In this JAMA Viewpoints column, KFF’s Drew Altman, Ashley Kirzinger and Mollyann Brodie explore the power of health care affordability as an economic issue, how it has played out in recent election cycles, and the implications for the 2026 midterm elections. The column notes how health care increasingly has become a dimension of voters’ economic worries rather than a stand-alone issue, which explains why the debate about whether to extend the Affordable Care Act’s expiring enhanced tax credits has so much salience now that could continue into the midterms if Congress does not strike a deal to address rising costs for consumers. It also explains why Medicaid cuts will have power as an issue even though the cuts will be phased in over time.

About this Dashboard

This dashboard monitors the status of the U.S. President’s Malaria Initiative’s (PMI) partner countries’ progress toward global malaria targets. It includes data for 30 countries, including 27 focus countries in Africa (including the three PMI partner countries – Burundi, Gambia, and Togo – that were added in 2023) and three countries in the Greater Mekong Subregion in South-East Asia.* Together, these 30 countries represent almost 90% of the global malaria burden. Data are from the WHO’s World Malaria Report 2024. The data powering this dashboard are available for download here. KFF will continue to track PMI country progress on these indicators and update the dashboard as new data become available.

Notes

*PMI countries include the following: Angola, Benin, Burkina Faso, Burma, Burundi, Cambodia, Cameroon, Côte d’lvoire, D.R. Congo, Ethiopia, Gambia, Ghana, Guinea, Kenya, Liberia, Madagascar, Malawi, Mali, Mozambique, Niger, Nigeria, Rwanda, Senegal, Sierra Leone, Tanzania, Thailand, Togo, Uganda, Zambia, and Zimbabwe. U.S. President’s Malaria Initiative (PMI), Where We Work, accessed: https:/www.pmi.gov/what-we-do/. PMI, Press release: U.S. President’s Malaria Initiative Announces Plans to Expand to New Partner Countries, accessed: https://www.pmi.gov/u-s-presidents-malaria-initiative-announces-plans-to-expand-to-new-partner-countries/.

About this Dashboard

This dashboard monitors the status of USAID’s tuberculosis (TB) priority countries’ progress toward global TB targets. It includes data for 24 countries* in which USAID’s bilateral TB program carries out TB efforts. Data are from the World Health Organization’s (WHO) Global Tuberculosis Report 2025. The data powering this dashboard are available for download here. KFF will continue to track country progress on these indicators and update the dashboard as new data become available.

Notes

* USAID TB priority countries include the following: Afghanistan, Bangladesh, Burma, Cambodia, Democratic Republic of Congo, Ethiopia, India, Indonesia, Kenya, Kyrgyz Republic, Malawi, Mozambique, Nigeria, Pakistan, Philippines, South Africa, Tajikistan, Tanzania, Uganda, Ukraine, Uzbekistan, Vietnam, Zambia, and Zimbabwe. USAID, Global Tuberculosis Countries webpage, accessed: https://www.usaid.gov/global-health/health-areas/tuberculosis/countries.

About This Dashboard

This dashboard monitors the status of PEPFAR countries’ progress toward global HIV targets from 2019-2024. It includes data for 54 countries required to develop a PEPFAR Country or Regional Operational Plan (COP/ROP) in FY 2024. To use the dashboard, click on any indicator and select a year to see country-level data for that year. Click on Trends Over Time to see the progress countries have made in recent years. Data are from UNAIDS AIDSinfo database and were last updated in July 2025. Data for the latest available year are for 2024. The data powering this dashboard are available for download here. KFF will continue to track PEPFAR country progress on these indicators and update the dashboard as new data become available.

The Affordable Care Act (ACA) offers premium tax credits to help make health insurance more affordable. Under original Affordable Care Act provisions, an income cap for premium tax credits was set at 400% of the federal poverty level. Above that threshold, federal financial assistance was not available, creating a “subsidy cliff.” The American Rescue Plan Act (ARPA) and later the Inflation Reduction Act (IRA) temporarily expanded eligibility for tax credits to people with incomes over 400% of poverty, in addition to providing more generous support for people at lower incomes.

Enhanced premium tax credits expire at the end of this year. Enrollees currently receiving premium tax credits at any level of income will see their federal assistance decrease or disappear if enhanced premium tax credits expire, with an average increase of 114% to what enrollees pay in premiums net of tax credits. Since premium payments are capped based on income and family size, there is little geographic variation in the resulting increases in premium payments for enrollees with incomes below 400% of poverty. Out-of-pocket premiums for people with incomes below 400% of poverty will increase by hundreds of dollars to over $1,500 per person on average.

Among those with incomes over 400% poverty who are losing the tax credit altogether, the impact will be greatest for those whose unsubsidized premiums are highest: older Marketplace enrollees and those living in higher-premium locales. Among enrollees with incomes over 400% of poverty, just over half are between ages 50 and 64, and will therefore have high unsubsidized premiums.

The maps below show how much average premium payments would increase for 2026 benchmark silver plans with the expiration of enhanced premium tax credits at four income levels above an income cap of 400% of federal poverty for a 40-year-old and 60-year-old individual, namely 401%, 501%, 601%, and 701%..

Among these four income levels, enhanced tax credits provide the most financial assistance for those at 401% of poverty, which represents an annual salary of $62,757 for an individual in the contiguous United States. Because the cost of living is higher in Alaska and Hawaii, 401% of federal poverty is $78,396 and $72,140 for individuals there, respectively. In 46 states and the District of Columbia, a 60-year-old at 401% of poverty will see their average annual premium payment for a benchmark silver plan at least double without enhanced tax credits. In 19 states, this person would see their premium payment at least triple on average for a benchmark silver plan, consuming more than 25% of annual income. States with the highest premium payment increases due to expired enhanced tax credits for a 60-year-old at 401% of poverty purchasing a benchmark silver plan are Wyoming ($22,452 increase per year), West Virginia ($22,006), and Alaska ($19,636). The smallest increases caused by the loss of enhanced tax credits for what enrollees pay annually for the benchmark silver plan are in New York ($4,469), Massachusetts ($4,728) and New Hampshire ($4,877).

At 501% of poverty ($78,407 in the contiguous U.S., $97,946 in Alaska, $90,130 in Hawaii), expiration of enhanced premium tax credits would at least double average premium payments for a benchmark silver plan in 37 states and the District of Columbia for a 60-year-old; at 601% of poverty ($94,057 in the contiguous U.S., $117,496 in Alaska, $108,120 in Hawaii), 19 states would see the average benchmark silver premium payments at least double for a 60-year-old if enhanced tax credits expire; at 701% of poverty ($109,707 in the contiguous U.S., $137,046 in Alaska, $126,110 in Hawaii), the average benchmark silver premium payment would be at least twice as high in five states without enhanced tax credits for a 60-year-old. The impact on a 40-year-old is more modest at all income levels.

Existing premium differences lead to variation in premium payments with the expiration of the enhanced premium tax credits at the congressional district level as well. For people with incomes over 400% of poverty, there will be smaller premium payment changes for 40-year-old enrollees and larger changes for 60-year-old enrollees, for whom plans are more expensive..

If enhanced premium tax credits under the Affordable Care Act (ACA) are allowed to expire at the end of the year, out-of-pocket premiums for 22 million enrollees that receive premium assistance will increase by an average of 114%, or $1,016 per person.

Democrats have pushed for the enhanced tax credits to be extended, and a vote is expected on their proposal in December. There have also been some bipartisan negotiations and proposals to extend the tax credits for up to two years, with changes like a cap on who is eligible by income and efforts to address any fraudulent signups by insurance brokers.

Meanwhile, proposals have emerged from some Republicans in Congress to effectively repeal some or all of the ACA premium tax credits and replace them with contributions to Health Savings Accounts (HSAs) or something similar. President Trump posted recently:

“THE ONLY HEALTHCARE I WILL SUPPORT OR APPROVE IS SENDING THE MONEY DIRECTLY BACK TO THE PEOPLE, WITH NOTHING GOING TO THE BIG, FAT, RICH INSURANCE COMPANIES, WHO HAVE MADE $TRILLIONS, AND RIPPED OFF AMERICA LONG ENOUGH. THE PEOPLE WILL BE ALLOWED TO NEGOTIATE AND BUY THEIR OWN, MUCH BETTER, INSURANCE.”

(The current ACA premium tax credits do not, in fact, go to insurance companies. The tax credits go to people to help them pay their premiums for ACA Marketplace plans. People can either wait until they file their taxes the following year to receive a lump sum or qualify for advance tax credits based on estimated income so they do not need to wait until they file their taxes. Those advance tax credits are forwarded directly to the insurance company they choose to purchase, directly lowering the enrollee’s monthly premium payments.)

Senator Scott Proposal

The most expansive health account proposal was recently introduced by Senator Rick Scott of Florida. It would allow the enhanced premium tax credits to expire but keep the value of the ACA premium tax credits from the original law. States could submit a waiver to the federal government to replace the original ACA premium tax credits with contributions by the federal government to accounts similar to HSAs. These “Trump Health Freedom Accounts” could be used for out-of-pocket health care costs, or to pay health insurance premiums (unlike traditional HSAs).

Unlike ACA premium tax credits, which can only be used for ACA Marketplace plans, the accounts in the Scott proposal could be used for any type of health insurance plan, including short-term plans that can exclude people based on pre-existing conditions. States could also waive certain provisions of the ACA, including the requirement to cover certain benefits.

While ACA plans would still be required to cover people with pre-existing conditions under the Scott proposal, it is likely that the ACA Marketplace would collapse in states that seek a waiver under his approach. Healthy people would be able to buy less expensive coverage that does not cover pre-existing conditions, or forgo insurance altogether and use their health accounts to pay for health care directly (carrying over any unused balanced from year to year). People with expensive health conditions would only be able to get coverage in ACA Marketplace plans, leading to a premium “death spiral” for those plans. Insurers would likely leave the ACA Marketplaces.

Senator Cassidy Proposal

Senator Bill Cassidy of Louisiana has proposed a different, narrower approach. Under the Cassidy proposal, the original ACA premium tax credits and benefit rules would remain in place. The value of the enhanced premium tax credits would be converted to federal contributions to HSAs, which could be used for out-of-pocket health care costs (e.g., deductibles and copays), but not to pay premiums. HSA contributions would only be available for people who enroll in bronze level ACA plans.

The Cassidy proposal is not yet available in legislative language, so a number of questions remain about how it would work. For example, how big would the HSA contributions be? Enhanced ACA premium tax credits vary by income, age, and the level of premiums in the county of residence, and they range from hundreds of dollars to thousands of dollars per person.

Because the health accounts in the Cassidy proposal could not be used to pay premiums, out-of-pocket premiums for ACA enrollees would more than double on average once the enhanced tax credits expire at the end of the year. HSA contributions would cushion the effect of the premium increases by helping people pay for deductibles, if people can afford the premiums to continue purchasing coverage.

However, to qualify for the HSA, enrollees would need to select a bronze plan and most people today are in a silver or gold plan. Many low-income people could get a bronze plan with no monthly premium payment, even without the enhanced tax credits. But, the lowest-income enrollees get cost-sharing reductions that bring their deductibles down to about $80 only if they purchase a silver plan. Deductibles in bronze plans average $7,476 per person.

Additionally, some middle-income people would no longer qualify for a tax credit because their incomes exceed four times the poverty level, and may be priced out of even a bronze plan premium, meaning they would not benefit from the HSA contribution.

While healthier people could benefit from the Cassidy proposal by receiving HSA contributions that could be used for a variety of health care expenses and carry over from year to year, sicker people could be stuck with higher premiums or higher out-of-pocket health costs. Because the HSAs in the Cassidy proposal are contingent upon having ACA Marketplace coverage, it does not pose the same risks of insurance market instability as the Scott plan.

Although the proposals from Senators Scott and Cassidy are quite different, they would both present trade-offs, generally benefiting people who are currently healthy at the expense of people who have expensive health conditions.

Introduction

Since 1980, the U.S. has had a formal system for admitting refugees and asylees—individuals and their families who are unable to return to their country of nationality due to a well-founded fear of persecution for certain protected reasons. The right to seek asylum is rooted in international law, and the system reflects the U.S.’s longstanding inclusion of humanitarian protection as a core principle of immigration law. Refugees and asylees are generally fleeing from unsafe conditions and arrive to the U.S. with few to no resources, with many facing traumatic experiences in their countries of origin and/or during their journey to the U.S. The U.S. historically provided refugees and asylees access to assistance with food, housing, and health care upon arrival to the country as well as other time-limited services to support their transition to the U.S.

Recently, President Trump has largely eliminated the entry of refugees and asylees into the U.S., and Congress passed legislation that will restrict refugees’ and asylees’ access to assistance programs. These changes could exacerbate the health and socioeconomic challenges refugees and asylees face and negatively impact the U.S. economy given that refugees and asylees have a long-term net positive impact on the U.S. economy, meaning that they contribute more through tax revenues than they cost the government.

This issue brief provides an overview of refugees and asylees in the U.S., trends in refugee and asylee admissions using data from the Department of Homeland Security (DHS), and recent changes in eligibility for assistance programs for refugees and asylees.

Overview of Refugees and Asylees

Following the passage of the Refugee Act of 1980, the U.S. established a standardized process for admitting refugees and asylees into the country through the U.S. Refugee Admissions Program. The right to seek asylum is rooted in international law, and this system reflects the longstanding inclusion of humanitarian protection as a core principle of U.S. immigration law.  Refugees and asylees are humanitarian immigrants who are unable or unwilling to return to their country of nationality due to persecution or fear of persecution based on one of five protected grounds that include race, religion, nationality, membership in a particular social group, and/or political opinion. For example, refugees living in the U.S. include young women who had to flee their lives and livelihoods in countries like Afghanistan following the departure of the U.S. military and subsequent takeover by Taliban, a fundamentalist group that is known for banning girls and women from going to school and working. Examples of asylum seekers in the U.S. include survivors of abuse, individuals from Central America who fear persecution due to identifying as Lesbian, Gay, Bisexual, Transgender, Queer (LGBTQ), and people fleeing death threats from drug cartels in Mexico. People seeking refugee status apply for their status from outside the U.S., and those seeking asylum apply for their status from within the U.S. or when seeking admission to the U.S. at a designated port of entry.

Refuges and asylees include significant shares who are children or female who mainly come from the Middle East, Central and South America, Asia, and Central Africa. In fiscal year (FY) 2023, the last year for which government data on the characteristics of refugees are available, the U.S. admitted 60,050 refugees. Nearly half (45%) were children ages 17 years and younger while 55% were adults ages 18 and older, who were primarily under age 35. They included equal shares of females and males (50%) (Figure 1). The top countries of nationality for refugees included Democratic Republic of the Congo (30%), Syria (18%), Afghanistan (11%), Burma (10%), Guatemala (3%), and Sudan (3%). In FY 2023, the last year for which government data are available, the U.S. granted asylum to 54,350 individuals. About a quarter (26%) of those receiving affirmative asylum were children ages 17 years and younger while the remaining nearly three in four were adults ages 18 and older, who were primarily under age 35. Over four in ten (44%) were female while 55% were male.¹ The leading countries of nationality for asylees included Afghanistan (27%), China (9%), Venezuela (7%), El Salvador (6%), India (5%), and Guatemala (5%). However, these data are incomplete because, as of October 2024, over 90% of asylum cases filed in FY 2023 were still pending with only 2% being granted approval due to immigration backlogs. 

Trends in Refugee and Asylee Admissions

President Trump placed an indefinite pause on the U.S. Refugee Admissions Program in January 2025. The pause led to halts in the processing of refugee applications, cancelation of refugee travel to the U.S., and the termination of the Welcome Corps program, which allowed for private sponsorship of refugees. While a court partially blocked the pause in March 2025 for refugees who were conditionally approved as of January 20, 2025, it still remains in effect for new refugees who may only be admitted on an excepted, case-by-case basis.

Reflecting the pause on admissions, the Trump administration reduced the refugee admissions ceiling to an all-time low of 7,500 for FY 2026 (Figure 2). The previous all-time low of 18,000 was in FY 2020 under the first Trump administration. Further, the Trump administration has stated that the FY 2026 refugee admissions will “primarily be allocated” to Afrikaners, who are White individuals from South Africa, representing a departure from admission patterns for previous years.

While there is no annual cap for asylum filings, President Trump took executive action in January 2025 to close the border to a vast majority of migrants, including asylum seekers. Building on limits to border entries established by President Biden in 2024, President Trump took executive action aimed at increasing border security that effectively closed the U.S. border for asylum seekers when he assumed office in January 2025. President Trump also rescinded a 2021 Biden administration Executive Order that was designed to aid in the “safe and orderly processing of asylum seekers.” While data on asylum grants under the second Trump administration are not yet available, there has been considerable variation in the number of individuals granted asylum over time reflecting shifting immigration policy priorities and reductions in border entry amid the COVID-19 pandemic (Figure 3). Going forward, it is likely that asylum grants will drop substantially due to the Trump administration’s border policies.

Refugee and Asylee Eligibility for Health Coverage and Other Assistance

Refugees and asylees are generally fleeing from unsafe conditions and arrive to the U.S. with few to no resources, with many having faced traumatic experiences in their countries of origin and/or during their journey to the U.S. Many refugees and asylees may not be able to immediately obtain jobs due to linguistic, cultural, and other barriers and, therefore, are likely to face challenges to accessing health coverage, health care, and meeting their basic needs. Research shows that refugees have significantly higher rates of food insecurity than the general U.S. population, with some refugee groups having food insecurity rates that are six times higher than the general U.S. population. Further, research shows that refugees face challenges navigating private and public health insurance and have higher uninsured rates compared to the general U.S. population. Research also shows that culturally competent and language accessible health care services for refugees can improve communication and trust between refugees and health care providers. 

Historically, the U.S. provided refugees and asylees access to health coverage and other assistance upon arrival to the U.S., with research showing that health coverage, cash assistance, and employment are important tools for helping them gain self-sufficiency. When the Refugee Act of 1980 was passed, Congress stated that part of its purpose was to help provide “humanitarian assistance” and “transitional assistance” to those fleeing persecution in their countries of nationality. While most lawfully present immigrants (including Lawful Permanent Residents or “green card holders”) have to wait five years after obtaining a “qualified” immigration status to enroll in federal public benefits, including federally funded health coverage such as Medicaid and the Children’s Health Insurance Program (CHIP), refugees and asylees historically have not been subject to this waiting period if they met income and other state-specific eligibility requirements. Refugees and asylees also have been able to enroll in subsidized Affordable Care Act (ACA) coverage and Medicare without a waiting period if they are otherwise eligible. Further, refugees and asylees could access other income-based federal assistance programs such as the Supplemental Nutrition Assistance Program (SNAP) (i.e., food stamps), Temporary Assistance for Needy Families (TANF), and Supplemental Security Income (SSI) if they met income and other eligibility requirements.

The 2025 tax and budget law, H.R.1, eliminates eligibility for health coverage and food assistance for many lawfully present immigrants, including refugees, asylees, and other humanitarian immigrants. The law restricts eligibility for Medicaid, CHIP, subsidized ACA Marketplace coverage, Medicare, and SNAP to immigrants who are Lawful Permanent Residents (LPRs or “green card” holders), certain 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. States that have taken up an option under Medicaid and/or CHIP to cover lawfully residing children and pregnant people, who include refugees and asylees, can also maintain this coverage. Under these changes, refugees and asylees will become ineligible for these programs, except for some in states that have taken up the Medicaid and CHIP option to expand coverage for lawfully residing children and pregnant people.

Implementation dates for the eligibility restrictions vary by program. Medicaid and CHIP restrictions will take effect October 1, 2026; limits for subsidized ACA coverage will go in place January 1, 2027; Medicare coverage limits took effect July 4, 2025 (the date the law was signed), with current beneficiaries losing coverage no later than 18 months from the enactment of the legislation (January 4, 2027); and SNAP restrictions for new applicants go into effect as early as November 1, 2025, with current beneficiaries losing access at the time of their next recertification.

The U.S. also provides refugees and asylees access to certain time-limited benefits and services through the Office of Refugee Resettlement (ORR) to facilitate their transition. These include:

• Refugee Medical Assistance (RMA): In cases where refugees and asylees are ineligible for Medicaid or CHIP, they may qualify for RMA, which had been available to refugees and asylees for up to 12 months prior to recent changes.
• Refugee Cash Assistance (RCA): RCA provides cash assistance to refugees and asylees for basic necessities such as housing, food, and transportation. RCA had been available to refugees and asylees for up to 12 months prior to recent changes.
• Refugee Support Services (RSS): Refugees and asylees also have access to a range of services to support employment and thereby, self-sufficiency, which include English language training, job training, childcare, and access to transportation. Access to RSS is available to refugees and asylees for up to five years.

The Trump administration has reduced access to time-limited support services that ORR provides to refugees and asylees. On March 21, 2025, the Administration for Children and Families issued a notice reducing the eligibility period for refugees and asylees to access RMA and RCA, citing budget constraints. This notice reduced access to RMA and RCA from 12 months to four months for refugees and asylees effective 45 days after the notice’s publication (i.e., May 5, 2025).

Together, these reductions are likely to exacerbate health and socioeconomic challenges faced by refugees and asylees and could also reduce their economic contributions to the U.S. Research by the Department of Health and Human Services Office of the Assistant Secretary for Planning and Evaluation (ASPE) finds that between 2005 and 2019, refugees and asylees had a net positive impact of about $124 billion on the U.S. economy, meaning that they contributed more in revenue ($581 billion) than they cost in expenditures ($457 billion) to the federal, state, and local governments. Actions to limit the assistance refugees, asylees, and other humanitarian immigrants receive when they arrive in the U.S. could create barriers to successful transition to employment and self-sufficiency and foreclose opportunities for them to make economic and workforce contributions in the future.

1. Data on individuals granted asylum defensively in FY 2023 not available by age and sex. Affirmative asylum applies to those not in removal proceedings who apply directly to U.S. Citizenship and Immigration Services whereas defensive asylum applies to individuals already in removal proceedings. ↩︎