Medicare 101

Name: Selected Demographic Characteristics of Medicare Beneficiaries, 2022
Creator: KFF

Published: October 8, 2025

Health Policy 101:

Introduction

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KFF Authors:

Juliette Cubanski ,

Meredith Freed ,

Nancy Ochieng ,

Alex Cottrill ,

Jeannie Fuglesten Biniek , and

Tricia Neuman

What Is Medicare?

Medicare is the federal health insurance program established in 1965 under Title XVIII of the Social Security Act for people age 65 or older, regardless of income or medical history, and later expanded to cover people under age 65 with long-term disabilities. Today, Medicare provides health insurance coverage to 68 million people, including 61 million people age 65 or older and 7 million people under age 65. Medicare covers a comprehensive set of health care services, including hospitalizations, physician visits, and prescription drugs, along with post-acute care, skilled nursing facility care, home health care, hospice, and preventive services. People with Medicare can choose to get coverage under traditional Medicare or Medicare Advantage private plans.

Medicare spending comprised 13.5% of the federal budget in 2024 and 21.2% of national health care spending in 2023. Funding for Medicare comes primarily from government contributions, payroll tax revenues, and premiums paid by beneficiaries. Over the longer term, the Medicare program faces financial pressures associated with higher health care costs, growing enrollment, and an aging population.

Who Is Covered by Medicare?

Most people become eligible for Medicare when they reach age 65, regardless of income, health status, or medical conditions. Residents of the U.S., including citizens and permanent residents, are eligible for premium-free Medicare Part A if they have worked at least 40 quarters (10 years) in jobs where they or their spouses paid Medicare payroll taxes and are at least 65 years old. People under age 65 who receive Social Security Disability Insurance (SSDI) payments generally become eligible for Medicare after a two-year waiting period. People diagnosed with end-stage renal disease (ESRD) and amyotrophic lateral sclerosis (ALS) become eligible for Medicare with no waiting period.

Medicare covers a diverse population in terms of demographics and health status, and this population is expected to grow larger and more diverse in the future as the U.S. population ages. Currently, most people with Medicare are White, female, and between the ages of 65 and 84 (Figure 1). The share of U.S. adults who are age 65 or older is projected to grow from 17% in 2022 to nearly a quarter of the nation’s total population (24%) in 2060. Among people ages 65 and older, the share of people ages 80 and older will increase from 23% in 2022 to 34% in 2060. As the U.S. population ages, the number of Medicare beneficiaries is projected to grow by more than one-third from 68 million people in 2024 to more than 93 million people in 2060. The Medicare population will also grow more racially and ethnically diverse. By 2060, people of color will comprise 44% of the U.S. population ages 65 and older, up from a quarter in 2022.

Selected Demographic Characteristics of Medicare Beneficiaries, 2022

While many Medicare beneficiaries enjoy good health, others live with health problems that affect their quality of life, including multiple chronic conditions, limitations in their activities of daily living, and cognitive impairments. In 2022, nearly half (45%) of Medicare beneficiaries had four or more chronic conditions, more than a quarter (28%) had a functional impairment, and 17% had a cognitive impairment (Figure 2).

Selected Measures of Health Status of the Medicare Population, 2022

Most Medicare beneficiaries have limited financial resources, including income and assets. In 2024, one in four Medicare beneficiaries - 16.5 million people with Medicare - lived on incomes below $24,600 per person, and half (32.9 million) of all Medicare beneficiaries lived on incomes below $43,200 per person; one in four Medicare beneficiaries had savings below $18,950 per person in 2024, while half had savings below $110,100 per person. Income among Medicare beneficiaries is generally lower for women than men, for people of color than White beneficiaries, and for beneficiaries under age 65 with disabilities than older beneficiaries (Figure 3).

Among Medicare Beneficiaries, Per Capita Income Declines with Age among Older Adults and Is Lower for Women, Black and Hispanic Beneficiaries, and Beneficiaries Under 65 (Split Bars)

What Does Medicare Cover and How Much Do People Pay for Medicare Benefits?

Benefits. Medicare covers a comprehensive set of medical care services, including hospital stays, physician visits, and prescription drugs. Medicare benefits are divided into four parts:

Part A, also known as the Hospital Insurance (HI) program, covers inpatient care provided in hospitals and short-term stays in skilled nursing facilities, hospice care, post-acute home health care, and pints of blood received at a hospital or skilled nursing facility. An estimated 67.5 million people were enrolled in Part A in 2024. In 2023, 13% of beneficiaries in traditional Medicare had an inpatient hospital stay, while 7% used home health care services (which are also covered under Part B), and 3% had a skilled nursing facility stay (Figure 4). (Comparable utilization data for beneficiaries in Medicare Advantage is not available.)
Part B,the Supplementary Medical Insurance (SMI) program, covers outpatient services such as physician visits, outpatient hospital care, and preventive services (e.g., mammography and colorectal cancer screening), among other medical benefits. An estimated 62 million people were enrolled in Part B in 2024. A larger share of beneficiaries use Part B services compared to Part A services. For example, in 2023, more than 9 in 10 (92%) traditional Medicare beneficiaries used physician and other services covered under Part B and 59% used outpatient hospital services.
Part C, more commonly referred to as the Medicare Advantage program, allows beneficiaries to enroll in a private plan, such as a health maintenance organization (HMO) or preferred provider organization (PPO), as an alternative to traditional Medicare. Medicare Advantage plans cover all benefits under Medicare Part A, Part B, and, in most cases, Part D (Medicare’s outpatient prescription drug benefit), and typically offer extra benefits, such as dental services, eyeglasses, and hearing exams. In 2025, 34.1 million beneficiaries are enrolled in Medicare Advantage, which is 54% of Medicare beneficiaries who are eligible to enroll in Medicare Advantage plans. (See “What Is Medicare Advantage and How Is It Different From Traditional Medicare?” for additional information.)
Part D is a voluntary outpatient prescription drug benefit delivered through private plans that contract with Medicare, either stand-alone prescription drug plans (PDPs) or Medicare Advantage prescription drug (MA-PD) plans. In 2025, 54.8 million beneficiaries are enrolled in Part D, with 58% enrolled in MA-PDs and 42% enrolled in PDPs. In 2023, over 9 in 10 Medicare beneficiaries enrolled in Part D (93%) used prescription drugs. (See “What Is the Medicare Part D Prescription Drug Benefit?” for additional information.)

Use of Selected Medicare-Covered Services by People with Medicare in 2023

Although Medicare covers a comprehensive set of medical benefits, Medicare does not cover long-term care services. Additionally, coverage of vision services, dental care, and hearing aids is not part of the standard benefit, though most Medicare Advantage plans offer some coverage of these services.

Premiums and cost sharing. Medicare has varying premiums, deductibles, and coinsurance amounts that typically change each year to reflect program cost changes.

Part A: Most beneficiaries do not pay a monthly premium for Part A services, but are required to pay a deductible for inpatient hospitalizations ($1,676 in 2025). (People who are working contribute payroll taxes to Medicare and qualify for premium-free Part A at age 65 based on having paid 1.45% of their earnings over at least 40 quarters.) Beneficiaries are generally subject to cost sharing for Part A benefits, including extended inpatient stays in a hospital ($419 per day for days 61-90 and $838 per day for days 91-150 in 2025) or skilled nursing facility ($209.50 per day for days 21-100 in 2025). There is no cost sharing for home health visits.
Part B: Beneficiaries enrolled in Part B, including those in traditional Medicare and Medicare Advantage plans, are generally required to pay a monthly premium ($185 in 2025). Beneficiaries with annual incomes greater than $106,000 for a single person or $212,000 for a married couple in 2025 pay a higher, income-related monthly Part B premium, ranging from $259 to $628.90. Approximately 8% of Medicare beneficiaries with Part B coverage are expected to pay income-related Part B premiums in 2025. Part B benefits are subject to an annual deductible ($257 in 2025), and most Part B services are subject to coinsurance of 20 percent.
Part C: In addition to paying the Part B premium, Medicare Advantage enrollees may be charged a separate monthly premium for their Medicare Advantage plan, although three-quarters (76%) of enrollees are in plans that charge no additional premium in 2025. Medicare Advantage plans are generally prohibited from charging more than traditional Medicare, but vary in the deductibles and cost-sharing amounts they charge. Medicare Advantage plans typically establish provider networks and may require higher cost sharing for services received from non-network providers.
Part D: Part D plans vary in terms of premiums, deductibles, and cost sharing. People in traditional Medicare who are enrolled in a separate stand-alone Part D plan generally pay a monthly Part D premium unless they qualify for full benefits through the Part D Low-Income Subsidy (LIS) program and are enrolled in a premium-free (benchmark) plan. In 2025, the average enrollment-weighted premium for stand-alone Part D plans is $39 per month, substantially higher than the enrollment-weighted average monthly portion of the premium for drug coverage in MA-PDs ($7 in 2025).

Sources of coverage. Most people with Medicare have some type of coverage that may protect them from unlimited out-of-pocket costs and may offer additional benefits, whether it’s coverage in addition to traditional Medicare or coverage from Medicare Advantage plans, which are required to have an out-of-pocket cap and typically offer supplemental benefits (Figure 5). However, based on KFF analysis of data from the 2022 Medicare Current Beneficiary Survey, 3.2 million people with Medicare have no additional coverage, which places them at risk of facing high out-of-pocket spending or going without needed medical care due to costs.

Medicare Advantage plans now cover more than half (54%) of all Medicare beneficiaries enrolled in both Part A and Part B, or 34 million people (in 2022, Medicare Advantage enrollment was just under half of beneficiaries, or 29.9 million people). (See “What Is Medicare Advantage and How Is It Different From Traditional Medicare?” for additional information.)
Employer and union-sponsored plans provided some form of coverage to 14.5 million Medicare beneficiaries – nearly a quarter (24%) of Medicare beneficiaries overall in 2022. Of the total number of beneficiaries with employer coverage, 9.1 million beneficiaries had this coverage in addition to traditional Medicare (31% of beneficiaries in traditional Medicare), while 5.4 million beneficiaries were enrolled in Medicare Advantage employer group plans. (These estimates exclude 5.6 million Medicare beneficiaries with Part A only in 2022, primarily because they or their spouse were active workers and had primary coverage from an employer plan and Medicare as a secondary payer.)
Medicare supplement insurance, also known as Medigap, covered 2 in 10 (21%) Medicare beneficiaries overall, or 42% of those in traditional Medicare (12.5 million beneficiaries) in 2022. Medigap policies, sold by private insurance companies, fully or partially cover Medicare Part A and Part B cost-sharing requirements, including deductibles, copayments, and coinsurance.
Medicaid, the federal-state program that provides health and long-term services and supports coverage to low-income people, was a source of coverage for 11.6 million Medicare beneficiaries with low incomes and modest assets in 2022 (19% of all Medicare beneficiaries), including 7.0 million enrolled in Medicare Advantage and 4.6 million in traditional Medicare. (This estimate is somewhat lower than KFF estimates published elsewhere due to different data sources and methods used.) For these beneficiaries, referred to as dual-eligible individuals, Medicaid typically pays the Medicare Part B premium and may also pay a portion of Medicare deductibles and other cost-sharing requirements. Most dual-eligible individuals are eligible for full Medicaid benefits, including long-term services and supports.

Nearly all People with Medicare Had Coverage Either Through Medicare Advantage Plans or Traditional Medicare Coupled with Some Other Type of Coverage in 2022

What Is Medicare Advantage and How Is It Different From Traditional Medicare?

Medicare Advantage, also known as Medicare Part C, allows beneficiaries to receive their Medicare benefits from a private health plan, such as a health maintenance organization (HMO) or preferred provider organization (PPO). Medicare pays private insurers to provide Medicare-covered benefits (Part A and B, and often Part D) to enrollees. Virtually all Medicare Advantage plans include an out-of-pocket limit for benefits covered under Parts A and B, and most offer additional benefits not covered by traditional Medicare, such as vision, hearing, and dental. The average Medicare beneficiary can choose from 34 Medicare Advantage plans with prescription drug coverage offered by eight insurance companies in 2025. These plans vary across many dimensions, including premiums, cost-sharing requirements, out-of-pocket limits, extra benefits, provider networks, prior authorization and referral requirements, denial rates, and prescription drug coverage.

More than half of all eligible Medicare beneficiaries (54%) are currently enrolled in a Medicare Advantage plan, up from 25% in 2010 (Figure 6). The share of eligible Medicare beneficiaries in Medicare Advantage plans varies across states, ranging from 2% in Alaska to 63% in Alabama and Michigan. Growth in Medicare Advantage enrollment is due to a number of factors. Medicare beneficiaries are attracted to Medicare Advantage due to the multitude of extra benefits, the simplicity of one-stop shopping (in contrast to traditional Medicare where beneficiaries might also purchase a Part D plan and a Medigap plan), and the availability of plans with no premiums beyond the Part B premium, driven in part by the current payment system that generates high gross margins in this market (see “How Does Medicare Pay Private Plans in Medicare Advantage and Medicare Part D?” for additional information). Insurers market these plans aggressively, airing thousands of TV ads for Medicare Advantage during the Medicare open enrollment period. In some cases, Medicare beneficiaries have no choice but to be enrolled in a Medicare Advantage plan for their retiree health benefits as some employers are shifting their retirees into these plans; if they are dissatisfied with this option, they may have to give up retiree benefits altogether, although they would retain Medicare and have the option to choose traditional Medicare (potentially with a Medigap supplement).

More Than Half (54%) of Eligible Medicare Beneficiaries Are Enrolled in a Medicare Advantage Plan in 2025

There are several differences between Medicare Advantage and traditional Medicare. Medicare Advantage plans can establish provider networks, the size of which can vary considerably for both physicians and hospitals, depending on the plan and the county where it is offered. These provider networks may also change over the course of the year. Medicare Advantage enrollees who seek care from an out-of-network provider might be required to pay higher cost sharing or pay in full out of pocket for their care. In contrast, traditional Medicare beneficiaries can see any provider that accepts Medicare and is accepting new patients. In 2019, 89% of non-pediatric office-based physicians accepted new Medicare patients, with little change over time. Only 1% of all non-pediatric physicians formally opted out of the Medicare program in 2024.

Medicare Advantage plans also often use tools to manage utilization and costs, such as requiring enrollees to receive prior authorization before a service will be covered and requiring enrollees to obtain a referral for specialists or mental health providers. In 2024, virtually all Medicare Advantage enrollees were in plans that required prior authorization for some services, most often higher-cost services. Medicare Advantage insurers made nearly 50 million prior authorization determinations in 2023 (Figure 7). Prior authorization and referrals to specialists are used less frequently in traditional Medicare, with prior authorization generally applying to a limited set of services.

Medicare Advantage Insurers Made Nearly 50 Million Prior Authorization Determinations in 2023

Medicare Advantage plans are required to use payments from the federal government that exceed their costs of covering Part A and B services (known as rebates) to provide supplemental benefits to enrollees, such as lower cost sharing, extra benefits not covered by traditional Medicare, or reducing the amount of Part B and/or Part D premiums. Examples of extra benefits include eyeglasses, hearing exams, preventive dental care, and gym memberships (Figure 8). (See “How Does Medicare Pay Private Plans in Medicare Advantage and Medicare Part D?” for a discussion of how Medicare pays Medicare Advantage plans.) Medicare Advantage plans must also include a cap on out-of-pocket spending, which provides protection from catastrophic medical expenses. Traditional Medicare does not have an out-of-pocket limit, though purchasing a Medigap policy effectively provides protection from catastrophic costs for beneficiaries in traditional Medicare. (See “What Does Medicare Cover and How Much Do People Pay for Medicare Benefits?” for a brief discussion of Medigap.)

Most Medicare Advantage Enrollees in Plans Available for General Enrollment Have Access to Some Benefits Not Covered by Traditional Medicare in 2025

What Is the Medicare Part D Prescription Drug Benefit?

Medicare Part D, Medicare’s voluntary outpatient prescription drug benefit, was established by the Medicare Modernization Act of 2003 (MMA) and launched in 2006. Before the addition of the Part D benefit, Medicare did not cover the cost of outpatient prescription drugs. Under Part D, Medicare helps cover prescription drug costs through private plans that contract with Medicare to offer the Part D benefit to enrollees, which is unlike coverage of Part A and Part B benefits under traditional Medicare, and beneficiaries must enroll in a Part D plan if they want this benefit.

A total of 54.8 million people with Medicare are currently enrolled in plans that provide the Medicare Part D drug benefit, including plans open to everyone with Medicare (stand-alone prescription drug plans, or PDPs, and Medicare Advantage drug plans, or MA-PDs) and plans for specific populations (including retirees of a former employer or union and Medicare Advantage Special Needs Plans, or SNPs). Nearly 6 in 10 Part D enrollees are in MA-PDs, as overall enrollment in Medicare Advantage plans has grown in recent years. Just over 13 million low-income beneficiaries receive extra help with their Part D plan premiums and cost sharing through the Part D Low-Income Subsidy Program (LIS).

For 2025, the average Medicare beneficiary has a choice of 14 stand-alone Part D plans and 34 Medicare Advantage drug plans. These plans vary in terms of premiums, deductibles and cost sharing, the drugs that are covered, any utilization management restrictions that apply, and pharmacy networks. People in traditional Medicare who are enrolled in a separate stand-alone Part D plan generally pay a monthly Part D premium unless they qualify for full benefits through the Part D LIS program and are enrolled in a premium-free (benchmark) plan. In 2025, the average enrollment-weighted premium for stand-alone Part D plans is $39 per month. In 2025, most stand-alone Part D plans include a deductible, averaging $491. Plans generally impose a tiered structure to define cost-sharing requirements and cost-sharing amounts charged for covered drugs, typically charging lower cost-sharing amounts for generic drugs and preferred brands and higher amounts for non-preferred and specialty drugs, and a mix of flat dollar copayments and coinsurance (based on a percentage of a drug’s list price) for covered drugs.

The standard design of the Medicare Part D benefit currently has three distinct phases, where the share of drug costs paid by Part D enrollees, Part D plans, drug manufacturers, and Medicare varies. Based on changes in the Inflation Reduction Act, these shares changed in 2024 and 2025 (Figure 9). Most notably, the Part D benefit now includes a $2,000 out-of-pocket spending cap, meaning Part D enrollees face no additional costs once their out-of-pocket costs exceed $2,000 in 2025. Previously, enrollees with high drug costs who did not receive low-income subsidies were responsible for paying 5% of their total drug costs when they reached the catastrophic coverage phase. This new out-of-pocket spending cap is projected to help an estimated 11 million Part D enrollees in 2025, including 6.1 million enrollees not receiving low-income subsidies.

The Share of Medicare Part D Drug Costs Paid by Enrollees, Plans, Drug Manufacturers, and Medicare Changed in 2024 and 2025

The Inflation Reduction Act of 2022, signed into law by President Biden on August 16, 2022, includes several provisions to lower prescription drug costs for people with Medicare and reduce drug spending by the federal government, including several changes related to the Part D benefit. These provisions include (but are not limited to) (Figure 10):

Requiring the Secretary of the Department of Health and Human Services to negotiate the price of some Part D and Part B drugs covered under Medicare. The law that established the Part D benefit included a provision known as the “noninterference” clause, which prevented the HHS Secretary from being involved in price negotiations between drug manufacturers and pharmacies and Part D plan sponsors. In addition, the Secretary of HHS does not currently negotiate prices for drugs covered under Medicare Part B (administered by physicians). To date, Medicare has completed one round of price negotiation on 10 Part D drugs, with negotiated prices available in 2026, and selected 15 more Part D drugs for price negotiation in the second round, with negotiated prices available in 2027.
Adding a hard cap on out-of-pocket drug spending under Part D, which phased in beginning in 2024, and was limited to $2,000 in 2025 (increasing to $2,100 in 2026). As noted above, under the original design of the Part D benefit, enrollees had catastrophic coverage for high out-of-pocket drug costs, but there was no limit on the total amount that beneficiaries paid out of pocket each year.
Limiting the out-of-pocket cost of insulin products to no more than $35 per month in all Part D plans and in Part B and making adult vaccines covered under Part D available for free as of 2023. Until these provisions took effect, beneficiary costs for insulin and adult vaccines were subject to varying cost-sharing amounts.
Expanding eligibility for full benefits under the Part D Low-Income Subsidy program in 2024, eliminating the partial LIS benefit for individuals with incomes between 135% and 150% of poverty. Beneficiaries who receive full LIS benefits pay no Part D premium or deductible and only modest copayments for prescription drugs until they reach the catastrophic threshold, at which point they face no additional cost sharing.
Requiring drug manufacturers to pay a rebate to the federal government if prices for drugs covered under Part D and Part B increase faster than the inflation rate, with the initial period for measuring Part D drug price increases running from October 2022-September 2023. Previously, Medicare had no authority to limit annual price increases for drugs covered under Part B or Part D. Year-to-year drug price increases exceeding inflation are not uncommon and affect people with both Medicare and private insurance.

Implementation Timeline of the Prescription Drug Provisions in the Inflation Reduction Act

How Does Medicare Pay Hospitals, Physicians, and Other Providers in Traditional Medicare?

In 2024, Medicare was estimated to spend $464 billion on benefits covered under Part A and Part B for beneficiaries in traditional Medicare. Medicare pays providers in traditional Medicare using various payment systems depending on the setting of care (Figure 11).

Spending on Part A and Part B Benefits in Traditional Medicare is Estimated to be $464 Billion in 2024

Medicare relies on a number of different approaches when determining payments to providers for Part A and Part B services delivered to beneficiaries in traditional Medicare. These providers include hospitals (for both inpatient and outpatient services), physicians, skilled nursing facilities, home health agencies, and several other types of providers. Of the $464 billion in estimated spending on Medicare benefits covered under Part A and Part B in traditional Medicare in 2024, $149 billion (32%) was for hospital inpatient services and $68 billion (15%) was for hospital outpatient services, $71 billion (15%) was for services covered under the physician fee schedule, and $176 billion (38%) was for all other Part A or Part B services for beneficiaries in traditional Medicare.

Medicare uses prospective payment systems for most providers in traditional Medicare. These systems generally require that Medicare pre-determine a base payment rate for a given unit of service (e.g., a hospital stay, an episode of care, a particular service). Then, based on certain variables, such as the provider’s geographic location and the complexity of the patient receiving the service, Medicare adjusts its payment for each unit of service provided. Medicare updates payment rates annually for most payment systems to account for inflation adjustments.

The main features of hospital, physician, outpatient, and skilled nursing facility payment systems (altogether accounting for 69% of spending on Part A and Part B benefits in traditional Medicare) are described below:

Inpatient hospitals (acute care): Medicare pays hospitals per beneficiary discharge using the Inpatient Prospective Payment System. The rate for each discharge corresponds to one of over 770 different categories of diagnoses – called Medicare Severity Diagnosis Related Groups (MS-DRGs), which reflect the principal diagnosis, secondary diagnoses, procedures performed, and other patient characteristics. DRGs that are likely to incur more intense levels of care and/or longer lengths of stay are assigned higher payments. Medicare’s payments to hospitals also account for a portion of hospitals’ capital and operating expenses.
Medicare also makes additional payments to hospitals in particular situations. These include additional payments for rural or isolated hospitals that meet certain criteria. Further, Medicare makes additional payments to help offset costs incurred by hospitals that are not otherwise accounted for in the inpatient prospective payment system. These include add-on payments for treating a disproportionate share (DSH) of low-income patients, as well as for covering costs associated with care provided by medical residents, known as indirect medical education (IME). While not part of the Inpatient Prospective Payment System, Medicare also pays hospitals directly for the costs of operating residency programs, known as Graduate Medical Education (GME) payments.
Physicians and other health professionals: Medicare reimburses physicians and other health professionals (e.g., nurse practitioners) based on the Physician Fee Schedule for over 10,000 services. Payment rates for these services are based on three components: (1) clinician work, (2) practice expenses, and (3) professional liability insurance (also known as medical malpractice insurance), which are measured in terms of “relative value units” (RVUs). Each component is adjusted to account for differences across geography and then multiplied by a conversion factor. Payment rates for individual services may be updated each year based in part on the recommendations of the AMA/Specialty Society RVS Update Committee (RUC), a volunteer committee of physicians and other professionals overseen by the American Medical Association (AMA). CMS also makes annual updates to the conversion factor based on statutory factors, as well as adjustments to preserve budget neutrality, which may result in payment cuts for physicians and other clinicians whenever the projected cost of all Physician Fee Schedule spending is expected to increase by more than $20 million for the year.
Payment rates specified under the Physician Fee Schedule are subject to further adjustments under the Quality Payment Program, established by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Clinicians can receive payment increases if they participate in qualified advanced alternative payment models (A-APMs), which bear some financial risk for the costs of patient care, while those who participate in the Merit-based Incentive Payment System (MIPS) may receive payment increases or decreases (or no change) depending on their performance on specific quality measures. (See “What Is Medicare Doing to Promote Alternative Payment Models?” for more information about alternative payment models in Medicare.)
While not part of the Physician Fee Schedule, Medicare also pays for a limited number of drugs that physicians and other health care providers administer. For drugs administered by physicians, which are covered under Part B, Medicare reimburses providers based on a formula set at 106% of the Average Sales Price (ASP), which is the average price to all non-federal purchasers in the U.S, inclusive of rebates (other than rebates paid under the Medicaid program).

Hospital outpatient departments: Medicare pays hospitals for ambulatory services provided in outpatient departments, using the Hospital Outpatient Prospective Payment System, based on the classification of individual services into Ambulatory Payment Classifications (APC) with similar characteristics and expected costs. Final determination of Medicare payments for outpatient department services is complex. It incorporates both individual service payments and payments “packaged” with other services, partial hospitalization payments, as well as numerous exceptions, such as payments for new technologies. Medicare payment rates for services provided in hospital outpatient departments are typically higher than for similar services provided in physicians’ offices, and evidence indicates that providers have shifted the billing of services to higher-cost settings. There is bipartisan interest in proposals to expand so-called “site-neutral” payments, meaning that Medicare would align payment rates for the same service across settings.
Skilled Nursing Facilities (SNFs): SNFs are freestanding or hospital-based facilities that provide post-acute inpatient nursing or rehabilitation services. Medicare pays SNFs based on the Skilled Nursing Facility Prospective Payment System, and payments to SNFs are determined using a base payment rate, adjusted for geographic differences in labor costs, case mix, and, in some cases, length of stay. Daily rates consider six care components – nursing, physical therapy, occupational therapy, speech–language pathology services, nontherapy ancillary services and supplies, and non–case mix (room and board services).

How Does Medicare Pay Private Plans in Medicare Advantage and Medicare Part D?

Medicare Advantage. Medicare pays firms offering Medicare Advantage plans a set monthly amount per enrollee. The payment is determined through an annual process in which plans submit “bids” for how much they estimate it will cost to provide benefits covered under Medicare Parts A and B for an average beneficiary. The bid is compared to a county “benchmark”, which is the maximum amount the federal government will pay for a Medicare Advantage enrollee and is a percentage of estimated spending in traditional Medicare in the same county, ranging from 95 percent in high-cost counties to 115 percent in low-cost counties. When the bid is below the benchmark in a given county, plans receive a portion of the difference (the “rebate”), which they must use to lower cost sharing, pay for extra benefits, or reduce enrollees’ Part B or Part D premiums. Payments to plans are risk adjusted, based on the health status and other characteristics of enrollees, including age, sex, and Medicaid enrollment. In addition, Medicare adopted a quality bonus program that increases the benchmark for plans that receive at least four out of five stars under the quality rating system, which increases plan payments.

Generally, Medicare pays more to private Medicare Advantage plans for enrollees than their costs would be in traditional Medicare. The Medicare Payment Advisory Commission (MedPAC) reports that while it costs Medicare Advantage plans 83% of what it costs traditional Medicare to pay for Medicare-covered services, plans receive payments from CMS that are 120% of spending for similar beneficiaries in traditional Medicare, on average. The higher spending stems from features of the formula used to determine payments to Medicare Advantage plans, including setting benchmarks above traditional Medicare spending in half of counties and higher benchmarks due to the quality bonus program, resulting in bonus payments of at least $12.7 billion in 2025. This amount is four times greater than spending on bonus payments in 2015 (Figure 12).

Total Spending on Medicare Advantage Plan Bonuses Quadrupled Between 2015 and 2025 From At Least $3 Billion to $12.7 Billion

The higher spending in Medicare Advantage is also related to the impact of coding intensity, where Medicare Advantage enrollees look sicker than they would if they were in traditional Medicare, resulting in plans receiving higher risk adjustments to their monthly per person payments, translating to an estimated $84 billion in excess payments to plans in 2025.

Higher payments to Medicare Advantage plans allow them to offer extra benefits attractive to enrollees. However, these benefits come at a cost to all beneficiaries through higher Part B premiums – amounting to $13 billion in 2025 alone – and contribute to the strain on the Medicare Part A Hospital Insurance Trust Fund. (See “How Much Does Medicare Spend and How Is the Program Financed?” for additional information .)

Medicare Part D. Medicare pays Part D plans, both stand-alone prescription drug plans and Medicare Advantage plans that offer drug coverage, based on an annual competitive bidding process. Plans submit bids yearly to Medicare for their expected costs of providing the drug benefit plus administrative expenses. Plans receive a direct subsidy per enrollee, which is risk-adjusted based on the health status of their enrollees, plus reinsurance payments from Medicare for the highest-cost enrollees and adjustments for the low-income subsidy (LIS) status of their enrollees. (Unlike Medicare Advantage, there is no quality bonus program that provides higher payments to Part D plans with higher Part D quality ratings.) Risk-sharing arrangements with the federal government (“risk corridors”) limit plans' potential total losses or gains.

Under reinsurance, Medicare subsidizes 20% of total drug spending incurred by Part D enrollees with relatively high drug spending above the catastrophic coverage threshold, as of 2025, down from 80% in prior years, based on a provision of the Inflation Reduction Act. This provision was designed to shift more of the responsibility for catastrophic drug costs to Part D plans and drug manufacturers. Plans now pay 60% of total drug costs above the catastrophic threshold, up from 15% to 20% in prior years. (See “What Is the Medicare Part D Prescription Drug Benefit?” for more detail on plan liability under various phases of the Part D benefit and more information on changes to Part D included in the Inflation Reduction Act.) In the aggregate, Medicare’s reinsurance payments to Part D plans in 2025 are estimated to account for 18% of total Part D spending, down from close to half of total Part D spending (46%) in 2024 (Figure 13).

Spending for Catastrophic Coverage (“Reinsurance”) Accounted for Close to Half (46%) of Total Medicare Part D Spending in 2024, But Is Estimated to Decrease to 18% in 2025 as Inflation Reduction Act Changes to the Part D Benefit Take Effect

For 2025, Medicare’s actuaries estimate that Part D plans will receive direct subsidy payments averaging $1,855 per enrollee overall, $1,313 for enrollees receiving the LIS, and $517 in reinsurance payments for very high-cost enrollees.

What Is Medicare Doing to Promote Alternative Payment Models?

While Medicare has traditionally paid providers on a fee-for-service basis, the program is implementing various alternative payment models designed to tie payments under traditional Medicare to provider performance on quality and spending. Although the overarching goals of these various models are similar—improving the quality and affordability of patient care, increasing coordination between care teams, and reducing health care costs—the specific aims vary by model.

A notable example of an alternative payment model within Medicare is the Medicare Shared Savings Program (MSSP), a permanent accountable care organization (ACO) program in traditional Medicare established by the Affordable Care Act (ACA) that offers financial incentives to providers for meeting or exceeding savings targets and quality goals. ACOs are groups of doctors, hospitals, and other health care providers who voluntarily form partnerships to collaborate and share accountability for the quality and cost of care delivered to their patients. The MSSP currently offers different participation options to ACOs, allowing these organizations to share in savings only or both savings and losses, depending on their level of experience and other factors.

ACOs have a defined patient population for the purpose of calculating annual savings or losses. Beneficiaries in traditional Medicare may choose to align themselves to an ACO (voluntary alignment) or may be assigned to a particular ACO based on where they received a plurality of their primary care services. In either case, beneficiaries are free to seek treatment from any provider who accepts Medicare and are not limited to ACO-affiliated providers. This contrasts with enrollment in Medicare Advantage, where beneficiaries are generally limited to seeing providers in their plan’s network or face higher out-of-pocket costs for seeing out-of-network providers.

In 2023, the Medicare Shared Savings Program saved Medicare an estimated $2.1 billion relative to annual spending targets. As of 2025, there are 476 MSSP ACOs nationwide, with over 643,000 participating clinicians and 10.8 million beneficiaries aligned to MSSP ACOs (Figure 14).

Medicare Shared Savings Program ACOs Are Operating in Every State and the District of Columbia

The ACA also established the Center for Medicare and Medicaid Innovation (CMMI, also known as the Innovation Center), an operating center within the Centers for Medicare & Medicaid Services tasked with designing and testing alternative payment models to address concerns about rising health care costs, quality of care, and inefficient spending within the Medicare, Medicaid, and CHIP programs. Since its start in 2010, CMMI has launched more than 80 models across six different categories, including accountable care models, disease-specific models, health plan models, and others (Figure 15). CMMI models are designed to be tested over a limited number of years, but Congress gave CMMI the authority to expand models nationwide permanently if they meet certain quality and savings criteria. As of the most recent estimate, six models have shown statistically significant savings, and four have met the requirements for permanent expansion into the wider Medicare program, including the Medicare Diabetes Prevention Program and the Home Health Value-Based Purchasing Model.

While the overall aims of CMMI are set in law, changes of administration have brought about changes in the strategic direction of the Innovation Center and the types of models that have been pursued, along with the reframing or termination of certain models from the previous administration. For example, the Biden administration placed a greater emphasis on health equity in CMMI models, while the second Trump administration is prioritizing evidence-based preventive care, empowering consumers with data and information to make health decisions, and promoting choice and competition in health care markets.

The Center for Medicare and Medicaid Innovation (CMMI) has Implemented Numerous Programs and Pilot Projects to Test New Payment Models

According to the Congressional Budget Office (CBO), the activities of CMMI increased federal spending by $5.4 billion from 2011 to 2020, which CBO attributes in part to the mixed success of many models at generating sufficient savings to offset their high upfront costs. (CBO had initially projected that CMMI would reduce federal spending by $2.8 billion in its first decade of operation.) However, evidence suggests that savings vary by model type, with the greatest savings found among state and community-based models. Further, a review of select CMMI models provides evidence of improvements in care coordination, team-based care, and other care delivery changes, even in the absence of savings. CBO projects that CMMI’s activities will come closer to the breakeven point regarding federal spending over the course of the current decade (2024-2033).

How Much Does Medicare Spend and How Is the Program Financed?

Spending. Medicare plays a significant role in the health care system, accounting for 21% of total national health spending in 2023, a quarter of spending on both hospital care and physician and clinical services, and 32% of spending on retail prescription drug sales (Figure 16).

In 20222023, Medicare Accounted for 21% of Total National Health Spending

In 2024, Medicare spending, net of income from premiums and other offsetting receipts, totaled $910 billion and accounted for 13% of the federal budget — a similar share as spending on Medicaid, the ACA, and the Children’s Health Insurance Program combined, and defense spending (Figure 17).

In 2024, Medicare Spending Accounted for 13% of the Federal Budget

In 2025, Medicare benefit payments are estimated to total $1.1 trillion, up from $632 billion in 2015 (including spending for Part A, Part B, and Part D benefits in both traditional Medicare and Medicare Advantage). Medicare spending per person has also grown, increasing from $5,800 to $16,700 between 2000 and 2023 – or 4.7% average annual growth over the 23-year period. In recent years, however, growth in spending per person has been lower in Medicare than in private health insurance .

Spending on Medicare Part A benefits (mainly hospital inpatient services) has decreased as a share of total Medicare spending over time as care has shifted from inpatient to outpatient settings, leading to an increase in spending on Part B benefits (including physician services, outpatient services, and physician-administered drugs). Spending on Part B services now accounts for the largest share of Medicare benefit spending (50% in 2024) (Figure 18). Moving forward, Medicare spending on physician services and other services covered under Part B is expected to grow to more than half of total Medicare spending by 2034, while spending on hospital care and other services covered under Part A is projected to decrease further as a share of the total.

Spending on Physician Services and Other Medicare Part B Services Now Accounts for the Largest Share of Total Medicare Benefits Spending

Payments to Medicare Advantage plans for Part A and Part B benefits tripled as a share of total Medicare spending between 2014 and 2024, from $156 billion to $462 billion, partly due to steady enrollment growth in Medicare Advantage plans. Growth in spending on Medicare Advantage also reflects that Medicare pays more to private Medicare Advantage plans for enrollees than their costs in traditional Medicare, on average. (See “How Does Medicare Pay Private Plans in Medicare Advantage and Medicare Part D?” for additional information.) These higher payments have contributed to growth in spending on Medicare Advantage and overall Medicare spending. In 2024, half of all Medicare program spending for Part A and Part B benefits was for Medicare Advantage plans, up from just under 30% in 2014. Between 2024 and 2034, Medicare Advantage payments are projected to total close to $9 trillion, $2.5 trillion more than spending under traditional Medicare (Figure 19).

Medicare Advantage Payments are Projected to Total Close to $9 Trillion Between 2024 and 2034, $2.5 Trillion More than Spending Under Traditional Medicare

Financing. Medicare funding, which totaled $1.1 trillion in 2024, comes primarily from government contributions (44%), payroll tax revenues (35%), and premiums paid by beneficiaries (15%). Other sources include taxes on Social Security benefits, payments from states, and interest.

The different parts of Medicare are funded in varying ways, and revenue sources dedicated to one part of the program cannot be used to pay for another part (Figure 20).

Medicare Revenues Come from Different Sources, Primarily Government Contributions, Payroll Taxes, and Premiums Paid by Beneficiaries

Part A, which covers inpatient hospital stays, skilled nursing facility (SNF) stays, some home health visits, and hospice care, is financed primarily through a 2.9% tax on earnings paid by employers and employees (1.45% each). Higher-income taxpayers (more than $200,000 per individual and $250,000 per couple) pay a higher payroll tax on earnings (2.35%). Payroll taxes accounted for 88% of Part A revenue in 2024.
Part B, which covers physician visits, outpatient services, preventive services, and some home health visits, is financed primarily through a combination of government contributions (72% in 2024) and beneficiary premiums (26%) (and 2% from interest and other sources). The standard Part B premium that most Medicare beneficiaries pay is calculated as 25% of annual Part B spending, while beneficiaries with annual incomes over $106,000 per individual or $212,000 per couple pay a higher, income-related Part B premium reflecting a larger share of total Part B spending, ranging from 35% to 85%.
Part D, which covers outpatient prescription drugs, is financed primarily by government contributions (75%) and beneficiary premiums (13%), with an additional 12% of revenues coming from state payments for beneficiaries enrolled in both Medicare and Medicaid. Higher-income enrollees pay a larger share of the cost of Part D coverage, as they do for Part B.
The Medicare Advantage program (sometimes referred to as Part C) does not have its own separate revenue sources. Funds for Part A benefits provided by Medicare Advantage plans are drawn from the Medicare HI trust fund. Funds for Part B and Part D benefits are drawn from the Supplementary Medical Insurance (SMI) trust fund. Beneficiaries enrolled in Medicare Advantage plans pay the Part B premium and may pay an additional premium if required by their plan. In 2025, 76% of Medicare Advantage enrollees pay no additional premium.

Measuring the level of reserves in the Medicare Hospital Insurance trust fund, out of which Part A benefits are paid, is a common way of measuring Medicare's financial status. Each year, Medicare’s actuaries provide an estimate of the year when the reserves are projected to be fully depleted. In 2025, the Medicare Trustees projected sufficient funds would be available to pay for Part A benefits in full until 2033, 8 years from now – three years earlier than the 2024 projection. At that point, in the absence of Congressional action, Medicare will be able to pay 89% of costs covered under Part A using payroll tax revenues. At the same time, the Congressional Budget Office has recently updated its projection of the Part A trust fund, extending the year of trust fund depletion to 2052, based on changes in its projections of Part A spending and revenues and a change in CBO’s modeling related to graduate medical education payments. OACT projects both lower income and higher spending under Part A than CBO, as well as faster Part A spending growth, which helps to account for the difference in the projected HI trust fund depletion dates.

Since 2010, the projected year of trust fund reserve depletion, based on projections by Medicare’s actuaries, has ranged from 5 years out (in 2021) to 19 years out (in 2010) (Figure 21).

The Medicare Hospital Insurance Trust Fund Reserves Are Projected to Be Depleted in 2033, Based on a Projection by Medicare's Actuaries

The level of reserves in the Part A Trust Fund is affected by growth in the economy, which affects revenue from payroll tax contributions, health care spending and utilization trends, and demographic trends: an increasing number of beneficiaries as the population ages, especially between 2010 and 2030 when the baby boom generation reaches Medicare eligibility age, and a declining ratio of workers per beneficiary making payroll tax contributions.

Part B and Part D do not have financing challenges similar to Part A, because both are funded by beneficiary premiums and government contributions that are set annually to match expected outlays. However, future increases in spending under Part B and Part D will require increases in government (and taxpayer) funding and higher premiums paid by beneficiaries.

Future Outlook

Looking to the future, Medicare faces a number of challenges from the perspective of beneficiaries, health care providers and private plans, and the federal budget. These include:

How best to address the fiscal challenges arising from an aging population and increasing health care costs through spending reductions and/or revenue increases.
Whether and how to improve coverage for Medicare beneficiaries, including an out-of-pocket limit in traditional Medicare, enhanced financial support for lower-income beneficiaries, and additional benefits, such as dental and vision.
How to control spending while ensuring fair and adequate payments to hospitals, physicians and other providers, and Medicare Advantage plans, including whether and how to reduce overpayments to Medicare Advantage plans.
How to address the implications for traditional Medicare of the predominant role that Medicare Advantage now plays in covering Medicare beneficiaries.

Any potential changes to Medicare to address these challenges could have implications for federal spending and taxpayers, the solvency of the Medicare Hospital Insurance trust fund, total health care spending, the affordability of health care for Medicare’s growing number of beneficiaries, many of whom have limited incomes, and access to high-quality medical care.

Resources

Citation

Cubanski, J., Freed, M., Ochieng, N., Cottrill, A., Fuglesten Biniek, J., & Neuman, T., Medicare 101. In Altman, Drew (Editor), Health Policy 101, (KFF, October 2025) https://www.kff.org/health-policy-101-medicare/ (date accessed).

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

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

Published: Sep 30, 2025

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Methods

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

Health Issues for Immigrants in Detention Centers

Authors: Akash Pillai, Drishti Pillai, and Samantha Artiga

Published: Sep 30, 2025

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

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

Detention Policies under the Trump Administration

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

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

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

Health Care Risks and Challenges for Immigrants in Detention Facilities

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

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

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

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

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

Authors: Clea Bell, Jennifer Tolbert, and Sammy Cervantes

Published: Sep 29, 2025

Editorial Note

For the latest county unemployment data and information on which states are currently planning to adopt the high unemployment rate hardship exception, visit KFF’s Medicaid Work Requirements Tracker and read our related policy watch.

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

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

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

What is the High Unemployment Rate Hardship Exception?

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

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

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

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

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

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

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

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

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

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

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

Appendix

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

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

Authors: Laurie Sobel, Alina Salganicoff, and Rolonda Donelson

Published: Sep 26, 2025

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

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

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

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

ACA Rules for Premiums for Abortion Coverage

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

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

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

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

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

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

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

Published: Sep 25, 2025

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

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

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

Key Takeaways

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Box 1. Types of Special Needs Plans

Dual Eligible Special Needs Plans

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

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

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

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

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

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

Chronic Condition Special Needs Plans

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

Institutional Special Needs Plans

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

Methods

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

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

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

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

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

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

Authors: Drishti Pillai, Alisha Rao, and Samantha Artiga

Published: Sep 25, 2025

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

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

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

Medicaid and CHIP

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

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

ACA Marketplaces

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

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

Medicare

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

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

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

Authors: Cynthia Cox and Gary Claxton

Published: Sep 25, 2025

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

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

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

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

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

Methods

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

VOLUME 31

September 25, 2025

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

Irving Washington , Hagere Yilma , and Joel Luther

Summary

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

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

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

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

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

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

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

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

Recent Developments

Health Committee Delays Vote on Changing Hepatitis B Vaccine Recommendation

THOM LEACH / SCIENCE PHOTO LIBRARY / *Getty Images*

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

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

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

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

ACIP Changes COVID-19 Vaccine Guidance After Safety Debate

thianchai sitthikongsak / *Getty Images*

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

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

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

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

HHS Links Autism to Tylenol Use During Pregnancy Without Conclusive Evidence

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

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

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

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

AI & Emerging Technology

Deepfakes of Doctors Used to Sell Unproven Health Products

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

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

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

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

View all KFF Monitors

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

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

Tracking State Actions on Vaccine Policy and Access

Authors: Jennifer Kates, Clea Bell, Josh Michaud, Elizabeth Williams, and Jennifer Tolbert

Published: Sep 24, 2025

There is a complex interplay between the federal government and states regarding vaccine regulations, policy, and access. While states have the primary responsibility for enacting and enforcing laws to promote the health, safety, and general welfare of people in their jurisdictions, including, for example, instituting vaccine mandates, the federal government has significant authority to influence and alter vaccine policy through approvals and licensure, recommendations to the public and clinicians, funding, and legislative requirements that most insurers cover vaccines recommended by the Centers for Disease Control and Prevention (CDC) and its Advisory Committee on Immunization Practices (ACIP) at no-cost. Moreover, states have generally relied on and linked their own vaccine policies to CDC/ACIP recommendations. However, with recent actions taken by Secretary of Health and Human Services, Robert F Kennedy, Jr., to curtail vaccine access – including narrowing both FDA-approval of COVID-19 vaccines and CDC’s COVID-19 vaccine recommendations for the public, as well as changes to the pediatric vaccine schedule (see boxes 1-2) — many states have moved to maintain broader access (some states pre-emptively did so before the start of the Trump administration).

This policy brief provides a snapshot of this rapidly changing landscape, tracking which states have instituted changes in response to or in anticipation of administration policy changes, as of September 22, 2025. It finds that, as of this date, 26 states had implemented or announced updates to their COVID-19 vaccine and other vaccine policies, providing broader access than current federal limits. There is a significant red-blue divide in these actions–Democratic governors lead 23 of the 26 states– suggesting that access to vaccines could increasingly vary and diverge by state along partisan lines, much like the divide in public opinion.

Findings

We examined state actions in the following three areas (note that school vaccine policy requirements and changes are tracked separately, here):

1) Pharmacy Access: State actions to allow pharmacists to administer COVID-19 vaccines, and in some cases other vaccines, without a prescription. Most adults get vaccinated at pharmacies, including for COVID-19, and pharmacies in general have become an important access point for vaccination across the United States. Pharmacists’ scope of practice, including the authority to prescribe and administer vaccines, is regulated at the state level and is typically tied in law or regulation to CDC/ACIP recommendations. Because of changes at the federal level, some states have taken action to explicitly authorize pharmacists to administer COVID-19 vaccines, and in some cases other vaccines, without a prescription.
2) Insurance Coverage. State actions to require state-regulated health insurers to cover COVID-19 vaccines, and in some cases other vaccines, at no-cost. The Affordable Care Act and other federal laws and regulations require almost all insurers to cover CDC/ACIP recommended vaccines at no cost. States also have the authority to regulate certain plans in their state (employer plans that are fully insured, and individual and small-group marketplace plans). States can use this authority to require that these plans provide coverage of services beyond those covered under federal law. States cannot regulate the benefits of self-insured employer plans, which cover 57% of people with employer-sponsored health coverage.
3) Sources of Guidance/Expertise. State reliance on non-federal entities for vaccine recommendations and guidance instead of or in addition to CDC/ACIP. States have generally relied on CDC/ACIP recommendations for determining state vaccine policies, including for school entry, pharmacist scope of practice, and insurance coverage, but they can choose to rely on other criteria or guidance in addition to or instead of CDC/ACIP.

To obtain state-level data, we reviewed state websites and official documentation. We only included actions that were taken in anticipation of or in response to changes in federal vaccine policy under the Trump administration. We counted a state as having taken an action if a new policy, law, or regulation was already put in place as well as if an executive order or other executive instruction had been issued requiring such an action be taken (even if it had not yet taken effect).

As of September 22, 2025 (also see Table 1):

Twenty-six states have moved to allow pharmacists to administer COVID-19 vaccines without a prescription in an effort to maintain access as federal guidelines narrow. Four states and DC have moved to do so beyond COVID-19 and include other vaccines, which could include those that may no longer be recommended by CDC/ACIP. Most of these states indicate that they are taking these actions to ensure COVID-19 vaccines remain widely available to all amid concerns about the narrowing of federal guidelines. Two states – North Carolina and Virginia – clarify that COVID-19 vaccines are available at pharmacies without a prescription (and allow individuals under the age of 65 to self-attest that they have an underlying condition in order to get vaccinated at a pharmacy without a prescription). Hawaii has joined a coalition of western states that has issued its own COVID-19 guidelines recommending universal vaccination for all those 6 months and older; it already authorizes pharmacists to administer vaccines to those ages 3 and older but has not issued an updated standing order for the COVID-19 vaccine. Among the remaining twenty-five states, while some may have general policies allowing pharmacists to administer recommended vaccines without a prescription, they have not made clear if this would permit them to do so for COVID-19 vaccines beyond federal limits.
Thirteen states have moved to require state-regulated health insurers to cover COVID-19 vaccines at no cost, including four that have done so for all vaccines recommended by the state. In these states, regardless of changes to CDC/ACIP recommendations, which govern insurance coverage requirements for most insurers, state-regulated insurers will still need to cover these vaccines for free. In states that have not taken steps to require continued coverage of COVID-19 and other vaccines at no cost, if CDC adopts recent ACIP recommendations, individuals will no longer be guaranteed access to vaccines previously recommended by ACIP (though AHIP, the trade association for commercial insurers and other plans, has announced that member insurers will continue to cover the vaccines with no cost sharing voluntarily, at least through 2026).
Twenty-two states specifically identify non-federal entities as sources for their vaccine recommendations, either in addition to or instead of CDC/ACIP. In over half (13) of these states, the recommendations only apply to COVID-19 vaccines, while in nine states, the recommendations apply to all vaccines. Several states indicate that they will follow the recommendations of independent medical associations and professional groups (most commonly, AAP, AAFP, and ACOG) while others have established or are setting up their own state-led advisory bodies to develop vaccine recommendations. In addition, two inter-state alliances have formed to develop shared recommendations and other resources, including the Northeast Public Health Collaborative and the West Coast Health Alliance, which together represent fourteen states (see Box 3). The West Coast Health Alliance recently issued its own vaccine recommendations for COVID-19, influenza and RSV for the 2025–26 respiratory virus season, which do not rely on ACIP.
There is a significant red-blue divide, with almost all states that have moved to maintain vaccine access despite federal changes having Democratic governors. Twenty-three of the twenty-six states that allow pharmacy access for COVID-19 vaccines without a prescription have Democratic governors. Of these, North Carolina is the only one that hasn’t explicitly recommended COVID-19 vaccines beyond federal guidelines but allows those ages 65 and older and those under the age of 65 who have an underlying health condition to get vaccinated in a pharmacy (and those under the age of 65 can self-attest that they meet the criteria). Among the three states with Republican governors – Nevada, Vermont, and Virginia – Nevada and Vermont allow individuals to access COVID-19 vaccines at pharmacies without a prescription and not necessarily linked to CDC/ACIP guidelines, while Virigina allows for self-attestation at pharmacies without a prescription. All of the thirteen states that have moved to require ongoing insurance coverage of COVID-19 vaccines have Democratic governors.

The recent moves by many states to de-couple their vaccine policy determinations from federal recommendations to ensure continued access as the federal government takes steps that narrow access is unprecedented, and will likely continue as the federal government pursues further changes to vaccine recommendations. This divergence between federal policy and the states and among states ultimately means that vaccine coverage and access could increasingly vary according to where one lives. More limited access in some states could, in turn, lead to decreased vaccine coverage, increased incidence of vaccine preventable diseases, as already has been seen with the recent measles outbreak, and declining vaccine coverage among school-aged children. Confusion and mistrust on the part of the public overall, and parents specifically, could exacerbate these trends.

Box 1. Trump Administration Changes to COVID-19 Vaccine Guidance

Until recently, CDC recommended that everyone in the United States ages 6 months or older be routinely vaccinated against COVID-19 and COVID-19 vaccines were authorized or approved by FDA for this purpose. Recent changes by the Trump administration have narrowed this scope. The changes are not completely consistent with one another, but each has implications for access and affordability. Key changes include the following:

On May 27, 2025, Secretary Kennedy announced that COVID-19 vaccines would no longer be recommended for healthy children and healthy pregnant women, and the CDC’s vaccine schedules were updated accordingly. The CDC update for the pediatric vaccine schedule indicated that COVID-19 vaccines for those ages 6 months to 17 years would be based on “shared clinical decision-making” (which requires an individual assessment and interaction with a health care provider to determine whether the vaccine should be recommended). Vaccination during pregnancy, which had been listed as a condition that increased risk for severe outcomes from COVID-19, is no longer recommended. This created some uncertainty for these populations regarding pharmacy access and insurance coverage, although updated COVID-19 vaccines were not yet available at this time, and no new data or evidence had been presented in support of these changes.
On August 27, 2025, the FDA, in approving updated COVID-19 vaccines for the 2025-2026 respiratory season, narrowed their approvals to individuals who were (1) 65 years of age and older or (2) those ages 6 months to 64 years (Moderna) or 5 years to 64 years (Pfizer) with at least one underlying condition that puts them at high risk for severe outcomes from COVID-19. This means that a health care provider prescribing or administering a COVID-19 vaccine outside of these parameters would technically be doing so off-label.
On September 19, 2025, the CDC’s Advisory Committee on Immunization Practices (ACIP) voted to change what had been a universal COVID-19 vaccine recommendation (except for HHS’ recent change for those under age 18) to “shared clinical decision-making”, including for those 65 and older. For those under 65, ACIP added that the assessment should include “an emphasis that the risk-benefit of vaccination is most favorable for individuals who are at an increased risk for severe COVID-19 disease and lowest for individuals who are not at an increased risk, according to the CDC list of COVID-19 risk factors.” These recommendations, should they be adopted by the CDC Director, mean that all individuals are recommended to have an individual assessment and interaction with a health care provider to determine whether getting a COVID-19 vaccination is recommended for them. If that determination is made, insurers should cover the vaccine at no-cost, although it is possible that some consumers may face challenges.

Box 2. Trump Administration Changes to Pediatric Vaccine Guidance

Secretary Kennedy has stated his intention to revise the pediatric vaccine schedule to reduce the number of vaccines and remove some vaccines from the schedule altogether. HHS and CDC have already taken some steps to do so:

On June 26, 2025, ACIP voted to remove thimerosal, a preservative used in multi-dose flu vaccines, from all flu vaccines distributed in the U.S., although data continue to demonstrate the safety of this vaccine formulation (while multi-dose flu vaccines have accounted for only a small percentage of flu vaccines used in the U.S., they offered an additional option in certain cases). Specifically, ACIP voted that all children 18 years and younger, pregnant women, and adults receive only single-dose influenza vaccines (without thimerosal). HHS adopted this recommendation on July 23.

On September 18-19, 2025, ACIP voted to no longer recommend the combination MMRV (measles, mumps, rubella, and varicella) vaccine for children under the age of 4 and instead to recommend that children in this age group receive separate measles, mumps, and rubella (MMR) vaccine and varicella vaccine (V). They also voted to no longer recommend it as part of the federal Vaccines for Children program which provides free, recommended vaccines to low-income, uninsured and other eligible children. While the separate MMR+V vaccines had been recommended as preferred by the CDC for many years, the combination MMRV provided an option for parents to reduce the number of injections their children receive. If adopted by the CDC Director, insurers will no longer be required to cover this vaccine at no-cost.

On September 18, 2025, ACIP considered voting on a change to the Hepatitis B vaccine recommendation. ACIP had been considering changing the current universal recommendation of a birth dose of Hepatitis B vaccine to delay it until at least one month of age (with an earlier dose possible based on shared clinical decision-making). The vote was postponed and ACIP may consider this recommendation or another version at a future meeting.

Box 3. Inter-State Vaccine Alliances (as of September 22, 2025)

Northeast Public Health Collaborative: Connecticut, Delaware, Maine, Maryland, Massachusetts, New York State, New York City, New Jersey, Pennsylvania, Rhode Island, Vermont

West Coast Health Alliance: California, Hawaii, Oregon, Washington

Recent State Actions on Vaccine Access and Policies (Table)

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

Summary

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

Recent Developments

Health Committee Delays Vote on Changing Hepatitis B Vaccine Recommendation

ACIP Changes COVID-19 Vaccine Guidance After Safety Debate

HHS Links Autism to Tylenol Use During Pregnancy Without Conclusive Evidence

AI & Emerging Technology

Deepfakes of Doctors Used to Sell Unproven Health Products

Tracking State Actions on Vaccine Policy and Access

Findings