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KFF’s January 2025 Prescription Drug Advertisements Poll looks at the public’s experiences with prescription drug advertisements. The poll measures the share of adults who report seeing such advertisements, as well as how these drug advertisements influence the care the public reports receiving from their doctor or health care provider.
On January 28, 2025, President Trump issued an Executive Order titled, “Protecting Children From Chemical And Surgical Mutilation.” Among other actions, the Order directs agencies and programs to work towards significantly limiting youth access to gender affirming care nationwide. It also includes misinformation about gender affirming care and young people who are transgender.
While the order does not immediately change policies or regulations that guide access to gender affirming care, it has already created significant confusion and some disruption of services, and there is now a legal challenge, as well as responses by several states. This Policy Watch reviews the key provisions of the Executive Order that aim to restrict youth access to gender affirming care and examines state and legal responses.
Key provisions related to care restrictions include:
Taken together, and if implemented broadly, restrictions across these programs and policies could significantly limit access to gender affirming care for most young people nationwide, including for those with both private and public insurance, and even for some who are able to pay out-of-pocket. It would also likely lead to a reinterpretation of the major sex nondiscrimination protections in the Affordable Care Act (Section 1557) to remove explicit named protections on the basis of sexual orientation and gender identity in health programs receiving federal funding.
Additionally, the Executive Order promotes misinformation, including that large shares of youth are seeking gender affirming medical care, which is not the case, that regret rates among those who do seek care are high, when regret rates are very low, and erroneously conflating “female genital mutilation” and gender-affirming care.
Notably, the Executive Order defines children to include 18 year olds, which goes beyond how most states define minors.
As of February 6, 2025, Attorneys General in seventeen (17) states have publicly responded to the Executive Order. Fifteen (15) have stated that they oppose the Executive Order in a coalition led by the Massachusetts Attorney General. The coalition press release states that the State Attorneys General “reaffirm their commitment to protecting access to gender-affirming care” and that the Executive Order “is wrong on the science and the law.” Additionally, the Oregon Attorney General issued a statement in support of youth access to gender affirming care and stated that they “are vigorously exploring all legal options to challenge any policies or actions that hinder access to the care Oregonians need and their rights to make their own medical decisions,” but stopped short of directly opposing the Executive Order.
In addition to being part of the coalition letter, some Attorneys General have directed providers to continue proving gender affirming care, noting that failing to do so could be in violation of state nondiscrimination protections.
In contrast, the Attorney General in at least one state, Virginia, instructed at least two university Hospital systems to stop providing care in order to comply with the order and minimize “significant legal risk and substantial financial exposure.”
None of the 26 states with laws prohibiting or limiting youth access to gender affirming care have yet to officially respond to the Executive Order.
On February 4, 2025 the ACLU, Lambda Legal, and others, filed a lawsuit in federal court challenging the Executive Order. The complaint states that the Executive Order aimed at restricting gender affirming care (and another related to “gender ideology”) “were issued for the openly discriminatory purpose of preventing transgender people from expressing a gender identity different from their sex designated at birth” and are unlawful and unconstitutional. Specific counts named in the filing are that the orders:
In addition to asking the court to find the orders unconstitutional and unlawful, the plaintiffs seek injunctive relief, enjoining their implementation and enforcement.
On February 7, 2025 a second lawsuit was filed in federal court by three states (Washington, Minnesota and Oregon) and three physicians from the state of Washington, challenging the gender affirming care Executive Order, calling it “blatantly unconstitutional.” Specific counts named in the filing are that the Order:
As with the plaintiffs in the first suit, the plaintiffs here ask the court to find certain sections of the Executive Order unconstitutional and seek injunctive relief, enjoining their implementation and enforcement. They also ask the court for an expedited hearing to determine whether the court should enter a preliminary injunction or the Temporary Restraining Order (in a separate case that stopped a pause on federal funding) should be extended.
On January 20, President Trump issued an Executive Order calling for a re-evaluation and realignment of U.S. foreign aid that put a 90-day pause on new obligations and disbursements and initiated a full review of all foreign aid programs. This was followed by a stop-work order for existing efforts (with limited exception) already funded and underway, freezing most service delivery in countries around the world. With reports of the effective dissolution of USAID, the international development agency created more than six decades ago, there is uncertainty about the future of the aid it provides if it is incorporated into the State Department as President Trump calls to “CLOSE IT DOWN!”.
To shed light on the role of USAID in global health, this brief provides an analysis of the share of global health assistance obligated or implemented by USAID and other agencies on behalf of countries (or, “bilateral”) in FY 2023, using data from foreignassistance.gov. This includes funding that agencies either: 1) obligated for global health activities (e.g., USAID manages and provides funding to an implementing partner, such as a non-governmental organization, to directly carryout health programs); or 2) received from other agencies to directly implement specific programs (e.g., State Department directs funding to USAID to implement HIV/AIDS programs in countries). This does not include funding appropriated by Congress to the Centers for Disease Control and Prevention (CDC) for global health efforts, as these totals are not part of the foreignassistance.gov database (in FY 2023 Congress appropriated approximately $693 million to CDC global health). As this analysis shows, the majority of U.S. bilateral global health assistance is obligated or implemented by USAID, including for PEPFAR. (For more information on federal funding flows for global health, see 10 Things to Know About U.S. Funding for Global Health).
In FY 2023, USAID obligated/implemented 73% of all U.S. global health bilateral assistance. Of the $8.5 billion for bilateral global health efforts, across all program areas, USAID obligated/implemented $6.2 billion (73%) (see Figure 1). The next largest share was at the Department of Health and Human Services (HHS) ($1.9 billion or 22%), primarily the Centers for Disease Control and Prevention (CDC). Two percent ($141 million) was at State and 3% ($280 million) at all other agencies combined.
For PEPFAR, the U.S. global HIV/AIDS program, USAID obligated/implemented 60% of bilateral assistance. Of the $4.2 billion for bilateral HIV programs in FY 2023, $2.5 billion (60%) was obligated/implemented by USAID, followed by $1.6 billion (37%) at HHS, and 2% ($79 million) at State (see Figure 2). Just 1% ($25 million) was at other agencies.
USAID’s role is even greater in some sectors, including 100% in some cases. For maternal and child health, TB efforts, and global health security, USAID obligated 100% of all bilateral support in FY 2023 (see Figure 3). It obligated 99% of family planning and reproductive health and 96% for malaria efforts. PEPFAR, as noted above, is 60%, and nutrition programs are 59%. As noted above, these totals do not include funding appropriated by Congress to the CDC for global health efforts, as these totals are not part of the foreignassistance.gov database.
There remains significant uncertainty surrounding the administration’s review of USAID and of U.S. foreign aid more generally, including which programs will be maintained, and how they will be carried out going forward. Given the current role of USAID in managing U.S. global health programs, through its thousands of staff around the world and its work with implementers on the ground, changing USAID, including by reducing or eliminating its capacity, would leave a gap that could affect service delivery and health outcomes, should it not be filled.
Options under consideration in Congress to reduce Medicaid spending by up to $2.3 trillion, nearly one-third over ten years, could have major implications for people with disabilities. Medicaid is the primary program providing comprehensive health and long-term care coverage to one in three with disabilities, including 2.3 million children, 8.8 million working-age adults, and 4.4 million adults ages 65 and older. Although some people with disabilities qualify for Medicaid because they receive Supplemental Security Income, most are eligible for Medicaid through other pathways, including the Affordable Care Act (ACA) expansion group.
Policy changes under consideration include imposing a per capita cap on federal Medicaid spending, reducing the federal government’s share of costs for the ACA expansion group, and imposing Medicaid work requirements, among other changes. Such policy changes would fundamentally alter how Medicaid financing works and federal spending reductions of this magnitude would put states at significant financial risk, forcing them to make tough choices about reducing the number of people covered, covering fewer benefits, or reducing payment rates for physicians, hospitals, nursing homes, and other providers. It is unknown how much Medicaid pays for people with disabilities because health care claims data do not include information about disabilities unless they are also a diagnosis code associated with the medical care being provided. However, Medicaid enrollees who are eligible because of disability or being over age 64 account for over half of Medicaid spending but less than a quarter of enrollees on account of their higher costs. That group includes most non-elderly adults with disabilities who qualify for Medicaid through regular eligibility pathways, such as the ACA expansion.
Because they have high levels of health care spending, people with disabilities may be particularly vulnerable if federal spending is capped. Loss of Medicaid coverage or benefits poses unique challenges for seniors and people with disabilities, many of whom live on fixed incomes, face barriers to employment and accessing private health coverage, have high health care needs and spending, and rely on Medicaid for coverage of long-term care and other services not available in other health coverage.
More than 1 in 3 people with disabilities (15 million) have Medicaid (35%). In comparison, only 19% of people without disabilities have Medicaid (Figure 1). Disability is defined as having any of the following difficulties: hearing, vision, cognitive, ambulatory, self-care, or independent living. The difference in coverage rates stems from lower rates of employment and employer-based coverage among working age adults with disabilities. Among working age adults with disabilities, almost half of people with disabilities do not work at all and only one third work full time (defined as 35 or more hours per week). In comparison, over 64% of adults without a disability work full time and only 16% do not work at all. Lower rates of employment result in lower rates of employment-based coverage among working age adults with disabilities: Only 33% have insurance through an employer compared with 64% among working age adults without disabilities.
Over 1 in 5 Medicaid enrollees have a disability, with the rate of disability among Medicaid enrollees rising steeply with age (Figure 2, Tab 1). Only 8% of children have a disability compared with 22% of adults ages 19 to 49 and 43% of adults ages 50 to 64. Over half of Medicaid enrollees ages 65 and older have a disability. Because disability incidence rises with age, Medicaid enrollees with disabilities tend to be older than those without (Figure 2, Tab 2). Among Medicaid enrollees with a disability, over 50% are ages 50 and older compared with less than 20% of Medicaid enrollees without disabilities.
Nearly 60% of Medicaid enrollees with disabilities have two or more difficulties and 16% have four or more difficulties (Figure 3, Tab 1). Among the over 15 million Medicaid enrollees with disabilities, 53% report difficulties with cognition, which is defined as difficulty concentrating, remembering, or making decisions; 48% report difficulties with ambulation (defined as difficulty with walking or climbing stairs); 44% report difficulties living independently (defined as difficulty doing errands alone such as visiting a doctor’s office or shopping); and 24% report difficulties with self-care (defined as difficult dressing or bathing). Fewer than 1 in 5 enrollees report difficulties with hearing or vision (Figure 3, Tab 2).
Although federal statutes generally require states to enroll people who receive SSI in Medicaid, only one third of Medicaid enrollees with disabilities receive SSI income (Figure 5). That rate varies from a low of 18% in North Dakota to a high of 44% in Texas (Appendix Table 1). SSI is a disability program that provides monthly income to people who are unable to work on account of a disability and who have income and financial resources below federal limits. Receipt of SSI increases with age: Only 15% of children ages 15-19 receive SSI but close to 40% of adults ages 50 and older do. Medicaid enrollees ages 19-64 who do not receive SSI are eligible for Medicaid through other eligibility pathways, and many adults could be subject to Medicaid work and reporting requirement policies (Appendix Table 2). A smaller number of Medicaid enrollees with disabilities are eligible for Medicaid through pathways that relate to their disability or need for long-term care. Those pathways have more complex eligibility requirements than coverage for children and non-elderly adults. Most Medicaid enrollees with disabilities qualify for Medicaid under regular adult pathways, including the ACA expansion group.
Nearly half of Medicaid enrollees with a disability (47%) report having a difficult with self-care or independent living, disabilities that frequently require long-term care. Medicaid is the primary payer of long-term care because it is generally not covered by Medicare or private health insurance. KFF estimates that nearly 6 million people use Medicaid long-term care and spending for those people is much higher than spending for other enrollees, with the costs of enrollees who use institutional care nearing $50,000 each year. In comparison, average Medicaid spending for enrollees who do not use long-term care is under $5,000. Because of the higher spending, enrollees who use long-term care comprise 6% of Medicaid enrollment but 34% of Medicaid spending (Figure 5).
Options under consideration in Congress to reduce Medicaid spending by nearly one-third in future years could have major implications for seniors and people with disabilities. Nearly 1 in 4 Medicaid enrollees are eligible for the program because they are ages 65 and older or have a disability, and they have higher per-enrollee costs than other enrollees. Within this group, there are multiple eligibility pathways, most of which are optional for states to cover, and all of which have more complex eligibility requirements than coverage for children and non-elderly adults. Proposals to limit federal spending on Medicaid may create incentives for states to drop or reduce their eligibility or coverage for seniors and people with disabilities in response to fewer federal revenues. Loss of Medicaid coverage poses unique challenges for seniors and people with disabilities, people who are likely to live on fixed incomes, have high health care spending, and rely on Medicaid for coverage of long-term care.
Considering the proposed reductions in Medicaid spending, this issue brief describes Medicaid eligibility pathways, enrollment, and spending among people eligible through the age and disability-related pathways (known as “non-MAGI” pathways because they do not determine eligibility based on Modified Adjusted Gross Income, as is the case for people covered under the Affordable Care Act Medicaid expansion and other groups). This analysis uses the most recent data available to KFF at the time of the analysis (Medicaid T-MSIS data, 2021, see Methods).
Over half of Medicaid spending ($339 billion in 2021) pays for care for people eligible through the non-MAGI pathways (Figure 1). Seniors and people with disabilities often have higher health care costs than other enrollees due to more complex health care needs, higher rates of chronic conditions and being more likely to utilize long-term care. There is significant state variation in the percentage of Medicaid spending that pays for non-MAGI enrollees (Appendix Table 1). In some states (Alaska, Nevada, Montana, Illinois and Indiana), only a third of spending went to these populations, and in five states (Alabama, Florida, Kansas, Mississippi, and North Dakota), care for seniors and people with disabilities accounted for at least two-thirds of spending (Figure 1). Differences in the percentage of spending across the states stem from differences in eligibility criteria for both MAGI and non-MAGI eligibility pathways, which also affects relative levels of enrollment in these pathways, as well as demographic variation across states.
Federal statutes require states to enroll people who receive Supplemental Security Income (SSI) in Medicaid and to enroll eligible Medicare beneficiaries in the Medicare Savings Programs. SSI is a disability program that provides monthly income to people who are unable to work on account of a disability and who have income and financial resources below federal limits. The Medicare Savings Programs provide Medicaid coverage of Medicare premiums and in most cases, cost sharing to Medicare beneficiaries with limited financial resources. People who are eligible for the Medicare Savings Programs, but not full Medicaid, only receive Medicaid coverage for the costs of Medicare premiums and usually, cost sharing. Beyond these two “mandatory” eligibility pathways, there are optional Medicaid eligibility pathways that states may choose to offer for people who have disabilities or are ages 65 and older, including options to expand coverage beyond what is required under federal law to low-income seniors and people with disabilities and coverage for people who need long-term care.
Roughly two-thirds of Medicaid enrollees who qualify based on old age or disability are eligible for Medicaid through a mandatory pathway and those enrollees account for about two-thirds of Medicaid spending on non-MAGI enrollees (Figure 2). The remaining third of enrollees includes people coming in through optional income-related pathways (28% of all non-MAGI enrollees and 19% of spending) and those coming in on account of their need for long-term care (6% of enrollees, 16% of spending).
Most seniors and people with disabilities who are eligible for non-MAGI Medicaid must demonstrate limited financial resources and go through an application process that requires documentation of their income and savings (Table 1). States that offer eligibility based on long-term care have higher income eligibility criteria for those eligibility pathways, but nearly all still require applicants to demonstrate having limited savings ($2,000 for an individual, $3,000 for a couple). Some assets, including the home, are excluded from the calculation of financial resources, but states are required to recoup the certain Medicaid costs after enrollees die through a process known as estate recovery. States that offer eligibility for seniors and people with disabilities based on income, have income limits generally little more than the federal poverty level with similarly low thresholds for applicants’ savings; and most states have more complicated eligibility processes for non-MAGI pathways than they do for MAGI pathways.
Among the four eligibility pathways specifically for people who use long-term care, per-enrollee spending is over $40,000 per year for three of the pathways (Figure 3). Per-enrollee spending for children with disabilities enrolled through Katie Beckett programs (which include Family Opportunity Act options too) is more similar to that of other eligibility pathways for seniors and people with disabilities (close to $20,000 per year) because many of those children also have private health insurance. In such cases, Katie Beckett coverage helps lower- and middle-income families cover the costs of long-term care for children, which are very difficult to save for. Although per-enrollee costs for people eligible through the long-term care pathways are high, they still represent a small share of total Medicaid spending because the number of people enrolled is so low.
For mandatory and income-related optional eligibility pathways, per-enrollee spending (including all services) varies from under $2,000 per enrollee to over $33,000 per enrollee for the Medicare Savings Programs and nearly $60,000 per enrollee for the SSI eligibility pathway (Figure 4). As large as that variation is, variation for the long-term care-related pathways is far greater: Variation in per-enrollee spending for people who use institutional care ranges from $24,000 to nearly $200,000 per year in Alaska. For people eligible through one of the two home care programs, per-enrollee spending ranges from about $3,000 to well over $100,000. in Washington, D.C. (Appendix Table 2).
The large variation in spending among the long-term care related pathways reflects states having considerable flexibility in determining who is eligible to receive optional benefits, what services to provide, and how much to pay providers. Long-term care is extremely expensive, with average nursing facility rates for all payers exceeding $100,000 per year, full-time home health aide costs nearing $70,000, and round-the-clock home health costs nearing $300,000 per year. Not all people use services for the full year, and Medicaid does not always cover 100% of the costs of people’s care or pay the same rate as private payers, contributing to the variation in spending. There is little information about how much states pay providers, but a KFF survey about payment rates for home care showed significant variation among states able to report. The Biden Administration finalized regulations that would require states to report payment rates for Medicaid, but Congress or the Trump administration may seek to undo that rule.
Although some researchers have criticized the ACA eligibility pathway as diverting resources away from Medicaid enrollees with disabilities, the data show per-enrollee spending for seniors and people with disabilities is two times larger in expansion states ($20,345 versus $9,950, Figure 5). The largest difference in per-enrollee spending stems from people eligible through optional income-related pathways, where spending is $17,000 per enrollee per year in expansion states but less than $5,000 per year in non-expansion states. Even in mandatory pathways, expansion states spent more per enrollee: Expansion states spent $6,386 more per enrollee eligible through the Medicare Savings Program pathway, and $7,219 more per enrollee through the SSI pathway.
Methods
Data: Data are from the 2021 and 2020 T-MSIS Research Identifiable Demographic-Eligibility and Claims Files (T-MSIS data). This analysis includes all Medicaid-eligible enrollees, with either full or partial benefits.
State Inclusion Criteria: National estimates include enrollees living in 48 states and DC and exclude residents in the U.S. territories. West Virginia and Mississippi enrollees were not included in the national estimates due to unusable data in 2021, according to the DQ Atlas. However, their reported state-level data in figures 1 and 4, and in the appendix tables, was calculated using 2020 T-MSIS data.
Medicaid non-MAGI eligibility pathways: Eligibility pathways for older adults and individuals with disabilities were identified using ELGBLTY_GRP_CD_LTST in the T-MSIS demographic-eligibility file.
Eligibility pathways for older adults and individuals with disabilities:
Supplemental Security Income (SSI) with values of 11-22, 37, 38, 40, 41
Medicare Savings Program (MSP) with values of 23-26.
Buy In Programs with values of 47, 48, 49.
Poverty Level with values of 46.
Medically Needy with values of 53-56, 59, 60.
Other Home Care with values of 39, 43, 51.
Special Income, Institutional with a value of 42.
Special Income, Home Care with a value of 52.
Katie Beckett with values of 45, 50.
Missingness: Approximately 0.36% (N=334,091) of Medicaid enrollees were missing a value for ELGBLTY_GRP_CD_LTST, representing 0.29% ($1.9 billion) of Medicaid spending, and were thus not included in this analysis.
Spending: Spending was calculated by summing the total Medicaid paid amount on all claims for each Medicaid-eligible enrollee with the desired ELGBLTY_GRP_CD_LTST code in the T-MSIS claims files.
President Trump has made a slew of immigration policy changes focused on restricting entry at the border and increasing interior enforcement efforts to support mass deportation. These include rescinding protections against enforcement action in previously protected areas such as health care facilities and schools. While many of these actions focus on the estimated 11 million undocumented immigrants in the U.S., they will have ripple effects among the much larger number of people in immigrant families, including millions of U.S.-born citizen children. During the first Trump administration, restrictive immigration policies and increased enforcement activity led to increased fears among immigrant families across immigration statuses that had negative effects on health and well-being, employment, and daily life. They also could lead to family separations as well as mass detentions, which can have negative mental and physical health impacts on immigrants across statuses and their children. Mass deportations also could negatively impact the U.S. economy and workforce, given the role immigrants play, particularly in certain industries, including health care.
The extent to which President Trump will be able to carry out his plans without additional legislative action and in the face of potential court challenges remains uncertain. However, these plans are already affecting immigrants’ daily lives and increasing fears, with Immigrations and Customs Enforcement (ICE) agents carrying out raids across communities, and reports of nearly 1,000 people arrested in one recent day. This brief discusses the potential implications of increased enforcement actions under the Trump administration for the health and well-being of families and potential broader impacts for communities, the workforce, and the economy, including health care.
Upon taking office, President Trump issued a series of executive orders focused on restricting immigration and increasing interior enforcement activity. These include orders limiting birthright citizenship, declaring a national emergency at the Southern border and restricting access at the border, expanding enforcement policies, suspending the refugee admissions program, and rescinding numerous Biden-era policies, including a policy that protected against enforcement in “sensitive areas,” including schools and health care facilities. Many of the changes outlined in the orders may require legislative or regulatory action to implement, and many are likely to be challenged in court. For example, a federal judge has already blocked the order to end birthright citizenship through a temporary restraining order. However, these changes are already increasing fears and uncertainty among families and communities. Other changes may put other groups with lawful status at risk of losing protections, including Deferred Action for Childhood Arrivals (DACA) recipients and people with Temporary Protected Status (TPS) designations from some countries. The administration recently revoked TPS for Venezuelans living in the U.S., which will make them at risk for deportation in coming months and eliminate their work authorizations.
While enforcement actions are focused on undocumented immigrants, they will have ripple effects across millions more people living in immigrant families, including U.S.-born citizen children. As of 2023, there were 47.1 million immigrants residing in the U.S., including 22.4 million noncitizen immigrants, of whom an estimated 11 million are undocumented. Additional immigrants that currently have lawful statuses may be at risk for enforcement actions under new policies if they lose protections, including nearly 1.2 million immigrants who either have or are eligible for TPS, the over 530,000 active DACA recipients, and individuals in the U.S. with pending asylum cases. Millions of additional individuals living in immigrant families also are likely to be impacted. Many undocumented immigrants live in families with mixed immigration statuses that may include people with lawful status and U.S. citizens. As of 2023, 19 million, or one in four, children in the U.S. had an immigrant parent, including one in ten (12%) who are citizen children with a noncitizen parent. An estimated 4.4 million U.S.-born children live with an undocumented immigrant parent.
Prior KFF focus groups with immigrant families during the first Trump administration found that restrictive immigration policies, including increases in detention and deportation, led to increased fears among immigrant families across immigration statuses that had negative effects on health and well-being. Immigrant families, including those with lawful status, reported experiencing resounding levels of fear and uncertainty. Some also reported changes in daily life such as increased difficulty finding employment, leading to increased financial strains on families. Some parents, particularly those who are undocumented or who have an undocumented family member, said they would only leave the house when necessary, such as for work; limit driving; or no longer participate in recreational activities, leading to children spending many hours inside. Parents and pediatricians reported a broad array of impacts of increased fears among children, including behavioral changes, such as problems sleeping and eating; psychosomatic symptoms, such as headaches and stomachaches; and mental health issues, such as depression and anxiety. Parents and pediatricians also felt that fears negatively affected children’s behavior and performance in school. Pediatricians expressed significant concerns about the long-term health consequences of these fears for children, including the damaging effects of toxic stress on physical and mental health over the lifespan, negative effects on children’s growth and development, and compounding social and environmental challenges that negatively impact health.
Increased fears under the first Trump Administration also led to growing reluctance among some families, including lawfully present immigrants and citizen children, about participating in programs and seeking services for which they are eligible, including health coverage and care. In KFF focus groups with immigrant families during the first Trump administration, parents noted that they highly prioritize their children’s health and generally viewed hospitals and doctors’ offices as safe spaces. However, there were some reports of changes in health care use, including decreased use of some care, and decreased participation in Medicaid and CHIP and other programs due to increased immigration-related fears. Despite efforts by the Biden administration to reduce these fears, data from the KFF/LA Times Survey of Immigrants showed that, as of 2023, nearly seven in ten (69%) likely undocumented immigrants, a third (33%) of lawfully present immigrants, and over one in ten (12%) naturalized citizen immigrants said they ever worried that they or a family member could be detained or deported. Moreover, about a quarter (27%) of likely undocumented immigrants and nearly one in ten (8%) lawfully present immigrants say they avoided applying for food, housing, or health care assistance in the past year due to immigration-related fears (Figure 1). Fears about accessing health care services may be enhanced under the second Trump administration, given the recission of a policy dating back to 2011, that protected against enforcement activity in sensitive areas, including health care facilities. Health care providers will face new challenges helping families feel safe accessing health care, protecting patient information, and establishing protocols to respond to potential encounters with ICE agents. Additionally, Florida and Texas have implemented policies that require hospitals to request immigration status from patients, which may further enhance fears about accessing care.
KFF interviews with individuals who had a family member detained or deported during the first Trump administration reported broad negative impacts on health and well-being. Respondents reported that detention and deportation of family members often occurred suddenly and unexpectedly, leaving families in shock and unprepared. One of the most immediate and significant effects on families was the loss of income, which left them struggling to pay their bills, including rent, food, and utilities. They further reported disruptions to children’s daily lives, and, in some cases, older children assuming new responsibilities and changing plans, such as no longer attending college, to support the family. Families also reported direct health impacts, including symptoms of depression and worsening chronic conditions. Some families reported losing health coverage and increased barriers to accessing coverage or care due to fears and increased financial challenges.
Other research shows that immigration enforcement raids and family separations can lead to worsened physical and mental health of both parents and children of deported parents. Exposing children to traumatic events and prolonged or toxic stress such as raids and separation from a parent disrupts a child’s healthy development and can result in short- and long-term negative effects on physical, mental, and behavioral health. Research has found that living near areas subject to immigration enforcement raids increased the risk of negative mental health among children of immigrants and worse birth outcomes among both Hispanic immigrant mothers as well as U.S.-born Hispanic mothers as compared to non-Hispanic White mothers. Education outcomes also worsened among Hispanic children in areas impacted by raids compared to White children. One potential consequence of raids and detentions and deportations is the separation of parents from their children. Studies have found that children and caregivers impacted by family separations experience worse mental health, including anxiety, depression, and posttraumatic stress disorder. Family separations can also lead to financial challenges for mixed-status households due to loss of income.
Prior experience suggests that immigrants held in detention facilities may not receive sufficient health care and face unsafe conditions. As the Trump administration escalates enforcement actions, the number of people held in detention facilities will grow likely beyond current capacity. Research showed that detainees, including children, experience poor conditions and inadequate care in detention facilities. An analysis found that most of the deaths of immigrants in detention occurred among “relatively young and healthy men” and were associated with ICE violating their own medical standards. Detention and solitary confinement can also worsen the mental health of immigrants. Studies show high levels of psychiatric distress, including depression and post-traumatic stress, among detained immigrants and their children, even after short detention periods. Research on immigrant detention centers have also found gaps in care for pregnant Hispanic migrants and that LGBT detainees experience higher rates of harassment than non-LGBT detainees.
Mass deportations could also negatively impact the U.S. workforce, given the role immigrants play, particularly in certain industries, including health care. Most immigrants say they came to the U.S. for better work and educational opportunities. Immigrants and their U.S.-born children fill unmet labor market needs and have been the primary drivers of workforce growth, accounting for 83% of the growth in the U.S. labor force between 2010 and 2018. Research shows that immigration does not displace nor lead to more unemployment among U.S. born workers as they often do not compete for the same jobs. Immigrants and their adult children play outsized roles in certain occupations, including agriculture, construction, and health care (Figure 1). As the U.S. 65 and older population grows, deportation of immigrants may exacerbate the health care workforce shortage. Immigrants and their adult children make up a larger share of physicians, surgeons, and other health care practitioners than they do of the population and play a particularly large role as direct care workers in home and community-based settings.
Mass deportations may also reduce the billions of dollars immigrants, including undocumented immigrants, pay in federal, state, and local taxes, which help subsidize health care for U.S.-born citizens. It is estimated that more than a third of their tax dollars are payroll taxes that fund programs they cannot access, including Social Security, Medicare, and the federal share of unemployment insurance. Children of immigrants also contribute more in taxes on average than their parents or the rest of the U.S.-born population. The Congressional Budget Office (CBO) estimates that the recent immigration surge will reduce the federal deficit over the next decade. Research further finds that immigrants pay more into the health care system through taxes and health insurance premiums than they utilize, helping to subsidize health care for U.S.-born citizens. Earlier research found that without the contributions undocumented immigrants make to the Medicare Trust Fund, it would reach insolvency earlier, and that undocumented immigrants result in a net positive effect on the financial status of Social Security.
Expanding capacity to carry out mass deportations would likely be a significant cost to taxpayers and may require additional allocations by Congress. New estimates suggest that Trump’s plan to deport millions of undocumented immigrants could cost hundreds of billions of dollars. Trump’s selected border czar reported an estimated cost of $86 billion. Increases in enforcement activity would likely strain limited resources at ICE and the current system of detention centers, which is already at capacity. Expanding detention capacity to support large-scale deportations would require large investments in infrastructure, including setting up new detention facilities, expanding immigration court capacity, increasing the use of private contractors, and paying for more flights used for deportations.
This resource provides visualizations on the U.S. global health budget and will be updated as needed. Click through the table of contents to jump to different figures.
Centene, CVS Health, Elevance, Molina, and UnitedHealth are the five largest publicly traded companies (also referred to as “parent” firms) operating Medicaid MCOs, accounting for half of Medicaid MCO enrollment nationally. During the unwinding of the pandemic-era Medicaid continuous enrollment provision, millions of people were disenrolled and states and plans have faced considerable rate setting uncertainty. Firms report current capitation rates do not align with higher member risk and utilization patterns, and many states have sought federal approval to adjust rates to address these shifts. As we look ahead, shifts in state fiscal conditions and talks in Congress about cutting federal Medicaid spending could result in the reductions in Medicaid funding with implications for coverage as well as plans and providers. While plans confront continued uncertainty looking ahead, plan attention and scrutiny has intensified in the aftermath of the killing of UnitedHealthcare’s CEO, Brian Thompson. Within this broad context, this brief examines enrollment and financial data through the end of September 2024 from quarterly company earnings reports and calls, financial filings, and other company materials as well as from national administrative data. Key findings include:
Five for-profit, publicly traded companies – Centene, Elevance (formerly Anthem), UnitedHealth Group, Molina, and CVS Health – account for 50% of Medicaid MCO enrollment nationally (Figure 1). All five are ranked in the Fortune 500. Each company operates Medicaid MCOs in 14 or more states (Figure 2).
All five firms also operate in the commercial and Medicare markets (Figure 3); however, the distribution of membership across markets varies across firms. Two firms – Molina and Centene – have historically focused predominantly on the Medicaid market. Medicaid members accounted for nearly 90% of Molina’s overall medical membership and about 60% of Centene’s medical membership as of September 2024 (Figure 3). Since March 2023 (just before unwinding began), Medicaid membership as a share of total medical membership has declined for all five firms, ranging from a decline of about 1 percentage point for UnitedHealth to 8 percentage points for Centene. The unwinding may have contributed to membership distribution shifts.
Despite a combined 7.3 million decline in enrollment during the unwinding, Medicaid enrollment across the five firms remains higher by 6.2 million (or 20%) compared to enrollment at the start of the pandemic (Figure 4). In comparison, national data show total Medicaid/CHIP enrollment in September 2024 was 11% higher than Medicaid/CHIP enrollment in February 2020, prior to the pandemic. These changes in “net” enrollment reflect the people who are dropped from Medicaid as well as those who newly enroll, and those who re-enroll within a short timeframe following disenrollment, also known as “churn.” Changes in parent firm enrollment also reflect activity including firm acquisitions or sales and new or lost Medicaid contracts.
While some firms report growth in Medicaid revenue through the end of September 2024, other measures of financial performance (gross margins and medical loss ratios) show a potential decrease in profitability (Figure 5). Even accounting for enrollment declines due to the unwinding, the three firms that report Medicaid-specific financial information through Q3 (UnitedHealth, Molina, and Centene) reported growth in Medicaid revenue in the first nine months of 2024 compared to the same period in 2023. For the first nine months of 2024, medical margins (the amount by which premium revenue exceeds medical costs) earned by the Medicaid segment declined by 27% for Centene and 2% for Molina when compared to the same period in 2023, and Medicaid simple medical loss ratios (medical costs as a share of premium revenue) increased for Centene from 89.9% to 92.3% and for Molina from 88.5% to 90.3%, implying a potential decrease in profitability.
During Q3 2024 earnings calls, firms reported current capitation rates do not align with increased Medicaid medical cost trends. Capitation provides upfront fixed payments to plans for expected utilization of covered services, administrative costs, and profit (see Box 1). Plan capitation rates, usually for a 12-month rating period, are set using baseline utilization and cost data from prior periods (which can lag one to two years, to allow claims to complete) trended forward to determine per member per month payment amounts. States may also use different mechanisms to adjust plan risk (e.g., to ensure payments are not too high or too low), including risk-sharing arrangements (see Box 1). During Q3 2024 earnings calls, firms reported higher member acuity (i.e., average risk profile) due to unwinding redeterminations as well as increased utilization trends in 2024. Specifically, firms pointed to increased utilization of behavioral health care, pharmaceuticals (including GLP-1s), and long-term services and supports (LTSS).
A recent analysis conducted by Wakely, a consulting firm with actuarial expertise, highlights many states have recently implemented program changes to improve access to care (e.g., increasing provider rates, implementing limitations to prior authorization, etc.), which can affect utilization trends and put upward pressure on per person costs. Wakely notes that these program changes may be adding complexity to an “already challenging year for capitation rate setting.”
Parent firms expect the misalignment between rates and emerging acuity and cost/utilization trends is temporary but may extend through 2025. In a 2024 KFF survey of Medicaid directors, about two-thirds of responding MCO states reported seeking CMS approval for a capitation rate amendment to address shifts in the average risk profile (or “acuity”) of MCO members in FY 2024 and/or FY 2025. During earnings calls, firms say that the rate updates they have received fall short of covering current acuity and cost trends. Parent firms also report continuing discussions with states on adjustments to 2024 rates and on the development of 2025 rates (which often renew on January 1 or July 1). Centene and Elevance reported sharing current experience / trend data with states to inform these discussions.
Box 1: Medicaid Managed Care Capitation Rate Setting
MCOs are at financial risk for services covered under their contracts, receiving a per member per month “capitation” payment for these services. While plans set rates in the commercial and Medicare Advantage markets, Medicaid managed care rates are developed by states and their actuaries and reviewed and approved by CMS. Under federal law, payments to Medicaid MCOs must be actuarially sound. Actuarial soundness means that “the capitation rates are projected to provide for all reasonable, appropriate, and attainable costs that are required under the terms of the contract and for the operation of the managed care plan for the time period and the population covered under the terms of the contract.” Unlike fee-for-service, capitation provides upfront fixed payments to plans for expected utilization of covered services, administrative costs, and profit.
In developing actuarially sound rates, states must follow accepted actuarial methods and specific federal requirements outlined in regulations and other guidance. Plan rates, usually for a 12-month rating period (which typically run on a state fiscal year or a calendar year basis), are set using baseline utilization and cost data from prior periods (which can lag one to two years, to allow claims to complete). Baseline spending data is trended forward to determine per member per month payment amounts and must take into account/adjust for factors such as medical cost inflation, expected changes in utilization, and state Medicaid program changes (e.g., changes to eligibility, benefits, cost-sharing, FFS payment rate changes (if state bases managed care rates on FFS rates)).
States may use a variety of mechanisms to adjust plan risk, incentivize plan performance, and ensure payments are not too high or too low, including risk-sharing arrangements (including risk corridors), risk and acuity adjustments, medical loss ratios (MLRs, which reflect the proportion of total capitation payments received by an MCO spent on clinical services and quality improvement), or incentive and withhold arrangements. (Many states implemented pandemic-related “risk corridors” (where states and health plans agree to share profit or losses), allowing for the recoupment of funds.) Even if the risk mitigation strategies are in place, states may determine rate amendments are necessary if their actual experience differs significantly from the assumptions used for the initial certified rates.
Starting on day one of his second term, President Trump began to issue several executive orders and other actions that affect global health. One was “Reevaluating and Realigning United States Foreign Aid” which calls for a 90-day pause in new foreign assistance obligations and disbursements pending review of all foreign aid programs. A notice sent to all diplomatic and consular officials on January 24 implementing the order went further, requiring stop-work orders to be issued for all existing foreign assistance awards, effectively halting implementation of U.S. global health efforts, including PEPFAR, in low and middle-income countries around the world. While PEPFAR was issued a limited waiver a week later, allowing it to restart some services, the situation remains fluid and fast-moving, intersects with several other executive orders and an apparent effort to dissolve USAID (the U.S. international development agency which implements most U.S. global health programs) as an independent agency. In addition, no waivers for other global health programs have been announced. This policy watch provides an overview of what has happened to date, as of February 3, 2025.
What does the Executive Order (EO) pausing foreign aid do? The order, issued on January 20, 2025, was one of the first to be issued by the President. It states that “It is the policy of United States that no further United States foreign assistance shall be disbursed in a manner that is not fully aligned with the foreign policy of the President of the United States” and calls for two main actions:
Determinations are to be made within 90 days about whether to continue, modify, or cease programs based on the review, with the concurrence of the Secretary of State. New obligations and disbursements may resume prior to the end of the 90-day period if a review and a determination are made to do so. The EO also allows the Secretary of State to waive the pause for specific programs but does not provide criteria for waivers.
Why was the executive order issued? The rationale for the order appears to be based on both economic efficiency and ideological grounds. According to its preamble, the U.S. “foreign aid industry and bureaucracy are not aligned with American interests and in many cases antithetical to American values. They serve to destabilize world peace by promoting ideas in foreign countries that are directly inverse to harmonious and stable relations internal to and among countries.” A media note issued by the State Department states that the EO is “rooting out waste” and “blocking woke programs.” It also states that “Every dollar we spend, every program we fund, and every policy we pursue must make America safer, stronger, and more prosperous”, a statement made Secretary Rubio during his confirmation hearing and one that underpins the current department’s mission and priorities in Trump’s second term. These ideas also echo several that were included in Project 2025’s Mandate for Leadership, a set of recommendations for the next Republican president released in 2023 by a coalition of conservative organizations. For example, Project 2025 called for freezing foreign aid pending a review by political appointees (p. 174), refocusing “attention away from the special interests and social experiments that are used in some quarters to capture U.S. foreign policy” (p. 196), realigning U.S. foreign assistance “with American national interests and the principles of good governance” and undoing “the gross misuse of foreign aid by the current Administration to promote a radical ideology that is politically divisive at home and harms our global standing” (p. 279).
What is the “stop-work”order and is that different than the pause of new funds? While the EO calls for a pause on new foreign assistance obligations and disbursements (funds that have already been appropriated by Congress usually for specific programs or activities but have not yet gone to programs), a notice sent to all diplomatic and consular officials on January 24 went further. It requires all grant and contract officers to immediately issue stop-work orders for all existing foreign assistance awards (not just new obligations and disbursements) until a review is conducted. This means that work already underway with funding provided to organizations must be immediately stopped, such as clinics providing services, health care workers being funded, and other activities. The notice indicates that waivers had been granted for foreign military financing for Israel and Egypt and emergency food assistance (as well as some salaries and administrative costs).
Have any waivers been granted? While the EO notice indicates that waivers for foreign military financing for Israel and Egypt and emergency food assistance have been granted, it does not provide any further detail or indicate what the process is for requesting a waiver. Separately, on January 28, Secretary Rubio announced that he had issued an additional emergency humanitarian waiver, which allows implementers of “existing life-saving humanitarian assistance programs” to continue or resume work. The waiver is temporary and does not apply to new contracts (unless a separate waiver is granted). Life-saving humanitarian assistance is defined as “core life-saving medicine, medical services, food, shelter, and subsistence assistance, as well as supplies and reasonable administrative costs as necessary to deliver such assistance.”
While additional waivers could be requested through the Director of Foreign Assistance at the Department of State, several activities are not eligible for waivers at all, including those that involve: abortions (which are not paid for using U.S. government funds anyway), family planning, conferences, administrative costs other than those covered by the humanitarian assistance waiver, gender or DEI ideology programs, transgender surgeries, or other non-life saving assistance. Some of these services are also the subject of other executive orders and actions issued by the President include (including “Ending Radical And Wasteful Government DEI Programs And Preferencing” and “Defending Women from Gender Ideology Extremism And Restoring Biological Truth to The Federal Government”).
Despite the emergency humanitarian waiver specifying life-saving medicine and medical services, it was still unclear what programs it actually applied to and whether it included services provided by PEPFAR, the President’s Malaria Initiative, and other health programs, since under the State Department’s framework for foreign aid, health programs and humanitarian assistance efforts are categorized separately. As a result, the PEPFAR program applied for a specific waiver, which was granted on February 1, for certain activities. No other waivers have been announced for any other U.S. global health program, such as for the President’s Malaria Initiative (PMI), TB, maternal and child health, and nutrition activities.
What does PEPFAR’s limited waiver allow for? PEPFAR’s limited waiver, granted on February 1, allows for some PEPFAR services to resume during the 90-day period (unless other guidance is issued). Specifically, the waiver was granted to “implement urgent life-saving HIV treatment services in alignment with the Secretary of State’s January 28 memo “Emergency Humanitarian Waiver to Foreign Assistance Pause.” Life-saving HIV treatment is defined by the waiver as follows:
Activities covered by the waiver may be resumed, including new disbursements and limited obligations (only where pre-planned obligations already existed for the activities or where they otherwise could not be restarted without new obligations). No other activities can be resumed. The waiver indicates that the PEPFAR program will create an interagency team to provide ongoing guidance to programs.
What are the implications of stopping U.S. global health programs? The stop-work orders on existing awards and pause on new obligations and disbursements have, for the time being, halted current U.S. global health (and other foreign assistance) programs, other than activities permitted under PEPFAR’s limited waiver. This is because health care workers have been told to stop work, clinics are having to close, and commodities and other supplies cannot be provided to clients, affecting access for millions of individuals around the world, many of whom are women and children. Some of the interventions at risk of interruption and discontinuation are:
Beyond these direct impacts on access to services for people, hundreds of health care and aid workers have lost their jobs and it is expected that many more will as well, and there are widespread reports of confusion as criteria are not often specified, changes are rapid, and high level health officials at the agency which has historically overseen implementation of many of these programs, have been placed on leave.
What happens next? The implications of the pause in global health efforts will likely increase over the 90-day period, as additional programs and activities — those without waivers — are forced to shut down and lay off staff, and more people are unable to get services. The review of foreign aid programs is also underway. Depending on the results of the review, some programs may be recommended for continuation, modification, or may be discontinued. For those that are allowed to continue, it is not clear whether they will still have the capacity (staff, clinic infrastructure, systems) to be able to do so. There is also some confusion regarding the legal status of the foreign aid EO, given that a separate administrative action requiring all federal agencies to temporarily pause all new obligations and disbursements of all Federal financial assistance to ensure compliance with EOs has been successfully challenged in court and temporary restraining orders are in effect, preventing any pause. There are also reports that a lawsuit may be brought specifically challenging the foreign aid EO. Finally, Congress could step in. Congress has oversight of foreign aid programs and, in some cases, Congressional notification is required for program changes. Still, only Democratic Senators have publicly weighed in on the foreign aid freeze and other changes underway thus far (https://www.foreign.senate.gov/press/dem/release/ranking-members-shaheen-schatz-meeks-frankel-we-cannot-afford-to-take-a-timeout-from-usaid-programs and https://www.coons.senate.gov/news/press-releases/senator-coons-decries-president-trumps-freeze-on-almost-all-foreign-assistance-in-speech-on-senate-floor) and it is unclear if additional oversight efforts will be made.
Enhanced Affordable Care Act (ACA) subsidies were first made available as part of the American Rescue Plan Act in 2021 and were extended through the end of 2025 by the Inflation Reduction Act. The enhanced subsidies build on the ACA’s original tax credits by increasing the amount of premium assistance lower-income enrollees receive, and by making middle- and higher-income enrollees (with incomes over four times poverty) newly eligible for financial assistance to buy health insurance. These enhanced subsidies will expire at the end of this year unless Congress further extends them and President Trump signs it into law. In 2024, 56% of ACA Marketplace enrollees live Congressional Districts represented by Republicans and 76% of enrollees are in states won by President Trump in the 2024 election.
If the enhanced subsidies expire, monthly premium payments for the vast majority of Marketplace enrollees will increase sharply starting January 1, 2026. Among subsidized enrollees living in states that use Healthcare.gov (where data are available), premium payments would have been an average of 93% higher in 2024 without the enhanced tax credits. If these enhanced subsidies expire, the Congressional Budget Office (CBO) projects that there will be an average of 3.8 million more uninsured people each year. Unsubsidized premiums will also likely rise as healthier enrollees drop their coverage. While some state-based Marketplaces offer additional premium financial assistance for certain enrollees, the amount of and availability of these state subsidies would not be enough to fully replace the federal enhanced subsidies.
The interactive map below illustrates how much premium payments would rise without the enhanced subsidies, net of tax credits, at the congressional district level. The tool presents average net premium increases (for states that use Healthcare.gov, where data are available) and two hypothetical scenarios (in all states): one of an older couple who would lose subsidy eligibility due to their income exceeding four times poverty and another for a single individual with a $31,000 income (206% of poverty). A KFF calculator allows users to evaluate zip-code specific changes in premium payments with and without enhanced subsidies for other income and family scenarios.
Because enhanced tax credits decrease premium payments across the board for people receiving a tax credit, all subsidized Marketplace enrollees will experience increases in their monthly premium payments if the enhanced subsidies expire. However, how much each enrollee’s premium payment increases will vary widely and will depend on their family size, location, and income.
In some congressional districts, there is both a large share of the population enrolled in ACA Marketplace coverage and an expectation of very high average increases in premium payments without the enhanced tax credits. Among states that use Healthcare.gov (where average enhanced tax credit data are available), there are 39 congressional districts where at least 10% of the population is enrolled in the ACA Marketplaces and where 2024 average premium payments would have been double or more had it not been for the enhanced subsidies (Table 1). While these 39 districts are politically split (19 are represented by Democrats and 20 are represented by Republicans), these districts are mostly concentrated in a few red states. Twenty of these 39 districts are in Texas, 7 are in Florida, and 3 are in Georgia. These states are among those that have seen ACA Marketplace enrollment grow the most since the enhanced subsidies went into effect. Since 2020, ACA Marketplace enrollment has more than doubled in Florida and more than tripled in Texas and Georgia.
The expiration of the enhanced premium tax credits would mean that people with incomes over four times the poverty level are no longer eligible for financial assistance. Prior to the availability of enhanced subsidies, ACA Marketplace premium assistance eligibility capped at 400% of poverty (which is $60,240 for a single person or $81,760 for a couple in 2025). If enhanced subsidies expire, Marketplace enrollees making just above 400% of poverty will encounter the “subsidy cliff” and would face the full price of a Marketplace plan. If the enhanced subsidies expire, a 60-year-old couple making $82,000 (401% of poverty) would see their premium payment for the benchmark silver plan, on average, at least double in the vast majority of congressional districts. The benchmark silver premium for a 60-year-old couple at this income would triple or more, on average, in 328 congressional districts.
A 40-year-old Marketplace enrollee in the contiguous U.S. making $31,000 (206% of poverty) would see monthly premium payments in 2025 rise by $95 (a 165% increase) from $58 to $153. (Alaska and Hawaii have different poverty guidelines). Nationally, there are 75 congressional districts where at least 10% of the population is enrolled in the Marketplace. For a 40-year-old making $31,000, premium payments would at least double on average in all 75 districts. 62 of these districts are in Florida, Georgia and Texas. 38 of these 62 districts are represented by Republicans while 24 are represented by Democrats.
Under the enhanced phase out caps, Marketplace enrollees with incomes up to 150% of poverty currently pay zero (or near zero) dollars for a benchmark silver plan. Should the enhanced subsidies expire, enrollees in this income group will be on the hook for some of the cost of their premiums if they want to keep a silver plan. Before the enhanced subsidies went into effect, Marketplace enrollees at this income group paid about 2-4% of their income for a benchmark plan. A sizeable portion of the Marketplace population benefits from zero dollar premiums, with 42% of HealthCare.gov enrollees in 2024 paying nothing for Marketplace coverage (up from 14% of HealthCare.gov enrollees in 2021).
Methods
These maps visualize the 119th Congressional District boundaries in place for 2025-2026, as of September 2024. County to Congressional District designations are taken from the Missouri Census Data Center GeoCorr 2022 data.
Premium changes displayed for the average scenario are calculated using CMS data on subsidized HealthCare.gov enrollees in 2024. Average premiums by congressional district for income-specific scenarios are calculated using 2025 county-level premiums weighted by 2024 county-level plan selections, which are taken from a combination of CMS files, state-provided data, or estimated using plan selections from prior years when otherwise not available. When a county is part of multiple congressional districts, an allocation factor from the GeoCorr tool is used to apportion county-level plan selections among the congressional districts based on the 2020 decennial census. 2025 county-level premiums are collected from a combination of insurer rate filings, state regulatory authorities, or state shopping tools. Hypothetical premium payments without enhanced subsidies are calculated using indexed required contribution percentages provided by CBO. Premiums used in this map do not account for state-based premium assistance and may not reflect non-essential health benefits.
Enrollment by Congressional District displayed for HealthCare.gov states is taken from CMS data, while estimates are displayed for state-based Exchanges using plan selections for each county allocated to Congressional District using the GeoCorr allocation factor. To calculate the share of people in each Congressional District enrolled in the ACA Marketplace, total Marketplace enrollment is divided by Census estimates of population for the 119th Congressional Districts. For non-HealthCare.gov states, the share of population enrolled in an ACA Marketplace plan may differ from the estimate if population growth diverge from the proportions recorded in the Census.