The federal government continues to focus on addressing fraud, waste, and abuse in Medicaid, with much of the attention focused on home care services. KFF estimates that over 5 million people use Medicaid home care, which provides help with self-care activities such as bathing, dressing, and eating for older adults and people with disabilities. Home care has been an area of emphasis in new fraud initiatives because spending on home care is growing, and the services are provided in people’s homes and the community where fewer institutional processes and procedures exist. However, spending growth often reflects states’ efforts to increase the availability of home care, and there are additional safeguards against fraud in home care compared with other types of Medicaid services. While additional scrutiny and oversight may limit fraudulent or inappropriate Medicaid spending, additional efforts to combat fraud can create new administrative burdens and limit provider participation, potentially reducing access to care. Aside from waiting lists (an imperfect measure of unmet need), there are generally no metrics to examine how many people who need Medicaid home care are not receiving benefits. States are engaged in many activities aimed at addressing fraud, waste, and abuse in their Medicaid home care programs; in KFF’s 2026 survey of states’ home care programs, the majority of responding states reported that program integrity was one of the top three priorities they were concerned with.

The data come from the 24^th annual KFF survey of officials administering Medicaid home care programs in all 50 states and the District of Columbia (hereafter referred to as a state). States completed the survey between April and August 2026. The survey was sent to each state official responsible for overseeing home care benefits (including home health, personal care, and waiver services for specific populations such as people with physical disabilities). All states except Florida and South Carolina responded to the 2026 survey, but response rates for certain questions were lower.

KFF’s survey finds that all responding states report using multiple program integrity practices beyond federal minimum requirements to prevent and detect fraud, with nearly all states employing a multifaceted approach. The federal government has requirements for states to identify and detect fraud in Medicaid home care; however, all responding states report using strategies that go beyond the federal requirements. KFF asked states whether they used any of eight strategies to “help identify and reduce fraud and abuse in the provision of waiver services,” and 42 states reported using all eight of the strategies that KFF asked about.

Federal law relies on electronic visit verification (EVV) as a core tool to prevent fraud in Medicaid home care, but all responding states reported using EVV practices that go beyond federal requirements (Figure 1). In 2016, Congress passed the 21^st Century Cures Act, which requires states to implement electronic visit verification (EVV) for all Medicaid personal care and home health services if a visit is made to a person in the home. EVV is a computer/mobile system that tracks and records details of services. States’ EVV systems must include six data elements: the enrollee receiving the service, caregiver providing the service, type of service, location of the service delivery, date of the service, and time the service begins and ends. EVV was established to help promote fiscal integrity for Medicaid home care, and states had until 2023 to fully implement the requirements.

While the 21st Century Cures Act mandates that states implement EVV and collect six specific data elements for each visit, it does not specify how states must store EVV data or use it as part of their payment processes. States may choose to apply EVV data in additional ways to support program integrity.

KFF asked states about three potential EVV strategies that go beyond minimum federal requirements and found they were widely used:

• Maintaining EVV data in machine-readable files (48 states),
• Cross-checking billed claims against EVV data (48 states), and
• Analyzing EVV data to identify unusual billing patterns (47 states).

Some states reported adopting strategies that precondition payment on EVV submissions, such as Ohio, which requires valid EVV data as a condition of payment in its waivers for people with intellectual and developmental disabilities (I/DD) and for adults ages 65 and older and those with physical disabilities. Claims that do not have a matching EVV record will be denied, rather than paid and later audited to track down mismatched claims.

In addition to EVV, all responding states reported using at least one other type of program integrity strategy beyond what is federally required. KFF asked states whether they were using any of the following non-EVV related strategies:

• Analyzing claims by provider to identify unusual billing patterns (48 states),
• Analyzing claims by enrollee to identify unusual patterns of service receipt (45 states),
• Updating the care plan and service authorizations annually or more frequently (47 states),
• Requiring in-person assessments to establish service authorizations in the care plan (46 states), and
• Verifying claims are in line with care plan service authorizations prior to payment (47 states).

Seventeen states also reported using other program integrity strategies outside of the options KFF included, although most states did not describe those options in much detail. Some strategies mentioned focused on provider certification and enrollment requirements whereas others were focused on identifying claims that required additional review before or after payment.

Nearly half of states are currently using or planning to incorporate artificial intelligence (AI) into program integrity and data monitoring activities (Figure 2). KFF asked states to report their current phase of AI tool use for “program integrity and data monitoring (to identify potential fraud, waste, and abuse).” States could report one of five options: currently using, piloting, planning to use, not using, or unknown. Twelve states reported currently using AI-enabled tools for program integrity and data monitoring purposes under at least one program (Arizona, Arkansas, Connecticut, Indiana, Michigan, Missouri, Montana, Nevada, New Mexico, North Carolina, Texas, and Washington). For example, North Carolina reported using AI to create algorithms that would detect fraud, waste, and abuse in its waiver for adults ages 65 and older or with physical disabilities, and Missouri reported using AI to aggregate information about critical incidents and grievances. Of the 12 states currently using AI tools, five states (Arkansas, Connecticut, Michigan, Montana, and North Carolina) also reported they are planning to incorporate AI tools under at least one additional program. One state (California) reported piloting AI-enabled tools for program integrity purposes. Eight states (Alaska, Delaware, Georgia, Hawaii, Mississippi, New Hampshire, New York, and Wyoming) reported that they are not currently using AI tools for program integrity, but that they are planning to incorporate them in the future.

The adoption of AI-enabled tools is most commonly reported under waivers for people with I/DD and adults ages 65 and older and those with physical disabilities. Over one in four states with waivers for people with I/DD and waivers for adults ages 65 and older and those with physical disabilities are currently using or are planning to incorporate AI-enabled tools for their program integrity and data monitoring activities. Seven states with waivers for adults ages 65 and older or those with physical disabilities and five states with waivers for people with I/DD are currently using AI tools for their program integrity and data monitoring activities, more than any other waiver type.

Appendix

Medicaid is the primary payer for long-term care (LTC) in the U.S. and pays for more than two-thirds of the LTC delivered in home- and community-based settings. Most home care (also known as “home- and community-based services” or HCBS) is optional for states to provide and is frequently offered through “waivers,” which allow states to cover a wide range of benefits and to choose—and limit—the number of people who receive services. KFF estimates that more than 5 million Medicaid enrollees use home care, and that about half of people are using home care through waivers. States’ ability to cap the number of people enrolled in home care waivers can result in waiting lists when the number of people seeking services exceeds the number of waiver slots available.

Passed last year, the 2025 reconciliation law made substantial changes to Medicaid that are expected to significantly reduce federal funding for Medicaid and lead to coverage loss for many current enrollees, placing new financial pressures on states, providers, and enrollees. Given the substantial share of Medicaid spending that pays for home care, and the optional nature of most home care programs, cuts to home care programs could occur as states respond to reduced federal spending. If states cut home care by reducing the number of people who can receive waiver services, waiting lists could increase. Proposals to cut home care may face challenges because people who rely on such services have complex health care needs and because elections may make it more difficult to restrict coverage. Recent tracking of programmatic changes to Medicaid home care highlights that some states have cut their programs, but in many cases, proposed cuts were not enacted, and other states continue to make enhancements.

Waiting lists could also increase because of changes to immigration policy in states that use waiting lists to manage shortages of home care workers. Three in 10 direct care workers are immigrants, and recent federal policy changes could further exacerbate the challenge of retaining and growing the workforce.

This data note provides new information about waiting lists in Medicaid home care before many of the provisions in the reconciliation law go into effect. Waiting lists are an incomplete measure of unmet need (Box 1) and are not necessarily comparable across states or over time. The data come from the 24^th KFF survey of officials administering Medicaid home care programs in all 50 states and the District of Columbia (hereafter referred to as a state), which states completed between April and August 2026. The survey was sent to each state official responsible for overseeing home care benefits (including home health, personal care, and waiver services for specific populations such as people with physical disabilities). All states except Florida and South Carolina responded to the 2026 survey. To facilitate comparisons over time, Florida’s responses to the 2022 survey and South Carolina’s responses to the 2025 survey were included with their permission. Survey findings are reported by state and waiver target population, although states often offer multiple waivers for a given target population. Key takeaways include:

• Forty states maintain waiting lists or interest lists for people who would like to receive home care, a number that fluctuated little between 2016 and 2026.
• In all years since 2016, there have been at least 0.5 million people on waiting lists or interest lists, with a total of almost 650,000 in 2026.
• In 2026, two states reported having at least one new waiting list (across three waivers), and 32 states reported an increase in the number of people on waiting lists or interest lists compared with only 7 states reporting a decrease.

• Most people on waiting lists or interest lists have intellectual or developmental disabilities (I/DD), and most live in states that do not screen any people for eligibility prior to adding them to waiting lists.
• Most people on waiting lists or interest lists are eligible for personal care provided through states’ regular Medicaid programs or for services provided through specialized state plan home care benefits.

KFF also recently updated the waiting list indicators on State Health Facts, which show data by state and target population.

How Many States Have Waiting Lists for Home Care?

Between 2016 and 2026, the number of states with waiting lists has fluctuated between 37 and 41 and is currently at 40 states (Figure 1). While some Affordable Care Act (ACA) opponents have cited waiver waiting lists to argue that expanding Medicaid diverts funds from adults ages 65+ and those with physical disabilities, research shows that ACA Medicaid expansion has led to gains in coverage for people with disabilities and chronic illnesses. Waiting lists for home care predate the ACA Medicaid expansion, which became effective in most states in 2014, and both expansion and non-expansion states have waiting lists. Waiver enrollment caps have existed since home care waiver authority was added to federal Medicaid law in the early 1980s.

While the overall number of states with waiting lists did not change much from 2025 to 2026, there were more changes in waiting lists for specific states and for specific types of waivers. Seven states (across eight waivers) removed waiting lists, including Nebraska, which no longer reported any waiting lists, and Oregon, which eliminated a waiting list of 1,000 people from its Section 1115 waiver for adults ages 65+ and those with physical disabilities. Two states (across three waivers) reported new waiting lists. Washington reported new waiting lists for people with I/DD (275 people) and adults ages 65+ and those with physical disabilities (waiting list size unknown), and Kentucky reported a new waiting list for individuals with traumatic brain or spinal cord injuries (5 people).

How Many People Are on Waiting Lists for Home Care?

Between 2025 and 2026, total enrollment in waiting lists and interest lists increased by about 7% and is almost 650,000 in 2026 (Figure 2). Overall, there was an increase in the number of people on waiting or interest lists in 32 states and a decrease in 7 states. One factor that contributes to changes over time is changes in states’ policies for managing their waiting lists. In 2026, several states changed their policies, but those changes did not result in any major increases or decreases in waiting lists. However, that has not been true in past years. For example, between 2018 and 2020, the total number of people on waiting lists decreased by 155,000, or 19%. Nearly half of that change came from Ohio’s implementation of a waiting list assessment of waiver eligibility, which reduced the size of the state’s waiting list by nearly 70,000 people. In 2026, most states (32) with waiting lists screen individuals for waiver eligibility for at least one waiver, but even among those states, four (California, Maryland, Mississippi, and Washington) do not screen for all waivers. The eight states that do not screen for eligibility among any waivers (Alaska, Florida, Iowa, New Mexico, Oklahoma, Oregon, South Carolina, and Texas) account for over half (56%) of all people on waiting lists.

In 2026 and earlier years, a disproportionate number of people on home care waiting lists or interest lists lived in states that did not screen people on waiting lists for eligibility. One reason waiting lists provide an incomplete picture of need is that not all people on waiting lists will be eligible for services. The number of states that do not screen for eligibility on any waiting lists ranged from six to eight states between 2022 and 2026, yet the share of individuals on waiting lists in these states ranged from 40% to 56%. Interviews about home care waiting lists found that when waiver services are provided on a first-come, first-served basis, people enroll in waiting lists in anticipation of future need. That study found that in some states, families would add their children to waiting lists for people with I/DD at a young age, assuming that by the time they reached the top of the waiting list, their children would have developed the immediate need for services. Many of those waivers offer comprehensive home care packages that include supported employment, supportive housing, or round-the-clock services. Among the eight states that do not screen people for eligibility on any lists, seven have only waiting lists and one has only interest lists.

Who Is on Waiting Lists for Home Care?

Most people on waiting lists have I/DD, particularly in states that do not screen for waiver eligibility before placing someone on a waiting list. People on waiting lists for waivers serving people with I/DD (which include waivers specific to people who have autism) make up 78% of waiting lists in states that do not screen for waiver eligibility, compared with 61% in states that do determine waiver eligibility before placing someone on a waiting list. People with I/DD make up almost three-quarters (72%) of the total waiver waiting list population (Figure 3). Adults ages 65+ and those with physical disabilities account for one-quarter (25%), while the remaining share (3%) includes children who are medically fragile or technology dependent, people with traumatic brain or spinal cord injuries, people with mental illness, and people with HIV/AIDS. People who are on home care waiting lists are generally not representative of the Medicaid population or the population that uses home care. Most people on waiting lists have I/DD, but KFF analysis shows that people with I/DD make up fewer than half of the people served through 1915(c) waivers (the largest source of Medicaid home care spending).

How Long Are People on Waiting Lists for Home Care?

In 2026, people on waiting or interest lists accessed services after an average of 34 months (35 of 40 states responding), up from 32 months in 2025. People with I/DD wait 38 months on average. The average waiting period for other waiver populations ranged from 8 months for waivers targeting medically fragile and technology-dependent children to 65 months for waivers that serve people with autism.

Most people on waiting or interest lists for whom living arrangements are known live in community settings while they wait. Among the 649,900 people on lists for waiver services in 2026, living arrangements are unknown for more than 425,000. Among the people whose living arrangements are known, 95% (213,800) live in the community and 5% (10,900) live in institutional settings. Although most people on waiting lists live in the community, that may not be true for all waivers. In one California waiver for adults ages 65+ and those with physical disabilities, nearly half of the 16,100 people on the waiting list are living in institutions.

While waiting for waiver services, people living in the community are likely to be eligible for other home care through Medicaid state plans. Of the more than 5 million people who use home care, KFF estimates that roughly half use services provided through the Medicaid state plan, such as personal care to help with bathing or preparing meals, therapies to help people regain or acquire independent living skills, and assistive technology. States may not use waiting lists to restrict the number of people eligible to use such services, and over 80% of people on home care waiting lists are eligible for personal care or other state plan services. They would not, however, have access to more specialized services such as supported employment or adult day care. People on waiting lists who receive state plan services may also have fewer hours of personal care than they would in a waiver program, or they may not have assistance with some of the activities they need help with, such as bathing, dressing, preparing meals, or managing medication.

The Centers for Medicare & Medicaid Services (CMS) has just released information about Medicare Part D plans for 2027, including plan availability and premiums for the coming year. The agency emphasized stability in the Part D prescription drug plan (PDP) marketplace for 2027 (as it did for 2026) and estimated only a modest $1 increase in the average monthly PDP premium from $35 to $36. KFF analysis of PDP availability and premiums for 2027 shows a mixed picture, with modest premium increases for many Part D enrollees for their current plan but steeper increases for others, and a reduction in the number of PDP options for the fourth year in a row. Key takeaways include:

• The number of stand-alone PDPs available to the average beneficiary will fall for the fourth year in a row, from 11 in 2026 to 9 in 2027. PDP availability in 2027 varies by state, ranging from 8 PDPs in 15 states to 12 PDPs in 1 state, the same range as in 2026 but with most states having 8 or 9 PDPs rather than 10 or more.
• Many PDP enrollees will see premium reductions or only modestly higher premiums in 2027 if they keep their current plan, but others will face substantially higher premiums. Enrollees in six of the eight PDPs that will continue to be offered on a national basis in 2027 will see premium reductions in some states if they keep their current plan, but enrollees in many other states will see higher premiums for these same plans if they don’t switch. Centene continues to offer the lowest-premium PDPs in 2027, with premiums for both Wellcare PDPs under $10 per month in many states, while enrollees in United’s AARP-branded PDPs will face substantially higher premiums and monthly increases of $50 or more in many states if they keep their current plan.
• There will be no zero premium PDPs available for Part D enrollees who do not receive low-income subsidies (LIS) in 2027. All 4 million PDP enrollees who paid no monthly premium in 2026 will face higher premiums in 2027 whether they keep their current plan or switch to a new PDP.
• With 56% of all Part D enrollees in Medicare Advantage drug plans in 2026, a majority of Part D enrollees will not be affected by PDP premium changes and may not face premium increases of any magnitude. Medicare Advantage plans can use rebate dollars from the federal government to reduce premiums for prescription drug coverage, funds that are not available to plan sponsors for PDPs.
• Ending the Part D Premium Stabilization Demonstration did not result in substantially higher across-the-board PDP premiums but still likely affected premium levels for 2027. The disappearance of zero premium PDPs for Part D enrollees without low-income subsidies and monthly premium increases greater than $50 for some PDP enrollees if they keep their current plan are possibly related to the termination of extra subsidies that were provided to PDP plan sponsors under the demonstration.

Findings

The number of stand-alone PDPs available to the average beneficiary will fall for the fourth year in a row, from 11 in 2026 to 9 in 2027, while the total number of stand-alone drug plans available will fall from 360 plans nationwide offered by 17 parent organization in 2026 to 316 plans offered by 15 parent organizations in 2027. The reduction in PDP offerings is largely due to two plan sponsors scaling back: Health Care Service Corporation is withdrawing the HealthSpring Extra Rx PDP from 22 regions, and CVS Health is withdrawing the Silverscript Choice PDP from 13 regions. Humana remains the only insurer offering three PDPs in all 34 PDP regions. PDP availability in 2027 varies by state, ranging from 8 PDPs in 15 states to 12 PDPs in 1 state (Figure 1) – the same range as in 2026 but with most states having 8 or 9 PDPs rather than 10 or more. Medicare Part D enrollees in almost all states will see a modest reduction in the number of PDPs for 2027, except Florida which is gaining 1 PDP and no change in 4 other states (Table 1).

Many PDP enrollees will see premium reductions or only modestly higher premiums in 2027 if they keep their current plan, but others will pay substantially higher premiums. Enrollees in six of the eight PDPs that will continue to be offered on a national basis in 2027 will see premium reductions in some states if they keep their current plan, but enrollees in many other states will see higher premiums for these same plans if they don’t switch (Figure 2).

Other takeaways from an initial analysis of 2027 PDP premiums and changes from 2026 include:

• There will be no $0 premium PDPs available for Part D enrollees who do not receive low-income subsidies (LIS) in 2027. According to KFF analysis, 28% of PDP enrollees without LIS, or 4 million PDP enrollees, paid no monthly premium in 2026. All these enrollees will face higher premiums in 2027 whether they keep their current plan or switch to a new PDP. This includes:
  • Humana Basic Rx PDP enrollees in 28 states, facing premium increases of $6.30 to $30.60 per month if they keep this plan;
  • Wellcare Value Script and Wellcare Classic enrollees in 16 states, facing monthly increases of $5.30 and $7.30 respectively;
  • HealthSpring Assurance Rx enrollees in 11 states, facing monthly increases of $9.30 to $14.70;
  • Humana Value Rx enrollees in 5 states, facing monthly increases of $17.20 to $22.30; and
  • AARP Medicare Rx Saver enrollees in 3 states, facing a monthly increase of $10.30.
• Centene continues to offer the lowest premium PDPs, with 2027 monthly premiums of $5.30 for Wellcare Value Script in 45 states and $7.30 for Wellcare Classic in 33 states. For the 5.9 million non-LIS enrollees in Wellcare Value Script in 2026, those in 29 states will see premium reductions in 2027 ranging from less than $1 to $17.50 if they keep their current plan, while those in another 22 states will see premium increases in 2027 ranging from less than $1 to $5.30.
• Enrollees in United’s AARP-branded PDPs will face substantially higher premiums in many states if they keep their current plan, with monthly premium increases of $50 or more in all 50 states and DC for AARP Medicare Rx Preferred (including 37 states with premium increases greater than $75 and 4 states with premium increases of more than $100) and increases of $50 or more in 33 states for AARP Medicare Rx Saver. Together, these plans enroll more than 2 million non-LIS enrollees in 2026. Switching to a less expensive PDP is an option in all areas, but KFF analysis shows that many enrollees don’t compare plans or switch during open enrollment.

With 56% of all Part D enrollees in Medicare Advantage drug plans in 2026, a majority of Part D enrollees will not be affected by PDP premium changes and may not face premium increases of any magnitude. According to CMS, the average Medicare Advantage drug plan premium for 2027 will continue to be considerably lower than the average monthly PDP premium, and it’s likely that most MA-PD enrollees will be in plans charging zero premium in 2027, as in 2026 and previous years. This is because Medicare Advantage plans can use rebate dollars from the federal government to reduce premiums for prescription drug coverage, funds that are not available to plan sponsors for PDPs.

Ending the Part D Premium Stabilization Demonstration did not result in substantially higher across-the-board PDP premiums but still likely affected premium levels for 2027. CMS’s decision to terminate the Part D Premium Stabilization Demonstration for 2027, rather than continue it for a third year as originally planned when the demonstration was announced, seemed to point in the direction of higher premiums for PDP coverage in 2027. The demonstration provided extra subsidies to PDP plan sponsors, and by extension PDP enrollees, in two ways – reducing the base beneficiary premium, which is used in the calculation of individual plan premiums, and capping the year-over-year increase in the monthly premium. CMS determined that the extra financial support provided to PDP sponsors under the demonstration was no longer needed after 2026, and in fact, across-the-board substantial PDP premium increases for 2027 didn’t materialize. However, the disappearance of zero premium PDPs for Part D enrollees without low-income subsidies is a possible outcome of the termination of the demonstration, and eliminating the cap on the year-over-year increase in the monthly PDP premium has meant that monthly premium increases greater than $50 are possible for some PDP enrollees if they keep their current plan.

Even if the monthly premium for a given Part D drug plan is decreasing or increasing only modestly, premiums are only one feature for beneficiaries to consider when evaluating their Part D coverage. As is commonly advised during open enrollment, Medicare beneficiaries may want to evaluate what other features of their Part D plan might be changing, including what drugs are and aren’t covered on the plan’s formulary, tier placement of covered drugs, deductibles, and cost-sharing requirements. With Part D costs overall on the rise, the tradeoff Part D enrollees might face as their premium increases are kept in check is that their coverage may be getting less generous, which could mean fewer drugs covered, higher cost-sharing requirements, or greater utilization management restrictions – or possibly a combination of all three.

Earlier this week, the Centers for Medicare and Medicaid Services (CMS) published information about the Medicare Advantage plans that will be available for the coming 2027 plan year. Starting October 1^st, insurers, brokers, and other third-party entities can market Medicare Advantage plans, and during the annual open enrollment period, which runs from October 15^th through December 7^th, Medicare beneficiaries can make changes to their Medicare coverage for the coming year. In a press release, CMS emphasized stability in the Medicare Advantage marketplace overall. This analysis explores Medicare Advantage plan availability for the average beneficiary and at the state level.

KFF’s analysis of plan offerings shows that, on average, Medicare beneficiaries will have the option of 28 Medicare Advantage prescription drug (MA-PD) plans in 2027, a decline from the 32 options available in 2026 (excluding employer plans and special needs plans not available for general enrollment). The number of MA-PD options grew steadily between 2010 and 2024, reaching a peak of 36 options for the average Medicare beneficiary in 2024. The number of options available for 2027 will be higher than the number available in 2021 (27) and every year before (Figure 1).

Across all Medicare Advantage plans for general enrollment, including those with and without prescription drug coverage, the average Medicare beneficiary can choose from among 35 plans in 2027, compared to 39 plans in 2026. Similar to the trend for MA-PDs, the total number of Medicare Advantage plans available to the average beneficiary is higher than the average number of plans available in every year between 2010 and 2021. While Medicare Advantage plans are required to cover all Medicare Part A and Part B benefits, plans decide whether to include Part D prescription drug coverage as part of the benefit package. Enrollees may pay a separate premium for Part D coverage, or plans can use the rebate portion of their payment from the federal government to cover these costs. Most Medicare Advantage enrollees are in plans that include prescription drug coverage and most pay no premium beyond the Part B premium.

The modest decrease in the number of Medicare Advantage plans available to the average beneficiary means that some Medicare beneficiaries will find that their current coverage is no longer an option for next year. In most cases, these beneficiaries live in counties where they will continue to have robust Medicare Advantage plan options available for 2027, as well as traditional Medicare. Some beneficiaries in plans that have exited the market will have the option to enroll in a plan offered by the same insurer, and in many cases, enrollees will be moved into a new plan offered by the same insurer automatically if the contract includes another plan of the same type (i.e., HMO or PPO) in the same county. Others will have to make an active choice about their Medicare coverage if they wish to enroll in another Medicare Advantage plan or will be automatically covered by traditional Medicare.

The number of Medicare Advantage plans with prescription drug coverage available to the average beneficiary varies across states (Figure 2). In 26 states and Puerto Rico, the average Medicare beneficiary has at least 20 MA-PD options in 2027, including 3 states (PA, MI, and OH), where the average beneficiary has at least 40 MA-PD options. In 9 states and DC, the average Medicare beneficiary has fewer than 10 MA-PD options in 2027. This includes Alaska, which has no plans available in 2027, as in 2026 (Alaska has historically had few or no Medicare Advantage plans available for general enrollment). Connecticut is not included in this calculation because of differences in how counties are reported across CMS enrollment and plan files.

Across most states, the average beneficiary will have fewer Medicare Advantage plan options in 2027 compared to 2026. The states with the largest drop in the number of MA-PDs available for general enrollment are Texas (-9), Illinois and Ohio (-8), and Minnesota, New Mexico, and Washington (-7). In nine states beneficiaries will have the same number of MA-PD options in 2027 as in 2026 (excludes Alaska where no MA-PDs are available in 2026 or 2027), and in four states beneficiaries will have more options (Figure 3).

Choosing how to receive Medicare benefits remains a challenge for Medicare beneficiaries. Beyond the number of plans available, every year there are changes to Medicare Advantage plan benefits and costs, including the scope and generosity of extra benefits, cost sharing for Medicare-covered benefits, out-of-pocket limits, rules for using covered services (such as referral requirements and prior authorization), drug formularies, and provider networks. (These data are released separately by CMS and a comprehensive analysis from KFF will follow.) Despite these changes, most Medicare beneficiaries report that they do not compare coverage options on an annual basis. Further, prior Medicare focus groups indicate that Medicare enrollees are often overwhelmed by the number of Medicare Advantage choices and have difficulty sorting through all plan options. With more than two dozen MA-PDs available in 2027, on average, and year-to-year changes in benefits and costs, understanding how plans differ and how these differences could affect costs and access remains a challenge for beneficiaries.

Overview

Amid the largest U.S. measles epidemic in decades, and one that threatens the country’s measles elimination status, a controversy has emerged regarding how to count deaths from measles. In August and September this year, Pennsylvania reported that four measles deaths had occurred in the state but so far, the Centers for Disease Control and Prevention (CDC) has recognized just one of these in its official measles statistics. CDC announced in early September that it would change how it counts measles deaths, no longer relying solely on reports from state health departments and instead looking to official death records as tracked by the National Center for Health Statistics (NCHS, a sub-agency within CDC). This new CDC policy of relying on NCHS-based mortality data to count measles deaths marks a departure from historical norms and processes that have accepted measles death reports from state health departments.

This Policy Watch reviews how measles deaths are typically determined, how these deaths are counted by the federal government and the role of two distinct but related federal public health surveillance systems at the center of the controversy – the CDC’s Nationally Notifiable Diseases Surveillance System (NNDSS) and NCHS’ National Vital Statistics System (NVSS). NNDSS and NVSS are separate public health surveillance systems with their own strengths and limitations: with NNDSS focused on real-time disease tracking that at times can also provide preliminary mortality information, while NVSS is focused on collecting longer-term, retrospective data on deaths and providing final determinations regarding the cause(s) of death though not necessarily designed for real-time tracking.  These two systems are complements, but one does not entirely replace the other.

Context

On August 25, Pennsylvania Governor Josh Shapiro held a press conference to announce that two deaths attributed to measles had occurred, the first such deaths in the state since 1992. As is standard protocol for cases of infectious diseases of national interest such as measles, the Pennsylvania Department of Health (PA DOH) also reported these as “measles-associated” deaths directly to CDC via the Nationally Notifiable Disease Surveillance System (NNDSS). PA DOH relied on pre-existing definitions for measles and for respiratory disease-associated mortality – which include clinical, laboratory, epidemiologic, and vital records criteria – in making the determination that these particular deaths were measles associated.

The Secretary of Health and Human Services (HHS) Robert F. Kennedy, Jr. initially objected to Pennsylvania’s classification of these deaths as measles-associated, saying Shapiro’s announcement was “premature” and suggesting the deaths “may even have been altogether fabricated.” CDC staff initially accepting the state’s death reports, though Kennedy later asked the CDC Director to remove any reference to those measles deaths on the CDC website. After the coroner in Lancaster County confirmed that measles was a contributing cause to the reported deaths, on September 4 Kennedy recognized measles as the cause for “only the second infant’s death” and stated: “The National Center for Health Statistics does not currently have any death records from 2026 that indicate measles is the underlying cause” but indicated CDC will update its measles death statistics upon receipt of such records. On September 14, a CDC spokesperson stated the agency had changed how it will count measles deaths in its official statistics, and going forward CDC would “report measles deaths if and when the National Center for Health Statistics reports measles as the underlying cause of death.”  The next day, PA DOH reported two additional measles-associated deaths, bringing the state’s own total to four. However, at present the CDC measles outbreak tally reports two deaths for 2026, with a note saying: “This number is subject to change; CDC will update its reporting as additional information becomes available and relevant reviews are completed.”

Two Systems with Different Purposes

The dispute around reporting measles deaths has brought new focus to two separate federal public health surveillance systems: the Nationally Notifiable Disease Surveillance System (NNDSS) and the National Vital Statistics System (NVSS). Each of these has a long history, dating back to the early 20^th century, but serves different purposes. These systems are described below (see Table 1). 

Nationally Notifiable Disease Surveillance System (NNDSS): Timely Case Reporting

NNDSS is a collaboration between CDC and jurisdictions across the country that supports sharing and monitoring public health information for a set of diseases and conditions of national interest. NNDSS has roots extending to a system established in 1893 by Congress for jurisdictions to report cases of disease to the Surgeon General. Over time the system expanded, with responsibility for overseeing the system transferred to CDC in 1961. Local and state public health departments have the authority and responsibility to track cases of disease, typically through reporting from health care providers, laboratories, and other sources. In turn, jurisdictions then may provide case information to CDC through NNDSS. Key characteristics of NNDSS include:

• A set of approximately 120 diseases and conditions that are designated by CDC as “nationally notifiable,” meaning the agency requests state and local health departments report to CDC when new cases of any of these conditions are identified. Measles is a nationally notifiable disease, and has been since 1912. Importantly, CDC cannot require jurisdictions to report case information, but all do, especially for high consequence infectious diseases such as measles. CDC itself says “since continuous endemic measles transmission has been eliminated, measles is an immediately notifiable disease.”
• For each NNDSS disease or condition there is a pre-established definition that jurisdictions can consult to help determine if a notifiable case has occurred. These case definitions assure a level of standardization across jurisdictions. The definitions for nationally notifiable diseases are developed in collaboration with the Council of State and Territorial Epidemiologists (CSTE) and intermittently updated and refined. The current NNDSS case definition for measles dates to 2013.
• Jurisdictions determine the extent of detail provided in their reports. Information shared through NNDSS is “de-identified” (i.e. with personally identifying information removed), but jurisdictions may include demographic, clinical, and epidemiologic characteristics and the course of clinical illness (including whether death occurred) in their case reports.
• NNDSS reports can preliminarily indicate the cause of death in a particular case, but are not expected or designed to be a final determination. For this reason, Pennsylvania has reported the four deaths as being “measles-associated” rather than presenting a final determination of measles as the cause of death. The NNDSS definition for measles does not include specific guidance for when and how to report a death as being caused by measles infection, though CDC reports it is working with CSTE to update the definition “to promote consistent classification and reporting of measles deaths across jurisdictions.” 
• A relative strength of NNDSS is the ability for rapid communication of case-level epidemiologic information between jurisdictions and the CDC, which can allow for near real-time tracking of outbreaks and disease trends. A limitation is that rapidly reported information may only be preliminary in nature, and case reports could be incomplete or lacking in detail.

National Vital Statistics System (NVSS): Comprehensive Cause of Death Reporting

NVSS is the federal government’s primary mechanism for tracking mortality (and other vital statistics) data. The NVSS has roots going back to 1902, when Congress created a permanent Census Bureau and authorized the government to obtain copies of state vital records. By 1933, all states were required to record births and deaths and provide data to the Census Bureau. The NCHS was created in 1960, with responsibility for federal vital statistics transferred there.  The responsibility and legal authority for documenting births, deaths, and other vital statistics resides at the state and local level, but by statute NCHS has authority to collect and review these data – each state has a contract with NCHS that allows the federal government access to this information to produce national vital statistics. Key characteristics of NVSS include:

• Housing the most complete set of data on deaths and births in the U.S. Death certificate information captured through NVSS is the most comprehensive source for mortality information nationally.
• Death certificate information captured through NVSS is considered the benchmark for cause of death data. When completing a death certificate, a provider must include the best and final judgement on the proximate cause(s) of death as well as potential other factors that may have contributed to the death. Information from an autopsy, or laboratory and other test results may be included. Demographic details are also reported through the system such as age, sex, race/ethnicity, and education.
• Nuances regarding a possible chain of events leading to a death and potentially multiple contributing factors can introduce complexity in cause of death determinations. Regarding the Pennsylvania cases, there has been some debate about measles being a primary cause of the deaths reported by the PA DOH, especially in relation to one of the initial reported deaths – a newborn infant that died from a lacerated spleen but was also positive for measles. 
• State/local vital records offices are responsible for inspecting death certificates for timeliness, completeness, and accuracy of information, processing, and storing the records. Data files derived from these state/local records are then transmitted to NCHS.
• NCHS reviews and processes vital statistics data and codes mortality statistics according to the current revision of the International Classification of Diseases (presently ICD-10, which the U.S. began to use in 1999). ICD-10 provides definitions and rules for selecting the underlying cause of death when generating vital statistics through NVSS. Typically, NVSS will release “provisional” cause of death data with a 3 to 9 month lag (depending on the cause of death), though full provisional data may take up to one a year to be released. Final cause of death data is made available after about two years. For example, the most recent NVSS provisional cause of death data are for 2025 while the most recent final cause of death data are from 2024. In special circumstances, provisional death data can become available even earlier – for example, during the COVID-19 pandemic NVSS provided updated COVID-19 related death statistics on a weekly basis.
• A relative strength of the NVSS is its completeness and the comprehensiveness of its cause of death information. A relative weakness of the NVSS is the time lag between when deaths occur and the availability of cause of death data.

This updated chart collection uses federal labor data to compare jobs and wages in the health care sector with the rest of the economy. Health sector employment has grown steadily while job growth in other non-farm sectors has plateaued. Over the past year, the health sector added 378,500 jobs—a 2% increase—compared with 0.2% growth in non-health, non-farm employment. Health care wage growth has slowed slightly compared to other industries over the past three years.

Health care jobs now account for 11.6% of all non-farm jobs, up from 10.7% a decade ago. Since 1990, health sector employment has grown over three times as much as all other non-health, non-farm employment sectors, increasing most in outpatient settings (up 40% since August 2016.)

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