The Politics of Health Care and Elections

Name: KFF Health Tracking Poll: The Public's Views on the ACA
Creator: KFF

Published: October 8, 2025

Health Policy 101:

Introduction

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KFF Authors:

Larry Levitt , and

Rakesh Singh

Introduction

Health policy and politics are inextricably linked. Policy is about what the government can do to shift the financing, delivery, and quality of health care, so who controls the government has the power to shape those policies.

Elections, therefore, always have consequences for the direction of health policy – who is the president and in control of the executive branch, which party has the majority in the House and the Senate with the ability to steer legislation, and who has control in state houses. When political power in Washington is divided, legislating on health care often comes to a standstill, though the president still has significant discretion over health policy through administrative actions. And, stalemates at the federal level often spur greater action by states.

Health care issues often, but not always, play a dominant role in political campaigns. Health care is a personal issue, so it often resonates with voters. The affordability of health care, in particular, is typically a top concern for voters, along with other pocketbook issues, and, at over 17% of the economy, health care has many industry stakeholders who seek influence through lobbying and campaign contributions. At the same time, individual policy issues are rarely decisive in elections.

Health Reform in Elections

Health “reform” – a somewhat squishy term generally understood to mean proposals that significantly transform the financing, coverage, and delivery of health care – has a long history of playing a major role in elections.

Harry Truman campaigned on universal health insurance in 1948, but his plan went nowhere in the face of opposition from the American Medical Association and other groups. While falling short of universal coverage, the creation of Medicare and Medicaid in 1965 under Lyndon Johnson dramatically reduced the number of uninsured people. President Johnson signed the Medicare and Medicaid legislation at the Truman Library in Missouri, with Truman himself looking on.

Later, Bill Clinton campaigned on health reform in 1992, and proposed the sweeping Health Security Act in the first year of his presidency. That plan went down to defeat in Congress amidst opposition from nearly all segments of the health care industry, and the controversy over it has been cited by many as a factor in Democrats losing control of both the House and the Senate in the 1994 midterm elections.

For many years after the defeat of the Clinton health plan, Democrats were hesitant to push major health reforms. Then, in the 2008 campaign, Barack Obama campaigned once again on health reform, and proposed a plan that eventually became the Affordable Care Act (ACA). The ACA ultimately passed Congress in 2010 with only Democratic votes, after many twists and turns in the legislative process. The major provisions of the ACA were not slated to take effect until 2014, and opposition quickly galvanized against the requirement to have insurance or pay a tax penalty (the “individual mandate”) and in response to criticism that the legislation contained so-called “death panels” (which it did not). Republicans took control of the House and gained a substantial number of seats in the Senate during the 2010 midterm elections, fueled partly by opposition to the ACA.

The Affordable Care Act (Obamacare)

The ACA took full effect in 2014, with millions gaining coverage, but more people viewed the law unfavorably than favorably, and repeal became a Republican rallying cry in the 2016 campaign. After the election of Donald Trump, a high-profile effort to repeal the law was ultimately defeated following a public backlash. The ACA repeal debate was a good example of the trade-offs inherent in all health policies. Republicans sought to reduce federal spending and regulation, but the result would have been fewer people covered and weakened protections for people with pre-existing conditions. KFF polling showed that the ACA repeal effort led to increased public support for the law, which persists today.

KFF Health Tracking Poll: The Public's Views on the ACA

While President Trump failed in his first term to repeal the ACA, his administration repealed the individual mandate penalty, reduced federal funding for consumer assistance (navigators) by 84% and outreach by 90%, and expanded short-term insurance plans that can exclude coverage of preexisting conditions.

In a strange policy twist, the Trump administration ended payments to ACA insurers to compensate them for a requirement to provide reduced cost sharing for low-income patients. But, insurers responded by increasing premiums, which in turn increased federal premium subsidies and federal spending, likely strengthening the ACA.

Between President Trump’s presidential terms, the Biden administration restored outreach funding and signed legislation increasing the premium tax credits that help ACA Marketplace enrollees pay their premiums, leading to record enrollment and historically low uninsured rates.

The increased premium tax credits are set to expire at the end of 2025 unless Congress and President Trump take action. If these tax credits do expire, people purchasing subsidized coverage will face significant increases in their monthly premium payments and some may become priced out of the market.

President Trump’s second term has already brought federal policy changes that will significantly alter ACA Marketplace operations, consumer protections, and premium tax credit eligibility. Key changes in the 2025 budget reconciliation law, such as ending auto-renewals, removing repayment limits for tax credits when income rises, and tightening eligibility verification, are projected by the Congressional Budget Office (CBO) to result in 2 million people becoming uninsured.

Medicaid

Since its establishment in 1965, Medicaid has evolved as states took up the optional joint federal-state program to the point that in the 1980s all 50 states were participating. Due to the nature of its federal and state management, there has been a give-and-take over the flexibility of and spending for the program, but it has generally expanded in its coverage of key population groups.

With the passage of the ACA, Medicaid experienced its largest federal policy coverage expansion with the addition of what was ultimately a state option to cover adults with incomes up to 138% of the federal poverty level in exchange for enhanced federal funding for the coverage. Much like the take-up of the original Medicaid program, states have gradually adopted the expansion so that only 10 states, mainly concentrated in the South, remain holdouts. However, recent federal actions may alter the expansion landscape.

Until 2025, the most serious attempt by federal policymakers to make cuts to the Medicaid program was during the 2017 failed attempt to repeal the ACA. Medicaid changes in the legislation included a rollback of enhanced federal matching funds for the Medicaid expansion and a per-enrollee cap of federal funds for most Medicaid enrollees. The 2025 budget reconciliation law includes the largest enacted cuts in Medicaid’s history, instituting Medicaid work requirements, tightening eligibility checks and reducing or capping types of provider funding. The CBO estimates that 7.5 million people will become uninsured due to the Medicaid provisions of the law. However, several of the Medicaid provisions will not be implemented until after the 2026 midterm elections.

Affordability of Health Care

One persistent feature of health care as an election issue is that it is fundamentally an economic issue for the country and for individuals. If you are uninsured, you not only experience access issues, but also the high cost of health care treatment. If you have health insurance, you worry about annual premium changes, deductibles, and cost-sharing related to health care services and prescription drugs whose prices continue to rise.

President Trump has often spotlighted the high price of prescription drugs, criticizing both the pharmaceutical industry and pharmacy benefit managers. Although he kept the issue of drug prices on the political agenda as president, in the end, his first administration accomplished little to restrain them.

President Biden signed the Inflation Reduction Act, which requires the federal government to negotiate the prices of certain drugs in Medicare, which was previously banned. How aggressively the prescription drug negotiation program proceeds during the second Trump administration is an open question. While President Trump has issued an executive order calling for a “most favored nation” policy for drug pricing, with prices in the U.S. matching the currently lower prices in other countries, it remains unclear how drug companies will respond to the call and whether there will be any enforcement mechanism.

Health Care Infrastructure of the Federal Government

A feature of the second Trump administration has been the push to remake the executive branch of the federal government to reflect his priorities at a scale that hasn’t occurred in the recent past. Secretary of Health and Human Services (HHS), Robert F. Kennedy, Jr., announced a plan to restructure the department in March 2025 that would reduce the workforce substantially, create the new agency Administration for a Healthy America, reorganize and consolidate divisions and relocate offices.

HHS Secretary Kennedy is also leading the Make America Healthy Again (MAHA) Commission and making substantial changes to the vaccine approval process by remaking the roster for the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices and having CDC change recommendations for who should receive the COVID-19 vaccine.

These changes to the federal health care infrastructure could impact the accessibility of vaccines and other preventive services, as well as undermine the confidence the public has in the government, particularly its scientific agencies.

Future Outlook

Ultimately, irrespective of the issues that get debated during the campaign, the outcome of federal elections – who controls the White House and Congress – has significant implications for the future direction of health care.

However, even with changes in party control of the federal government, generally incremental movement to the left or the right is the norm. Sweeping changes in health policy, such as the creation of Medicare and Medicaid or passage of the ACA, are rare in the U.S. political system and are usually preceded by one-party control of Congress and the presidency. More fundamental changes in health care financing and coverage, such as Medicare for All, face long odds. This is the case even though most of the public favors Medicare for All, though attitudes shift significantly after hearing messages about its potential impacts.

It has historically been politically difficult to take benefits away from people once they have them. That, and the fact that seniors are a strong voting bloc, has been why Social Security and Medicare have been considered political “third rails.” While Medicare and Social Security were largely untouched in the Republican tax and spending law passed in 2025, the law made substantial cuts to the ACA and Medicaid, and millions more people are projected to become uninsured in what will be the biggest rollback in federal support for health coverage ever. Looking toward the 2026 midterm election and beyond, changes to both the ACA and Medicaid, as well as fundamental changes to the health care infrastructure and public health policies of the federal government, may emerge as major campaign issues.

Resources

Citation

Levitt, L. & Singh, R., The Politics of Health Care and the 2024 Election. In Altman, Drew (Editor), Health Policy 101, (KFF, October 2025) https://www.kff.org/elections/health-policy-101-the-politics-of-health-care-and-elections/ (date accessed).

The Affordable Care Act 101

Published: October 8, 2025

Health Policy 101:

Introduction

All Chapters

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KFF Authors:

Jared Ortaliza ,

Matt McGough , and

Cynthia Cox

What Is the Affordable Care Act?

On March 23, 2010, President Obama signed the Affordable Care Act (ACA) into law, marking a significant overhaul of the U.S. health care system. Prior to the ACA, high rates of uninsurance were prevalent due to unaffordability and exclusions based on preexisting conditions. Additionally, some insured people faced extremely high out-of-pocket (OOP) costs and coverage limits. The ACA aimed to address these issues, though it did not eliminate all of them.

The ACA affects virtually all aspects of the health system, including insurers, providers, state governments, employers, taxpayers, and consumers. The law built on the existing health insurance system, making changes to Medicare, Medicaid, and employer-sponsored coverage. A fundamental change was the introduction of regulated health insurance exchange markets, or Marketplaces, which offer financial assistance for ACA-compliant coverage to those without traditional insurance sources. This chapter has a special focus on these Marketplaces that are integral to the ACA’s framework.

What Did the ACA Change About Health Coverage in the U.S.?

A key goal of the ACA was to expand health insurance coverage. It did so by expanding Medicaid to people with incomes up to 138% of the federal poverty level (the poverty level in the continental U.S. is $15,650 for a single individual in 2025); creating new health insurance exchange markets through which individuals can purchase coverage and receive financial help to afford premiums and cost sharing, in addition to separate exchange markets through which small businesses can purchase coverage; and requiring employers that do not offer affordable coverage to pay penalties, with exceptions for small employers. In the years leading up to the passage of the ACA, about 14-16% of people in the United States were uninsured (across all ages). By 2023, the uninsured rate had fallen to a record low of 7.7%. Most of the gains in insurance coverage have come from the ACA’s expansion of Medicaid, followed by the creation of the exchange markets.

For people with private health insurance, the ACA also includes several consumer protections and market rules (discussed in more detail in the chapter on regulation of private insurance). For example, the ACA prohibits health plans from denying people coverage, charging them higher premiums, as well as rescinding or imposing exclusions to coverage due to preexisting health conditions. The ACA also prohibits annual and lifetime limits on the dollar amount of coverage and restricts the amount of out-of-pocket costs individuals and families may incur each year for in-network care. Additionally, the law requires most health plans to cover preventive health services with no out-of-pocket costs. Health insurers must also issue rebates to enrollees and businesses each year if they fail to meet Medical Loss Ratio standards. Moreover, people with private coverage can keep their young adult children on their health plan up to age 26.

The ACA imposes additional new regulations on private health plans sold to individuals and small businesses. These rules significantly limit the ways in which health plans can charge higher premiums. ACA-compliant health plans sold on the individual and small group markets can only vary premiums based on location, family size, tobacco use, and age (with older adults being charged no more than three times younger adults). This means that people with preexisting conditions cannot be charged higher premiums, nor can insurers charge higher rates based on gender or other factors. The ACA requires individual and small group insurers planning to increase premiums significantly to justify those rate increases publicly and also included grants for states to improve their rate review programs. The ACA also created risk programs in the individual and small group markets to mitigate adverse selection and to reduce health insurers’ incentives to avoid attracting sicker enrollees.

Federal Law Market Rules for Private Health Insurance Sold to Individuals And Groups (Table)

While Medicaid expansion is one of the most impactful provisions of the ACA, the law changed Medicaid in other ways too. For example, people gaining coverage through the Medicaid expansion are guaranteed a benchmark benefit package that covers essential health benefits. Furthermore, the ACA required state Medicaid programs to cover preventive services without cost sharing. The law also increased Medicaid payments to primary care providers, provided new options for states to cover in-home and community-based care, increased Medicaid drug rebates, and extended those rebates to Medicaid managed care plans.

The ACA also made a number of changes to Medicare. Notably, the ACA phased out the Medicare Part D prescription drug benefit coverage gap (colloquially known as the “donut hole”) and provides preventive benefits for Medicare enrollees without cost sharing. The ACA also includes several changes aimed at reducing the growth in Medicare spending. For example, the ACA includes reductions in the growth of Medicare payments to hospitals and other providers, and to Medicare Advantage plans. The law also created an Innovation Center within the Centers for Medicare and Medicaid Services (CMS) tasked with developing and testing new health care payment and delivery models and established the Medicare Shared Savings Program, a permanent accountable care organization (ACO) program in traditional Medicare that offers financial incentives to providers for meeting or exceeding savings targets and quality goals.

Finally, the ACA includes many other provisions that do not relate directly to health coverage. For example, the ACA authorizes the Food and Drug Administration to approve generic versions of biologic drugs. There are also provisions that aim to reduce waste and fraud, expand the health care workforce, increase data collection and reporting on health disparities, and improve public health preparedness.

When passed, the ACA was designed to be budget neutral, with health insurance subsidies and expansions of public programs financed through a variety of taxes and fees on individuals, employers, insurers, and certain businesses in the health sector, as well as savings from the Medicare program. As discussed in more detail below, some of these taxes or fees have since been repealed or reduced to zero dollars, including the individual mandate penalty, the medical device tax, and the so-called “Cadillac Tax,” which would have imposed an excise tax on high-cost employer health plans. Additionally, at times, a tax on health insurance carriers has been temporarily put on hold.

What are the ACA Marketplaces or Exchanges?

Health Insurance Marketplaces (also known as exchanges) are organizations set up to create more organized and competitive markets for individuals and families buying their own health insurance. The Marketplaces offer a choice of different health plans, certify plans that participate, and provide information and in-person assistance to help consumers understand their options and apply for coverage. Premium and cost-sharing subsidies based on income are available through the Marketplace to make coverage more affordable for individuals and families. People with very low incomes can also find out if they are eligible for coverage through Medicaid and CHIP while shopping on the Marketplace.

Some small businesses can buy coverage for their employees through separate exchanges called Small Business Health Options Program (SHOP) Marketplace plans, but this chapter focuses primarily on the Marketplaces for individuals and families.

There is a health insurance Marketplace in every state for individuals and families and for small businesses. Some enrollment websites are operated by the state government or quasi-governmental bodies at the state level and have a special state name (such as Covered California or The Maryland Health Benefit Exchange). In 28 states where the federal government runs the enrollment website, it is called HealthCare.gov. As of early 2025, three state-based Marketplaces (Arkansas, Illinois, and Oregon) use the federal platform.

The Marketplaces exist alongside other coverage that is also sold to individuals or small businesses. The Marketplaces for individuals and families are part of what is called the “individual insurance market,” which also includes ACA-compliant and non-compliant insurance sold off the Marketplace (also called off-exchange coverage). Similarly, the “small group insurance market” includes the SHOP Marketplace plans as well as other ACA-compliant and non-compliant coverage sold to small businesses.

Who Can Enroll in Individual ACA Marketplace Coverage?

While many Americans are allowed to purchase unsubsidized coverage on the ACA Marketplaces, these markets primarily exist to fill a gap in coverage options for people who cannot get insurance through work or public programs. Some people who sign up for Marketplace coverage are unemployed or between jobs, while others are students, self-employed or work at businesses that do not offer coverage (e.g., very small companies) or offer coverage that is deemed unaffordable.

To receive the premium tax credit for coverage starting in 2025, a Marketplace enrollee must meet the following criteria:

Have a household income at least equal to the Federal Poverty Level (FPL), which for the 2025 benefit year will be determined based on 2024 poverty guidelines.
Not have access to affordable coverage through an employer (including a family member’s employer).
Not be eligible for coverage through Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP).
Have U.S. citizenship or proof of legal residency (lawfully present immigrants whose household income is below 100 percent FPL can also be eligible for tax subsidies through the Marketplace if they meet all other eligibility requirements, though this exception is set to end starting in 2026).
If married, must file taxes jointly.

Employer coverage: If a person’s employer offers health coverage but that coverage is deemed unaffordable or of insufficient value, the employee and/or their family may be able to receive subsidies to buy Marketplace coverage. Employer coverage is considered affordable if the required premium contribution is no more than 9.02 percent of household income in 2025. The Marketplace will look at both the required employee contribution for self-only and (if applicable) for family coverage. If the required employee contribution for self-only coverage is affordable, but the required employee contribution for family coverage is more than 9.02 percent of household income, the dependents can purchase subsidized exchange coverage while the employee stays on employer coverage.

The employer’s coverage must also meet a minimum value standard that requires the plan to provide substantial coverage for physician services and for inpatient hospital care with an actuarial value of at least 60 percent (meaning the plan pays for an average of at least 60 percent of all enrollees’ combined health spending, similar to a bronze plan). The plan must also have an annual OOP limit on cost sharing of no more than $9,200 for self-only coverage and $18,400 for family coverage in 2025.

People offered employer-sponsored coverage that fails to meet either the affordability threshold or minimum value requirements can qualify for Marketplace subsidies if they meet the other criteria listed above.

Eligibility for Medicaid: In states that have expanded Medicaid under the ACA, adults with income up to 138 percent FPL are generally eligible for Medicaid and, therefore, are ineligible for Marketplace subsidies. In the states that have not adopted the Medicaid expansion, adults with income as low as 100 percent of FPL can qualify for Marketplace subsidies, but those with lower incomes are not eligible for tax credits and generally not eligible for Medicaid unless they meet other state eligibility criteria.

Starting in 2026, federal policy changes will restrict premium tax credit eligibility for legal immigrants who are ineligible for Medicaid due to their alien status. An exception to the rule restricting tax credit eligibility for adults with income below the FPL was previously made for certain lawfully present immigrants. Other federal rules restrict Medicaid eligibility for lawfully present immigrants, other than pregnant women, refugees, and asylees, until they have resided in the U.S. for at least five years. Prior to the implementation of this policy change, immigrants who would otherwise have been eligible for Medicaid but had not yet completed their five-year waiting period instead qualified for tax credits through the Marketplace. If an individual in this circumstance has an income below 100 percent of FPL, for the purposes of tax credit eligibility, their income would have been treated as though it was equal to the FPL. Immigrants who are not lawfully present are ineligible to enroll in health insurance through the Marketplace, receive tax credits through the Marketplace, or enroll in non-emergency Medicaid and CHIP. In November 2024, the Biden administration published new rules that deemed Deferred Action for Childhood Arrivals (DACA) recipients as lawfully present, making them eligible for subsidized ACA Marketplace coverage. However, finalized Marketplace Integrity and Affordability rules undo this change.

What Services Do ACA Marketplace Plans Cover?

The ACA requires all qualified health benefits plans to cover essential health benefits, including those offered through the Marketplaces and those offered in the individual and small group markets off-exchange. Grandfathered individual and employer-sponsored plans (which existed before the ACA was passed) and non-compliant plans (which include short-term plans) do not have to cover essential health benefits.

The law specifies that the essential health benefits package must include at least 10 categories of items and services: ambulatory patient services; emergency services; hospitalization; pregnancy, maternity, and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care. It also requires that the scope of benefits be equal to that of a “typical employer plan.”

These categories are broad and subject to interpretation. For example, there could be limits on the number of physical therapy services an enrollee receives in a year. For more specific guidance on how to interpret these requirements, the federal government allows states to select a “benchmark” health plan (often one that was already offered to small businesses) as a standard.

Essential health benefits are a minimum standard. Plans can offer additional health benefits, like vision, dental, and medical management programs (for example, for weight loss). The ACA prohibits abortion coverage from being required as part of the essential health benefits package. The premium subsidy does not cover non-essential health benefits, meaning that people enrolling in a plan with non-essential benefits may have to pay a portion of the premium for these additional benefits.

Although plans must cover essential health benefits, they are allowed to apply cost sharing (deductibles, copayments, and coinsurance). This means enrollees may still face some out-of-pocket costs when receiving these services. However, preventive health services are required to be covered without cost sharing. Examples of preventive health services include vaccinations, cancer screenings, and birth control.

How Much Do People Pay for Marketplace Plans and How are Subsidies Calculated?

There are two types of financial assistance available to Marketplace enrollees. The first type, called the premium tax credit (or premium subsidy), reduces enrollees’ monthly payments for insurance coverage. The second type of financial assistance, the cost-sharing reduction (CSR), reduces enrollees’ deductibles and other out-of-pocket costs when they go to the doctor or have a hospital stay. To receive either type of financial assistance, qualifying individuals and families must enroll in a plan offered through a health insurance Marketplace. In addition to the federal subsidies discussed here, some states that operate their own exchange markets offer additional state-funded subsidies that further lower premium payments and/or deductibles or other forms of cost sharing.

Premium Subsidies

Premium tax credits can be applied to Marketplace plans in any of four “metal” levels of coverage: bronze, silver, gold, and platinum. Bronze plans tend to have the lowest premiums but have the highest deductibles and other cost sharing, leaving the enrollee to pay more out-of-pocket when they receive covered health care services, while platinum plans have the highest premiums but very low out-of-pocket costs. There are also catastrophic plans, usually only available to younger enrollees, but the subsidy cannot be used to purchase one of these plans.

The premium tax credit works by limiting the amount an individual must contribute toward the premium for the “benchmark” plan – or the second-lowest cost silver plan available to the individual in their Marketplace. This “required individual contribution” is set on a sliding income scale. In 2025, for individuals with income up to 150 percent FPL, the required contribution is zero, while at an income of 400 percent FPL or above, the required contribution is 8.5 percent of household income.

Required Individual Contribution to Benchmark Plan Premium for 2025 Coverage Year

These contribution amounts were set by the American Rescue Plan Act (ARPA) in 2021 and temporarily extended by the Inflation Reduction Act (IRA) through the end of 2025. Prior to the ARPA, the required contribution percentages ranged from about two percent of household income for people with income at the FPL to nearly 10 percent for people with income from 300 to 400 percent of FPL. Before the ARPA was passed, people with incomes above 400 percent of FPL were not eligible for premium tax credits. If Congress does not act to extend the IRA enhanced premium tax credits before the end of 2025, they will expire, and the original ACA premium caps will return.

The amount of tax credit is calculated by subtracting the individual’s required contribution from the actual cost of the “benchmark” plan. So, for example, if the benchmark plan costs $6,000 annually, the required contribution for someone with an income of 150 percent FPL is zero, resulting in a premium tax credit of $6,000. If that same person’s income equals 250 percent FPL (or $37,650 in 2025), the individual contribution is four percent of $37,650, or $1,506, resulting in a premium tax credit of $4,494.

The premium tax credit can then be applied toward any other plan sold through the Marketplace (except catastrophic coverage). The amount of the tax credit remains the same, so a person who chooses to purchase a plan that is more expensive than the benchmark plan will have to pay the difference in cost. If a person chooses a less expensive plan, such as the lowest-cost silver plan or a bronze plan, the tax credit will cover a greater share of that plan’s premium and possibly even the entire cost of the premium. When the tax credit exceeds the cost of a plan, it lowers the premium to zero and any remaining tax credit amount is unused.

As mentioned above, the premium tax credit will not apply for certain components of a Marketplace plan premium. First, the tax credit cannot be applied to the portion of a person’s premium attributable to covered benefits that are not essential health benefits (EHB). For example, a plan may offer adult dental benefits, which are currently not included in the definition of EHB. In that case, the person would have to pay the portion of the premium attributable to adult dental benefits without financial assistance. In addition, the ACA requires that premium tax credits may not be applied to the portion of premium attributable to “non-Hyde” abortion benefits. Marketplace plans that cover abortion are required to charge a separate minimum $1 monthly premium to cover the cost of this benefit; this means a consumer who is otherwise eligible for a fully subsidized, zero-premium policy would still need to pay $1 per month for a policy that covers abortion benefits. Finally, if the person smokes cigarettes and is charged a higher premium for smoking, the premium tax credit is not applied to the portion of the premium that is the tobacco surcharge.

The second form of financial assistance available to Marketplace enrollees is a cost-sharing reduction. Cost-sharing reductions lower enrollees’ out-of-pocket cost due to deductibles, copayments, and coinsurance when they use covered health care services. People who are eligible to receive a premium tax credit and have household incomes from 100 to 250 percent of FPL are eligible for cost-sharing reductions.

Unlike the premium tax credit (which can be applied toward any metal level of coverage), cost-sharing reductions (CSR) are only offered through silver plans. For eligible individuals, cost-sharing reductions are applied to a silver plan, essentially making deductibles and other cost sharing under that plan more similar to that under a gold or platinum plan. Individuals with income between 100 and 250 percent FPL can continue to apply their premium tax credit to any metal level plan, but they can only receive the cost-sharing subsidies if they pick a silver-level plan.

Cost-sharing reductions are determined on a sliding scale based on income. The most generous cost-sharing reductions are available for people with income between 100 and 150 percent FPL. For these enrollees, silver plans that otherwise typically have higher cost sharing are modified to be more similar to a platinum plan by substantially reducing the silver plan deductibles, copays, and other cost sharing. For example, in 2025, the average annual deductible under a silver plan with no cost-sharing reduction is nearly $5,000, while the average annual deductible under a platinum plan is $0. Silver plans with the most generous level of cost-sharing reductions are sometimes called CSR 94 silver plans; these plans have 94 percent actuarial value (which represents the average share of health spending paid by the health plan) compared to 70 percent actuarial value for a silver plan with no cost-sharing reductions.

Somewhat less generous cost-sharing reductions are available for people with income greater than 150 and up to 200 percent FPL. These reduce cost sharing under silver plans to 87 percent actuarial value (CSR 87 plans). In 2025, the average annual deductible under a CSR 87 silver plan was about $700.

For people with income greater than 200 and up to 250 percent FPL, cost-sharing reductions are available to modestly reduce deductibles and copays to 73 percent actuarial value (sometimes called CSR 73 plans). In 2025, the average annual deductible under a CSR 73 silver plan was about $3,600.

Insurers have flexibility in how they set deductibles and copays to achieve the actuarial value under Marketplace plans, including CSR plans, so actual deductibles may vary from these averages. The ACA also requires maximum annual out-of-pocket spending limits on cost sharing under Marketplace plans, with reduced limits for CSR plans. In 2025, the maximum OOP limit is $9,200 for an individual and $18,400 for a family for all QHPs. Lower maximum OOP limits are permitted under cost-sharing reduction plans.

Maximum Annual Limitation on Cost Sharing, 2025

Cost-sharing reductions work differently for Native American and Alaska Native members of federally recognized tribes. For these individuals, cost-sharing reductions are available at higher incomes and can be applied to metal levels other than silver plans.

How Has the ACA Changed Since It Was First Passed?

Since it was first signed into law, the ACA has undergone many changes through regulation, legislation, and legal challenges. Some provisions never got off the ground, and others were repealed, while more recent changes have expanded and enhanced other provisions. This section summarizes some of the most significant changes to the law.

Medicaid Expansion: The ACA originally expanded Medicaid to all non-Medicare eligible individuals under age 65 with incomes up to 138% of the FPL. A Supreme Court ruling on the constitutionality of the ACA upheld the Medicaid expansion, but limited the ability of HHS to enforce it, thereby making the decision to expand Medicaid effectively optional for states. As of the beginning of 2025, 40 states and the District of Columbia had expanded Medicaid. Additionally, while not taking up Medicaid expansion under the ACA, Wisconsin did increase Medicaid eligibility to 100% of the FPL, which is where ACA Marketplace subsidy eligibility begins. In the remaining states that have not expanded Medicaid, an estimated 1.4 million people fall into the so-called Medicaid coverage gap, meaning their incomes are too high to qualify for Medicaid but too low to qualify for ACA Marketplace subsidies. The federal government covers 90% of the cost of Medicaid expansion.

Individual Mandate: The ACA also originally included an “individual mandate” or requirement for most people to maintain health insurance. In health insurance systems designed to protect people with pre-existing conditions and guarantee availability of coverage regardless of health status, countervailing measures are also needed to ensure people do not wait until they are sick to sign up for coverage, as doing so would drive up premiums. The ACA included a variety of these countervailing measures, with both “carrots” (e.g., premium tax credits and cost-sharing reductions) and “sticks” (e.g., the individual mandate penalty and limited enrollment opportunities) to encourage healthy as well as sick people to enroll in health insurance coverage.

American citizens and U.S. residents without qualifying health coverage had to pay a tax penalty of the greater of $695 per year up to a maximum of three times that amount ($2,085) per family or 2.5% of household income. The penalty was set to increase annually by the cost-of-living adjustment. Exemptions were granted for financial hardship, religious objections, American Indians, those without coverage for less than three months, undocumented immigrants, incarcerated individuals, those for whom the lowest cost plan option exceeds 8% of an individual’s income, and those with incomes below the tax filing threshold.

Despite the popularity of the ACA’s protections for people with pre-existing conditions, the individual mandate was politically controversial and consistently viewed negatively by a substantial share of the public. In early 2017, under President Trump, the Internal Revenue Service (IRS) stopped enforcing the individual mandate penalty. After several attempts to repeal and replace the ACA stalled out in the summer of 2017, Congress reduced the individual mandate penalty to $0, effective in 2019, as part of tax reform legislation passed in December 2017.

Cost-Sharing Reduction Payments: The ACA originally included two types of payments to insurers participating in the ACA Marketplace. First, insurers received advanced payments of the premium tax credit to subsidize monthly premiums for people buying their own coverage on the Marketplace. Second, insurers were required to reduce cost sharing (i.e., deductibles, copayments, and/or coinsurance) for low-income enrollees and the federal government was required to reimburse insurers for these cost-sharing reductions (CSRs). However, the funds for the payment of cost-sharing reductions were never appropriated. The Trump administration ended federal CSR payments to insurers weeks before ACA Marketplace Open Enrollment for 2018 coverage began. In response to this, most states allowed insurers to compensate for the lack of government payments by raising premiums. At the time, the Congressional Budget Office (CBO) estimated termination of CSR payments to insurers would increase the federal deficit by $194 billion over 10 years, because of these higher premiums and corresponding increased premium tax credit subsidies. Although the CSR payments have ceased, cost-sharing reduction plans continue to be available to low-income Marketplace enrollees.

Enhanced and Expanded ACA Marketplace Premium Tax Credits: Another controversial aspect of the ACA was the so-called “subsidy cliff,” where people with incomes over 400% of the FPL were ineligible for financial assistance on the Marketplace and, therefore, would have to pay a large share of their household income for unsubsidized health coverage. As a result, many middle-income people were being priced out of ACA coverage. The March 2021 COVID-19 relief legislation, the American Rescue Plan Act (ARPA), extended eligibility for ACA health insurance subsidies to people with incomes over 400% of FPL buying their health coverage on the Marketplace. The ARPA also increased the amount of financial assistance for people with lower incomes who were already eligible under the ACA, making many low-income people newly eligible for free or nearly free coverage. Both provisions were temporary, lasting for two years, but the Inflation Reduction Act extends those subsidies through the end of 2025.

Family Glitch: Financial assistance to buy health insurance on the Affordable Care Act (ACA) Marketplaces is primarily available for people who cannot get coverage through a public program or their employer. Some exceptions are made, however, including for people whose employer coverage offer is deemed unaffordable or of insufficient value. For example, people can qualify for ACA Marketplace subsidies if their employer requires them to spend more than about 8-9% (indexed each year) of their household income on the company’s health plan premium. For many years, this affordability threshold was based on the cost of the employee’s self-only coverage, not the premium required to cover any dependents. In other words, an employee whose contribution for self-only coverage was less than the threshold was deemed to have an affordable offer, which means that the employee and their family members were ineligible for financial assistance on the Marketplace, even if the cost of adding dependents to the employer-sponsored plan would far exceed the approximately 8-9% of the family’s income. This definition of “affordable” employer coverage has come to be known as the “family glitch,” which affected an estimated 5.1 million people. Under a Biden administration federal regulation, the worker’s required premium contributions for self-only coverage and for family coverage will be compared to the affordability threshold of approximately 8-9% of household income. If the cost of self-only coverage is affordable, but the cost for family coverage is not, the worker will stay on employer coverage while their family members can apply for subsidized exchange coverage.

Public Opinion: Americans’ views of the Affordable Care Act have evolved over time. From the time the ACA passed, to when the Marketplaces first opened in 2014, and through the months leading up to President Trump’s election in 2016, public opinion of the ACA was strongly divided and often leaned more negative than positive. Many individual provisions of the ACA, such as protections for people with preexisting conditions, were popular, but the individual mandate was particularly unpopular.

News coverage during the ACA Marketplaces’ early years often centered on the rocky rollout, from the early Healthcare.gov website glitches to skyrocketing premiums in subsequent years. Coverage in later years focused on how unprofitable insurers exited the market, leaving people in some counties at risk of having no Marketplace insurer—and thus, no Marketplace through which to access health insurance subsidies.

In 2017, during his first term, President Trump and Republicans in Congress attempted to repeal or fundamentally alter the ACA. As proposals to replace the ACA became more concrete, though, public support for the ACA, particularly among Democrats and Independents, began to grow. Ultimately, the only key aspect of the law that was removed was the penalty for not purchasing health insurance—now lowered to $0 as part of the 2017 tax reform package. Following repeal efforts and the removal of the individual mandate penalty, as well as a stabilization of the ACA Marketplaces, public support for the law has continued to grow and is now solidly more positive than negative. Although this support remains divided by party lines, several Republican-led states have adopted the ACA’s Medicaid expansion through popular votes.

Following repeal efforts and the removal of the individual mandate penalty, as well as a stabilization of the ACA Marketplaces, public support for the law has continued to grow and is now solidly more positive than negative. Although this support remains divided by party lines, several Republican-led states have adopted the ACA’s Medicaid expansion through popular votes.

How Have the ACA Marketplaces Changed Over Time?

After volatile initial years, the ACA Marketplaces have become more stable—a pattern which can be seen across a variety of measures, including enrollment, premiums and insurer participation.

Enrollment

ACA Marketplace enrollment has more than tripled since its launch in 2014. The number of people who enrolled and effectuated their Marketplace coverage in early 2024 reached 20.8 million, surpassing prior record-setting years in 2021, 2022, and 2023. The recent enrollment growth was likely primarily driven by the enhanced tax credits in the American Rescue Plan Act and the Inflation Reduction Act, as well as the Biden administration’s decision to direct more resources toward marketing, outreach, and enrollment assistance, reversing substantial reductions in funding by the Trump administration.

Individual Market Enrollment Has Reached a Record High of 25.2M People in 2025

The ARPA’s subsidies didn’t simply bring people from off-Marketplace plans to the Marketplace; they also helped increase overall individual market enrollment. Enrollment grew to 25.2 million in early 2025, which is an increase of about 81% from early 2020.

With passage of enhanced tax credits in the American Rescue Plan Act (ARPA), combined with boosted outreach and an extended enrollment period, 2021 marked the first year since 2015 when individual market enrollment increased relative to the year prior. Individual market enrollment grew about 5% from 13.9 million in the first quarter of 2020 to 14.7 million in the first quarter of 2021.

In the early years of the rollout of the ACA Marketplaces, on-exchange enrollment was comparable to off-exchange enrollment, meaning that the Marketplaces represented about half of overall individual market enrollment. Some off-exchange enrollment was represented by people in ACA-compliant coverage (similar to that offered on-exchange, but without subsidies), while other individual market enrollees were signed up for non-compliant coverage, like “grandmothered” or short-term plans.

The Share of Compliant Enrollment Reached a High of 93% In Mid-2022

Non-compliant short-term plans often do not include certain benefits or coverage for pre-existing conditions and can impose a dollar limit on insurance coverage. For example, many short-term plans do not cover maternity care, prescription drugs, or mental health or substance use treatment, and most impose a dollar limit on covered services or drugs. In 2024, the Biden administration finalized a rule that reverses the Trump administration’s expansion of short-term plans. The share of individual market enrollment in ACA-compliant plans has increased to 93% in mid-2022 compared to 71% in mid-2015.

Premiums

ACA Marketplace premiums have risen substantially over time. When insurers entered the ACA Marketplaces in 2014, most were operating with virtually no experience participating in an individual market like this (e.g., with subsidies, preexisting condition protections, and an individual mandate). Insurers also had to submit premiums almost a year in advance for review and approval by state regulators. Even 2015 premiums were submitted in early 2014, meaning insurers did not have much experience in the market on which to base their premium and claim projections. Eventually, though, it became clear that they were underpriced and unprofitable, so in 2016, many insurers began to raise premiums. By 2017, the temporary reinsurance and risk corridors programs had phased out, leading to another market correction. In 2018, with the discontinuation of cost-sharing reduction payments, insurers raised premiums yet again, though most insurers concentrated these premium increases on silver plans (a practice known as “silver loading”). More recently, though, as the markets have stabilized and as the pandemic led to a temporary reduction in health care utilization, premiums have at times fallen or at least grown at a slower pace. Heading into 2025, ACA Marketplace benchmark premiums rose by about 4% on average, driven primarily by inflation and increased utilization of specialty drugs.

Generally, deductibles have also risen since the ACA Marketplaces were first launched in 2014. Bronze plans, which typically have the highest deductibles among ACA Marketplace plans, have an average deductible of $7,186 in 2025, compared to $5,113 in 2014. However, as discussed above, many ACA Marketplace enrollees are low income and therefore qualify for cost-sharing reductions if they purchase a silver plan. For the most generous cost-sharing reduction plans, which are available to people with incomes just above the FPL, the average deductible is $87 in 2025, compared to $183 in 2014.

Average Deductible in ACA Marketplace Plans, 2014-2025

Insurer participation

Insurer participation in 2025 is more robust than in recent years, surpassing record high levels of participation set in 2023 and 2024.

Insurer participation on the ACA Marketplaces fell dramatically in 2017 with the exit of UnitedHealthcare from most states. In 2018, with President Trump’s announcement that cost-sharing reduction payments would cease and the corresponding attempts to repeal the ACA in Congress, many more insurers exited or scaled back their participation. Though all counties in the country continued to have at least one ACA Marketplace insurer, there had initially been concern that there could have been counties left without any insurer, thus leaving residents in those counties without access to ACA subsidies.

However, in subsequent years, with premium increases and changes in strategies, it became apparent that the ACA Marketplaces could be quite profitable and many insurers entered or expanded their footprints.

Average Number of Issuers Participating in ACA Marketplaces, Per State, 2014-2025

What Does the Federal Government Spend on ACA Subsidies?

The cost of the ACA subsidies largely depends on how many people enroll and the cost of monthly premiums. The Congressional Budget Office (CBO) expects the number of people with subsidized Marketplace coverage to continue to grow through 2025, but then drop after if the Inflation Reduction Act tax credits expire that year.

From 2025-2034, CBO expects the cost of federal Marketplace subsidies and related programs to total $1.32 trillion, ranging from $118 billion to $147 billion per year. This includes an estimated $966 billion in direct spending on ACA Marketplace subsidies, $177 billion on the Basic Health Program and 1332 waivers, as well as $176 billion in revenue reductions over ten years. These estimates, however, do not account for federal policy changes that were finalized in summer 2025 as part of the budget reconciliation legislation and finalized Marketplace Program Integrity and Affordability rule.

Future Outlook

The ACA has faced both support and opposition over time, and its fate has been subject to numerous political and legal debates, including efforts to repeal and replace the law and to overturn it in whole or in part in several court cases. Future changes in presidential administrations and shifts in the composition of Congress will likely continue to impact the implementation and stability of the ACA.

Key issues to watch include:

Federal Policy Changes: Federal policy changes finalized and passed in the summer of 2025 will change how the ACA Marketplaces will operate in the coming years. Combined, the finalized Marketplace Integrity and Affordability final rule as well as the budget reconciliation legislation will make several changes to consumer protections, ACA Marketplace coverage and premium tax credit eligibility, as well as verification processes. Implementation dates of specific policies vary, but some are set to begin in August of 2025. Changes include effectively ending auto-renewals, removing repayment limits on the premium tax credit, and implementing new eligibility verification procedures. The CBO estimates that an additional 10 million people would become uninsured due to the impact of the budget reconciliation legislation, with about 2 million becoming uninsured due to changes to the ACA Marketplaces.

Enhanced Premium Tax Credits: Currently, the enhanced premium tax credits in the ACA Marketplaces are set to expire at the end of 2025. If these tax credits are allowed to expire, people purchasing subsidized coverage will face significant increases in their monthly premium payments and some may become priced out of the market. Some action has been taken ahead of a potential expiration. In preparation for the possibility of enhanced tax credits expiring, some states are working on ways to fund state subsidies that keep the cost of ACA Marketplace coverage affordable. The CBO previously projected that an additional 4.2 million people would become uninsured by 2034 if the enhanced premium tax credits expire.

State Actions: In recent years, some states have moved off the federal platform (Healthcare.gov) to implement their own enrollment websites. Additionally, more states have expanded Medicaid. Some states have sought 1332 waivers under the ACA to implement reinsurance programs, expand coverage to undocumented residents (though federal policy changes discussed above will undo these efforts), and create public options.

Consumer Protections: The ACA includes various consumer protections that continue to evolve through the regulatory process. For example, proposed and finalized rulemaking has focused on improving network adequacy, simplifying the shopping process, and reexamining essential health benefits. Planned federal policy changes will undo some of the consumer protection processes currently in place. In response to claims of mass fraudulent enrollment, the finalized Marketplace Integrity and Affordability Rule was issued in June 2025. In it, CMS issued rules permitting coverage denials for outstanding premium payments from prior coverage and eliminated the automatic 60-day extension to resolve income discrepancies.

Funding Cuts: In February 2025, CMS announced that it would be reducing funding for its navigator program down from $100 million to $10 million starting next year. This is equal tothe amount awarded to navigators in 2018-2020 during President Trump’s first administration.

Health Costs and Affordability: Though the ACA has made insurance coverage more accessible and affordable for millions of people, health costs in the United States continue to be high and many people with insurance nonetheless face cost-related barriers to care.

Resources

Citation

Ortaliza, J., McGough, M., & Cox, C., The Affordable Care Act 101. In Altman, Drew (Editor), Health Policy 101, (KFF, October 2025) https://www.kff.org/health-policy-101-the-affordable-care-act/ (date accessed).

ACA Marketplace Premium Payments Would More than Double on Average Next Year if Enhanced Premium Tax Credits Expire

Authors: Justin Lo, Larry Levitt, Jared Ortaliza, and Cynthia Cox

Published: Sep 30, 2025

Affordable Care Act (ACA) enhanced premium tax credits are set to expire at the end of this year. Enhanced premium tax credits were introduced in 2021 and later extended through the end of 2025 by the Inflation Reduction Act. The enhanced tax credits both increased the amount of financial assistance already eligible ACA Marketplace enrollees received as well as made middle-income enrollees with income above 400% of federal poverty guidelines newly eligible for premium tax credits.

Since the introduction of the enhanced premium tax credits, enrollment in the Marketplace has more than doubled from about 11 to over 24 million people, the vast majority of whom receive an enhanced premium tax credit. If enhanced tax credits expire, many Marketplace enrollees will continue to qualify for a smaller tax credit, while others will lose eligibility altogether and be hit by a “double whammy” of losing their entire tax credit and being on the hook for rising premiums.

Since 2014, the ACA has capped how much subsidized enrollees pay for their health insurance premiums at a certain percent of their income, on a sliding scale, with the federal government covering the remainder in the form of a tax credit. Enhanced tax credits work by further lowering the share of income ACA Marketplace enrollees pay for a plan. For example, with the enhanced tax credits in place, an individual making $28,000 will pay no more than around 1% ($325) of their annual income towards a benchmark plan. If the enhanced tax credits expire, this same individual would pay nearly 6% of their income ($1,562 annually) towards a benchmark plan in 2026. In other words, if the enhanced tax credits expire, this individual would experience an increase of $1,238 in their annual premium payments net of the tax credit.

ACA Marketplace Enrollees Will Pay More for Benchmark Coverage if Enhanced Tax Credits Expire (Table)

A previous KFF analysis, based on data released by the federal government, showed the enhanced premium tax credits saved subsidized enrollees an average of $705 annually in 2024, bringing their annual premium payment down to $888. Without the enhanced premium tax credits, annual premium payments in 2024 would have averaged $1,593 (over 75% higher than the actual $888). More recent data have not been released.

Based on the earlier federal data and more recent other publicly available information, KFF now estimates that, if Congress extends enhanced premium tax credits, subsidized enrollees would save $1,016 in premium payments over the year in 2026 on average. In other words, expiration of the enhanced premium tax credits is estimated to more than double what subsidized enrollees currently pay annually for premiums—a 114% increase from an average of $888 in 2025 to $1,904 in 2026. (The average premium payment net of tax credits among subsidized enrollees held steady at $888 annually in 2024 and 2025 due to the enhanced premium tax credits).

Premium Payments in 2026 Will More than Double if ACA Enhanced Premium Tax Credits Expire (Grouped column chart)

The increase in premium payments with expiration of the enhanced premium tax credits is even higher than previously estimated for two reasons:

Trump administration changes to tax credit calculations, and
Rising 2026 premiums.

The Trump administration made changes to the way tax credits are calculated, which were finalized in the ACA Marketplace Integrity and Affordability rule. The required contribution levels that will be in place for 2026 if the enhanced tax credits are not renewed will be higher relative to the required contribution levels calculated under the original methodology based on rules in effect at the time. This means that enrollees are expected to pay a higher share of their income towards a benchmark premium plan in 2026 than they otherwise would have. Additionally, inflation in private insurance premiums has led to higher premium contribution levels than previously expected.

Additionally, insurers in the ACA Marketplace are proposing to raise their rates by a median of 18%. Fueled by rising health care costs and the expiration of the enhanced premium tax credits, insurers are proposing the largest rate increases in 2026 since 2018, the last time uncertainty over federal policy changes contributed to sharp premium increases. As premiums increase, the enhanced tax credits provide additional savings to enrollees that receive them. This means that middle-income enrollees, whose payment for a benchmark plan is currently capped at 8.5% of their income and will lose financial assistance altogether, will have to cover the cost of premium increases in addition to the amount their tax credits would have previously covered to keep their same plan.

Enrollees across the income spectrum can expect big increases in premium payments

Annual Premium Payments Would Increase for Subsidized Enrollees by an Average of ,016 (114%) if Enhanced Premium Tax Credits Expire (Stacked column chart)

Enrollees with incomes above 400% of poverty will be subject to large increases in premium payments if enhanced premium tax credits expire. On average, a 60-year-old couple making $85,000 (or 402% FPL) would see yearly premium payments rise by over $22,600 in 2026, after accounting for an annual premium increase of 18%. This would bring the cost of a benchmark plan to about a quarter of this couple’s annual income, up from 8.5%. Meanwhile, a 45-year-old earning $20,000 (or 128% FPL) in a non-Medicaid expansion state would see their premium payments for a benchmark plan rise from $0 to $420 per year, on average, from the loss of enhanced premium tax credits. About half (45%) of ACA Marketplace enrollees have incomes between 100-150% of poverty, about a fourth (28%) have incomes between 150-250% of poverty, and roughly 1 in 10 have incomes above 400% of poverty.

Methods

The average savings by income group for 2024 were taken from the 2024 Open Enrollment report. The average yearly premium savings from enhanced premium tax credits (ePTC) for enrollees under 400% FPL were defined as the sum of the differences between the required contribution amounts with and without ePTC, using the estimated percent of plan selections with ePTC by income category and assuming a uniform income distribution within each category. To extrapolate to 2026, income was inflated by the ratio of the 2025 federal poverty guidelines to the 2023 federal poverty guidelines for an individual in the continental US. For each income category, the savings were assumed to grow as the ratio of the savings between 2026 and 2024. Due to a provision in the reconciliation bill related to subsidized ACA Marketplace eligibility for immigrants, no enrollees under 100% FPL are assumed to receive premium tax credits in 2026 and are thus not included in the calculation of average savings. For enrollees at or above 400% FPL, savings were defined as difference between the average unsubsidized premium and 8.5% of the average individual income, the required contribution under the enhanced tax credits for enrollees in this income category. For 2026, the average unsubsidized premium was assumed to be 18% higher than the 2025 average unsubsidized premium, based on analysis of rate filings. Calculations assume that there are no changes in plan selection, family composition, income relative to FPL, and geography between 2024 and 2026. The annual premium payment for 2026 comprises the estimated savings from enhanced tax credits in 2026 and the average premium payment among subsidized enrollees in 2025 obtained from the 2025 Open Enrollment State-Level Public Use File. State-funded subsidies might offset some increases of premiums but are not accounted for in the estimation. Numbers from the Open Enrollment report for estimated consumer APTC savings due to the ARP and IRA by income category (Table 8) were reported as whole numbers; a Monte Carlo method was used to account for this rounding, keeping all observations that rounded to the grand mean listed in the report.

Health Issues for Immigrants in Detention Centers

Authors: Akash Pillai, Drishti Pillai, and Samantha Artiga

Published: Sep 30, 2025

President Trump has increased immigration enforcement activity to support mass deportation and detention. The administration has shifted enforcement actions from focusing on criminals and recent border crossers to prioritizing all of the estimated 14 million undocumented immigrants for deportation, even though many who have some form of temporary deportation protections. As a result, there has been a significant increase in the number of immigrants detained in Immigration and U.S. Customs Enforcement (ICE) detention facilities, which have a history of inadequate compliance with health and safety standards, insufficient health care, and limited oversight.

The extent to which President Trump will be able to implement interior enforcement policies in the face of potential court challenges remains uncertain. Meanwhile, Congressional Republicans and President Trump passed the tax and spending law in July 2025, which included $191 billion for the Department of Homeland Security (DHS) to support immigration enforcement and expand detention capacity. This brief provides an overview of recent trends in detention using ICE detention data and health care risks and challenges facing those held in detention facilities. These efforts also have broader ramifications for the nation’s workforce and economy given the role immigrants play.

Detention Policies under the Trump Administration

President Trump has identified deportation as a key priority and enhanced interior immigration enforcement efforts since taking office though some policies face legal challenges. President Trump has prioritized all undocumented immigrants for deportation and rescinded numerous Biden-era policies, including a policy that protected against enforcement in “sensitive areas,” such as schools and health care facilities; a ban on collateral arrests, which will allow ICE to pursue arrests without a warrant; and deportation protections for immigrants with humanitarian parole and Temporary Protected Status from numerous countries. The 2025 tax and spending law appropriated $191 billion to DHS to support these actions and increase detention capacity.

As of September 2025, the Trump administration has nearly 60,000 immigrants held in ICE detention facilities, a 50% increase from 39,000 immigrants held in ICE facilities at the end of the Biden administration in December 2024 (Figure 1). The number of immigrants held in detention increased slightly during the first few months of the year and then saw a sharp uptick in June 2025 due to heightened interior enforcement activity by ICE. ICE detention statistics likely undercount the number of immigrants held in detention due to reporting methodology issues and because they do not include immigrants held by local authorities on detainer requests, where local jails may detain immigrants upon request until they can be transferred to ICE. An analysis of ICE facilities in July 2025 found that many facilities were at or exceeded contractual capacity, which can lead to overcrowding conditions if deportations do not keep up with the pace of arrests. Due to facilities operating at capacity limits, ICE has expanded detaining immigrants in facilities such as hotels and military bases that may be excluded from public reporting. Reflecting the shift to prioritize all undocumented immigrants for deportation, seven in ten (72%) of immigrants in detention facilities have no criminal convictions as of September 2025. The number of immigrants held in detention varies by state, reflecting a combination of where immigrants live, logistics of ICE deportation operations, and the extent to which local laws support coordination with ICE.

Number of Immigrants Detained in ICE Facilities, December 2024 to September 2025 (Line chart)

Health Care Risks and Challenges for Immigrants in Detention Facilities

ICE is responsible for oversight and management of detention facilities, but it has a history of inadequate compliance with detention standards and insufficient health care, and research shows that immigrants in detention experience widespread health risks. ICE has published health care and safety standards for detention centers, including those that are privately run. As part of its published standards, immigrants arriving at detention facilities must undergo an initial health screening and have access to 24-hour emergency care, daily sick calls, and comprehensive health services including prevention, health education, screening, diagnosis, and treatment. However, ICE provides little to no publicly available data on health care use, quality, and outcomes, and oversight reporting is inconsistent. According to a Congressional Research Service (CRS) report, there is a history of inadequate health care standard compliance in ICE facilities. The Government Accountability Office (GAO) reported on the lack of informed consent for immigrants when receiving offsite medical care, and a DHS report found instances where ICE did not establish medical necessity for surgical procedures, including when performing sterilization procedures on migrant women. Research shows that detainees, including pregnant people and children, can receive inadequate care in detention facilities, and that most detention center deaths were associated with ICE violating their own medical standards. A study on LGBT detainees found they experienced higher rates of harassment than non-LGBT detainees. Immigrants in detention are increasingly being placed in solitary confinement, which can worsen mental health and tends more frequently utilized for those with serious mental illness. The suicide rate also significantly increased from 2010-2020 among immigrants in ICE facilities. Further, a study of immigrants released from detention found significantly higher likelihood of poor or fair self-rated health, mental illness, and PTSD among those detained 6 months or longer compared to those detained less than 6 months. Research also shows that family separation policies while in detention worsened the mental health of both children and caregivers.

The Trump administration has reduced oversight of operations in immigration detention facilities, which may have negative implications for conditions and health risks in detention centers, including for children and families in detention. The Trump administration has shut down watchdog agencies in DHS, including the Immigration Detention Ombudsman office that conducted oversight on conditions at immigration detention centers. Fewer watchdog agencies may further limit transparency and oversight of ICE operations, including on issues such as overcrowding and inadequate medical care. The administration has also attempted to terminate the Flores Settlement Agreement, which set standards for the detention, treatment, and release of immigrant children in federal custody, but federal court recently upheld the settlement. The settlement requires the government to hold minors in the least restrictive settings, prioritize release to family members, and ensure access to basic necessities like food, medical care, and sanitation. Minors may be held with their families in ICE family detention centers, while unaccompanied minors are sent to other facilities when their parents are detained or deported. The tax and spending law approved funds for indefinite family detention, which may be in violation of the Flores Settlement Agreement.

Recent reports suggest immigrants in detention facilities are facing poor and sometimes dangerous conditions for extended periods of time. Some immigrants may be held in holding facilities while they are processed, such as local jails and field offices not designed for long-term detention, and they may not be included in ICE detention statistics. An analysis of ICE detention found that most facilities exceeded contractual capacity, which can lead to overcrowding conditions if deportations do not keep up with the pace of arrests. ICE inspectors found that immigrants held in an unfinished Texas facility still under construction violated many detention standards and failed to properly treat medical conditions. Recent reports have also detailed how immigrants in detention face poor living conditions, including inadequate meals and sanitation, lack of ventilation, and exposure to extreme temperatures. Immigrants held in a Florida detention facility experienced severe overcrowding and a lack of food, and those in Texas and Louisiana experienced extreme cold that the facilities were not equipped to handle. A judge ordered a facility in New York to improve conditions after reports of immigrants being in overcrowded conditions deprived of showers, meals, and bedding. Immigrants held in detention facilities across states reported not receiving adequate meals and foodborne illnesses spreading due to poor hygiene. Families and children in a Texas family detention center reported experiencing extreme temperatures and lacked access to showers or toilets. As of September 2025, 15 immigrants have died in detention, compared to 8 deaths in all of 2024 and the most seen under ICE custody since 2020.

Mass detention efforts may lead to increased fears among immigrant families, which can have negative mental and physical health impacts on immigrants across statuses and their children. As of 2023, 19 million, or one in four, children in the U.S. had an immigrant parent, including one in ten (12%) who are citizen children with a noncitizen parent. An estimated 4.6 million U.S.-born children live with an undocumented immigrant parent. Enforcement efforts have increased worries about detention and deportation among immigrants, including among naturalized citizens, and worsened the mental health and well-being of immigrant families with undocumented immigrants. KFF survey data from March 2025 find that about a third (32%) of immigrants overall say they have experienced negative health repercussions due to worries about their own or a family member’s immigration status. Immigrants also reported they avoided seeking health care due to concerns about costs and fears, were fearful of accessing public programs, and were confused whether these programs can negatively impact immigration status. Research has found that living near areas subject to immigration enforcement raids increased the risk of negative mental health among children of immigrants and worse birth outcomes among both Hispanic immigrant mothers as well as U.S.-born Hispanic mothers as compared to non-Hispanic White mothers. Education outcomes also worsened among Hispanic children in areas impacted by raids compared to White children. Studies have also found that children and caregivers impacted by family separations experience worse mental health, including anxiety, depression, and posttraumatic stress disorder. Family separations can also lead to financial challenges for mixed-status households due to loss of income. Mass detention efforts may also have negative impacts on the nation’s economy and workforce given the outsized role immigrants play in certain industries, including health care. Over 1 million immigrants are estimated to have left the workforce since January 2025.

A Look at the Potential Impact of the High Unemployment Hardship Exception to Medicaid Work Requirements

Authors: Clea Bell, Jennifer Tolbert, and Sammy Cervantes

Published: Sep 29, 2025

The Republican budget reconciliation package, signed into law on July 4^th, will—for the first time—require some individuals enrolled in Medicaid to meet work requirements as a condition of eligibility. When implemented by January 2027 (or sooner at state option), adults enrolled through the Medicaid expansion and certain adults enrolled in Medicaid waiver programs in Wisconsin and Georgia, will be required to work or participate in work-related activity for 80 hours or more a month or attend school half time. The law exempts certain individuals from the requirements, including parents of children ages 13 and younger, people who are medically frail, and people who meet similar work requirements in the Supplemental Nutrition Assistance Program (SNAP). The law also permits states to allow for short-term hardship exceptions for individuals who live in areas of high unemployment, where it may be more difficult to find a job.

This issue brief describes the hardship exception for individuals living in counties with high unemployment, and using the most recent available county-level unemployment data from the Bureau of Labor Statistics (BLS) and county-level Medicaid expansion enrollment data, estimates the number of counties that could meet the criteria for this exception and the number of expansion enrollees living in those counties who could be exempt from the work requirements. Because county-level enrollment data for enrollees who would be subject to work requirements in Georgia and Wisconsin are not available, this analysis only includes expansion states.

Based on this analysis, the scope of this hardship exception may be limited; just 7% of counties meet the high unemployment criteria using a 12-month average unemployment rate and 7% of enrollees live in these counties and could be exempt if their state requests the hardship exception. However, how CMS operationalizes the criteria will affect the number of counties and enrollees that qualify. Allowing states to identify counties that meet the criteria using 6-month or 3-month average unemployment rates in addition to the 12-month average rate would increase the number of counties that qualify. Also, while the current national unemployment rate is low, changes in the economy and a tightening job market could cause unemployment rates to rise. If unemployment rates increase, the number of enrollees who would qualify for this hardship exception would also increase.

What is the High Unemployment Rate Hardship Exception?

The law allows states to request a hardship exception for individuals who live in counties with high unemployment rates. Specifically, the law permits states to request exemptions for individuals who reside in counties that have unemployment rates at or above 8% or below 8% but 1.5 or more times the national average unemployment rate. This exception is optional, but for states that request the exception and receive approval, all individuals who reside in counties that meet the criteria would be exempt from the work requirements for a specified period of time. The language in the reconciliation package is similar to the statutory language that defines a waiver exemption to the work requirements in SNAP, which permits states to request exemptions for areas that have unemployment rates over 10% or that lack a sufficient number of jobs.

The law grants the Secretary of Health and Human Services (HHS) discretion in how to implement this hardship exception, including what information states must submit. While the law lays out the broad criteria needed to meet the exception, the Secretary will have the discretion to set the parameters for how the criteria will be operationalized, including what information states must provide, the length of the exception period, and the process for applying for the exception. These decisions by the Secretary will affect how easy it is for states to apply for the exception and ultimately how many counties meet the criteria and how many enrollees will be exempt from the work requirements. The law requires the Secretary of HHS to issue an interim final rule implementing the Medicaid work requirements by June 1, 2026.

CMS may look to existing SNAP regulations to help guide the criteria for qualifying for an exception. CMS officials have indicated that they plan to follow sub-regulatory guidance that already exists in other programs with similar provisions, where possible. Existing SNAP regulations provide options for the data states can use to support a waiver request, including a readily approvable waiver using 12-month average unemployment rates. The regulation also specifies that the data states submit must rely on standard BLS data or methods. Waivers are generally approved for one year; however, waivers may be approved for a shorter or longer period, if deemed appropriate. CMS may choose to follow the SNAP regulations or allow for more or less flexibility in the data that states can use to identify counties with high unemployment. These decisions will affect the number of enrollees who could qualify for the exception. States can choose whether to apply for the exception, and some may decide not to for ideological reasons or because few counties and enrollees would meet the criteria. Notably, 18 states do not have SNAP work requirement waivers.

How Many Counties and Enrollees Could Meet the High Unemployment Exception?

KFF analysis uses 12-month average county unemployment rates from June 2024 through May 2025 to estimate the number of counties that meet the criteria for the high unemployment hardship exception. The 12-month average unemployment rate is the metric used in the readily-approvable SNAP exemption waivers. The analysis then uses enrollment data for the expansion population from the 2023 T-MSIS Research Identifiable Files to estimate the number of enrollees who live in qualifying counties and who could be exempt from the work requirements if all states applied for and were granted the exceptions.

Nationally, 158 counties in expansion states meet the high unemployment criteria, and 1.4 million enrollees in these states could qualify for the hardship exception, accounting for 7% of counties and enrollees. Alternative methods could have different effects. For example, using a method where counties could qualify for the exception by meeting the unemployment criteria in any month from June 2024 to May 2025, 386 counties in 34 expansion states had unemployment rates that met the criteria. These counties represented 17% of all counties in expansion states, and 4.6 million expansion enrollees, or 23% of all expansion enrollees, reside in these counties and could be exempt from the work requirements.

1.4 million Medicaid expansion enrollees live in counties with high unemployment rates and could qualify for a hardship exception to work requirements. (Choropleth map)

Overall, while 80% of counties that meet the criteria are rural, over 80% of expansion enrollees who could be exempt from work requirements live in urban counties (Figure 2). Of the 158 counties with unemployment rates that meet the statutory criteria, 126 are located in rural areas. Because of the higher unemployment rates in rural areas, a slightly larger share of all rural counties in expansion states meet the criteria (8.5% of rural counties vs. 7% of all counties). However, because the population in rural areas is smaller, over 80% of expansion enrollees who could qualify for the hardship exception live in urban counties. Of the 1.4 million expansion enrollees who could qualify for the exception, just 273,350 (19%) are in rural counties, accounting for 10% of all expansion enrollees who live in rural counties.

While 80% of counties that meet the high unemployment criteria are rural, 80% of enrollees who could be exempt from the work requirements live in urban counties. (Stacked column chart)

Nine in ten expansion enrollees who are in counties that meet the high unemployment criteria and could be exempt from the work requirements live in five states (Figure 3). Expansion enrollees who live in counties with high unemployment rates are concentrated in just five states—California, New York, Michigan, Kentucky, and Ohio. Expansion enrollees in California account for over 50% of all enrollees living in counties that meet the criteria. In New York, over 260,000 expansion enrollees, representing 18% of all enrollees who could be exempt, live in Bronx County, the only county in the state to meet the high unemployment criteria. Overall, 93% of enrollees who could be exempt live in states with Democratic governors, who would be expected to request the exception. Across the majority of expansion states, however, the impact of the high unemployment hardship exception is small. In nine states, 2,000 or fewer expansion enrollees live in counties that meet the criteria, and in 17 states no counties meet the criteria.

Rural expansion enrollees who could qualify for the hardship exception are similarly concentrated in seven states. Half of the 273,350 expansion enrollees who live in rural counties with unemployment rates that meet the criteria and who could be exempt from the work requirements live in Kentucky and Michigan (Figure 3). Another 14% live in California, 6% live in Oregon, and 5% each live in Arizona, Louisiana, and Ohio. As with counties overall, the impact of this hardship exception in rural counties is limited. Just 10% of rural expansion enrollees live in qualifying counties, and in 20 expansion states, no rural counties meet the high unemployment criteria.

Appendix

1.4 Million People May Be Exempt from the Medicaid Work Requirements through the High Unemployment Exception (Table)

Deja Vu: the Future of Abortion Coverage in ACA Marketplace Plans

Authors: Laurie Sobel, Alina Salganicoff, and Rolonda Donelson

Published: Sep 26, 2025

Abortion coverage was a key issue in the debate leading up to the passage of the Affordable Care Act. Again, it could be an issue if Congress considers extending the enhanced premium tax credits that will expire by the end of the year absent Congressional action. Without the extension of these enhanced premium tax credits, out-of-pocket premiums would rise by over 75% on average for the vast majority of individuals and families buying coverage through the ACA Marketplaces leading to an estimated 3.8 million more people becoming uninsured as they drop their coverage over the next 10 years. Anti-abortion advocates are currently urging Congress to prohibit any premium tax credits to be used towards any plans that include abortion coverage. This policy watch explains how abortion coverage works in ACA Marketplace plans, state actions to include or exclude abortion coverage in these plans, and the potential impact if Congress bans abortion coverage in all Marketplace plans.

The ACA Explicitly Says that Federal Funds May Not Be Used to Pay for Marketplace Abortion Coverage Beyond the Hyde Limitations

The ACA statute has specific language that applies Hyde Amendment restrictions to the use of premium tax credits, limiting them to using federal funds to pay for abortions only in cases that endanger the life of the woman or that are a result of rape or incest. The ACA also explicitly allows states to bar all plans participating in the state Marketplace from covering abortions, which 25 states have done since the ACA was signed into law in 2010. On the other hand, twelve states now have laws that require all fully-insured group plans and individual plans (including Marketplace plans) to include abortion coverage. Thirteen states and DC neither require nor prohibit abortion coverage in Marketplace plans (Figure 1). Federal law prohibits Marketplace plans from offering any riders, a supplemental benefit policy that covers certain services which are not included in a standard health insurance plan. So, if a plan does not include abortion coverage, an enrollee cannot buy a rider for abortion coverage.

Twelve States Currently Require ACA Marketplace Plans to Cover Abortion Services (Choropleth map)

ACA Rules for Premiums for Abortion Coverage

In states that do not bar coverage of abortions on plans available through the Marketplace, insurers may offer a plan that covers abortions beyond the permissible Hyde amendment situations when the pregnancy is a result of rape, or incest or the pregnant person’s life is endangered. , but this coverage cannot be paid with federal dollars. Plans must notify consumers of the abortion coverage as part of the summary of benefits and coverage explanation at the time of enrollment. The ACA outlines a methodology for states to follow to ensure that no federal funds are used towards coverage for abortions beyond the Hyde limitations. Any plan that covers abortions beyond Hyde limitations must estimate the actuarial value, the amount the plan expects to pay on behalf of its members on average, of such coverage by taking into account the cost of the abortion benefit (valued at least $1 per enrollee per month). The law says that this estimate cannot take into account any savings that might be achieved as a result of the abortions (such as prenatal care or delivery).

The Anti-Abortion Advocates’ Claim That Federal Funds Are Subsidizing Abortion Coverage

Abortion opponents are claiming that federal funds are being used to subsidize abortion because they believe these subsidies enable individuals to have coverage through the ACA Marketplace that includes abortion coverage, even though plans must charge each enrollee a $1 per month to pay for the costs of covered abortions and segregate these funds from other premium funds. While the anti-abortion advocates claim that the requirement for plans to segregate premiums for abortion coverage is an “accounting gimmick,” the required minimum of $1 per member per month that is specified in the ACA is higher than issuers estimate to be the actuarial value of the premium attributable to the cost of abortion coverage. In other words, the $1 month charge per enrollee (regardless of age or gender) exceeds the cost of abortions that plans are paying for with those funds. For example, a recent review showed that Maryland plans were holding $25 million in unspent funds from policyholder payments for segregated premiums for abortion coverage and it is very likely that plans in other states have surplus funds that have been collected for abortion coverage.

What Would Be the Impact if Congress Bans Premium Tax Credits for Plans that Include Abortion Coverage?

Twelve states require plans that are not self-insured to cover abortion. If Congress were to ban the use of premium tax credits for Marketplace plans that include abortion coverage beyond the Hyde restrictions, individuals in these 12 states would not be able to use federal tax credits to obtain coverage in a Marketplace plan. In 2023, approximately 3.7 million people were enrolled in ACA marketplace plans in the 12 states that require abortion coverage. In addition, it will also affect people in the 13 states and DC that allow abortion coverage but don’t mandate it. While Democrats may not agree to a ban on the availability of ACA premium taxes for plans that cover abortion, the lack of a ban could make it harder to attract Republican support for an extension of the enhanced tax credits.

A Closer Look at the Growing Role of Special Needs Plans in Medicare Advantage

Authors: Abby Sachar, Jeannie Fuglesten Biniek, Maiss Mohamed, and Alice Burns

Published: Sep 25, 2025

Enrollment in Medicare Advantage, the private plan alternative to traditional Medicare, has increased steadily over the past two decades, and since 2023, more than half of eligible beneficiaries have enrolled in Medicare Advantage. Amidst this growth, an increasing number of beneficiaries are enrolling in special needs plans (SNPs), especially since 2018, when SNPs became a permanent part of the Medicare Advantage program. SNPs now account for 21% of all Medicare Advantage enrollees, compared with just 13% in 2018. The increase in the share of Medicare Advantage enrollees in SNPs also means that SNPs contribute disproportionately to the growth in Medicare Advantage enrollment. For example, between 2024 and 2025, growth in SNPs comprised nearly half (48%) of the total increase in Medicare Advantage enrollment.

There are three types of SNPs, and enrollment in each is restricted to specific groups of beneficiaries, all of which comprise some of the highest-need beneficiaries in the Medicare population. Over 4 in 5 (82%) SNP enrollees are enrolled in dual eligible SNPs (D-SNPs), which are limited to people with both Medicare and Medicaid (“dual-eligible individuals”). Dual-eligible individuals tend to have lower incomes, more chronic conditions, and more functional and cognitive impairments than Medicare beneficiaries without Medicaid coverage. The two other types of SNPs are chronic condition SNPs (C-SNPs, 16% of enrollees), which are limited to people with certain chronic conditions, and institutional SNPs (I-SNPs, 2% of enrollees), which are limited to people who require an institutional level of care. All SNPs are required to have a model of care, or framework detailing how the plan will identify the needs of each enrollee and address those needs through the plan’s care management practices. Other requirements vary across the three types of SNPs. D-SNPs may have additional requirements depending on the state in which they operate. (See Box 1 for additional information.)

In recent years, the Centers for Medicare and Medicaid Services (CMS) has made several changes to requirements for D-SNPs and other Medicare Advantage plans, which may affect insurer decisions about the types of plans they offer and promote. To better understand the growing role of SNPs in Medicare Advantage and the potential implications for beneficiaries of changes to SNP and Medicare Advantage plan requirements, this brief examines SNP enrollment patterns and trends using recent Medicare Advantage enrollment data published by CMS.

Key Takeaways

Since 2018 when SNPs became a permanent part of the Medicare program, SNP enrollment has tripled, rising from 2.6 million to 7.3 million, an increase of nearly 4.7 million enrollees.
Through 2024, growth in SNPs was driven by an increase in enrollment in D-SNPs, which grew from 2.2 million enrollees in 2018 to 5.8 million enrollees in 2024, comprising more than 90% of SNP enrollment growth over that time.
C-SNPs comprised 75% of total SNP enrollment growth between 2024 and 2025, in contrast to prior years, where enrollment growth was mainly in D-SNPs. In 2025, C-SNP enrollment increased by 476,300 new enrollees, triple the increase in D-SNP enrollment (159,400 new enrollees).
A small share of SNP enrollees, just 14%, are in plans administered by non-profit insurers. SNP enrollment is highly concentrated among a small number of large national carriers, with UnitedHealth Group and Humana plans comprising over half (54%) of total SNP enrollment. UnitedHealth Group accounts for half of all C-SNP enrollees.
The acceleration of C-SNP enrollment growth and slowing of D-SNP enrollment growth coincided with implementation of new rules for D-SNPs requiring greater integration between Medicare and Medicaid. C-SNPs are not required to have a similar level of integration.

From 2018-2024, growth in SNP enrollment was driven by increases in D-SNP enrollment, plans for dual-eligible individuals.

From 2018, when SNPs became a permanent part of the Medicare Advantage program, through 2024, growth in SNP enrollment was predominantly due to growth in enrollment in D-SNPs. In 2018, 2.2 million people were enrolled in a D-SNP, and in 2024, 5.8 million people were enrolled in a D-SNP. That increase comprises more than 90% of the total increase in SNP enrollment between 2018 and 2024.

C-SNP enrollment and I-SNP enrollment also increased during this period, though on a smaller scale relative to D-SNP enrollment growth. C-SNP enrollment grew from 346,000 enrollees in 2018 to 674,500 enrollees in 2024, and I-SNP enrollment grew from 71,500 enrollees in 2018 to 115,100 enrollees in 2024.

SNPs receive higher per capita payments under the Medicare Advantage payment system, on average, because enrollees have higher expected spending due to their higher health care needs. It is well-documented, however, that Medicare Advantage pays more for Medicare Advantage enrollees than spending would be for the same people if they were covered under traditional Medicare, and in 2025, MedPAC estimates that payments were 20% higher, on average. The higher payments are largely driven by the risk adjustment system, which pays more for people who are sicker, and less for those who are healthier, relying heavily on diagnosed heath conditions to determine adjustments to payment based on health status. SNPs are potentially better positioned to leverage this system to increase their payments relative to enrollee’s costs, contributing to higher margins for SNPs, on average, than other Medicare Advantage plans. MedPAC found that in 2022, the average margins for D-SNPs (7.5%) and C-SNPs (7.4%) were double the average margins of Medicare Advantage plans overall (3.6%). In turn, those higher payments leave more resources for plans to offer supplemental benefits that appeal to a population with complex health care needs.

Between 2018-2024, D-SNP Enrollment Grew from 2.2 Million to 5.8 Million Enrollees, Comprising Over 90% of the Total Increase in SNP Enrollment (Stacked column chart)

Enrollment growth in SNPs from 2024-2025 was driven by an increase in enrollment in C-SNPs, plans for people with chronic conditions.

In recent years, CMS has made several changes to requirements for Medicare Advantage plans generally available to the public and D-SNPs, but not C-SNPs, which may affect insurer decisions about what types of plans to offer. Starting in 2022, CMS no longer contracts with conventional Medicare Advantage plans that enroll at least 80% dual-eligible individuals (“D-SNP look-alikes”). In 2025, this threshold was lowered to 70% and is scheduled to be lowered to 60% starting in 2026. Additionally, beginning in 2025, fully integrated dual eligible (FIDE) SNPs and highly integrated dual eligible (HIDE) SNPs have new enrollment, benefit, and coordination requirements (see Box 1 for additional details). The additional requirements are intended to promote better integration between Medicare and Medicaid for enrollees but could make D-SNPs less attractive to private insurers. These requirement changes could incentivize efforts to enroll more dual-eligible individuals in C-SNPs, which are not subject to the look-alike thresholds like conventional Medicare Advantage plans or Medicaid integration and coordination requirements like D-SNPs, particularly since many dual-eligible individuals have chronic conditions that may qualify them for C-SNP enrollment.

In contrast to previous years when enrollment growth in SNPs was driven by increased enrollment in D-SNPs, the largest increase in enrollment in SNPs from 2024 to 2025 was in C-SNPs, comprising more than three-quarters of the change in overall SNP enrollment. C-SNP enrollment increased sharply, rising by 476,300 enrollees from 2024 to 2025. That translates into a 71% jump over a one-year period. D-SNP enrollment and I-SNP enrollment remained relatively stable over the same period, with D-SNP enrollment growing by only 3% (159,400 enrollees) and I-SNP enrollment staying essentially unchanged.

While C-SNP enrollment has increased more quickly since the D-SNP look-alike rules first went into effect in 2022, the change accelerated over the last year, as the rules tightened further and other Medicaid integration and coordination requirements for FIDE and HIDE SNPs went into effect. This is the first time that the number of additional C-SNP enrollees has surpassed the number of additional D-SNP enrollees. A recent analysis of 2025 enrollment data (not yet available to KFF) shows that through January of 2025, just under 20% of the increase in C-SNP enrollment was comprised of dual-eligible individuals.

Dual-eligible individuals comprised a larger share of enrollment in SNPs than in non-SNP Medicare Advantage plans. For example, in 2023, 93% of SNP enrollees were dual-eligible individuals, which aligns with the dominance of D-SNPs in the SNP market. Over 90% of I-SNP enrollees were also dual-eligible individuals in 2023, reflecting the fact that Medicaid is the primary payer of long-term care, so people relying on an institutional level of care are more likely to be enrolled in both Medicare and Medicaid. In 2023, a quarter of enrollees in C-SNPs were dual-eligible individuals, while 9% of enrollees in individual Medicare Advantage plans were dual-eligible individuals.

In 2025, C-SNP Enrollment Grew by Nearly Half a Million Enrollees (Split Bars)

For all SNP types, enrollment is highly concentrated among a small number of large national carriers.

Across all three SNP types, which enroll some of the most vulnerable beneficiaries in the Medicare population, a few large national carriers account for larger shares of enrollment in the SNP market as compared with the overall Medicare Advantage market. The distribution of D-SNP enrollment by insurer is more heavily concentrated in UnitedHealth Group Inc. (38% vs 29%) and Elevance Health Inc. (10% vs 7%) than for the overall Medicare Advantage market. UnitedHealth Group Inc. accounts for half (51%) of all C-SNP enrollment. Additional firms comprising larger shares of enrollment in C-SNPs than in the overall Medicare Advantage market include Humana Inc. (20% vs 17%) and Elevance Health Inc. (12% vs 7%). Although UnitedHealth Group Inc. accounts for a majority (51%) of I-SNP enrollment in 2025, smaller insurers play a larger role in the I-SNP market than in the overall Medicare Advantage market (42% vs 33%). Overall, 14% of SNP enrollees are in a plan offered by a non-profit organization (16% of D-SNP enrollees, 3% of C-SNP enrollees, and 5% of I-SNP enrollees).

UnitedHealth Group Inc. and Humana Inc. Account for Over Half (54%) of SNP Enrollment in 2025 (Stacked Bars)

For dual-eligible individuals, D-SNPs offer more integration with Medicaid than C-SNPs.

To facilitate integration of Medicare and Medicaid coverage, D-SNPs are required to contract with state Medicaid agencies, while C-SNPs are not subject to additional integration requirements. The minimum D-SNP requirements, which are set at the federal level, differ across the three categories of D-SNPs and can change year-to-year during annual rule making. D-SNPs with higher levels of integration, HIDE and FIDE SNPs, have additional requirements (see Box 1 for more details). Additionally, D-SNPs can be designated as applicable integrated plans if they meet federal requirements, including exclusively aligned enrollment, covering at least some Medicaid services through the D-SNP or an affiliated Medicaid managed care plan, and a unified grievance and appeals system. Given the lack of C-SNP integration requirements, to the extent the acceleration in C-SNP enrollment was driven by dual-eligible individuals, efforts to encourage greater integration between Medicare and Medicaid may face challenges.

States may establish additional requirements for D-SNPs through their contracts. Responses from KFF’s 24^th annual budget survey of Medicaid officials in all 50 states and the District of Columbia in July 2024 show that these requirements vary across the different types of D-SNPs. For example, just over half (19) of the 35 states with coordination-only D-SNPs required these plans to include any of the additional optional requirements, the most common of which was offering certain supplemental benefits (7 states) and providing integrated member materials, such as one summary of benefits document that provides information on benefits covered by both Medicare and Medicaid (5 states). HIDE and FIDE SNPs operated in less than half of states in 2024, though most states had additional requirements for these types of plans beyond the federal requirements (14 of 15 for HIDE SNPs and all 12 states for FIDE SNPs) (Figure 4). New federal requirements for HIDE and FIDE SNPs went into effect in 2025. For FIDE SNPs, these include exclusively aligned enrollment, which limits enrollment to full-benefit dual-eligible individuals who were enrolled in the affiliated Medicaid managed care plan, and the requirement that the affiliated plan cover behavioral health, and certain other Medicaid benefits. To the extent these were not previously required by states, the new requirements may represent an additional burden for Medicare Advantage insurers and could influence their decisions on which plans to offer. In 2024, most states with FIDE SNPs did have these requirements. Specifically, of the 12 states with FIDE SNPs, 9 required exclusively aligned enrollment and 10 required the affiliated Medicaid managed care plan to cover behavioral health. (New requirements for HIDE SNPs were not among the items asked in the budget survey.) While these requirements are intended to facilitate integration and coordination between the programs, the relatively low availability of HIDE and FIDE SNPs may limit how effective they are at achieving that goal.

States Have Various Requirements in State Medicaid Agency Contracts to Improve Medicare and Medicaid Integration in D-SNPs (Split Bars)

Box 1. Types of Special Needs Plans

Dual Eligible Special Needs Plans

Dual eligible special needs plans (D-SNPs) are limited to people who are enrolled in both Medicare and Medicaid. There are three types of D-SNPs:

Coordination-only Dual Eligible Special Needs Plans: This type of D-SNP provides Medicare-covered services and is required to coordinate the delivery of benefits with the Medicaid program, contract with state Medicaid programs, and notify states when enrollees are admitted to an inpatient hospital or skilled nursing facility.

Highly Integrated Dual Eligible Special Needs Plans: This type of D-SNP must meet the requirements of coordination-only D-SNPs (except the notification requirements) and must also include coverage of long-term care, behavioral health, or both.

New for 2025: HIDE SNPs must have aligned service areas, meaning they must also have a Medicaid plan operating in the same counties as the D-SNP.

Fully Integrated Dual Eligible Special Needs Plans: This type of D-SNP must meet the requirements of coordination-only D-SNPs (except the notification requirements) and provide Medicare and included Medicaid covered services through a single managed care organization. The same organization that offers the FIDE SNP must also offer a Medicaid managed care plan for any Medicaid benefits not included in the FIDE SNP. In some cases, certain Medicaid benefits may be provided by the state or by a different health plan. FIDE SNPs are paid by Medicare for Medicare-covered services and supplemental benefits included in the plan, and by Medicaid for Medicaid-covered services.

New for 2025: FIDE SNPs must have exclusively aligned enrollment, meaning they may only enroll full-benefit dual-eligible individuals who are enrolled in both the FIDE SNP and the Medicaid plan sponsored by the same organization, and either the D-SNP or Medicaid plan must cover long-term care and all Medicaid benefits via a separate capitated payment arrangement.

Chronic Condition Special Needs Plans

Chronic condition special needs plans enroll individuals who have specific severe or chronic disabling conditions. Nearly all (97%) C-SNPs plans are for people with diabetes or cardiovascular conditions.

Institutional Special Needs Plans

Institutional special needs plans enroll individuals who need services to be provided in a long-term care facility for at least 90 days.

Methods

Data: SNP enrollment data are from the Special Needs Plan (SNP) data published by Centers for Medicare & Medicaid Services (CMS) in the Medicare Advantage (MA)/Part D Contract and Enrollment Data section in March of the respective year. Enrollment data are only provided for plan-county combinations that have at least 11 beneficiaries; thus, we exclude any plans that do not meet this enrollment threshold.

This analysis uses data from the CMS Medicare Advantage Benefit and Landscape files for the respective year. Medicare Advantage enrollment and dual-eligible beneficiary enrollment are based on analysis of the Centers for Medicare & Medicaid Services (CMS) Chronic Conditions Data Warehouse (CCW) research-identifiable Master Beneficiary Summary File (MBSF) Base in 2023.

Identifying dual-eligible enrollees as a share of SNP enrollees: Beneficiaries with a valid contract ID and plan ID in March 2023 were identified as enrolled in Medicare Advantage. To determine the type of plan in which the beneficiary was enrolled, the contract ID and plan ID were matched to the March 2023 Monthly Enrollment by Plan, or the Special Needs Plan Report data published by CMS. This includes enrollment in all private plans which are predominately Medicare Advantage plans.

Counts of dual-eligible individuals include both full-benefit and partial-benefit dual-eligible individuals. Dual status in March (03) 2023 was identified using the Medicare monthly dual status code DUAL_STUS_CD_03 with values of 01,02,03,04,05,06, or 08. Enrollees also had to have both Part A and B in March 2023 to be included in this analysis. We excluded enrollees from Puerto Rico and the Virgin Islands from this analysis.

This work was supported in part by Arnold Ventures. KFF maintains full editorial control over all of its policy analysis, polling, and journalism activities.

1.4 Million Lawfully Present Immigrants are Expected to Lose Health Coverage due to the 2025 Tax and Budget Law

Authors: Drishti Pillai, Alisha Rao, and Samantha Artiga

Published: Sep 25, 2025

Congressional Republicans and President Trump passed the tax and budget reconciliation bill in July 2025. The new law includes significant cuts to the Medicaid program as well as eligibility restrictions for many lawfully present immigrants, including refugees and asylees, to access Medicaid and the Children’s Health Insurance Program (CHIP), subsidized Affordable Care Act (ACA) Marketplace, and Medicare coverage. Under longstanding federal policy, undocumented immigrants already are ineligible for federally funded health coverage. This policy watch outlines the groups of lawfully present immigrants that will lose access to federally funded health coverage due to the 2025 tax and budget law and the Congressional Budget Office’s (CBO’s) estimates of the increases in the number of uninsured and federal savings and revenue changes due to these provisions.

CBO estimates that the law’s restrictions on eligibility for federally funded health coverage for lawfully present immigrants will result in about 1.4 million lawfully present immigrants becoming uninsured, reduce federal spending by about $131 billion, and increase federal revenues by $4.8 billion as of 2034. Additional lawfully present immigrants are likely to lose Marketplace coverage and become uninsured due to the anticipated expiration of the enhanced subsidies for this coverage. Moreover, under Trump administration regulatory changes, the more than 530,000 Deferred Action for Childhood Arrivals (DACA) recipients are ineligible for federally funded coverage options.

Changes in Eligibility for Lawfully Present Immigrants Under the 2025 Tax and Budget Law

Medicaid and CHIP

Under prior law, to be eligible for Medicaid and CHIP, immigrants were required to have a “qualified” immigration status in addition to meeting other eligibility requirements such as income. Qualified immigrants, as defined by the 1996 Personal Responsibility and Work Opportunity Act and subsequent additions, include lawful permanent residents (LPRs or “green card” holders); refugees; individuals granted parole for at least one year; individuals granted asylum or related relief and certain abused spouses and their children or parents; certain victims of trafficking; Cuban and Haitian entrants; and citizens of the Freely Associated (COFA) nations of the Marshall Islands, Micronesia and Palau residing in U.S. states and territories. In addition, many had to wait five years after obtaining qualified status before they could enroll in Medicaid even if they met other eligibility requirements. States have an option to extend Medicaid and/or CHIP coverage to all children and/or pregnant individuals who are lawfully residing and waive the five-year wait for these groups, which 39 states plus D.C. had taken up as of January 2025. States also have the option in CHIP to provide prenatal care and pregnancy related benefits to targeted low-income children beginning from conception to end of pregnancy (FCEP) regardless of their parent’s immigration status, which 24 states plus D.C. had taken as of April 2025.

The 2025 tax and budget law will restrict Medicaid or CHIP eligibility to LPRs, Cuban and Haitian entrants, people residing in the U.S. under COFA, and lawfully residing children and pregnant immigrants in states that cover them under the Medicaid and/or CHIP option (Table 1). States also will still have the option to extend prenatal and pregnancy-related benefits to targeted low-income children from conception through the end of pregnancy through the FCEP option. These restrictions will eliminate eligibility for many other groups of lawfully present immigrants, including refugees and asylees without a green card, among others (Table 1). This provision will become effective October 1, 2026, and CBO estimates that it will reduce federal spending by $6.2 billion and lead to an additional 100,000 individuals becoming uninsured by 2034.

ACA Marketplaces

Under prior law, lawfully present immigrants have been eligible to enroll in ACA Marketplace coverage and receive premium subsidies and cost-sharing reductions, including individuals with Temporary Protected Status (TPS), those with Deferred Enforced Departure, and people on work visas. In general, Marketplace coverage is limited to individuals with incomes at or above 100% of the federal poverty level (FPL), since most of those with lower incomes would be eligible for Medicaid. However, some lawfully present immigrants with lower incomes remain ineligible for Medicaid (e.g., due to the five-year waiting period and eligibility limits to qualified immigrants). To address this gap, Marketplace eligibility was also extended to lawfully present immigrants with incomes under 100% FPL who do not qualify for Medicaid due to their immigration status, including those in the five-year waiting period for Medicaid coverage. In the years after the ACA was passed, DACA recipients were excluded from eligibility for the Marketplaces despite being lawfully present. Under regulations issued by the Biden Administration in May 2024, DACA recipients were made newly eligible for the Marketplaces and to receive subsidies to offset costs starting November 2024. However, this coverage was blocked in some states due to legal challenges, and on June 25, 2025, the Trump administration finalized a rule that once again made DACA recipients ineligible to purchase ACA Marketplace coverage as of August 25, 2025. Most states will terminate coverage for enrolled DACA recipients on September 30, 2025.

The law will also limit eligibility for subsidized ACA Marketplace coverage to lawfully present immigrants who are LPRs, Cuban and Haitian entrants, and people residing in the U.S. under COFA. (Table 1). A broader group of lawfully present immigrants will lose access to subsidized Marketplace coverage under this change, including refugees and asylees without green cards, people with TPS, and individuals on work visas, among others, beginning January 1, 2027. The CBO estimates that this provision will lead to an additional one million individuals becoming uninsured and reduce federal spending by $91.4 billion over the 2026 to 2035 time period. In addition, the provision is expected to increase federal revenue by $4.8 billion as of 2034. The law also eliminates access to subsidized Marketplace coverage for lawfully present immigrants earning less than 100% FPL who are not eligible for Medicaid due to immigration status, including those in the five-year waiting period for coverage, beginning January 1, 2026. During the 2025 open enrollment period, nearly 550,000 people with incomes under 100% FPL were enrolled in a Marketplace plan, who are likely primarily lawfully present immigrants who are ineligible for Medicaid due to immigration status. The CBO estimates that this provision will lead to an additional 200,000 individuals becoming uninsured and reduce federal spending by $27.3 billion over the 2026 to 2035 time period. In addition, the provision is expected to increase federal revenue by $176 million as of 2034.

Medicare

Lawfully present immigrants have been eligible for Medicare if they have the required work quarters and meet the disability or age requirements. Those without required work history could also purchase Medicare Part A after residing legally in the U.S. for five years continuously.

Under the new law, Medicare eligibility also will be limited to lawfully present immigrants who are LPRs, Cuban and Haitian entrants, and people residing in the U.S. under COFA, eliminating eligibility for refugees and asylees without a green card, people with TPS, and people with work visas, among others (Table 1). Current beneficiaries subject to the new restrictions will lose coverage no later than 18 months from the enactment of the legislation (January 4, 2027). The CBO estimates that this provision will lead to an additional 100,000 individuals losing coverage, with a federal spending reduction of $5.1 billion and a federal revenue decrease of $123 million as of 2034.

Occupations with Large Shares of Workers Who Rely on Individual Market Coverage

Authors: Cynthia Cox and Gary Claxton

Published: Sep 25, 2025

While most working age people get their health insurance through an employer-sponsored plan, the individual market – which is largely made up by the Affordable Care Act (ACA) Marketplaces – is also an important source of health insurance coverage for many workers. This is particularly true for people who have jobs that do not offer health benefits (such as small companies or gig jobs). In fact, nearly half of adult individual market insurance enrollees are small business owners, employees, or are self-employed.

On average, 8% of adults under age 65 who usually worked more than 20 hours per week in 2023 got their coverage in the individual market. However, the Individual market is a particularly important source of health insurance for workers in certain occupations, such as chiropractors and dentists, real estate brokers, and farmers, ranchers, and agricultural managers, where more than a quarter of adult workers were covered in the individual market.

Occupations Where at least 25% of Adult Workers Rely on Individual Market Coverage, 2023 (Table)

Based on KFF analysis of administrative data, over 90% of individual market health insurance enrollees get their coverage through the ACA Marketplaces, and of them, 93% receive a tax credit to lower the monthly cost of their premiums.

For nearly 5 years, enhanced premium tax credits have further lowered monthly premiums for these enrollees, including people with middle and higher incomes who previously received no financial assistance and were sometimes priced out of insurance coverage. However, these enhanced premium tax credits are set to expire at the end of 2025. If this additional financial help expires, people currently receiving a tax credit will see their out-of-pocket premium payments increase sharply, by over 75% on average. The Congressional Budget Office estimates that nearly 4 million more people will eventually be uninsured if the enhanced tax credits expire, and the cost to extend them would be an average of $35 billion per year.

Methods

Estimates based on KFF analysis of the 2023 American Community Survey. People are considered to have individual market coverage if they report direct purchase coverage and do not report any other coverage options; people with more than one coverage type (e.g., employer-group coverage) are considered to be covered by that other type. Percentages are of adults ages 19 through 64 who usually had worked more than 20 hours per week over the previous 12 months.

VOLUME 31

September 25, 2025

New KFF-Washington Post Poll Explores Parents’ Vaccine Attitudes, and Confusion Follows ACIP Meeting on Vaccine Recommendations

Irving Washington , Hagere Yilma , and Joel Luther

Summary

This volume highlights findings from the KFF-Washington Post Survey of Parents, which explores parents’ views on childhood vaccines and their choices when it comes to vaccinating their own children. It also examines how questions from the Advisory Committee on Immunization Practices (ACIP) about the safety and necessity of some vaccines, including for COVID-19 and hepatitis B, may be impacting trust and public confusion. Additionally, it discusses recent HHS warnings about alleged links between Tylenol use during pregnancy and autism, and the rise in AI-generated deepfake videos impersonating doctors to sell unproven health products.

Featured: New KFF-Washington Post Survey Finds Many Parents Express Doubt and Confusion Over Childhood Vaccine Recommendations

The new KFF-Washington Post Survey of Parents takes a deep dive into parents’ views and decisions related to childhood vaccines. The survey finds that while a large majority of parents report following current vaccine guidance and are confident in the safety of MMR and polio vaccines, some, including larger shares of Republican parents and younger parents, express doubts about the current childhood vaccine schedule. One-third (35%) of parents say that vaccines don’t go through enough safety testing before being recommended for children, and one in four (26%) say the CDC recommends too many childhood vaccines. Republican and independent parents are more likely to express these views compared to Democratic parents. There are further divisions among Republican parents, with those who support the Make America Great Again (MAGA) movement more likely than non-MAGA Republican parents to say that childhood vaccines don’t go through enough safety testing (57% v. 32%) and that the CDC recommends too many childhood vaccines (49% v. 28%). Parents under age 35 are also more likely than parents ages 50 and over to say vaccines do not get enough safety testing (39% vs. 26%) and that the CDC recommends too many vaccines (29% vs. 23%).

When it comes to confidence in the safety of specific vaccines, majorities of parents across partisanship express confidence in the safety of polio (85%) and MMR (84%) vaccines for children, while the flu and COVID-19 vaccines are much more divisive. Two-thirds (65%) of parents say they are confident that flu vaccines are safe for children, while fewer than half (43%) express confidence in the safety of the COVID-19 vaccine for children. Partisans are sharply divided on the COVID-19 vaccine’s safety, with Democratic parents more than three times as likely as Republican parents to say they are confident COVID-19 vaccines are safe for children (70% v. 22%).

Many Parents Express Doubt Over Childhood Vaccine Recommendations and Safety, Including Larger Shares of Younger Parents and Republican Parents (Split Bars)

The KFF-Post survey finds that large shares of parents express uncertainty about false or misleading claims about vaccines and measles – many of which have been amplified by HHS Secretary Robert F. Kennedy Jr. Overall, few parents say they think it is true that chronic diseases are rising because of an increase in the number of vaccines children get (13%), that MMR vaccines can cause autism in children (9%), that the measles vaccine causes the same illness it is supposed to prevent (8%), or that vitamin A is an effective treatment for measles (6%). For each of these false or misleading claims, however, at least four in ten parents say they don’t know enough to say whether they are true or false, suggesting many parents may be confused about some of the science behind childhood vaccines.

Stacked bar chart showing percent who say specific false claims about vaccines and diseases are true, they don't know enough to say, or are false.

When it comes to parents’ choice to vaccinate their children, a large majority (83%) report keeping their children up to date on childhood vaccines, however, about one in six (16%) say they have skipped or delayed at least one vaccine for any of their children (excluding vaccines for the flu or COVID-19). Parents’ reasons for skipping or delaying vaccines for their own children mirror many of the general concerns and uncertainty expressed by parents overall. About two-thirds (67%) of parents who skipped or delayed vaccines for their child say concerns about side effects were a “major reason” for their decision, while half cited not thinking vaccines are safe (53%) or necessary (51%) as major reasons they skipped or delayed their child’s vaccines.

Recent Developments

Health Committee Delays Vote on Changing Hepatitis B Vaccine Recommendation

THOM LEACH / SCIENCE PHOTO LIBRARY / *Getty Images*

Last week, the CDC’s Advisory Committee on Immunization Practices (ACIP) considered changing its recommendation that all newborns receive a hepatitis B vaccine at birth to waiting until newborns are at least one month old, but postponed the vote to allow more time to discuss safety and timing. The discussion and delayed vote came after HHS Secretary Robert F. Kennedy Jr. and members of the ACIP questioned the agency’s recommendation that all newborns be vaccinated against hepatitis B, saying that the virus is primarily spread through sexual activity and drug use in adults. However, hepatitis B can also be transmitted from mother to child during birth and potentially cause chronic infection and death. While most adults recover completely from hepatitis B infection, newborns infected at birth have a 90% chance of developing a chronic form of the disease, and 15-25% of people with chronic infection die from cirrhosis or liver cancer.

Although ACIP ultimately postponed the vote, the debates about timing and necessity that led up to last week’s meeting could contribute to public confusion. Administering the vaccine and immune globulin to newborns is 94% effective at preventing transmission of the disease, but the narrative that hepatitis B vaccines are unnecessary for babies spread on social media throughout September. Senator Rand Paul, who has more than 6 million followers on X, posted that universal newborn vaccination is unnecessary because mothers are routinely tested for hepatitis B infection and that the recommendation represented pharmaceutical industry influence. Senator Bill Cassidy, a physician who chairs the Senate’s health committee, shared one of Paul’s posts on X and disputed its claims, correctly saying that not all mothers receive prenatal care or testing. Paul’s posts were among the most-engaged-with posts about hepatitis B vaccines identified in KFF’s monitoring of social media in September thus far, and were reposted by influential accounts with large followings that regularly post about health, including one with nearly two million followers. Reactions to the posts reflected confusion about why the hepatitis B vaccine is given within the first hours of life, while most other vaccines are scheduled for later months. Kennedy has also alleged that the CDC concealed findings from a study that he claimed showed the hepatitis B vaccine increased the risk of autism, but he did not provide evidence to support these claims and research has shown there is no such association.

The timing of the hepatitis B vaccine has become a focal point for public debate, and these discussions may influence trust in health officials. Some parents who would otherwise vaccinate their children may feel uneasy about giving the vaccine in the first hours of life, particularly if the mother tests negative and there appear to be few immediate risk factors. Framing the decision as a personal choice rather than a scientific recommendation can create opportunities for confusion and vaccine hesitancy. At the same time, the vaccine’s history underscores the rationale for early administration, with universal newborn vaccination helping to reduce cases of perinatal transmission from thousands to only seven in 2023.

The KFF/Washington Post Survey of Parents found that about one in ten (9%) parents report skipping or delaying the hepatitis B vaccine for at least one of their children, including 5% who report skipping the vaccine and 4% who report delaying it. These are similar to the shares that report skipping or delaying other recommended childhood vaccines like MMR or chickenpox.

ACIP Changes COVID-19 Vaccine Guidance After Safety Debate

thianchai sitthikongsak / *Getty Images*

Federal health authorities presented misleading data about the safety of COVID-19 vaccines during last week’s meeting of ACIP, potentially undermining public confidence in vaccine guidance. The committee voted to eliminate universal COVID-19 recommendations, instead recommending that people consult healthcare providers before getting vaccinated. It also requested that the CDC consider adding language about what it said were risks or uncertainties related to COVID-19 vaccines to the Vaccine Information Sheet, a document that explains vaccine risks and benefits to recipients.

The votes came after presentations to the committee that included a number of false or misleading claims about COVID-19 vaccines. One presentation included a reference to a recent study that purported to show the vaccines were “contaminated” with DNA at rates beyond what is allowed by federal regulators, but that study is now under investigation by the publisher. Another study referenced at the meeting, which claimed that COVID-19 vaccines caused autism-like behaviors in rats, was retracted after it was found to contain inconsistencies in methods and data.

The use of unsubstantiated claims in a high-profile ACIP meeting to question vaccine safety has the potential to undermine public trust in COVID-19 vaccines. Despite the links made at the ACIP meeting, COVID-19 vaccines have been extensively studied and the dangers of COVID-19 itself outweigh the risks of the vaccine for most. False claims about the vaccines’ safety spread on social media following the committee meeting, with one account with more than 100,000 followers sharing news about the new guidance and claiming that COVID-19 vaccines were dangerous. The claims reflect broader concerns about COVID-19 vaccine safety. The KFF-Washington Post Survey of Parents found that about four in ten (43%) parents are confident in the safety of COVID-19 vaccines for children, including one in five who are “very confident.”

The debates within ACIP reflect a larger struggle over who is seen as credible in setting vaccine policy. Monitoring these reactions is part of understanding how public trust in the CDC and federal health officials shifts as disputes over childhood vaccines become more visible. The day before ACIP’s meeting, former CDC director Susan Monarez testified before the Senate on September 17 that she was dismissed for refusing Kennedy’s request to pre-approve vaccine recommendations by ACIP and to remove career scientists from their positions. Kennedy previously disputed Monarez’s accounts of their conversations, testifying before an earlier Senate committee that she was fired after telling him she was not trustworthy, though Monarez refuted this claim. KFF will continue to track reactions to these developments to provide insight into how public perception of vaccine safety and federal guidance evolves over time.

HHS Links Autism to Tylenol Use During Pregnancy Without Conclusive Evidence

On September 22, the Trump administration announced that FDA will now begin warning against Tylenol (acetaminophen) use during pregnancy, except in cases of high fever, citing a possible link to autism despite inconclusive evidence and opposition from major medical groups. The press release acknowledged the lack of established causation linking acetaminophen to neurodevelopmental disorders, but it advises providers to use their best judgment when prescribing acetaminophen during pregnancy.

Large, well-designed studies have found no increased risk and scientific consensus pointing to a strong genetic basis for autism. Although some smaller observational studies reported associations, they may have relied on self-reporting of acetaminophen use and failed to adequately control for other risk factors. For example, one recent review of 46 studies was shared by news outlets to warn of a link between maternal acetaminophen use and neurodevelopmental disorders. However, the conclusion from the review authors was in line with the current standard of care and the authors cautioned that their findings did not prove a causal link and called for further research. Of the 46 studies, only eight investigated autism, and most either relied on self-reported acetaminophen use or failed to adequately control for genetic factors, family history, or other confounders.

The anticipation of HHS’s announcement contributed to a large increase in people discussing the alleged link between acetaminophen and autism on X. In August, before news of the anticipated HHS report was shared, KFF’s monitoring of social media found just under 4,000 posts, reposts, or comments mentioning terms related to both autism and acetaminophen prior to reporting about the upcoming HHS announcement. The narrative received a small bump in the number of posts about it on August 19, when Kennedy’s former organization posted about the connection on X. Over the next few days, several news stations ran segments claiming that taking acetaminophen while pregnant could increase a child’s risk of developing autism. In September, after reports indicated the HHS guidance was forthcoming, the number of posts, reposts, and comments mentioning these terms on X increased to almost 150,000, as of the morning of September 22. In fact, more than 90% of such posts in 2025 thus far occurred in the month of September. Many of the most-engaged-with posts challenged the supposed link, with some sharing personal anecdotes about their experiences raising children with autism.

Acetaminophen is one of the few recommended treatments for pain and fever during pregnancy, as ibuprofen and other nonsteroidal anti-inflammatory drugs (NSAIDs) are known to increase risk of miscarriage and birth defects. Major medical organizations, including the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM), continue to state acetaminophen is safe in pregnancy but advise consultation with a doctor. Unsupported claims about its safety could discourage pregnant people from treating fevers and pain when medically necessary, putting them at increased risk of severe adverse outcomes. Misleading narratives linking common medications to autism may also contribute to stigma against people with autism and their families by reinforcing the idea that autism is a condition that could have been prevented, echoing historical patterns which have often sought to assign blame to mothers of children with autism.

AI & Emerging Technology

Deepfakes of Doctors Used to Sell Unproven Health Products

Artificial intelligence (AI) tools are being used to create convincing fake videos impersonating doctors to sell unproven health products, with technology now sophisticated enough to generate realistic impersonators from only a few images or videos. Reporting from The New York Times and CBS News has documented a rise in deepfake videos across social media platforms featuring fabricated medical professionals, some using the identities of real physicians to give health advice or sell products primarily related to beauty, wellness, and weight loss. One physician who is known for debunking false health claims online discovered deepfake videos using his likeness to promote products he had never endorsed, appearing across TikTok, Instagram, Facebook, and YouTube.

Many of the videos promoted products as supposed “miracle cures,” with one featuring a deepfake of a doctor promoting a non-FDA approved product that the video said was “96% more effective than Ozempic.” Some were viewed millions of times before being removed, and the doctors who were impersonated reported difficulty getting the content removed through standard reporting channels.

Celebrities and popular entertainment figures have been the subject of health-related deepfakes before, often promoting similar “miracle cure” or weight-loss products. Research has shown that most people struggle to identify deepfake videos, with one meta-analysis showing that on average, humans did not accurately detect deepfake videos at levels significantly above chance. Videos impersonating doctors may exploit trust in physicians, which KFF polling has shown remains high even as trust in federal health agencies declines. So why does this matter? People are generally poor at detecting deepfakes and could be persuaded to purchase harmful or ineffective products. Traditional health literacy advice, which emphasizes verifying credentials or institutional affiliations, is largely undercut by these new techniques. The spread of deepfake videos of healthcare providers may erode trust in legitimate healthcare communications and make it difficult for patients to recognize authentic medical guidance, potentially putting them at risk of following dangerous health advice or purchasing ineffective treatments.

About The Health Information and Trust Initiative: the Health Information and Trust Initiative is a KFF program aimed at tracking health misinformation in the U.S., analyzing its impact on the American people, and mobilizing media to address the problem. Our goal is to be of service to everyone working on health misinformation, strengthen efforts to counter misinformation, and build trust.

View all KFF Monitors

The Monitor is a report from KFF’s Health Information and Trust initiative that focuses on recent developments in health information. It’s free and published twice a month.

Support for the Health Information and Trust initiative is provided by the Robert Wood Johnson Foundation (RWJF). The views expressed do not necessarily reflect the views of RWJF and KFF maintains full editorial control over all of its policy analysis, polling, and journalism activities. The data shared in the Monitor is sourced through media monitoring research conducted by KFF.

The Politics of Health Care and Elections

KFF Authors:

The Affordable Care Act 101

KFF Authors:

Premium Subsidies

Cost-Sharing Reductions

Enrollment

Premiums

Deductibles and other cost sharing

Insurer participation

ACA Marketplace Premium Payments Would More than Double on Average Next Year if Enhanced Premium Tax Credits Expire

Enrollees across the income spectrum can expect big increases in premium payments

Related Content

There is No Drop-Dead Date for an ACA Tax Credit Extension, But Coverage Losses Will Mount as the Clock Ticks

Quiz: Test Your Knowledge of the Affordable Care Act

From Drew Altman: How an ACA Premium Spike Will Affect Family Budgets, and Voters

Health Issues for Immigrants in Detention Centers

Detention Policies under the Trump Administration

Health Care Risks and Challenges for Immigrants in Detention Facilities

Related Content

Deaths and Health Care Issues in ICE Detention Centers Under the Second Trump Administration

Potential Impacts of Mass Detention and Deportation Efforts on the Health and Well-Being of Immigrant Families

KFF/New York Times 2025 Survey of Immigrants: Worries and Experiences Amid Increased Immigration Enforcement

A Look at the Potential Impact of the High Unemployment Hardship Exception to Medicaid Work Requirements

What is the High Unemployment Rate Hardship Exception?

How Many Counties and Enrollees Could Meet the High Unemployment Exception?

Appendix

Related Content

Tracking Implementation of the 2025 Reconciliation Law: Medicaid Work Requirements

A Closer Look at the Work Requirement Provisions in the 2025 Federal Budget Reconciliation Law

Most Adults Subject to Medicaid Work Requirements Are Working or Face Barriers to Work

Deja Vu: the Future of Abortion Coverage in ACA Marketplace Plans

The ACA Explicitly Says that Federal Funds May Not Be Used to Pay for Marketplace Abortion Coverage Beyond the Hyde Limitations

ACA Rules for Premiums for Abortion Coverage

The Anti-Abortion Advocates’ Claim That Federal Funds Are Subsidizing Abortion Coverage

What Would Be the Impact if Congress Bans Premium Tax Credits for Plans that Include Abortion Coverage?

Related Content

Litigation Challenging the 2025 Budget Reconciliation Law’s Provision Blocking Federal Medicaid Payments to Planned Parenthood

Abortion on the 2026 Ballot: The Evolving Landscape of State Abortion Initiatives

State Policies on Abortion Coverage in Medicaid, Private Insurance, and ACA Exchange Plans in 2025

A Closer Look at the Growing Role of Special Needs Plans in Medicare Advantage

Key Takeaways

From 2018-2024, growth in SNP enrollment was driven by increases in D-SNP enrollment, plans for dual-eligible individuals.

Enrollment growth in SNPs from 2024-2025 was driven by an increase in enrollment in C-SNPs, plans for people with chronic conditions.

For all SNP types, enrollment is highly concentrated among a small number of large national carriers.

For dual-eligible individuals, D-SNPs offer more integration with Medicaid than C-SNPs.

Related Content

Medicare Advantage 2026 Spotlight: A First Look at Plan Offerings

The Landscape of Medicare and Medicaid Coverage Arrangements for Dual-Eligible Individuals Across States

Congressional District Interactive Map: People with Medicare and Medicaid (Dual-Eligible Individuals)

1.4 Million Lawfully Present Immigrants are Expected to Lose Health Coverage due to the 2025 Tax and Budget Law

Changes in Eligibility for Lawfully Present Immigrants Under the 2025 Tax and Budget Law

Medicaid and CHIP

ACA Marketplaces

Medicare

Occupations with Large Shares of Workers Who Rely on Individual Market Coverage

Related Content

ACA Marketplace Premium Payments Would More than Double on Average Next Year if Enhanced Premium Tax Credits Expire

About Half of Adults with ACA Marketplace Coverage are Small Business Owners, Employees, or Self-Employed

How Individual Market Enrollment Changed with the Enhanced Premium Tax Credits

Poll: Most of the Public Support Extending the ACA’s Enhanced Premium Tax Credits, Including Most Republicans and MAGA Supporters

New KFF-Washington Post Poll Explores Parents’ Vaccine Attitudes, and Confusion Follows ACIP Meeting on Vaccine Recommendations

Summary

Featured: New KFF-Washington Post Survey Finds Many Parents Express Doubt and Confusion Over Childhood Vaccine Recommendations

Recent Developments

Health Committee Delays Vote on Changing Hepatitis B Vaccine Recommendation

ACIP Changes COVID-19 Vaccine Guidance After Safety Debate

HHS Links Autism to Tylenol Use During Pregnancy Without Conclusive Evidence

AI & Emerging Technology

Deepfakes of Doctors Used to Sell Unproven Health Products

Litigation Challenging the 2025 Budget Reconciliation Law’s Provision Blocking Federal Medicaid Payments to Planned Parenthood