On July 3, the House passed the same version of the budget reconciliation bill that the Senate passed on July 1. On July 4, President Trump signed the bill, previously known as the “One Big Beautiful Bill Act,” into law. This summary describes the health care provisions in four categories: Medicaid, the Affordable Care Act, Medicare and Health Savings Accounts (HSAs). Included are the Congressional Budget Office (CBO) estimates for the impact of each provision (note coverage estimates for each provision will not sum to the law’s total coverage estimate). The CBO has stated the law will reduce federal spending on health care by over $1 trillion and lead to a 10 million increase in the country’s uninsured population.

An implementation timeline of the health provisions is available along with more background and a side-by-side comparison of the House and Senate passed bills.

• Medicaid
• Affordable Care Act
• Medicare
• Health Savings Accounts

Eligibility and Cost Sharing Policies

Section 71119: Work Requirements

Background

Prior to passage of the federal budget reconciliation law, Medicaid eligibility could not be conditioned on meeting a work or reporting requirement without obtaining a Medicaid Section 1115 waiver. During the first Trump administration, 13 states received approval to implement work requirements through Section 1115 waivers. Work requirement waiver approvals were either rescinded by the Biden administration or withdrawn by states, and Georgia is the only state with a Medicaid work requirement waiver currently in place. Since the beginning of Trump’s second term, some states have shown renewed interest in pursuing work requirement policies through 1115 waivers.

Description

• Requires states to condition Medicaid eligibility for individuals ages 19-64 applying for coverage or enrolled through the ACA expansion group (or a waiver) on working or participating in qualifying activities for at least 80 hours per month or attending school at least half-time.
• Mandates that states exempt certain adults, including parents with children ages 13 and under, those who are medically frail, and those who are participating in a substance use disorder treatment program, from the requirements.
• Requires states to verify that individuals applying for coverage meet the requirements for 1 and up to a maximum of 3 consecutive months preceding the month of application and that individuals who are enrolled meet the requirements for 1 or more months between the most recent eligibility redeterminations (at least twice per year).
• Requires states to use data matching “where possible” to verify whether an individual meets the requirement or qualifies for an exemption.
• Specifies that if a person is denied or disenrolled due to work requirements, they are also ineligible for subsidized Marketplace coverage.
• Prohibits these provisions from being waived, including under Section 1115 authority.
• Allows the Secretary to exempt states from compliance with the new requirements until no later than December 31, 2028, if the state is demonstrating a good faith effort to comply and submits progress in compliance or other barriers to compliance.
• Provides $200 million in funding to states for systems development for FY 2026 and an additional $200 million to HHS to support implementation (for FY 2026).

Effective Date: Not later than December 31, 2026, or earlier at state option.

Budgetary and Coverage Impact

CBO estimates this provision will reduce federal Medicaid spending by $326 billion over 10 years and will increase the number of people who are uninsured by 5.3 million in 2034.

KFF Resources

• A Closer Look at the Medicaid Work Requirement Provisions in the “Big Beautiful Bill”
• Implementing Work Requirements on a National Scale: What We Know from State Waiver Experience
• Implications of Medicaid Work and Reporting Requirements for Adults with Mental Health or Substance Use Disorders
• Medicaid Work Requirements: Implications for Low Income Women’s Coverage
• Understanding the Intersection of Medicaid and Work: An Update
• Different Data Source, But Same Results: Most Adults Subject to Medicaid Work Requirements Are Working or Face Barriers to Work
• 5 Key Facts About Medicaid Work Requirements

• An Overview of Medicaid Work Requirements: What Happened Under the Trump and Biden Administrations?
• Section 1115 Waiver Tracker Work Requirements

Section 71107: More Frequent Eligibility Determinations

Background

Under the Affordable Care Act (ACA), states are required to renew eligibility every 12 months for Medicaid enrollees whose eligibility is based on modified adjusted gross income (MAGI), including children, pregnant individuals, parents, and expansion adults. For enrollees whose eligibility is based on age 65+ or disability, states must renew eligibility at least every 12 months . States are required to review eligibility within the 12-month period if they receive information about a change in a beneficiary’s circumstances that may affect eligibility.

Description

• Requires states to conduct eligibility redeterminations every 6 months for Medicaid expansion adults.
• Provides $75 million in implementation funding for FY 2026.

Effective Date: For renewals scheduled on or after December 31, 2026.

Budgetary and Coverage Impact

CBO estimates this provision will reduce federal Medicaid spending by $63 billion over 10 years years and will increase the number of people who are uninsured by 700,000 in 2034.

KFF Resources

• Medicaid and CHIP Eligibility, Enrollment, and Renewal Policies as States Resume Routine Operations Following the Unwinding of the Pandemic-Era Continuous Enrollment Provision
• Recent Medicaid/CHIP Enrollment Declines and Barriers to Maintaining Coverage

Section 71103: Verifying Enrollee Address and Other Information

Background

The Eligibility and Enrollment final rule issued in April 2024 requires states to leverage reliable data sources to update enrollee address information, effective June 2025.

Description

• Requires states to update enrollee address information using reliable data sources, including the National Change of Address Database and managed care entities.
• Requires the Secretary to establish a system to share information with states for purposes of preventing individuals from being simultaneously enrolled in two states and requires states to submit monthly enrollee SSNs and other information to the system.

Effective Date: January 1, 2027 for states to obtain contact information; October 1, 2029 to establish system to prevent enrollment in two states simultaneously.

Budgetary and Coverage Impact

CBO estimates this provision will reduce federal Medicaid spending by $17 billion over 10 years. This provision is not expected to impact the number of people who are uninsured.

KFF Resources

• Medicaid and CHIP Eligibility, Enrollment, and Renewal Policies as States Resume Routine Operations Following the Unwinding of the Pandemic-Era Continuous Enrollment Provision

Section 71104: Ensuring Deceased Individuals Do Not Remain Enrolled

Description

• Requires states to review the Master Death File at least quarterly to determine if any enrolled individuals are deceased.

Effective Date: January 1, 2027.

Budgetary and Coverage Impact

CBO estimates this provision will not affect federal Medicaid spending over 10 years. This provision is not expected to impact the number of people who are uninsured.

KFF Resources

• Medicaid and CHIP Eligibility, Enrollment, and Renewal Policies as States Resume Routine Operations Following the Unwinding of the Pandemic-Era Continuous Enrollment Provision

Section 71102: Eligibility and Enrollment Final Rule

Background

In April 2024, CMS issued a final rule to streamline application and enrollment processes in Medicaid, align renewal policies for all Medicaid enrollees, facilitate transitions between Medicaid, CHIP, and subsidized Marketplace coverage, and eliminate certain barriers in CHIP. Implementation deadlines for states vary across provisions, but many provisions in the rule are already in effect, and for others, states are already in compliance.

Description

• Prohibits the Secretary from implementing, administering, or enforcing certain provisions that have not yet taken effect in an April 2024 CMS final rule until October 1, 2034.

Effective Date: Upon enactment.

Budgetary and Coverage Impact

CBO estimates this provision will reduce federal Medicaid spending by $56 billion over 10 years and will increase the number of people who are uninsured by 400,000 in 2034.

KFF Resources

• Medicaid Changes in House and Senate Reconciliation Bills Would Increase Costs for 1.3 Million Low-Income Medicare Beneficiaries
• 5 Things to Know: A Look at the Proposed Medicaid Eligibility & Enrollment Rule
• What Does the Medicaid Eligibility Rule Mean for Low-Income Medicare Beneficiaries and the Medicare Savings Programs (MSPs)?
• Potential Effects of the Proposed Medicaid Eligibility Rule for Newly Enrolled Medicare-Medicaid Enrollees

Section 71101: Medicare Savings Program Final Rule

Background

In September 2023, CMS issued a final rule to reduce barriers to enrollment in Medicare Savings Programs (MSPs), which provide Medicaid coverage of Medicare premiums and cost sharing for low-income Medicare beneficiaries. Implementation deadlines for states vary across provisions in the rule, but many provisions are already in effect, and for others, states are already in compliance.

Description

• Prohibits the Secretary from implementing, administering, or enforcing certain provisions in a September 2023 final rule that have not yet taken effect until October 1, 2034.

Effective Date: Upon enactment.

Budgetary and Coverage Impact

CBO estimates this provision will reduce federal Medicaid spending by $66 billion over 10 years. This provision is not expected to impact the number of people who are uninsured.

KFF Resources

• Medicaid Changes in House and Senate Reconciliation Bills Would Increase Costs for 1.3 Million Low-Income Medicare Beneficiaries
• 5 Things to Know: A Look at the Proposed Medicaid Eligibility & Enrollment Rule
• What Does the Medicaid Eligibility Rule Mean for Low-Income Medicare Beneficiaries and the Medicare Savings Programs (MSPs)?
• Potential Effects of the Proposed Medicaid Eligibility Rule for Newly Enrolled Medicare-Medicaid Enrollees

Section 71109: Restricting Immigrant Eligibility for Medicaid and CHIP

Background

In addition to meeting other eligibility requirements, lawfully present immigrants must have a “qualified” immigration status to be eligible for Medicaid or CHIP. Qualified immigrants include: lawful permanent residents (LPRs); refugees; individuals granted parole for at least one year; individuals granted asylum or related relief; certain abused spouses and children; certain victims of trafficking; Cuban and Haitian entrants; and citizens of the Freely Associated States (COFA migrants) residing in states and territories. Many lawfully present immigrants must wait five years after obtaining qualified status before they may enroll in Medicaid; states may waive the five-year wait for children and pregnant individuals (referred to as the ICHIA option). Some states have state-only funded coverage programs for undocumented immigrants.

Description

• Restricts the definition of qualified immigrants for purposes of Medicaid or CHIP eligibility to Lawful Permanent Residents (“green card” holders), certain Cuban and Haitian immigrants, citizens of the Freely Associated States (COFA migrants) lawfully residing in the US, and lawfully residing children and pregnant adults in states that cover them under the ICHIA option.
• Provides $15 million in implementation funding for FY 2026.

Effective Date: October 1, 2026.

Budgetary and Coverage Impact

CBO estimates this provision will reduce federal Medicaid spending by $6 billion over 10 years and will increase the number of people who are uninsured by 100,000 in 2034.

KFF Resources

• 5 Key Facts About Immigrants and Medicaid

Section 71112: Retroactive Coverage

Background

Under current law, states are required to provide Medicaid coverage for qualified medical expenses incurred up to 90 days prior to the date of application for coverage.

Description

• Limits retroactive coverage to one month prior to application for coverage for individuals enrolled through the Medicaid expansion and two months prior to application for coverage for traditional enrollees.
• Provides $15 million in implementation funding for FY 2026.

Effective Date: January 1, 2027.

Budgetary and Coverage Impact

CBO estimates this provision will reduce federal Medicaid spending by $4 billion over 10 years and will increase the number of people who are uninsured by 100,000 in 2034.

Section 71120: New Cost Sharing Requirements for Certain Expansion Individuals

Background

States have the option to charge premiums and cost-sharing for Medicaid enrollees within limits, and certain populations and services (emergency, family planning, pregnancy and preventive) are exempt from cost-sharing. Cost-sharing is generally limited to nominal amounts but may be higher for those with income above 100% of the federal poverty level (FPL). Out-of-pocket costs cannot exceed 5% of family income. States may allow providers to deny services to enrollees for nonpayment of copayments.

Description

• Requires states to impose cost sharing of up to $35 per service on expansion adults with incomes 100-138% FPL; maintains existing exemptions of certain services from cost sharing and exempts primary care, mental health, and substance use disorder services and services provided by federally qualified health centers, behavioral health clinics, and rural health clinics from cost sharing; limits cost sharing for prescription drugs to nominal amounts.
• Maintains the 5% of family income cap on out-of-pocket costs.
• Permits states to allow providers to deny services for failure to pay cost sharing but does not prevent providers from reducing or waiving cost sharing.
• Eliminates enrollment fees or premiums for expansion adults.

Effective Date: October 1, 2028.

Budgetary and Coverage Impact

CBO estimates this provision will reduce federal Medicaid spending by $7 billion over 10 years. This provision is not expected to impact coverage.

KFF Resources

• Cost Sharing Requirements Could Have Implications for Medicaid Expansion Enrollees With Higher Health Care Needs
• Understanding the Impact of Medicaid Premiums & Cost-Sharing: Updated Evidence from the Literature and Section 1115 Waivers

Financing

Section 71115: Provider Taxes

Background

States are permitted to finance the non-federal share of Medicaid spending through multiple sources, including state general funds, health care related taxes (or “provider taxes”), and local government funds. Federal rules specify provider taxes must be broad-based and uniform (i.e., states can’t limit provider taxes to only Medicaid providers) and may not hold providers “harmless” (i.e., guarantee providers receive their money back). The hold harmless requirement does not apply when tax revenues comprise 6% or less of providers’ net patient revenues from treating patients (referred to as the “safe harbor” limit).

Description

• Prohibits all states from establishing any new provider taxes or from increasing the rates of existing taxes.
• Reduces the safe harbor limit for states that have adopted the ACA expansion by 0.5% annually starting in fiscal year 2028 until the safe harbor limit reaches 3.5% in FY 2032.
• Applies the new safe harbor limit in expansion states to state and local government taxes on all providers except nursing facilities and intermediate care facilities.
• Provides $20 million in implementation funding for FY 2026.

Effective Date: Upon enactment for prohibition of new or increased taxes; October 1, 2027 for reduction in safe harbor limit.

Budgetary and Coverage Impact

CBO estimates this provision will reduce federal Medicaid spending by $191 billion over 10 years and will increase the number of people who are uninsured by 1.1 million in 2034.

KFF Resources

• Which States Might have to Reduce Provider Taxes Under the Senate Reconciliation Bill?
• 5 Key Facts About Medicaid and Provider Taxes
• Medicaid Budget Survey 2024-2025 – Provider Rates and Taxes

Section 71117: Requirements for Provider Tax Uniformity Waivers

Background

States are permitted to finance the non-federal share of Medicaid spending through multiple sources, including state general funds, health care related taxes (or “provider taxes”), and local government funds. Federal rules specify provider taxes must be broad-based and uniform (i.e., states can’t limit provider taxes to only Medicaid providers) and may not hold providers “harmless” (i.e., guarantee providers receive their money back).

Description

• Revises the conditions under which states may receive a waiver of the requirement that taxes be broad-based and uniform so that some currently permissible taxes, such as those on managed care plans, will no longer be permissible in future years.
• Provision overlaps with a proposed rule released May 12, 2025.

Effective Date: Upon enactment; HHS Secretary may provide a transition period of up to three years.

Budgetary and Coverage Impact

CBO estimates this provision will reduce federal Medicaid spending by $35 billion over 10 years and will increase the number of people who are uninsured by 100,000 in 2034.

KFF Resources

• Which States Might have to Reduce Provider Taxes Under the Senate Reconciliation Bill?
• 5 Key Facts About Medicaid and Provider Taxes
• Medicaid Budget Survey 2024-2025 – Provider Rates and Taxes

Section 71116: State Directed Payments

Background

States are generally not permitted to direct how managed care organizations (MCOs) pay their providers. However, subject to CMS approval, states may use “state directed payments” (SDPs) to require MCOs to pay providers certain rates, make uniform rate increases (that are like fee-for-service supplemental payments), or to use certain payment methods.

A 2024 rule on access to care in Medicaid managed care codified that the upper limit for SDPs is the average commercial rate for hospitals and nursing facilities, which is generally higher than the Medicare payment ceiling used for other Medicaid fee-for-service supplemental payments.

Description

• Directs HHS to revise Medicaid regulations for state directed payment to cap the total payment rate for inpatient hospital and nursing facility services at 100% of the total published Medicare payment rate for expansion states and at 110% of the total published Medicare payment rate for non-expansion states.
• Prevents payments approved after May 1, 2025 in excess of the new limits from taking effect unless they are for rural hospitals.
• Reduces existing payments that are above the allowable Medicare-related payment limit by 10 percentage points each year until they reach the new lower limit.
• Specifies that in the absence of published Medicare payment rates, the limit is set at the Medicaid fee-for-service payment rate.

Effective Date: Upon enactment for lower limit on new state directed payments; January 1, 2028 for reduction in existing state directed payments above new allowable Medicare-related limit.

Budgetary and Coverage Impact

CBO estimates this provision will reduce federal Medicaid spending by $149 billion over 10 years. This provision is not expected to impact coverage.

KFF Resources

• Reconciliation Language Could Lead To Cuts in Medicaid State-Directed Payments to Hospitals and Nursing Facilities
• 10 Things to Know About Medicaid Managed Care
• 5 Key Facts about Medicaid and Hospitals
• Medicaid Budget Survey FY 2024-2025, Provider Rates and Taxes

Section 71118: Section 1115 Demonstration Waiver Budget Neutrality

Background

Under long-standing policy and practice, Section 1115 demonstration waivers must be “budget neutral” to the federal government over the course of the waiver. Federal costs under an 1115 waiver may not exceed what they would have been for that state without the waiver. Typically, budget neutrality calculations are determined on a per enrollee basis—so, per enrollee spending over the course of the waiver (usually 5 years) cannot exceed the projected per enrollee spending calculated in the “without-waiver baseline.”

Budget neutrality calculations and the use of “savings” when expenditures decrease on account of the waiver are negotiated between states and CMS and the Office of Management and Budget.

Description

• Specifies the Chief Actuary for CMS must certify 1115 waivers are not expected to result in an increase in federal expenditures compared to federal expenditures without the waiver.
• Provides $5 million in implementation funding for each of FY 2026 and FY 2027.

Effective Date: January 1, 2027.

Budgetary and Coverage Impact

CBO estimates this provision will reduce federal Medicaid spending by $3 billion over 10 years. This provision is not expected to impact coverage.

KFF Resources

• Medicaid Section 1115 Waivers: The Basics

Section 71106: Payment Reduction for Certain Erroneous Medicaid Payments

Background

Federal law directs CMS to recoup federal funds for erroneous payments made for ineligible individuals and overpayments for eligible individuals if the state’s eligibility “error rate” exceeds 3%. CMS may waive the recoupment if the Medicaid agency has taken steps to demonstrate a “good faith” effort to get below the 3% allowable threshold.

Description

• Requires HHS to reduce federal financial participation to states for identified improper payment errors related to payments made for ineligible individuals and overpayments made for eligible individuals.
• Expands the definition of improper payments to include payments where insufficient information is available to confirm eligibility.

Effective Date: October 1, 2029.

Budgetary and Coverage Impact

CBO estimates this provision will reduce federal Medicaid spending by $8 billion over 10 years and will increase the number of people who are uninsured by 100,000 in 2034.

KFF Resources

• 5 Key Facts About Medicaid Program Integrity – Fraud, Waste, Abuse and Improper Payments

Medicaid Expansion

Section 71114: Eliminating Temporary Financial Incentive for Medicaid Expansion

Background

The Affordable Care Act expands Medicaid eligibility to non-elderly adults with incomes up to 138% FPL based on modified adjusted gross income and provides 90% federal financing for the expansion population. The Supreme Court effectively made expansion an option for states. The American Rescue Plan Act (ARPA) added a temporary financial incentive for states that newly adopt expansion. Currently, 41 states, including DC, have implemented the Medicaid expansion.

Description

• Eliminates the temporary incentive for states that newly adopt the Medicaid expansion.

Effective Date: January 1, 2026.

Budgetary and Coverage Impact

CBO estimates this provision will reduce federal Medicaid spending by $14 billion over 10 years and will increase the number of people who are uninsured by 100,000 in 2034.

KFF Resources

• 5 Key Facts About Medicaid Expansion
• New Incentive for States to Adopt the ACA Medicaid Expansion: Implications for State Spending
• Eliminating the Medicaid Expansion Federal Match Rate: State-by-State Estimates
• Medicaid Expansion Tracker

Section 71110: Federal Medical Assistance Percentage (FMAP) for Emergency Medicaid

Background

Emergency Medicaid reimburses hospitals for the costs of emergency care provided to immigrants who would qualify for Medicaid except for their immigration status, which hospitals are required to provide under federal law. States receive federal matching payments based on the federal medical assistance percentage (FMAP), which is computed using a formula that takes into account states’ per capita income, for traditional populations; they receive a 90% federal match rate for individuals enrolled in the Medicaid expansion.

Description

• Limits federal matching payments for Emergency Medicaid for individuals who would otherwise be eligible for expansion coverage except for their immigration status to the state’s regular FMAP.
• Provides $1 million in implementation funding for FY 2026.

Effective Date: October 1, 2026.

Budgetary and Coverage Impact

CBO estimates this provision will reduce federal Medicaid spending by $28 billion over 10 years. This provision is not expected to impact coverage.

KFF Resources

• Key Facts on Health Coverage of Immigrants

Long-term Care

Section 71111: Nursing Home Staffing Final Rule

Background

A 2024 Biden-administration final rule requires long-term care facilities (LTC) to meet minimum staffing levels (including a 24/7 RN on-site and a minimum of 3.48 total nurse staffing hours per resident day), requires state Medicaid agencies to report the share of Medicaid payments for institutional LTC that are spent on worker compensation, and provides funding for people to enter careers in nursing homes.

Description

• Prohibits the Secretary of Health and Human Services from implementing, administering, or enforcing the minimum staffing levels required by the final rule until October 1, 2034.

Effective Date: Upon enactment.

Budgetary and Coverage Impact

CBO estimates this provision will reduce federal Medicaid spending by $23 billion over 10 years. This provision is not expected to impact coverage.

KFF Resources

• Texas Judge Overturns Controversial Nursing Facility Staffing Rule
• A Closer Look at the Final Nursing Facility Rule and Which Facilities Might Meet New Staffing Requirements
• 10 Things About Long-Term Services and Supports (LTSS)

Section 71108: Home Equity Limits

Background

Most Medicaid enrollees who qualify for Medicaid because they need long-term care (LTC) are subject to limits on their home equity. In 2025, federal rules specified that states’ limits on home equity must be between $730,000 and $1,097,000, and those amounts are updated each year for inflation.

Description

• Reduces the maximum home equity limits to $1,000,000 regardless of inflation.
• Allows states to apply different requirements for homes that are located on farms.

Effective Date: January 1, 2028.

Budgetary and Coverage Impact

CBO estimates this provision will reduce federal Medicaid spending by $195 million over 10 years. This provision is not expected to impact the number of people who are uninsured.

KFF Resources

• Medicaid Eligibility Levels for Older Adults and People with Disabilities (Non-MAGI) in 2025

Section 71121: New Home and Community Based Services (HCBS)

Background

States are required to cover nursing facility care under Medicaid, but nearly all home care (HCBS) is optional. Nearly all states provide home care through “1915(c) waivers,” which limit services to people who require an institutional level of care. Because those services are optional, states may limit the amount of care people receive and the number of people receiving services. Most states have waiting lists because the number of people seeking services exceeds the amount of care available.

Description

• Allows states to establish 1915(c) HCBS waivers for people who do not need an institutional level of care.
• Requires state waiver submissions to demonstrate that new waivers will not increase the average amount of time that people who need an institutional level of care will wait for services.
• Includes $50 million in FY 2026 and $100 million in FY 2027 for implementation.

Effective Date: July 1, 2028 for new waiver approvals.

Budgetary and Coverage Impact

CBO estimates this provision will increase federal Medicaid spending by $7 billion over 10 years. This provision is not expected to impact the number of people who are uninsured.

KFF Resources

• What is Medicaid Home Care (HCBS)?
• A Look at Waiting Lists for Medicaid Home- and Community-Based Services from 2016 to 2024

Access

Section 71401: Rural Health Transformation Program

Description

• Establishes a rural health transformation program that will provide $50 billion in grants to states between fiscal years 2026 and 2030, to be used for payments to rural health care providers and for other purposes.
• Distributes 50% of payments equally across states with approved applications; the remaining funds will be distributed by CMS based at least in part on states’ rural populations that live in metropolitan statistical areas, the percent of rural health facilities nationwide that are located in a state, and the situation of hospitals that serve a disproportionate number of low-income patients with special needs.
• Uses of funds include promoting care interventions, paying for health care services, expanding the rural health workforce, and providing technical or operational assistance aimed at system transformation.
• Provides CMS with $200 million in implementation funding for FY 2025.

Effective Date: Upon enactment but funding is first available in fiscal year 2026. CMS to determine state application deadline, which will be no later than December 31, 2025.

Budgetary and Coverage Impact

CBO estimates this provision will increase federal spending by $47 billion over 10 years. This provision is not expected to impact coverage.

KFF Resources

• A Closer Look at the $50 Billion Rural Health Fund in the New Reconciliation Law
• How Might Federal Medicaid Cuts in the Senate-Passed Reconciliation Bill Affect Rural Areas?
• 5 Key Facts About Medicaid Coverage for People Living in Rural Areas
• 10 Things to Know About Rural Hospitals

Section 71113: Prohibiting Federal Medicaid Payments to Certain Providers

Background

States must generally allow beneficiaries to obtain Medicaid services from any provider that is qualified and willing to furnish services. Managed care organizations (MCOs) may restrict enrollees to providers in the MCO’s network, except that such plans cannot restrict free choice of family planning providers.

Description

• Prohibits federal Medicaid funds to be paid to providers that meet the following criteria on October 1, 2025: are nonprofit organizations, essential community providers primarily engaged in family planning services or reproductive services, provide for abortions outside of the Hyde exceptions and received $800,000 or more in payments from Medicaid in 2023; this would affect Planned Parenthood and other Medicaid essential community providers.
• Provides $1 million in implementation funding for FY 2026.

Effective Date: Upon enactment for 1 year; implementation is currently blocked for some providers due to ongoing litigation.

Budgetary and Coverage Impact

CBO estimates this provision will increase federal spending by $53 million over 10 years. This provision is not expected to impact coverage.

KFF Resources

• Planned Parenthood Remains in Limbo as Court Reviews Their Request to Block Federal Medicaid Funding Ban
• What’s at Stake in the Supreme Court Case Medina v. Planned Parenthood South Atlantic?
• The Impact of Medicaid and Title X on Planned Parenthood
• Recent Policy Proposals Could Weaken the Reproductive Health Safety Net as More People Become Uninusred

Section 71105: Medicaid Provider Screening Requirements

Background

Provider screening and enrollment is required for all providers in Medicaid fee-for-service or managed care networks. Additionally, the ACA requires states to terminate provider participation in Medicaid if the provider was terminated under Medicare or another state program. CMS has multiple tools to assist states with provider screening and enrollment compliance, including leveraging Medicare data.

Description

• Requires states to conduct checks at provider enrollment or reenrollment and on a quarterly basis of the Social Security Administration’s Death Master File to determine whether providers enrolled in Medicaid are deceased.

Effective Date: January 1, 2028.

Budgetary and Coverage Impact

CBO estimates this provision will not affect federal Medicaid spending over 10 years. This provision is not expected to impact coverage.

KFF Resources

• 5 Key Facts About Medicaid Program Integrity – Fraud, Waste, Abuse and Improper Payments

Sec. 71303: Pre-Enrollment Verification of Eligibility for Premium Tax Credit

Background

Currently, new enrollees are granted conditional eligibility if there is a mismatch in the information they provided and that in federal databases. Enrollees can retain coverage and tax credits for up to 90 days while submitting verification documents. Returning enrollees who take no action during open enrollment are auto-renewed into the same or similar plan. Nearly half of Marketplace enrollees in 2025 auto-renewed.

Description

• Requires verification of household income, health coverage status or eligibility for coverage, place of residence, family size, status as an eligible alien, and any other information that the Secretary of Health and Human Services deems necessary are verified before coverage.
• Exchanges can use any third-party sources and any available data for verification.
• Consumers can still enroll in a plan but cannot receive premium tax credits or cost-sharing reductions (CSRs) until after they verify their eligibility.
• This provision effectively ends auto-renewals.
• Restricts premium tax credit eligibility for enrollees who fail to file and reconcile their premium tax credits for one year.
• Restricts premium tax credit eligibility for enrollees who fail to file and reconcile their premium tax credits for one year.

Effective date: Taxable years beginning after December 31, 2027.

Budgetary and Coverage Impact

Decreases budgetary spending by $36.9 billion and increases revenue by $4.4 billion through 2034 and will increase the number of people who are uninsured by 700,000 in 2034.

KFF Resources

• FAQs: Health Insurance Marketplace and the ACA
• State Health Facts: Affordable Care Act
• Signing Up for Marketplace Coverage Remains a Challenge for Many Consumers

Sec. 71305: Recapture of Excess Premium Tax Credits

Background

Currently, if an enrollee receives excess premium tax credits because their estimated income was lower than their actual income, they must repay the excess. However, for most enrollees, there is a repayment cap that varies based on household income. For enrollees with household incomes at least 400% of the federal poverty level (FPL), there is no limit. They must repay the entirety of their excess tax credit. Other repayment limits vary from $375 for a single person with an income that is 100% FPL up to 200% FPL to $3,250 for families with an income between 300%-400% FPL for tax year 2025.

Description

• Requires that all premium tax credit recipients repay the full amount of any excess, no matter their income.

Effective date: taxable years beginning after December 31, 2025.

Budgetary and Coverage Impact

Decreases budgetary spending by $17.3 billion and increases revenue by $2.3 billion through 2034 and will increase the number of people who are uninsured by 100,000 in 2034.

KFF Resources

• Explaining Health Care Reform: Questions About Health Insurance Subsidies

Sec. 71301: ACA Marketplace Coverage Eligibility for Lawfully Present Immigrants

Background

Currently, U.S. citizens and lawfully present immigrants are eligible to enroll in ACA Marketplace coverage and receive premium subsidies and cost-sharing reductions.

Description

• Limit eligibility for subsidized ACA Marketplace coverage to lawfully present immigrants who are lawful permanent residents (LPRs or “green card” holders), Compact of Free Association (COFA) migrants residing in the U.S., or Cuban and Haitian entrants as defined in section 501(e) of the Refugee Education Assistance Act of 1980, eliminating eligibility for many lawfully present immigrants including refugees, asylees, and people with Temporary Protected Status.

Effective date: Taxable years beginning after December 31, 2026.

Budgetary and Coverage Impact

Decreases budgetary spending by $69.8 billion and increases revenue by $4.8 billion through 2034 and will increase the number of people who are uninsured by 900,000 in 2034.

KFF Resources

• FAQs: Health Insurance Marketplace and the ACA
• Potential Impacts of 2025 Budget Reconciliation on Health Coverage for Immigrant Families

Sec. 71302: Premium Tax Credit Eligibility for Lawfully Present Immigrants Ineligible for Medicaid

Background

Currently, lawfully present immigrants with incomes under 100% of the federal poverty level (FPL) who do not qualify for Medicaid coverage due to their immigration status also are eligible for ACA Marketplace coverage.

Description

• Prohibits lawfully present immigrants ineligible for Medicaid due to immigrant status from receiving tax credits if making below 100% of poverty.

Effective Date: taxable years beginning after December 31, 2025.

Budgetary and Coverage Impact

Decreases budgetary spending by $49.5 billion and increases revenue by $176 million through 2034 and will increase the number of people who are uninsured by 300,000 in 2034.

KFF Resources

• FAQs: Health Insurance Marketplace and the ACA
• Potential Impacts of 2025 Budget Reconciliation on Health Coverage for Immigrant Families

Sec. 71304: Special Enrollment Periods (SEPs) and Tax Credit Eligibility

Background

In addition to qualifying life events (QLEs) that enable eligibility for an SEP, people in states that use Federally-Facilitated Marketplaces (FFM) and make no more than 150% of the federal poverty level can apply for a year-round SEP to sign up for coverage. Some state-based exchanges also offer SEPs that are based on the relationship of people’s income to the poverty line. Any person who enrolls in a plan via an SEP is eligible for both premium tax credits and cost-sharing reductions (CSRs). In 2025, enrollees with an income of less than 150% of the federal poverty line made up the largest share of all Marketplace enrollees (47%).

Description

• Bars any consumer who enrolls in a plan via a non-qualifying life event (QLE) SEP from receiving either premium tax credits or CSRs.

Effective date: Plan years beginning after December 31, 2025.

Budgetary and Coverage Impact

Decreases budgetary spending by $39.5 billion and increases revenue by $1.3 billion through 2034 and will increase the number of people who are uninsured by 400,000 in 2034.

KFF Resources

• FAQs: Health Insurance Marketplace and the ACA
• State Health Facts: Affordable Care Act
• Explaining Health Care Reform: Questions About Health Insurance Subsidies

Expiration of Enhanced Premium Tax Credits

Background

The enhanced premium tax credits were first made available as part of the American Rescue Plan Act in 2021 and later extended through the end of 2025 as part of the Inflation Reduction Act. The ARPA and IRA’s enhanced health insurance tax credits both increase the amount of financial help available to those already eligible for assistance under the ACA and also newly expand subsidies to middle-income people (with incomes over four times the poverty level), many of whom were previously priced out of coverage. These enhanced tax credits, combined with increased funding for outreach and marketing have led to record-high enrollment in the ACA Marketplaces.

Description

• There was no extension of the enhanced tax credits in the law. The Republican-led Senate opted to use a “current law” baseline for Congressional Budget Office scoring of the budget impact. Therefore, the expiration of the enhanced tax credits was not scored as a new policy change and has no impact in the law’s official budget and coverage estimates.
• The number of uninsured people will rise by 4.2 million through 2034, and gross benchmark premiums will increase by 7.9% through 2034 without an extension. Permanent extension would increase the budget deficit by $335 billion through 2034.

Effective date: January 1, 2026 (unless extended by Congress).

KFF Resources

• How Much More Would People Pay in Premiums if the ACA’s Enhanced Subsidies Expired?
• Inflation Reduction Act Health Insurance Subsidies: What is Their Impact and What Would Happen if They Expire?
• Five Things to Know about the Renewal of Extra Affordable Care Act Subsidies in the Inflation Reduction Act
• Early indications of the impact of the enhanced premium tax credit expiration on 2026 Marketplace premiums
• KFF Health Tracking Poll: ACA Enhanced Subsidies

Eligibility Policies

Section 71201: Limiting Medicare Coverage of Certain Individuals

Background

Prior to passage of the law, residents of the United States, including citizens, permanent residents, and other immigrants that are lawfully present in the country, were eligible for premium-free Medicare Part A if they or their spouses have worked in a job for at least 40 quarters where they paid Medicare payroll taxes and are at least 65 years old. People under age 65 with a qualifying disability, end-stage renal disease (ESRD), and amyotrophic lateral sclerosis (ALS) are also generally eligible. Legal immigrants age 65 or older who do not have this work history could purchase Medicare Part A after residing legally in the U.S. for five years continuously.

Description

• Restricts Medicare eligibility to U.S. citizens, green card holders, Cuban-Haitian entrants, and people residing under the Compacts of Free Association, eliminating Medicare eligibility for people not included in these groups, such as those with temporary protected status and refugees and asylees.
• Terminates Medicare coverage no later than 18 months from enactment for anyone who is currently covered but no longer eligible under these changes.

Effective Date: Upon enactment.

Budgetary and Coverage Impact

CBO estimates this provision will reduce Medicare spending by $5.1 billion over 10 years and will increase the number of people who are uninsured by 100,000 in 2034.

KFF Resources

• Key Facts on Health Coverage of Immigrants
• Medicare Open Enrollment FAQ: Can immigrants enroll in Medicare?

Section 71101: Moratorium on Implementation of Rule Relating to Eligibility and Enrollment in Medicare Savings Programs

Background

In September 2023, CMS issued a final rule to reduce barriers to enrollment in Medicare Savings Programs (MSPs), which provides Medicaid coverage of Medicare premiums and cost sharing for low-income Medicare beneficiaries. Implementation deadlines for states vary across provisions in the rule, but some provisions are already in effect, and for others, states are already in compliance.

Description

• Prohibits the Secretary from implementing, administering, or enforcing certain provisions in a September 2023 CMS final rule that have not yet taken effect until October 1, 2034.

Effective Date: Upon enactment.

Budgetary and Coverage Impact

CBO estimates the moratorium on this rule will reduce federal Medicaid spending by $66 billion over 10 years due to lower enrollment in the Medicare Savings Programs than if all the provisions of the rule were implemented and enforced. CBO has not provided an updated estimate of how many fewer dual-eligible individuals will be enrolled in Medicaid.

KFF Resources

• Medicaid Changes in House and Senate Reconciliation Bills Would Increase Costs for 1.3 Million Low-Income Medicare Beneficiaries
• 5 Things to Know: A Look at the Proposed Medicaid Eligibility & Enrollment Rule
• What Does the Medicaid Eligibility Rule Mean for Low-Income Medicare Beneficiaries and the Medicare Savings Programs (MSPs)?
• Potential Effects of the Proposed Medicaid Eligibility Rule for Newly Enrolled Medicare-Medicaid Enrollees

Physician Payment

Section 71202: Temporary Payment Increase Under the Medicare Physician Fee Schedule

Background

Medicare payment rates to physicians and other clinicians under the Physician Fee Schedule are determined in part by a scaling factor, known as the conversion factor, which is updated each year. Under current law, conversion factor updates are based on statutory factors and other budgetary requirements. Beginning in 2026, the Physician Fee Schedule conversion factor was scheduled to increase by 0.25% each year for most Medicare providers.

Description

• Provides a temporary one-year increase of 2.5% to the Physician Fee Schedule conversion factor for all services furnished between January 1, 2026 and January 1, 2027.

Effective Date: January 1, 2026.

Budgetary and Coverage Impact

The CBO estimates that this change will increase Medicare spending by $1.9 billion in 2026 and 2027. This provision is not expected to impact coverage.

KFF Resources

• What to Know About How Medicare Pays Physicians

Prescription Drugs

Section 71203: Expanding and clarifying the exclusion for orphan drugs under the Drug Price Negotiation Program

Background

Under the Medicare Drug Price Negotiation Program, drugs qualify for price negotiation if they are single source brand-name drugs or biological products without therapeutically equivalent generic or biosimilar alternatives, and are at least 7 years (for small-molecule drugs) or 11 years (for biologics) past the FDA approval or licensure date, as of the date that the list of drugs selected for negotiation is published. Under the Inflation Reduction Act of 2022, the law that established the drug price negotiation program, drugs designated for only one rare disease or condition and approved for an indication (or indications) only for that disease or condition were exempt from negotiation. This is known as the orphan drug exclusion.

Description

• Modifies the orphan drug exclusion of the Medicare drug price negotiation program to exclude drugs from negotiation that are designated for one or more rare diseases or conditions and where the only approved indication or indications are for one or more rare diseases or conditions, rather than only one rare disease or condition.
• Excludes the period of time that drugs are on the market with only one or more orphan indications from the 7-year or 11-year waiting period that determines a drug’s eligibility for selection for price negotiation.

Effective Date: applies for drug price selection beginning in February 2026 for negotiated prices available on or after January 1, 2028.

Budgetary and Coverage Impact

The CBO estimates that this change will increase Medicare spending by $4.9 billion over 10 years. This provision is not expected to impact coverage.

KFF Resources

• FAQs about the Inflation Reduction Act’s Medicare Drug Price Negotiation Program

Long-term Care

Section 71111: Moratorium on Implementation of Nursing Home Staffing Final Rule

Background

A 2024 Biden administration final rule requires long-term care facilities (LTC) to meet minimum staffing levels (including a 24/7 RN on-site and a minimum of 3.48 total nurse staffing hours per resident day), requires state Medicaid agencies to report the share of Medicaid payments for institutional LTC that are spent on worker compensation, and provides funding for people to enter careers in nursing homes.

On April 7, 2025, the US District Court for Northern Texas ruled to overturn the minimum staffing requirements, and it is expected that the Administration will not appeal that decision.

Description

• Prohibits the Secretary of Health and Human Services from implementing, administering, or enforcing the minimum staffing levels required by the final rule until October 1, 2034.

Effective Date: Upon enactment.

Budgetary and Coverage Impact

The CBO estimates the moratorium of this rule will reduce federal spending by $23 billion over 10 years. This provision is not expected to impact coverage.

KFF Resources

• Texas Judge Overturns Controversial Nursing Facility Staffing Rule
• A Closer Look at the Final Nursing Facility Rule and Which Facilities Might Meet New Staffing Requirements
• 10 Things About Long-Term Services and Supports (LTSS)

Section 71306. Permanent Extension of Safe Harbor for Absence of Deductible for Telehealth Services

Background

Health savings accounts (HSAs) are tax-advantaged savings accounts that enrollees in certain high-deductible health plans (HDHPs) can use to pay for qualified medical expenses. Enrollees must pay all medical costs, except for certain preventive services and insulin products, out-of-pocket until they reach the deductible. Individuals cannot have other health coverage in order to be eligible for an HDHP with an HSA. In response to the COVID pandemic, federal law permitted HSA-eligible HDHPs to cover telehealth and other remote services before the deductible until the end of 2024.

Description

• Permanently allows HDHPs with an HSA to cover telehealth and other remote services before the enrollee meets the deductible.
• Individuals that have other coverage for telehealth and other remote care services will still be eligible for an HDHP with an HSA.

Effective date: Plan years beginning after December 31, 2024.

Budgetary and Coverage Impact

The CBO and JCT estimate a decrease in revenue of $4.3 billion through 2034. This provision is not expected to impact the number of people who are uninsured.

KFF Resources

• Expansions to Health Savings Accounts in House Budget Reconciliation: Unpacking the Provisions and Costs to Taxpayers 
• Health Savings Accounts and High Deductible Health Plans: Are They An Option for Low-Income Families?
• 2024 KFF Employer Health Benefits Survey

Section 71307. Allowance of Bronze and Catastrophic Plans in Connection with Health Savings Accounts

Background

ACA-compliant health insurance plans are categorized into “metal levels” based on the amount of cost sharing they require. Some bronze plans meet the deductible requirements to be paired with an HSA (the out-of-pocket maximum or other design features might not meet IRS rules though). Catastrophic plans, which have the highest cost sharing and are only available to people under age 30 or those who cannot find other affordable ACA-compliant coverage, are ineligible to be paired with an HSA.

Description

• Treats bronze and catastrophic plans sold on the ACA Marketplace as HDHPs that can be paired with an HSA.

Effective date: January 1, 2026.

Budgetary and Coverage Impact

The CBO and JCT estimate a decrease in revenue of over $3.5 billion through 2034. This provision is not expected to impact the number of people who are uninsured.

KFF Resources

• FAQs: Health Insurance Marketplace and the ACA

Section 71308. Treatment of Direct Primary Care Arrangements

Background

Direct primary care (DPC) arrangements typically offer unlimited primary care services to patients in exchange for a periodic fee paid to the DPC practice. Current law may treat DPC arrangements as a health plan under certain circumstances, making an individual covered by a DPC arrangement ineligible to use an HSA.

Description

• Certain DPC arrangements will not be considered health plans, allowing individuals covered by these arrangements to be eligible for an HSA. This will apply if the only compensation for the DPC is a fixed periodic fee that does not exceed $150 monthly, or $300 monthly where more than one individual is covered.
• For the purposes of this provision, DPC arrangements not considered health plans are limited to those only offering primary care services, and do not include:
• services that require general anesthesia;
• prescription drugs, except for vaccines, and;
• laboratory services not typically administered in an ambulatory primary care setting.
• Treats fees paid for any DPC arrangement as a medical expense (not the payment of insurance) that can be paid for with HSA funds.

Effective date: January 1, 2026.

Budgetary and Coverage Impact

The CBO and JCT estimate a decrease in revenue of over $2.8 billion through 2034. This provision is not expected to impact the number of people who are uninsured.

KFF Resources

• Expansions to Health Savings Accounts in House Budget Reconciliation: Unpacking the Provisions and Costs to Taxpayers 

The Survey of 1988 NFL players, conducted by KFF in partnership with ESPN, looks at the overall health and well-being of former professional football players who played in the 1988 NFL season. The results of this survey provide insight into the lives of these former players as they approach traditional retirement age. While many are grappling with the immense toll the sport has taken on their physical and neurological health, most say they would do it all over again.

Explore ESPN’s Reporting on This Survey

• Survey: Most NFL retirees would play again despite costs
• Survey details physical and mental health toll of NFL
• Survey: Black NFL vets report more disability, dementia
• Survey: NFL vets split on youth tackle football risks
• Voices from the ESPN/KFF Survey of 1988 NFL Players

The Survey of 1988 NFL players, conducted by KFF in partnership with ESPN, explores the overall health and well-being of former professional football players who played in the 1988 NFL season. The aim of the project is to examine the physical, emotional, and financial well-being of a cohort of professional football players as they approach typical U.S. retirement age. Overall, the survey finds that these former players face a variety of health issues, including chronic pain and mobility problems, cognitive impairment, and mental health challenges – often at higher rates than their peers in the general population.

The survey also finds that former Black players are consistently more likely than White players to face physical, neurological, and mental health issues alongside poorer financial outcomes. This survey’s results document how racial disparities in health, health care, and income that occur in the U.S. persist among these former NFL players despite the potential financial and career benefits of playing in the NFL. At the same time, former Black players face unique challenges, as some of the racial disparities in health outcomes found in this survey – such as disability and cognition issues — are not always similarly observed among men the same age in the general population. Such data may inform and direct efforts to address such disparities among former NFL players and advance equity.

Despite these struggles, players’ views on their careers are overwhelmingly positive, and the vast majority, including both Black players and White players, say they would make the choice to play professional football again, extolling the benefits of the game on their life and relationships and citing the importance of brotherhood and the bonds they formed while playing.

5 Key Takeaways From the KFF/ESPN Survey of 1988 NFL Players

1. Overall, majorities of these players say professional football has had a positive impact on their life, including their finances, career opportunities, and relationships with family and friends. At the same time, most say the game has negatively impacted their physical health and one-third say it has had a negative impact on their mental health. For more information, see: Career Reflections / Views on Youth Football

2. Compared to men in their age range in the population overall, former NFL players from the 1988 season are more likely to rate their physical health negatively and to report living with certain types of disability, chronic pain that interferes with their daily lives, cognitive challenges, and mental health issues. The gaps between players and men their age on these health outcomes hold when controlling for race. Incidence of these reported adverse health outcomes does not differ consistently between different position groupings (such as linemen v. skill positions, offensive v. defensive positions, and others), however, defensive players are more likely than offensive players to report some cognitive issues, such as worsening confusion and memory loss in the past year. For this survey, analysis by individual position types was not possible due to insufficient sample sizes. For more information, see: Health Issues

3. The survey also finds stark racial disparities between players across a wide array of health measures. Black players are consistently more likely than White players to report adverse health outcomes, including physical limitations, cognitive problems, mental health challenges, pain, and disability. In many of these instances, similar disparities are not present among men in a similar age range in the population overall. These racial disparities may reflect a range of demographic and other differences between Black and White players, including racial differences by positions played (See Appendix Fig. 4), income, and access to health care and insurance. Nonetheless, some of these racial differences in reported physical disabilities and cognitive problems remain even when controlling for other factors such as higher risk position groups, income, age, and years played, suggesting that other socioeconomic factors may impact health. For more information, see: Health Issues and Mental Health

4. Given the range of health issues reported by former players, health care access plays a key role in players’ overall well-being. While these former players have higher average incomes than men their age in the population at large, many report having gone without health insurance and necessary care since they stopped playing football, with about one in five saying they went without needed health care in the past year because of the cost. In addition, struggles affording medical bills, health insurance and other day-to-day expenses are particularly pronounced among Black players and those living with a disability. For many players, these financial difficulties may be tied to injuries they incurred during their professional football careers, as about three in ten say they were unable to work at some point since they stopped playing due to a football-related injury. For more information, see: Health Care and Finances

5. Despite the physical toll playing football has had on many of these players, the vast majority say they would choose to play in the NFL again if they could go back, citing a love of the game, camaraderie with teammates, and a strong sense of purpose. Most players who are parents say they encouraged their children to play football if they expressed an interest, and a majority oppose banning youth tackle football below the high school level – although they are more divided on the whether the benefits of youth football outweigh the overall risks. For more information, see: Career Reflections

Key Takeaways

• The vast majority of former players from the 1988 NFL season say playing professional football has had a positive impact on their life but a negative impact on their physical health. Overall, nine in ten former players say playing professional football has had a positive impact on their life in general (91%), with majorities reporting positive impacts on their social life (73%), financial situation (72%), employment situation (65%), and relationships with family (65%). At the same time, about three in four (77%) players say the game has had a negative impact on their physical health, and one-third say it had a negative impact on their mental health.
• Despite these negative health impacts, the overwhelming majority (90%) of 1988 players say they would choose to play professional football again if they could go back, while just 4% say they would not play again. These shares are consistent across Black and White players despite disparities in reported health and financial outcomes and among players who report negative impacts on their physical or mental health. In open-ended responses, players cite a love of the game, the importance of brotherhood, the instillation of a strong sense of purpose, and valuable life skills as reasons why they would do it all over again.
• Nearly all former 1988 NFL players are parents, and two-thirds (73%) say at least one of their children played organized tackle football at some level. However, when it comes to children playing tackle football, players from the 1988 season are somewhat divided on the risks: about half (47%) of ’88 players say that when it comes to youth playing tackle football before high school, “the benefits outweigh the risks,” while about four in ten (37%) say the “risks outweigh the benefits.” Nonetheless, most players who are parents (57%) say they encouraged their children to play football if they expressed an interest, and seven in ten (71%) oppose banning youth tackle football below the high school level. This may be a reflection of how much the sport has changed since their time in the NFL; about eight in ten (78%) former players say that professional football is safer now compared to when they were playing.

Views on the Overall Impact of an NFL Career

An overwhelming majority of 1988 players (91%) say that playing professional football has had a positive impact on their life in general. This positive impact is echoed in other facets of their lives, with a majority saying professional football had a positive impact on their social life and relationship with friends (73%), their financial situation (72%), relationships with family (65%), and their employment situation or career opportunities (65%) since they stopped playing football. Just about one in ten say their football career has had a negative impact in each of these areas.

Players paint a far more negative picture when it comes to the game’s impact on their physical health. About three in four players (77%) say playing professional football had a negative impact on their physical health, while just 14% say it had a positive impact. Players are more divided on how their careers impacted their mental health. About four in ten (43%) say the game had a positive impact on their mental health, while one-third say it had a negative impact (33%). Among Black players, similar shares say playing football had a negative (41%) and a positive (39%) impact on their mental health (see Appendix for details on player race and ethnicity).

Most players report being generally satisfied with their lives, including majorities of Black and White players who say they are “very” or “somewhat satisfied” with their life as whole, their relationships with their spouses, children, and former teammates, the number of meaningful connections they have with other people, and their personal financial situation.

Large majorities of both Black and White players express satisfaction with these aspects of their lives, but fewer Black players than White players report being satisfied with their life as a whole (74% vs. 89%) or their financial situation (62% vs. 86%).

Despite reporting negative impacts on their mental and physical health, an overwhelming majority of players from the 1988 season (90%) say they would still make the decision to play professional football if they could go back—a share that is consistent across Black and White players despite disparities in reported health and financial outcomes. Even among players who say football negatively impacted their physical health, nine in ten (88%) say they would make the decision to play again. A somewhat smaller share, but still a large majority, of players who say the game had a negative impact on their mental health say they would play again (78%).

When it comes to supportive relationships, most players from the 1988 seasons say they think their teammates (79%) and their coaches (64%) cared “a lot” or “some” about their overall well-being during their professional football career. Far fewer (36%) say they think the owners of the teams they played for cared about their overall well-being. The shares who say their teammates, coaches, or team owners cared about their well-being is similar among Black players and White players.

Views on Safety, Youth Football, and Today’s NFL

When it comes to youth playing tackle football, players from the 1988 season are somewhat divided on whether the benefits outweigh the risks. Nonetheless, most players who are parents say they encouraged their children to play football if they expressed an interest, and a majority oppose banning youth tackle football below the high school level. This may be partially explained by the fact that the vast majority of 1988 players say they think professional football is safer now compared to when they played.

Nearly all players from the 1988 season are parents (96%) and a majority of players (67%) say they have coached a high school or youth football team. Among players who are parents, most say their children played football at some level (73%). This includes four in ten who say at least one of their children played at the college (33%) or professional level (8%).

Most former players say they encouraged their children to play football, with many citing the important life lessons instilled by playing, including the importance of teamwork, camaraderie, discipline and work ethic. Overall, about six in ten (57%) players from the 1988 season say they encouraged their children to play tackle football if they expressed an interest compared to just 7% who say they discouraged their children. One in five (19%) say it depends on the child, while 16% report that none of their children ever expressed an interest in playing.

Players are somewhat divided on the relative risks of children playing tackle football below the high school level, with about half (47%) saying the “benefits outweigh the risks” and about four in ten (37%) saying the “risks outweigh the benefits,” while 16% say they have no opinion. Perhaps reflecting the sport’s impact on their health, Black players and players living with a disability are each less likely than White players and those without a disability, respectively, to say the benefits of youth playing tackle football outweigh the risks. Past studies among former NFL players have linked playing youth tackle football with cognitive issues later in life.

In recent years, there has been much debate over banning youth tackle football across the U.S., with legislators in several states introducing bills to ban tackle football below the high school level. Attempts to ban tackle football for youth, including a recent bill in California, have been unsuccessful thus far. The majority (71%) of players from the 1988 season say they oppose banning youth tackle football under the high school level and a quarter (26%) saying they would support such a ban. While few players across demographics support banning youth tackle football, the shares who support a ban are slightly higher among Black players compared to White players (29% v. 22%) and players living with a disability compared to those who are not (29% v. 21%).

Since many of these players have retired from professional football, the game has changed markedly when it comes to safety, with changes to personal equipment and updated rules aimed at making the game safer. Most players (78%) from the 1988 season agree that professional football is safer now compared to when they were playing football, while 15% say it’s about the same and just 6% say it is more dangerous now.

Key Takeaways

• Across a range of measures, former NFL players from the 1988 season report being in worse health and experiencing more frequent pain and higher levels of disability compared to men their age in the general population, even when controlling for race. Former players are about three times as likely as other men their age to report living with a disability (60% v. 21%) and about twice as likely to report experiencing pain all or most days in the past three months (69% v. 33%). In open-ended responses players describe the isolating effects of pain and the toll it has taken on their daily life and mental health.
• Just over half (55%) of players say they have experienced confusion or memory loss in the past year that is happening more often or getting worse – more than three times the share of men their age who say the same (16%). A notable share of former players report having been diagnosed with a neurological disorder, including about three in ten (28%) who say a health provider has told them they have post-concussion syndrome (28%) and 15% who report being diagnosed with dementia, including Alzheimer’s disease. Nearly one in five (18%) say a doctor or other health care provider has told them they have chronic traumatic encephalopathy (CTE), although CTE cannot definitively be diagnosed until after death. Defensive players are more likely than those in offensive positions to report worsening confusion and memory loss in the past year (63% v. 50%) and being diagnosed with a neurological condition (52% v. 37%), including post-concussion syndrome (36% v. 23%). Incidence of these neurological health issues does not differ consistently by other position groupings, such as linemen v. skill positions. Analysis by individual positions is not possible due to insufficient sample sizes.
• Among former ’88 NFL players, there are consistent, stark racial disparities when it comes to physical and neurological health outcomes. Black players are more likely than White players to report living with some kind of disability (69% v. 48%), particularly those related to difficulty concentrating, remembering, or making decisions (60% v. 30%), and difficulty walking or climbing stairs (45% v. 27%). Notably, these wide racial disparities are not present among men in the same age range in the general population. Black players are twice as likely as White players to say they’ve been told by a doctor that they have CTE (25% v. 10%) or dementia (21% v. 9%), and significantly more likely to say they’ve been diagnosed with post-concussion syndrome (36% v. 19%). Though Black players are more likely than White players to have played in positions that previous research has linked to increased risk for cognitive problems, Black players’ higher incidence of disability and worsening confusion and memory problems remain significant compared to White players even when controlling for other factors, including higher risk position groups , income, age, and years played, suggesting other socioeconomic factors or experiences may be a contributing factor.
• While Black players are more likely to report disability and pain that limits their life activities, White players report having a higher number of football-related surgeries compared to Black players, with half of White players compared to a third of Black players saying they’ve had five or more. Higher incidence of surgeries among White players may reflect disparities in health care access and financial situation. Black players are more likely than White players to say they did not have health insurance coverage for a year or more after their NFL career.

Overall Health and Disability

About six in ten (62%) players from the 1988 season describe their physical health as either “excellent,” “very good,” or “good,” while about four in ten (38%) describe their physical health as “fair” or “poor.” Compared to men in their age cohort in the population overall, these former NFL players are more likely to describe their health negatively (38% v. 24%). These differences hold among Black players and White players when compared to their respective peers in the general population. (See Methodology for additional details on general population data.)

Players from the 1988 season are much more likely than men their age to report living with a disability, especially those related to cognition and mobility. Overall, six in ten players from the 1988 season report currently living with a disability — three times the share of men in their age range overall (21%). Players living with a disability include those who say they have difficulty concentrating, remembering, or making decisions (47%), serious difficulty walking or climbing stairs (36%), difficulty dressing or bathing (18%), are deaf or have serious difficulty hearing (14%), or are blind or have serious difficulty seeing even when wearing glasses (8%). Players are about eight times as likely as men their age to report serious difficulty concentrating, remembering or making decisions, and at least three times as likely to report serious difficulty walking or climbing stairs or difficulty dressing or bathing. The higher incidence of disability among 1988 players compared to men their age holds when controlling for race, with both Black players and White players more likely than their peers in the general population to report living with a disability. Players who played in defensive positions are somewhat more likely than offensive players to report difficulty concentrating, remembering, or making decisions (55% v. 42%). The share who reports living with a disability overall, however, does not significantly differ by defensive v. offensive positions or linemen v. skill positions. Incidence of reported disability by specific positions is not possible due to insufficient sample sizes.

Larger shares of Black players compared to White players report having some type of disability (69% v. 48%), with Black players twice as likely to report serious difficulties concentrating or remembering (60% v. 30%). Larger shares of Black players than White players also report serious difficulty walking or climbing stairs, difficulty dressing or bathing, or being blind or having serious difficulty seeing. These large racial disparities are not similarly observed among men in this age range in the general population.

Black players’ higher incidence of disability compared to White players remains significant when controlling for other factors, including higher risk position groups, income, age, and years played. The higher incidence of disabilities – and other adverse health outcomes – among Black players could be attributed to a number of factors, including racial differences in positions played (See Appendix Fig. 4), injury incidence, and access to health care and other services. Notably, Black players are more likely than White players to say they did not have health insurance coverage for a year or more after their NFL career.

Chronic Pain

Seven in ten (69%) players say they experienced pain either “every day” or “most days” in the past three months, twice the share of men their age in the general population (33%) – a difference that holds among both Black players and White players compared to their peers in the general population. This includes about a third (35%) of players who say they experienced pain that limited their life or work activities every or most days in the past three months, compared to about half that share among men their age overall (13%). While similar shares of Black players and White players report experiencing pain all or most days (71% and 67%, respectively), Black players are more likely than White players to report experiencing pain that limited their life or work activities all or most days in the past three months (41% v. 28%). Similar racial disparities are not present among men in a similar age range in the general population. The share who reports living with chronic pain does not notably differ by different position groupings, such as linemen v. skill positions or offensive v. defensive. Incidence of chronic pain by specific positions is unreportable due to insufficient sample sizes.

In open-ended responses, many players describe the enormous toll pain has had on their daily life, inhibiting their ability to spend time with family and friends, partake in hobbies, and work. Alongside these isolating effects of chronic pain, many describe negative impacts on their mental health and emotional well-being.

In addition to dealing with chronic pain in higher shares than men their age, players from the 1988 season are also more likely than men in their age cohort to say they’ve been diagnosed with arthritis and related disorders. Two-thirds (66%) of players say they have been told by a doctor or other health professional that they have arthritis, gout, lupus, or fibromyalgia compared to about four in ten (38%) men in a similar age range in the general population who report a diagnosis. This difference holds across racial groups, with both Black players and White players more likely than their peers to report a diagnosis. When it comes to other common chronic health conditions like hypertension, high cholesterol, and diabetes, somewhat similar shares of players and men their age overall report having been diagnosed.

One-third of players say they have been told by a doctor that they have obesity or are overweight, including similar shares of Black players and White players. Prior KFF polling found a similar share of men in this age range (38%) saying they were diagnosed as overweight or obese in the past five years.

Football-Related Surgeries

The overwhelming majority (87%) of NFL players from the 1988 season say they have had at least one orthopedic surgery related to playing football, including three in ten (39%) who have had five or more surgeries. While Black players are more likely than White players to report adverse physical health issues including disabilities and chronic pain that limits their life and work, a somewhat larger share of White players compared to Black players say they have had at least one football-related surgery (91% v. 84%), with White players being more likely to say they’ve had five or more surgeries (50% v. 33%). These racial disparities may reflect differences between Black and White players in post-football income and access to health care, which in turn may contribute to the long-term effects of increased pain and disability among Black players.

Neurological Health, Confusion and Memory Loss

Many players from the 1988 season report cognitive issues, including worsening confusion or memory loss and being diagnosed with neurological conditions including chronic traumatic encephalopathy (CTE)²  and dementia. There are stark racial disparities when it comes to neurological health among these players, with much larger shares of Black players reporting dementia and CTE diagnoses. Black players are also more likely than White players to report worsening confusion and memory issues, a disparity that is not similarly observed among men their age in the general population. Players, including both Black and White players, are much more likely to report worsening confusion and memory loss issues compared to their peers in the general population.

Notably, nearly all players from the 1988 season (95%) report experiencing a head injury while playing football, which could include anything from “seeing stars,” a mild concussion, or fully losing consciousness. Past research has linked head injuries sustained while playing contact sports like football to the development of neurological issues, including CTE – a link that has been acknowledged by the National Football League (NFL).

About four in ten (43%) players from the 1988 season say they have been told by a doctor or other health professional that they have some type of neurological disease or condition, with the largest shares reporting diagnoses for post-concussion syndrome (28%), CTE (18%), and dementia, including Alzheimer’s disease (15%). Fewer players report being diagnosed with other neurological issues, including having a stroke (5%), Parkinson’s disease (5%), chronic fatigue syndrome (4%), or a seizure disorder (2%). Defensive players are more likely than those in offensive positions to have been diagnosed with a neurological condition (52% v. 37%), including post-concussion syndrome (36% v. 23%).

Black players are about twice as likely as White players to report neurological diagnoses, including for post-concussion syndrome (36% v. 19%), CTE (25% v. 10%), and dementia (21% v. 9%). Previous studies have shown that Black adults are more likely to develop dementia compared to White adults but less likely to receive a diagnosis.

About half (55%) of players from the 1988 season say they have experienced confusion or memory loss in the past year that is happening more often or getting worse, including larger shares of Black players compared to White players (65% v. 43%) – a disparity that is not present among men their age overall. Players are much more likely than men their age overall (55% v. 16%) to report worsening confusion or memory loss in the past year, a difference that holds among both Black players and White players when compared to their peers in the general population.

Beyond experiencing worsening confusion and memory issues, many players report that these issues have adversely affected their ability to carry out daily tasks, from household chores to working and socializing. About one-third of players say they have experienced worsening confusion or memory loss in the past year that has either caused them to give up day-to-day household activities at least “sometimes” (34%) or interfered with their ability to work, volunteer, or engage in social activities outside their home at least “sometimes” (37%). Black players are twice as likely as White players to report these adverse effects of worsening confusion and memory loss. Players who played in defensive positions are more likely than those who played offensive positions to report worsening confusion and memory loss in the past year (63% v. 50%). Incidence of reported worsening confusion or memory loss by specific positions is not possible due to insufficient sample sizes.

Key Takeaways

• Many former NFL players from the 1988 season report struggling with mental health issues, and often in higher shares than men their age in the general U.S. population. About one-third (34%) of former players describe their mental health and emotional well-being as “fair” or “poor,” compared to just one in ten men their age overall. Additionally, players are more likely than men their age to report feeling lonely (40% v. 25%), depressed (45% v. 24%), or anxious (53% v. 34%) at least “sometimes” in the past year.
• Black players are particularly likely to report negative mental health outcomes and are much more likely than White players to report regular feelings of anxiety (62% v. 42%), depression (52% v. 36%), and loneliness (51% v. 25%). These racial differences among former NFL players are not similarly observed among the general population of men ages 55 to 75, and Black players are more likely than Black men their age to report feelings of loneliness, anxiety, and depression in the past year.
• One-quarter of former ’88 players say there was a time in the past three years when they needed mental health services or medication but didn’t get them, about three times the share among other men their age. The share of players who report skipping needed mental health services rises to over half (55%) among those who describe their mental health negatively, and Black players are twice as likely as White players to say they skipped needed mental health services in the past three years (31% v. 16%).
• While self-reported addiction issues are not particularly common among players from the ’88 season, those with chronic pain, disabilities, and those in fair or poor mental health are more likely to say they’ve ever been addicted to alcohol or prescription painkillers compared to their peers. For example, players with fair or poor mental health are more likely than those who describe their mental health as at least “good” to say they’ve been addicted to alcohol (24% v. 15%) or prescription pain killers (14% v. 5%). Similarly, players who experience pain at least “most days” are more likely than those who do not to report ever being addicted to alcohol (21% v. 12%) or prescription painkillers (10% v. 2%).

Self-Reported Mental Health and Wellbeing

About one-third (34%) of players from the 1988 NFL season describe their current mental health and emotional well-being as “fair” or “poor,” including a larger share of Black players (46%) compared to White players (21%) (see Appendix for more details on player race and ethnicity). Notably, Black players are nearly twice as likely as White players to say that playing professional football had a negative impact on their mental health (41% v. 23%). Players who report having a disability, worsening confusion and memory loss, and fair or poor physical health are all more likely than those who do not to negatively rate their current mental health status. Past research has found that Black players are more likely to report negative physical and mental health outcomes, even when controlling for position and years played. Other factors may contribute to such disparities, such as social determinants of health, income, and access to health care. Among players from the 1988 season, Black players are more likely than their White counterparts to report negative physical health status, disability, and cognitive problems – all of which may contribute to and exacerbate mental health challenges.

Former ‘88 players are about three times as likely as men their age overall, per prior KFF polling, to describe their mental health as fair or poor. While both Black players and White players are each more likely than their peers in the general population to describe their mental health negatively, the gap between Black players and Black men their age is much wider (46% v. 12%). In fact, self-reported mental health status does not differ notably by race among men ages 55-75 overall.

Poorer mental health outcomes among former players may be tied to physical health issues, including chronic pain and disabilities. Players who report having pain at least “most days” in the past three months are far more likely than those who experienced pain less frequently to describe their mental health negatively (43% v. 13%). Similarly, players who report living with a disability are far more likely than those who do not to describe their mental health negatively (52% v. 6%).

Players from the 1988 NFL season are more likely than men their age overall to report regular feelings of loneliness, anxiety and depression, with Black players much more likely than both White players and Black men their age to say they experienced these feelings. About half of former players from the ’88 season say they have felt anxious (53%) or depressed (45%) at least “sometimes” in the past 12 months, while four in ten say they’ve felt lonely at least “sometimes.” Larger shares of Black players compared to White players report experiencing these feelings at least “sometimes” in the past year, including anxiety (62% v. 42%), depression (52% v. 36%), and loneliness (51% v. 25%).

In each instance, players are more likely than men their age to report these feelings per past KFF polling, with large gaps between Black players and Black men their age overall. While White players are more likely than White men their age in general to report regular feelings of depression and anxiety by about a 10-point margin, they report feelings of loneliness in similar shares to White men their age.

As with their mental health overall, players who report living with disabilities or chronic pain are much more likely than those who do not to report regular feelings of loneliness, anxiety, and depression. For example, players who report living with a disability are at least twice as likely as players without a disability to say they at least sometimes felt anxious (71% v. 27%), depressed (60% v. 21%), or lonely (54% v. 19%) in the past year.

Having a strong, local support network of friends or family is associated with a lower incidence of feelings of anxiety, depression, and loneliness among players. Players who say they have at least “a fair amount” of friends or family living nearby whom they can ask for support are far less likely than those who say they have “just a few” or “none” to say they felt anxious (40% v. 70%), depressed (30% v. 61%), or lonely (25% v. 58%) at least sometimes in the past year. Prior KFF polling has found a strong relationship between local support networks and mental health.

Even among players living with a disability, strong support networks are linked with a lower incidence of regular feelings of loneliness, anxiety, and depression. Among players with a disability, those who have at least a fair amount of friends of family living nearby who they can ask for help or support are far less likely than those who do not to report feeling lonely (35% v. 71%), depressed (45% v. 73%), or anxious (56% v. 85%) at least sometimes in the past 12 months.

Notable shares of 1988 NFL players report sleep, appetite, and anger problems, with these issues far more common among players who also report cognitive issues. Most players (68%) say they have had trouble falling or staying asleep or sleeping too much at least “sometimes” in the past 30 days, while around four in ten say they have experienced poor appetite or overeating (44%) or difficulty controlling their temper (39%). The share reporting these issues, however, rises drastically among players with worsening cognitive issues. Players who say they have experienced worsening confusion or memory loss in the past year are much more likely than those who have not to report experiencing issues related to sleep (82% v. 51%), eating (60% v. 23%) or controlling their temper (57% v. 17%) at least sometimes in the past 30 days.

Access to Mental Health Care

With many 1988 players reporting mental health issues, notable shares say they have forgone needed mental health services in the past three years, including even larger shares of those who describe their mental health negatively. Overall, 16% of players say they have received mental health counseling or therapy in the past 12 months. However, a quarter of players say there was a time in the past three years when they thought they needed mental health services or medication but did not get them — three times the share of men their age overall who said the same (8%) in prior KFF polling. The share of former players who say they’ve gone without needed mental health services in the past three years is even higher among those who are likely most in need of such services; just over half (55%) of players who describe their mental health as “fair” or “poor” say they’ve gone without needed mental health care in the past three years.

Disparities in accessing mental health care also occur across race, with Black players about twice as likely as White players to report forgoing needed mental health care (31% v. 16%). This disparity is not similarly observed among the general population; among men ages 55 to 75, similar shares of Black and White men report forgoing needed mental health services in the past three years.

Substance Use and addiction

While self-reported addiction issues are not particularly common among players from the ’88 season, the shares are higher among those who report experiencing chronic pain, disability, or describe their mental health negatively. Overall, about one in five (18%) players say they have ever been addicted to alcohol and fewer say they have ever been addicted to prescription painkillers (8%) or any illegal drug such as heroin, fentanyl, methamphetamine, or cocaine (3%).

Players who say they experience pain at least “most days” are nearly twice as likely as those who do not to say they’ve been addicted to alcohol (21% v. 12%) and much more likely to say they’ve ever been addicted to prescription painkillers (10% v. 2%). Similarly, players who describe their mental health as “fair” or “poor” and players who are living with a disability are each more likely than their peers to say they’ve ever been addicted to alcohol or prescription painkillers. Few players (1%) – including similar shares across mental health status and experiences with pain or disability – say they have ever had a drug overdose that required hospitalization.

Among players who say they were ever addicted to alcohol, prescription painkillers, or any illegal drug, three-quarters (75%) say they have never gotten treatment for addiction or substance use disorder.

Key Takeaways

• With many former players from the 1988 NFL season reporting an array of health issues, access to health care and insurance likely plays a key role in players’ overall well-being. While most players (95%) say they are currently covered by some type of health insurance, four in ten (41%) report being uninsured at some point since they stopped playing professional football, including about a quarter (27%) who say they were uninsured for a year or more. Black players – who are much more likely than White players to report physical and cognitive health issues – are more likely than White players to say they have been uninsured at some point since leaving the NFL (48% v. 33%), including for a year or more (33% v. 20%).
• Some former ‘88 NFL players report facing cost barriers when accessing health care in the past year. About one in five (21%) say they skipped or postponed getting health care they needed because of the cost in the past 12 months, while 16% say they’ve had problems paying their medical bills and 14% have had problems affording health insurance. These problems are even more common among players living with a disability, including skipping needed health care because of the cost (28%), problems paying medical bills (24%), and problems affording health insurance (21%).
• While most 1988 NFL players say their football career had a positive impact on their finances and report higher average incomes than men their age in the general population, there are stark disparities in income and financial challenges by race and disability status. One-third of former players say it has been at least “somewhat difficult” to maintain steady employment or have a stable career since they stopped playing professionally, rising to 44% among Black players and 46% among players living with a disability. For some of these players, difficulties maintaining employment are tied to health issues they incurred from playing professional football. Three in ten (29%) former players say since they stopped playing professional football they have been unable to work at some point due to a football-related injury, including a larger share of Black players compared to White players (37% v. 19%) and defensive players compared to offensive players (36% v. 25%).

Health Insurance and Access to Care

While nearly all former players (95%) say they are currently covered by health insurance, about four in ten (41%) report not being covered by health insurance at some point since they stopped playing football, including about one in four (27%) who say they were uninsured for a year or more. The share who reports being uninsured at some point post-NFL rises to about half of players living with a disability (49%) and Black players (48%). Notably, past KFF analysis has found that nationally, Black adults have a higher uninsured rate than White adults.

About one in five (21%) players from the 1988 season – including similar shares of Black players and White players – report postponing or skipping health care they needed in the past 12 months because of the cost, compared to 12% of men in a similar age range who reported the same in past KFF polling. This difference may reflect an increased need for care among these players, who are more likely than other men their age to be living with disabilities and cognitive issues. Overall, one in eight players (12%) – including similar shares across race – say their health got worse because they skipped or postponed needed care because of the cost (compared to 4% of men their age nationally who reported worsening health after skipping needed care for any reason).

Players living with disabilities are more likely than non-disabled players to report skipping or postponing needed health care because of the cost in the past 12 months (28% v. 11%) and to say their health got worse as a result (17% v. 3%). Forgoing needed health care is also much more common among players with lower household incomes. One-third (35%) of players with annual incomes below $90,000 say they’ve skipped or delayed needed care because of the cost in the past year, with one in four (23%) of this group overall reporting worse health for this reason. Far fewer players with annual incomes of $200,000 or more report skipping or postponing care because of the cost (9%) or worse health as a result (6%). Notably, players living with a disability report average lower incomes than players without a disability.

Financial Situation

While most 1988 NFL players say their football career had a positive impact on their finances and report higher average incomes than men their age overall, there are stark disparities in income and financial challenges among players by race and disability status. Black players are more likely than White players to report lower incomes, difficulties maintaining employment, affording health care and housing, having debt, and declaring bankruptcy. These issues are also reported in higher shares among players living with a disability, who are themselves made up of larger shares of Black players.

Players from the 1988 season – including Black players and White players – have higher self-reported household incomes than men their age overall. However, similar to disparities seen in the U.S. population, Black players are much more likely than White players to have lower household incomes. Four in ten Black players report incomes of less than $90,000 compared to just 16% of White players. Conversely, White players are twice as likely as Black players to report annual incomes of $200,000 or greater (42% v. 19%).

Most 1988 players (66%) say it was either “very” or “somewhat easy” for them to maintain steady employment or have a stable career after they stopped playing professional football, while one-third say it was either ”very” or “somewhat difficult.” The share who reports these difficulties, however, is much higher among Black players, lower-income players, and those living with a disability. For example, Black players are more than twice as likely as White players to say it was difficult to maintain steady employment or have a stable career after they stopped playing (44% vs. 20%).

About three in ten players (29%) say that since they stopped playing football they were at some point unable to work due to a disability that was the result of a football-related injury, including a larger share of Black players (37%) compared to White players (19%) and a larger share of defensive players (36%) compared to offensive players (25%). Among players who report being unable to work due to a football-related disability since they retired from the NFL, most (73%) say they were unable to work for a year or more, and half (48%) were unable to work for five years or longer.

Despite high rates of insurance coverage, some 1988 players report problems affording health care-related expenses, while one in ten or fewer report problems affording other needs like food and housing.

Overall, about one in six players from the ’88 season say that, in the past 12 months, they have had problems paying their medical bills (16%), and a similar share report problems affording health insurance (14%). Despite their relatively high incomes, one in ten say they’ve fallen behind in paying their rent or mortgage in the past year (10%), and about one in twenty report problems paying for food (6%). These affordability issues are far more common among players living with a disability compared to those who are not, including problems paying their medical bills (24% v. 5%), affording their health insurance (21% v. 5%), falling behind on their rent or mortgage (14% v. 2%) or problems affording food (10% v. 1%) in the past 12 months.

Black players are at least twice as likely as White players to report these affordability issues, including problems paying medical bills (22% v. 10%), affording health insurance (18% v. 10%), falling behind on housing costs (14% v. 23%), and problems paying for food (8% v. 3%).

Reflecting income differences, Black players are more likely to report experiencing certain financial hardships than White players, including having outstanding debt, declaring bankruptcy, and losing a home due to eviction or foreclosure. Overall, a quarter (24%) of 1988 players say they have debt that is past due or that they are unable to pay, while just under one in five say that, since they have stopped playing football, they declared personal bankruptcy (17%) or lost a home due to eviction or foreclosure (16%).

Black players are more than twice as likely as White players to say they have outstanding debt (34% v. 13%), three times as likely to say they’ve declared bankruptcy (24% v. 8%), and six times as likely to say they lost a home due to eviction or foreclosure (25% v. 4%) since they stopped playing football.

Details on Race and Ethnicity of 1988 Player Sample

For this survey, Black players include all players who identify as Black, including those who may also identify as another race and/or Hispanic. White players are those who identify White as their only racial identity and are non-Hispanic. While players who identified with other racial groups are included in the total, there are insufficient sample sizes to report findings among players who identify as Hispanic (n=9), Asian (n=1), American Indian (n=9), Native Hawaiian (n=1), or Pacific Islander (n=3).

Comparison of 1988 Player Sample to Full 1988 Player Population

The project team took careful consideration to ensure the sample accurately reflected the population under study. One step in order to accomplish this was to track the sample demographics to the population demographics across key variables such as race and ethnicity, position, teams, and years in the league. While the majority of this information was publicly available for the population, race and ethnicity were coded by researchers at Davis Research and KFF. The following tables compare the survey sample to the full 1988 player population who were alive at the time of fieldwork.

Positions Played by Race

This KFF/ESPN Survey of 1988 NFL Players was designed and analyzed by public opinion researchers at KFF in collaboration with reporters at ESPN. The survey was designed to reach a representative sample of former NFL players who participated in at least one game during the 1988 season. 1,532 individuals were identified as meeting this criteria. The survey was conducted from October 17 through November 30, 2024 online and by telephone. All fieldwork was managed by Davis Research.

Sample and Contact MethodsAll players included in the population were researched and contact information was verified using multiple sources including Lexis-Nexis and Marketing Systems Group (MSG). Of the 1,532 former NFL players who participated in at least one game during the 1988 season, 128 were identified as deceased either prior to fielding or learned about during fielding.  For those cases, interviews with proxy respondents were attempted. Population members were originally contacted using USPS business letter explaining the project and providing both a website to complete the survey as well as an inbound telephone number for the individual to complete the survey with a live trained interviewer. Nonresponse follow-up included email contacts, a reminder letter, as well as telephone calls and text messages. Each player record contained up to six telephone numbers, and attempts were made to contact each record up to eight times. Calls and text messages were made at various times, including evenings and weekends, to maximize response rates.

The final sample includes interviews with 546 former players. An additional 18 interviews with family members of deceased players, and 1 interview with a family member of a living player who was identified as having cognition issues helped to contribute to the reporting.

Participants, including proxy respondents, were offered a $100 gift card or the option to donate the amount to Gridiron Greats, a charity supporting former NFL players.

Representation Considerations The project team took careful consideration to ensure the sample accurately reflected the population under study. One step in order to accomplish this was to track the sample demographics to the population demographics across key variables such as race and ethnicity, position, teams, and years in the league. While the majority of this information was publicly available for the population, race and ethnicity were coded by researchers at Davis Research and KFF. Intercoder reliability was achieved with 10% of the population, Cohen’s kappa (κ) of .898.

In order to increase the likelihood of interviewing Black players, Davis Research in collaboration with KFF maximized efforts to increase participation for that population, including additional telephone calls to targeted records, mailing approximately 500 USPS Priority Mail envelopes to non-responsive records flagged as likely Black/African American, and conducted additional research to refine contact information for records flagged as likely Black/African American.

Response rates were closely monitored throughout fielding to ensure both quality and balanced representation. The net effective response rate (AAPOR Response Rate 5) for living players was 40% and 16% respectively for family members of deceased players.

The final sample quality was assessed by researchers and no weighting adjustments were needed. The margin of sampling error for the full sample is plus or minus 3 percentage points. Numbers of respondents and margins of sampling error for key subgroups are shown in the table below. For results based on other subgroups, the margin of sampling error may be higher. Sampling error is only one of many potential sources of error and there may be other unmeasured error in this or any other public opinion poll.

KFF public opinion and survey research is a charter member of the Transparency Initiative of the American Association for Public Opinion Research.

National comparison data throughout the accompanying reports is based on KFF analysis of Centers for Disease Control and Prevention (CDC) 2023 Behavioral Risk Factor Surveillance System (BRFSS); National Center for Health Statistics 2023 National Health Interview Survey (NHIS); the U.S. Census Bureau’s 2023 American Community Survey (ACS); and KFF’s Racism, Discrimination, and Health Survey (June 6 – August 14, 2023.) Data from BRFSS is among men ages 55-74; all other data is among men ages 55-75. All estimates are based on self-reported survey results and may differ from other clinical estimates.

1. A series of logistic regression models were conducted to test whether the relationship between race and different health outcomes held after controlling for higher risk position groups, income, age, and years played. ↩︎
2. While CTE cannot definitively be diagnosed before death, these self-reports likely reflect instances where a health professional indicated to a player that they were showing signs or symptoms consistent with CTE. Other surveys of former professional football players have found that many players believe they have CTE. ↩︎