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.

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.

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.

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.

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.

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.

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. 

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.

Cost-Sharing Reductions

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.

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.

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.

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.

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.

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.

Deductibles and other cost sharing

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.  

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.

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.

• KFF Subsidy Calculator
• How Much More Would People Pay in Premiums if the ACA’s Enhanced Subsidies Expired?
• Explaining Health Care Reform: Questions About Health Insurance Subsidies
• Implementation Dates for 2025 Budget Reconciliation Law
• Health Provisions in the 2025 Federal Budget Reconciliation Law
• Health Reform FAQs
• Inflation Reduction Act Subsidies  
• Ten Things to Watch for 2025 ACA Open Enrollment
• State Health Facts – ACA state data
• Enrollment Growth in the ACA Marketplaces
• Deductibles in ACA Marketplaces

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).

The federal government is not the only place health policy is made in the U.S., but it is by far the most influential. Of the $4.9 trillion the U.S. spent on health in 2023, the federal government was responsible for roughly a third of all health services. The payment and coverage policies set for the Medicare program, in particular, often serve as a model for the private sector. Many health programs at the state and local levels are also impacted by federal health policy, either through direct spending or rules and requirements. Federal health policy is primarily guided by Congress, but carried out by the executive branch, predominantly by the Department of Health and Human Services. 

No one is “in charge” of the fragmented U.S. health system, but the federal government probably has the most influence, a role that has grown over the last 75 years. Today the federal government pays for care, provides it, regulates it, and sponsors biomedical research and medical training.  

The federal government pays for health coverage for well over 100 million Americans through Medicare, Medicaid, the Children’s Health Insurance Program (CHIP), the Veterans’ Health Administration, the Indian Health Service, and the Affordable Care Act (ACA).  It also pays to help provide insurance coverage for tens of millions who are active-duty and retired military and for civilian federal workers.

Federal taxpayers also underwrite billions of dollars in health research, mainly through the National Institutes of Health (NIH) and the Agency for Healthcare Research and Quality (AHRQ).

Federal public health policy is spearheaded by the Centers for Disease Control and Prevention. Its portfolio includes tracking not just infectious disease outbreaks in the U.S. and worldwide, but also conducting and sponsoring public health research and tracking national health statistics. 

The Health Resources and Services Administration (HRSA) funds critical health programs for underserved Americans (including Community Health Centers) and runs workforce education programs to bring more health services to places without enough health care providers. 

Meanwhile, in addition to overseeing the nation’s largest health programs, the Centers for Medicare and Medicaid Services (CMS) also operates the federal insurance Marketplaces created by the ACA and enforces rules made by the law for private insurance policies. 

While the federal government exercises significant authority over medical care and its practice and distribution, state and local governments still have key roles to play.  

States oversee the licensing of health care professionals, distribution of health care resources, and regulation of health insurance plans that are not underwritten by employers themselves. State and local governments share responsibility for most public health activities and often operate safety-net facilities in areas with shortages of medical resources. 

All three branches of the federal government – Congress, the executive branch, and the judiciary – play important roles in health policy. 

Congress makes laws that create new programs or modify existing ones. It also conducts “oversight” of how the executive branch implements the laws Congress has passed. Congress also sets the budget for “discretionary” and “mandatory” health programs (see below) and provides those dollar amounts. 

The executive branch carries out the laws made by Congress and operates the federal health programs, often filling in details Congress has left out through rules and regulations. Federal workers in the health arena may provide direct patient care, regulate how others provide care, set payment rates and policies, conduct medical or health systems research, regulate products sold by the private sector, and manage the billions of dollars the federal government spends on the health-industrial complex.  

Historically, the judiciary has had the smallest role in health policy, but has played a pivotal role in recent cases. It passes judgment on how or whether certain laws or policies can be carried out and settles disputes between the federal government, individuals, states, and private companies over how health care is regulated and delivered.  Recent significant decisions from the Supreme Court have affected the legality and availability of abortion and other reproductive health services and the constitutionality of major portions of the ACA.

The Executive Branch – The White House

Although most of the executive branch’s health policies are implemented by the Department of Health and Human Services (and to a smaller extent, the Departments of Labor and Justice), over the past several decades the White House itself has taken on a more prominent role in policy formation. The White House Office of Management and Budget not only coordinates the annual funding requests for the entire executive branch, but it also reviews and approves proposed regulations, Congressional testimony, and policy recommendations from the various departments. The White House also has its own policy support agencies – including the National Security Council, the National Economic Council, the Domestic Policy Council, and the Council of Economic Advisors – that augment what the President receives from other portions of the executive branch.

Most federal health policy is made through the Department of Health and Human Services. Exceptions include the Veterans Health Administration, run by the Department of Veterans Affairs; TRICARE, the health insurance program for active-duty military members and dependents, run by the Defense Department; and the Federal Employees Health Benefits Program (FEHB), which provides health insurance for civilian federal workers and families and is run by the independent agency the Office of Personnel Management.  

The health-related agencies within HHS are roughly divided into the resource delivery, research, regulatory, and training agencies that comprise the U.S. Public Health Service and the health insurance programs run by the Centers for Medicare and Medicaid Services (CMS). 

Ten of the 13 operating divisions of HHS are part of the U.S. Public Health Service, which also plays a role in U.S. global health programs. They are: 

• The Administration for Strategic Preparedness and Response (ASPR) 
• The Advanced Research Projects Agency for Health (ARPA-H)
  • The Agency for Healthcare Research and Quality (AHRQ) 
  • The Agency for Toxic Substances and Disease Registry (ATSDR) 
  • The Centers for Disease Control and Prevention (CDC) 
  • The Food and Drug Administration (FDA) 
  • The Health Resources and Services Administration (HRSA) 
  • The Indian Health Service (IHS) 
  • The National Institutes of Health (NIH) 
  • The Substance Abuse and Mental Health Services Administration (SAMHSA) 

The Centers for Medicare and Medicaid Services (CMS) is by far the largest operating division of HHS. It oversees not just the Medicare and Medicaid programs, but also the federal Children’s Health Insurance Program (CHIP) and the health insurance portions of the Affordable Care Act. Together, the programs under the auspices of CMS account for nearly a quarter of all federal spending in fiscal 2023, cost an estimated $1.5 trillion in fiscal 2023, and served more than 170 million Americans – more than half the population.

The current Trump administration has proposed a major restructuring of the health agencies under HHS, including creation of a new “Administration for a Healthy America.” As of September 2025, that restructuring has been blocked by court action.  However, a data analysis conducted by the news organization ProPublica found that as of August 2025, more than 20,500 workers – about 18 percent of the department’s workforce – had been laid off or left their jobs.

How Congress oversees the federal health care-industrial complex is almost as byzantine as the U.S. health system itself. Jurisdiction and responsibility for various health agencies and policies is divided among more than two dozen committees in the House and Senate (Tables 1 and 2). 

In each chamber, however, three major committees deal with most health issues.  

In the House, the Ways and Means Committee, which sets tax policy, oversees Part A of Medicare (because it is funded by the Social Security payroll tax) and shares jurisdiction over other parts of the Medicare program with the Energy and Commerce Committee. Ways and Means also oversees tax subsidies and credits for the Affordable Care Act and tax policy for most employer-provided insurance.  

The Energy and Commerce Committee has sole jurisdiction over the Medicaid program in the House and shares jurisdiction over Medicare Parts B, C, and D with Ways and Means. Energy and Commerce also oversees the U.S. Public Health Service, whose agencies include the Food and Drug Administration, the National Institutes of Health, and the Centers for Disease Control and Prevention.  

While Ways and Means and Energy and Commerce are in charge of the policymaking for most of the federal government’s health programs, the actual amounts allocated for many of those programs are determined by the House Appropriations Committee through the annual Labor-Health and Human Services-Education and Related Agencies spending bill.  

In the Senate, responsibility for health programs is divided somewhat differently. The Senate Finance Committee, which, like House Ways and Means, is in charge of tax policy, oversees all of Medicare and Medicaid and most of the ACA.  

The Senate counterpart to the House Energy and Commerce Committee is the Senate Health, Education, Labor and Pensions Committee, which has jurisdiction over the Public Health Service (but not Medicare or Medicaid).  

The Senate Appropriations Committee, like the one in the House, sets actual spending for discretionary programs as part of its annual Labor-HHS-Education spending bill. 

Under Article 1 of the U.S. Constitution, Congress is granted the exclusive power to “lay and collect Taxes, Duties, Imposts and Excises, and to pay the Debts and provide for the common Defence and General Welfare of the United States.”  

In 1974, lawmakers passed the Congressional Budget and Impoundment Control Act in an effort to standardize the annual process for deciding tax and spending policy for each federal fiscal year and to prevent the executive branch from making spending policy reserved to Congress. Among other things, it created the House and Senate Budget Committees and set timetables for each step of the budget process.  

Perhaps most significantly, the 1974 Budget Act also created the Congressional Budget Office (CBO). This non-partisan agency has come to play a pivotal role in not just the budget process, but in the lawmaking process in general. The CBO issues economic forecasts, policy options, and other analytical reports, but it most significantly produces estimates of how much individual legislation would cost or save the federal government. Those estimates can and do often determine if legislation passes or fails.

The annual budget process is supposed to begin the first Monday in February, when the President is to present his proposed budget for the fiscal year that begins the following Oct. 1. This is one of the few deadlines in the Budget Act that is usually met. 

After that, the action moves to Congress. The House and Senate Budget Committees each write their own “Budget Resolution,” a spending blueprint for the year that includes annual totals for mandatory and discretionary spending. Because mandatory spending (roughly two-thirds of the budget) is automatic unless changed by Congress, the budget resolution may also include “reconciliation instructions” to the committees that oversee those programs (also known as “authorizing” committees) to make changes to bring the cost of the mandatory programs in line with the terms of the budget resolution. The discretionary total will eventually be divided by the House and Senate Appropriations Committees between the 12 subcommittees, each responsible for a single annual spending (appropriations) bill. Most of those bills cover multiple agencies – the appropriations bill for the Department of Health and Human Services, for example, also includes funding for the Departments of Labor and Education.  

After the budget resolution is approved by each chamber’s Budget Committee, it goes to the House and Senate floor, respectively, for debate. Assuming the resolutions are approved, a “conference committee” comprised of members from each chamber is tasked with working out the differences between the respective versions. A final compromise budget resolution is supposed to be approved by both chambers by April 15 of each year. (This rarely happens.) Because the final product is a resolution rather than a bill, the budget does not go to the President to sign or veto.  

The annual appropriations process kicks off May 15, when the House may start considering the 12 annual spending bills for the fiscal year that begins Oct. 1. By tradition, spending bills originate in the House, although sometimes, if the House is delayed in acting, the Senate will take up its own version of an appropriation first. The House is supposed to complete action on all 12 spending bills by June 30, in order to provide enough time to let the Senate act, and for a conference committee to negotiate a final version that each chamber can approve by October 1. 

That October 1 deadline is the only one with consequences if it is not met. Unless an appropriations bill for each federal agency is passed by Congress and signed by the President by the start of the fiscal year, that agency must shut down all “non-essential” activities funded by discretionary spending until funding is approved. Because Congress rarely passes all 12 of the appropriations bills by the start of the fiscal year (the last time was in 1996, for fiscal year 1997), it can buy extra time by passing a “continuing resolution” (CR) that keeps money flowing, usually at the previous fiscal year’s level. CRs can last as little as a day and as much as the full fiscal year and may cover all of the federal government (if none of the regular appropriations are done) or just the departments for the unfinished bills. Congress may, and frequently does, pass multiple CRs while it works to complete the appropriations process. 

While each appropriations bill is supposed to be considered individually, to save time (and sometimes to win needed votes), a few, several, or all the bills may be packaged into a single “omnibus” measure. Bills that package only a handful of appropriations bills are cheekily known as “minibuses.”  

Meanwhile, if the budget resolution includes reconciliation instructions, that process proceeds on a separate track. The committees in charge of the programs requiring alterations each vote on and report their proposals to the respective budget committees, which assemble all of the changes into a single bill. At this point, the budget committees’ role is purely ministerial; it may not change any of the provisions approved by the authorizing committees.  

Reconciliation legislation is frequently the vehicle for significant health policy changes, partly because Medicare and Medicaid are mandatory programs. Reconciliation bills are subject to special rules, notably on the Senate floor, which include debate time limitations (no filibusters) and restrictions on amendments. Reconciliation bills also may not contain provisions that do not pertain directly to taxing or spending. 

Unlike the appropriations bills, nothing happens if Congress does not meet the Budget Act’s deadline to finish the reconciliation process, June 15. In fact, in more than a few cases, Congress has not completed work on reconciliation bills until the calendar year AFTER they were begun.   

Congress writes the nation’s laws, but it cannot account for every detail in legislation. So, it often leaves key decisions about how to interpret and enforce those laws to the various executive departments. Those departments write (and often rewrite) rules and regulations according to a very stringent process laid out by the 1946 Administrative Procedure Act (APA). The APA is intended to keep the executive branch’s decision-making transparent and to allow public input into how laws are interpreted and enforced.

Most federal regulations use the APA’s “informal rulemaking” process, also known as “notice and comment rulemaking,” which consists of four main parts: 

• Publication of a “Notice of Proposed Rulemaking (NPRM)” in the Federal Register, a daily publication of executive branch activities. 
• Solicitation to the public to submit written comments for a specific period of time (usually from 30 to 90 days). 
• Agency consideration of public reaction to the proposed rule; and, finally 
• Publication of a final rule, with an explanation including how the agency took the public comments into account and what changes, if any, were made from the proposed rule. Final rules also include an effective date, which can be no less than 30 days but may be more than a year in the future. 

In situations where time is of the essence, federal agencies may truncate that process by issuing “interim final rules,” which can take effect even before the public is given a chance to comment. Such rules may or may not be revised later.  

Not all federal interpretation of laws uses the APA’s specified regulatory process. Federal officials also distribute guidance, agency opinions, or “statements of policy.” 

Given how fragmented health policy is in both Congress and the executive branch, it should not be a surprise that major changes are difficult and rare.  

Add to that an electorate divided over whether the federal government should be more involved or less involved in the health sector, and huge lobbying clout from various interest groups whose members make a lot of money from the current operation of the system, and you have a prescription for inertia. 

Sometimes change does happen suddenly, however. In 2025, Republicans in control of the House, Senate, and White House narrowly passed a budget reconciliation bill that is projected to make deep cuts to the Medicaid program as well as add new barriers for people to maintain or enroll in health insurance under the ACA.

Another potential wildcard—in June of 2024, the Supreme Court overturned a 40-year-old precedent, known as “Chevron deference,” that gave the benefit of the doubt in interpreting ambiguous laws passed by Congress to federal agencies rather than judges. Overturning Chevron will likely make it easier for outsiders to challenge federal agency actions, but it will be some time before the full ramifications become clear.   

Another problem is that when a new health policy can dodge the minefield of obstacles to become law, it almost by definition represents a compromise that may help it win enough votes for passage, but is more likely to complicate an already byzantine system further. 

Unless the health system completely breaks down, it seems unlikely that federal policymakers will be able to move the needle very far in either a conservative or a liberal direction, although the second Trump administration is attempting to circumvent Congress entirely to remake federal health agencies and how they work. Whether that will withstand review by the courts remains to be seen.

• FAQs on Health Spending, the Federal Budget, and Budget Enforcement Tools
• Medicare 101
• Medicaid 101
• The Affordable Care Act 101
• Employer-Sponsored Health Insurance
• The Regulation of Private Insurance
• U.S. Public Health
• The U.S. Government and Global Health
• The U.S. Congress and Global Health: A Primer

Rovner, J., Congress, the Executive Branch, and Health Policy. In Altman, Drew (Editor), Health Policy 101, (KFF, October 2025) https://www.kff.org/health-policy-101-congress-and-the-executive-branch-and-health-policy/ (date accessed).

Private health coverage is subject to significant requirements at the state and federal levels. While the Affordable Care Act (ACA) of 2010 ushered in many new requirements for the federal regulation of private health coverage, another federal law, the Employee Retirement Income Security Act (ERISA), has for over 50 years regulated the most predominant form of health coverage for people under age 65, employer-sponsored coverage.

States have traditionally been the primary regulators of health insurance, and state health insurance protections continue to play a major role alongside a growing list of federal protections aimed at addressing a variety of consumer concerns, including access to coverage, affordability, and adequacy. This chapter describes the landscape of laws and regulations that address health care coverage and the complicated interactions between state and federal requirements that can make these protections challenging for consumers to navigate. In this chapter, it is not possible to cover every single state and federal requirement for private plans, so the focus is on the primary laws and regulations that apply to private insurance coverage.

Private health coverage is a mechanism for people to finance the health care services and medications they need, protecting them from the potentially extreme financial costs of this care.

At its core, health coverage is a financial contract between a private organization insuring the risk of loss and a policyholder. Where those insuring the risk or paying health claims are private entities such as insurance companies or private employers, this coverage is considered “private.” Coverage available in Health Insurance Marketplaces created by the ACA is considered private coverage, even though the Marketplaces are administered by state or federal government agencies. Public coverage, by contrast, involves financing arrangements for programs such as Medicare and Medicaid, which are paid primarily from public sources. This includes private plans participating in Medicare Advantage and Medicaid managed care arrangements. (See the chapters on Medicare and Medicaid for more information.)

A fundamental concept for the private provision of health coverage is pooling the health care “risk” of a group of people to make the costs of coverage more predictable and manageable. The goal typically is to maintain a risk pool of people whose health, on average, is the same as that of the general population. Private health coverage regulation has historically included steps to prevent insurers and plan sponsors from avoiding people in poor health, while also ensuring that risk pools include people in good health to guard against “adverse selection.”

A risk pool with adverse selection that attracts a disproportionate share of people in poor health, who are more likely to seek health coverage than people who are healthy, will result in increased costs to cover those in the pool, leaving those in better health to seek out a pool with lower costs.

Sources of private coverage. An individual with private coverage generally obtains it through one of two sources, either through their employer (“group” coverage) or by directly purchasing it from an insurer (“nongroup” coverage). Other related sources of coverage don’t exactly fit into one of these two categories, such as coverage provided by professional associations.

1. Employer coverage: In 2023, about 165 million people under age 65 had coverage through an employer. Employer-sponsored coverage is offered to eligible employees and usually to employees’ dependents, such as spouses and children. This coverage is referred to as “group” coverage, which is further broken down into small-group or large-group depending on the number of employees (Figure 1).

Private employers who “sponsor” group health plan coverage could include a range of entities, from a single nationwide retail employer with thousands of employees in many states to a small “mom and pop” operation with a handful of employees in one location. A single union can also be a group health plan sponsor of private coverage as an “employee organization,” as well as entities called “multiemployer” plans that are collectively bargained entities run by a joint board of trustees from labor and management that oversee collectively bargained benefits provided to employees of more than one employer, often in the same industry (for example, hotel workers or skilled workers in the building trades).

Public employers—federal, state, or local government—also sponsor group health coverage. The Federal Employee Health Benefit (FEHB) Program is the largest employer-sponsored health plan in the US. State and local government health plans are often referred to as non-federal governmental plans.

Employers, private and public, have at least two approaches to make coverage available to employees:

• Fully-insured. An employer can purchase coverage from an insurer to cover their employees for a set premium. In this “fully-insured” arrangement, the insurer bears the financial risk if that group of employees ends up costing more than expected; these plans are regulated by the state in which they are sold. Each state has a group market for the sale of health insurance that is divided by size of the group for oversight and regulation: large group and small group.
  • Large Group Insurance Market typically involves insurance products sold to employers with 51 or more individuals (employees).
  • Small Group Insurance Market is generally an employer group of 50 or fewer individual employees. Small employers can purchase small group coverage from an insurer or through the state’s health insurance exchange or Small Business Health Options Program (SHOP). In a handful of states, the SHOP is the only place where a small employer can purchase state-regulated small group insurance coverage.
• Self-insured. Employers can also use a “self-insured” (also often referred to as “self-funded”) arrangement where the employer assumes the financial risk by directly paying all covered claims. The employer typically contracts with a third-party administrator (TPA) to administer benefits by paying claims, designing benefits, establishing provider networks, and coordinating other aspects of coverage. TPAs are some of the same private organizations that provide health insurance as another line of business, as well as organizations called Pharmacy Benefit Managers (PBMs) that administer prescription drug benefits. As a result, coverage may not appear different to the covered worker than if they had fully-insured coverage. As explained in an upcoming section, unlike fully insured health coverage, self-insured coverage provided by private employers is largely not subject to state law but is governed primarily by federal law—mainly ERISA. Self-insuring health benefits are more common among larger employers because they can spread risk over a larger number of enrollees.

2. Individually-purchased insurance coverage: An individual can purchase private health coverage for themselves and their family without the involvement of their employer, referred to as “nongroup” coverage. Every state has an “individual insurance market” that consists of the following:

• Marketplace. The ACA required the creation of health insurance Marketplaces in each state, where individuals can purchase insurance, with federal financial assistance for premiums and cost sharing if eligible. The coverage purchased from a Marketplace must meet certain minimum standards, including coverage of essential health benefits, no preexisting condition exclusions, and limits on varying premiums based on health status (“ACA-compliant” insurance). (See the ACA chapter for more information.)
• Off Marketplace. People can also purchase individual insurance outside the Marketplace where federal financial assistance is unavailable. This could include ACA-compliant plans similar to those offered on the health insurance Marketplaces, and other types of coverage or financial products with lower premiums, but less comprehensive coverage than ACA-compliant plans, such as short-term limited duration coverage, fixed and hospital indemnity arrangements, health care sharing ministries, and others.

3. Other Sources of Private Health Coverage: Other sources of health coverage subject to unique regulatory standards include health coverage provided through entities called “multiple employer welfare arrangements” (MEWAs), “church plans,” and coverage provided by colleges and universities for their students.

• A MEWA is generally any arrangement that provides benefits – in this case, health benefits – to employees of more than one unrelated employer. Historically, MEWAs have been vehicles for organizations to market less expensive health benefits to groups of employers, especially small employers. To address a history of MEWA insolvencies attributed to a lack of proper government oversight, changes to ERISA in 1983 created a complicated regulatory regime just for MEWAs, subjecting them to a mix of federal and state laws.
• One type of MEWA, also governed by ERISA, allows groups of more than one employer to sponsor health coverage for their employees, known as an “Association Health Plan.” Traditionally, these types of plans have been available to groups of small employers in a similar industry, such as those who sell real estate or work in a similar profession. In recent years, federal efforts to expand the criteria for what types of employers may form an AHP have been the subject of litigation and regulations.
• Church plans are offered to employees by a church or association of churches, including entities controlled by or associated with a religion, such as religiously-affiliated hospitals and schools. Unlike other employer-sponsored plans, church plans are exempt from most ERISA requirements and some of the ACA’s health reforms. These regulatory gaps in church plans, including coverage of contraception, have been the subject of numerous legal proceedings.
• A student health plan is any health coverage sponsored by a college or university for students. While it is not group coverage, it can be sponsored by a university in the same way employers sponsor health coverage. The ACA has special rules for this coverage. While an insured arrangement is considered individual market coverage, exceptions allow it to be provided without the insurer having to meet certain ACA market rules. A university can also sponsor a self-insured health plan for students. These arrangements do not have to meet the ACA’s market rules, although states may regulate them.

Most private plans utilize a “network” of health care providers and hospitals, with some plans requiring a referral from a primary care provider (PCP) for enrollees to see a specialist. These types of arrangements, referred to as “managed care plans,” attempt to control costs and utilization through financial incentives, development of treatment protocols, prior authorization rules, and (in limited circumstances) dissemination of information on the quality of provider practices. Most private health coverage, whether employer-sponsored or individually purchased, falls into one of the following types:

All of these plan types are available in the individual market, both on and off the Marketplace. Most employers that offer health benefits offer just one type of health plan, though larger firms may offer more. PPOs are the most common type of health plan offered by employers.

Other employer-sponsored health coverage arrangements: Employers also can offer a Health Reimbursement Arrangement (HRA), which is an employer-funded group health plan, sometimes paired with a high-deductible health plan (HDHP), that reimburses an employee up to a certain amount for qualified medical expenses and, in some instances, health insurance premiums. Reimbursements are tax-free to the employee, and amounts in the account can carry over to the following year, but employees lose any amounts when they leave the employer. Other variations of HRAs include an Individual Coverage HRA (ICHRA), where an employee can use funds in the HRA to purchase individual insurance either on or off the Marketplace. Qualified Small Employer Health Reimbursement Arrangements (QSEHRAs) are HRAs that certain small employers can make available for tax-free reimbursement of certain expenses.

Health Savings Accounts (HSAs): HSAs are tax-advantaged savings accounts that enrollees in certain HDHPs can use to pay for qualified medical expenses. While the HDHP associated with an HSA is usually sponsored by an employer or obtained through a Marketplace plan, the HSA itself is not usually considered employer-sponsored coverage (in contrast to HRAs). HSAs are owned by the individual and are portable, meaning consumers can carry them from job to job and use them after retirement.

Value-Based Arrangements: Some private health plans utilize “value-based” coverage and alternative payment models. These designs, primarily used in federal Medicare and Medicaid demonstration projects, aim to make providers more accountable for patient outcomes through various financial and other incentives. The objective of value-based care design is to shift the fee-for-service reimbursement model of paying for care based on “volume” to a system that pays based on the “value” of a service. Demonstration results to date have not shown major savings, but these designs are still discussed as a potential cost-containment tool for private health coverage. Payers and providers have also looked to value-based payment models to improve health disparities and to provide more patient-centered care.

The regulatory framework for private health coverage has evolved into a complicated system of overlapping state and federal standards. This federalism framework creates a sometimes precarious “marriage” between state and federal authority in order to implement health policy goals.

1. States lead on insurance regulation, but with a federal fallback for most protections.

The regulation of insurance has traditionally been a state responsibility. States license entities that offer private health insurance and have a range of insurance standards, including financial requirements unique to state law. However, the federal government has played an increasingly significant regulatory role over the past 50 years.

The federal pension law, ERISA, passed in 1974, applies to insured and self-insured private employer-sponsored health coverage with similar legal and enforcement mechanisms to protect individuals covered by private group health plans as those created for pension plans.

Separately, the federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) created new federal requirements and the basic framework for how state and federal law now interact. Under this “federal fallback” structure, states may require that insurers in the group and individual market (as well as state and local government self-insured plans) implement federal requirements on health coverage. If a state fails to “substantially enforce” the federal requirements, the federal government will enforce those protections. The federal fallback framework was intended to allow states to continue to regulate private coverage while ensuring that all consumers nationwide have a floor of federal protections when a state fails to implement them.

The federal fallback framework does not apply to self-insured employer-sponsored coverage. The U.S. Department of Labor (DOL) almost exclusively regulates private self-insured employer-sponsored plans. The Center for Medicare and Medicaid Services (CMS) directly enforces federal protections against state and local government self-insured employer plans (although states can also do so).

2. ERISA limits the application of state law for those with private employer-sponsored coverage.

ERISA specifically “preempts” or prevents state law from applying to most self-insured group health plans, limiting the scope and application of state protections for many Americans covered by employer-sponsored plans.

Aspects of this preemption have been the topic of almost 50 years of litigation, resulting in three overall conclusions:

• Most state insurance laws, including state benefit mandates, don’t apply to self-insured ERISA plans, resulting in fewer regulatory requirements on these plans than on fully-insured plans.
• State insurance laws generally do apply to fully-insured ERISA plans.
• ERISA provides exclusive, yet limited, civil remedies for enrollees in ERISA plans who are harmed due to a violation of the law.

Today, some argue that ERISA preemption sustains the employer-based health coverage system because meeting an ever-growing list of state laws would be costly for employers, particularly those with employees in multiple states. Having national uniform standards, they argue, provides employers with an incentive to offer coverage. Others argue that preemption handcuffs states’ ability to protect consumers and control health care costs and that it is no longer needed given the ACA’s employer shared responsibility provision for larger employers and the increased regulation that applies a variety of rules to both fully-insured and self-insured plans. Prospects for change are limited, but some have explored the possibility of alternative approaches.

3.  Federal regulation of private health coverage can differ based on the market/source of coverage.

Private health insurance regulations vary based on the insurance market and the source of coverage. This is in part due to ERISA preemption and the ACA, which applies many reforms only to the individual and small-group markets.

Further complicating this are plans that existed before the ACA was passed, called “grandfathered” plans, that do not have to meet many of the ACA standards, so long as no significant changes in cost sharing and benefits are made to the plan.

The ACA did, however, alter federal law to create a large number of consumer protections that apply many of the same regulatory requirements across almost all sources of private health coverage. (See Table 7.)

Finally, some federal standards only apply to employer-sponsored plans (insured and self-insured) that are governed by ERISA, such as the requirement on employers with 20 or more employees to provide temporary continuation of coverage in certain situations, known as COBRA, which also applies to certain state and local government employers. There are also obligations on plan “fiduciaries” that are unique to ERISA plans.

This all means consumers can have different legal protections with their private coverage based on their coverage type and the state where they live.

4. Special exceptions in regulations allow certain types of private coverage to avoid having to meet many insurance protections.

Some private plans are specifically exempt from most federal private health coverage protections, including the ACA. These forms of coverage are often called “non-ACA compliant” coverage. While “non-ACA compliant” does not automatically mean it is illegal or inappropriate, some forms of this coverage have come under increasing scrutiny by federal and state authorities due to their gaps in consumer protections.

These types of coverage fall into these general categories:

• Coverage that is an “excepted benefit” is specifically carved out of most of the ACA and other federal requirements. Some are considered health coverage under federal law, such as certain dental and vision benefits, and other forms of coverage may not be, such as fixed and hospital indemnity, cancer-only coverage, accidental death and dismemberment, and long-term care coverage. (This Health Affairs article provides a more detailed description of excepted benefits.)
• Short-term limited-duration coverage and other forms of coverage are not regulated as health insurance under federal rules (as mentioned in the previous section).
• Employer-sponsored plans with less than two participants who are current employees. This exception was included in the 1996 HIPAA law and has been interpreted as excluding employer-sponsored plans that cover only retirees from many federal insurance requirements.

Some of these forms of coverage are the focus of business promoters looking to market cheaper, largely unregulated forms of coverage. In some instances, this coverage might be promoted by unscrupulous actors who falsely market the coverage as meeting ACA requirements or as providing comprehensive coverage. In other cases, coverage is sold as supplemental “health” coverage along with ACA-compliant health insurance, sometimes with very high deductibles. These exceptions to the ACA’s broad coverage requirements can operate as loopholes in the implementation of consumer health coverage protections and may create ambiguities for consumers as well as employers.

5. Tax regulation matters for cost and access to health care and coverage.

Central to evaluating how private coverage works are the tax subsidies that reduce the cost of coverage and benefits, which can incentivize employers to sponsor and individuals to purchase private health coverage. Tax regulations also interpret what medical expenses (as opposed to general wellness or other non-medical expenses) get a tax preference.

The largest health care tax subsidy is applied to employer-sponsored coverage. Tax-exempt employer contributions for medical insurance premiums and medical care resulted in more than $224 billion in lost revenue for the federal government in 2022. Employer-sponsored health coverage is excluded from federal income tax, as well as federal employment taxes (and equivalent state taxes). The exclusion also applies to amounts reimbursed to employees by an employer under arrangements called “health flexible spending arrangements” (health FSAs), where an employee elects to have amounts withheld from their wages to pay for medical expenses. The exclusion provides considerable tax savings for employers and employees making contributions toward health coverage. The value of this exclusion increases as income increases, making income tax savings greater for higher-income individuals than for lower-income individuals. For various policy reasons, including to rein in health care costs, there have been efforts to change or cap this exclusion over the years, but to date, none have been successful. The most recent, the “Cadillac tax” provision of the ACA, was removed from the law before it was implemented (see the Employer-Sponsored Health Insurance chapter).

Additionally, the ACA created refundable tax credits based on household income to help individuals purchase coverage on a health insurance Marketplace (see the Affordable Care Act chapter). In contrast to the employer exclusion, tax subsidies for Marketplace participants are higher for those with lower incomes. Temporary increases in these credit amounts, passed as part of the American Rescue Plan and the Inflation Reduction Act, have led to record Marketplace enrollment. Unless Congress extends them, the temporary increases expire at the end of 2025. Unlike employer-sponsored insurance, Marketplace enrollees who pay a premium for their individual market insurance coverage generally do so with after-tax dollars (although an employer can sponsor tax-advantaged ICHRAs or QSEHRAs, as described above, to help employees pay for Marketplace and other individual market coverage).

In addition to the tax advantages related to employer-sponsored health coverage and tax subsidies received by lower-income individuals with Marketplace coverage, HSAs bring their own set of tax advantages for those who use funds in the account to pay for cost sharing and for items the IRS includes as qualified medical expenses. In 2025, a federal budget reconciliation law was enacted that may increase the use of HSAs.

The scope and extent of federal regulation affecting private health coverage has vastly increased, especially with the passage of the Affordable Care Act (ACA) in 2010. The ACA largely retained the framework for the regulation of private coverage, adding a long list of new provisions to different regulated pieces of our fragmented health care system. This means specific and overlapping requirements on insurers, employer-sponsored plans, and, more recently, in the No Surprises Act, also on providers.

The ACA also unleashed a firestorm of activity resulting from longstanding political and philosophical differences on the role of federal government regulation of health care. Efforts to repeal and replace the ACA in 2017, several U.S. Supreme Court cases challenging ACA provisions, and hundreds of other cases in the lower courts on the ACA and other federal requirements mean the law in this area has and will continue to be in flux.

Regulatory priorities can and have shifted depending on what party controls the White House and Congress, resulting in ever-changing federal standards. This section reviews the current landscape of federal requirements. A discussion of every single relevant federal regulation is beyond the scope of this chapter, but the major requirements have been divided into six categories:

• Access to health coverage
• Affordability of health coverage
• Benefit design and adequacy
• Reporting and disclosure of information concerning coverage
• Review and appeal of health claims
• Other federal standards

1. Access to coverage

Federal health care reform has prioritized expanding health coverage to those without it for quite some time, especially for those not eligible for a public program such as Medicaid or Medicare, or who do not have coverage through their current employer. Prior to the passage of the Affordable Care Act in 2010, state laws and regulations were designed to address the potential for adverse selection in health insurance by allowing insurers to engage in certain practices such as “underwriting,” which allowed insurers in the individual and group markets to decline to cover or renew coverage due to a person’s health status or a group’s claims history, and helped plans maintain predictable and stable risk pools. Further, an insurer could cover the applicant, but charge a higher premium based on age, health status, gender, occupation, or geographic location. In addition, insurers could exclude benefits for certain health conditions if the person was diagnosed or treated for that condition before becoming insured (a “preexisting condition exclusion”).

States made some reforms, particularly in the small group market, to address these barriers to coverage. Some of these changes became part of the federal Health Insurance Portability and Accountability Act (HIPAA) of 1996. However, it was not until the ACA that the regulation of private insurance, at least for the individual and small group markets, was fundamentally changed.

Core Private Insurance Coverage Protections. The ACA established core market rules designed to expand coverage to most people in the U.S. New ACA legal requirements include:

Requirements for premium stabilization and other efforts to protect the risk pool. The ACA’s private insurance market regulations also ushered in concerns that its protections, including guaranteed issue and the elimination of health underwriting for some coverage, would result in adverse selection (discussed in the first section). Regulatory efforts to prevent adverse selection have also focused on certain plans and products that do not have to meet most of the ACA rules, such as short-term limited-duration plans. Non-ACA-compliant coverage may be attractive to consumers looking for lower monthly costs, but these plans can leave consumers underinsured and may compromise the risk pool by drawing out healthier individuals.

Federal guidance and regulation aimed at protecting the risk pool as part of the ACA include:

Standards to prevent coverage gaps. Access to coverage is also enhanced by federal requirements to provide for the continuity of coverage or care to prevent gaps for those who do or could lose coverage, including:

2. Financial Protection and Affordability

High costs, in the form of both premiums and cost sharing, have been a defining feature of employer-sponsored and individually-purchased (for unsubsidized enrollees) health coverage. Federal reforms have sought to address the stability and affordability of health insurance. Key provisions include:

3. Benefit Design and Adequacy

Federal requirements also include a list of minimum standards for how a plan is designed or operated in an effort to ensure that enrollees have coverage that is comprehensive enough to cover medically necessary care, with processes that do not unnecessarily limit access to covered benefits. Such requirements include laws that prohibit plans from imposing annual dollar limits on coverage or requiring waiting periods longer than 90 days before employer-sponsored coverage kicks in. States may have additional benefit mandates for state-regulated plans, such as comprehensive coverage requirements for mental health or substance use disorders or fertility services.

Required coverage.

The ACA requires all private, non-grandfathered health plans to cover preventive services with no cost sharing for enrollees. These requirements change over time as preventive service recommendations are updated and new services are added. In general, these include:

The preventive care coverage requirement has been the subject of extensive litigation since the ACA was passed. KFF briefs provide more detail on this litigation and a 2025 U.S. Supreme Court decision involving ACA preventive care standards. The contraceptive coverage requirement has been the topic of two U.S. Supreme Court cases and several regulations, now allowing employers to not cover contraception if they have a religious objection.

Other required design standards across most health plans.

Large group, small group, individual, and self-insured health plans are required to abide by other benefit design standards that aim to contain out-of-pocket costs and improve access to quality care. These design standards include:

Design standards limited to individual and small group plans. Federal requirements on health plan design standards for certain segments of the individual and small-group markets have evolved since the ACA was passed. Plans must meet these rules as part of annual certification requirements for qualified health plans. Examples of these standards include:

4. Disclosure, Reporting and Transparency

The 2023 KFF Survey of Consumer Experiences with Health Insurance found that most Marketplace and employer-sponsored insurance (ESI) enrollees reported difficulty understanding some aspect of their health insurance compared to consumers enrolled in Medicaid and Medicare:

Lack of information or understanding about key features of an individual’s health coverage can put patients at financial risk and result in negative health outcomes. Employers and other health purchasers have also struggled to get the information they need to make prudent decisions about cost-effective coverage options and hold their service providers accountable for their plan designs, contracting, and administration activities. Regulations have increased over time to make more information available to enrollees or prospective enrollees, as well as to federal agencies to conduct their oversight responsibilities. What to disclose and how much information is useful is a continuing policy challenge.

Most federal disclosure, reporting, and transparency requirements fall into two categories: Disclosure of information to enrollees and/or the public (Table 9) and reporting to the federal government (Table 10). Note that the requirements provided in these tables are not exhaustive, but include examples of some of the main reporting, disclosure, and transparency requirements that plans, providers, and facilities are subject to.

Ongoing reporting by private plans to federal agencies is a tool for agency oversight to assess compliance with regulations and evaluate trends. In some instances, agencies are required to use this information to report aggregate information to the public and Congress.

5. Claims and Appeals Processes

Access to a fair system of review for consumer grievances about plan actions and claims denials has been a key element of federal consumer protection.

A 1997 Clinton Administration initiative, the Patient Bill of Rights, resulted in several federal agencies taking regulatory actions to enhance consumer protections for patients and workers. As part of this initiative, the DOL updated claims and appeals rules that applied to private-sector employer plans regulated by ERISA to make the claims review process:

• Faster (shortened timeframe for plans to make a decision on claims and appeals)
• Fairer (ensure plan decision makers were free of conflicts of interest)
• Fuller (more transparent through the disclosure of more information to consumers–including language access standards–about the reason for a claim denial)

The DOL issued regulations in 2000 governing the “internal” claims review process, conducted internally by a plan or plan-sponsor employer. For the first time, these updated rules accounted for managed care features such as prior authorization, where health plans determine medical necessity before the plan covers an item or service, requiring, for example, shorter time frames for claim decisions and appeals for these “pre-service” claims.

These rules were the basis for reforms applied across all private health coverage in the ACA. These reforms established a federal floor of protections for the internal claims and appeals process and added an option for consumers to appeal denied claims through an “external review” by an entity independent of the plan. Only certain types of claims, such as those that involve clinical judgment, are eligible for external review.

Policymakers have renewed scrutiny of the prior authorization process, as well as claims review and appeals generally. Claims and appeals standards that apply to Medicare Advantage plans, Medicaid, and some Marketplace plans were updated in 2024 to reduce delays in decision-making and to provide more transparency about the outcomes of claims and appeals decisions.

6. Other Federal Standards

Several other federal laws and regulations provide consumer protections in private health insurance, often indirectly, that sometimes have stronger enforcement mechanisms and penalties than federal insurance laws. These include:

Civil Rights Law. The Civil Rights Act of 1964 (and later amendments to it, including the Pregnancy Nondiscrimination Act) and the Americans With Disabilities Act of 1990 created protections against discrimination based on race, color, national origin, sex, age, and disability. At a minimum, these standards apply to employers with 15 or more employees, and, in effect, regulate those employers’ group health plan coverage.

Section 1557 of the ACA is a nondiscrimination provision that potentially applies many existing civil rights laws directly to health care entities, including insurers that receive federal funds. The extent of its reach has been the subject of several sets of regulations, with the iteration issued by the Biden administration addressing Section 1557’s ban on sex discrimination (among other issues) and reinstating protections against discrimination for LGBTQ+ people seeking health care and coverage, including for gender-affirming care. Trump administration actions will likely seek to undo this requirement and place restrictions on gender affirming care that the courts will be tasked with evaluating in the years to come.

Antitrust Laws. Antitrust laws in health care prohibit anticompetitive practices and mergers by health care providers, hospitals, and insurers, which can reduce competition and increase prices. As provider consolidation increases, federal agencies such as the Department of Justice (DOJ) and the Federal Trade Commission (FTC) have engaged in enforcement initiatives in recent years. Health insurers have also faced antitrust scrutiny as the market shares of the largest health insurers continue to dominate in most locations. Oversight of pharmacy benefit managers, now mostly owned by or affiliated with the largest health insurers, is one area of focus where Congress continues to debate whether additional standards are warranted, and state attorneys General are increasingly focusing their attention.

Privacy Laws. As digital health technology has advanced, so have concerns about protecting consumer health information, as the fast development of new technology (e.g., health-related apps, artificial intelligence) has made it difficult for regulation to keep up. The leading federal privacy requirements for health plans’ use of certain patient information, set out in HIPAA regulations, are now almost 25 years old. Efforts to update this regulation have been discussed, but have not yet been finalized. Updates to the HIPAA privacy rules were proposed toward the end of the first Trump administration. Updates to HIPAA’s security standards were proposed at the end of the Biden administration. It is unclear whether renewed proposals in this area are imminent. Regulatory changes to HIPAA in 2023 aimed at clarifying reproductive health care privacy were struck down by a federal court in 2025. The FTC has sought to regulate areas not covered directly by HIPAA, such as software applications increasingly marketed as part of health coverage. Continuing federal efforts to advance electronic information sharing (known as “interoperability”) will mean renewed calls for increased federal privacy and security protections.

Special privacy protections for substance use disorder information are regulated under a law known as “Part 2.” This law aims to protect the confidentiality of this information while still allowing providers to share patients’ mental health and substance use disorder information with plans and others to coordinate care and administer benefits.

Gag Clauses. Plans and issuers are prohibited from entering into an agreement with a provider, third-party administrator, or other service provider (including pharmacy benefit managers) that restricts the plan and issuer from accessing claim, cost, or quality information on providers, enrollees, plan sponsors, and other entities, known as a “gag clause.” Plans and issuers must annually submit an attestation of compliance with these requirements to the federal government.

Three federal agencies have overlapping jurisdiction for most federal regulation of private health plans: the U.S. Department of Health and Human Services (HHS), the U.S. Department of Labor (DOL), and the U.S. Treasury Department. Through a structure created by HIPAA in 1996, these three agencies jointly issue regulations and other guidance on laws passed by Congress that place the same or similar standards across all private plans.

The same or similar federal requirements for private health plans are typically contained in three separate statutes that each agency oversees:

As an example, if Congress passes a federal law that requires all insurers of individual and group coverage and all employer-sponsored plans to meet a certain standard, any regulations issued to implement that standard are usually issued jointly by HHS, DOL, and Treasury with separate but identical language added to the Public Health Service Act (PHSA), ERISA, and the Internal Revenue Code (IRC). However, each agency has its own requirements for how these laws are enforced. In addition to these overlapping authorities, each of these three agencies has exclusive federal authority over certain aspects of private health insurance regulation (though the federal authority might be shared with states in some instances):

Other agencies with important oversight roles of private health coverage include:

• HHS’s Office of Civil Rights: Implements HIPAA’s administrative simplification standards; ACA section 1557 nondiscrimination rules
• HHS’s Office of the National Coordinator: Coordinates efforts to implement and use health information technology and health information exchange
• HHS’s Food and Drug Administration: Regulates clinical investigations and supervises the safety of pharmaceutical drugs, biological products, and medical devices
• Department of Justice: Antitrust enforcement
• Federal Trade Commission: Antitrust enforcement
• Equal Employment Opportunity Commission (EEOC): Nondiscrimination in health coverage and wellness program standards

As the executive branch of the U.S. government, the federal government has the authority to execute laws passed by Congress and signed by the President, including issuing regulations to operationalize and implement a statute. In addition, specific agencies have the authority to investigate violations of the law and enforce the law through policy form review, market conduct exams, assessment of penalties, and/or bringing a court action to stop an insurer from violating the law (called an injunction).

Regulations and Other Guidance

Process: The federal regulatory process is governed primarily by the Administrative Procedure Act (APA). This law, along with specific executive orders, governs the process known as “notice and comment rulemaking,” where regulations are proposed (through a notice of proposed rulemaking or “NPRM”) and are subject to public comment for a certain period of time and then finalized. The process is administered by the Office of Management and Budget (OMB), an agency within the Executive Office of the President. The OMB’s Office of Information and Regulatory Affairs (OIRA) coordinates the review and release of regulations from the agencies. Regulations are published in the Federal Register, a daily publication of regulations and notices. Information about regulations under OIRA review is available by agency at Reginfo.gov, and the public can view all regulations and comment letters at Regulations.gov. Twice a year, OMB issues a regulatory agenda of regulations agencies expect to publish in the coming months.

Authority: Once a regulation has gone through the notice and comment process and a final rule is issued, it is generally considered to have the force of law, meaning private actors must comply with it, and individuals can rely on having the protections set out in the law and the regulation. However, regulations are subject to legal challenge under the APA if they are inconsistent with the statute.

Review of regulations by courts: Traditionally, if a regulation interprets a part of a statute that was not clear as drafted by Congress, and a federal court reviews a challenge to the regulation, the court would uphold the interpretation in a regulation unless it is unreasonable or arbitrary. Essentially, courts deferred to the expertise of government regulators and the regulatory review process to uphold a regulatory requirement if they deemed the interpretation reasonable. This practice is called “Chevron deference,” named after a Supreme Court case from 1984, Chevron v. Natural Resources Defense Council, that set out the framework for court review of ambiguous language in a statute. This standard of review can result in agencies having discretion to implement policy changes through the interpretation of regulation. That discretion was challenged in recent years as too broad, giving regulators too much authority, and in June 2024, the U.S. Supreme Court overruled its previous decision, meaning federal courts are no longer required to defer to regulations of administrative agencies in circumstances where they traditionally would have. Eliminating Chevron deference could weaken the impact of regulation on public policy and shift more policy decisions to courts.

Sub-regulatory guidance: Other types of information and guidance commonly issued by a federal agency that do not go through the formal regulatory notice and comment process are referred to as “sub-regulatory.” Information and interpretation in sub-regulatory guidance usually do not have the force of law as regulations do, and typically do not create legally binding obligations on private parties. They are, however, useful in quickly communicating information to regulated entities and the public to signal how and when the agency plans to implement a new law, and the timing of that implementation. However, reliance on these types of guidance by consumers has its limits since regulated entities might still assert that this type of guidance is not binding on them. Examples of sub-regulatory guidance include:

• Frequently asked questions, manuals, memos, and letters used by CMS, DOL, and the IRS: Certain provisions of the ACA have been the subject of numerous sub-regulatory guidance, including over 60 pieces of guidance in the form of frequently asked questions issued jointly by CMS, DOL, and the IRS. Sub-regulatory guidance also includes implementation manuals, policy letters, and enforcement memos.
• Advisory opinion or information letters: The DOL and IRS have used advisory or information letters and chief counsel notices to address fact-specific questions at the request of regulated entities. DOL and IRS responses to these inquiries only apply to the specific parties and scenarios addressed, so they can’t be relied on by the public and can create ambiguities about what the law requires, which can remain unresolved for years until formal regulations are finalized. Note that the IRS also has several other types of guidance with varying levels of authority.

Enforcement

Given the federal fallback framework described in previous sections, the enforcement mechanism for most federal requirements on private coverage depends on the type of health plan and the federal agency enforcing the requirement, as summarized in Table 13 below.

Government enforcement. Under the existing federal fallback framework, CMS has developed a process for determining whether a state is substantially enforcing each specific federal insurance protection. This means that whether a state or CMS is responsible for enforcement can differ for each health coverage standard, resulting in a patchwork of federal and state enforcement responsibilities. In addition, both the DOL and the IRS each have their own separate enforcement processes for the federal standards they implement.

Private Right of Action and Remedies. Some laws also allow individual consumers or their representatives to bring a lawsuit independent of the government to address a violation. These laws may detail what types of “remedies” are available if the challenge is successful—for example, an injunction to stop a violation, a civil penalty, or compensatory or punitive damages. Without this “private right of action,” aggrieved consumers must rely solely on the government to act to address a violation of the law. Even federal laws, such as ERISA, that allow individual consumers to bring a lawsuit to resolve certain disputes, have limited remedies to address a violation. ERISA does not generally allow monetary damages as a remedy.

The federal fallback framework also applies to most of the requirements on health care providers and facilities that are now part of federal law. In 2020, Congress passed and President Trump signed the Consolidated Appropriations Act (CAA), which includes new protections on balanced billing (the No Surprises Act) and various provider rules regarding disclosure and transparency. States are expected to enforce these standards against providers, with CMS as the federal fallback. State health departments or state agencies that oversee provider and facility licensing and practice standards oversee these rules. CMS has surveyed states and entered into collaborative enforcement agreements with each state, including which CAA rules the state is prepared to enforce and which ones CMS will need to implement. CMS can assess a penalty of up to $10,000 per violation against a provider or facility for non-compliance.

Enforcement of other standards. Outside of the above federal fallback framework, each agency has its own separate enforcement mechanisms for the laws it implements alone. For instance, HHS has the authority to assess fines under HIPAA privacy rules for violations, but individuals harmed by a HIPAA violation do not have a private right of action under that law. Enforcement processes and remedies available under federal nondiscrimination requirements under the Civil Rights Act or the Americans with Disabilities Act vary, but some include monetary damages in the form of compensatory damages.

The McCarran-Ferguson Act, enacted by Congress in 1945, clarified that states have the primary role in regulating the business of insurance. Although changes have since been made to that law, states have several mechanisms in place to regulate insurance. States license entities that offer private health coverage in a process that reviews the insurer’s finances, management, and business practices to ensure it can provide the coverage promised to enrollees. States also license the insurance agents and brokers in the state (see the section “What Is the Role of Health Insurance Brokers and Other Assisters?” for more information).

State insurance laws and regulations vary by state, though commonly include:

Most states require health plans to provide specific data that is included in the state’s all-payer claims databases (APCDs). These are state databases that include medical, pharmacy, and often dental claims, as well as eligibility and provider files collected from and aggregated across all private and public payers in a state. APCDs can provide states with a perspective on cost, service utilization, and quality of health care services across the full spectrum of payers in a state, which can be a tool in state efforts to control health care costs and promote value-based care.

Some states are also developing additional state-level regulations related to health plan network adequacy, health plan price transparency, public option plans, reinsurance programs, and more. These state-level regulations and protections do not apply to enrollees in self-insured plans offered by private employers (see the section “What is Private Health Insurance” for more information). However, these enrollees may have some of these protections through other federal laws and regulations.

State legislatures enact state insurance laws and typically grant regulatory authority to the state’s insurance regulator/commissioner. State enforcement mechanisms vary widely by state, regulation, state resources, and staffing capacity. Shifting political priorities at the state level can also influence enforcement priorities and actions. For example, state insurance agencies may ensure compliance with certain benefit mandates by primarily relying on complaints from consumers, consumer advocates, or health care providers to trigger a compliance review of the plan in question, while other state insurance agencies conduct periodic systematic reviews of all plans subject to the law or regulation.

Navigating an increasingly complicated health coverage landscape has increased the focus on the availability and expertise of entities that assist purchasers of health coverage (consumers and employers). Assisters can include agents and brokers who are paid commissions from insurers, as well as consumer assistance programs created by the ACA, which are often publicly funded and nonprofit, who may provide similar assistance as agents and brokers, but also specialize in individuals transitioning in and out of public programs such as Medicaid or assisting those without insurance to find coverage.

Agents and brokers have long played a significant role in connecting individuals and employers to private health coverage by helping them understand health insurance options and costs. An “agent” typically represents a single insurer and provides information about that insurer’s coverage options. A “broker” is not aligned with any one insurer but could, in theory, place coverage from any insurer selling products in a state.

Agents and brokers assist individuals in choosing a qualified health plan on a health insurance Marketplace. Their role in Marketplace enrollment has grown over the years. In the 2024 plan year, 78% of ACA coverage was sold through health insurance agents compared to 43% in 2016. Web brokers, who facilitate plan selection online through Marketplace capabilities, have also played a large role in Marketplace enrollment.

Agents and brokers in the health insurance Marketplace have faced scrutiny for alleged fraudulent activity in recent years due to consumer reports of unauthorized enrollment and plan switches by agents and brokers. In response, CMS, under President Biden, began requiring additional steps to be taken before agents and brokers can make changes to a consumer’s HealthCare.gov enrollment, and hundreds of agents’ and brokers’ Marketplace agreements were suspended for reasonable suspicion of fraudulent activity. In an attempt to address Marketplace fraud, the Trump administration finalized a regulation in 2025 that, along with the 2025 budget reconciliation law, creates new administrative hurdles for consumers to enroll in Marketplace coverage and receive premium tax credits. These 2025 actions made few changes to broker oversight requirements for Marketplace plans. The Trump administration also reinstated many agents and brokers suspended in recent years, and federal indictments related to broker fraud for actions that allegedly occurred as far back as 2018 still await resolution.

Even before the creation of the Marketplaces, agents and brokers had been selling coverage in the individual and group insurance market, especially to small employers needing expertise in finding health insurance for their employees. Large employers also use agents and brokers, who often work for employee benefit consultants or brokerage firms and receive commissions (or, in some cases, a fixed fee) to find vendors to support their self-insured group health plan or for placing other forms of insurance that they provide or make available to employees as “voluntary” benefits.

Broker Compensation Reporting. Employer plans governed by ERISA must meet ERISA fiduciary standards. These standards prohibit plans from contracting with a “party-in-interest,” which is an entity that may have a conflict of interest because it is receiving compensation from a third party for activity it is doing for the employer plan. For instance, a benefits consultant may be helping an employer find a third-party administrator (TPA) for its group health plan, and the consultant is paid by the employer for their work but also gets a commission from the TPA if the employer decides to use its services. Employers are prohibited from entering into this type of transaction with the consultant unless they can show it was done in a “reasonable manner.”

Under rules added to ERISA by the CAA, one way an employer plan can demonstrate that its contract with a broker/consultant is reasonable is to show that it received information from the broker/consultant about the compensation the broker/consultant received from the TPA. Under these rules, an employer plan fiduciary violates ERISA if it does not receive from a broker or consultant information about the direct and indirect compensation the broker receives. Also, insurers offering individual insurance (on- and off-Marketplace) and those offering short-term limited-duration plans must disclose to enrollees and report to CMS any direct or indirect compensation they pay to agents and brokers for enrolling individuals in this coverage.

Consumer Assistance Programs. The ACA required the creation of other types of assisters to assist consumers with enrollment, plan selection, insurance problems, and, in some cases, post-enrollment support. These programs must provide impartial, no-cost help to consumers and cannot be affiliated with an insurance company.

Navigator programs, which are federally funded through grants, were created to raise public awareness and assist individuals in enrolling in qualified health plans as well as provide post-enrollment support. Navigators participate in trainings and are required to be knowledgeable in eligibility and enrollment rules and available QHP options, and maintain privacy and security standards. In 2025, CMS announced a 90% cut in Navigator funding, the largest funding cut since the program began. The current plan year funding of $100 million will be reduced to $10 million for 2026. These cuts come as enhanced Marketplace subsidies are set to expire at the end of 2025 and federal cuts to Medicaid begin to take effect in 2026, both of which could result in significant coverage losses.

Related assisters include Certified Application Counselors (CACs) who also assist consumers in resolving insurance issues and identifying the coverage option that best suits their needs. CACs, however, are not required to meet the same standards as Navigators or participate in all of the activities required of Navigators (e.g., providing post-enrollment assistance). In states using the federally-facilitated Marketplace (FFM), CACs are overseen by Certified Application Counselor Designated Organizations (CDOs), which are designated by CMS and include organizations such as community health centers, hospitals, and social services agencies. To serve as a CAC in an FFM state, the individual must be affiliated with a CDO and is typically a staff member or volunteer. CACs are not federally funded and instead rely primarily on outside non-profit organizations and foundations. 

The ACA also established Consumer Assistance Programs (CAPs) to assist consumers with insurance problems and identify their best options for health coverage. Unlike the Navigator program, which was specifically created to assist Marketplace, Medicaid, and CHIP consumers, CAP programs also assist consumers with employer-sponsored coverage and other types of coverage. The ACA provided an initial appropriation for CAPs, which 35 states and Washington, D.C., took advantage of, but CAP programs have received no federal funding since 2012. Many states have continued their CAP programs using their own funds, but others have discontinued their operations.

2025 and beyond will likely see a retrenchment in regulation at the federal level that could impact the private coverage gains of the last decade. While states will still play a significant role in regulating private health insurance, the fragmented structure of private health care regulation and enforcement means that states alone are limited in what they can do to affect national change or influence private employer-based coverage, where most insured Americans under 65 get their coverage. The future regulatory outlook for private health coverage will be shaped by the following three key features:

Deregulation and Litigation. The Trump administration has put in motion, through several executive orders and other actions, deregulation across the health care sector. For example, a January 2025 executive order required that for every new regulation promulgated, federal agencies must identify at least ten existing regulations to repeal, which could impede future rulemaking. Another executive order required all federal agencies to coordinate with the president’s Department of Government Efficiency (DOGE) to review all regulations to make sure they are consistent with “law and Administration policy.” Using this executive order, the Trump administration has limited the enforcement of final regulations on mental health parity and short-term, limited-duration plans. Also in February 2025, President Trump issued an executive order that rescinded several executive orders issued by President Biden, including one aimed at strengthening the ACA.

These types of regulatory rescissions and a general deregulatory executive agenda, along with disruptions in agency structure and the personnel layoffs in the federal health care agencies, could have long-term impacts on private health care regulation. The outcome of court challenges to many of these deregulatory actions will determine future developments. In addition, changes in how courts review agency decisions—that is, the major decisions by the Supreme Court to limit agency discretion—could be a barrier to the Trump administration’s deregulation initiatives, as federal courts now have more power to second-guess policy decisions of the President. Look for attempts at codifying the Trump administration’s priorities through congressional action to get past any court barriers. Also, expect to see more actions from this administration through executive orders, voluntary industry agreements, and sub-regulatory guidance (e.g., advisory opinions that approve various industry arrangements). Changing enforcement priorities for federal agencies could leave patients looking to state and private mechanisms to get the protections written in federal law.

Technology Advancements. Expect wide-ranging recommendations from major stakeholders on which aspects of artificial intelligence (AI) and telehealth should be promoted and protected from federal regulation. The Trump administration has already announced its plans to speed up the development of AI and reduce regulation. With limited federal regulation anticipated during this administration, much of the future outlook for consumer protections will depend on the voluntary actions of industry and how transparent those activities are. For example, in July 2025, the Trump administration announced a new voluntary initiative aimed at enhancing health data interchange (known as “interoperability”) and expanding patients’ access to their own health data and reported that more than 60 companies had pledged to participate. Open questions about data privacy, security, and accuracy are key concerns as the details of this initiative and new apps are developed. Participation is optional, and the initiative does not create any new legally binding requirements for these companies. While the market for digital health care tools could benefit from the emphasis on AI and virtual care, without updated federal privacy and security rules, such as HIPAA, and nondiscrimination requirements, consumers may have to look to state regulation for these protections. Additionally, new, expensive gene therapies and blockbuster medications will likely increase the overall cost of health care and could also challenge policymakers to rethink existing reimbursement structures and government intervention in pricing.

Consumer Choice. Look for policy shifts from consumer assistance and protection to efforts to broaden the health coverage choices available to consumers to include those that may not meet all of the ACA’s consumer protection requirements. The emphasis on “choice” will likely include efforts to encourage consumers to use tax-advantaged accounts such as health savings accounts, which can be used to set aside funds to purchase an increasing variety of items and pay for health care services provided via direct primary care arrangements and telehealth before the deductible applies. Policy debates on whether low-income individuals and those with chronic illnesses are best served by these account-based models are also possible.

• KFF Survey of Consumer Experiences with Health Insurance
• Explaining Health Care Reform: Risk Adjustment, Reinsurance, and Risk Corridors
• What resources are available for privately insured patients who get surprise balance bills?
• No Surprises Act Implementation: What to Expect in 2022
• Examining Prior Authorization in Health Insurance
• Final Prior Authorization Rules Look to Streamline the Process, but Issues Remain
• Mental Health Parity at a Crossroads
• Consumer Appeal Rights in Private Health Coverage
• Price Transparency and Price Variation in U.S. Health Services
• Network Adequacy Standards and Enforcement
• Pre-existing Conditions: What Are They and How Many People Have Them?
• Proposals for Insurance Options That Don’t Comply with ACA Rules: Trade-offs in Cost and Regulation
• Supreme Court Decision Limiting the Authority of Federal Agencies Could Have Far-Reaching Impacts for Health Policy
• 2022 Survey of ACA Marketplace Assister Programs and Brokers
• Rise in Use of Mental Health Apps Raises New Policy Issues
• Navigating the Maze: A Look at Health Insurance Complexities and Consumer Protections
• How Pending Health-Related Lawsuits Could be Impacted by the Incoming Trump Administration
• Charting the Way Forward: New Efforts to Advance Electronic Health Information Sharing

Pestaina, K., Wallace, R., & Long, M., The Regulation of Private Health Insurance. In Altman, Drew (Editor), Health Policy 101, (KFF, October 2025) https://www.kff.org/health-policy-101-the-regulation-of-private-health-insurance/ (date accessed).

Health care is a central element of women’s lives, shaping their ability to care for themselves and their families, to be productive members of their communities, to contribute to the workforce, and to build a base of economic security. Women’s reproductive health care needs, their central roles managing family health as parents and as family caregivers, and their longer lifespans, albeit with greater rates of chronic health problems and functional limitations than men, all shape their relationships with the health care system. While women are major consumers of health care services and play a central role as health navigators and caregivers for their families, structural factors can challenge their ability to get the health care they need. Factors, including national and state policies that shape the health care delivery system to research priorities and discriminatory economic and societal forces, can deprioritize women’s health concerns. Access challenges are greater for women who are in low-income households, who face structural and societal racism and discrimination, who struggle with complex or understudied medical conditions, or who live in states or communities that have enacted or invested in policies and programs that do not support their health needs.

In the United States, the women’s health movement gained significant traction in the 1960s and 1970s as part of a larger grassroots women’s rights movement that challenged long-standing inequities and discrimination that limited women’s economic and social opportunities. The book, “Our Bodies, Ourselves,” brought a wide range of women’s health concerns, ranging from abortion and sexuality to menopause and cancer, into the mainstream. Over time, federal action also began to address many of the long-standing discriminatory sex and gender-based policies that were baked into our employment, health, and research policies. The 1973 U.S. Supreme Court ruling in Roe v. Wade decriminalized and protected the right to abortion care for nearly 50 years; the Pregnancy Discrimination Act of 1978 offered workplace and insurance protections to pregnant workers; the National Institutes of Health (NIH) Revitalization Act of 1993 mandated the inclusion of women in clinical research and formally established the NIH Office of Women’s Health; and in 2010, the Affordable Care Act (ACA) banned many of the discriminatory practices that had shaped women’s coverage of and access to care. While many of these policy changes have resulted in improvements and advances in women’s health, including access and coverage, the advances have not been linear.  In 2022, the Supreme Court, with a conservative supermajority, struck down the right to abortion in Dobbs v Jackson Women’s Health, resulting in the outright banning of abortion in many states. Despite advances in women’s health research, many gaps remain and the Trump Administration has targeted and blocked federal funding that focuses on gender, a pillar of women’s health research.     

This primer focuses on some of the key areas disproportionately affecting women today that are shaped by national and state health policies. This includes health coverage and costs, reproductive health services, maternal health, mental health, and intimate partner violence. In addition, it highlights some of the structural factors and inequities that still impact women’s health, particularly women of color and gender-expansive individuals such as those who are transgender or non-binary or otherwise gender fluid or non-conforming who are at risk of being marginalized or discriminated against by their health coverage or providers. We note that while we refer to “women” and “women’s health” throughout this chapter, some persons assigned female sex at birth do not identify as women, such as transgender men, non-binary individuals, and otherwise gender-expansive individuals. Still, many of the issues discussed in this chapter also apply to them.

More than 128 million adult women over the age of 19 live in the U.S. today, with great diversity in many demographic characteristics. A third of adult women are between the ages of 35-54 (33%) and the majority are White (60%) (Figure 1). Nearly 1 in 5 (17%) women are Hispanic, 12% are Black and 6% are Asian.

Almost two-thirds (65%) of women live in a household with at least one full-time worker, while 1 in 10 (9%) live in a household with only part-time workers, and 25% of women live in households with no workers (data not shown). Given the important role of employment in shaping health coverage, workforce participation is a significant determinant of the type of health insurance that working women or women who live in households with full-time workers can obtain.

While most women in the U.S. report having good health, nearly 1 in 5 (18%) women 18 and older rate their health as “fair” or “poor” and 14% report having a disability such as difficulty with vision, hearing, or walking. As women age, they are more likely to experience chronic health problems and declines in health status. These factors are highly predictive of their need for and use of health care services.

Income also plays a major role in health coverage and access to care. Income affects the resources that women have to pay for out-of-pocket health care costs and contribute to premium costs. Income also determines women’s eligibility for programs such as Medicaid or subsidies to secure coverage through the ACA Marketplace. Almost three in 10 (28%) adult women are part of households with low incomes (family income below 200% of the FPL was $49,720 for a family of three in 2023). Almost 4 in 10 (36%) women have completed a bachelor’s degree or higher, almost a third (27%) have a child under the age of 19 living at home, and 92% are U.S. citizens. Nearly 4 in 10 women live in the South (39%), almost a quarter (23%) live in the West, a fifth (20%) live in the Midwest, and 17% live in the Northeast (Figure 2).

While most adult women have some form of either private or public health insurance, the coverage profile for those who are under and over age 65 differs considerably. For those who are under age 65, employer-sponsored coverage, individually purchased policies, and Medicaid—the state-federal program for people with low incomes—comprise the majority of coverage options. However, nearly 1 in 10 women in that age group are currently uninsured. Among women 65 years and older, the Medicare program plays a critical role covering nearly all seniors in the U.S., though often with considerable coverage gaps (such as hearing, vision and long-term services and supports) and cost-sharing burdens.

Employer-Sponsored Insurance

Approximately 58.3 million women aged 19-64 (60%) received their health coverage from employer-sponsored insurance in 2023 (Figure 3). Women in families with at least one full-time worker are more likely to have job-based coverage (70%) than women in families with only part-time workers (33%) or without any workers (17%).

Employer-sponsored insurance can come with substantial out-of-pocket costs based on premiums, deductibles, co-insurance, and co-payment levels. In 2023, annual insurance premiums for employer-sponsored insurance averaged $8,435 for individuals and $23,968 for families. On average, workers paid 17% of premiums for individual coverage and 29% for family coverage with the employers picking up the balance.

Non-Group Insurance

In 2023, about 9% of women ages 19 to 64 (approximately 8.4 million women) and 8% of their male counterparts purchased insurance in the non-group market. This includes individuals who purchased private policies from state-based Marketplaces established under the ACA, as well as those who purchased coverage from private insurers that operate outside of the ACA Marketplaces.

Most individuals who seek insurance policies in their state’s Marketplace qualify for assistance with the coverage costs. Individuals with incomes below $58,320 (400% of the Federal Poverty Level in 2023) can receive federal tax credits which lower premium costs. The American Rescue Act (ARPA) of 2021, and subsequently the Inflation Reduction Act of 2022, have provided a temporary extension of Marketplace subsidies to people with higher income levels and led to record high enrollments in the ACA marketplace. These subsidies are set to expire at the end of 2025 and if they are not renewed, it would lead to a steep increase in insurance premium payments for ACA Marketplace enrollees. 

The ACA set new standards for all individually purchased plans and eliminated many historically discriminatory practices that affected disadvantaged women in particular. Today, plans are prohibited from charging women higher premiums than men for the same level of coverage (gender rating) or from disqualifying women from coverage because they had certain pre-existing medical conditions, including pregnancy. All direct purchase plans must also cover certain “essential health benefits” (EHBs) that fall under 10 different categories, including maternity and newborn care, mental health, and a wide range of preventive health care services. Prior to the ACA, many individual plans excluded maternity care benefits or required policyholders to purchase costly riders to obtain maternity coverage.

Medicaid

Medicaid, the state-federal program for individuals with low incomes, covered 19% of adult women ages 19 to 64 in 2023, compared to 14% of men. Historically, to qualify for Medicaid, women had to have very low incomes and be in one of Medicaid’s eligibility categories: pregnant, mothers of children 18 and younger, a person with a disability, or over 65. Women who didn’t fall into these categories typically were not eligible regardless of how low their incomes were. The ACA allowed states to broaden Medicaid eligibility to most individuals with incomes less than 138% of the FPL regardless of their family or disability status, effective January 2014. As of April 2025, 40 states and Washington, D.C. have expanded their Medicaid programs under the ACA, but 10 states have not and still base eligibility on historical categorical and income standards. For example, in Mississippi, the Medicaid income eligibility for parents is 28% of the FPL, which was approximately $6,900 for a family of three in 2023. Therefore, parents in families of three in Mississippi with incomes above this amount do not qualify for Medicaid because their income exceeds the state’s eligibility level.

Medicaid covers the poorest segment of women in the U.S. Forty-four percent of women with incomes below 200% of the FPL and 52% of women with incomes below 100% of the FPL have Medicaid coverage.By federal law, all states must provide Medicaid coverage to pregnant women with incomes up to 133% of the FPL through 60 days postpartum. However, in recent years, there has been a growing interest in expanding the length of the postpartum coverage period and, as of April 2025, nearly all states have taken steps to extend postpartum Medicaid coverage to one year.

Medicaid covers many health services that are essential for women. Medicaid financed 41% of births in the U.S. in 2022 and accounts for 75% of all publicly-funded family planning services. State Medicaid programs are prohibited from charging any cost-sharing for pregnancy-related care or family planning services. Over half of states have established programs that use Medicaid funds to cover the costs of family planning services for women with low incomes who remain uninsured, and most states have limited scope Medicaid programs to pay for breast and cervical cancer treatment for certain uninsured women with low incomes. Conversely, coverage for abortion is very limited under Medicaid as a result of the Hyde Amendment, a rider to federal appropriations that bans any federal funds from being used to pay for abortions unless the pregnancy is determined to be a result of rape or incest or poses a threat to the pregnant person’s life (more on abortion in the following section).

Uninsured Women

In 2023, approximately 10% of non-elderly women (9.3 million) were uninsured. This rate is slightly lower than that of men (13%) because, on average, women have lower incomes and have been more likely to qualify for Medicaid than men under one of Medicaid’s eligibility categories: pregnant, parent of children under 18, disability, or over 65. The ACA opened the door for states to eliminate the categorical requirements, but the gender gap in the insured rates between men and women persists.

The disadvantage uninsured individuals experience in accessing care and health outcomes is well established. Compared to women with insurance, those who are uninsured have lower use of important preventive services such as mammograms, Pap tests, and timely blood pressure checks. They are also less likely to report having a regular doctor, which is associated with better access to care and higher rates of use of recommended preventive services.

Women with lower incomes, women of color, and non-citizen women are at greater risk of being uninsured (Figure 4). One in 5 Hispanic (20%) and American Indian and Alaska Native (19%) women and 17% of women with incomes under 200% of the FPL are uninsured. A higher share of single mothers are uninsured (10%) than women in two-parent households (7%) (data not shown). Most uninsured women live in a household where someone is working; 69% are in families with at least one adult working full-time; and 82% are in families with at least one part-time or full-time worker (data not shown).

Many women who are uninsured are eligible for financial assistance with the costs of coverage. A fifth of uninsured women (20%) are eligible for Medicaid coverage but are not enrolled in the program (Figure 5). Over a third of uninsured women (36%), about 3.3 million women, qualify for subsidies to cover the premium costs and some of the out-of-pocket costs of Marketplace plans but may not be aware of coverage options or may face barriers to enrollment. However, 7% of uninsured women live in states that have not adopted the ACA Medicaid expansion and fall into a “coverage gap” because their incomes are above the thresholds to qualify for Medicaid but below the levels to qualify for Marketplace tax credits (below 100% of the FPL). Another 1 in 3 (37%) uninsured women are not eligible for any assistance with health coverage due to their immigration status, their income, or because they have an offer of coverage from their employer.

There is considerable state-level variation in uninsured rates across the nation, ranging from 20% of women in Texas to 3% of women in Washington D.C., Hawaii, Massachusetts, and Vermont (Figure 6). Of the 16 states with uninsured rates above the national average (10%), eight have not adopted the ACA Medicaid expansion.

Medicare

Medicare is the federal program that provides health coverage to virtually all people ages 65 and older as well as younger people with long-term disabilities. In 2020, Medicare covered 35 million women, including nearly 31 million ages 65 and older, and over 4 million under age 65 with long-term disabilities.

More than half (55%) of all Medicare beneficiaries are women and 45% are men. The population of women covered by Medicare is diverse, with varying social, economic, and health circumstances. Women live longer than men on average (80 years vs. 75 years life expectancy at birth in 2022), and many live with certain chronic illnesses, cognitive and mental impairments, and functional problems at higher rates than men. A higher share of older women than men also experience urinary incontinence, depression, osteoporosis, pulmonary disease, and Alzheimer’s/dementia. Medicare plays a key role in supporting the health and well-being of women, covering a broad range of essential services, including preventive, primary and specialty care, and prescription drugs. However, reflecting Medicare’s original role as a program to serve the medical needs of older adults, coverage of services for enrollees of reproductive age may be more limited. For example, there is no federal requirement for Medicare to cover all contraceptive services and supplies for the purpose of preventing pregnancy for younger Medicare enrollees with permanent disabilities.

Another gap in the Medicare program is the absence of coverage for long-term care services and supports (LTSS), such as nursing home stays and home care services, which many older adults need and seek but are expensive and unaffordable for some. Compared with men, women are more likely to require these services because they have more chronic conditions, have higher rates of physical and cognitive impairments, and are more likely to live alone. Medicare only covers time-limited LTSS after a hospitalization and does not cover ongoing LTSS for those with chronic conditions or functional impairments. Some older women can qualify for Medicaid for LTSS, but only if they have low incomes and, in some cases, must spend down most of their assets. Just a small share of seniors have private long-term care insurance to help cover some of the costs of LTSS. As a result, unless they have incomes low enough to qualify for Medicaid, many older people do not have any coverage for LTSS and rely on unpaid caregiving provided by family, friends, or neighbors. The majority of informal caregivers are women, who are most commonly caring for aging parents and spouses.

Women with Medicare also tend to have more modest incomes than men—a consequence of smaller lifetime savings, lower retirement income, and divorce and widowhood that result in only one income. While Medicare covers many necessary health care services, gaps in benefits, cost-sharing requirements, and spending on premiums for Medicare and supplemental coverage can translate into high out-of-pocket expenses for some people in the program. In 2020, 13% of women and 11% of men with Medicare reported that they had faced cost-related challenges in the past 12 months, such as trouble getting care due to cost or problems paying medical bills. These challenges are more common among female Medicare enrollees who are Black (22%) and Hispanic (18%), do not have a bachelor’s degree (15%), and those with annual incomes below $20,000 (20%).

The ACA set national standards for the scope of benefits offered in private plans. As mentioned earlier, many insurance plans had adopted practices that discriminated against women that were addressed in the ACA. In addition to the broad categories of essential health benefits (EHBs) offered by Marketplace plans, all privately purchased plans must cover maternity care, which had been historically excluded from most individually purchased plans requiring the purchase of an expensive rider for that benefit to be covered. In addition, most private plans must cover preventive services without co-payments or other cost sharing. This includes screenings for breast and cervical cancers, well-woman visits (including prenatal visits), prescribed contraceptives, breastfeeding supplies and supports such as breast pumps, and several services for sexually transmitted infections (STI). Higher shares of women with private and Medicaid coverage report having had recommended preventive services such as mammograms, Pap screenings or colonoscopies compared to those who were uninsured (Figure 7).

Affordability of coverage continues to be a significant concern for many women, both for those who are uninsured as well as those with coverage. The leading reason why uninsured adults report that they have not obtained coverage is that it is too expensive. Under employer-sponsored insurance, the major source of coverage for women, 61% of all covered workers with a general annual deductible have deductibles of at least $1,000 for single coverage. Despite having coverage, many insured women (31%) report that their plans did not always cover all of their needed care or paid less than they expected (Figure 8).

Reproductive Health

Pregnancy

Maternity Care

In 2023, there were approximately 3.6 million births in the U.S. Childbirth is the leading reason for hospitalization, and most private insurance plans and the Medicaid program are required to cover care associated with childbirth. Medicaid covers about 4 in 10 births nationally and, in some states, more than half. The Medicaid program prohibits plans from charging out-of-pocket charges for pregnancy-related care, and coverage lasts through one year postpartum in most, but not all, states. For people with private insurance, which finances just over half of  births (51%), the federal Pregnancy Discrimination Act requires employer plans to cover maternity care benefits. However, even for those with private insurance, a pregnancy often comes with significant out-of-pocket health expenses that can reach thousands of dollars. A KFF analysis estimated that women enrolled in large group plans pay around $3,000 out-of-pocket for costs associated with pregnancy, childbirth, and post-partum care. On average, Caesarean section births, which account for approximately one-third of births in the U.S., are significantly more expensive than vaginal deliveries. The ACA also requires individual plans to cover maternity care and bans plans from implementing restrictions on coverage of pre-existing health conditions, including pregnancy.

In recent years, there has been growing attention to pregnancy-related quality of care and maternal health. Maternal and infant mortality rates in the U.S. are far higher than those in similarly large and developed countries, and people of color are at a considerably higher risk for poor maternal and infant health outcomes compared to their White peers. Despite continued advancements in medical care, rates of maternal mortality and morbidity and preterm birth have been rising in the U.S., characterized by stark racial disparities. Notably, rates of pregnancy-related death (deaths within one year of pregnancy) among American Indian and Alaska Native (AIAN), Native Hawaiian or Pacific Islander (NHPI) and Black women are over four to two times higher, respectively, compared to the rate for White women (118.7, 111.7, 69.3 and 24.3 per 100,000 live births, respectively) (Figure 9). The Centers for Disease Control (CDC) has determined that many of these pregnancy-related deaths were preventable, caused by cardiac-related conditions, infection, hemorrhage, and mental health conditions, including substance use. Maternal death rates increased during the COVID-19 pandemic and racial disparities widened for Black women. Black, AIAN, and NHPI women also have higher shares of preterm births, low birthweight births, or births for which they received late or no prenatal care compared to White women. Infants born to Black, AIAN, and NHOPI people have markedly higher mortality rates than those born to White women.

The disparities in maternal and infant health are symptoms of broader underlying social and economic inequities that are rooted in racism and discrimination. Differences in health insurance coverage and access to care play a role, but notably, disparities in maternal and infant health persist even when controlling for certain underlying social and economic factors, such as education and income, pointing to the roles racism and discrimination play in driving disparities. Moreover, with the overturning of Roe v. Wade and the numerous states that have enacted abortion bans across the nation, increased barriers to abortion for people of color may widen the already existing large disparities in maternal and infant health.

There have been efforts at the policy level and in clinical circles to improve maternal health and address disparities. At the state and local levels, multidisciplinary maternal mortality review committees and perinatal quality collaboratives have focused on data collection and reviewing the causes behind pregnancy-related deaths in their communities to try to prevent deaths in the future.

Fertility Assistance

Many people require fertility assistance to have children. These services include diagnostic services, treatment services, and fertility preservation. People seek fertility assistance for several reasons, such as if they or their partner has infertility, or because they are in a same-sex relationship or are single and desire children. Both female and male factors contribute to infertility, including problems with ovulation (when the ovary releases an egg), structural problems with the uterus or fallopian tubes, problems with sperm quality or motility, and hormonal factors. About 25% of the time, infertility is caused by more than one factor, and in about 10% of cases, infertility is unexplained. Infertility estimates, however, do not account for LGBTQ+ or single individuals who may also need fertility assistance for family building. Thus, there are varied reasons that may prompt individuals to seek fertility care.

Despite a need for fertility services, fertility care in the U.S. is inaccessible to many due to the cost. Fertility treatments are expensive and often are not covered by insurance. While some private insurance plans cover diagnostic services, there is very little coverage for costly treatment services such as intrauterine insemination, in vitro fertilization, and cryopreservation.

Most people who use fertility services must pay out of pocket, with costs often reaching thousands of dollars depending on the services received. This means that in the absence of insurance coverage, fertility care is out of reach for many people. Few states require private insurance plans to cover fertility assistance services, but these only apply to a subset of insurance plans and beneficiaries. Additionally, even fewer states have any fertility coverage requirement under Medicaid, the health coverage program for people with low incomes. The Trump Administration has issued an executive order requesting policy recommendations to protect access and reduce the costs for IVF, but Congressional action is required to meaningfully expand options to cover IVF services for the vast majority of people.

Abortion

Nearly 1 in 4 women in the U.S. have an abortion in their lifetime. Starting with the 1973 landmark Supreme Court ruling in Roe v. Wade, women in the U.S. had the right to abortion up until the point of viability, regardless of where they lived. On June 24, 2022, the Supreme Court issued a ruling in Dobbs v. Jackson Women’s Health Organization that overturned the constitutional right to abortion as well as the federal standards of abortion access, established by prior decisions in the cases Roe v. Wade and Planned Parenthood v. Casey. The Dobbs decision allows states to set policies regarding the legality of abortions and establish gestational limits. Access to and availability of abortions vary widely between states, with large swaths of the country banning or restricting almost all abortions, with few exceptions, and some states enshrining and protecting abortion rights (Figure 10).

There are different types of abortion methods, broadly divided into procedures such as a dilation and evacuation (D&E) or dilation and curettage (D&C) and medication, which typically involves two pills – mifepristone and misoprostol. The Guttmacher Institute estimates that approximately two-thirds (63%) of all abortions are medication abortion, which can be provided by a clinician in person or by telehealth when the pills are mailed or dispensed at a retail pharmacy. Telehealth abortion care has grown in recent years, and now account for one in four abortions in the U.S.

Decades of research have shown that abortion is a very safe medical service. Still, despite its strong safety profile, abortion is the most highly regulated medical service in the country and is now banned or restricted to early gestational stages in many states. In addition to bans on abortion altogether, many states impose other limitations on abortion that are not medically indicated, including waiting periods, ultrasound requirements, and parental notification and consent requirements. These restrictions typically delay receipt of services and can increase costs associated with abortion care. As use of medication abortion has risen, some have tried to cast false doubt about the safety of the medications, despite the extensive body of research on the drug’s safety. There are multiple efforts to restrict use of the drug nationally, and two states have classified mifepristone as a controlled substance to limit its availability.

Obtaining an abortion can be costly, with median costs exceeding $500 in out-of-pocket expenses for patients who self-pay. On average, the costs are higher for abortions in the second trimester than in the first trimester. People may have to travel if abortions are prohibited or not available in their area, adding costs related to travel and lodging. Given abortion bans and Hyde Amendment restrictions on payment for abortions under Medicaid and state restrictions on insurance coverage of abortion services, many people pay for abortion services out of pocket. Some people are able to receive assistance from local abortion funds if they need financial support to obtain abortion services, particularly if they have to travel out of state or have low incomes and cannot afford the costs of the abortion. For some, however, the costs of abortion services and travel will put the service out of reach and force them to have a birth that is not desired or is a risk to their health or life.

Insurance coverage for abortion services is heavily restricted in some state-regulated private insurance plans and public programs, like Medicaid and Medicare. Private insurance covers most women of reproductive age, and states can choose whether abortion coverage is included or excluded in private plans that are not self-insured. Prior to the Dobbs ruling, about half of the states had enacted private plan restrictions and banned abortion coverage from ACA Marketplace plans. Since the Dobbs ruling, some of these states have also banned the provision of abortion services altogether. However, 12 states have enacted laws that require private plans to cover abortion, typically without cost-sharing.

The Hyde Amendment has banned the use of federal funds for abortion unless the pregnancy is a result of rape, incest, or it endangers the woman’s life. States may use non-federal state-only funds to pay for abortions under other circumstances for women covered by Medicaid, which 20 states currently do. However, more than half (56%) of women covered by Medicaid live in states where they have no coverage for abortion, unless they qualify for an exception.

The impact of the Dobbs decision goes far beyond abortion care. It has also affected the provision of related health care services, including management of miscarriages and pregnancy-related emergencies, treatments for cancer and other chronic illnesses, contraceptive options, and much more. Women with low incomes, women of color, sexual/gender minorities, and other pregnant people have been disproportionately affected by the sweeping impacts of this ruling, as they are less likely to have the resources to travel potentially long distances to seek care.

Since the Dobbs ruling, there has been a constant stream of legal challenges, with a plethora of cases that seek to challenge abortion bans as well as block access to abortion medication or services. The Supreme Court has considered two abortion related cases—one case involving the FDA’s approved conditions for using and dispensing mifepristone, one of the drugs used for medication abortion, as well as a case about potential conflict between state-level abortion bans and Emergency Medical Treatment and Labor Act (EMTALA), the federal law that requires hospitals to provide care to stabilize patients experiencing medical emergencies, including emergency abortions that must be performed to save the life or preserve the health of the pregnant patient. Several other cases about abortion access are pending in lower courts.

Paradoxically, the most recent data show that the abortion volume in the U.S. slightly increased overall in the two years following the Dobbs ruling (Figure 11). In 2024, the national abortion volume averaged 95,200 abortions per month, higher than the monthly averages in 2023 and before the Dobbs decision. This overall increase can be largely attributed to broader availability of lower cost medication abortions through telehealth, virtual clinics, brick and mortar clinics, and shield laws, where clinicians in legal states mail pills to individuals residing in states with bans and restrictions. Additionally, in several states without bans, there has been increased interstate travel for abortion access, expanded capacity to see patients, increased measures to protect abortion rights and improve coverage of abortion care.

However, the small upswing nationally obscures the massive declines in abortion access to in-state providers in states with bans and restrictions as well as the hardships that many pregnant people experience in accessing abortion care. Additionally, there are month-to-month variations in all states, and changes in policy can cause larger shifts. For example, in May 2024 Florida implemented a ban on abortions after six weeks of gestation (previously permitted up to 15 weeks), and subsequently there was a noticeable decline in abortions in the state and nationally.

Contraception

Contraceptive care is an important component of overall health care for many women and people capable of becoming pregnant. Federal and state policies shape access to and the availability of contraceptive care, but factors such as provider characteristics, as well as individual preferences and experiences also impact contraceptive choices and use. For most people, private insurance coverage and Medicaid greatly reduce or eliminate financial barriers to contraceptive care. However, access is still limited in many parts of the U.S. with more than 19 million women living in contraceptive deserts where they may not have access to a health center offering the full range of contraceptive methods. There have been more efforts to broaden contraceptive availability outside of traditional clinical settings, including through commercial apps that use telehealth platforms, state efforts to allow pharmacists to prescribe birth control, and, most recently, over-the-counter (OTC) access to contraceptives without a traditional prescription.

The importance and impact of contraceptives in women’s lives are unquestionable. The 2024 KFF Women’s Health Survey highlighted that the majority of women ages 18 to 49 (82%) have used contraception in the past 12 months,  most commonly oral contraceptives and male condoms (Figure 12). The types of contraception women use shift over the course of their reproductive years. Forty-four percent of women ages 18 to 25 report having used oral contraceptives in the past 12 months compared to 19% of women ages 36 to 49. Conversely, higher shares of older women say they have had a sterilization procedure compared to younger women.

The ACA requires that most private plans cover contraceptive services for females without cost-sharing – this includes patient education and counseling and FDA-approved methods of contraception with a prescription. This provision has dramatically reduced cost-sharing for contraception among females with private insurance plans, though some privately insured females who are eligible for no-cost coverage are still paying some of the cost of their contraceptives (Figure 13). Reasons include someone using a brand-name contraceptive that is not in the plan’s formulary or consumers unaware of or not offered a generic alternative.

Despite its far-reaching impact, the ACA’s requirement for contraceptive coverage has been challenged in the courts on multiple occasions, with three cases reaching the Supreme Court. The earlier cases, Burwell v. Hobby Lobby (2014) and Zubik v. Burwell (2016), challenged the Obama Administration’s regulations implementing the contraceptive coverage requirement, contending that the requirement violated some employers’ religious rights. The most recent cases, Little Sisters of the Poor v. Pennsylvania (2020) and Trump v. Pennsylvania (2020), involved regulations issued by the Trump Administration, which currently exempt employers with religious objections from providing contraceptive coverage to their employees.

For people with lower incomes, the Medicaid program is the primary funding source for contraceptives. The federal Medicaid statute establishes minimum standards, and, for decades, has classified family planning as a mandatory benefit category that all state programs must cover. States may not charge any out-of-pocket costs for family planning services and must allow beneficiaries to see any Medicaid provider within their state for family planning care. Many states also have programs that provide Medicaid coverage just for family planning services to people who have lower incomes but do not qualify for full Medicaid benefits.

Additionally, the federal Title X family planning program, administered by the HHS Office of Population Affairs (OPA), is the only federal program specifically dedicated to supporting the delivery of family planning care for individuals who are uninsured and have lower incomes. The program provides funding to more than 4,000 health clinics, public health departments, and nonprofit agencies across the country to deliver contraceptives and other family planning services to individuals with low incomes. Title X-funded providers must follow the program’s requirements, which include offering a broad range of family planning methods for low or no cost and ensuring confidentiality for adolescents. Federal rules also require that participating clinics offer their patients non-directive pregnancy option counseling that includes abortion, adoption, and prenatal referral for those who seek those services. Over the last decade, there have been major changes to the Title X program based on shifting administrations’ priorities. During the first Trump Administration, the regulations were revised to disqualify clinics that had co-located abortion services and provided abortion referrals. Over 1,000 clinics were no longer eligible for Title X funds. The Biden Administration reversed the Trump Administration regulations and funding was restored to many of these clinics. The second Trump administration has been withholding funds from some of the program’s grantees, including all 9 Planned Parenthood grantees. Hundreds of Title X Clinics are affected, and some have reported that they are closing as a result . In addition, the President’s proposed budget calls for the elimination of the Title X program.  

While there have been numerous over-the-counter contraceptive methods available (e.g. condoms, spermicides), in July 2023, the Food and Drug Administration (FDA) approved the first over-the-counter daily oral contraceptive pill, known as Opill. FDA’s approval of Opill makes it the most effective form of contraception available OTC intended for regular use. Private insurers and Medicaid generally require a prescription to cover OTC products, so even though Opill and other OTC products are available without needing a prescription from a clinician, coverage without a prescription will be limited without federal or state action.

Mental Health

Mental health has emerged as a rapidly growing concern in recent years, with 90% of Americans saying there is a mental health crisis in a 2023 KFF-CNN poll. Women experience several mental health conditions such as anxiety, depression, and eating disorders more frequently than men, and some also experience mental health disorders that are unique to women, such as perinatal depression (including prenatal and postpartum depression) and premenstrual dysphoric disorders that may occur when hormone levels change.

A KFF survey found that in 2024, a higher share of women (28%) than men (23%) describe their mental health as fair or poor (data not shown). Higher rates of women 18 to 25 (36%), those with incomes below 200% of the FPL (38%), those who identify as LGBT+ (45%), and those who identify as having a mental health-related disability (73%) report fair or poor emotional wellbeing. Roughly three in the ten women (29%) say they received mental health services from a mental health professional, however many experience challenges while trying to find care. Among women who received mental health care in the past 12 months, more than half (55%) say they experienced a barrier during their care seeking journey, including trouble finding a provider that was accepting new patients (25%), trouble finding a provider that accepted their  (21%), and trouble scheduling an appointment in a reasonable amount of time (24%).

Cost is a commonly reported barrier to mental health care. More than one in ten women 18 to 64 (13%) say they did not get mental health care or could not continue to afford the mental health care they were receiving because of cost (Figure 14). Insurance networks can be very narrow for mental health care, and a significant portion of mental health clinicians do not participate in insurance networks. These findings on cost barriers underscore the ongoing challenges with affordable mental health care, especially among women who are uninsured, but even for those with coverage.

The ongoing opioid epidemic is a commonly cited stressor that has exacerbated long-standing mental health issues and prompted growing demand for mental health services in the past several years. Women face unique gender and sex-related differences when it comes to substance use, including greater physical, psychological, and social harms associated with drug use. Use of certain substances in women has been linked to increased rates of depression and anxiety disorders. Studies have also shown that women who use substances are at risk for issues related to pregnancy, fertility, breastfeeding, menstrual cycle, and more. All of these factors also shape the availability of treatment and services accessible to women.

Intimate Partner Violence Against Women

Intimate partner violence (IPV), defined as sexual violence, stalking, physical violence, and psychological aggression perpetrated by a current or former intimate partner, affects nearly a third of all Americans at some point in their lives. Although IPV affects men and women of all ages, women experience IPV at higher rates. Rates are higher among some groups of women, particularly those who are young, Black, American Indian or Alaska Native, and LGBTQ. People who experience IPV are more likely to experience a range of health problems such as chronic pain, cardiovascular problems, and neurological problems. Both the CDC and U.S. Preventive Services Task Force (USPSTF) have identified IPV as a significant public health issue in the U.S.

It is difficult to quantify the number of people who experience IPV, as many cases are not reported. Some studies have estimated 6.5 million women in the U.S. experience sexual violence, physical violence, or stalking by an intimate partner in a single year. According to the 2024 KFF Women’s Health Survey, one in five women report experiencing some form of IPV in the past five years (19%), including instances where a current or former partner made them fear for their safety (11%), tried to control most of all of their daily activities (11%), physically hurt them (9%), or forced them into any type of unwanted sexual activity (9%) (Figure 15).

Several federal programs and laws fund health care services and supports to survivors of IPV. The Violence Against Women Act (VAWA) has a broad scope, covering domestic violence, sexual harassment, stalking, and sexual assault. VAWA provides grants to states, local governments, and other organizations to establish their own violence-related programs and protocols. While some of the focus of VAWA and other public policies is prosecution of those who commit violence, provisions in VAWA also address health care coverage and costs for people who have experienced IPV.

It is well recognized that the health care system can serve as a site of IPV screening and support, and some professional medical organizations recommend that clinicians screen women for IPV. Under the ACA, IPV screening is considered a preventive service as screening is recommended by the USPSTF and Health Resources and Services Administration (HRSA) preventive services for women. When health care providers routinely screen patients for IPV, it helps identify cases and connect survivors to resources and supports. However, this can be challenging as a KFF survey of OBGYNs found that many clinicians say they do not have sufficient resources within their practices to provide follow-up services when cases of IPV are identified. Connections to community-based services are particularly important for clinicians to be able to care for patients who disclose IPV.

Women’s health has become one of the most politicized issues in society and health care. The overturning of Roe v. Wade in 2022 marked a seismic change in an important aspect of women’s health care that has implications for all pregnancy-related care and women’s economic future and well-being. The high and rising rates of maternal mortality and morbidity in the U.S. and the persistent gaps in mortality rates experienced by women of color highlight the need to address the roles that poverty, racism, and discrimination play in women’s health.

The Trump Administration has proposed major changes that could affect many recent gains in women’s health care. Within the first few months of taking office, the Administration has sought to define sex as “an individual’s immutable biological classification as either male or female,” which is not supported by science, proposed to eliminate the Office of Population Affairs (OPA), and raised doubts about the safety of mifepristone without scientific basis, to name a few. Significant cuts to several HHS agencies, including HRSA, CDC, FDA, and NIH, have reduced support for women’s health programs and research across the country, with more likely to come. The Administration opposes federal programs related to racial equity, which is integrally connected with most women’s health issues such as maternal health. In addition, the federal budget reconciliation law that was enacted in 2025 made major cuts to the Medicaid program and the ACA, which will affect access to affordable coverage and care for women and families with low incomes. Over the next several years, these cuts in federal spending are projected to lead to a steep rise in people who are uninsured and reduced funding for states and health care providers, including those that care for women with lower incomes. At the same time, the Administration is calling for an increase in births while cutting programs that support families, such as food stamps and HeadStart. While much of the focus in the years will be on the effects of these cuts to federal health spending and programs, some of the key challenges that remain to be addressed in women’s health include:

• How to address and eliminate the persistent inequities in health coverage and outcomes experienced by women of color?
• How to build a delivery system and develop coverage policies that is responsive to the reproductive and sexual health needs of women and other gender minorities to promote optimal health outcomes?
• How to maintain a strong safety-net that offers high quality sexual and reproductive health services, with rising health care costs, a potential increase in uninsured rates, and a decrease in public funds?
• How to shape policies that protect women with low incomes from experiencing financial barriers to care
• Identifying and implementing policies that improve maternal health outcomes and also eliminate the structural and systemic barriers to care
• Providing access to comprehensive care to pregnant people who live in areas where abortion is unavailable due to state-level bans and restrictions
• How to provide care to women dealing with issues that are heavily stigmatized and marginalized, such as intimate partner violence and mental health challenges.

• Women’s Health Policy Dashboard
• Abortion in the United States Dashboard
• State Profiles for Women’s Health
• Women’s Health Insurance Coverage
• Medicaid Coverage for Women | KFF
• State Health Facts Women’s Health Indicators
• 2024 Women’s Health Survey reports
• State and Federal Reproductive Rights and Abortion Litigation Tracker
• Preventive Services Tracker
• A Focus on Contraception in the Wake of Dobbs
• Resources about the Title X National Family Planning Program

Ranji, U., Diep, K., Gomez, I., Sobel, L., & Salganicoff, A., Health Policy Issues in Women’s Health. In Altman, Drew (Editor), Health Policy 101, (KFF, October 2025) https://www.kff.org/health-policy-101-health-policy-issues-in-womens-health/ (date accessed).

The share of individuals identifying as LGBTQ+ in the United States has increased over time, rising from just 4% in 2012 to 8% in 2023. In addition, support for same-sex marriage has also grown (27% in 1996 v. 69% as of 2024) and fewer believe there should be less acceptance for LGBTQ+ people (26% in 2001 v. 8% in 2020). Increases in identity and acceptance have been punctuated by several Supreme Court decisions providing new civil rights for LGBTQ+ people. Still, widespread stigma and discrimination persist for many LGBTQ+ people, including in health care as well as across a range of social institutions. These experiences can fuel significant health care disparities among LGBTQ+ people, challenging well-being and affecting health outcomes. Further, LGBTQ+ rights and health care access have become increasingly politicized at the federal and state levels, especially when it comes to young people.

All people’s health and health care experiences are informed by the socioeconomic context in which they live, including the policy environment. Federal and state policy can facilitate or impede access to health care for LGBTQ+ people. At the federal level, there have been both expansions as well as restrictions in protections and access over time and across presidential administrations, including the second Trump administration. Starting on the first day of his second term, President Trump began to issue numerous executive actions, several of which directly address or affect health programs, efforts, or policies designed to meet the health needs of LGBTQ+ people. These include actions that seek to limit data collection, lessen civil rights protections, restrict access to care, and remove acknowledgement of diverse sexual and gender identities. At the state level, there has been a rapid increase in the number of laws and policies impacting LGBTQ+ people’s health, especially, though not exclusively, that of young people. An increasing number of legal challenges to federal and state laws may ultimately decide access to care and the extent to which protections remain. This chapter provides an overview of LGBTQ+ people’s identities, experiences with health and health care, and the related health policy landscape.

The concepts of sex, gender, and sexual orientation are discreet. However, they are often thought of as interrelated and dependent on one another, though their actual relationship is more diverse and complex:

• Sex is often described as one’s biological categorization of being male or female based on anatomical, hormonal, and genetic factors. At birth, individuals are typically assigned a sex based on external genitalia. While sex is often thought of as a binary, as many as 1.7% of the population has been estimated to have some intersex trait, with population estimates of people with anatomical variations being lower (less than 0.5% of the population).
• Gender identity is an individual’s sense or experience of being male, female, transgender (trans), non-binary, gender non-conforming, or something else. Gender identity may or may not align with the sex that was assigned at birth. Gender expression is the public expression of gender identity, which may occur through attire, body characteristics (e.g., hair), voice, etc. Gender expression may or may not align with traditional assumptions related to sex or gender identity.
• Sexual orientation refers to emotional, romantic or sexual attraction to other people, often in relationship to one’s own sex and/or gender identity.

While many people and institutions historically considered these three concepts to be inseparably linked and linear (e.g., assigned the male sex at birth, identifies as male, and is attracted to women), there is wide variation in how these concepts relate, and they can be dynamic over time.

It is estimated that 9.3% of U.S. adults identify as LGBTQ+, as of 2024, nearly triple the share in 2012 (3.5%), and LGBTQ+ identity is expected to continue to increase over time. This increase may reflect changes in behavior and desire, and an increased willingness to self-identify and disclose as societal acceptance has grown. Indeed, these two factors are likely interrelated. LGBTQ+ identity is strongly associated with age; younger generations self-identify at higher rates than older generations (23% of those aged 18-27 identify as LGBTQ+ compared to just 2% among those aged 79 and older). In addition, as of 2023, about 1 in 4 high school students identifies as LGBQ+. As the LGBTQ+ population ages and new generations identify at higher rates, it is expected that the share of adults who identify as LGBTQ+ will increase as well.

As such, the LGBTQ+ population is younger than the U.S. population overall. Almost half (47%) of LGBT adults are under age 30, compared to 18% of non-LGBT adults. Just 6% are 65 or older, compared to nearly one-quarter (24%) of non-LGBT adults (see Figure 1). LGBT adults are also more likely to have lower incomes and be living on less than $40,000 per year than non-LGBT adults (42% v. 33%), which may reflect their lower age. (See Table 1.)

Within the LGBTQ+ community, identity is complex and multifaceted. Among adults who identify as LGBTQ+, the majority identify as bisexual (56%), a finding driven by younger adults, followed by gay (21%), and lesbian (15%). Smaller shares identify as transgender (14%), pansexual (1%), or in some other way (5%).

It is estimated that over 2.8 million adults and youth (over 13 years old) living in the U.S. identify as transgender or trans, which translates to 1% of all those 13 and older. A 2023 KFF/Washington Post Survey of a nationally representative sample of transgender adults in the U.S shows the trans adult population is younger than the larger cisgender adult population, with the majority of trans adults under the age of 35, echoing trends seen in the larger LGBTQ+ population. Additionally, most (70%) trans adults identify as lesbian, gay, or bisexual, compared to one in ten cisgender adults. Trans adults and cisgender adults do not notably differ when it comes to race and ethnicity or income. (See Table 2.)

Most trans adults, or about 6 in 10, describe themselves as “trans, gender non-conforming” or “trans, nonbinary,” while smaller shares say they would describe themselves as a “trans woman” (22%) or a “trans man” (12%). (See Figure 1.)

In addition to sexual orientation and gender identity, the lives of people who are LGBTQ+ are also shaped and informed by a range of other intersectional sociodemographic factors, including race/ethnicity, income, geography, educational opportunities, language, citizenship status, disability status, and other variables, which, together, affect health access and outcomes in both positive and negative ways.

Many LGBTQ+ people report having experienced stigma and discrimination in health care and other social institutions due to their actual or perceived sexual orientation, gender identity, and/or gender expression.

KFF polling has shown that LGBT adults face higher rates of discrimination and unfair treatment in their daily lives compared to others, with about two-thirds (65%) saying they have experienced at least one type of discrimination at least a few times in the past year, compared to four in ten non-LGBT adults. (See Figure 2.). These experiences are higher among LGBT adults who are younger and lower income.

The KFF/Washington Post Trans survey found that many trans adults say they feel discriminated against at least “sometimes” due to their gender identity or expression, with trans adults of color even more likely to report multiple types of discrimination, including because of their race or ethnicity, income level or education, or sexual orientation, reflecting how discrimination can cut across intersecting identities. (See Figure 3.)

Experiences of stigma and discrimination also occur in health care settings, in part because pathologizing LGBTQ+ identity, behavior, and desire has a long history in medicine. Indeed, much of the early language of LGBTQ+ identity has its origins in 19^th-century psychiatry, which defined LGBTQ+ people in opposition to heterosexual people (and health). The early medical literature promotedthe idea that individuals with LGBTQ+ behavior or desire needed treatment, a notion that persisted for more than a century in dominant medical literature and, in 1952, homosexuality was defined as a psychiatric disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM), the tool for classifying mental health conditions in the United States; it was not removed as such until 1974 (though as a compromise APA added “sexual orientation disturbance” as diagnosis which was then replaced with “ego dystonic homosexuality” which was not removed until 1987.) While mainstream medicine has evolved from the view of needing to treat LGBTQ+ identity as a medical or psychological disorder, stigma and discrimination within medicine persist.

KFF polling shows that 6 in 10 LGBT adults report at least one of several negative experiences with a health care provider in the past three years – about twice the share of non-LGBT adults who report this. (See Figure 4.)

Additionally, about 3 in 10 trans adults say they have had to teach a doctor or other health care provider about trans people to receive appropriate care, had a doctor refuse to acknowledge their preferred gender identity, or been asked unnecessary or invasive questions about their gender identity that were unrelated to their care. (See Figure 5.)

Experiences of stigma, discrimination, and mistreatment based on sexual orientation or gender identity occur in multiple non-health care environments and institutions as well, and these also negatively affect health and well-being.

Hate crimes, defined as “bias against people or groups with specific characteristics that are defined by the law,” have negative effects on health, including both physical and psychological harm, and LGBTQ+ people are more likely to experience hate crimes than non-LGTBQ+ people. According to the FBI, in 2023, more than 1 in 5 hate crimes (23%) were related to being LGBTQ+. In 2022, of crimes related to being LGBTQ+, 17% were based on sexual orientation and 4% on gender identity, accounting together for 2,416 crimes in total. Hate crimes against gay men accounted for nearly half (45%) of these, followed by crimes against a combined group of LGBT people (26%), and then transgender people (14%). A smaller share was reported against lesbians (8%), gender non-conforming people (5%), bisexual people (1%), and heterosexual people (1%). (Notably, whether a hate crime gets reported to the FBI and how it is defined are highly variable, so these statistics are likely an underrepresentation of actual crimes that occur.) (See Figure 6.) LGBT+ people are also nine times more likely to self-report that they have experienced a hate crime than non-LGBT+ people.

Sexual violence, in particular, is a common experience among LGBTQ+ people relative to non-LGBTQ+ people and is especially high among bisexual women and gay and bisexual men. Bisexual women report higher lifetime experiences with rape, other sexual violence and stalking, and lesbian women report higher rates of sexual violence and unwanted sexual contact across their lifetimes than heterosexual women. Gay and bisexual men report higher rates of sexual violence, unwanted sexual experiences, and sexual coercion than heterosexual men, with gay men also reporting higher rates of stalking across their lifetimes than heterosexual men.

Transgender people also face higher rates of intimate partner violence and are more likely to be the victim of a violent crime, with surveys finding that trans people report high rates of violence across a range of measures. KFF polling shows that a majority of trans adults (64%) say they have been verbally attacked and 1 in 4 say they have been physically attacked because of their gender identity, gender expression, or sexual identity. The share of trans adults who have been physically attacked because of their gender identity increases to 31% among trans people of color.

Young LGBTQ+ people are also impacted by higher rates of bullying and violence, including sexual violence, compared to non-LGBTQ+. LGBTQ+ high school students report higher rates of being bullied than non-LGBTQ+ students, with LGBTQ+ students about twice as likely as non-LGBTQ+ students to report that they have been bullied on school property (29% v. 16%) or to report electronic bullying (25% v. 13%). Additionally, LGBTQ+ high school students are twice as likely to report having been injured or threatened with a weapon at school compared to non-LGBTQ+ students (14% v. 7%). Experiences with sexual violence generally (20% v. 8%) and forced sex in particular (17% v. 6%) were also more common among LGBTQ+ high school students than non-LGBTQ+ high school students. (See Figure 7.)

LGBTQ+ people’s disproportionate experiences of maltreatment, stigma, and discrimination can have a significant and negative impact on present and future mental health. Indeed, LGBT adults who had recent experiences with at least one form of discrimination in the past year are more likely to report feeling always or often lonely (42% v. 15%), depressed (38% v. 21%) or anxious (65% v. 34%) than those who rarely or never experienced discrimination in daily life. Additionally, larger shares of LGBT women, younger LGBT adults, and lower-income LGBT adults report regular feelings of anxiety, loneliness, or depression. While other underlying factors beyond discrimination may contribute to these differences, the relationship between feelings of loneliness, anxiety, and depression and experiences with discrimination among LGBT adults remains significant even after controlling for race/ ethnicity, education, income, gender, and age (see section on mental health below). (See Figure 8.)

Overall, LGBT people report similar rates of being uninsured as non-LGBT people (9% v. 10%). LGBT adults, who are notably both younger and lower income than the general population, have higher rates of Medicaid coverage (25% v. 15%) and lower rates of Medicare coverage (8% v. 22%). They are slightly more likely to be covered by private insurance than non-LGBT adults (57% v. 51%). (See Figure 9.)

Research has found that having a usual source of care is associated with increased use of preventive care and better health outcomes, but LGBT people are more likely to report not having a usual source of care than non-LGBT people (19% v. 12%). (From KFF’s Survey of Racism, Discrimination, and Health). One study found that LGBTQ people were more likely to lack access to providers, delay care, face issues taking medications due to cost, and have fewer routine checkups than heterosexual cisgender people.

KFF polling has also found that many LGBT adults say negative health care experiences have affected their willingness to seek care, their health care coverage, and their physical health. For example, LGBT adults are significantly more likely than non-LGBT adults to report that having a negative health care experience in the last three years caused their health to get worse (24% v. 9%), made them less likely to seek health care (39% v. 15%), or caused them to switch health care providers (36% v. 16%).

While in some areas, the health experiences of LGBTQ+ people mirror those of non-LGBTQ+ people, in other areas, LGBTQ+ people face disparities in health outcomes due to their sexual orientation and gender identity, as well as other factors such as race/ethnicity, class, nationality, and age. Disparities related to mental health, substance use, and sexual health are especially apparent, and LGBTQ+ people also experience certain chronic conditions at higher rates than heterosexual and cisgender people. In some cases, these are driven by social factors such as the biosocial impact of experiencing stigma and discrimination, higher rates of alcohol use and smoking, and obesity. They may also stem from fear of engaging with the health system, including from past experiences of discrimination, which may lead to forgoing routine screening or needed care.

There may also be a link between health care access, competency, and affordability (discussed above) and the ability to detect, control and treat disease. For example, research has found that transgender and gender-diverse people are both less likely to receive cancer screenings and also have a higher incidence of HIV- and HPV-associated cancers.

HIV and STIs

There are significant HIV and STI-related disparities among gay and bisexual men, other men who have sex with men, and transgender women compared to other groups and the population as a whole. These disparities may arise for a range of reasons, including sexual networks, differences in behavior, and biological or social factors. In addition, increased incidence of HIV and STIs can, in turn, put these groups at higher risk for other comorbid conditions like other STIs and certain cancers. Nearly three-quarters (71%) of people diagnosed with HIV in 2022 were gay and bisexual men or other men who have sex with men, and of those, young Black and Latino men were disproportionately represented. (See Figure 10.)

A meta-analysis estimated that 14% of transgender women and 3% of transgender men are HIV positive. Black and Hispanic transgender women are disproportionately impacted, with prevalence estimates of 44% and 26%, respectively.

Among those seeking care at STD clinics, gay and bisexual men are more likely to test positive for gonorrhea and chlamydia than women or heterosexual men. An estimated 58% of cases of primary and secondary syphilis reported among men with known sex of sex partners in 2023 were among gay and bisexual men and other men who have sex with men, and cases have increased significantly over the past decade. Additionally, the 2022 mpox outbreak occurred almost exclusively among gay and bisexual men and other men who have sex with men, with Black and Hispanic men being especially impacted. While data are limited on gender identity and STIs, studies have indicated that incidence and prevalence levels of gonorrhea and chlamydia among transgender women are similar to those among cisgender gay and bisexual men.

Mental Health and Substance Use

LGBTQ+ people face greater mental health challenges and disparities than non-LGBTQ+ people, including in accessing mental health care. The drivers of these disparities are complex and may relate, in part, to widespread experiences of stigma and discrimination (as described above). Current attempts to institute anti-LGBTQ+ policies in many states and communities may contribute to poor mental health outcomes and increase the need for care.

LGBT adults are more likely than non-LGBT adults to describe their mental health and emotional well-being as either “fair” or “poor” (39% v. 16%). LGBT adults with household incomes below $40,000 are about twice as likely as LGBT adults with higher incomes to report fair or poor mental health (55% v. 27%), as are LGBT adults ages 18-29 compared to those ages 50 and older (56% v. 24%). Across racial and ethnic groups, about 4 in 10 Black (40%), Hispanic (35%) and White (41%) LGBT adults describe their mental health as fair or poor. (See Figure 11.)

More specifically, about half (54%) of LGBT adults report feeling anxious either “always” or “often” in the past year, while a third report feeling lonely (33%) or depressed (32%) “always” or “often” – more than twice the shares of non-LGBT adults who report the same. As noted earlier, those who experienced recent discrimination were more likely to report these feelings than those who did not. 

LGB adults also report having serious thoughts of suicide, making a suicide plan, or attempting suicide at higher rates than non-LGB adults, with disparities especially pronounced among bisexual adults. LGB adults also report higher rates of substance use and substance use disorder (SUD) than non-LGB adults, with rates especially high among bisexual adults.

KFF’s polling of trans adults shows that many struggle with serious mental health issues, including 4 in 10 (43%) who say they have had suicidal thoughts in the past year. Trans adults are about six times as likely as cisgender adults to say they have engaged in self-harm in the past year, and more than twice as likely to say they have had an eating disorder in the past year or had suicidal thoughts in the past year. (See Figure 12.)

Mental health disparities are especially significant among young LGBTQ+ people. In 2023, more than half (53%) of LGBTQ+ high school students reported poor mental health in the past 30 days compared to 1 in 5 (21%) non-LGBTQ+ students and more than twice as many reported persistent feelings of sadness or hopelessness over the past year (65% among LGBTQ+ students compared to 31% among non-LGBTQ+ students). In addition, 41% of LGBTQ+ high school students reported having seriously considered suicide during the past year, with 20% having attempted suicide, rates that are substantially higher than for non-LGBTQ+ students (13% and 6%, respectively). (See Figure 13.)

Substance use rates were also higher among LGBTQ+ high school students than their non-LGBTQ+ peers.LGBTQ+ students and students with any same-sex partners were more likely to engage in a range of substance use behaviors than their peers, including use of alcohol, marijuana, any illicit drug, vaping, and prescription opioids.

In addition to higher reported rates of mental health challenges, LGBT people, particularly those in fair or poor mental health and younger adults, report greater challenges accessing mental health care and are more likely to report forgoing needed mental health care than non-LGBT adults. About half (46%) of LGBT adults say there was a time in the past three years when they thought they might need mental health services but didn’t get them, more than twice the share of non-LGBT adults who say so (20%). Reported challenges to care include affordability and accessibility of providers, including finding a provider who can relate to their background and experiences.

Access to competent and inclusive health care that meets the needs of LGBTQ+ people can improve engagement with the health system and, ultimately, health outcomes.

The American Medical Association (AMA) provides recommended standards of practice with LGBTQ patients and resources to help make medical practices LGBTQ-friendly, such as including posters, brochures, and other materials that are LGBTQ-inclusive, revising intake materials to be affirming and inclusive, and participating in further provider education.

Similarly, the American Psychiatric Association also provides guidance, including acknowledgment of the role the association played in perpetuating stigma for LGBTQ+ people in the past and guiding practitioners to not make assumptions about sexual orientation or gender identity in gathering medical information, reminding providers that families can be helped to move towards more acceptance of LGBTQ+ children to improve their mental health, and explicitly coming out against ‘conversion or reparative’ therapy. Indeed, the use of “conversion therapy” is condemned among all major health groups, 28 of which signed a 2023 joint statement against its use, stating that such interventions are both ineffective and harmful, and about half of states have enacted a ban on coverage therapy for minors.

Other resources highlight the importance of language use in caring for LGBTQ+ people, including when it comes to how sexual orientation and gender are discussed and described and how patients are addressed with respect to names and pronoun use. Leadership “buy-in” and the role of LGBTQ+ champions are also highlighted, as are the benefits of inclusive policies. Data collection used to improve health outcomes, staff training, and partnering locally with the LGBTQ+ community are also noted as ways to be a more affirming practice.

Providing health care services or competent referrals for health services that are disproportionately needed by the LGBTQ+ community is another way to offer inclusive care. This might include behavioral health services, STI care and screening, or inclusive family planning services. Another such service is gender affirming care (see below).

Gender affirming care is a model of care which includes a spectrum of “medical, surgical, mental health, and non-medical services for transgender and nonbinary people” aimed at affirming and supporting an individual’s gender identity.Gender affirmation is highly individualized. Not all trans people seek the same types of gender affirming care or services and some people choose not to use medical services as a part of their transition. Gender affirming care is tailored to an individual’s needs across the lifespan.

Virtually all major U.S. medical associations support youth access to gender affirming care, including the American Medical Association, American Academy of Pediatrics, and the American Psychological Association, among others. In particular, these groups point to the evidence demonstrating that medically necessary gender affirming care enhances mental health outcomes for transgender youth, including by reducing suicidal ideation. Professional guidance for gender affirming care, including for young people, is provided by the Endocrine Society and the World Professional Association for Transgender Health, bodies that also support access to this care model.

There is no one way to transition. KFF polling finds commonly utilized gender affirming activities are related to a social transition, such as changing the types of clothes worn (77%), changing hairstyles/grooming habits (76%), or going by different pronouns (72%). Slightly fewer, but still a majority, of trans adults use a different name than the one on their birth certificate (57%). Fewer than half of trans adults report attending counseling or therapy as a part of their gender transition (38%) (which is sometimes a requirement for other gender affirming care), legally changing their name on identifying documents (24%), or using hormone treatments or puberty-blocking hormones (31%) Despite common rhetoric, surgical care is a rare component of gender affirming care, with just 16% of trans adults reporting having received gender-affirming surgery. While the number of young trans people using puberty blockers or hormone therapy has increased modestly in recent years, the overall number of those using these prescriptions remains fairly low and multiple studies have shown gender affirming surgery is extremely rare among minors.

Lack of insurance coverage for gender affirming care is a barrier to receiving these services. KFF’s polling finds, for example, that among trans adults with health insurance, about a quarter (27%) say their insurance covers gender affirming treatment or health care, while 14% say their health insurance does not cover this and 6 in 10 (58%) are unsure. One in 5 trans adults say they have had health insurance that would not cover gender affirming treatments or health care (22%). About 1 in 7 trans adults have changed jobs or health insurance in order to get gender affirming treatments or health care. (See Figure 14.)

Despite the evidence around the role gender affirming care can play in promoting well-being for young people and support from the medical community, some have argued against this care claiming that the services are experimental and lack an evidence base or that young trans people commonly change their minds about their gender identity. The Trump administration, in particular, has moved to limit access to gender affirming care, particularly for youth, through executive orders and other actions (see discussion below). The administration has also promoted misinformation about gender affirming care relating to issues like regret rates, how common surgical care is, and conflating it with female genital mutilation. It has stated that it will seek to prohibit providers receiving federal funding from providing certain gender affirming care services to minors. To date, more than half (27) of US states (as of July 2025) have enacted restrictions on gender affirming care for minors (discussed further below). As a result, young people may be unable to get medically necessary care depending on where they live and the resources their families have. Research has demonstrated that young transgender people’s mental health is negatively impacted when this care is denied, including leading to an increased risk of suicidality. Further, claims around lack of evidence and regret are not borne out by the data and, in fact, the very same services are provided to young people in other medical circumstances without controversy. 

Policymaking, including in health care, can both facilitate and hinder access to care and coverage, and ultimately, health outcomes, for LGBTQ+ people. Recent examples of how policymaking addresses LGBTQ+ people’s health include:

Supreme Court of the United States (SCOTUS) Decisions: Several recent Supreme Court decisions have impacted the health and well-being of LGBTQ+ people. SCOTUS decisions regarding marriage equality have been particularly far reaching with both the Windsor (2013) and Obergefell (2015) decisions providing same-sex married couples with legal access to spousal health insurance benefits for the first time, among other changes. In Bostock (2019), SCOTUS ruled that in the context of employment, discrimination based on sex encompasses sexual orientation and gender identity—a decision that was subsequently used to support extending sex protections in health care to LGBTQ+ people (see discussion of Section 1557 below). In June 2025, in United States v. Skrmetti, SCOTUS ruled that a Tennessee law banning gender affirming care for minors did not violate the 14^th Amendment’s Equal Protection clause, allowing it and other similar laws to remain in place, resulting in a continued patchwork of access. On March 10, 2025, SCOTUS granted certiorari in Chiles v. Salazar and will review a challenge to Colorado’s conversion therapy ban for minors, assessing “whether a law that censors certain conversations between counselors and their clients based on the viewpoints expressed regulates conduct or violates the Free Speech Clause.” 

• Section 1557: One area that has received significant attention over the last decade is Section 1557 of the Affordable Care Act (ACA). Section 1557 prohibits discrimination on the basis of a range of factors, including sex, and applies to health programs and activities receiving federal financial assistance (referred to as covered entities). Specifically, it prevents covered entities from discriminating against certain protected groups in providing health care services, insurance coverage, and program participation. Across different Presidential administrations, lengthy rulemaking and court challenges have affected the application of Section 1557, particularly around whether sexual orientation and gender identity should be encompassed in sex protections. The Obama administration interpreted the statute to include protections on the basis of gender identity and sex-stereotyping, laying out specific protections for trans people, while the Trump administration removed such protections. The Biden administration has since restored and expanded on protections, including by also interpreting sex protections to protect against discrimination on the basis of sexual orientation, following the Bostock decision. As of May 2025, the Trump administration had not yet issued rulemaking on Section 1557, but multiple executive orders suggest that the administration will view sex narrowly, laying the groundwork for removing explicit protections for LGBTQ+ people.
• Mental Health: Policy can also positively or negatively impact the mental health of the LGBTQ+ community. For example, 988, the federally-mandated suicide and crisis line, supported by the Substance Abuse and Mental Health Services Administration (SAMHSA), historically included specific services to meet the needs of LGBTQ+ young people. While the service represented 10% of all contacts to 988 funded by Congress, the Trump administration ended this service in July 2025. Under the Biden administration, SAMHSA released a “road map” for supporting LGBTQ+ youth, an LGBTQI+ Family Support Grant providing nearly $2 million in funding for programs that address behavioral health for LGBTQ youth, and more than $5 million for “Family Counseling and Support for Lesbian, Gay, Bisexual, Transgender, Queer/Questioning, Intersex+ Youth and their Families,” and also funded the Center of Excellence: LGBTQ+ Behavioral Health Equity aimed at supporting “implementation of change strategies within mental health and substance use disorder treatment systems to address disparities impacting the LGBTQ+ community.” The Biden administration issued a rule to better protect LGBTQ+ youth in foster care. In addition to federal efforts, some states are also electing to highlight and address the behavioral health needs of LGBTQ+ people, sometimes through the use of federal funds. On the other hand, there is evidence that the promulgation of state laws and policies restricting access to LGBTQ+ health and other services negatively affects the mental health of the community. The Trump administration’s approach to LGBTQ people’s health has differed significantly. Following President Trump’s campaign promises, the administration has prioritized actions and policymaking aimed at limiting young people’s access to gender affirming care and, in some cases, denying existence of transgender people and fueling misinformation about transgender and intersex people and trans health care. The administration has reversed Biden-era agendas, roadmaps, and interpretations of civil rights protections regarding LGBTQ people’s well-being. Collectively, these actions can have a negative impact on well-being and access to medically necessary best practice care.
• Gender affirming care: As noted above, the Trump administration has taken a range of actions and made proposals to limit gender affirming care for minors, differing from the Biden administration which had supported access to this care on principles of equity and well-being. These orders have generally sought to restrict access to services, limit research related to gender diversity, and stated that the federal government will only acknowledge two sexes and will not recognize diverse gender identities, including transgender people. As of July 2025, most of these actions do not formally prohibit entities from providing care, but they have led to a climate of fear and a chilling effect, with many providers walking back gender affirming care services for minors. Actions that led to this include creating an FBI tip line to report clinicians providing surgical care to minors, detailed collection of personal and institutional information offering gender affirming care, issuing subpoenas, and explicitly stating that the administration is seeking to make providing gender affirming care to minors a violation of terms of condition for participation in the Medicare and Medicaid programs, among others. Further actions limiting access are expected, as is litigation challenging these restrictions. The administration also released an evidence review related to information about treatment of gender dysphoria, concluding that the quality of evidence on the effects of intervention is low, and evidence on harms is “sparse.” It also states that there are significant risks and supports the use of psychotherapeutic approaches, including an approach termed “exploratory therapy”, which can include conversion therapy, departing from most U.S. medical associations. While the report has been used to promote restrictions, it has also faced criticism including for its approach to the review and promotion of misinformation, among other factors. Impacting both adults and minors, the administration also adopted a policy that would not require broad financial protections in the individual market and small group health insurance marketplaces from applying to gender affirming care.
• Data collection: (See also callout box on data collection.)Better understanding who the LGBTQ+ community is and what challenges they face allows policymakers, providers, and other individuals and groups to meet their needs better and provide care and coverage that is culturally competent. Addressing care needs may happen in the provider’s office, at the health system level, or in the policy arena. Research on LGBTQ+ people and health has generally increased over time though that trend is currently reversing at the federal level. Both the Obama and Biden administrations implemented a range of efforts to improve collection and reporting of data on LGBTQ+ people. For example, in 2016, the NIH designated sexual and gender minorities (SGMs) as a health disparity population for research purposes. In doing so, NIH recognized the health disparities faced by this population and that “the extent and causes of health disparities are not fully understood, and research on how to close these gaps is lacking.” Many federal surveys also began to ask sexual orientation and gender identity (SOGI) questions, including the Behavioral Risk Factor Surveillance System Survey, the National Survey on Drug Use, the National Health Interview Survey, and the Youth Risk Behavior Survey, though data collection was not routine and it was sometimes an optional variable for states or a restricted variable for researchers. The Biden administration also issued an executive order calling for agencies to enhance routine collection of SOGI data to improve outcomes and address disparities, and an implementing roadmap in a Federal Evidence Agenda. However, SOGI data collection has become politicized. The first Trump administration sought to roll back some of the activities of the Obama administration, and these efforts have intensified in President Trump’s second term. On his first day in office President Trump rescinded the Biden-era executive order on data collection and issued executive orders taking a narrow view of sex and removing recognition of gender identity and limiting diversity, equity, inclusion, and accessibility (DEIA) activities in government programs, which led to limiting data collection efforts. A range of datasets, questionnaires, codebooks, reports, and other documents were removed from federal websites in the early days of the administration (some of which have been reposted due to a court order)and SOGI data collection in major surveys, including the Census, have been discontinued to comply with executive orders. Beyond survey data, data collection is also limited by efforts to rescind LGBTQ related research funding. Data collection efforts are also variable at state and health system levels and, if not reliant on federal funding, may be able to continue.
• State and Local Policymaking: While federal policymaking plays an important role in individuals’ lives, so too does state and local policymaking, perhaps, especially so in health care. Over the past few years, there has been a rash of policymaking addressing LGBTQ+ people’s health. Policies have both aimed to expand protections and well-being for LGBTQ+ people and sought to restrict access to care or loosen antidiscrimination standards. For example, as of July 2025, over half of states have enacted policies aimed at limiting or prohibiting youth access to gender affirming care and most of this policymaking took place within an 18-month period . Other states have enacted “refuge laws” (also known as “shield laws”) that generally aim to protect individuals, families, and providers living in states where these bans have been enacted. State policymaking has also focused on LGBTQ+ people and access to services through private and public insurance coverage. For example, while some states expressly prohibit insurers from discriminating against people based on sexual orientation and gender identity, others are silent on the issue. Similarly, some state Medicaid programs explicitly cover gender affirming care, others have exclusions, and some have no clear policy; even those that do cover this care may not cover all the services an individual needs. About half of states have enacted laws banning conversion therapy for minors, but the Supreme Court is set to hear a challenge to Colorado’s ban in the fall of 2025. Finally, some LGBTQ+ related policy is not overtly health-related but has the potential to impact well-being. For example, preventing schools from adopting LGBTQ+ anti-bullying policies or enacting laws that require school staff to out transgender youth to their families stand to negatively impact health outcomes.

Despite the increase in the share of people identifying as LGBTQ+ and in public support for LGBTQ+ relationships and protections against discrimination, LGBTQ+ people continue to face health disparities and worse health outcomes in several areas. In many cases, these are directly related to ongoing experiences of stigma, discrimination, and violence. Policy efforts to address health disparities among LGBTQ+ people, including those tied to experiences of stigma and discrimination, had increased over time but under the second Trump administration are reversing, with numerous executive branch actions designed to limit access to care and remove protections for LGBTQ+ people.  More generally, there has been growing partisanship in some areas of LGBTQ+ rights and access, particularly for LGBTQ+ youth, and a rise in the number of policies and laws that restrict access to recommended care. Monitoring these policies, the shifting legal landscape, and better understanding the actual experiences of LGBTQ+ people will help inform efforts to address and mitigate health disparities for this population moving forward.

• LGBT Adults’ Experiences with Discrimination and Health Care Disparities: Findings from the KFF Survey of Racism, Discrimination, and Health
• Overview of President Trump’s Executive Actions Impacting LGBTQ+ Health
• Trans People in the U.S.: Identities, Demographics, and Wellbeing
• Policy Tracker: Youth Access to Gender Affirming Care and State Policy Restrictions
• Mental Health Care Needs and Experiences Among LGBT+ People
• The Biden Administration’s Final Rule on Section 1557 Non-Discrimination Regulations Under the ACA

Dawson, L., Kates, J., Montero, A., and Kirzinger, A., LGBTQ+ Health Policy. In Altman, Drew (Editor), Health Policy 101, (KFF, October 2025) https://www.kff.org/health-policy-101-lgbtq-health-policy/ (date accessed).

Health and health care disparities refer to preventable differences in health and health care among groups that stem from broader social and economic factors. Despite the recognition of disparities for decades and overall improvements in population health over time, many disparities persist, and in some cases, have widened over time. Disparities limit the overall health of the nation and result in unnecessary costs. This chapter provides an overview of what health and health care disparities are, the factors that drive them, the status of racial and ethnic health and health care disparities today, how recent federal actions may impact disparities, and future considerations. The information and data included in this chapter are current as of July 2025.

In the wake of the COVID-19 pandemic and racial reckoning following the murders of George Floyd and others, the federal government as well as many states and private entities increased efforts focused on addressing health disparities. Since taking office, the Trump administration has taken a range of actions to eliminate federal diversity and disparities-related initiatives, restructured and eliminated federal staff and offices that played key roles in identifying and addressing disparities, and implemented policies focused on restricting immigration and increasing interior enforcement to support mass deportation of immigrants. Moreover, the 2025 federal budget reconciliation law makes large cutbacks to federal spending for Medicaid and the Affordable Care Act’s (ACA’s) provisions. These actions will likely lead to widening disparities in health and health care going forward.

Health and health care disparities refer to preventable differences in health and health care among groups that stem from broader social and economic factors. There are multiple definitions of health disparities. The Centers for Disease Control and Prevention (CDC) defines health disparities as “preventable differences that populations experience in the burden of disease, injury, violence, or opportunities.” A health care disparity typically refers to differences between groups in health insurance coverage, affordability, access to and use of care, and quality of care. The terms “health inequality” and “inequity” also are used to describe differences that stem from systemic and unjust or inequitable social and economic policies. Racism, which the CDC previously defined as a system that includes structural, institutional, interpersonal, and internalized racism that assigns value and determine opportunities based on the way people look or the color of their skin, results in conditions that unfairly advantage some and disadvantage others. Racism and discrimination at all levels, intentional or not, contribute to differences in experiences across many aspects of everyday life as well as in health care settings, which can negatively impact people’s health and well-being.

Reflecting the intersectional nature of people’s identities, some individuals experience disparities across multiple dimensions beyond race and ethnicity such as citizenship, sexual orientation and gender identity, and disability status.  Disparities also occur within subgroups of broader racial and ethnic groups, such as gender, ethnic identity, immigration status, and English proficiency. For example, a KFF survey shows that Black women report more pervasive negative experiences in health care settings compared to other groups. These groups are not mutually exclusive and often intersect in meaningful ways.  The Healthcare Research and Quality Act of 1999, which established an Office of Priority Populations within the Agency for Healthcare Research and Quality (AHRQ) identifies designated priority populations, including “low-income populations, racial/ethnic minorities, maternal health, women, children/adolescents, elderly, and individuals with special health care needs.” The National Institute on Minority Health and Health Disparities, established under the Minority Health and Health Disparities Research and Education Act also has designated populations with health disparities, including “racial and/or ethnic minority populations, low socioeconomic status, underserved rural populations, people with disabilities, and sexual minority groups.”

Health equity generally refers to individuals achieving their highest level of health through the elimination of disparities in health and health care. The CDC describes health equity as when everyone has a fair and just opportunity to be as healthy as possible. The World Health Organization (WHO) states that “health equity is achieved when everyone can attain their full potential for health and well-being.” The WHO defines equity as the absence of unfair and avoidable differences among groups, regardless of their identity, where they live, and other social and economic factors. The terms health equity and equality both refer to efforts to achieve better health outcomes and access to health care services for all groups. While health equality refers to providing all people with the same resources and opportunities, it does not account for people’s different underlying needs or circumstances that may affect their ability to achieve optimal health outcomes and health care access.

The U.S. has a long history of policies and events that have resulted in stark differences in access to resources, opportunities, and power that contribute to racial and ethnic disparities in health today. Dating back to slavery and colonization of the Americas, people of color have been subject to abuse and mistreatment, including medical exploitation and experimentation, family separation, and efforts to eliminate cultural practices and languages. Historical discriminatory policies, such as redlining, have lasting effects today, leading to residential segregation of Black and Hispanic people into urban neighborhoods with more limited resources and increased health risks, including climate-related risks. Within medicine, disproven beliefs about biological differences by race persist today and have led to race permeating clinical decision making and treatment in multiple ways, including through providers’ attitudes and implicit biases, disease stereotyping and clinical nomenclature, and its use in clinical algorithms, tools, and treatment guidelines. Similarly, historical anti-immigrant policies have excluded and discriminated against certain groups, contributing to “othering” and “perpetual foreigner” stereotypes, particularly among Asian immigrants, with a resurgence in anti-Asian rhetoric amid the COVID-19 pandemic. Policies, such as the 1996 Welfare Reform Law, have restricted access to public assistance programs, including health coverage, contributing to persistent disparities in health coverage and care for immigrants today, who are disproportionately Hispanic or Asian.

Underlying inequities in social and economic factors that reflect historical and contemporary policies drive racial and ethnic disparities in health (Figure 1). Though health care is essential to health, studies suggest that social and economic factors, often referred to as  social determinants of health, are the primary drivers of health outcomes. These include factors such as access to housing, food, and economic and educational opportunities. Hispanic, Black, AIAN, and NHPI people fare worse compared to White people across many social and economic factors. Experiences for Asian people are mixed, although some subgroups of Asian people fare worse compared to White people. Asian immigrants face certain additional challenges.

Experiences with unfair treatment and discrimination negatively impact health and well-being. Despite growing calls to address racism in the wake of the COVID-19 pandemic and the accompanying racial reckoning, many adults continue to experience unfair treatment and discrimination in their daily lives and in health care settings. A 2023 KFF survey finds that at least half of AIAN (58%), Black (54%), Hispanic adults (50%), and about 4 in 10 Asian adults (42%) say they experienced at least one type of discrimination in daily life in the past year. These experiences include receiving poorer service than others at restaurants or stores; people acting as if they are afraid of them or as if they aren’t smart; being threatened or harassed; or being criticized for speaking a language other than English. Consistent with other research, which shows that racism has negative effects on mental health and results in certain negative physical health outcomes, among those with discrimination experiences, 4 in 10 (40%) say they “always” or “often” felt anxious in the past year, compared to 14% of adults who rarely or never experience such discrimination (Figure 2). Similarly, those with experiences of discrimination in their daily life are more than three times as likely as others to say they always or often felt lonely (26% vs. 7%) or depressed (25% vs. 7%) in the past year.

Racism and discrimination also negatively affect people’s health care experiences. KFF survey data also show that Black, Hispanic, AIAN, and Asian adults report higher levels of unfair treatment when seeking health care than their White counterparts and are more likely to report having certain negative experiences with a health care provider because of their race and ethnicity (Figure 3). About a quarter of adults who experienced unfair treatment, a negative experience with a provider, or a language access challenge say it led to worse health, being less likely to seek care, and/or switching providers. Similarly, as of 2023, one in four (25%) immigrant adults said that they were treated unfairly by a health care provider in the U.S., including nearly four in ten (38%) Black immigrant adults.

Addressing disparities in health and health care is important not only from an equity standpoint but also for improving the nation’s overall health and economic prosperity. Racial and ethnic health and health care disparities result in higher rates of illness and death across a wide range of health conditions, limiting the overall health of the nation. Research further finds that health disparities are costly, resulting in excess medical care costs and lost productivity, as well as additional economic losses due to premature deaths each year.

It is increasingly important to address health disparities as the population becomes more diverse and stark income inequalities persist (Figure 4). The population has become increasingly racially diverse, reflecting shifting immigration patterns, a growing multiracial population, as well as adjustments to how the U.S. Census Bureau measures race and ethnicity. The U.S. Census Bureau projects that people of color will account for over half (52%) of the population in 2050, with the largest growth occurring among people who identify as Asian or Hispanic. Income inequality within the U.S. has also widened over time. As of 2023, the top 10% of households in the U.S. had incomes above $216,000 compared with incomes at or below $17,100 among the lowest 10% of households.

Major recognition of health disparities began nearly four decades ago. In 1985, the Report of the Secretary’s Task Force on Black and Minority Health (commonly known as the Heckler Report) documented persistent health disparities that accounted for 60,000 excess deaths each year and synthesized ways to advance health equity. The Heckler Report led to the creation of the Office of Minority Health within the Department of Health and Human Services (HHS) (which was reportedly shut down by the Trump administration as part of the HHS staff restructuring and reductions) and influenced federal recognition of and investment in many aspects of health equity. In 2003, the Institute of Medicine’s Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care report was issued, which identified systemic racism as a major cause of health disparities in the United States.

Despite the recognition and documentation of disparities for decades and overall improvements in population health over time, many disparities persist, and in some cases, have widened over time .Analysis across a broad range of health measures finds that Black and AIAN people fare worse than their White counterparts across half or more of these measures. Data for Hispanic people are more mixed relative to White people, with them faring better on some measures but worse on others. In the aggregate, Asian people fare the same or better than White people on many measures of health, although this finding masks disparities among subgroups of the population. Data gaps limit the ability to examine disparities among NHPI people; where data are available, they point to disparities, particularly for certain subgroups of this population. Overall, Black, Hispanic, and AIAN people fare worse compared to White people across many measures of health outcomes including:

• AIAN and Black people had a shorter life expectancy at birth compared to White people based on provisional data from 2022. Life expectancy for Black people was about five years shorter than White people (72.8 vs. 77.5), and nearly ten years shorter for AIAN people (67.9).
• AIAN, Hispanic, and Black people experienced larger declines in life expectancy than White people between 2019 and 2021, largely reflecting an increase in excess deaths due to COVID-19.
• NHPI people had the highest age adjusted mortality rates for diabetes among all racial and ethnic groups at 49.6 per 100,000 deaths. The age-adjusted mortality rates for diabetes for AIAN (41.5 per 100,000) and Black people (39.1 per 100,000) were about twice as high as the rate for White people (19.8 per 100,000); Hispanic people (26.5 per 100,000) also had a higher diabetes death rate compared to White people in 2023. Although Black people did not have higher cancer incidence rates than White people overall and across most types of cancer, they had the highest overall cancer-related mortality rate as of 2022. Black people (165 per 100,000 deaths) were more likely to die from cancer than White people (148.4 per 100,000), and NHPI people had a slightly lower overall cancer-related mortality rate (141.4) to White people in 2022.
• Black infants were more than two times as likely to die as White infants (10.9 vs. 4.5 per 1,000 live births) as of 2023. AIAN infants (9.1 per 1,000) were roughly twice as likely to die as White infants (Figure 5). Hispanic infants (4.9 per 1,000) also had a slightly higher mortality rate than White infants in 2023.
• AIAN (118.7 per 100,000), NHPI (111.7 per 100,000), and Black (69.3 per 100,000) women also had the highest rates of pregnancy-related mortality in 2021

There are also ongoing racial and ethnic disparities in health coverage and access to care.  Despite large gains in coverage across groups since the ACA coverage expansions were implemented in 2014, as of 2022, nonelderly AIAN, Hispanic, Black, and NHPI people were more likely to be uninsured compared to their White counterparts (Figure 6). There are also large coverage disparities by immigration status, with a 2023 KFF/LA Times Survey of Immigrants showing that about one in five (18%) lawfully present immigrant adults and half (50%) of likely undocumented immigrant adults reported being uninsured as compared to less than one in ten citizens. In addition, Hispanic, Black, Asian, AIAN, and NHPI adults are more likely than White adults to report not having a personal health care provider, and Hispanic, Black, AIAN, and NHPI adults are more likely than White adults to report not seeing a doctor in the past 12 months because of cost.

In the wake of the COVID-19 pandemic and racial reckoning following the murders of George Floyd and others, the federal government as well as many states and private entities increased efforts focused on addressing health disparities. This increased focus led to the development of programs and initiatives focused on mitigating disparities, including efforts to address disparities in maternal and infant health, cancer, and chronic disease, as well as other efforts, such as increasing diversity in clinical trials for development of new drugs and devices. Research efforts also increased to understand disparities, the factors driving them, and effective interventions to mitigate them.

The Biden administration issued a series of executive orders and other efforts to advance health equity.  These included orders that outlined equity as a priority for the federal government, equity as a central part of the pandemic response and recovery efforts, and also directed federal agencies to develop Equity Action Plans. HHS’ equity action plan outlined a series of strategies that included efforts to improve access and address barriers to quality and affordable health care; prioritize behavioral health for underserved populations; and improve maternal health outcomes for rural, Tribal, and underserved racial and ethnic groups. HHS also enacted its climate action plan, including establishing the Office of Climate Change and Health Equity to address the impacts of climate change on health outcomes and health equity.  The administration released a Blueprint for Addressing the Maternal Health Crisis, a whole government approach to combatting maternal mortality and morbidity with a focus on reducing disparities in maternal health outcomes and improving overall pregnancy, birth, and postpartum outcomes. Federal efforts were also made to increase the availability of disaggregated data for smaller population groups, including AIAN and NHPI people, to understand and address the health and heath care disparities they face. During his term, President Biden reversed public charge regulations from the Trump administration’s first term to reduce fears about participating in programs, including Medicaid and the Children’s Health Insurance Program.

As one of his first actions in office, President Trump signed executive orders revoking federal diversity, equity, inclusion, and accessibility (DEIA) related programs and actions in the federal government and among federal contractors and grantees.  In implementing President Trump’s executive orders, the administration has taken significantly broader actions beyond eliminating DEI programs to eliminate priorities, actions, information, data, and funding related to concepts of diversity or disparities among federal agencies as well as federal contractors and grantees.The Office of Personnel Management directed agencies and departments to take down all outward facing media that “inculcate or promote” “gender ideology,” as well as to remove all public facing DEI related websites and content. This resulted in the temporary shutdown of websites and removal of key health datasets. While some web pages and datasets began returning in several days, they included a warning message that they were being modified to comply with President Trump’s executive orders and some materials, such as codebooks and questionnaires, did not immediately return. The administration also directed departments and agencies to pause grants provided to federal contractors to identify and review programs and activities for consistency with the President’s policies. Reports indicate that the administration flagged over 100 words that federal agencies should limit or avoid to comply with the President’s policies, including disparities, diversity, equity, and race; that the CDC ordered the withdrawal of papers pending publication to ensure language compliance; and that research grants were terminated to comply with new restrictions. As part of efforts to eliminate diversity and disparities related initiatives the administration also eliminated environmental justice actions and programs

The administration also eliminated about 10,000 employees from HHS, including many of those focused on addressing disparities as part of a restructuring effort. The HHS Office of Minority Health, CDC’s Office of Health Equity, the Office of Women’s Health, and the Office for Civil Rights are among the offices facing partial or complete cuts. The impact of these cuts is compounded by the loss of population-specific initiatives and offices. The administration’s proposed budget cuts to the Indian Health Services (IHS) and HHS include $900 million in cuts to the IHS budget and eliminating advanced appropriations.  In addition to eliminating staff directly working on disparities, other cuts were made that will have important implications for disparities. The restructuring cut jobs from the CDC’s National Center for Chronic Disease Prevention and Health Promotion, which has resulted in the termination of programs focused on diabetes, obesity, dementia, and kidney disease, which disproportionately affect people of color. The HHS restructuring has also impacted federal maternal and infant health programs, including layoffs of most staff at the CDC’s Division of Reproductive Health, which serves to provide data, research, and assistance to states “on issues related to reproductive health, maternal health, and infant health.” These staff cuts are accompanied by the suspension of the Pregnancy Risk Assessment Monitoring System, which has documented disparities in maternal mortality and morbidity for 38 years.

The actions to eliminate diversity and disparities related initiatives will likely lead to widening disparities, reversing recent efforts to advance health equity. Elimination of focused efforts to address health disparities will potentially further exacerbate disparities, contributing to worsening overall health and unnecessary health care costs. Focused plans and initiatives to mitigate health disparities seek to address the underlying inequities that drive disparities and meet the needs and preferences of diverse populations. In the absence of focused efforts, disparities will likely widen because the underlying inequities that contribute to them persist. Additionally, the elimination of information, data, and research will inhibit the ability to identify disparities and understand the factors driving them. Data are essential for identifying where disparities exist, directing efforts and resources to address disparities as they are identified, measuring progress toward achieving greater equity, and establishing accountability for achieving progress. Without adequate data and research, disparities may remain unseen and unaddressed.

The Trump administration has also made immigration policy changes focused on restricting entry at the border and increasing interior enforcement efforts to support mass deportation, which may contribute to widening disparities among immigrant families. Research suggests that these policies negatively affect the health and well-being of immigrant families, including citizen children living in these families. KFF survey data from 2025 show that immigrants’ worries about detention or deportation have risen sharply since 2023, even among lawfully present immigrants and naturalized citizens, and many say these worries are affecting their health. Moreover, accompanying KFF focus groups  found that immigration policies and actions undertaken by the Trump administration have led to increased fears, uncertainty, and financial hardships among immigrant families across immigration statuses that have had negative effects on their daily lives, health, and well-being, including negative mental health impacts on them and their children. Efforts to restrict immigration not only impact the health and well-being of immigrant families, but can also negatively impact the U.S. economy and workforce, given the role immigrants play, particularly in certain industries such as health care, construction, and agriculture.

Under the recently passed budget reconciliation law there are large cuts to federal spending for Medicaid and the ACA, which will likely lead to widening racial and ethnic disparities in health coverage and, in turn, exacerbate disparities in access to care. Medicaid is a major source of coverage for people of color, helping to fill gaps in employer sponsored coverage, particularly for children (Figure 7). The ACA’s coverage expansions through Medicaid and the Marketplaces contributed to large gains in health coverage across racial and ethnic groups and reduced racial disparities in coverage. The law includes substantial cuts to federal Medicaid spending and changes to the ACA, which the Congressional Budget Office projects will increase the number of uninsured by about 10 million by 2034. The law includes provisions that eliminate eligibility for Medicaid, subsidized ACA Marketplace, and Medicare coverage for many lawfully present immigrants. In addition to reductions in the legislation, the scheduled expiration of tax credits for Marketplace coverage in 2025 and recent Trump administration regulatory changes that make it harder to sign up for ACA coverage are expected to further increase the growth in the uninsured by millions.  Coverage losses, particularly in Medicaid, would widen racial and ethnic disparities in coverage given that larger shares of people of color are covered by the program. In turn, widening disparities in coverage would likely contribute to gaps in access to care and ultimately health outcomes.

Looking to the future, racial and ethnic disparities in health and health care remain a persistent problem, particularly as longstanding efforts to recognize and address them are being dismantled. These disparities are rooted in the ongoing impacts of racism and discrimination, which contribute to structural inequities in access to resources, opportunities, and health care as well as bias within health systems and daily life. As efforts to advance health equity face increasing challenges some key issues include:

How to mitigate bias and disparate treatment in the medical system, amid the growing use of AI and data-driven tools in health care and perpetuation of disproven beliefs about biologic differences by race.

How rollbacks to federal disparities initiatives and DEI programs will impact long term efforts to address disparities in health.

How to close racial and ethnic gaps and prevent further widening of disparities in health coverage and access to care amid efforts to cut Medicaid and other public programs.

What data and research will remain available to identify and understand disparities and develop interventions to address them.

How uneven impacts of climate change and climate-related health risks may impact disparities amid the rollbacks of federal environmental justice efforts.

• Survey on Racism, Discrimination and Health: Experiences and Impacts Across Racial and Ethnic Groups
• Health and Health Care Experiences of Immigrants: The 2023 KFF/LA Times Survey of Immigrants
• Disparities in Health and Health Care: 5 Key Questions and Answers
• Key Data on Health and Health Care by Race and Ethnicity
• Health Coverage by Race and Ethnicity, 2010-2022
• What is Driving Widening Racial Disparities in Life Expectancy?
• Racial Disparities in Maternal and Infant Health: Current Status and Efforts to Address Them
• Key Facts on Health Coverage of Immigrants
• Climate Change and Health Equity: Key Questions and Answers
• Medicaid and Racial Health Equity
• How History Has Shaped Racial and Ethnic Health Disparities: A Timeline of Policies and Events

Ndugga, N., Pillai, D., Hill, L., & Artiga, S., Race, Inequality, and Health. In Altman, Drew (Editor), Health Policy 101, (KFF, October 2025) https://www.kff.org/health-policy-101-race-inequality-and-health/ (date accessed).

Medicaid is the primary program providing comprehensive coverage of health and long-term care to about 80 million low-income people in the United States. Medicaid accounts for nearly one-fifth of health care spending (and over half of spending for long-term care) and a large share of state budgets. Medicaid is jointly financed by states and the federal government but administered by states within broad federal rules. Because states have the flexibility to determine what populations and services to cover, how to deliver care, and how much to reimburse providers, there is significant variation across states in program spending and the share of people covered by the program.  Changes to Medicaid and the Affordable Care Act included in the tax and spending budget reconciliation law enacted in July 2025 are expected to reduce federal Medicaid spending by $911 billion over 10 years and reduce the number of people with health insurance by 10 million (three-quarters of which stems from the cuts to Medicaid).

Medicaid is the primary program providing comprehensive coverage of health care and long-term care to about 80 million low-income people in the United States. Medicaid accounts for nearly one-fifth of health care spending (and half of spending for long-term care) and a large share of state budgets (Figure 1).

Subject to federal standards, states administer Medicaid programs and have flexibility to determine what populations and services to cover, how to deliver care, and how much to reimburse providers. States can obtain Section 1115 waivers to test and implement approaches that differ from what is required by federal statute if the Secretary of Health and Human Services (HHS) determines the waivers would advance program objectives. Because of this flexibility, there is significant variation across state Medicaid programs, and, as a result, the share of state residents covered by the program (Figure 2).

Title XIX of the Social Security Act and a large body of federal regulations and sub-regulatory guidance govern the program, defining federal Medicaid requirements and states’ options and authorities. At the federal level, the Centers for Medicare and Medicaid Services (CMS) within the Department of Health and Human Services (HHS) administers Medicaid and oversees states’ programs. States may choose to participate in Medicaid, but if they do, they must comply with core federal requirements. Not all states opted to participate in Medicaid immediately after its enactment in 1965, but by the 1980s, all states had opted in. Medicaid coverage was historically tied to cash assistance—either Aid to Families with Dependent Children (AFDC) or federal Supplemental Security Income (SSI). Over time, Congress expanded federal minimum requirements and provided new coverage requirements and options for states, especially for children, pregnant women, and people with disabilities. In 1996, legislation replaced Aid to Families with Dependent Children with Temporary Assistance to Needy Families (TANF) and severed the link between Medicaid eligibility and cash assistance for children, pregnant women, and low-income parents. The Children’s Health Insurance Program (CHIP) was established in 1997 to cover low-income children above the cut-off for Medicaid with an enhanced federal match rate (Figure 3).

In 2010, the Affordable Care Act (ACA) expanded Medicaid to nearly all nonelderly adults with income up to 138% FPL ($21,597 annually for an individual in 2025) through a new coverage pathway for parents with incomes above states’ mandatory eligibility levels for parents/caretakers and adults without dependent children who had traditionally been excluded from Medicaid coverage. However, the ACA Medicaid expansion coverage is effectively optional for states because of a 2012 Supreme Court ruling. As of July 2025, 41 states, including Washington, D.C., have expanded Medicaid (Figure 4). States receive a higher rate of federal matching funding for people who are enrolled through the expansion coverage pathway. Under the ACA, all states were also required to modernize and streamline Medicaid eligibility and enrollment processes to help individuals obtain and maintain coverage.

The COVID-19 pandemic profoundly affected Medicaid spending and enrollment. At the start of the pandemic, Congress enacted legislation that included a requirement that Medicaid programs keep people continuously enrolled in exchange for enhanced federal funding. As a result, Medicaid/CHIP enrollment grew substantially, and the uninsured rate dropped. The unwinding of these provisions started on April 1, 2023, and millions were disenrolled from Medicaid; however, Medicaid enrollment remains higher than prior to the start of the pandemic in February 2020.

Passage of the tax and spending reconciliation budget bill in July 2025 included significant changes to Medicaid that are expected to reduce federal Medicaid funding and reduce Medicaid enrollment over the next 10 years relative to what would have been expected under current law. For the first time, the law conditions Medicaid eligibility for Medicaid expansion enrollees on meeting work and reporting requirements.  These work requirements, which will go into effect on January 1, 2027, or sooner at state option, represent the largest source of federal Medicaid funding reductions and the largest source of enrollment declines in the law. The law makes other changes. Beyond work requirements, the largest cuts to Medicaid stem from provisions that would: reduce and limit provider taxes, a mechanism that nearly all states use to finance the state share of Medicaid; reduce the payments states require managed care organizations to make to health care providers (“state-directed payments”); delaying enforcement of certain provisions in the Biden administration’s rules simplifying Medicaid eligibility and renewal processes; and increasing frequencies of eligibility redeterminations for expansion enrollees. Combined, those changes and work requirements account for nearly 90% of the expected cuts in federal spending according to the Congressional Budget Office (CBO).

States are guaranteed federal matching dollars without a cap for qualified services provided to eligible enrollees. The match rate for most Medicaid enrollees is determined by a formula in the law that provides a match of at least 50% and provides a higher federal match rate for states with lower per capita income (Figure 5). States may receive a higher match rate for certain services and populations. The ACA expansion group is financed with a 90% federal match rate, so states pay 10%, and the American Rescue Plan Act included an additional temporary fiscal incentive to states that newly adopt the Medicaid expansion; however, the tax and spending law eliminated the incentive, effective January 1, 2026. In FY 2023, Medicaid spending totaled $880 billion of which 69% was federal spending. Medicaid spending growth typically accelerates during economic downturns as enrollment increases. Spending growth also peaked after the implementation of the ACA and, more recently, due to enrollment growth tied to the pandemic-related continuous enrollment provision.

Overall, Medicaid accounts for a large share of most states’ budgets and is often central to state fiscal decisions; however, state spending on Medicaid is second to state spending on elementary and secondary education, and the program is also the largest source of federal revenue for states. In state fiscal year 2023, Medicaid accounted for 30% of total state expenditures, 15% of expenditures from state funds (general funds and other funds), and 57% of expenditures from federal funds received by the state.

Social Security, Medicare , and Medicaid are the three main entitlement programs, accounting for 41% of all federal outlays in FFY 2024. Of these three programs, Medicaid is the smallest in terms of federal outlays, though it covers more people than Medicare or Social Security. Overall, federal spending on domestic and global health programs and services accounted for 29% of net federal outlays in FFY 2023, including spending on Medicare (13%), Medicaid and CHIP (10%), and other health spending (6%). Dating back to the 1980s, there have been efforts to limit federal financing for Medicaid either through a block grant to states or through a cap on spending per enrollee as a way to help reduce federal spending. Such efforts could shift costs to states, forcing them to make tough choices about whether to pay for the federal cuts, which would require higher taxes or reductions in non-Medicaid state spending, or to reduce Medicaid spending by limiting Medicaid eligibility, covering fewer benefits, or paying less to providers. Although early discussions over the tax and spending law included proposals that would have reduced the federal Medicaid match rate and imposed a cap on per-enrollee spending, these changes to Medicaid financing were not included in the final version of the bill that passed.

Medicaid is an entitlement, meaning individuals who meet eligibility requirements are guaranteed coverage. The federal government sets minimum eligibility standards, but states may expand coverage beyond these minimum requirements.  Federal minimum eligibility levels for children and pregnant individuals are set at 133% of the federal poverty level (FPL) with a mandatory 5 percentage point income disregard or effectively 138% FPL ($36,777 for a family of 3 in 2025); however, median eligibility levels for these groups were 255% FPL for children and 213% FPL for pregnant individuals as of January 2025. As a result of the ACA, the median coverage level for parents and adults without dependent children is 138% FPL, but for states that have not adopted the ACA expansion, the median eligibility for parents was 33% FPL. In non-expansion states, adults without dependent coverage are not eligible for Medicaid coverage and those with incomes below the FPL fall into the coverage gap.

Medicaid coverage is also available to certain individuals who qualify on the basis of being age 65 and older or having a disability. These coverage categories are referred to as “non-MAGI” pathways because they do not use the Modified Adjusted Gross Income (MAGI) financial methodology that applies to pathways for pregnant people, parents, and children with low incomes. In addition to considering advanced age, disability status, and income, many non-MAGI pathways also have asset limits. Medicaid generally covers individuals who qualify for Supplemental Security Income (SSI), but nearly all other non-MAGI pathways are optional, resulting in substantial state variation.  Each group has different rules about income and assets, making eligibility complex (Figure 6).

Medicaid coverage is limited for immigrants, and except for emergency services, Medicaid coverage is not available for undocumented immigrants. A number of states, however, use state funds to provide coverage to all or some undocumented immigrants.

While Medicaid covers 1 in 5 people living in the United States, Medicaid is a particularly significant source of coverage for certain populations. In 2023, Medicaid covered 4 in 10 children, 8 in 10 children in poverty,  1 in 6 nonelderly adults, and 6 in 10 nonelderly people in poverty. Relative to White children and adults, Medicaid covers a higher share of Black, Hispanic, and American Indian or Alaska Native (AIAN) children and adults. Medicaid covers over 1 in 3 people with disabilities overall (4 in 10 people with disabilities ages 19-64), who are defined as having one or more difficulty related to hearing, vision, cognition, ambulation, self-care, or independent living (Figure 7).

Medicaid provides coverage for a number of special populations.  For example, Medicaid covers 41% of all births in the United States, 42% of children with special health care needs, 5 in 8 nursing home residents, 29% of non-elderly adults with any mental illness, and 40% of non-elderly adults with HIV. Medicaid pays Medicare premiums and often provides wraparound coverage for services not covered by Medicare (like most long-term care) for nearly 1 in 5 Medicare beneficiaries (13 million).  Medicaid is a key source of coverage for individuals experiencing homelessness and those transitioning out of carceral settings, particularly in states that have adopted the Medicaid expansion.

Among the non-elderly covered by Medicaid, nearly half are children under age 19, 6 in 10 are people of color, 57% are female, and three-quarters are in a family with a full- or part-time worker. Even though most adult Medicaid enrollees are working, many do not have an offer of employer-sponsored coverage, or it is not affordable.

Medicaid covers a broad range of services to address the diverse needs of the populations it serves. In addition to covering the services required by federal Medicaid law, all states elect to cover at least some services that are not mandatory (Figure 8). All states cover prescription drugs, and most states cover physical therapy, eyeglasses, and dental care. Medicaid provides comprehensive benefits for children, known as Early Periodic Screening Diagnosis and Treatment (EPSDT) services. EPSDT is especially important for children with disabilities because it allows children access to a broader set of benefits to address complex health needs than what is traditionally covered by private insurance. Unlike commercial health insurance and Medicare, Medicaid also covers non-emergency medical transportation, which helps enrollees get to appointments, and long-term care, including nursing home care and many home care services (also known as home and community-based services, or HCBS). Coverage for long-term care is mandatory for nursing facilities, but most coverage of home care is optional. In recent years, states have expanded coverage of behavioral health services and benefits to help enrollees address social determinants of health (SDOH) like nutrition or housing.

Most people age 65 and older and many people under age 65 with disabilities have Medicare, but Medicare does not cover most LTC; instead, Medicaid is the primary payer for LTC. LTC encompasses the broad range of paid and unpaid medical and personal care services that assist with activities of daily living (such as eating, bathing, and dressing) and instrumental activities of daily living (such as preparing meals, managing medication, and housekeeping). They are provided to people who need such services because of aging, chronic illness, or disability. These services include nursing facility care, adult daycare programs, home health aide services, personal care services, transportation, and supported employment. They may be provided over several weeks, months, or years, depending on an individual’s health care coverage and level of need. There have been longstanding challenges finding enough workers to provide LTC for all people who need such services, and the COVID-19 pandemic exacerbated those issues considerably. As the population ages and advances in medicine and technology enable people with serious disabilities to live longer, the number of people in need of LTC is expected to grow.

In 2024, the median annual costs of care in the U.S. were $127,750 for a private room in a nursing home, $70,800 for an assisted living facility, and $77,792 for a home health aide. Medicare provides home health and skilled nursing facility care under specific circumstances, but the Medicare benefit is considered “post-acute” care and generally not available for people needing services on an ongoing basis. Medicaid plays a key role in access to LTC for people who qualify because LTC costs are difficult for most people to afford when paying out-of-pocket. In some cases, people only qualify for Medicaid after exhausting their savings on the costs of LTC. In 2023, Medicaid paid 61% of the $459 billion spent on LTC in the U.S. (Figure 9).

LTC may be provided in various settings broadly categorized as institutional or non-institutional. Institutional settings include nursing facilities and intermediate care facilities for people with intellectual disabilities. Services provided in non-institutional settings are known as home care (also known as home and community-based services, or HCBS), and these settings may include a person’s home, adult day care centers, assisted living settings, and group homes. Federal Medicaid statutes require states to cover institutional LTC and home health, but nearly all home care is optional. Even without a mandate to cover home care, Medicaid LTC spending has shifted from institutional to non-institutional settings over time. In 2023, most spending for LTC in the U.S. was for home care (Figure 9). That shift reflects beneficiary preferences for receiving care in non-institutional settings and requirements for states to provide services in the least restrictive setting possible stemming from the Olmstead decision. In 2023, there were 6.3 million people who used Medicaid LTC, of which 4.9 million (77%) used home care and 1.4 million (23%) used institutional care (Figure 10). While overall, over three-quarters of people who used Medicaid LTC exclusively used home care services, the share varied across states (Figure 10).  To qualify for coverage of LTC under Medicaid, people must meet state-specific eligibility requirements regarding their levels of income, wealth, and functional limitations.

Managed care is the dominant delivery system for Medicaid enrollees with 75% of Medicaid beneficiaries enrolled in comprehensive managed care organizations (MCOs). Medicaid MCOs provide comprehensive acute care and, in some cases, LTC to Medicaid beneficiaries and are paid a set per member per month payment for these services. In FFY 2023, payments to managed care and health plans accounted for the largest share (55%) of Medicaid spending, with capitated payments to comprehensive MCOs accounting for 52% of Medicaid spending and payments to other Medicaid managed care (e.g., primary care case management (PCCM) arrangements or specialty plans) accounting for another 3% (Figure 11). Smaller shares of total Medicaid spending in FFY 2023 were for fee-for-service acute care (21%), fee-for-service LTC (19%), Medicaid spending for Medicare premiums on behalf of enrollees who also have Medicare (3%), and disproportionate share hospital (DSH) payments (2%).

Medicaid spending is driven by multiple factors, including the number and mix of enrollees, their use of health care and long-term care, the prices of Medicaid services, and state policy choices about benefits, provider payment rates, and other program factors. During economic downturns, enrollment in Medicaid grows, increasing state Medicaid costs while state tax revenues are declining. Due to the federal match, as spending increases during economic downturns, so does federal funding. During the pandemic-induced recession and the two economic downturns prior to the pandemic, Congress enacted legislation that temporarily increased the federal share of Medicaid spending to provide increased support for states to help fund Medicaid. High enrollment growth rates, tied first to the Great Recession, then ACA implementation, and later the pandemic, were the primary drivers of total Medicaid spending growth over the last two decades (Figure 12).

People eligible based on being age 65 or older or based on a disability comprise about 1in 5 enrollees but account for more than half of Medicaid spending, reflecting high health care needs and in many cases, use of LTC (Figure 13).

Across the states, spending per full-benefit enrollee ranged from a low of $4,780 in Alabama to $12,295 in the District of Columbia in 2023. Variation in spending across the states reflects considerable flexibility for states to design and administer their own programs – including what benefits are covered and how much providers are paid — and variation in the health and population characteristics of state residents. Within each state, there is also substantial variation in the average costs for each eligibility group, and within each eligibility group, per-enrollee costs may vary significantly, particularly for individuals eligible based on disability (Figure 14).

In 2023, people who used Medicaid LTC comprised 6% of Medicaid enrollment but 36% of federal and state Medicaid spending (Figure 15). High per-person Medicaid spending among enrollees who use LTC likely reflects the generally high cost of LTC and more extensive health needs among such groups that lead to higher use of other health care services and drugs as well.

As of July 2024, 42 states (including Washington, D.C.) contract with comprehensive, risk-based managed care plans – often administered by private insurance companies – to provide care to at least some of their Medicaid beneficiaries (Figure 16). Medicaid MCOs provide comprehensive acute care (i.e., most physician and hospital services) and, in some cases, LTC to Medicaid beneficiaries and are paid a set per member per month payment for these services. Medicaid MCOs represent a mix of private for-profit, private non-profit, and government plans. States have increased their reliance on MCOs with the aim of improving access to certain services, enhancing care coordination and management, and making future costs more predictable. While the shift to MCOs has increased budget predictability for states, the evidence about the impact of managed care on access to care, costs, and outcomes is both limited and mixed. Children and adults are more likely to be enrolled in MCOs than adults aged 65 and older and people eligible because of a disability; however, states are increasingly including beneficiaries with complex needs in MCOs. States are also increasingly leveraging Medicaid MCOs to help identify and address social determinants of health and to reduce health disparities.

A large body of research shows that Medicaid enrollees have substantially better access to care than people who are uninsured (who are also primarily low-income) and are less likely to postpone or go without needed care due to cost. Key measures of access to care and satisfaction with care among Medicaid enrollees are generally comparable to rates for people with private insurance (Figure 17). Given Medicaid enrollees have low incomes, federal rules include protections to limit out-of-pocket costs that can help improve access.  A 2023 KFF Survey of Consumer Experiences with Health Insurance found Medicaid enrollees report fewer cost-related problems compared to those with Marketplace or employer coverage. While most Medicaid enrollees will continue to be protected against large out-of-pocket costs, the tax and spending law newly requires states to impose cost sharing of up to $35 on certain services on Medicaid expansion adults who have incomes 100% – 138% FPL.

Longstanding research shows that Medicaid eligibility during childhood is associated with positive effects on health (including reduced avoidable hospitalizations and mortality) and impacts beyond health, such as improved long-run educational attainment. Early and updated research findings show that state Medicaid expansions to low-income adults are associated with increased access to care, increased economic security, improved self-reported health status, and other outcomes including increased early-stage cancer diagnosis rates, lower mortality rates for certain conditions (e.g., cancer, cardiovascular disease, liver disease), decreased maternal mortality, improved treatment management for conditions (e.g., diabetes, HIV), and improved outcomes related to substance use disorders. Gaps in access to certain providers (e.g., psychiatrists and dentists) are an ongoing challenge in Medicaid that may reflect system-wide problems, but may be exacerbated by provider shortages in low-income communities, Medicaid’s lower physician payment rates, and lower Medicaid physician participation compared with private insurance. In 2021, MACPAC found physicians were less likely to accept new Medicaid patients (74%) than those with Medicare (88%) or private insurance (96%), but these rates may vary by state, provider type, and setting. Medicaid acceptance was much higher where physicians practiced in community health centers, mental health centers, non-federal government clinics, and family clinics compared to the average for all settings. Provider participation rates may contribute to findings that Medicaid enrollees may experience more difficulty obtaining health care than those with private insurance.  A 2023 KFF Survey of Consumers found Medicaid enrollees report more problems with prior authorization and provider availability compared to people with other insurance types.

Section 1115 demonstration waivers offer states the ability to test new approaches in Medicaid that differ from what is required by federal statute, if CMS determines that such proposals are “likely to assist in promoting the objectives of the Medicaid program.” Nearly all states have at least one active Section 1115 waiver and some states have multiple 1115 waivers. Section 1115 waivers have been used over time and generally reflect priorities identified by the states as well as changing priorities from one presidential administration to another (Figure 18). Waivers have been used to expand coverage or benefits, change policies for existing Medicaid populations (e.g., testing premiums or other eligibility requirements), modify delivery systems, restructure financing or authorize new payments (e.g., supplemental payments or incentive-based payments), as well as make other program changes. 

Activity from the first Trump administration and the Biden administration tested how 1115 waivers can be used to advance administrative priorities and also tested the balance between states’ flexibility and discretion by the federal government. The first Trump administration’s Section 1115 waiver policy emphasized work requirements and other eligibility restrictions, payment for institutional behavioral health services, and capped financing. The Biden administration withdrew waiver approvals with work requirements, phased out approval of premium requirements, and instead encouraged states to propose waivers that expand coverage, reduce health disparities, advance “whole-person care,” and improve access to behavioral health care. Areas of focus during the Biden administration included leveraging Medicaid to address health-related social needs (including housing instability, homelessness, nutrition insecurity) and to provide health care to individuals transitioning from incarceration back into the community. Several states also received approval to provide multi-year continuous Medicaid coverage for children. Recent actions from the new Trump administration could signal efforts to curtail waivers related to social determinants of health, continuous eligibility and to limit 1115 waiver financing tools and flexibility. In addition, several states are seeking approval for work requirements waivers. Although the tax and spending reconciliation law now includes a national work requirement, some states may continue to pursue waivers to implement work requirements prior to January 1, 2027 when the national requirement goes into effect.

Various types of waivers and other emergency authorities can also be used to respond to emergencies. These authorities can help expand Medicaid capacity and focus on specific services, providers, or groups of enrollees that may be particularly impacted. During the COVID-19 pandemic, all 50 states and Washington, D.C. received approval to make changes using emergency authorities to facilitate access to care by expanding telehealth, eligibility, benefits and help address workforce issues for home- and community-based services.

Looking to the future, Medicaid faces a number of challenges, including: 

• How will the new work requirements, eligibility and cost sharing changes affect Medicaid enrollment and access to care, particularly for adults covered through the Medicaid expansion?
• What impact will the Medicaid changes have on the number of people without health insurance?
• How will states respond to federal Medicaid spending cuts and limits on their ability to use provider taxes to help finance the non-federal share of Medicaid spending?
• How will the cuts in Medicaid spending and enrollment affect health care providers (including rural providers) and the broader health care system? To what extent will a new temporary rural health fund totaling $50 billion blunt some of the effects of the cuts?
• Will administrative actions and federal funding cuts for Medicaid as well as broader federal changes in immigration policy affect Medicaid payment rates for long-term care and the long-term care workforce?
• Will Congress move to reverse some of the Medicaid cuts before they go into effect?

Policy changes to Medicaid have implications for the roughly 80 million people who rely on the program for health coverage, state and federal budgets and spending, and health care providers, including nursing facilities and home care providers. As the source of nearly one fifth of total health care spending, these changes will also have implications for the broader health care system. Changes in Medicaid enrollment will also affect overall coverage trends. Declines in Medicaid enrollment can be expected to increase the number of people who are uninsured, jeopardizing improvements in the affordability of and access to care for potentially millions of people.  

• 10 Things to Know About Medicaid
• Medicaid: What to Watch in 2025 | KFF
• Medicaid Financing: The Basics
• 10 Things to Know About Medicaid Managed Care
• 10 Things About Long-Term Services and Supports (LTSS)
• 50-State Medicaid Budget Survey Archives
• 50-State Medicaid Eligibility Survey Archives
• 50-State Survey Archives: Medicaid HCBS and Eligibility Based on Disability or Age 65+
• Status of State Medicaid Expansion Decisions: Interactive Map
• Medicaid Waiver Tracker: Approved and Pending Section 1115 Waivers by State
• Allocating CBO’s Estimates of Federal Medicaid Spending Reductions Across the States: Enacted Reconciliation Package | KFF
• Health Provisions in the 2025 Federal Budget Reconciliation Law
• Implementation Dates for 2025 Budget Reconciliation Law

Rudowitz, R., Tolbert, J., Burns, A., Hinton, E., Chidambaram, P., & Mudumala, A., Medicaid 101. In Altman, Drew (Editor), Health Policy 101, (KFF, October 2025) https://www.kff.org/health-policy-101-medicaid/ (date accessed)

Health care costs in the United States generally grow faster than inflation. The U.S. far exceeds other large and wealthy nations in per capita health spending, and health care represents a much larger share of the economy in the U.S. than in peer nations. Despite substantial spending, the U.S. health system grapples with disparities and gaps in coverage. Elevated health care expenditure in the U.S. does not consistently translate into superior health outcomes. Rising health care costs instead contribute to Americans facing difficulties affording medical care and drugs, even among those with insurance.

Many people are familiar with the high and rising cost of health care in the United States from seeing how much they spend on their own health insurance premiums and out-of-pocket costs. In addition to these very visible health costs, there are also tax dollars that go to fund public programs and the amounts employers spend toward their employees’ health insurance premiums. Total national health expenditures include spending by both public programs and private health plans, as well as out-of-pocket health spending. Total health expenditures represent the amount spent on health care (such as doctor visits, hospital stays, and prescription drugs) and related activities (such as insurer overhead and profits, health research and infrastructure, and public health).

Total Health Spending Reached $4.9 Trillion in 2022

Health spending in the U.S. has risen sharply over the last several decades. The official data on national health expenditures from the Centers for Medicare and Medicaid Services (CMS) show health spending totaled $74.1 billion in 1970. By 2000, health expenditures had reached about $1.4 trillion, and in 2023 the amount spent on health had more than tripled to $4.9 trillion. In the first year of the COVID-19 pandemic, health spending accelerated by 10.4% from 2019 to 2020, even as the use of health care dropped, driven largely by public health spending and financial relief provided to health care providers. Most recently, health spending grew 7.5% from 2022 to 2023, faster than the previous year’s 4.6% increase from 2021 to 2022. Health spending is expected to continue to grow at a similar pace for the foreseeable future.

In the chart above, spending is shown in terms of both nominal dollar values (not inflation-adjusted) and constant 2023 dollars (inflation-adjusted based on the personal consumption expenditures, or PCE, index). Inflation in the health sector increased slightly faster than across the general economy in 2023.

Currently, health care represents about 18% of the U.S. economy (measured as a share of gross domestic product, or GDP). In other words, almost 1 out of every 5 dollars spent in the U.S. goes toward health care. Back in 1960, health spending represented just 5% of GDP, meaning 1 in every 20 dollars in the U.S. economy was spent on health care. 

Out-of-pocket costs have also risen over time. Out-of-pocket costs represent the amount of money spent by individuals on health care that is not paid for by a health insurance plan or public program like Medicare or Medicaid. This includes cost-sharing, the most common forms of which are deductibles (an amount that must be paid before most services are covered by the plan), copayments (fixed dollar amounts), and coinsurance (a percentage of the charge for services). (i.e., copays, deductibles, coinsurance), as well as health spending by uninsured people or spending by insured people for care that is not covered at all by health insurance. Out-of-pocket spending does not include the amount spent on a person’s monthly health insurance premium.

Out-of-pocket spending per person was $115 in 1970 (or, adjusted for inflation, $703). By 2023, out-of-pocket spending had reached $1,514 per person. Despite this rise in out-of-pocket spending, health insurance now covers a larger share of total health spending (73%) than it did in 1970 (27%), in part because more people have gained coverage, especially public coverage, but also because health insurance spending per enrollee has grown.

Over the last several decades, health spending has been driven higher by a number of factors, including but not limited to an aging population, rising rates of chronic conditions, advancements in medicine and new technologies, higher prices, and expansions of health insurance coverage. While there are always differences across countries, many of these factors driving health costs upward in the U.S. are also driving health costs growth in peer nations. For example, while the U.S. population is indeed aging and that is driving health costs up, many large and wealthy nations have even more rapidly aging populations.

Other factors may explain the United States’ relatively high health spending compared to its peers. The U.S. health system is fragmented, with many private and public payers, and with regulation of these payers split between states and the federal government. However, these features are not entirely unique to the U.S., either. Indeed, some other countries with much lower health spending have multiple private payers or differences in public programs across states or provinces.  The U.S. is also not alone in having a mainly fee-for-service payment system.

The U.S. health insurance system is largely voluntary, whereas peer countries’ health systems are almost entirely compulsory. Additionally, the U.S. federal and state governments have generally done less to directly regulate or negotiate prices paid for medical services or prescription drugs than have governments of similarly large and wealthy nations. The U.S. often pays higher prices for the same brand-name prescription drugs, hospital procedures, and physician care than similarly large and wealthy countries do.

There are other factors, largely outside the control of the health system that are also likely at play, such as socioeconomic conditions (like income inequality and other social determinants of health), and differences in so-called lifestyle factors (like diet, drug use, or physical activity) that could contribute both to higher spending and worse outcomes.

Breaking total national health spending into its components can reveal the major drivers of health costs and where cost containment efforts could be most effective. The charts below show various ways of examining the key contributors to health spending. For example, the National Health Expenditure Accounts show trends in how health spending varies by type of service (e.g., hospital care vs. retail prescription drugs) or by source of funds (e.g., private health plans vs. public programs). An alternative and relatively new approach to understanding health spending is to break out total health spending into the share that goes to treat certain diseases (e.g., heart disease, cancer). Finally, health spending can also be better understood by looking at trends in prices (e.g., the dollar amount for a hospital stay) and utilization (e.g., the number of hospital stays). 

Hospital and Physician Services Represent Half of Total Health Spending

Most health spending in the U.S. and in peer countries is on hospital and physician care, followed by prescription drugs. In the U.S., hospital spending represented close to a third (31.2%) of overall health spending in 2023, and physicians/clinics represented 20.1% of total spending. In comparison to other large and wealthy countries, the U.S.’s higher spending on inpatient and outpatient care explains the vast majority of higher spending on health care overall.

Spending Has Grown for Hospitals, Physicians, and Drugs

During the 1970s, growth in hospital expenditures outpaced other services, while prescriptions and physician and clinic services saw faster spending growth during the 1980s and 1990s. From 2020 to 2023, retail prescription drugs experienced the fastest growth in spending at 8.6%, following 3.3% average annual growth from 2010 to 2020. Average spending growth for hospitals and physicians/clinics between 2020 and 2022 was 6.2% and 6.3%, respectively.

On a Per-Enrollee Basis, Private Insurance Spending Has Typically Grown Much Faster Than Medicare and Medicaid Spending

Per enrollee spending by private insurance grew by 80.4% from 2008 to 2023 – much faster than both Medicare and Medicaid spending growth per enrollee (50.3% and 30.3%, respectively). Private insurance often pays higher prices for health care compared to prices paid by Medicare and Medicaid.

Per enrollee spending by Medicaid rose by 7.9% in 2023 from the previous year, and also continued to increase in private insurance and Medicare (5.9% and 7.1% respectively). Medicare and private insurance per-enrollee spending continued to grow faster between 2021 and 2023 after slower growth in 2020. Medicaid per-enrollee spending had previously declined in 2021 as total enrollment grew, particularly among children and non-elderly adults, who generally have lower per-enrollee spending.

A Substantial Share of Health Spending Goes Toward the Treatment of Circulatory and Musculoskeletal Conditions

An alternative way of examining the components of health spending is to use the Bureau of Economic Analysis (BEA)’s Health Care Satellite Account, which estimates spending and price growth by disease category (e.g., cancer, infectious disease). This approach differs from the official categorization of health spending by service type (e.g., provider services). Essentially, the new satellite account redefines the “commodity” in healthcare as the treatment for specific diseases, rather than a hospital stay or a physician visit. BEA researchers found that the largest categories of medical services spending include the treatment of circulatory diseases (10.4% of health spending in 2021), musculoskeletal conditions (9.4%) and infectious diseases (9%). Another large share of health spending (15.1%) is for “ill-defined conditions,” which can include routine check-ups and follow-up care that is not easily designated for a particular illness.

Health Spending is a Function of Prices and Use

Health services spending is generally a function of prices (e.g., the dollar amount charged for a hospital stay) and utilization (e.g., the number of hospital stays).

People and health plans in the U.S. often pay higher prices for the same prescription drugs or hospital procedures than people in other large and wealthy nations do. In terms of utilization, there is not much evidence that people in the U.S. use more health care. In fact, Americans generally have shorter average hospital stays and fewer physician visits per capita. Therefore, a large part of the difference in health spending between the U.S. and its peers can be explained by higher prices, more so than higher utilization.

Over time, within the U.S., prices and utilization have driven health cost growth to varying degrees. In the 1980s and early 1990s, growth in health care prices far exceeded growth in use. Faster growth in health prices in the U.S. during this time drove the divergence in per capita health spending between the U.S. and other large, wealthy OECD countries. While health care prices have grown more moderately in recent decades, prices in the U.S. for health services continue to exceed what other countries pay.

More recently, the COVID-19 pandemic led to fluctuations in health care use. Early in the pandemic, many health services, such as elective surgeries, were postponed or cancelled and many elected to not get care to avoid infections at health care sites. In 2021, health services use increased by 9% from the previous year, but subsequent years showed slightly lower growth rates (2024 health services use increased 5.6% from 2023). This increase in health care use in 2021 followed a sharp decrease in health utilization in 2020. Health care prices increased moderately – between 2 and 3% – between 2020 and 2024, but changing market conditions since the pandemic and policies enacted in 2025 are likely to increase health costs at an increasing rate.

A small portion of the population accounts for a large share of health spending in a given year. Although we tend to focus on averages, a small number of people spend around the average since individual health needs vary over the life course. Some portions of the population (older adults and those with serious or chronic illnesses) require more and higher-cost health services than those who are younger, healthier, or otherwise in need of fewer or less costly services.

Older People and People with Significant Health Needs Account for Most Health Expenditures

While there are people with high spending at all ages, overall, people 55 and over accounted for 54% of total health spending in 2022, despite making up only 31% of the population. In contrast, people under age 35 made up 44% of the population but were responsible for only 23% of spending.

People with significant health needs account for a large portion of total health spending. People reporting fair or poor health status account for 11% of the population and 27% of the total health spending.

A Small Share of the Population Incurs Most of Health Spending

In 2022, the top 5% of people with the highest health spending accounted for half of total health spending and had an average of $67,300 in health expenditures annually; people with health spending in the top 1% have average spending of over $147,000 per year. At the other end of the spectrum, the 50% of the population with total health spending below or equal to the 50th percentile accounted for only 3% of all health spending; the average spending for this group was $374.

Out-of-pocket spending on health services is concentrated similarly to overall health spending. In this chart, out-of-pocket spending includes direct payments to providers and cost-sharing, including deductibles, copays, and coinsurance, but does not include monthly premium payments or contributions towards health coverage. Out-of-pocket health spending is similarly concentrated among high-health-need individuals. A small portion of the population accounts for a substantial share of total out-of-pocket health spending in a year.

In 2022, people in the top 1% of out-of-pocket spending paid about $23,700 out-of-pocket for health services on average per year, and people in the top 10% spent an average of $6,126 out-of-pocket per year. People who are in the bottom 50% of out-of-pocket spending spent an average of $24 out of pocket.

In addition to being expensive for the nation as a whole, health care is often also expensive for individuals. High health costs can particularly pose a hardship for people who are in worse health and those with lower incomes. However, challenges affording health care are not limited to certain groups; these challenges are pervasive across the U.S. Even people with private health insurance through their employers are often exposed to high and rising deductibles, and therefore also face affordability challenges. A substantial share of the population does not have enough savings or other liquid assets to afford a high deductible or out-of-pocket maximum common in private health plans.

When health care is unaffordable, it can lead to cost-related access barriers, like forgoing or delaying needed medical care. For those who still receive unaffordable health care, this care can lead to medical debt and other forms of financial instability. Some people experience both types of affordability challenges, missing some needed care while also incurring medical debt for other care.

Half of Adults Say it is Difficult to Afford Health Care Costs

Almost half of U.S. adults say it is difficult to afford health care costs, and one in four say they or a family member in their household had problems paying for health care in the past 12 months. Younger adults, those with lower incomes, adults in fair or poor health, and the uninsured are particularly likely to report problems affording health care in the past year.

Among those under age 65, uninsured adults are more likely to say affording health care costs is difficult (82%) compared to those with health insurance coverage (44%).

Those who are covered by health insurance are not immune to the burden of health care costs. About 4 in 10 insured adults worry about affording their monthly health insurance premium, and 62% worry about affording their deductible before health insurance kicks in. Indeed, large shares of adults with employer-sponsored insurance (ESI) and those with Marketplace coverage rate their insurance as “fair” or “poor” when it comes to their monthly premium and out-of-pocket costs to see a doctor.

1 in 3 Adults Report Putting Off Health Care Because of Cost

Cost-related barriers to accessing health care are more common for some demographic groups than others. For example, people who are Hispanic, lower-income, in worse health, and/or uninsured tend to have higher rates of self-reported cost-related access barriers.

One-quarter of adults say that in the past 12 months they have skipped or postponed getting health care they needed because of the cost, according to KFF polling. Women are more likely than men to say they have skipped or postponed getting health care they needed because of the cost (38% vs. 32%). Adults ages 65 and older, most of whom are eligible for health care coverage through Medicare, are much less likely than younger age groups to say they have not gotten health care they needed because of cost. Three in four uninsured adults (75%) say they have skipped or postponed getting health care they needed due to cost. Insured people are not immune from cost-related barriers to accessing care and more than one in three adults with insurance (37%) report not getting health care they needed due to cost.

Despite the vast majority of the United States population having health insurance, medical debt is not uncommon. Different ways of measuring medical debt result in different estimates of prevalence, but regardless of the method, there is consensus that medical debt is a persistent and pervasive problem in the United States, including for people with insurance.

One way to examine medical debt is through credit reporting, but medical debt is often disguised as other forms of debt when people pay for medical bills on their credit cards or choose to pay off their medical bills while falling behind on other payments.

Another way to measure medical debt is with surveys, which can allow respondents to describe their debt with more detail or nuance. Questions about medical debt and other financial matters can be difficult to compare across surveys. For example, it is not always clear whether respondents are answering about their personal experiences or about their broader family or household. Surveys may also differ in the way they define medical debt or describe what forms of debt to include. 

The KFF Health Care Debt Survey asked respondents to think about money that they currently owe for their own health or dental care or someone else’s, such as a family member or dependent. The KFF Health Care Debt Survey finds that 41% of adults currently have some form of debt caused by their own or a family member’s medical or dental bills.

The  U.S. Survey of Income and Program Participation (SIPP)  asks whether money was owed for a medical bill and not paid in full during the past year for each person in the sample household. SIPP results, therefore, can be looked at on the individual level or for an overall household. This survey shows that about 1 in 12 adults have medical debt they owe for themselves or their family’s medical care in the past year.

Regardless of the survey used to examine medical debt, common themes emerge when looking at differences across demographic groups: adults who are Black, uninsured, lower-income, and in worse health are more likely to have medical debt. People with incomes under $40,000 are significantly more likely than people with higher incomes to go into debt to cover an unexpected medical bill, and people with disabilities are also much more likely to have significant medical debt, which, in addition to the burden of medical costs, could also reflect inadequate supplemental income for people who are unable to work due to disability or illness.

Nationally, Medical Debt Totals at Least $200 Billion

The Consumer Financial Protection Bureau (CFPB) estimates that $88 billion in medical debt is reflected on Americans’ credit reports. However, credit reports may not capture all forms of medical debt. For example, medical debt disguised as credit card debt or money owed to family or friends may not be captured. Surveys may capture medical debt that is not visible on credit reports or is otherwise disguised as another form of debt. The 2023 Survey of Income and Program Participation suggests that total medical debt owed was at least $200 billion at the end of 2023.

Medical Debt is Associated with Financial Vulnerability Across a Range of Indicators

The National Financial Capability Survey (NFCS) is a triennial survey sponsored by the FINRA Foundation that provides information on the financial security, experiences, and vulnerabilities of people and households.

People with medical debt are much more likely to have other forms of financial distress than those without medical debt. Indicators of financial vulnerability — such as spending more money than one’s income, having no “rainy day” fund, or agreeing with the statement “I am just getting by financially” — are more common among adults with medical debt than those without. Additionally, people with medical debt are more likely to overdraw their checking account, have a credit card balance that exposes them to interest payments, take a cash advance on their credit card, or have been contacted by debt collectors. Adults with medical debt are much more likely to use payday loans or other costly loans than those without medical debt.

Each year, actuaries from the Centers for Medicare and Medicaid Services (CMS) project future spending on health. With health care utilization returning to pre-pandemic levels and price inflation in the health sector continuing to outpace general economic inflation, per-person health spending increased 7% in 2023. Annual per capita health spending is projected to grow at an annual rate of 5% per capita on average from 2023 to 2032.

An aging population, labor pressure driving higher prices, and new high-cost prescription drugs coming to market are expected to contribute to a growth in health spending. Health spending was 17.6% of the U.S. economy in 2023 and is expected to reach 19.7% by 2032.

The pandemic has had direct and indirect effects on the health system that can make projections difficult. COVID-19 has led to new costs for vaccination, testing, and treatment and has also caused other shifts in health utilization and spending. Some people avoided medical settings out of concern of contracting COVID and thus missed or delayed routine care or cancer screenings earlier in the pandemic, for example, which could lead to pent-up demand, worsening health conditions, or more complex disease management going forward. Increased use of telemedicine could also shift spending patterns in the future. Further, the recent broad-based inflation trends in the economy and health sector employment trends also add to the uncertainty of these projections.

Federal Government Infusion of Public Health Funding Has Subsided Since Early in the COVID-19 Pandemic

Total national health spending includes spending on direct patient care, as well as spending on public health or prevention. After a sharp increase in federal funding in 2020 driven by the national response to the COVID-19 pandemic, spending on public health has fallen, decreasing by over 58% between 2022 and 2023. Meanwhile, state and local public health spending grew 5%, in line with previous years. Overall public health spending is expected to continue to decline over the next couple of years.

Signed in July 2025, the tax and budget reconciliation law (formerly known as the “One Big Beautiful Bill Act”) includes provisions for addressing federal spending on Medicaid and Affordable Care Act exchanges. The Congressional Budget Office (CBO) expects the law to decrease spending on Medicaid and the Affordable Care Act (ACA) Marketplaces by over $1 trillion and lead to 10 million more uninsured people through 2034.

Additional policy issues that will shape future health spending and affordability include:

• Evolution of State Cost Controls: States implementing measures to control health cost growth, including those potentially supported by the Biden Administration’s new AHEAD model, may prompt further experimentation; however, states can only regulate a subset of private health insurance plans.
• Price Transparency Requirements: Federal price transparency requirements aim to illuminate prices paid to hospitals and providers. There remain challenges with the quality of the data, though CMS continues to request suggestions for improved guidelines. As for a budgetary impact, CBO predicted minimal impact on health sector prices.
• Prescription Drug Pricing: The Trump administration’s 2025 executive order called on pharmaceutical manufacturers to match most-favored-nation prices (MFN, the lowest price offered in other developed nations). The effects of this order on prescription drug prices in the U.S. remain uncertain. Additionally, the Inflation Reduction Act of 2022, targeting Medicare drug spending through government negotiation of drug prices, is expected to reduce Medicare costs, but potential far-reaching effects are still unclear. While CBO expects minimal effects on the availability of new treatments, there is considerable uncertainty surrounding those estimates.
• Expansion of Virtual Care: The COVID-19-induced rise in telehealth, with expanded reimbursement and access, has uncertain impacts on care coordination, quality, health outcomes, and costs.
• Market Dynamics and Anticompetitive Practices: Consolidation among providers, insurers, and drug manufacturers has elevated health care prices, leading to regulatory actions against anticompetitive practices, aiming to protect consumers from rising costs.
• Provider Payment Reforms: Bipartisan efforts in site-neutral payment reform, addressing concerns about higher payments in outpatient settings, have led to Medicare implementing site-neutral payments in some settings and additional legislative proposals. However, challenges in provider charging practices and facility fees persist.
• Value-Based Payment Models: The proliferation of value-based care aims to transfer some of the cost risks from payers to providers, but concerns remain about the effectiveness of these approaches, limited quality improvement, administrative burdens, and reduced physician participation incentives. 
• Changes in Coverage: Despite reduced uninsured rates through continuous Medicaid enrollment and expanded Affordable Care Act Marketplace subsidies during the pandemic, affordability challenges persist among the insured. Renewed disenrollments from Medicaid and the expiration of Marketplace subsidies after 2025 may increase uninsured rates and affordability issues.
• Addressing Medical Debt: Ongoing efforts to address medical debt involve buying medical debt for forgiveness and regulatory actions. However, the root causes of high health costs and underinsurance remain untouched by most efforts to mitigate the negative effects of medical debt.

• National Health Spending Explorer – Peterson-KFF Health System Tracker
• How has U.S. spending on healthcare changed over time? – Peterson-KFF Health System Tracker
• How much is health spending expected to grow? – Peterson-KFF Health System Tracker
• What are the recent and forecasted trends in prescription drug spending? – Peterson-KFF Health System Tracker
• How does medical inflation compare to inflation in the rest of the economy? – Peterson-KFF Health System Tracker
• How many people have enough money to afford private insurance cost sharing? – Peterson-KFF Health System Tracker
• Americans’ Challenges with Health Care Costs | KFF
• How does cost affect access to healthcare? – Peterson-KFF Health System Tracker
• The burden of medical debt in the United States – Peterson-KFF Health System Tracker
• Health Care Debt In The U.S.: The Broad Consequences Of Medical And Dental Bills | KFF

Amin, K., Cox, C., Ortaliza, J. & Wager, E., Health Care Costs and Affordability. In Altman, Drew (Editor), Health Policy 101, (KFF, October 2025) https://www.kff.org/health-policy-101-health-care-costs-and-affordability/ (date accessed).