be a major source of revenues for those providers. Payment policies vary considerably by state, and research has shown that Medicaid base payment rates are below those of Medicare and often below hospitals or nursing facilities’ costs of providing services to Medicaid enrollees, causing some states to rely more heavily on supplemental payments than others to help cover costs. Beyond institutional providers, states have taxes on managed care organizations (MCOs) (22 states), ambulance providers (21 states), and “other” provider types (9 states) such as ambulatory care facilities and home care providers.

Since the 1990s, federal rules have governed states’ use of provider taxes to fund Medicaid. Provider taxes were established in the 1980s, but particularly aggressive use of provider taxes following their establishment in the 1980s led to statutory and regulatory limitations beginning in the 1990s. Federal rules prior to passage of the 2025 reconciliation law specified that provider taxes must be:

• Broad-based, which means the tax is imposed on all providers within a specified class of providers (e.g., the tax cannot be imposed only on providers that see primarily Medicaid patients);
• Uniform, which means the tax must apply equally to all providers within the specified class (e.g., the tax rate cannot be higher on Medicaid revenue than non-Medicaid revenue); and
• Not hold taxpayers (providers) “harmless,” which means states are prohibited from directly or indirectly guaranteeing that providers will receive their tax revenues back (i.e., be “held harmless”).

There are 19 classes of providers that the Centers for Medicare and Medicaid Services (CMS) uses to ensure that the tax programs are broad-based and uniform (see 42 CFR Section 433.56). In assessing whether provider taxes comply with federal laws, regulations prior to the 2025 reconciliation law’s passage specify that the hold harmless requirement does not apply when the tax revenues comprise 6% or less of net patient revenues from treating patients (see 42 CFR Section 433.68), a level sometimes referred to as a “safe harbor” or “hold harmless” limit. Provider tax revenues are most likely to be near the 6% safe harbor limit for nursing facilities followed by hospitals and intermediate care facilities for people with intellectual or developmental disabilities (Figure 2). States may obtain “uniformity waivers” of the requirements that taxes be broad-based and uniform if the state could prove the net effect of the tax is “generally redistributive,” and the amount of tax was not directly related to Medicaid payments.

3. Changes to federal rules for provider taxes are estimated to cut federal Medicaid spending by $226 billion over 10 years.

In addition to a number of other substantial Medicaid policy changes and federal funding cuts, the 2025 reconciliation law, signed by President Trump on July 4, 2025, imposes significant new restrictions on states’ ability to generate Medicaid provider tax revenue. The Congressional Budget Office (CBO) estimates these provider tax policy changes will reduce federal Medicaid spending by $226 billion over 10 years (Figure 3). Those savings stem from three new restrictions on states’ ability to raise revenues through Medicaid provider taxes including:

• An effective prohibition on new provider taxes or increases to existing ones (accounting for $89 billion in federal savings over 10 years),
• Reduced limits on provider taxes in states that adopted the Affordable Care Act (ACA) Medicaid expansion ($102 billion in federal savings), and
• Revisions to the conditions under which states may receive uniformity waivers ($35 billion over 10 years).

The effective prohibition on new provider taxes or increases to existing ones and the reduced provider tax limits in ACA Medicaid expansion states collectively account for $191 billion of the federal savings and will have the most widespread effects. Both changes stem from restrictions on the hold harmless limit. The new law effectively prevents the enactment of any new provider taxes by establishing a hold harmless limit of 0% for any taxes that were not in effect as of July 4, 2025. It also prevents any increases to existing provider taxes, which are capped at their rates as of July 4, 2025. Beginning in FFY 2028, the 2025 reconciliation law also gradually reduces the hold harmless limit for states that have adopted the ACA expansion by 0.5% annually until the safe harbor limit reaches 3.5% in FFY 2032.

CMS recently published a letter clarifying that to be “in effect” as of July 4, 2025, state or local governments must have been “actively collecting revenues” at that time. In KFF’s budget survey, four states reported plans to add new taxes in FY 2026: MCO taxes in Indiana and Nebraska and ambulance taxes in Montana and Nevada. An additional 18 states reported plans to increase existing taxes in that year, most commonly for hospital taxes. The new guidance suggests that if states had started collecting revenues for the new or increased taxes before July 4, 2025, they would be able to implement the new taxes or planned increases. This would include states that collect taxes on a delayed schedule if the collection is applicable as of July 4. If states’ taxes required waivers of the uniformity or broad-based requirements, those also had to be approved by CMS before July 4 for the tax to be “in effect.” In cases where states had enacted new taxes but scheduled implementation to start after July 4 or if the tax required an additional waiver and CMS approval for that waiver was still pending as of July 4, the states would not be able to implement the new taxes or higher rates.

CBO estimates provider tax changes in the 2025 reconciliation law will increase the number of uninsured people by 1.2 million by 2034. CBO estimates that restrictions on provider taxes would reduce the number of people with Medicaid coverage because there would be reduced resources available for states to fund Medicaid. With fewer resources available, states would need to either raise general taxes or reduce spending on other programs to maintain existing Medicaid eligibility levels, benefits, and provider payments. Although states responses will vary, CBO estimates that on average, states would replace half of the lost revenues with other state resources (either tax increases or cuts to other programs). States would make up the other half of revenue losses by reducing Medicaid spending through lower payment rates to providers, fewer covered services, or more restrictive eligibility.

4. The effective prohibition on new or increased provider taxes could impact all states, with expected cuts to existing taxes in 31 states.

All states could potentially be affected by the prohibition on new provider taxes or increases to existing ones, which will limit states’ ability to respond to the health care cuts in the 2025 reconciliation law. In KFF’s 2025 Medicaid budget survey, states noted the potential for significant state budget impacts as a result of the new provider tax changes as well as reductions in provider payment rates and state directed payments. Historically, states have used provider tax revenues as a mechanism to sustain Medicaid spending during budget shortfalls or to bolster Medicaid provider rates. The new law makes the largest reductions in federal support for health care in U.S. history and, combined with the expiration of enhanced subsidies for coverage in the ACA marketplaces, could increase the number of people without health insurance by 14.2 million people in 2034. The Medicaid cuts have particularly large effects in ACA expansion states, but the non-expansion states are expected to incur larger increases in the uninsured resulting from the loss of coverage through the ACA marketplaces. Increases in the uninsured could result in higher uncompensated care costs for providers (and have implications for the health of individuals who lose coverage or have access to fewer benefits). The effects of increased uncompensated care on hospitals and other safety net providers could be more profound because of states’ inability to bolster provider rates through new or increased provider taxes.  More broadly, the inability to add or increase provider taxes could exacerbate states’ budget challenges, especially during economic downturns.

While the prohibition on new provider taxes or increases to existing taxes cut a key source of future state Medicaid funding for all states, the revenue impacts will be even larger in the ACA expansion states that are also forced to reduce existing provider taxes. KFF data show that an estimated 31 states will have to reduce one or more provider taxes because of the lower hold harmless limits in ACA expansion states (Figure 4). As of July 1, 2025, 31 Medicaid expansion states reported having a non-exempt provider tax exceeding 3.5% (Figure 4), meaning at least 31 states will be required to reduce affected provider taxes on hospitals, MCOs, ambulances, or other affected providers (nursing facilities and intermediate care facilities are exempt). Hospital taxes are the most affected, with 28 of the 31 affected states having a hospital tax over 3.5% of net patient revenues as of July 1, 2025. Over half of the Medicaid provisions in the 2025 reconciliation law apply only to ACA expansion states, including the lower hold harmless limits. Those changes—coupled with lower provider tax revenues—may make it particularly difficult for ACA expansion states to navigate a challenging fiscal climate and increasing numbers of uninsured residents.

5. New requirements for “uniformity waivers” will force changes to provider taxes in at least seven states.

Uniformity waivers have allowed states to waive the requirement that provider taxes be broad-based and uniform if CMS determines that the tax is “generally redistributive.”  Provider taxes established through such waivers have generally taxed some types of providers within a class more heavily than others. States may use uniformity waivers to achieve policy goals such as limiting tax burdens for sole community hospitals, rural hospitals, or other vulnerable providers; but states have also used the waivers to impose taxes primarily on Medicaid providers. The disproportionate taxation of Medicaid providers has raised CMS concerns, including during the Biden Administration, and in May 2025, the Trump Administration released a proposed rule that aimed to address those concerns. The final rule was published on February 2, 2026 (Box 1).

The 2025 reconciliation law prohibits states from using uniformity waivers if the tax charges higher or lower rates based on the volume of Medicaid revenues or patients. The law specifies that taxes may not be considered generally redistributive if the state effectively varies tax rates based on the providers’ Medicaid revenues or patients, even if the tax does not explicitly name “Medicaid” when establishing the tax rates. The requirement is largely targeted at MCO taxes but may also apply to other provider tax types. It is effective as of July 5, 2025, but the Secretary may give states up to three fiscal years to come into compliance. The final rule on uniformity waivers provides states with transition periods that depend on what type of tax the waiver applies to and the most recent date of CMS approval for the waiver. Specifically:

• For taxes on MCOs with a waiver approval within 2 years of April 3, 2026, states have until the end of the current calendar to transition their taxes (this is expected to be the case in California and at least three other states).
• For all other taxes on MCOs, states have until the end of FY 2027 (which in most states, means they would need to be complying by July 1, 2027).
• For taxes on entities other than MCOs, states have through the end of FY 2028 to come into compliance.

States may come into compliance by either submitting a new waiver proposal that meets the new requirements from the final rule (Box 1) or they may otherwise modify their tax such that no waiver is necessary.

The final rule states that new limits on uniformity waivers will affect at least nine taxes in at least seven states, with effects starting as early as January 1, 2027 (Figure 5). CMS did not identify the specific states in the final rule, but in the proposed rule, CMS specifically named California, Massachusetts, Michigan, and New York as being affected.  KFF and other researchers expect that the other three states are Illinois, Ohio, and West Virginia. The final rule states that existing MCO taxes would now be prohibited in seven states unless the taxes were modified, and that within those seven states, there were at least two additional taxes affected, including one on hospitals and one on nursing homes. However, elsewhere, in the preamble to the final rule, CMS indicated that there were two nursing facility taxes that would now be prohibited. (It’s unclear whether the second nursing facility tax is within the seven states or in an eighth state.) CMS indicates that additional taxes may need to be modified or eliminated, but it is unknown which states have such taxes or what types of providers the taxes pertain to. Beyond uncertainty surrounding the scope of affected taxes, much remains unknown about how states may respond to the new rule. For example:  

• How much flexibility will states have when using differential tax rates for policy purposes such as protecting sole community hospitals, rural hospitals, or other vulnerable providers?
• How will states adjust impermissible taxes to eliminate differential rates and how much will those adjustments affect states’ revenue collections?
• How will states that experience declining revenues to finance the state share of Medicaid respond to the loss of revenues?

Access to contraception is a key element in shaping health and well-being for many women in their reproductive years. The Affordable Care Act (ACA) created a minimum set of benefits for most health plans regulated by the federal government and states, requiring most private plans to cover, without any cost sharing, the full range of FDA-approved contraceptives and services as a preventive service. In the years since its implementation in 2012, there has been a sharp decrease in the share of privately insured women who pay out of pocket costs for their prescribed contraceptives. Despite its impact reducing costs for women, the contraceptive coverage requirement has been one of the most contentious elements of the ACA leading to heated policy debates and multiple lawsuits, including three cases that reached the Supreme Court. Since the passage of the ACA, Presidential administrations have taken divergent approaches to the regulations that affect how this provision is implemented. For example, during the first Trump administration, the Department of Health and Human Services (HHS) and other related agencies promulgated a regulation that provided a broad exception to the contraception requirement to employers or plan with religious or moral objections to contraception. The Biden administration issued a proposed regulation, that was ultimately withdrawn, that would have expanded contraceptive coverage to include over-the-counter methods.

It is not known what, if any, actions the current Trump administration will make regarding contraceptive coverage. With major plans for reorganization of agencies within HHS including HRSA, the agency that has issued the contraceptive coverage requirement under the ACA rules, as well as actions to dismantle and restructure federal advisory committees, the future of contraceptive coverage is not clear. Concern about the future of this provision has spurred multiple efforts by Congressional Democrats and some state legislatures to enshrine the right to contraception, especially since Roe v Wade was overturned by the Supreme Court. This issue brief explains the rules for private insurance coverage of contraceptives at the federal and state level, the exemptions and accommodations available for certain employers, gaps in coverage for contraceptives obtained outside of the traditional clinical setting, and how changes in the agencies responsible for making contraceptive recommendations may affect coverage for contraceptives.

Use of Contraception

Contraceptive care is an important component of overall health care for many people in their reproductive years, and most women use contraception at some point in their lifetime. The majority (82%) of women of reproductive age (18 to 49) say they used some form of contraception in the past 12 months (Figure 1) and three quarters say that preventing a pregnancy is very or somewhat important to them. While most women who use contraception use it to prevent pregnancy (65%), one in five (20%) use it to both prevent pregnancy and for some other reason (such as managing a medical condition or preventing a sexually transmitted infection) and 14% use it solely for reasons outside of preventing pregnancy (such as to regulate their periods or manage acne). Among women who use contraception, nearly half (48%) report using more than one kind of contraceptive method in the past 12 months. Three in 10 (31%) women rely on permanent methods (either their own sterilization or their partner’s) and one in four (24%) used long-acting reversible methods (LARCS) like intrauterine devices (IUDs) or contraceptive implants. Four in ten (40%) women use short acting hormonal methods, with three in 10 (29%) relying on oral contraceptive pills.

Despite the fact that the ACA has been in place for 15 years, there are still gaps in awareness that federal law requires most private plans to cover the full cost of contraceptives. Among women of reproductive age, less than half (43%) know that plans are required to cover all FDA approved prescribed contraceptives. Higher shares of Black women are aware of this requirement compared to White women (49% vs. 42%). Notably, less than half (44%) of women with private insurance coverage, for whom this requirement applies, are aware that most insurance plans are required to pay the full cost of birth control for women.

ACA Federal Requirements for Contraceptive Coverage and State Laws

The Affordable Care Act requires most private plans to cover a range of recommended preventive health services provided by in-network health care providers, including contraceptives, without any cost-sharing (such as copays, deductibles or co-insurance). This requirement applies to all private plans—fully insured and self-insured plans in the individual, small group, and large group markets, except those that maintain “grandfathered” status. Individual, small, and large group plans are regulated by the state, whereas self-insured plans are regulated by the federal government under the Employee Retirement Income Security Act (ERISA). The required preventive health services for adults are those that: receive an A or B recommendation by the U.S. Preventive Services Task Force (USPSTF); are recommended by the Health Resources and Services Administration (HRSA) currently based on guidelines issued by the Women’s Preventive Services Initiative (WPSI), the expert body currently commissioned by HRSA to issue and update preventive clinical recommendations for women; and vaccine recommendations for children and adults made by the Advisory Committee on Immunization Practices (ACIP).

The HRSA contraceptive services and counseling recommendation requires plans to cover all FDA-approved, -granted, or -cleared contraceptive methods, as well as sterilization procedures, and patient screening, education, and counseling for all adolescent and adult women. This also includes any follow-up care that is required, as well as insertion and removal of implants and IUDs. The initial 2011 HRSA recommendation included the language “as prescribed” in reference to the coverage requirement for contraception. When WPSI updated the contraceptive coverage recommendation in 2021, it did not include a prescription requirement for coverage of contraception. HRSA subsequently dropped the prescription requirement in its language when the preventive services guidelines were updated and posted. While “as prescribed” is only referenced in the U.S. Departments of Labor, Health and Human Services, and Treasury (“tri-agency”) federal FAQs, plans are “encouraged” but are not required to cover over-the-counter methods, and very few do without a prescription.

Over the years, the federal tri-agency has released additional guidance clarifying the contraceptive coverage requirement. Some of this guidance has been adopted into the updated versions of the contraceptive recommendation, such as the requirement that plans must cover without cost-sharing at least one product within each FDA -approved, granted, or cleared contraceptive method category. Federal guidance clarifications include:

• Clarifying that plans must cover any contraceptives that are deemed “medically necessary” by a health care provider for an individual, including brand name drugs if a generic is not available, a clinician-recommended brand name product, and contraceptive products that are not specifically identified by HRSA, such as new contraceptive products approved by the FDA.
• Requiring plans to have an exceptions process in place for individuals whose health care provider has determined that a different contraceptive within a category (including a brand name or a different generic), that is not the one covered without cost-sharing by the plan, is “medically appropriate” for them. The exceptions process must be easily accessible and timely for patients and providers to request coverage for a medically necessary contraceptive.
• As an alternative to covering one method within each contraceptive category without cost-sharing, plans can also choose to cover all products within a contraceptive category that have no therapeutic equivalents (with the same active ingredients, dosage form, route of administration, and strength). For example, plans could choose to cover all types of hormonal IUDs currently available in the US, since none of them has a therapeutic equivalent.

Plans can use reasonable medical management to control costs and promote efficient delivery of contraceptive care. Within the categories of contraceptives that must be covered, plans may limit coverage in these categories to generic drugs and can impose cost-sharing for equivalent branded drugs. However, as noted above, plans must cover with no cost-sharing any brand names or therapeutically equivalent products that a health provider deems as “medically appropriate” for an individual. Federal guidance has also clarified that plans are not allowed to require individuals to first fail using some methods (like oral contraceptive pills) before covering a different method (such as IUDs) and cannot require that individuals first fail using certain products within a category (e.g. requiring a person to first fail using pill A before covering pill B). Plans cannot impose age limits to contraceptive services, since the recommendation applies to women with reproductive capacity.

Since the implementation of the ACA’s contraceptive coverage provision, fewer women are paying out of pocket for contraceptives. Research has found that the share of women with employer sponsored coverage who pay $0 for oral contraceptives, injectables, vaginal rings and IUDs has dramatically increased since the contraceptive coverage requirement took effect. However, a significant share of privately insured women are still paying out of pocket. Among privately insured contraceptive users, one in four (24%) report paying out-of-pocket for some or all of their contraception because their plan did not cover the full cost (Figure 2). Reasons for having out-of-pocket costs could include being enrolled in a grandfathered plan, working for an employer that has a religious objection to covering contraception, going to an out of network provider, or using a brand name method that has a generic alternative.

Before the ACA, coverage for prescription contraceptives was generally widespread in the private and public sectors, but not universal, and typically subject to cost-sharing. Unless a state had a contraceptive coverage mandate, insurers and employers could choose whether or not to provide coverage for contraception. In 2000, a ruling by the Employment Equal Opportunity Commission found that employers that covered preventive prescription drugs and services, but did not cover prescription contraceptives were in violation of the Civil Rights Act. Currently, 31 states and DC have laws requiring insurance plans to cover contraceptives and 19 states and DC prohibit cost sharing (Figure 3). State laws, however, fall short of universal coverage. They only apply to state regulated plans (Table 1), but not self-funded plans where 67% of covered workers are insured and many of these state laws also do not require plans to cover the full range of contraceptive products or do not prohibit cost-sharing (Appendix Table 1). If the ACA preventive services requirement were invalidated by the courts, only individuals with fully-insured state plans living in states with laws requiring contraceptive coverage would be guaranteed some sort of coverage.

Exemptions and Accommodations to the Contraceptive Coverage Requirement

While most employers are required to include contraceptive coverage in their plans, houses of worship can choose to be exempt from the requirement if they have religious objections. This exception means that women workers and female dependents of exempt employers do not have guaranteed coverage for either some or all FDA -approved, -granted, or -cleared contraceptive methods if their employer has an objection. Meanwhile, religiously- affiliated nonprofits and closely held for-profit corporations are not eligible for an exemption but can choose an accommodation (Figure 4). This option was first offered to religiously-affiliated nonprofit employers and then extended to closely held for-profits after the Supreme Court ruling in Burwell v. Hobby Lobby. The accommodation allows these employers to opt out of providing and paying for contraceptive coverage in their plans by either notifying their insurer, third party administrator (TPA), or the federal government of their objection. The insurers are then responsible for covering the costs of contraception, which assures that their workers and dependents have contraceptive coverage while relieving the employers of the requirement to pay for it. Because the federal government does not track this information, it is not known how many employers or plans do not cover or only provide partial coverage for contraceptive services and supplies. 

Despite its far-reaching impact, the ACA’s requirement for contraceptive coverage has been challenged in the courts on multiple occasions, with three cases reaching the Supreme Court. The earlier cases, Burwell v. Hobby Lobby (2014) and Zubik v. Burwell (2016), challenged the Obama Administration’s regulations implementing the contraceptive coverage requirement, contending that the requirement violated some employers’ religious rights. The most recent cases, Little Sisters of the Poor v. Pennsylvania (2020) and Trump v. Pennsylvania (2020), involved regulations issued by the first Trump Administration in 2018. These regulations allowed any nonprofit or for-profit employers, including private institutions of higher education, with religious objections to contraception coverage and all but publicly-traded employers with moral objections to qualify for an exemption and exclude contraceptive coverage from their plans.

In August 2025, a U.S. District Court issued a ruling in Commonwealth of Pennsylvania v. Trump in favor of Pennsylvania vacating the 2018 Trump regulations. The court found the regulations are arbitrary and capricious and were promulgated in excess of Defendants’ statutory authority and in violation of the Administrative Procedure Act’s (“APA”). The Trump administration has appealed this ruling to the Third Circuit Court of Appeals. While the Obama regulations allowing only houses of worship to be exempt are now in effect, it is not clear whether employers that dropped some or all contraceptive coverage under the Trump regulations are now in compliance or whether the Trump administration will enforce these regulations while the litigation proceeds.

Gaps in Coverage for Contraceptives Outside of the Traditional Clinical Setting

Over the past 15 years there have been efforts to broaden contraceptive availability outside of traditional clinical settings, including through commercial apps that use telehealth platforms, state efforts to allow pharmacists to prescribe birth control, and, most recently, over-the-counter (OTC) access to contraceptives without a traditional prescription. However, because the ACA’s contraceptive requirement only applies to contraception prescribed by in-network health care providers as well as challenges working getting insurance providers to work with non-traditional venues, it has been nearly impossible for individuals to obtain contraception at no cost from these new avenues using their insurance or Medicaid.

Telecontraception: A variety of online platforms are providing a new option for people to conveniently obtain contraceptive supplies that need a prescription without the need for an in-person visit (“telecontraception”). While these platforms offer a variety of brands and generic equivalents, and most offer a $10 to $15 per month oral contraception option, many report barriers working with private insurance companies. Companies that accept insurance have reported that private insurance companies are sometimes unwilling to cover contraceptive mail order deliveries beyond the first few months, likely due to pharmacy contract limitations and competition by the private insurance companies’ internal mail orders. Companies have also experienced issues with Pharmacy Benefit Managers (PBM) placing limits on refills from the telecontraception company and requiring patients to use their insurance companies PBM mail order program. One company also reported that they are considered an out-of-network provider, which means that their clients can be charged copays.

Over-the-Counter Contraceptives: In July 2023, the FDA approved the progestin-only Opill for over the counter (OTC) use, making it the first OTC daily oral contraceptive pill available for over-the-counter purchase in the U.S. without age restriction in stores and online. The suggested retail price of Opill is $19.99 for one month’s supply or $49.99 for a three-month supply. While the ACA currently requires most private plans to cover contraceptives without cost-sharing, as discussed earlier, plans typically require a prescription to trigger coverage, even for contraceptive methods that are available OTC without a prescription (such as emergency contraception). Currently, eight states (CA, CO, DE, MD, NJ, NM, NY, and WA) have laws or regulations requiring state-regulated private health insurance plans to cover, without cost sharing, some or all OTC contraception without a prescription. Requiring all plans to cover non-prescribed contraceptives would require legislation at the federal level or administrative changes to the ACA’s preventive services policy. Federal FAQs from July 2022 encourage, but do not require, plans to cover without cost sharing OTC emergency contraceptive products that are purchased without a prescription. In October 2024, the Biden Administration proposed a new rule that would have required most private plans to cover OTC methods purchased without a prescription from an in-network pharmacy and would have required plans to disclose to enrollees that OTC products were included in their coverage. In January 2025, days before the end of their presidential term, the Biden administration withdrew the proposed regulation.

Pharmacist Prescribing:  Thirty-five states and D.C. have passed laws to allow pharmacists to prescribe certain self-administered contraceptives to women, such as oral contraceptives, emergency contraception, the patch and the vaginal ring. In these states pharmacist prescribing helps reduce barriers to accessing contraception by removing the need to visit a clinician to obtain a prescription, and for people without insurance, it can be less expensive than getting a prescription from a clinician. However, challenges remain for women seeking a prescription for contraception from a pharmacist. For example, pharmacies typically charge consultation fees, which some reports suggest can be as high as $50 in certain areas. While insurers are generally required to cover contraceptives without cost sharing, they are not obligated to cover this fee. This lack of payment can lead to pharmacies charging patients a consultation fee.

The Future of Contraceptive Coverage

Changes in the Department of HHS and the agencies responsible for making women’s preventive health services recommendations may affect access and coverage to contraceptives. HHS under the Trump Administration has announced a proposal that would make major changes go through a “transformation to Make American Healthy Again.” Should this proposal be implemented, they could result in elimination of many positions and significant restructuring and consolidation of the divisions within HHS. HRSA, along with the Office of the Assistant Secretary for Health (OASH), the Substance Abuse and Mental Health Services Administration (SAMHSA), the Agency for Toxic Substances and Disease Registry (ATSDR), and the National Institute for Occupational Safety and Health (NIOSH) would be combined to form a new division, the Administration for a Health America (AHA). The statutory language in the ACA specifically names HRSA as the division responsible for making preventive services recommendations for women and it is unclear how or whether this new consolidated agency would be able to make updates or make new recommendations given the specificity of HRSA as the agency responsible for issuing the coverage guidelines for women’s preventive services in section governing coverage of preventive services in the ACA law.

The American College of Obstetricians and Gynecologists (ACOG), the organization that convenes the WPSI panel of leading medical and health professional organizations that make recommendations to for women’s preventive services to HRSA, has publicly announced that it will stop accepting federal funds for any continuation of its current contracts following changes in federal funding guidelines by the Trump administration, citing that “Recent changes in federal funding laws and regulations significantly impact ACOG’s program goals, policy positions, and ability to provide timely and evidence-based guidance and recommendations for care.” In their letter, ACOG has stated that they will continue the work, but the decision to withdraw was applauded by a Trump administration spokesman. Prior to this announcement, Project 2025 and other anti-abortion advocates had called for the federal government to cut ties with ACOG.  It is not clear how the Trump Administration will proceed after the ACOG contract expires. Whether HRSA or a new AHA agency would contract with a different organization or convene its own panel is unknown. HHS could convene a new panel to make new contraceptive recommendations or make changes to the existing one. Project 2025 and other anti-abortion organizations have called for removing IUDs and the emergency contraception pill Ella from the contraceptive coverage requirement, based on the false claim they prevent the implantation of a fertilized embryo. Research has consistently found that emergency contraception pills do not terminate a pregnancy, stop the implantation of a fertilized egg, nor affect a developing embryo and is stated on the product information available on the FDA website.

In addition, the courts continue to litigate different aspects of the ongoing preventive health services case Braidwood v. Kennedy. A federal district court is currently considering whether the Secretary of Health and Human Services’ ratification of HRSA and ACIP recommendations violates the Administrative Procedure Act and thus invalidates the preventive services issued by these agencies, including contraceptive coverage. In the original case, filed in 2022, the respondents claimed that the preventive services requirements for private health insurance are unconstitutional and that the requirement to cover pre-exposure prophylaxis treatment (PrEP) (medication to prevent getting HIV from sex or injection drug use for those at risk) violates the Religious Freedom Restoration Act (RFRA). The Supreme Court ruled in June 2025 that the ACA requirement that most private insurers and Medicaid expansion programs cover preventive services recommended by USPSTFwith no cost-sharing is constitutional. Depending on how the District Court rules regarding HRSA and ACIP and whether there are appeals to the ruling, this case may end up before the Supreme Court once again.