Nearly half (46%) of the public says that they expect the new tax and budget law signed by President Trump earlier this month to generally hurt them and their families, nearly twice the share (26%) who say it will generally help, a new KFF Health Tracking Poll finds. Among people who rely on Medicaid for their health coverage, two-thirds (65%) say it will hurt their families compared to one in five (18%) who say it will help.

The law combines tax cuts with spending reductions, including cuts and changes to Medicaid and the Affordable Care Act that are expected to leave millions more people without health insurance. Among people with household incomes under $40,000 annually, most (56%) say that the law will hurt them.

Perceptions of how the law will impact people’s families varies among partisans. Most Democrats (72%) and just over half of independents (53%) say it will mostly hurt them and their families, while just over half of Republicans (54%) say it will help. Those who identify as supporters of President Trump’s “Make America Great Again” movement are more than five times more likely to say the law will help their families (61%) than hurt (9%).

The law itself remains largely unpopular, with many more people holding unfavorable views (63%) than favorable ones (36%).

The split is unchanged from June before the legislation dubbed the “big beautiful bill” by President Trump became law, though the new poll shows a sharper partisan divide, with Republicans more likely to view the law favorably and Democrats more likely to view it unfavorably.

Two-thirds (68%) of the public now say that they’ve heard “a lot” or “some” about the legislation, up from half who said the same in June.

The poll also examines what people are seeing about the legislation on social media. Most (73%), including similar shares of partisans, say they saw information about the bill on social media in the past month.

Among those who saw information about the legislation on social media, about half (47%) say most of the content they saw was in opposition to the legislation, while about one in ten (11%) say it was mostly in support. The others (41%) say they saw a mix of both.

Designed and analyzed by public opinion researchers at KFF, this survey was conducted July 8-14, 2025, online and by telephone among a nationally representative sample of 1,283 U.S. adults in English and in Spanish. The margin of sampling error is plus or minus 3 percentage points for the full sample. For results based on other subgroups, the margin of sampling error may be higher.

Since the Supreme Court overturned Roe v. Wade in June 2022, states have been able to set policy that defines abortion access across this nation. In the past three years, voters in 10 states have passed constitutional amendments to protect abortion rights. These amendments, however, do not automatically invalidate the states’ laws restricting abortion such as waiting periods, coverage bans, and ultrasound requirements. The restrictions need to be challenged in court before they can be invalidated. This process can take years, and in states with new constitutional protections, people seeking abortion care may still face access restrictions while the litigation proceeds. Additionally, in some instances, after courts have blocked restrictions, conservative state legislatures have passed laws enacting very similar restrictions, lengthening the process to block these laws, since advocates have to challenge multiple state laws or amend already-existing challenges to block the newly passed laws. This policy watch provides an update on the status of abortion restrictions in states that passed a constitutional amendment protecting abortion, or where a state court previously interpreted the state constitution as protecting abortion access.

Status of Litigation Based on Recent Constitutional Amendments

In four states with recently passed constitutional amendments protecting the right to abortion or a broader right to reproductive freedom — Arizona, Michigan, Missouri, and Ohio – advocates have filed lawsuits seeking to block abortion restrictions, alleging that these restrictions violate the newly passed constitutional amendments. These lawsuits test the reach of these constitutional amendments beyond pre-viability gestational limits. In Montana, another state that recently passed a constitutional amendment, abortion providers are also challenging prior abortion restrictions, but because this challenge was filed before the state’s constitutional amendment passed, they are relying on previous state supreme court precedent to make their arguments. Advocates in Alaska and Kansas, where there is no specific constitutional amendment protecting abortion, have challenged restrictions based on state supreme court cases finding abortion is protected in the state constitution.

Whether or not the restrictions that are being challenged will be permanently blocked depends on how each respective state’s supreme court interprets the state constitution’s right to abortion. The language of the constitutional amendments varies and some might provide greater protections than others (Table 9). States that rely on state supreme court precedent protecting a right to abortion—as opposed to a constitutional amendment explicitly protecting this right—may provide protections today, but future courts may overturn that precedent, much like the U.S. Supreme Court did with Roe v. Wade.

The following section provides an overview of the status of legal challenges to abortion restrictions in states with recently passed constitutional amendments or litigation that has found that the state constitution protects abortion rights.

Arizona

The Arizona constitutional amendment – passed in November 2024 – protects a fundamental right to abortion and forbids the state from enacting, adopting, or enforcing any law that “denies, restricts or interferes with that right before fetal viability unless justified by a compelling state interest that is achieved by the least restrictive means.” Currently, the gestational limit in the state is fetal viability. However, there are other restrictions that are still in effect.

Abortion rights advocates in Arizona filed a lawsuit in May 2025 challenging the in-person counseling requirement, 24-hour waiting period, ultrasound requirement, and ban on the use of telehealth for abortion care. The state court where this challenge was filed is yet to issue a ruling.

Michigan

In November 2022, voters passed a constitutional amendment in Michigan that protects a fundamental right to reproductive freedom, the right to make decisions regarding pregnancy, including the right to abortion, among others. It states that “[a]n individual’s right to reproductive freedom shall not be denied, burdened, nor infringed upon unless justified by a compelling state interest achieved by the least restrictive means.”

The state has no gestational limit on abortion, however, a state funding ban on abortion funding for Medicaid enrollees and a parental consent requirement are still in effect.

In two separate lawsuits, advocates in Michigan are challenging the exclusion of abortion coverage from the state’s Medicaid program and laws requiring a 24-hour waiting period and limiting abortion provision to physicians. A trial court recently ruled that the latter two requirements are unconstitutional and blocked them permanently. However, the state’s supreme court is yet to rule on these restrictions.

Missouri

In November 2024, voters in Missouri passed a constitutional amendment protecting a fundamental right to reproductive freedom, including the right to make decisions about abortion care. The amendment states that this right “shall not be denied, interfered with, delayed, or otherwise restricted unless the Government demonstrates that such action is justified by a compelling governmental interest achieved by the least restrictive means. Any denial, interference, delay, or restriction of the right to reproductive freedom shall be presumed invalid.” Currently, the gestational limit in the state is fetal viability, but other restrictions are still in effect.

Several clinics in Missouri filed a lawsuit alleging that the state’s pre-viability bans as well as many restrictions violate the state’s newly granted constitutional right to reproductive freedom. In December 2024, a Missouri state trial court sided with the clinics, and blocked the state’s pre-viability abortion bans, as well as many of the restrictions, while the litigation continues. However, in late May 2025, the Missouri Supreme Court lifted the preliminary injunction for the restrictions, and ordered the trial court to use a more strenuous test to determine if the plaintiffs meet the bar for a preliminary injunction. When restrictions went back into effect, clinics stopped providing abortion care, even though the total ban was not in effect. The case went back before the trial court, where the judge reviewed the request for a preliminary injunction using the standard set forth by the state supreme court and in response issued an order on July 3, 2025 blocking once again the state’s pre-viability ban and some restrictions, including the 72-hour waiting period. The state has appealed this order to the Missouri Supreme Court.

Ohio

The Ohio constitution was amended by voter initiative in November 2023 protecting the right to make and carry out reproductive decisions, including decisions about abortion care. Per the amendment, “[t]he State shall not, directly or indirectly, burden, penalize, prohibit, interfere with, or discriminate against… the exercise of this right, unless the State demonstrates that it is using the least restrictive means to advance the individual’s health in accordance with widely accepted and evidence-based standards of care.”

Currently, the gestational limit in the state is 22 weeks LMP (last menstrual period), however, are other restrictions are still in effect or temporarily blocked.

In two different lawsuits, abortion providers in Ohio challenged the 24-hour waiting period, the in-person counseling appointment, the telehealth abortion ban, and a law that limits the provision of abortion care to physicians. Abortion providers used the state’s constitutional amendment as the basis for these challenges. In both of these lawsuits, the trial courts have temporarily blocked the challenged restrictions while litigation proceeds. After the constitutional amendment was passed by voters, some Ohio legislators sought to curtail judges’ ability to block these laws and interpret the constitutional amendment, but these efforts did not progress.

Status of Litigation in States with State Supreme Court Precedent Protecting the Right to Abortion

Alaska

In 1997, the Alaska Supreme Court found that the state constitutional right to privacy protects the right to abortion. The state has no gestational limit on abortion, however, other restrictions are still in effect.

Advocates in Alaska are challenging a law that limits abortion provision to physicians, using previous state supreme court precedent as the basis for their challenge. This requirement was originally blocked by a preliminary injunction in 2021 and in September 2024, a state trial court ruled that the requirement violates the constitutional protection for the right to abortion.

Kansas

In 2019, the Kansas Supreme Court found that the Kansas Bill of Rights includes the right to abortion. The gestational limit in the state is 22 weeks LMP (last menstrual period), other restrictions are still in effect.

In Kansas, advocates are challenging a 24-hour waiting period law that is temporarily blocked due to a court order while litigation proceeds and a law banning advanced practice registered nurses from providing medication abortion care. Advocates in Kansas have also used Kansas Supreme Court precedent to successfully challenge laws that limit the provision of abortion care to physicians and require ultrasounds before an abortion, as well as in-person dispensing of medication abortion.

Montana

In 1999, the Montana Supreme Court found that the state constitution protects the right to abortion. In 2024, the Montana Supreme Court reaffirmed this protection.

In addition, voters approved an amendment in November 2024 recognizing an individual’s right to make decisions about pregnancy, including the right to abortion. It states that “[t]his right shall not be burdened unless justified by a compelling government interest achieved by the least restrictive means.”

The gestational limit in the state is fetal viability, however, a state parental consent law is still in effect.

Abortion providers in Montana are challenging a law that excluded abortion coverage from the state’s Medicaid program, relying on previous Montana Supreme Court precedent that held that the state constitutional protection for privacy includes a protection for the right to abortion, instead of relying on the state’s newly passed constitutional amendment, since the challenge was underway before the constitutional amendment passed. In March 2025, a trial court ruled that this restriction is unconstitutional and permanently blocked it. Additionally, the Montana Supreme Court recently concluded in a different case that was also brought by abortion providers, that restrictions including an in-person dispensing requirement, a 24-hour waiting period, and a ban on telemedicine for abortion were unconstitutional. These restrictions are no longer in effect.

On July 4, President Trump signed into law a budget reconciliation package once called the “One Big, Beautiful Bill” that made major reductions in federal health care spending to offset part of the costs of extending expiring tax cuts. The Congressional Budget Office’s (CBO) latest cost estimate shows that the reconciliation package would reduce federal Medicaid spending over a decade by an estimated $911 billion (after accounting for interactions that produce overlapping reductions across different provisions of the law) and increase the number of uninsured people by 10 million. Building on prior KFF analysis of the House-passed reconciliation bill, this analysis allocates CBO’s federal spending reductions in the enacted reconciliation package across the states. The Medicaid reconciliation provisions are numerous and complicated, but the majority of federal savings stem from work requirements for the Affordable Care Act (ACA) expansion group, limiting states’ ability to raise the state share of Medicaid revenues through provider taxes, restricting state-directed payments to hospitals, nursing facilities, and other providers, and increasing barriers to enrolling in and renewing Medicaid coverage.

This analysis allocates the CBO’s estimated reduction in federal spending across states based on KFF’s state-level data and where possible, prior modeling work; and shows the federal spending reductions relative to KFF’s projections of federal spending by state under current law. KFF allocates the spending reductions provision-by-provision, pulling in a variety of data sources on which states are estimated to be most affected by each provision (see Methods). The total Medicaid spending cuts, nationally and by state, equal the sum of spending changes for each Medicaid provision ($990 billion over 10 years) less KFF’s estimate of the CBO interaction effects that are tied to Medicaid interactions ($79 billion over 10 years, see Methods). KFF did not apply the interaction effects to the estimated effects for each provision because it is unknown which provisions are driving CBO’s estimated interactions. The estimates exclude the $50 billion in funding for state grants through a Rural Health Transformation Program because it is highly uncertain how those funds will be allocated across the states.

CBO has not published updated estimates of the number of people who would lose Medicaid under the reconciliation package once called the “One Big, Beautiful Bill,” so this analysis does not include updated enrollment estimates like those included in KFF’s analysis of the House-passed reconciliation bill. CBO’s most recent estimate of Medicaid enrollment loss from an earlier version of the House reconciliation bill was 10.3 million people in 2034, which was associated with a $625 billion decrease in Medicaid spending (reflecting preliminary estimates prepared for the House Committee on Energy and Commerce). Given the Medicaid spending reductions are considerably larger in the enacted reconciliation package, more than 10.3 million people are likely to lose Medicaid.

This analysis does not predict how states will respond to federal policy changes, and anticipating how states will respond to Medicaid changes is a major source of uncertainty in CBO’s cost estimates. Instead of making state-by-state predictions, CBO generates a national figure by estimating the percent of the affected population that lives in states with different anticipated types of policy responses. For example, different states might choose to implement a work requirement with reporting requirements that are easier or harder to comply with. In estimating the costs of the legislation, CBO assumes that in aggregate, states would replace half of reduced federal funds with their own resources in response to provisions that reduce the resources available to states, such as limits on provider taxes. For provisions that reduce enrollment but don’t affect the division of costs between the federal and state governments, such as work requirements, CBO estimates that the federal and state Medicaid spending would go down. However, those assumptions reflect states’ responses as a whole and are likely to vary and may not apply in all states.

To the extent that states’ responses are far different from the overall average response, changes in federal Medicaid spending will be larger or smaller than what is shown here. States could make further Medicaid cuts, which would result in spending reductions greater than is estimated here and further reduce states’ Medicaid spending. Alternatively, states could increase their spending on Medicaid to mitigate the effects of federal cuts, which could result in spending reductions that are smaller than is estimated here. This analysis illustrates the potential variation by showing a range of spending effects in each state, varying by plus or minus 25% from the CBO estimated midpoint.

Key Take-Aways

• After accounting for CBO’s estimated interactions, KFF estimates that the enacted reconciliation package would reduce federal Medicaid spending by $911 billion. (Without accounting for interactions, the total is $990 billion, see Methods).
• The five biggest sources of Medicaid savings in the reconciliation package sum to $851 billion in savings, which is 86% of the gross savings (before accounting for interactions) and include:
  • Mandating that adults who are eligible for Medicaid through the ACA expansion meet work and reporting requirements ($326 billion),
  • Establishing a moratorium on new or increased provider taxes and reducing existing provider taxes in expansion states ($191 billion),
  • Revising the payment limit for state directed payments ($149 billion),
  • Increasing the frequency of eligibility redeterminations for the ACA expansion group ($63 billion).  
• Provisions that would only apply to states that have adopted the ACA expansion account for $526 billion, over half of the total gross federal spending reductions.
• Over three-quarters (76%) of the ten-year reductions in federal Medicaid spending in the reconciliation package would occur in the final five years of the period. While policy effects do typically compound overtime, many of the health care spending reductions are also backloaded and occur from 2030 through 2034.
• Federal cuts to states of $911 billion over 10 years would represent 14% of federal spending on Medicaid over the period. The spending cuts vary by state; Louisiana, Illinois, Nevada, and Oregon are the most heavily affected with spending cuts of 19% or more over the period.

Introduction

Racial and ethnic disparities in health outcomes remain persistent in the United States, driven by inequitable access to and utilization of health care services and broader social and economic factors that reflect historical and ongoing racism. One factor that can mitigate these disparities is racial concordance between physicians and patients, that is, when providers and patients share the same racial or ethnic background. Research suggests that patient and provider racial concordance may be linked to increased visits for preventative care, greater treatment adherence, and lower emergency department use. One study found that greater representation of Black primary care physicians was associated with increased life expectancy and lower mortality among Black people. KFF 2023 survey data show Black, Hispanic, and Asian adults who have more health care visits with providers who share their racial and ethnic background more frequently report having positive and respectful interactions. Despite these benefits, many people of color face challenges accessing racially concordant providers. KFF survey data show that most Hispanic, Black, Asian, and American Indian and Alaska Native (AIAN) adults say that fewer than half of their health care visits in the past three years were with a provider who shared their racial or ethnic background. While data show that adults of color are more likely than White adults to prefer a provider of the same race or ethnicity, they are significantly less likely to have one and are more likely to have difficulty finding one.

Recent policy changes may exacerbate challenges to obtaining racially concordant care for those who value it most. In 2023, the U.S. Supreme Court effectively ended race-conscious admissions in higher education, overturning decades of precedent supporting affirmative action. Additionally, as one of his initial actions in office, President Trump issued executive orders eliminating federal diversity, equity, inclusion, and accessibility (DEIA) related programs and actions in the federal government and among federal contractors and grantees. These actions may reduce matriculation rates for students of color and reverse progress in diversifying the health care workforce to reflect the population it serves. For instance, research indicates that the Supreme Court’s 2023 ruling has already led to a decline in the number of Black, Hispanic, and AIAN students entering medical school. Among Black, Hispanic, AIAN, and Native Hawaiian and Pacific Islander (NHPI) medical school enrollees, there was a decline in matriculants between 2023 and 2024. Despite there being more Black and Hispanic applicants in 2024 compared to the previous year, the number of matriculants from historically underrepresented groups declined. It’s unclear how much impact the Supreme Court ruling has already had on medical school matriculation. However, the ruling has the potential to further decrease the diversity of the future physician workforce.

This brief provides an overview of the racial and ethnic composition of physicians compared to the total population at the national and state level based on KFF analysis of 2023 Association of American Medical Colleges (AAMC) Physician Workforce data and American Community Survey data. This analysis shows that Hispanic, Black, AIAN, and NHPI people were underrepresented among physicians relative to their share of the population, with the widest gap observed among Hispanic people who comprised 20% of the total population but only 7% of the total physician workforce. The pattern of underrepresentation held true across most states for Hispanic and Black people, with particularly large gaps for Hispanic people. Asian people accounted for a higher share of physicians than their share of the total population nationally and in all states; in most states, the share of White physicians was similar to or higher than their share of the total population. Data were not available for AIAN and NHPI populations in many states due to small numbers.

Racial and Ethnic Distribution of Physicians

Nationally, Hispanic, Black, AIAN, and NHPI people were underrepresented among physicians relative to their share of the population with the widest gap observed among Hispanic people. While one in five people in the U.S. population was Hispanic, they accounted for just 7% of the physician workforce (Figure 1). Similarly, 12% of the population was Black compared to 6% of the physician workforce. AIAN and NHPI individuals were also underrepresented among physicians compared to their share of the overall population. However, the absolute differences were small, as both groups make up less than one percent of the total population and the physician workforce. In contrast, White people accounted for similar shares of the total population and physician workforce, and Asian people accounted for a larger share of physicians (19%) than their share of the population (6%).

Across most states, Hispanic and Black people made up a smaller share of physicians compared to their share of the total population, with particularly large gaps for Hispanic people. In 45 states and DC, Hispanic people accounted for a smaller share of providers than their share of the population, as measured by a more than one percentage point difference (Figure 2). In seven states, the difference between the share of the population and providers who are Hispanic was over 15 percentage points. These tended to be states with the highest shares of Hispanic people, including New Mexico, California, and Texas. In New Mexico, Hispanic people made up nearly half (48%) the population but accounted for 17% of providers (a difference of 31 percentage points). In California and Texas, about 40% of the population was Hispanic compared to 7% and 13% of physicians, respectively. In only five states (West Virginia, Vermont, Maine, Mississippi, and Ohio) did Hispanic people account for a similar share of the population and the physician workforce, with a difference of less than one percentage point.

Similarly, in 35 of 50 states and DC, Black people made up a smaller share of physicians compared to their share of the population. In five states and DC, the difference between the share of the population and providers who are Black was 15 percentage points or higher, with the largest gap of 26 percentage points in DC and Mississippi (Figure 3). In DC, 17% of providers were Black compared with 43% of the population, and in Mississippi, Black people made up 11% of physicians compared with 37% of the population.

Data were insufficient for comparisons for AIAN and NHPI people in most states, but where data were available, AIAN and NHPI people were underrepresented among physicians relative to their share of the population. This pattern was most prominent in states where the majority of AIAN and NHPI people live. For example, In Alaska, AIAN people accounted for 14% of the population, seven times higher than their share of physicians (2%). Additionally, in New Mexico, AIAN people made up 9% of the population compared to 2% of providers, and in South Dakota they comprised 7% of the population compared with 1% of providers. Similarly, in Hawaii, NHPI people made up 10% of the population compared to 2% of physicians. In most remaining states, AIAN and NHPI people accounted for both a small share of the population and providers, so absolute differences in their shares were small.

Asian people accounted for a higher share of physicians than their share of the total population in all states. The largest differences were in Illinois, California, Delaware, and Texas. In Illinois, Asian people made up more than one in four physicians but accounted for only about 5% of the population (Figure 4). There were sizeable differences in the states with the highest shares of Asian people. In Hawaii, 37% of the population was Asian compared with 43% of providers, and in California, 15% of the population was Asian versus 32% of providers. The differences were smaller in other states, like Alaska, Montana, and Vermont, where Asian people accounted for a small share of both providers and the population.

In most states, the share of White physicians was similar to or higher than their share of the total population. States where White people were most underrepresented among physicians compared to their share of the population included West Virginia (67% vs. 90%), North Dakota (67% vs. 83%), and Michigan (58% vs. 73%) (Figure 5). The pattern in these states reflected higher representation of Asian people among physicians. States where White people were most overrepresented among physicians compared to their share of the population included New Mexico (56% vs. 37%), Alaska (77% vs. 58%), and Mississippi (70% vs. 55%).

A similar pattern was observed across medical specialties, with Hispanic and Black individuals underrepresented in more specialties than other racial and ethnic groups. Specialties providing primary care—such as family medicine, pediatrics, and obstetrics/gynecology—tended to better reflect the racial and ethnic distribution of the population. Among all specialties, providers in nephrology and interventional cardiology had the least racial and ethnic representation compared to the national population. The Hispanic population was the most underrepresented group in more than half of the specialties analyzed (27 out of 51 specialties). The Black population was the most underrepresented group in 9 out of 51 specialties.

San Francisco – KFF announced today that Dr. Victoria DeFrancesco Soto has joined KFF’s Board of Trustees. DeFrancesco Soto is the Dean of the Clinton School of Public Service at the University of Arkansas and previously served as Assistant Dean at the LBJ School of Public Affairs at the University of Texas at Austin. She has served as a trusted voice of political analysis for NBC News and Telemundo.

“It is my honor to serve on the KFF board,” said DeFrancesco Soto. “As an educator I am passionate about making research tangible to our day-to-day lives. KFF is a national model for translating the power of data and research into action. I am excited to roll up my sleeves and deeply engage in the impactful work of KFF.”

“Victoria’s deep knowledge of politics, policy, and media is a perfect fit for KFF, and we will benefit tremendously from her expertise and experience as we continue to expand our role as health care’s independent source of policy analysis, polling, and journalism,” said Dr. Drew Altman, President and CEO.

Dr. DeFrancesco Soto is the first Latina Dean at a presidential institution and is a fellow of the National Academy of Public Administration. She previously taught at Northwestern University and Rutgers and received her Ph.D. in political science from Duke University.

Her areas of expertise include civic engagement, women, immigration, Latinos and political psychology. Underlying all of her research interests is the applicability of high-quality, rigorous research to on-the-ground policy realities. 

KFF’s Board of Trustees is chaired by former U.S. Senator Olympia Snowe and its members have deep backgrounds in public service, academia, nonprofit organizations, health care, and the media.

Board members serve up to two, five-year terms. Additional information about KFF’s board can be found at https://www.kff.org/board-of-trustees/.

On July 14, 2025, the U.S. Department of Health and Human Services (HHS) issued a notice of a policy change to update the definition of “federal public benefits” as outlined in the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) to add an additional 13 programs to the 31 programs considered “federal public benefits” that are restricted to individuals with a “qualified” immigration status. The notice further indicates that the updated list of federal benefits is not exhaustive, and additional programs may be added in the future. This change bars many groups of lawfully present immigrants as well as undocumented immigrants from accessing many health care, educational, and other social services and will likely have negative impacts on the health and well-being of immigrant families due to more limited access to services as well as confusion and fear about using services. It also may create new challenges and complexities for service providers. Many implementation questions remain unclear and subject to future guidance, including how verification of immigration status may occur and how the policy will be reconciled with existing conflicting statutory and regulatory requirements, which supersede the guidance. This policy change was expected to take effect immediately upon publication of the notice in the federal register on July 14, 2025, although it provided for a 30-day comment period. However, the HHS has agreed to delay implementation until September 11, 2025, following court orders. Further, on September 10, 2025, a District Court issued an injunction on the administration’s new policy, blocking the implementation of the policy as it relates to the Health Center Program and Head Start in 20 states and D.C.

Prior Policy under PRWORA

When enacted in 1996, PRWORA established federal requirements that limited eligibility for “federal public benefits” to groups who are “qualified immigrants.” The groups defined as “qualified immigrants” are more limited than groups who are considered lawfully present in the U.S. and exclude undocumented immigrants. Notably, qualified immigrants do not include people with Temporary Protected Status and people with deferred action, including Deferred Action for Childhood Arrivals recipients, among other lawfully present groups (Box 1).

The PROWRA legislation provided discretion to federal agencies to determine which benefits and programs are “federal public benefits,” while also identifying specific exemptions such as treatment for emergency medical conditions, certain disaster relief, immunizations, and testing and treatment for communicable diseases. It also clarified that non-profit organizations were not required to verify the immigration status of individuals receiving benefits or services. Under policy established in 1998, HHS identified 31 health and social programs considered to be “federal public benefits” restricted to “qualified immigrants,” including major health coverage programs such as Medicaid (excluding emergency Medicaid), Medicare, and the Children’s Health Insurance Program (CHIP).

Changes under the 2025 Policy

The 2025 policy expands the list of programs considered “federal public benefits” by adding 13 additional programs, including Head Start, the health center program, the Title X family planning program, among others (Box 2). The notice further indicates that the list is not exhaustive, and additional programs may be added to in the future. However, policy implementation related to the Health Center Program and Head Start is blocked in 20 states and D.C. following an injunction issued by a District Court in September 2025.

Implications of the Policy Change

The policy change bars many lawfully present and undocumented immigrants from services that are important for their health and well-being. These programs include certain programs that are particularly important for immigrant families, such as the federal Health Center program, which funds a network of Community Health Centers (CHCs). Community health centers are a national network of over 1,300 safety-net primary care providers located in medically underserved communities and serve all patients regardless of their ability to pay, providing a range of medical, behavioral, and supportive services. Data from the 2023 KFF/LA Times Survey of Immigrants show that three in ten immigrant adults say a CHC is their usual source of care, with this share rising to about four in ten among likely undocumented immigrant adults (42%) and those with limited English proficiency (39%) (Figure 1). The policy also bars immigrants without a “qualified” immigration status from accessing federally funded mental and behavioral health services at a time when many immigrant families are experiencing heightened stress and anxiety due to immigration-related fears and financial uncertainty, as well as from Title X services, which provide comprehensive family planning services to low-income and uninsured individuals.

Beyond health care, the policy also limits access to services that support education, including the Head Start Program. Research shows that adults with higher educational attainment tend to have longer lifespans and be healthier than their counterparts with lower educational attainment. High educational attainment also is associated with better jobs that are more likely to provide employer-sponsored health coverage and higher incomes which, in turn, improve access to health care and resources to support health.

The new policy also will affect service providers who may need to update their policies and procedures to comply with the changes. Under PRWORA, program benefit providers are prohibited from providing “federal public benefits” to people who are not citizens or qualified immigrants and are required to verify that an applicant is a qualified immigrant eligible for services. The notice confirms an existing exemption in the law that non-profit charitable organizations are not required to verify immigration status. However, many implementation questions currently remain unclear and subject to future guidance, including how verification of immigration status may occur. Moreover, the policy does not supersede existing statutory and regulatory requirements. For example, although the notice limits the health center program to “qualified immigrants,” it does not change the underlying statutory requirements for CHCs to serve patients regardless of immigration status. While federal law supersedes guidance, this conflict creates challenges for CHCs in how they will apply this guidance, and it remains to be seen how enforcement of the guidance will affect CHCs' ability to provide care. Additionally, as noted, the notice indicates that the list of programs affected by the change is not exhaustive, so additional programs may be added in the future.

The notice estimates that the policy change will result in savings from reduced use of programs by certain immigrants as well as new administrative costs. Savings are estimated to derive from excluding certain immigrants from HHS programs with a corresponding increase in benefits for U.S. citizens and qualified immigrants. There also are estimated to be new administrative costs associated with individuals being required to document their eligibility, for immigration status to be verified, and for changes in program eligibility and operating policies and procedures.

The policy change occurs against a backdrop of other policy changes restricting immigrant access to health and other programs and increased immigration enforcement activity. These changes include new restrictions established under budget reconciliation that limit Medicaid, Medicare, and subsidized Affordable Care Act (ACA) Marketplace coverage to lawful permanent residents, certain Cuban and Haitian entrants, and citizens of the Freely Associated States (COFA migrants). Together, these changes will likely have broad chilling effects on immigrant families, resulting in increased reluctance to access services and programs due to fear and confusion. More limited access to programs and services may lead to negative impacts on their health and well-being. These effects may extend across immigrant families, who often include citizen children—with one in four children in the U.S. living with at least one immigrant parent—and have broader impacts on communities, given immigrants’ role in the workforce.

Note: For updated data on proposed ACA Marketplace premiums from more than 300 insurers in all 50 states and DC, read our updated analysis.

ACA Marketplace insurers are proposing a median premium increase of 15% for 2026, according to a new analysis of preliminary rate filings. Based on the early indications, individual market insurers will introduce the largest hike in premiums since 2018, the last time policy uncertainty contributed to sharp premium growth.

Across the 105 ACA Marketplace insurers in 19 states and DC that have submitted rate filings so far, most are requesting premium increases of 10% to 20% for 2026, and more than a quarter are proposing premium increases of 20% or more.

In addition to the anticipated growth in the cost of health care services, insurers have cited several policy changes that they expect to drive up rates next year, including the following:

• The expiration of the enhanced premium tax credits at the end of this year, which have made coverage more affordable and contributed to record-high enrollment in the ACA Marketplaces, is expected to drive up out-of-pocket premium payments by more than 75% on average and cause many healthier enrollees to drop their coverage.
• The impact of tariffs on some drugs, medical equipment, and supplies. Some insurers estimate that they could increase premiums by an average of 3% more than they otherwise would have.

Other factors could also affect premium changes, including the budget reconciliation legislation and Marketplace Integrity and Affordability rule, both of which were enacted and finalized after many of these insurers submitted their preliminary rate filings. Finalized 2026 rate changes are expected to be published in late summer.Subsidized enrollees are generally shielded from annual rate increases as their tax credits keep premium payments capped at a portion of their income.

However, with enhanced tax credits set to expire later this year if Congress takes no action to extend them, subsidized enrollees will pay more because they have less financial assistance. Middle income people with incomes above four times the poverty level would no longer be eligible for assistance and would have to shoulder the full premium.

The full analysis and other data on health costs are 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.

Note: For updated data on ACA Marketplace premiums from more than 300 insurers in all 50 states and DC, read our updated analysis.

This analysis of preliminary rate filings submitted by 105 ACA Marketplace insurers in 19 states and DC finds that ACA Marketplace insurers are requesting a median premium increase of 15% for 2026, which would represent the largest hike in premiums since 2018, the last time policy uncertainty contributed to sharp premium growth.

In addition to the anticipated growth in the cost of health care services, insurers have cited several policy changes that they expect to drive up rates next year, including the expiration of the enhanced premium tax credits at the end of this year and the impact of tariffs on some drugs, medical equipment, and supplies.

The full analysis and other data on health costs are 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.