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 President Trump has prioritized all undocumented immigrants for deportation and rescinded numerous Biden-era policies, including a policy that protected against enforcement in “sensitive areas,” such as schools and health care facilities; a ban on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.

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.

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.

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.

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

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.   

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.  

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.

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.

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).

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.

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.

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.

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.

Small businesses with Affordable Care Act (ACA)-compliant plans could face a median premium increase of 11% for 2026, according to an analysis of preliminary rate filings from 318 insurers across all 50 states and DC. A deep dive into filings from 16 states and D.C. (with a 12% median proposed rate increase) shows that these small group market insurers cite rising health care costs (commonly estimated at about 9%) as the primary driver of the 2026 rate hike, including higher prices for hospital care, physician services, and prescription drugs.

Some insurers also cite broader inflation, labor shortages, uncertainty about tariff-driven cost increases, specialty drugs like GLP-1s, and decreased enrollment and worsening risk pools in small group plans as sources of the cost increases. A subset of insurers have responded to mounting prescription drug costs by excluding coverage of GLP-1s for weight-loss in 2026. Final premium changes are expected to be published in early fall.

The analysis is part of the Peterson-KFF Health System Tracker, an online information hub dedicated to monitoring and assessing the performance of the U.S. health system.

One-fifth of the U.S. population (close to 70 million people) receive health insurance coverage through the Medicare program, a share which is expected to grow larger in the coming years as the population ages. While satisfaction with Medicare is high, Medicare beneficiaries often report feeling overwhelmed by their coverage options. In 2025, the average beneficiary has a choice of 42 Medicare Advantage plans, with or without prescription drug coverage, and 14 stand-alone Part D plans. Often these decisions are made in conjunction with beneficiaries’ access to supplemental coverage, such as Medicaid, employer coverage, and Medigap. Recent years have also seen a steep rise in advertising for private Medicare plans, as well as aggressive marketing tactics by insurance brokers and other third-party marketing groups, which may make it increasingly difficult for beneficiaries to seek clear guidance and select the coverage that best meets their needs.

The State Health Insurance Assistance Program (SHIP) provides funding to a national network of state-based SHIPs that offer free, local, in-depth counseling and education to Medicare beneficiaries and their families to help them make informed decisions about their health coverage and benefits. Established by Congress in 1990, the program funds SHIPs in every state and assists up to 4 million beneficiaries each year, relying on both paid staff and trained volunteers to counsel beneficiaries. In comparison to 1-800-MEDICARE, the federal helpline for information and assistance with Medicare health coverage issues, SHIPs cover counseling topics in greater depth and offer more personalized assistance. For this reason, SHIPs often take referrals from 1-800-MEDICARE and other federal aging and disability resources to address more complex beneficiary concerns.

While SHIPs serve as an important source of unbiased information about the Medicare program and coverage choices, federal funding has been relatively modest over the last decade, despite an increasingly complex landscape of Medicare coverage options. At $70 million in 2025, up from $60 million in 2015, SHIP spending has amounted to roughly $1 per beneficiary each year from 2015 to 2025, and has been relatively flat for the past several years (Figure 1). Federal administration of the program also appears to be in transition. The Trump administration has announced plans to make significant organizational changes to the Department of Health and Human Services (HHS), including a proposal to eliminate the Administration for Community Living (ACL), which has administered the SHIP program since 2012, and consolidate its functions within a new Administration for Children, Families, and Communities (ACFC). Congress has yet to approve funding for the ACFC, leaving the future outlook for the ACL and the administration of the SHIP program somewhat uncertain.

To give context to the changing demands facing the SHIP program and the population it serves, this brief provides an overview of the services offered by SHIP, describes the level and sources of program funding and trends in service utilization, and discusses potential effects of policy proposals under consideration.

SHIPs Provide Free Counseling and Education Related to Medicare Health Coverage Issues for Beneficiaries and Their Families

SHIPs are state-based programs currently administered by the Office of Healthcare Information and Counseling within the Department of Health and Human Services (HHS) Administration for Community Living (ACL). HHS provides federal funding to states and U.S. territories to offer outreach, counseling, and education to Medicare beneficiaries and their families. There are a total of 54 SHIPs nationwide, operating in every state and the District of Columbia, as well as Guam, Puerto Rico, and the U.S. Virgin Islands. State SHIPs in turn contract with a network of approximately 2,000 local affiliates, including health systems, senior centers, and Area Agencies on Aging, to oversee the daily operations of the program. This structure enables SHIPs to offer locally focused counseling that reflects the Medicare coverage options, hospitals, and physician groups available in a given area, as well as any regional- or county-level aging and disability resources.

One of the primary services offered by SHIPs is one-on-one counseling. Medicare beneficiaries and their families or caregivers can connect with SHIP staff and trained volunteers for personalized assistance with questions related to Medicare benefits and coverage decisions, Medicare Advantage network restrictions and denials, Medicaid eligibility and coverage issues, Part D prescription drug coverage, long-term care insurance, and a variety of other topics. Counseling is available in person at SHIP counseling sites, as well as over the phone, online, or by email. SHIPs also conduct outreach and educational activities through community presentations, senior fairs, and Medicare enrollment events, and share Medicare news and information through the SHIP Technical Assistance Center online resource. All SHIP services are free to the public and not limited by level of income or any other beneficiary demographic criteria.

Medicare Coverage and Enrollment Decisions are Becoming More Complex, Increasing the Need for Unbiased One-On-One Counseling

The Medicare coverage landscape has undergone significant shifts in recent years, due in large part to the expanding role of private Medicare plans. In 2025, more than half of eligible Medicare beneficiaries are enrolled in a Medicare Advantage plan, with an average of 42 plans to choose from—more than twice the number available in 2015. This growth in the Medicare Advantage market has come with an increase in television advertising, as well as reports of aggressive marketing by insurance brokers and other third-party marketing groups. Beneficiaries in traditional Medicare must also navigate numerous choices about their coverage, including an average of 14 options for stand-alone prescription drug coverage, as well as potential sources of supplemental coverage, such as Medicaid, Medigap, and retiree health benefits.

At the same time, a growing share of adults are now working past the age of 65, in part due to the rising age of eligibility for Social Security benefits. Working adults and their spouses may retain their employer-sponsored health insurance for some time after they become eligible for Medicare, necessitating several choices about when and how to enroll in the Medicare program. These include whether to waive Part B coverage until retirement, whether to enroll in Part A alongside an employer-sponsored health plan, and whether to extend employer-sponsored health benefits after retirement under the Continuation of Health Coverage Act (COBRA). Active or retired federal employees who receive health insurance through the Federal Employee Health Benefits (FEHB) Program face a choice of whether to receive their FEHB benefits alongside Medicare Part B or opt out of Part B entirely, which may impact their total premium costs, ability to enroll in Medicare Advantage, and numerous other considerations.

A KFF analysis of focus groups held with Medicare beneficiaries during the 2022 open enrollment period found that many participants felt overwhelmed by their coverage options, and often sought the advice of insurance brokers to assist them in choosing a plan. In contrast, most participants had not heard of or used SHIP services, consistent with other research suggesting that SHIPs are relatively underutilized. SHIPs have fairly modest resources to dedicate to outreach campaigns, and often rely on smaller community events, referrals, and word of mouth to boost awareness of their services, which may make it challenging to compete with the large volume of open enrollment advertising by brokers and other third-party marketing groups.

Nonetheless, while many beneficiaries find brokers to be a helpful resource, they generally do not offer the same level of unbiased counseling as financially disinterested resources such as SHIPs or 1-800-MEDICARE, as they may not represent all coverage options available in a given county or region, and often have a financial incentive to steer beneficiaries towards Medicare Advantage over other forms of coverage. Following a rise in beneficiary complaints about misleading marketing practices by brokers and other third-party marketing groups, the Centers for Medicare & Medicaid Services (CMS) began requiring third-party marketing materials to mention SHIPs as an additional resource in 2024, highlighting the unique service that SHIPs provide in Medicare’s increasingly complex coverage environment.

More than 4 Million Medicare Beneficiaries Received SHIP Services in 2022, Including Lengthy One-On-One Counseling

Roughly 4.3 million Medicare beneficiaries, family members, and caregivers received SHIP services in 2022. Of these, more than one-third (1.7 million) received direct one-on-one counseling, most often in person or over the phone. Counseling sessions may be lengthy and often involve more in-depth issues than those handled by other beneficiary resources, such as 1-800-MEDICARE. In 2021, the most recent year for which these data are available, SHIP counselors spent an average of 33 minutes on each one-on-one counseling contact, more than three times the 9.5 minutes spent on the average call to 1-800-MEDICARE. Moreover, some evidence suggests that the counseling needs of SHIP clients have become more complex in the past decade. The average length of one-on-one counseling sessions increased by nearly 20% from 2014 to 2021.

Given the more extensive one-on-one support provided by SHIP counselors, CMS often coordinates with local SHIP offices to refer beneficiaries whose cases are too complex to be addressed during calls to 1-800-MEDICARE alone. Demand for SHIP services is highest during the annual Medicare open enrollment period, when SHIPs are primarily focused on helping beneficiaries compare plan options for the coming year. In 2021, the six-week open enrollment period accounted for one-third of all one-on-one counseling sessions for the year. Other common topics that may require substantial in-depth counseling include coordinating Medicare benefits with employer or retiree health coverage, completing applications for financial assistance programs such as the Medicare Savings Programs and the Part D Low-Income Subsidy, navigating claims denials and appeals, and shopping for long-term care insurance to cover extended nursing home stays and other services not generally covered by Medicare.

To gain the knowledge and expertise required to offer these counseling services, all SHIP team members (nearly half of whom are volunteers) are required to undergo a thorough training and certification process before interacting with the public. The SHIP Technical Assistance Center provides an Online Counselor Certification Tool to assist with this process, which includes 21 courses and special topics on various aspects of the Medicare program. Reliance on volunteers enables SHIPs to make more efficient use of the funding available to them, and is a common strategy used by similar insurance and benefit navigation programs, such as the Affordable Care Act (ACA) Navigator program. On the other hand, SHIP program coordinators cite availability of volunteers as one of the primary barriers to expanding access to SHIP services, and note that the breadth of learning required often leads to volunteer attrition during training.

Federal Funding for SHIPs Has Been Fairly Modest in the Past Decade, Despite the Growing Complexity of the Medicare Program

The majority of SHIP funding (roughly 80%) comes from discretionary appropriations, provided to the ACL under the annual Departments of Labor, Health and Human Services, Education, and Related Agencies (LHHS) Appropriations Bill. The bulk of this funding is used to supply federal grants to each of the 54 states and territories within the SHIP network, based on regulatory formulas that account for the size of the state’s Medicare population and other factors, such as the share of the state’s Medicare beneficiaries that live in rural areas or have incomes below a certain threshold. In 2025, the ACL received just over $55 million in discretionary funding for SHIP, of which $51 million was distributed in grants with an average award size of roughly $950,000 (Appendix Table 1). The remaining $4 million was reserved for program administration and national program resources, such as the SHIP Technical Assistance Center (see above).

Additional SHIP funding comes from the Medicare Improvements for Patients and Providers Act (MIPPA) program. MIPPA provides targeted grants to states and territories in select programs administered by the ACL to assist low-income beneficiaries with applying for cost assistance through Medicare. SHIP grants under MIPPA are distributed based on a statutory funding formula that considers the number of Medicare beneficiaries in the state who meet certain criteria, such as those who are eligible for the Part D low-income subsidy but have not yet enrolled to receive it. In 2025, the ACL received $15 million in MIPPA funding for SHIP, of which $13.5 million was distributed in grants with an average award size of roughly $260,000 (Appendix Table 1). Finally, some states may supplement federal funding for SHIP with additional state funds.

Federal funding for SHIP has increased modestly over the past decade, but has remained below $1 per beneficiary each year, despite evidence that the cases fielded by SHIPs are becoming more complex. While certain aspects of the SHIP program, such as the use of volunteer counselors and staff, have allowed SHIPs to make efficient use of these funds, greater resources could enable them to reach a larger number of beneficiaries and accommodate the growing complexity of one-on-one counseling services being provided.

HHS Has Proposed Significant Changes to SHIP Program Administration for Fiscal Year 2026

In March 2025, the Trump administration announced a restructuring throughout the Department of Health and Human Services (HHS), including plans to eliminate the ACL, which administers the SHIP program through its Office of Healthcare Information and Counseling. The ACL was formed in 2012 to consolidate the functions of several agencies aimed at supporting the health and wellbeing of older adults and people with disabilities, enabling them to live more independently within their communities. Since that time, the ACL has also been responsible for administering grants to Senior Medicare Patrol offices, which often coordinate with SHIPs to resolve beneficiary complaints of suspected health care fraud, and State Units on Aging, which in turn supply funding to Area Agencies on Aging where many local SHIP offices are housed, along with numerous other programs that serve the aging and disabled populations.

The President’s HHS FY 2026 budget proposal proposes to integrate the programs administered by the ACL into a new Administration for Children, Families, and Communities (ACFC). The proposal maintains discretionary funding for SHIP, as well as mandatory funding through MIPPA, at FY 2025 levels, which may allow SHIPs to continue operating with minimal disruption. On the other hand, HHS has not confirmed whether the ACL staff that administer SHIP funding at the federal level will be subject to staffing cuts during the restructuring, which has included layoffs of roughly 10,000 full-time employees. Media reports from earlier in 2025 suggested that as many as four in 10 (40%) ACL staff were laid off or offered early retirement during prior waves of staffing cuts, such as the “Fork in the Road” deferred resignation program.

Adding to this uncertainty, funding for the ACFC and other new agencies included in the President’s HHS budget proposal has not yet been approved by Congress. The Appropriations Committees in the Senate and the House have recently passed their respective versions of the FY 2026 Labor, Health and Human Services, Education, and Related Agencies (LHHS) Appropriations Bill. While there are numerous differences between the two bills, both maintain funding for the ACL as an independent agency, and do not generally reflect many of the administration’s proposed changes to HHS’s departmental structure. Congress has until September 30 to reconcile the two bills, or else enact a Continuing Resolution (CR) to preserve federal funding at current levels. While these developments do not impact SHIP funding in the short term, they create some uncertainty about the future outlook for the SHIP program and refocus attention on longstanding questions about whether SHIPs will have the resources to meet the demand among Medicare beneficiaries for one-on-one counseling to make informed health coverage decisions in the coming years.

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