This analysis takes a first look at how hospitals are reporting prices under updated federal hospital price transparency requirements that took effect in January 2026. The hospital price transparency (HPT) rule requires most non-federal hospitals to publish their standard charges for each item and service they provide.

The analysis describes several key issues with how hospitals are reporting rates and other required information, which limits the usefulness of the new data for researcher comparing hospital prices. Notably, the negotiated payment arrangements between hospitals and payers are complicated and can take many forms, making it difficult to accurately compare prices across hospitals.

The brief is 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

As of October 7, 2026, 11 carriers have announced that they will exit the ACA Marketplaces in plan year 2027, either in some or all states that they are currently offering plans; six carriers have announced they will enter new state Marketplaces. These changes in insurer participation follow the expiration of the enhanced premium tax credits at the end of 2025, which drove sign-ups to fall by over a million from the 2025 to 2026 Open Enrollment Periods—with further membership declines in the ACA Marketplaces expected as the year progresses. ACA Marketplace enrollment declines affect the size of the potential market for insurers, and, potentially, the risk pool—to the extent that healthier than average enrollees are more likely to drop coverage.

As people leave the Marketplace, insurers may reassess the profitability of their Marketplace participation and decide to pull out in the future. Cigna has decided to leave the individual market in 2027 to focus on other segments given the lack of potential to grow their ACA Marketplace business. Cigna, which reported first-quarter on-exchange enrollment of over 350,000 individuals, will exit the 11 states in which it currently participates both on- and off-exchange. In some cases, multiple insurers are announcing exits in the same state. In some states, with fewer insurers participating in the ACA Marketplaces, remaining insurers will have less competition and consumers will be left with fewer choices.

Amidst challenging fiscal conditions and upcoming national and state elections, states are working to implement major federal changes to Medicaid. The 2025 reconciliation law made major changes to federal revenues and spending. Shortly after enactment, the Congressional Budget Office (CBO) estimated the new law would reduce federal spending on Medicaid by $911 billion over the 2025–2034 period and that the Medicaid changes would increase the number of people without health insurance by 7.5 million in the year 2034. Recognizing the risks such changes posed for rural areas, policy makers added a $50 billion rural health transformation program (referred to here as the “rural health fund”) to the reconciliation law. All 50 states have received first-year allotments from the rural health fund and are implementing new initiatives to support rural health care, although these funds will not offset reductions in federal Medicaid support.

Even before the new restrictions take effect, the landscape is evolving, making it difficult to isolate the effects of the changes in the law. Medicaid enrollment is declining, and states are facing tight fiscal conditions due to slowing revenue growth and increased spending pressures. The forthcoming policy changes from the 2025 reconciliation law are expected to increase coverage loss, decrease provider reimbursement rates, and place new strain on state budgets. Some more recent estimates of the law’s provisions—such as those included in proposed or final regulations—are not comparable to the older CBO estimates because they cover different time periods, use different baseline projections of spending and health coverage, and have different assumptions about how states, providers, and people will respond to the changing Medicaid policies.

Although current estimates of the effect of the law on Medicaid are not available—and are unlikely to be available in the future, this policy watch illuminates how the impacts will vary across states by showing which key eligibility and financing provisions are expected to affect each state and Washington DC (hereafter referred to as a state). Some provisions in the law affect all states, while some provisions only apply to certain states. The effects of many provisions vary by state and states that have adopted the Affordable Care Act (ACA) Medicaid expansion face the most restrictions (Figure 1). In many cases, the full effects of the law are still unknown and will depend on how federal rules are finalized and how states implement the changes. Many of the changes are administratively challenging for states to implement. Those challenges could be amplified in the 36 states with gubernatorial elections in 2026 if the election results in a change of administration. With only 17 incumbent governors currently on the ballot, at least 19 states are expecting some change in leadership.

Which States Will Be Affected by Key Medicaid Eligibility Changes?

The reconciliation law included Medicaid eligibility policies that will lead to fewer people being covered by Medicaid and disproportionately apply to Medicaid expansion states. The most substantial changes include new work requirements, more frequent eligibility redeterminations for expansion adults, and restrictions on Medicaid eligibility for immigrants (Figure 2). The law also reduces the availability of retroactive coverage to pay incurred medical expenses to two months for traditional enrollees and one month for expansion enrollees and imposes new cost-sharing requirements on expansion adults with income 100–138% of the federal poverty level (FPL, Appendix Table 1). While states will face increased administrative costs to implement these changes, lower Medicaid enrollment could reduce state and federal Medicaid costs. However, the drop in Medicaid enrollment over time may shift costs from states to providers as more people become uninsured but still have health care needs. States required to implement key Medicaid eligibility changes include:

• Forty-four states are required to implement new work requirements on certain adults. These states, including 41 expansion states and 3 non-expansion states, will be required to condition Medicaid eligibility for enrollees with coverage through the ACA Medicaid expansion or under certain waivers on meeting work requirements or qualifying for an exclusion.
• Forty-one Medicaid expansion states will need to increase the frequency of eligibility redeterminations for expansion adults from annually to every six months. This new 6-month renewal period only applies to expansion adults; states must maintain the 12-month renewal period for other populations eligible on the basis of modified adjusted gross income (MAGI), including most children, pregnant individuals, and parents who are not enrolled in expansion coverage.
• All states must restrict eligibility for certain lawfully present immigrants. As of October 1, 2026, all states are required to limit Medicaid eligibility to only certain lawfully present immigrants, eliminating eligibility for many other groups of lawfully present immigrants, including refugees and asylees without a green card, among others.

Which States Will Be Affected by Key Medicaid Financing Changes?

The reconciliation law makes major changes to Medicaid financing that will affect how states can raise the state share of Medicaid payments and how they can pay providers. Changes to Medicaid financing include new limits on provider taxes that constrain all states in their ability to raise future revenues from provider taxes and further limit the amount of revenues ACA expansion states are permitted to collect. Those new limits are likely to exacerbate states’ current fiscal challenges and may force states to make additional reductions in Medicaid spending. Changes to provider payment rates primarily stem from new limits on state directed payments (SDPs), which cap future payment rates at or near the rates paid by Medicare in all states. Unless states can offset this funding loss, providers are likely to face a significant drop in Medicaid payments at the same time they are experiencing revenue losses resulting from fewer people having health insurance. Although the rural health fund does not offset the loss of federal Medicaid revenues, it may help the 50 states that are receiving funding to adapt their systems to the loss of revenues. However, the extent to which any benefits from these initiatives persist after the time-limited funds are exhausted remains unknown.

Beyond limiting states’ future use of provider taxes, the law may reduce revenues from existing taxes in nearly all states that have adopted the ACA Medicaid expansion. New limits on provider taxes effectively prohibit all states from establishing new provider taxes or increasing the rates of existing taxes, thus limiting one tool states may have used to respond to the 2025 reconciliation law’s reduction in federal funding. For ACA expansion states, the 2025 reconciliation law decreases the percent of net patient revenues (currently 6.0%) that can be collected for all provider taxes except those on nursing facilities and intermediate care facilities. Starting October 1, 2027, the limit will decrease by 0.5 percentage points each year, until it reaches 3.5%. At least 31 states have current taxes on hospitals, managed care organizations, or ambulances that are above 3.5% of net patient revenues (Figure 3). Additional states have other provider taxes that could be affected, and a proposed rule to implement the reconciliation law requirements would expand the new limits to include health insurer taxes.

At least 41 states have SDPs, which govern the payments managed care organizations make to health care providers and could be affected by new limits in the 2025 reconciliation law. Most SDPs are for hospital services, and most set payment rates at or near rates paid by private health insurance plans. Starting January 1, 2028, payment rates for hospital services will decrease in at least 37 states with directed payments that exceed the new limits. KFF estimates that the federal government spends $93 billion on SDPs each year, $78 billion of which pays for hospital services. Of the $78 billion on hospital services, an estimated $60 billion exceeds the new payment limits and could be reduced as the reconciliation law limits take effect. Some states will be far more affected than others, with over half of the spending above new limits coming from only eight states (California, Illinois, Kentucky, Texas, North Carolina, Louisiana, Arizona, and Michigan).

All 50 states (not including Washington DC) are receiving money from the rural health fund, but the amount they are receiving per rural resident ranges from $66 (Texas) to $6,305 (Rhode Island). The rural health fund will provide grant funding to states for a period of five years, with $10 billion awarded across the states each year. First-year awards range from $147 million in New Jersey to $281 million in Texas (Appendix Table 2). Ten states’ awards are less than $100 per rural resident, but eight states’ awards are greater than $500 per rural resident. The range in funding reflects a financing formula that awards 50% of the total amount equally among all states, 25% based on “state need” (which reflects the characteristics of the states’ rural geographies, populations, and providers), and 25% based on states’ proposed initiatives (which reflects states’ plans and their use of initiatives consistent with the priorities of the current administration).

Appendix

Federal vaccine policy has shifted toward fewer recommended routine childhood vaccinations, more emphasis on individual decision-making, and greater skepticism about the safety and efficacy of some vaccines. In response, some states are relying less on federal recommendations in setting vaccination requirements. The changes coincide with declining childhood vaccination rates, rising exemptions from school vaccine requirements, and a major measles resurgence. The public’s trust in federal health officials remains low.

Overview

Since January 2025, the Trump administration has made major changes in federal vaccine policy, including which vaccines the federal government recommends, who makes those recommendations, and the kinds of messages that it is providing to the public.  

The changes represent a shift from an expert-driven federal vaccine framework with broad support for routine childhood immunizations toward narrower federal recommendations, fewer recommended childhood vaccinations, greater state variation and greater reliance on individual decision-making. They are unfolding against a backdrop in which childhood vaccination rates were already declining and as vaccine-preventable diseases such as measles are resurging in several states.

Key Developments

Health and Human Services Secretary Robert F. Kennedy Jr., a longtime critic of federal vaccine policy who has questioned the safety and effectiveness of vaccines, has spearheaded the overhaul. Kennedy also is a leading figure in the Make America Healthy Again (MAHA) movement, which has elevated issues such as vaccine safety, the role of corporate interests in federal health agencies, and the presence of chemicals in the food supply.

In June 2025, Kennedy fired and replaced all the members of the Advisory Committee on Immunization Practices (ACIP), the expert panel charged with providing evidence-based recommendations to the Centers for Disease Control and Prevention (CDC).

During 2025, among other policy changes, the CDC revoked its recommendation that healthy children and pregnant women receive routine COVID-19 vaccines and later, in line with guidance from the reconstituted ACIP, revised its immunization schedule to recommend “shared clinical decision-making” for COVID-19 vaccines. In December, ACIP members voted to end the 34-year-old recommendation that all newborns receive the hepatitis B vaccine within 24 hours of birth.

That same month, federal health officials made vaccination reporting measures voluntary rather than mandatory in Medicaid and the Children’s Health Insurance Program, which could make it harder to monitor and understand vaccination trends for children.

The most significant changes came in January 2026, when HHS adopted a substantially revised childhood vaccination schedule. This reduced the number of diseases targeted from 17 to 11 and the number of routine vaccines from 13 to 7, making the U.S. an outlier among peer nations. As a result, six vaccines are no longer recommended for routine use by all children in the U.S.: rotavirus, COVID-19, influenza, hepatitis A, hepatitis B, and meningococcal vaccines. Some of these vaccines are now recommended for a narrower group of children, and all six have been moved from the routine category of vaccination to “shared clinical decision making.” (A federal judge has temporarily blocked the revised HHS recommendations.)

In August, The White House released an executive order reiterating the changes to the childhood vaccination schedule. It also called on the HHS Secretary to offer some childhood vaccines such as measles, mumps, and rubella (MMR) as “single vaccines rather than combination products”, meaning they would be delivered in three separate shots rather than in a single vaccination covering all three.

More generally, President Trump and Secretary Kennedy have repeatedly raised safety concerns about vaccines, including advancing the idea that vaccines cause autism and linking childhood vaccinations with a rise in chronic diseases in children — assertions for which there is no evidence.

At the state level, at least nine states have enacted changes since 2025 that make non-medical exemptions to mandatory school vaccinations more permissive, including by reducing documentation or procedural requirements. Research indicates that easier-to-obtain non-medical exemptions are associated with higher exemption rates and declining childhood vaccination coverage.

Recent Issues and Looking Ahead

In response to the federal changes, a growing number of states has begun to separate their vaccination requirements from federal recommendations. As of August 2026, 30 states and DC had announced they would no longer follow CDC/ACIP recommendations for one or more childhood vaccines, with 27 states delinking from CDC/ACIP recommendations for all childhood vaccines. States are relying instead on prior recommendations, state recommendations, and/or the guidance of external entities such as the American Academy of Pediatrics (AAP) in shaping their state vaccination requirements for children.

The federal changes also have raised concerns about insurance coverage of vaccines. Many private insurers, Medicaid programs, and the federally funded Vaccines for Children program are required to cover ACIP-recommended vaccines without cost-sharing. Changes in recommendations can affect which vaccines insurers must cover at no cost. In practice, the effects vary because states can establish additional requirements, particularly for state-regulated insurance plans and school entry. As a result, vaccine recommendations and potentially the coverage available to families can differ by state. For now, insurers have said they will continue to cover the same vaccinations, and the federal court ruling means the HHS changes to the childhood vaccination schedule remain blocked.

All of this is occurring in a landscape in which childhood vaccination rates were already falling. Data show that 92.4% of kindergarteners had been vaccinated against measles, mumps, rubella (MMR) and polio and 92.0% against DTaP (diphtheria, tetanus, and acellular pertussis) for the 2025-2026 school year. That was down from 95% across all three vaccines for the 2019-2020 (pre-pandemic) school year and below coverage levels of the past decade. At the same time, the share of kindergarteners with exemptions from one or more school vaccination requirements rose to 4.2%, up from 2.5% in 2019-2020.

A vaccination rate of at least 95% is needed to prevent community transmission of measles. Thirty-nine states had MMR coverage below the 95% level, and 18 states were below 90%.

Although measles has been officially “eliminated” from the U.S. since 2000, measles cases have surged over the past two years. In 2026, the U.S. has reported nearly 3,887 confirmed cases of measles as of October 1, more than in any year since 1991, already exceeding the total for all of 2025 and putting the U.S.’s elimination status at risk. Measles cases have been reported in most states, with South Carolina, Utah, Pennsylvania, Texas, and Virginia seeing the largest outbreaks so far in 2026.

The Public’s Views

KFF polling finds that the public’s trust in the CDC remains at its lowest point following the Trump administration’s revisions to the childhood vaccination schedule. Fewer than half (47%) now say that they trust the agency at least “a fair amount” to provide reliable vaccine information, down more than 10 percentage points since the beginning of the second Trump administration, and continuing a downward trend first measured during the COVID-19 pandemic. Views differ along partisan lines, and the recent decline reflects falling confidence in the CDC among Democrats.

About four in ten voters approve of the Trump administration’s handling of vaccine policy (38%) while six in ten disapprove (61%). Democrats hold the advantage over Republicans in whom voters trust to handle vaccine policy (41% vs. 25%), though one quarter trust neither party. While some of the administration’s vaccine policy changes may have been intended to appeal to MAHA voters, among voters who support MAHA, four in ten say lowering health care costs should be the government’s top health care priority, while only one in ten choose reevaluating vaccine safety.

More people than ever got coverage through the Affordable Care Act (ACA) Marketplaces in 2025, but the expiration of enhanced premium tax credits has driven up what people pay and contributed to declining enrollment in 2026. Law and regulatory changes also tightened ACA eligibility and enrollment requirements, including for some lawfully present immigrants. Public opinion of the ACA remains generally favorable, although views remain divided along partisan lines.

Overview

The Affordable Care Act (ACA) Marketplaces, sometimes called Obamacare markets, allow individuals and families who don’t get coverage from other sources to buy their own insurance, often with the help of federal tax credits based on income to make comprehensive coverage more affordable.

Effectuated enrollment – that is, the number of people who paid their premiums – climbed to a record 21.8 million in 2025 in large part due to more generous temporary enhanced premium tax credits. These enhanced tax credits reduced premium payments for lower and middle-income Marketplace enrollees and also made some upper-middle class and higher-income enrollees newly eligible for financial assistance. The enhanced tax credits were first passed as part of a relief package during the COVID-19 pandemic and later extended temporarily by the Inflation Reduction Act.

The expiration of those temporary tax credits at the end of 2025 sharply increased what people have to pay out of pocket toward premiums. The total cost of marketplace insurance also is on the rise, with insurers seeking a median premium increase of about 15% for 2027. While the remaining tax credits will protect most enrollees from the full impact of next year’s premium hikes, those with higher incomes who are no longer eligible for financial assistance would have to pay the full costs.

There are also concerns about how shrinking enrollment and rising prices will affect the marketplace’s stability going forward. Some insurers cite a deteriorating risk pool as a factor in rate increases as healthier enrollees drop coverage rather than paying more, and some insurers plan to leave some ACA markets.

Key Developments

As part of the 2025 reconciliation law, sometimes called “the One Big Beautiful Bill,” Congress created new pre-enrollment verification requirements, which could effectively end autorenewals  starting in 2028; required enrollees who underestimated their incomes at the start of the year to fully repay any excess tax credits; and prohibited many lawfully present immigrants from receiving ACA tax credits.

The Trump administration also finalized stricter enrollment and eligibility procedures, including additional verification of income, household information, immigration status, and other eligibility details. Many of these requirements, as well as other changes included in a 2026 regulation, are on hold due to pending litigation but could lead to further enrollment decline if implemented.

The reconciliation law enacted in July 2025 did not address the expiring enhanced premium tax credits. Late last year, Republicans in Congress blocked efforts by Democrats to extend the tax credits before they expired, arguing that they were so generous that they allowed insurers to charge more and encouraged improper or fraudulent enrollment.

The Trump administration also is working to make it easier for consumers to enroll in alternatives to ACA Marketplace coverage, such as short-term limited duration health plans. Unlike Marketplace insurance, short-term plans can reject consumers based on their medical history. Enrollees are also not eligible for any of the ACA’s premium tax credits, meaning they have to pay the full cost themselves regardless of their income.

In September, the Trump administration announced it would send $500 check to nearly 1 million ACA Marketplace enrollees in 30 states – a small share of current enrollees. Enrollees who won’t get rebates include those in mostly blue states that run their own Marketplace and those who receive premium tax credits, even though what they’re paying has gone up. The Administration also announced it would cancel coverage for more than 760,000 people it says were improperly enrolled and did not respond to a request for more information within 30 days. That process likely resulted in some legitimately enrolled consumers losing their coverage.

Recent Issues and Looking Ahead

After the temporary tax credits expired, what people would have to pay in premiums after accounting for tax credits increased by 114% or more than $1,000 annually to stay in the same plan in 2026. Facing higher premium payments, some dropped coverage, while some others switched to lower-premium plans with higher deductibles. On net, premium payments increased 58% on average (as opposed to 114%), but deductibles increased by 37% or about $1,000 more per person due to many people buying down to lower levels of coverage. Eight in ten of those who chose to remain in the marketplace say their health care costs went up, and more than half said they were cutting back on other expenses to afford the increases.

Effectuated enrollment in Marketplace plans fell for the first time in seven years, from 21.8 million last year to 19.2 million in 2026.  Enrollment dropped in every state except New Mexico, which offered state subsidies to replace the expired tax credits. Enrollment is expected to drop further this year, potentially as low as 17.5 million, as consumers wrestle with higher premium payments.

Looking ahead, the Congressional Budget Office projected that the reconciliation law’s ACA provisions alone would increase the number of uninsured by 2.1 million by 2034. Combined with the law’s Medicaid changes and the expiration of the enhanced tax credits, the estimated increase in the uninsured by 2034 topped 14 million people.

The Public’s Views

Most of the public views the ACA favorably as it has since 2017, when congressional Republicans failed to repeal the law during the first Trump administration. As of March, 61% of the public hold favorable views, while 38% hold unfavorable views. Views diverge by political party, with nine in ten Democrats and nearly two thirds of independents (64%) viewing the law favorably, while two thirds of Republicans (67%) hold unfavorable views.

Support for extending the ACA’s enhanced tax credits was also strong throughout 2025. Earlier this year, two thirds of the public (67%), including strong majorities of Democrats and independents, said that Congress did the wrong thing by failing to extend the tax credits. Most Republicans (63%) said Congress did the right thing.