Premiums for ACA Marketplace benchmark silver plans grew by about 5% in 2024, on average before taking into account subsidies. Meanwhile, premiums for the lowest cost unsubsidized bronze plans grew by about 6%, on average, in 2024.

However, premium changes vary by location and by metal level, with premiums decreasing in some cases. As most enrollees receive premium subsidies on the ACA Marketplaces, the net premium amount an exchange enrollee pays depends on their income and the difference in the cost between the benchmark plan (second-lowest-cost silver plan) and the premium for the plan they choose.

The map below illustrates changes in premiums for the lowest-cost bronze, silver, and gold plans by county, with and without subsidies. For data at the state-level, see our Health Insurance Marketplace tables.

2024 ACA Premium and Subsidy Changes

In 2024, 9 in 10 marketplace enrollees received premium tax credit subsidies and therefore will not necessarily pay a higher premium, even if the unsubsidized premiums in their county are rising. To account for premium increases, federal spending to finance subsidies will also increase. With the enhanced financial assistance for ACA Marketplace coverage provided by the Inflation Reduction Act, subsidized enrollees with incomes at or below 150% of poverty ($21,870 for an individual and $45,000 for a family of 4) can get a free ($0 premium) or nearly free silver plan with a very low deductible if they sign up for the lowest or second-lowest cost silver plan. Relative to the original ACA subsidies, the Inflation Reduction Act also reduced payments for middle-income enrollees and removed the upper income limit on subsidy eligibility.

The Medical Loss Ratio (MLR) provision of the Affordable Care Act (ACA) limits the amount of premium income that insurers can keep for administration, marketing, and profits. Insurers that fail to meet the applicable MLR threshold are required to pay back excess profits or margins in the form of rebates to individuals and employers that purchased coverage.

In the individual and small group markets, insurers must spend at least 80% of their premium income on health care claims and quality improvement efforts, leaving the remaining 20% for administration, marketing expenses, and profit. The MLR threshold is higher for large group insurers, which must spend at least 85% of their premium income on health care claims and quality improvement efforts. MLR rebates are based on a 3-year average, meaning that rebates issued in 2024 will be calculated using insurers’ financial data in 2021, 2022 and 2023 and will go to people and businesses who bought health coverage in 2023.

This analysis, using preliminary data reported by insurers to state regulators and compiled by Mark Farrah Associates, finds that insurers estimate they will issue a total of about $1.1 billion in MLR rebates across all commercial markets in 2024. Since the ACA began requiring insurers to issue these rebates in 2012, a total of $11.8 billion in rebates have already been issued to individuals and employers, and this analysis suggests the 2012-2024 total will rise to about $13 billion when rebates are issued later this year.

Estimated total rebates across all commercial markets in 2024 ($1.1 billion) are similar to total rebates issued in 2022 ($1.0 billion) and in 2023 ($950 million). In 2023, rebates were issued to 1.7 million people with individual coverage and 4.1 million people with employer coverage. In the individual market, the 2023 average rebate per person was $196, while the average rebates per person for the small group market and the large group market were $201 and $104, respectively (though enrollees could receive only a portion of this as rebates may be shared between the employer and employee or be used to offset premiums for the following year).

The estimated $1.1 billion in rebates to be issued later this year will be larger than those issued in most prior years but fall far short of recent record-high rebate totals of $2.5 billion issued in 2020 and $2.0 billion issued in 2021, which coincided with the onset of the pandemic.

In 2023, the average individual market simple loss ratio (meaning that there’s no adjustment for quality improvement expenses or taxes and therefore, don’t align perfectly with ACA MLR thresholds) was 84%, meaning these insurers spent an average of 84% of their premium income in the form of health claims in 2023. However, rebates issued in 2024 are based on a three-year average of insurers’ experience in 2021-2023. Consequently, even insurers with high loss ratios in 2023 may expect to owe rebates if they were highly profitable in the prior two years.

In the small and large group markets, 2023 average simple loss ratios were 84% and 88%, respectively. Only fully-insured group plans are subject to the ACA MLR rule; about two thirds of covered workers are in self-funded plans, to which the MLR threshold does not apply.

Rebate Payment Logistics

The 2024 rebate amounts in this analysis are still preliminary. Rebates or rebate notices are mailed out by the end of September and the federal government will post a summary of the total amount owed by each issuer in each state later in the year.

Insurers in the individual market may either issue rebates in the form of a check or premium credit. For people with employer coverage, the rebate may be shared between the employer and the employee depending on the way in which the employer and employee share premium costs.

If the amount of the rebate is exceptionally small (less than $5 for individual rebates and less than $20 for group rebates), insurers are not required to process the rebate, as it may not warrant the administrative burden required to do so.

Medicaid is the primary program providing comprehensive coverage of health care and long-term services and supports to about 80 million low-income people in the United States. Medicaid accounts for one-sixth of health care spending (and half of spending for long-term services and support) and a large share of state budgets. Medicaid is jointly financed by states and the federal government but administered by states within broad federal rules. Because states have the flexibility to determine what populations and services to cover, how to deliver care, and how much to reimburse providers, there is significant variation across states in program spending and the share of people covered by the program.

Medicaid has been a political touchstone for the past several decades. Republican candidates often run on the promise on cutting back on federal Medicaid spending and giving states more flexibility to administer programs, while Democrats have run on expanding Medicaid coverage to reduce the number of lower-income people who are uninsured. Amidst all of this, large majorities of the public, across partisanship, continue to hold favorable views of the program and most say the current program is working well for most low-income people covered by the program.

Earlier this year, the KFF Medicaid Unwinding Survey found Medicaid enrollees¹  reporting overall positive experiences with their Medicaid coverage even as some of them lost their coverage as states began unwinding their Medicaid enrollment. The latest release from KFF examines the attitudes of the public overall on the future of the Medicaid program, as well leveraging the survey of adult Medicaid enrollees, to better understand how the public’s perception of the program compares to the population who most recently was enrolled by the program.

The Public and Medicaid Enrollees Want Medicaid Financing To Stay As Is

Former President Trump said that he would not cut Social Security or Medicare if elected, but has notably not released any detailed statements on his plans for the future of Medicaid, though his budget proposals as president included plans to cap federal Medicaid spending. One way to do this is through the “block grants” – a recurring Republican proposal that would give a set amount of funding each year (usually lower than anticipated under current law) and in turn states have greater flexibility to administer program but the entitlement to coverage for enrollees and the guarantee of federal of matching dollars to states without a cap would end.

Asked which comes closer to their view of what Medicaid should look like in the future, nearly nine in ten (86%) Medicaid enrollees say “Medicaid should largely continue as it is today, with the federal government guaranteeing coverage for low-income people, setting standards for who states cover and what benefits people get, and matching state Medicaid spending as the number of people on the program goes up or down.” This is more than six times the share of enrollees (14%) who say “Medicaid should be changed so that instead of matching state Medicaid spending and setting certain requirements for health coverage, the federal government limits how much it gives states to help pay for Medicaid and states have greater flexibility to decide which groups of people to cover without federal guarantees.”

While an overwhelming majority of Medicaid enrollees prefer the program to “largely continue as it is today,” somewhat fewer adults overall – though notably still a large majority – say the same (86% vs. 71%).

Among Medicaid enrollees, majorities across gender, age, racial and ethnic groups, and partisanship agree that Medicaid should largely continue as it is today. For example, more than eight in ten Democrats and Democratic-leaning independent enrollees (89%) and Republicans and Republican-leaning independent enrollees (83%) say they want Medicaid to largely continue as it is. One in ten (11%) Democratic enrollees and one in seven (16%) of Republican enrollees would rather move to a block grant system.

While partisans among Medicaid enrollees are in consensus of keeping Medicaid as it is, the public is more divided along party lines. Among all adults, nearly nine in ten Democrats and Democratic-leaning independents say the future of Medicaid should largely continue as it is today (87%) compared to just half of Republicans or Republican-leaning independents (53%).

The Public and Medicaid Enrollees Largely Support Medicaid Expansion

Under the ACA, most states have expanded their Medicaid programs to cover nearly all adults with incomes up to 138% of poverty ($20,783 for an individual in 2024). For states that expand their Medicaid program, the federal government pays for 90 percent of the costs of this expansion with the state paying 10 percent. Under the American Rescue Plan Act states that newly adopt expansion are eligible for an additional 5 percentage point increase in the state’s traditional FMAP (federal medical assistance percentage) for two years, resulting in a temporary net fiscal benefit for these states. Several of the ten states that have not yet expanded their Medicaid programs debated expansion, but ultimately no new states adopted expansion after North Carolina implemented expansion in December 2023.

The KFF Survey of Medicaid unwinding finds that more than three in four (78%) enrollees in a non-expansion state say their state should expand Medicaid to cover more low-income uninsured people. Similarly, our recent KFF Health Tracking Poll found that a majority of adults in non-expansion states support their state expanding its Medicaid program – but to a lesser degree (66%).

Once again, among the public overall, expanding Medicaid is largely split along partisan lines, with eight in ten (83%) Democrats or Democratic-leaning independents saying they want to expand Medicaid, compared to six in ten (58%) of Republicans or Republican-leaning independents who want to keep Medicaid as it is today.

1. KFF interviewed 1,227 U.S. adults who had Medicaid coverage in prior to April 1, 2023 – as states began the process of determining who was still eligible for Medicaid in their state ↩︎

Despite significant improvements to health throughout the world over the century, many global health challenges remain, particularly in low- and middle-income countries. The United States government has been engaged in global health activities for more than 100 years and its involvement has grown considerably over time. How much do you know about U.S. efforts to improve health around the world?

Note: Figure 1 was updated on Sept. 18, 2024, to correct a typographical error. The FPL for a family of three in 2017 was $19,730, not $19,370.

The DMPA contraceptive injection is a commonly used reversible contraceptive method among women in the United States. Also known as the “shot,” the injection is commonly known by its brand-name Depo Provera (depot-medroxyprogesterone acetate or DMPA), although generic alternatives are available. It was first introduced in the United States in 1959 for management of menstruation and was approved for contraceptive use by the U.S. Food and Drug Administration (FDA) in 1992. This factsheet provides an overview of the types, use, awareness, availability, and insurance coverage of contraceptive injection in the U.S.

How does the DMPA Injection work?

The shot works by releasing the hormone DMPA, a progestin, which suppresses ovulation and thickens cervical mucus that also helps keep sperm from fertilizing an egg. DMPA can be provided by an intramuscular shot (DMPA-IM) administered by a clinician or by a subcutaneous shot (DMPA-SC) that can be injected by the patient at home (Table 1). Both forms are FDA-approved and need to be administered once every 12 weeks to be effective. Brand-name Depo-Provera and the generic equivalents for medroxyprogesterone acetate are intramuscular injections, providing 150mg of progestin in one dose. The Depo-subQ Provera 104 injection uses a smaller needle and a lower dose of progestin (104 mg) than the intramuscular alternative. Because Depo-subQ Provera 104 uses a smaller needle, it can be less painful than the intramuscular injection and can be administered by the patient at home. This method is considered a safe, “off-label” method while having the same contraceptive effectiveness. Like most contraceptives, the DMPA shot does not protect against STDs; use of condoms is recommended to reduce the risk for STDs, including HIV, while using DMPA shots.

The DMPA shot has a typical use failure rate of 4% when used once every 12 weeks or three months. Long-acting reversible contraceptive (LARCs) methods such as implants, intrauterine devices (IUDs), and permanent contraceptive methods such as vasectomies and tubal ligations are typically more effective than the shot because these methods involve little to no follow-up care, while injections need to be repeated every 12 weeks in order to be effective. Condoms or another non-hormonal contraceptive are recommended as a back-up for 7 days after the first injection. If a patient is more than four weeks late for a shot (16 weeks after their last shot), it is recommended that they take a pregnancy test before the next dose and that they use condoms or another non-hormonal contraceptive as a back-up for another 7 days if they receive another shot. It takes an average of 10 months for pregnancy to occur after stopping the injection, which is comparable to other methods such as IUDs and oral contraceptive pills.

Benefits and Side Effects

The DMPA shot has several non-contraceptive benefits but also has some side effects and risks. Benefits include lower risk of uterine cancer and reduced symptoms of endometriosis. However, the injectable has the highest discontinuation rate among contraceptives in the U.S., associated with side effects which include menstrual irregularities (spotting or cessation of periods) and weight gain. Of note, Depo-Provera comes with a black box warning from the FDA that the contraceptive injection should not be used as a long-term (longer than 2 years) method unless other contraceptive methods are considered inadequate, as women who use Depo-Provera may lose significant bone density. However, the American College of Obstetricians and Gynecologists (ACOG) and the World Health Organization (WHO) disagree with this warning, stating that loss in bone density from DMPA is not associated with fractures and appears to be reversible after discontinuation of the injectable. Both organizations conclude that the benefits of DMPA use outweigh the theoretical fracture risk, and that DMPA may be prescribed without limitations on its duration of use.

Use, Awareness, and Availability of the Contraceptive Injection

Based on the most recent data on contraceptive use from the National Survey of Family Growth, approximately 3% of women who used contraception from 2017-2019 reported that they used the contraceptive injection in the past month. Over the last two decades, women’s access to and options of various contraceptive choices have changed, and overall use of the injection has declined, as more women are using LARCs, such as IUDs and implants. During the first few years of the COVID-19 pandemic, however, the availability of and interest in using DMPA-SC increased due to restrictions placed on in-person clinic appointments. A 2023 Contraception study reports that there was a significant increase in provision of DMPA-SC for self-injection during this time, although this is still a small portion of overall use of DMPA-SC.

Among reproductive age women who used any form of contraception from 2017-2019, the contraceptive injection was most often used by young women, lower-income women, and Black women. Use of the injection also decreased with educational attainment – smaller shares of women with bachelor’s degrees reported using the shot as their contraceptive method (Figure 1).

Insurance Coverage and Cost of the Contraceptive Injection

The Affordable Care Act (ACA) requires most private insurance plans and Medicaid expansion programs to cover one of each of the 18 FDA-approved contraceptive methods without cost sharing. Women with private insurance and those with Medicaid coverage are eligible for patient education, counseling, and access to at least one form of the contraceptive injection without cost-sharing. Coverage also includes the first doctor’s visit, discontinuation of the shot, and management of side effects. Although coverage includes at least one form of the injection, plans may not cover both the intramuscular formulation and Depo-subQ Provera 104; however, if a clinician determines that a particular injectable formulation is medically appropriate for a patient then the plan must cover that form.

Safety-net clinics that participate in the federal Title X family planning program offer low or no-cost contraceptives to uninsured adults and teens on a sliding scale and may forego charges for those on the lowest end of the income scale. The Office of Population Affairs (OPA) within the U.S. Department of Health and Human Services (HHS) reported that, in 2022, approximately 302,000 women received the DMPA injection as their primary contraceptive method from a Title X service provider.

In 16 states (CA, CO, HI, ID, IL, IN, MD, ME, MN, NV, NM, NH, OR, SC, TN, VA) and the District of Columbia, pharmacists can provide the intramuscular contraceptive shot directly to women without the need to first visit a physician to obtain the prescription and injection (Figure 2). In some states like Hawaii, Indiana, and Maryland, the statewide protocol or standing order does not explicitly state that the DMPA injection can be offered but does state that all FDA-approved hormonal contraceptive methods can be administered by pharmacists. However, pharmacist participation in these programs is not required and implementation has varied across states. Furthermore, while the actual DMPA shot is typically covered, women will likely have to have to pay out-of-pocket for a pharmacist consultation fee, which is not required to be covered under the contraceptive coverage laws in most of these states and by federal law through the ACA.

Key Facts

• HIV testing is integral to HIV prevention, treatment, and care. Knowledge of one’s HIV status enables individuals to engage in HIV treatment and is important for preventing transmission. While the share who know their HIV status has increased over time, as of 2021, 13% of people with HIV did not know they were HIV positive. Studies show that those who learn they are HIV positive modify their behavior to reduce the risk of HIV transmission and that those who do not know they are positive account for nearly 40% of new HIV infections.
• In 2022, only about a third (36%) of nonelderly adults in the United States (U.S.) had ever been tested for HIV. The Centers for Disease Control and Prevention (CDC) recommends that everyone aged 13-64 be tested for HIV at least once as part of routine health care, and at least annually for those at higher risk.
• Early knowledge of HIV status allows for linkage to medical care and treatment that can reduce morbidity and mortality and improve quality of life. Treatment guidelines recommend starting antiretroviral treatment as soon as one is diagnosed with HIV. Individuals with HIV who have an undetectable viral load, achieved through used of effective antiretroviral therapy, cannot sexually transmit HIV to others.
• Most people with health insurance – both public and private – have access to HIV testing, often at no cost. And, for those without insurance, HIV testing can often be obtained at little or no cost in community settings.

Testing Statistics

• Through earlier detection, raising awareness of HIV status, and linkage to care and treatment, testing plays an important role in addressing the U.S. epidemic.
• Among the 2 million people with HIV in the U.S., an estimated 13% do not know they are living with HIV and this share accounts for nearly 40% of new transmissions.  Awareness of HIV status allows those who are positive to engage in HIV treatment which optimizes health outcomes, reduce viral load (the amount of virus in the body) and prevent transmission. Additionally, studies show that those who learn they are living wtih HIV modify their behavior to reduce the risk of HIV transmission.
• According to the CDC’s Behavioral Risk Factor Surveillance System (BRFSS), in 2022, 3 in 10 (36%) U.S. adults, aged 18-64, reported ever having been tested for HIV (see Figure 1). HIV testing rates vary by state, age, race/ethnicity, and other factors. Some communities of color report having ever been tested for HIV at higher rates than White people. For example, 57% of Black people and 44% of Hispanic people report ever having been tested for HIV compared to 32% of White people. On the other hand Asian people, Native Hawaiian and Pacific islanders as a group report lower rates of testing (26%), potentially reflecting lower rates of HIV on those communities. (See Figure 1.)
• The most recent KFF survey found that 37% of gay and bisexual men report being tested in the past two years.

Testing Recommendations and Requirements

Since 2006, the CDC has recommended that everyone aged 13-64 receive at least one HIV test as a part of routine health care and more frequent testing, at least annually, for those at higher risk. Per the CDC, individuals who may benefit from at least annual screening include:

• sexually active gay or bisexual men (some of whom may benefit from more frequent testing, such as every 3 to 6 months)
• individuals who have had sex with an HIV-positive partner
• individuals who have had more than one partner since their last HIV test
• those who have shared needles or works to inject drugs
• people who have exchanged sex for drugs or money
• individuals who have another sexually transmitted disease, hepatitis, or tuberculosis
• those who have had sex with someone who has participated in any of the above activities or with someone with an unknown sexual history

Additionally, HIV testing is recommended for:

• anyone who has been sexually assaulted at original assessment, repeating at 6 weeks and 3 months
• all pregnant people and for any newborn whose mother’s HIV status is unknown (treatment provided to pregnant HIV-positive people early in pregnancy can reduce the risk of transmitting HIV to 1% or less)
• anyone who is PrEP, repeating every 3 months
• those who have an occupational exposure, such as healthcare personnel, to blood and/or other body fluids that may contain HIV
• local policies and recommendations may also inform or facilitate HIV testing. For example, in New York state, it mandatory to offer HIV testing to patients in the emergency room department, inpatient departments of hospitals, and primary care centers.

CDC recommends that all HIV screening be voluntary, and opt-out (patient is notified that the test will be performed and consent is inferred unless the patient declines) vs. opt-in (test is offered to the patient who must explicitly consent to an HIV test, often in writing).

HIV testing is mandatory in the U.S. in certain cases, including for: blood and organ donors; military applicants and active duty personnel; federal and state prison inmates under certain circumstances; and newborns in some states. As of January 2010, HIV testing is no longer mandatory for those wishing to emigrate to the United States or for refugees.

All states/territories have moved to HIV name reporting (in addition to reporting AIDS cases) where a person’s name is reported to the state if they test HIV positive. The state then reports the number of unique positive HIV tests to CDC (no names or other personally identifying information are reported to CDC; only clinical and basic demographic information are forwarded). This is considered confidential HIV testing. There is also anonymous HIV testing offered at some testing sites where identifying information is not collected/reported.

Insurance Coverage of HIV Testing

Most insurers now broadly cover HIV testing as part of routine healthcare without cost-sharing due to the Affordable Care Act (ACA). Under the ACA, any preventive service given an “A” or “B” rating by the United States Preventive Services Task Force (USPSTF) must be covered by most insurers without cost-sharing; in addition, traditional Medicaid programs, while not required to provide USPSTF top graded services, are incentivized to do so. In 2013, the USPSTF gave HIV screening an “A” rating for all adolescents and adults, ages 15 to 65. It also gave an “A” grade to HIV screening for pregnant women. Both of these recommendations were reaffirmed in 2019. The current insurance coverage landscape of HIV testing is as follows:

• Private Insurance: Most private plans cover routine HIV testing without cost-sharing. All plans created after the ACA was signed in 2010 must provide coverage aligning with the USPSTF “A” and “B” grades without cost sharing.
• Medicaid: All Medicaid programs cover “medically necessary” HIV testing and most cover routine HIV screening. Each state Medicaid program determines its own definition of medical necessity, although it generally refers to procedures recommended by a physician. In the case of HIV testing, it is clinically indicated based on a patient’s risk factors and/or signs of HIV infection.
• Traditional Medicaid Programs: While all Medicaid programs must cover “medically necessary” HIV testing, coverage of “routine” HIV screening is an optional benefit in traditional (non-expansion) Medicaid programs. Still, most states do cover routine HIV screening. In a 2021 survey, of 42 responding jurisdictions, 40 states and DC (41 total) reported covering routine HIV testing. Just one state, Florida, reported covering “medically necessary” testing. Nine states did not respond, including 3 that reported covering only “medically necessary” testing in a prior survey (GA, NE, and SD).As of November 2021, among the 42 states that cover routine HIV screening, 16 (CA, CO, DE, HI, KY, LA, MA, MT, NH, NJ, NV, NY, OH, OR, WA and WI) cover all USPTSF “A” and “B” graded services and have sought an additional 1% increase in their federal matching rate (FMAP) for these services under Sec. 4106 of the ACA.

• Medicaid Expansion Programs: In addition to covering medically necessary testing, Medicaid programs expanded under the ACA are required to cover preventive services rated “A” or “B” by the USPSTF, including HIV screening, without cost-sharing. To date, 40 states and DC have expanded their Medicaid programs.
• Medicare: In April 2015, following the 2013 USPSTF recommendation and a subsequent National Coverage Determination, CMS expanded Medicare coverage to include annual HIV testing for beneficiaries ages 15-65 regardless of risk, and those outside this age range at increased risk without cost-sharing. Additionally, Medicare will cover up to three tests for pregnant beneficiaries.
• Uninsured: For those without insurance coverage (or wishing not to use their insurance), HIV testing can be obtained at little or no cost in some community based settings (e.g., stand-alone HIV testing sites, community health centers, mobile testing clinics).

Testing Sites

• HIV testing is offered at CDC-funded testing sites (accounting for about 1.7 million tests in 2021) and in other public and private settings, including free-standing HIV counseling and testing centers, health departments, hospitals, private doctor offices, STD clinics, and mobile testing units. The overall positivity rate at CDC funded test sites was 1.1% in 2021. The positivity rate for new diagnoses was 0.5% but was substantially higher for certain sub-populations (e.g. 1.4% for transgender people, 1.9% for men who have sex with men and 2.8% for men who have sex with men and also use injection drugs). Among CDC-funded testing sites, non-health care facilities have a higher rate of clients testing HIV positive than do health care and correctional facilities.
• HIV testing is a component of the Ending the HIV Epidemic Initiative (EHE), a federal effort launched in 2019 to reduce new HIV infections in the United States by 75% in five years and 90% in ten years. HIV testing as part of the EHE is largely conducted through Health Resources and Services Administration (HRSA) funded Health Centers. Prior to EHE in 2018, HRSA funded Health Centers conducted 2,427,075 HIV tests. Between 2018 and 2022, there was a 44% increase in HIV tests as over a million more patients were tested in 2022 (3,492,034).

Testing Techniques

• HIV tests aim to detect the virus by looking for evidence of the body’s immune response (antibodies), proteins on the surface of the virus (antigens), or genetic material from the virus (RNA). Detectable antibodies usually develop within 3-8 weeks after infection but may take longer; the period after initial infection with HIV before detectable antibodies develop is the “window period.”
• In 2010, the FDA approved the first HIV diagnostic test that detects both antibodies and antigen, a component of the virus that triggers the production of antibodies. In 2013, the FDA approved the first rapid antigen-antibody test, the first test also to distinguish between acute and established HIV-1 infection. Tests for antigen allow for earlier detection of HIV because they can detect the virus before the body has mounted a response, although there will still be a window period of approximately two weeks after initial infection during which no test can detect the virus. RNA, or nucleic acid tests, which detect the virus itself in the blood, are also available, but not routinely used for screening. The test may be used in cases where there has been a high-risk exposure to HIV because they are able to detect the virus earliest in infection, as a follow-up test to a positive antibody or antigen test and are now recommended in certain cases as part of assessment for PrEP.

HIV diagnostics in the U.S differ based on type of specimen tested (whole blood, serum, or plasma; oral fluid; urine); how the specimen is collected (blood draw/venipuncture; finger prick; oral swab; via urination); where the test is done (laboratory; point-of-care site; at home); and how quickly results are available (conventional or rapid). The main types of tests are:

• Conventional Blood Test: Blood sample drawn by health care provider; tested at lab. Results: less than an hour to several days.
• Conventional Oral Fluid Test: Oral fluid sample collected by health care provider, who swabs inside of mouth; tested at lab. Results: a few days to two weeks.
• Rapid Tests: Whole blood finger prick or venipuncture; plasma; oral fluid sample collected depending on complexity of rapid test and individual administering test. Results: approximately 10 minutes. If test is negative, no further testing is needed. If positive, test must be confirmed with a more specific test through conventional method. Some rapid tests have been granted CLIA waivers which allow them to be used outside traditional laboratories.
• Self and Home Tests: There is one FDA approved self-test, which is a rapid oral fluid test. Results: approximately 20 minutes. The second FDA test is collected at home and performed with a finger prick with a lancet, placing two drops of blood on a treated card, and mailing to a lab for testing. An identification number on the card is used when phoning for results; counseling and referral are available by phone. Results: in approximately three days. Self or home testing may help address some barriers to HIV testing that may make some people more hesitant to access in person health services.
• Urine Test: Urine sample collected by health care provider; tested at lab. Results: a few days to two weeks.

After an HIV Test

Following an HIV test, individuals who test positive can expect a confirmatory test and linkage to HIV care and treatment. It is recommended to initiate antiretroviral treatment as soon as possible after diagnosis. Doing so facilitates the best possible clinical outcomes for the HIV positive individual and is also a prevention opportunity, as once that individual has an undetectable viral load HIV cannot be transmitted to others. Individuals who test HIV negative but who are at high risk for the infection, may be referred to additional prevention services such as PrEP which can reduce the risk of HIV acquisition through sex by about 99%.

Key Takeaways

• Funding for Medicare, which totaled $1 trillion in 2023, comes primarily from general revenues (government contributions), payroll tax revenues paid by employers and workers, and premiums paid by beneficiaries.
• Based on current projections from the Medicare Board of Trustees’ 2024 report, the Medicare Part A (Hospital Insurance, or HI) trust fund is projected to be depleted in 2036, 12 years from now – an improvement of five years compared to the projected depletion date of 2031 in the previous report due to higher expected revenues and lower projected spending. To date, lawmakers have never allowed the HI trust fund to be fully depleted.
• Total Part A spending is projected to exceed revenues beginning in 2030, which means trust fund reserves will be needed to pay benefits in full. By 2036, there will be insufficient revenues, including reserves, to pay full benefits for the year. Medicare would be able to pay 89% of costs covered under Part A using payroll tax revenues in that year.
• The revenues for Medicare Parts B and D are determined annually to meet expected spending obligations for the coming year, meaning that the Supplementary Medical Insurance, or SMI, trust fund does not face a funding shortfall, in contrast to the HI trust fund. But higher projected spending on Part B and Part D will increase the amount of general revenues and beneficiary premiums required to cover this spending. Altogether, beneficiary premiums and cost sharing for Part B and Part D are estimated to account for 26% of the average Social Security benefit in 2024.
• With rising enrollment in Medicare Advantage, payments to Medicare Advantage plans are rising as a share of Part A and Part B spending, which affects the balance of the HI Trust Fund and Part B premiums. In 2024, MedPAC estimates that the Medicare program will spend 22% more per Medicare Advantage enrollee than for similar beneficiaries in traditional Medicare – an additional $83 billion in total.
• The Medicare trustees estimate that an increase of 0.35% of taxable payroll (increasing the 2.9% payroll tax to 3.25%) or a spending reduction of 8% would bring the HI trust fund into balance over the long term.

Introduction

Medicare, the federal health insurance program for 67 million people ages 65 and over and younger people with long-term disabilities, helps to pay for hospital and physician visits, prescription drugs, and other acute and post-acute care services. In 2023, Medicare benefit payments totaled $839 billion, net of premiums and other offsetting receipts. Accounting for 21% of national health care spending and 12% of the federal budget in 2022, Medicare spending often plays a major role in federal health policy and budget discussions.

In discussions of Medicare’s financial condition, attention frequently centers on one specific measure —the solvency of the Medicare Hospital Insurance (HI) trust fund, out of which Medicare Part A benefits are paid. Based on current projections from the Medicare Board of Trustees in their 2024 report, the HI trust fund is projected to be depleted in 2036, 12 years from now – an improvement of five years compared to the projected depletion date of 2031 in the previous report due to higher expected revenues and lower projected spending.

The HI trust fund depletion date is only one way of measuring Medicare’s financial status and doesn’t present a complete picture of total program spending and revenues, but it does indicate whether there is an imbalance between spending and financing for inpatient hospital and other benefits covered under Medicare Part A. These FAQs answer key questions about Medicare financing and trust fund solvency.

How is Medicare financed?

Funding for Medicare, which totaled $1 trillion in 2023, comes primarily from general revenues (government contributions), payroll tax revenues paid by employers and workers, and premiums paid by beneficiaries (Figure 1). Other sources include taxes on Social Security benefits, payments from states, and interest. The different parts of Medicare are funded in varying ways, and revenue sources dedicated to one part of the program cannot be used to pay for another part.

• Part A, which covers inpatient hospital stays, skilled nursing facility (SNF) stays, some home health visits, and hospice care, is financed primarily through a 2.9% tax on earnings paid by employers and employees (1.45% each). Higher-income taxpayers (more than $200,000 per individual and $250,000 per couple) pay a higher payroll tax on earnings (2.35%). Payroll taxes accounted for 88% of Part A revenue in 2023.
• Part B, which covers physician visits, outpatient services, preventive services, and some home health visits, is financed primarily through a combination of general revenues (71% in 2023) and beneficiary premiums (27%) (and 1% from interest and other sources). Beneficiaries with annual incomes over $103,000 per individual or $206,000 per couple pay a higher, income-related Part B premium reflecting a larger share of total Part B spending, ranging from 35% to 85%. The standard monthly Part B premium in 2024 is $174.70, while the income-related monthly premiums range from $244.60 to $594.
• Part D, which covers outpatient prescription drugs, is financed primarily by general revenues (73%), with additional revenues coming from beneficiary premiums (14%) and state payments for beneficiaries enrolled in both Medicare and Medicaid (12%). Higher-income enrollees pay a larger share of the cost of Part D coverage, as they do for Part B.

The Medicare Advantage program (Part C) is not separately financed. Medicare Advantage plans, such as HMOs and PPOs, cover Part A, Part B, and (typically) Part D benefits. Funds for Part A benefits provided by Medicare Advantage plans are drawn from the Medicare HI trust fund (accounting for 48% of total spending on Part A benefits in 2023). Funds for Part B and Part D benefits are drawn from the Supplementary Medical Insurance (SMI) trust fund. Beneficiaries enrolled in Medicare Advantage plans pay the Part B premium and may pay an additional premium for their plan.

What does Medicare trust fund solvency mean and why does it matter?

The solvency of the Medicare Hospital Insurance (HI) trust fund, out of which Part A benefits are paid, is a common way of measuring Medicare’s financial status, though because it only focuses on the status of Part A, it does not present a complete picture of total program spending. Medicare solvency is measured by the level of reserves in the HI trust fund. In years when annual income to the trust fund exceeds benefits spending, the level of reserves increases, and when annual spending exceeds income, the level of reserves decreases. This matters because when spending exceeds income and the reserves are fully depleted, Medicare will not have sufficient funds to pay hospitals and other providers for all Part A benefits that are provided in a given year. Based on current projections from the Medicare trustees, Part A spending will exceed Part A revenues beginning in 2030.

When are HI trust fund reserves projected to be depleted?

Each year, the Medicare trustees provide an estimate of the year when the HI trust fund reserves are projected to be fully depleted. In the 2024 Medicare Trustees report, the trustees project that reserves in the Part A trust fund will be depleted in 2036, 12 years from now. This is an improvement of five years from the projection in the 2023 Medicare Trustees report, when the depletion date was projected to be 2031 (Figure 2).

In the coming decade, based on current projections from the Medicare trustees, Part A spending will exceed Part A revenues beginning in 2030, leading to a gradual reduction in the level of reserves in the HI trust fund (Figure 3). By 2033, the Medicare trustees project that the HI trust fund will begin the year with $254 billion in reserves, but because spending is projected to exceed revenue by $55 billion that year, the trust fund is expected to end the year with $198 billion in reserves. As Part A spending is projected to continue to exceed Part A revenues in the years that follow, the reserves will be depleted at some point during the year in 2036.

What happens if the reserves in the HI trust fund are fully depleted? Can Medicare go bankrupt?

Medicare cannot go bankrupt or go broke. While some describe Medicare or the Medicare HI trust fund as heading toward bankruptcy or going broke when referring to the depletion of HI trust fund reserves, Medicare will not cease to operate if HI trust fund reserves are fully depleted because revenue will continue flowing into the fund from payroll taxes and other sources.

Based on current projections of trust fund reserve depletion in 2036, Medicare would be able to pay 89% of costs covered under Part A using payroll tax revenues in that year. However, there is no automatic process in place or precedent to determine how to apportion the available funds or how to fill the shortfall.

What factors affect the solvency of the HI trust fund and what explains the improved status in 2024?

The solvency of the Medicare HI trust fund is affected by several factors. In addition to legislative and regulatory changes that affect Part A spending (both utilization of services and payments for services provided by hospitals, skilled nursing facilities, and other providers, and for Part A services covered by Medicare Advantage plans) and revenues, Part A trust fund solvency is affected by:

• the level of growth in the economy, which affects Medicare’s revenue from payroll tax contributions: economic growth that leads to higher employment and wages boosts revenue to the trust fund, while an economic downturn can have the opposite effect,
• overall health care spending trends: higher health care price and cost growth can lead to higher spending for services covered under Medicare Part A that could hasten the depletion date, while moderation in the growth of prices and costs could slow spending growth, and
• demographic trends: this includes the aging of the population, which is leading to increased Medicare enrollment (especially between 2010 and 2030 when the baby boom generation reaches Medicare eligibility age); a declining ratio of workers per beneficiary making payroll tax contributions, which means lower revenue; and other factors, such as fertility rates, disability rates, and immigration.

In the 2024 report, the Medicare trustees attributed the improvement in the financial status of the HI trust fund to a combination of factors:

• Income to the HI trust fund is projected to be higher than in the 2023 report due to higher employment and average wage growth.
• Part A spending is projected to be lower than last year’s estimates due to a policy change to exclude graduate medical education expenses associated with enrollees in Medicare Advantage from the fee-for-service costs used to determine payments to Medicare Advantage plans.
• Projected Part A spending on inpatient and home health services is lower than previously estimated, with more recent spending data informing these projections.

How have the solvency projections of the HI trust fund changed over time?

Since 1990, the HI trust fund came within 10 years of depletion for much of the 1990s, in 2009, and again in each year between 2018 and 2023 (Figure 4). To improve the fiscal outlook of the trust fund in the 1990s, Congress enacted legislation to reduce Medicare spending obligations, while policy changes adopted in the Affordable Care Act of 2010 – including reduced Medicare payments to plans and providers and increased revenues – helped to improve the status of the HI trust fund between 2009 and 2010. To date, lawmakers have never allowed the HI trust fund to be fully depleted.

What is the Medicare funding warning and why does it matter?

The Medicare Modernization Act of 2003, the law that created the Medicare Part D drug benefit, also included a provision that required the Medicare Trustees to calculate annually whether the difference between total Medicare outlays and specified dedicated financing sources is expected to account for more than 45% of Medicare outlays in the current fiscal year or any of the next six fiscal years. If so, the trustees issue a determination of “excess general revenue Medicare funding,” and making such a determination in two consecutive reports triggers a “Medicare funding warning.”

In their 2024 report, the Medicare Trustees made a determination of “excess general revenue Medicare funding” based on projections of general revenue funding exceeding 45% in the next seven years, and because the same determination was made in the 2023 report, this triggered a “Medicare funding warning” (Figure 5). In fact, the trustees have made a determination of excess general revenue funding for eight years in a row and issued funding warnings for seven years in a row.

While this measure is intended to draw attention to Medicare spending and revenues and the role of government contributions in funding the Medicare program, no automatic changes are made to Medicare if the funding warning is issued. Instead, the President is required to submit legislation to Congress to respond to the warning, and an expedited process is in place for the Congress to consider the President’s proposed legislation. To date, however, only President George W. Bush in 2008 submitted a proposal to Congress in direct response to a Medicare funding warning issued by the Medicare Trustees in 2007, but Congress took no action on that proposal.

Are Medicare Part B and Part D also facing a trust fund shortfall?

The Hospital Insurance trust fund provides financing for only one part of Medicare, so it represents only one part of Medicare’s total financial picture. While Part A is funded primarily by payroll taxes, benefits for Part B physician and other outpatient services and Part D prescription drugs are funded by general revenues (government contributions) and premiums paid for out of separate accounts in the Supplementary Medical Insurance, or SMI, trust fund. The revenues for Medicare Parts B and D are determined annually to meet expected spending obligations for the coming year, meaning that the SMI trust fund does not face a funding shortfall, in contrast to the HI trust fund.

However, higher projected spending for benefits covered under Part B and Part D will increase the amount of general revenues and beneficiary premiums required to cover costs for these parts of the Medicare program in the future. The Medicare trustees project that the standard monthly Part B premium will increase from $174.70 in 2024 to nearly $300 in 2033, accounting for 15% of the average retired worker’s Social Security benefit in 2033, up from 10% in 2024. Altogether, premiums and cost sharing for Part B and Part D are estimated to account for 26% of the average Social Security benefit in 2024.

How do payments to Medicare Advantage plans affect the solvency of the Part A Trust Fund and Part B premium and general revenue spending?

With the rise in Medicare Advantage enrollment, payments to private Medicare Advantage plans account for a growing share of total Medicare spending under Part A and Part B. According to current projections, payments to Medicare Advantage plans are projected to rise as a share of total Part A spending from 48% in 2023 to 54% in 2033, a shift that could impact HI trust fund solvency. Medicare Advantage is also projected to rise as a share of total Part B spending, from 55% in 2023 to 65% in 2033, which could impact both beneficiary premiums and general revenue spending. In 2024, MedPAC estimates that the Medicare program will spend 22% more per Medicare Advantage enrollee than for similar beneficiaries in traditional Medicare – an additional $83 billion in total.

What is the longer-term outlook for Medicare financing and trust fund solvency?

Although current projections show that the short-term solvency outlook for the Medicare HI trust fund has improved, the Medicare program continues to face longer-term financial pressures associated with higher health care costs and an aging population. The Medicare trustees estimate that an increase of 0.35% of taxable payroll (increasing the 2.9% payroll tax to 3.25%) or a spending reduction of 8% would bring the HI trust fund into balance over the long term.

To sustain Medicare for the long run, policymakers may consider adopting broader changes to the program that could include both reductions in payments to providers and plans or reductions in benefits, and additional revenues, such as payroll tax increases or new sources of tax revenue. Evaluating such changes would likely involve careful deliberation about the effects on federal expenditures, the Medicare program’s finances, and beneficiaries, health care providers, and taxpayers.

As of May 21, 2024, KFF tracking shows that half of all U.S. states have enacted a law that prohibits or limits youth access to gender affirming care. The uptick in this lawmaking was slow at first but then rapidly accelerated over the course of the past 18 months. LGBTQ civil rights, including those related to health care access, continue to be the subject of divisive political debates at the state and national level, particularly as the election season heats up.

Figure 1

Arkansas was the first state to enact a youth gender affirming care ban in April 2021, with Arizona and Alabama following about a year later. Beginning in January 2023, the number of states enacting these policies rapidly proliferated and by August, the number of states with bans reached 22 – a seven-fold increase in an eight-month period. As of last week, the total number of states has now reached 25.  While these laws do mainly impact youth access to health care, some impact adult access too, and a majority of the laws (23 of 25) include professional and/or civil penalties for health care practitioners who provide such care, including six states with felony penalties. Similar to the proliferation of bans, legal challenges are piling up, and laws in 17 of the 25 states are being challenged in state or federal court. (Detailed information about these state laws and litigation available in our Policy Tracker: Youth Access to Gender Affirming Care and State Policy Restrictions, which KFF will continue to update as developments occur.)