Introduction

On July 23, 2026, the Department of Health and Human Services (HHS) finalized revisions to regulations implementing Title VI of the Civil Rights Act of 1964 to eliminate disparate impact as a basis for determining whether discrimination has occurred in programs, services, or activities receiving HHS federal financial assistance. It was issued following Executive Order 14281, “Restoring Equality of Opportunity and Meritocracy,” and similar actions by other federal agencies, including the Department of Justice (DOJ), Department of Education (DOE), and Department of Housing and Urban Development (HUD). This issue brief provides background on Title VI, summarizes the key changes in the 2026 final rule, and discusses the potential implications for racial and ethnic health disparities.

The rule marks a significant change in the federal government’s approach to enforcing civil rights protections, which may have significant implications for its enforcement of civil rights law and health and health care disparities. The changes under the rule narrow the scope for administrative enforcement of civil rights law; may allow for policies and practices that lead to disparate outcomes in health and health care to remain in place, which may exacerbate disparities; and may reduce proactive review of whether policies and practices have unintended disproportionate effects on certain racial or ethnic or other protected groups.

Overview of the HHS Title VI Civil Rights Rule

Title VI of the Civil Rights Act of 1964 is a federal law that prohibits discrimination based on race, color, or national origin in programs and activities receiving federal financial assistance. It was enacted during the Civil Rights Movement in response to widespread racial discrimination by institutions receiving federal funds, including hospitals that refused to treat Black patients, maintained segregated wards and waiting rooms, or otherwise provided unequal care. Title VI has since served as a cornerstone of federal civil rights enforcement across health care, education, and other federally funded programs.

While the Supreme Court has interpreted Title VI to prohibit intentional discrimination, federal agencies historically implemented broader protections against discrimination through regulations. In its initial regulations implementing Title VI, HHS (then the Department of Health, Education and Welfare) and other federal agencies also prohibited disparate-impact discrimination. Disparate impact refers to policies or practices that have a disproportionately adverse effect on people of a particular race, color, or national origin, even when there is no evidence of intentional discrimination. These regulations recognized that facially neutral policies can perpetuate or exacerbate inequities in access to programs, services, and benefits.

In health care, disparate impact can arise from inequities embedded in institutional policies and practices, although intentional discrimination still persists. For example, historical discriminatory policies, such as redlining, have lasting effects today, leading to residential segregation of Black and Hispanic people into urban neighborhoods with more limited resources and increased health risks. Within medicine, disproven beliefs about biological differences by race persist today and have led to race permeating clinical decision making and treatment in multiple ways, including through its use in clinical algorithms, tools, and treatment guidelines. Similarly, language barriers can reduce the quality of care patients receive and increase the risk of adverse outcomes or medical errors. Studies have found that inadequate language assistance can delay patients’ access to timely care and contribute to suboptimal care and dissatisfaction with the care received, leading to poor chronic disease management and resulting in worse health outcomes. 

The federal government has used disparate-impact regulations for over 50 years to investigate and resolve policies and procedures of recipients of federal financial assistance that disproportionately negatively affect a protected group. For example:

• HHS’s Office for Civil Rights (OCR) investigated the proposed closure of University of Pittsburgh Medical Center (UPMC) Braddock, a hospital serving a predominantly Black community in Pennsylvania, to assess whether the closure would have a disparate impact on Black residents’ access to care. The investigation resulted in a voluntary resolution agreement requiring UPMC to implement measures to reduce potential barriers to care, including expanded transportation services, enhanced primary care and behavioral health services, and ongoing monitoring of the closure’s impact on the affected community.
• Similarly, OCR entered into a voluntary resolution agreement with Mee Memorial Hospital (MMH) following an investigation into allegations that the hospital had failed to provide meaningful language assistance to Triqui-speaking patients with limited English proficiency (LEP). Although the hospital was not intentionally withholding services from Mexican indigenous patients, it’s lack of language assistance disproportionately prevented them from receiving effective care. The agreement required the hospital to strengthen its language access policies, interpreter services, staff training, and monitoring.
• More recently,in 2021, HHS’s OCR and the DOJ investigated the Alabama Department of Public Health (ADPH) over concerns that its wastewater and public health practices disproportionately burdened Black residents of Lowndes County. The agencies reached an interim resolution agreement requiring ADPH to take steps to address the community’s longstanding exposure to raw sewage, including improving access to functioning septic systems, suspending criminal enforcement against residents unable to afford compliant systems, and strengthening public health data collection and infrastructure planning. In 2024, HHS and DOJ reported progress in implementing these reforms. However, in April 2025, the Trump Administration terminated the agreement, ending the federal agencies’ enforcement of the reforms.

Disparate-impact standards have also shaped HHS guidance to recipients about designing and administering programs and policies. For example, HHS issued guidance on serving individuals with LEP explaining that recipients could violate Title VI by using criteria or methods that had the effect of discriminating based on national origin and translated this standard into expectations for providing meaningful access to care. HHS’s Office of Minority Health (OMH) National Culturally and Linguistically Appropriate Services (CLAS) Standards also reflect principles underlying disparate-impact protections, particularly in their language access standards. During the COVID-19 pandemic, HHS’s OCR issued guidance advising that Title VI applied to procedures, criteria, and methods of administration that have a disparate impact based on race, color or national origin. The guidance specifically identified examples of disparate-impact discrimination that could arise in COVID-19 vaccination programs, such as requirements for vaccines to be distributed solely through pharmacies or appointments needing to be scheduled online, which could disproportionately limit access in communities of color, even in the absence of discriminatory intent. HHS also advised vaccine providers to review policies for barriers, collect and analyze demographic data, address language and transportation barriers, and locate vaccination sites in historically underserved communities. HHS also incorporated disparate-impact principles into a training curriculum for medical students by including examples of facially neutral health care policies that could disproportionately limit access for racial and ethnic communities and instructing participants to consider whether less discriminatory alternatives could achieve the same objectives.

Potential Implications of Eliminating Disparate Impact Enforcement

The 2026 final rule eliminates disparate impact as a basis for administratively enforcing Title VI under HHS’s implementing regulations. Under the revised regulations, HHS will enforce Title VI only when there is evidence of intentional discrimination based on race, color, or national origin. As a result, a policy or practice that disproportionately affects a protected group, by itself, is no longer sufficient to establish a violation of Title VI under HHS regulations. HHS states that these revisions are intended to align its regulations with the text of Title VI, Supreme Court precedent, and Executive Order 14281, “Restoring Equality of Opportunity and Meritocracy,” issued by President Trump on April 23, 2025, directing federal agencies to eliminate the use of disparate-impact liability. The final rule also clarifies that statistical evidence showing racial or ethnic disparities may still be considered as part of an investigation, but disparities alone are not sufficient to establish discrimination absent evidence of intentional discriminatory treatment.

The 2026 final rule marks a shift in HHS’s approach to investigating and resolving Title VI complaints and will likely have a range of implications for enforcement of civil rights law and health disparities. The changes under the rule:

• Narrow the scope for administrative enforcement of civil rights law. The rule changes what the federal government will identify as discrimination in its activities and investigations since the federal government will no longer enforce policies and procedures that result in disparate effects for protected groups but cannot be tied to intentional discrimination. Moreover, parties seeking administrative enforcement of the law will face a higher burden to demonstrate discrimination, since they must be able to show intentional discrimination.
• May allow for policies and practices that lead to disparate outcomes in health and health care to remain in place, which may exacerbate disparities. As noted, even in the absence of intentional discrimination, policies and procedures may lead to disparate impact for protected groups. For example, hospital or clinic closures; reductions in obstetric, behavioral health, or specialty services; provider network changes; transportation or service relocation decisions; eligibility or enrollment procedures; lack of effective language access services; and resource allocation decisions may lead to or exacerbate disparities because of longstanding differences in where individuals live and the resources they have available, where health care services are located, insurance coverage, transportation, and other social and economic factors. Moreover, the increasing use of artificial intelligence (AI) in health care and language services may exacerbate cases of disparate impact because underlying data, model design, or implementation may reinforce or widen existing disparities.
• Reduce incentives for HHS and recipients of federal financial assistance to ensure policies and practices are equitable and do not disproportionately adversely affect certain racial or ethnic groups or other protected groups. Without disparate impact as an enforcement standard, the federal government has reduced incentive to investigate policies and procedures for discrimination unless there are claims of intentional discrimination. Despite civil rights statutes remaining in full effect, federal funding recipients may have less incentive to proactively assess the equity implications of institutional decisions, policies, and procedures. Some organizations may continue to focus on equitable practices as a part of their accreditation standards, state laws, Medicaid requirements, quality improvement initiatives, or organizational priorities, but they will not be subject to federal enforcement to ensure equitable impacts or outcomes for the groups they serve unless there is evidence of intentional discrimination.

In the absence of Title VI disparate impact enforcement, other federal and state authorities may provide mechanisms for addressing disparate impacts, but these protections may have more limited reach and may apply to different protected groups, entities, programs, jurisdictions, or forms of discrimination than Title VI. For example, Section 1557 of the Affordable Care Act continues to prohibit discrimination in covered health programs based on race, color, national origin, disability, age and sex and includes requirements related to providing meaningful language access. However, the Administration has indicated it will make changes to Section 1557 implementing regulations. Medicaid also provides mechanisms for addressing disparities, particularly through managed care contracting practices, although efforts vary across states. States may also retain or establish their own protections against disparate-impact discrimination. For example, California statute prohibits discrimination in state-funded programs and activities based on a broader range of protected characteristics than Title VI with state regulations prohibiting practices with discriminatory effects, providing a state-level disparate impact standard similar to one the one eliminated from HHS’s Title VI regulations. Illinois also enacted the Civil Rights Safeguard Act in 2026, expanding existing state protections against disparate impact discrimination in employment, financial credit, and public accommodations, including health care.  However, without a federal standard of enforcement, protections and mechanisms to address discrimination will vary across states.

The Medicare program provides health insurance coverage to over 70 million people ages 65 or older and younger adults with long-term disabilities. While Medicare covers a wide range of health care services, Medicare beneficiaries generally pay out-of-pocket for their monthly premiums, deductibles, and cost sharing for Medicare covered services. Medicare premiums and other cost-sharing requirements have increased steadily in recent years and are projected to continue growing over the next decade. At the same time, many Medicare beneficiaries have modest incomes which can make it difficult to afford these costs: one in four Medicare beneficiaries lived on incomes below $24,600 per person in 2024, and out-of-pocket spending on Medicare premiums and cost-sharing expenses accounted for more than a third (36%) of the average Medicare beneficiary’s Social Security income in 2023.

Out-of-pocket costs may also vary depending on the choices Medicare beneficiaries make about their coverage. People with Medicare can choose to receive their benefits through traditional Medicare or through a privately administered Medicare Advantage plan. Beneficiaries in traditional Medicare can sign up for prescription drug coverage through a stand-alone Part D plan, and may also purchase a Medicare supplemental insurance policy, known as Medigap, to assist with Medicare cost sharing. Medicare Advantage plans typically include prescription drug coverage, as well as limits on how much enrollees pay out of pocket each year for Medicare covered services (in contrast to traditional Medicare, which has no limit on out-of-pocket costs), but most plans also require enrollees to use a specified network of providers or charge higher cost sharing for services from out-of-network providers. Each of these Medicare coverage options comes with different premium and cost-sharing requirements, as well as considerable variation from plan to plan. Overall, navigating these options and expenses can be complex, and the costs can be substantial, particularly for beneficiaries with high health care needs.

This brief provides an overview of the costs faced by Medicare beneficiaries in traditional Medicare, Medicare Advantage, and Medicare Part D, including premiums, deductibles, copays, and coinsurance, focusing on costs in 2026. (The brief will be updated with cost information for 2027 when available.)

Premiums for Medicare Part A and Part B

Part A Premiums

Most Medicare beneficiaries, whether they are covered under traditional Medicare or Medicare Advantage, pay no monthly premium for Medicare Part A, which covers inpatient hospital stays, short-term nursing facility care, hospice, and some home health services. People generally qualify for premium-free Part A if they or a spouse have worked at least 40 quarters (10 years) in jobs where they paid Medicare payroll taxes. People who are otherwise eligible for Medicare but do not meet this requirement may still enroll in Part A but are required to pay a monthly premium. In 2026, the Part A premium is $311 per month (or $3,732 for the year) for beneficiaries with more than 30 quarters but less than 40 quarters of covered employment and $565 per month (or $6,780 for the year) for beneficiaries with fewer than 30 quarters of covered employment.

Late enrollment penalty. If a Medicare-eligible person is required to pay a Part A premium but delays enrollment beyond their initial enrollment period and lacks qualifying group coverage in the interim, they are subject to a late enrollment penalty in the form of a 10% increase to their monthly Part A premium when they enroll in Part A. The Part A late enrollment penalty applies for twice the number of years enrollment was delayed. For example, if a person with 30 quarters of covered employment was initially eligible to enroll in Part A in January 2023, but delayed enrollment for two years until January 2025, they would incur late enrollment penalties until 2029 and would pay $342.10 per month for Part A coverage in 2026 (based on $311 times 10%).

Part B Premiums

Beneficiaries are required to pay a monthly premium for Part B coverage, whether they are covered under traditional Medicare or Medicare Advantage. Part B covers physician visits, outpatient hospital services, preventive services, diagnostic tests, and physician-administered drugs. In 2026, the standard Part B premium is $202.90 per month (or $2,434.80 for the year). Beneficiaries with incomes greater than $109,000 for individuals or $218,000 for married couples in 2026 pay a higher, income-adjusted Part B premium ranging from $284.10 to $689.90 per person per month in 2026 (Figure 1). Beneficiaries with low incomes and modest assets may qualify for help from their state Medicaid program to pay their Medicare Part B premium.

Late enrollment penalty. As with Part A, Medicare-eligible people who delay enrolling in Part B beyond their initial enrollment period and who lack other qualifying group coverage in the interim are subject to a late enrollment penalty when they enroll in Part B. The Part B late enrollment penalty is a lifetime penalty and is calculated as 10% of the monthly standard Part B premium for each 12-month period enrollment was delayed. For example, someone who delayed enrollment in Part B for two years would face a 20% monthly Part B premium penalty and would pay $243.48 per month in 2026 (based on $202.90 times 20%).

Cost-Sharing Requirements in Traditional Medicare

Cost Sharing for Part A Services

Inpatient hospital services covered under Medicare Part A are subject to a deductible of $1,736 in 2026, which applies per benefit period rather than per year, meaning that some beneficiaries may pay the deductible more than once if they are hospitalized multiple times in a year. Cost sharing only applies after the first 60 days of a hospital stay, at a rate of $434 per day for days 61-90 and $868 for each additional day afterwards in 2026 (up to a lifetime cap of 60 additional days).

For a stay in a skilled nursing facility following a qualifying hospitalization, beneficiaries pay no cost sharing for the first 20 days and $217 per day for days 21-100 in 2026. Medicare covers a maximum of 100 days of skilled nursing facility care per benefit period, after which point beneficiaries are responsible for the full cost of any additional days. Other Part A services, such as hospice care or home health services, are covered with no deductible and no cost sharing (with the exception of certain services, such as pain management medications and respite care, for which modest cost sharing may apply).

Cost Sharing for Part B Services

Services covered under Medicare Part B, such as doctor visits, outpatient hospital services, diagnostic tests and imaging, mental health and substance use disorder services, and durable medical equipment (e.g., prosthetics or mobility devices) are generally subject to an annual deductible of $283 in 2026 and a coinsurance rate of 20%. Many preventive services, such as annual wellness visits, flu shots and certain other vaccines, mammograms, and prostate cancer screenings are covered with no deductible or coinsurance.

Traditional Medicare has No Out-of-Pocket Limit

Traditional Medicare does not include an annual limit on how much beneficiaries pay out-of-pocket for Part A and Part B services. For this reason, many beneficiaries choose to purchase a Medigap policy, which helps cover Part A and B cost-sharing requirements in traditional Medicare, offering beneficiaries protection against unforeseen or catastrophic out-of-pocket expenses. Beneficiaries who choose to purchase a Medigap policy must pay a separate monthly premium to their Medigap insurer (in addition to the Part B premium). The average premium among current Medigap policyholders was $217 per month in 2023 (or $2,604 for the year), though Medigap premiums may rise with age and other factors, with considerable variation by state and policy type.

In addition to Medigap, some beneficiaries have access to other types of supplemental coverage, such as employer- or union-sponsored coverage or Medicaid coverage, which may also assist with out-of-pocket expenses, as well as coverage of services not included in traditional Medicare. Beneficiaries with low incomes and modest assets who do not qualify for full Medicaid coverage may still qualify for help from their state Medicaid program to cover Medicare Part A and Part B deductibles and cost-sharing requirements (as well as premium costs, as noted above).

Costs Under Medicare Advantage

Medicare Advantage plans are private health plans that contract with Medicare to provide Part A and Part B benefits, and serve as an alternative to traditional Medicare. Most Medicare Advantage plans also include prescription drug coverage and offer supplemental benefits not covered in traditional Medicare, such as dental, vision, and hearing services. Medicare Advantage plans often have lower cost-sharing requirements for many services than what beneficiaries would face in traditional Medicare. At the same time, Medicare Advantage plans frequently use provider networks, prior authorization, and referral requirements to manage enrollees’ use of services, in contrast to traditional Medicare where these types of restrictions are rarely used.

Premiums

People in Medicare Advantage plans are required to pay the standard monthly Part B premium, plus the income-related surcharge as applicable, and the Part A premium if they do not qualify for premium-free Part A, as well as any additional premium charged by their Medicare Advantage plan. However, most Medicare Advantage enrollees are in plans with no additional plan premium. Among Medicare Advantage plans that include prescription drug coverage (known as MA-PDs) available for individual enrollment, the average enrollment-weighted premium is $15 per month in 2026. This amount is heavily weighted by zero-premium plans, as three-quarters (75%) of all MA-PD enrollees are in plans that charge no monthly premium.

Some Medicare Advantage plans use rebate dollars from Medicare payments to buy down a portion of the monthly Part B premium for their enrollees. In 2026, roughly one third (31%) of all MA-PD enrollees are in plans that reduce the Part B premium, most often by less than $10 per month.

Cost Sharing for Part A and Part B Services

Medicare Advantage plans are required to cover all services covered under Medicare Parts A and B. Overall cost sharing in Medicare Advantage cannot exceed what would be paid across Part A and Part B services in traditional Medicare, though specific cost-sharing requirements vary across plans and may be higher or lower for a given service, with some exceptions. Cost-sharing requirements may also vary depending on whether or not a given provider or health care facility is included in the plan’s network. Preferred provider organizations (PPOs) generally offer coverage of out-of-network services but may require higher cost sharing than would be required for in-network services, while health maintenance organizations (HMOs) do not include any coverage of out-of-network services.

Among an illustrative sample of six high-enrollment Medicare Advantage plans available in 2026, representing five of the largest insurers in six different states across the country, none of the six plans required an additional premium or a deductible for medical services covered under Medicare Part A and Part B, but plan costs for Part A and Part B services varied widely (Figure 2).

• Inpatient hospitalization: Among the three PPOs examined, daily copays for inpatient services at in-network facilities ranged from $330 per day for days 1-7 to $550 per day for days 1-5, after which no additional cost sharing was required, while coinsurance for inpatient services at out-of-network facilities ranged from 40% to 50% for all covered days. Among the three HMOs examined, daily copays for inpatient services ranged from $0 for all days to $275 for days 1-8, after which no additional cost sharing was required.
• Primary care visits: Among the three PPOs examined, copays for primary care visits ranged from $0 to $5 for in-network providers and from $45 to a 50% coinsurance fee for out-of-network providers. None of the three HMOs examined charged a copay for primary care visits.
• Specialty care visits: Among the three PPOs examined, copays for specialty care visits ranged from $35 to $60 for in-network providers and from $95 to a 50% coinsurance for out-of-network providers. Among the three HMOs examined, copays for specialty care visits ranged from $0 to $30.
• Outpatient hospital services: Among the three PPOs examined, copays for outpatient services at in-network facilities ranged from $0 for select services (such as colonoscopies) to $550 for most covered services, while coinsurance for outpatient services at out-of-network facilities ranged from 40% to 50%. Among the three HMOs examined, copays for outpatient services ranged from $0 to $275 for most services.

Out-of-Pocket Limits are Required in Medicare Advantage

Medicare Advantage plans are required to include a limit on enrollees’ out-of-pocket spending. In 2026, this limit may not exceed $9,250 for in-network services or $13,900 for all covered services, though plans may choose to offer limits below these amounts. The average out-of-pocket limit among Medicare Advantage enrollees in 2026 is $5,421 for in-network services (across HMOs and PPOs) and $9,825 for in- and out-of-network services combined (among PPOs, as HMOs do not include coverage of out-of-network services). Just over one in ten (13%) Medicare Advantage enrollees are in plans with limits of $3,000 or less for in-network services, while one in five (19%) are in plans with limits greater than $7,000. Among PPO enrollees, roughly, one in ten (9%) are in plans with limits of $6,000 or less for in-network and out-of-network services combined, while one in four (25%) are in plans with limits greater than $12,000. Out-of-pocket limits apply to Part A and Part B services only, though out-of-pocket spending for Part D drugs is subject to a separate limit (as discussed below).

Out-of-pocket limits varied among the six illustrative plans described above. Among the three PPOs examined, out-of-pocket limits ranged from $5,200 to $6,700 for in-network services and from $10,000 to $10,100 for in-network and out-of-network services combined. Among the three HMOs examined, out-of-pocket limits ranged from $699 to $3,850 for covered services.

Non-Medicare Covered Services

Most Medicare Advantage plans include some coverage of services not covered in traditional Medicare, such as dental care, glasses and eye exams, and hearing exams or hearing aids. The scope of coverage for these benefits varies widely between plans, with some limited to coverage of basic preventive services (e.g., dental cleanings) while others offer a broader range of covered services (e.g., root canals or dentures). Cost sharing for these benefits also varies between plans, and coverage may be subject to network restrictions, limits on the number of services covered per year, or annual dollar caps on the amount the plan will pay towards covered services.

Costs for Part D Prescription Drug Coverage

Medicare Part D is a voluntary outpatient prescription drug benefit for people with Medicare provided through private plans that contract with the federal government. Beneficiaries can choose to enroll in either a stand-alone prescription drug plan (PDP) to supplement traditional Medicare or a Medicare Advantage drug plan (MA-PD) that includes drug coverage and all other Medicare-covered benefits. Monthly premiums, deductibles, cost-sharing requirements for covered drugs, pharmacy networks, and formularies (the list of drugs covered by a plan) all vary across Part D plans.

Part D Premiums

Many, though not all, Part D enrollees pay a monthly premium for Part D coverage, with premiums varying by plan. In 2026, the average Part D premium among stand-alone PDPs is $36 per month. For MA-PD enrollees, the Part D premium is included as a portion of their Medicare Advantage plan premium. In 2026, the Part D portion of the average MA-PD premium is $8 per month, but 75% of Medicare Advantage enrollees in individual plans pay no premium for Part D coverage (because the Medicare Advantage insurer uses payments from the federal government to buy down these costs).

As with the Part B premium, beneficiaries with incomes greater than $109,000 for individuals or $218,000 for married couples in 2026 pay a higher, income-adjusted Part D premium, with monthly adjustment amounts ranging from $14.50 to $91.00 added to their individual Part D plan’s premium. Beneficiaries with low incomes and modest assets can qualify for financial assistance through the Part D Low-Income Subsidy (LIS). People who qualify for the LIS program pay modest copayments for prescription drugs, no drug deductible, and no premium for drug coverage if they are enrolled in premium-free “benchmark” plans.

Late enrollment penalty. Beneficiaries who go without Part D coverage for 63 days or more at any point after their initial enrollment period and lack other qualifying drug coverage in the interim are subject to a late enrollment penalty. The Part D late enrollment penalty is a lifetime penalty equal to 1% of the Part D base beneficiary premium ($38.99 in 2026) for each month of delayed coverage. For example, someone who went without Part D or equivalent coverage for eighteen months would face an 18% monthly Part D premium penalty and would pay $7 per month in 2026 in addition to any premium charged by their Part D plan (based on $38.99 times 18%).

Cost Sharing

The standard Part D deductible is $615 in 2026, but Part D plans can offer an enhanced benefit with a lower or no deductible. In 2026, MA-PD enrollees face an average Part D deductible of $371, while PDP enrollees face an average deductible of $544. Part D plans typically charge different amounts for covered drugs, with lower cost-sharing amounts charged for generic drugs and preferred brands and higher cost-sharing amounts for non-preferred and specialty drugs. Cost sharing typically consists of a mixture of flat dollar copays and coinsurance (based on a percentage of the drug’s list price). Part D plans can also designate certain pharmacies where enrollees will face lower (“preferred”) cost-sharing requirements.

In 2026, the median copay for generic drugs is $3 among PDPs and $5 among MA-PDs. For preferred brand drugs, the median copay is $45 among PDPs and $47 among MA-PDs. Virtually all PDP enrollees pay coinsurance for non-preferred drugs (with a median rate of 34%), while MA-PDs may charge either coinsurance (with a median rate of 38%) or a flat dollar copay (with a median of $100). The median coinsurance rate for specialty drugs is 25% among PDPs and 28% among MA-PDs (Figure 3).

An Out-of-Pocket Limit Applies Under Part D

Out-of-pocket costs for Part D enrollees are capped at $2,100 in 2026. Once this out-of-pocket limit is reached, enrollees pay no additional costs for the remainder of the year for drugs covered by their Part D plan. Part D enrollees in plans that offer enhanced benefits could pay less than $2,100 out of pocket before they qualify for catastrophic coverage. Part D enrollees also have the option of spreading out their out-of-pocket costs over a calendar year to lower their monthly costs.

The Medicare Advantage market, the private plan alternative to traditional Medicare, is dynamic, and plan offerings can change from year to year. With 28 Medicare Advantage prescription drug (MA-PD) plans available to the average beneficiary in 2027, most people with Medicare have a robust set of MA-PD options. However, Medicare Advantage plans are offered at the county level, and variation in plan availability across the country has long been a feature of the Medicare Advantage market. This analysis uses Medicare plan landscape data from the Centers for Medicare & Medicaid Services to examine county-level variation in MA-PD plan availability in 2027 and changes from 2026. This analysis does not examine changes in costs, benefits, or other plan characteristics. The analysis shows that plan level availability varies widely across the country in 2027, with a modest reduction in the share of enrollees having more than 40 MA-PDs to choose from compared to 2026, and some major insurers exiting a much larger number of counties than they are entering.

Findings

One in five Medicare beneficiaries (20%) can choose from more than 40 MA-PDs for coverage in 2027.

The 20% of Medicare beneficiaries who have more than 40 MA-PD options are concentrated in 4% of counties (Figure 1). This is a decrease from 2026 when 27% of beneficiaries, who resided in 6% of counties, had more than 40 options. Similar to 2026, the counties with the most plan options are predominantly in Pennsylvania, Ohio, and Michigan, as well as Los Angeles County, California. Beneficiaries in Lancaster, Pennsylvania can choose from 66 MA-PDs – the most offerings of any county in the U.S.

For 2027, Medicare beneficiaries residing in 193 counties will have no MA-PDs available for general enrollment, an increase from 123 counties in 2026.

Beneficiaries in the 193 counties without any MA-PD option for general enrollment for 2027 comprise 1% of all Medicare beneficiaries, or 638,000 people. This is an increase from 2026, when 399,000 beneficiaries did not have an MA-PD option (an increase of 239,000 beneficiaries).

The counties with no MA-PD options are located in 16 states (Alaska, California, Colorado, Idaho, Kansas, Minnesota, Montana, Nebraska, Nevada, New Hampshire, North Dakota, Oklahoma, Oregon, South Dakota, Utah, and Vermont) and U.S. territories other than Puerto Rico. These are the same states as 2026, with the addition of New Hampshire, North Dakota, and Oklahoma. Similar to 2026, there are no MA-PDs for general enrollment being offered in any county in Alaska in 2027, which includes about 110,000 beneficiaries.

In six counties (Boyd, Nebraska; Aurora, Beadle, Bon Homme, Brown, and Charles Mix, South Dakota) there is a Medicare Advantage plan option without prescription drug coverage, but in the other 187 counties, no Medicare Advantage plans with or without prescription drug coverage for general enrollment are available. In some counties where Medicare Advantage plans for general enrollment are not available, there are other private plan options, including cost plans as well as special needs plans, which restrict enrollment to Medicare beneficiaries who meet specific criteria.

The two largest Medicare Advantage insurers – UnitedHealth Group and Humana – are exiting more counties, meaning they are no longer offering any MA-PDs in those counties, than they are entering in 2027.

UnitedHealth Group is exiting 228 counties and entering 9 new counties, and Humana is exiting 62 counties and entering 4 new counties (Figure 2). Humana is offering MA-PDs in the largest number of counties relative to other insurers - about 80% of all U.S. counties, similar to 2026 - while UnitedHealth Group is offering plans in about 70% of counties, a decline from 2026, when the insurer offered plans in nearly 80% of counties.

Among insurers offering MA-PD plans, Health Care Service Corporation is making the largest reduction in its county footprint, exiting the greatest number of counties in 2027 (498 counties) while entering no new counties. Centene has the second largest reduction, exiting 359 counties and entering 15 new counties for 2027. Blue Cross Blue Shield of Michigan Mutual Ins. Co., which had offered MA-PDs in Iowa, Michigan, North Dakota, South Dakota, and Wyoming in 2026, is exiting 177 counties and entering one new county, and will only offer MA-PDs in Michigan and Wyoming for 2027. Elevance Health is exiting 66 counties and entering 10 new counties in 2027.

Two insurers - Group 1001 (marketed as Clear Spring Health), which offered plans in Colorado, Georgia and Illinois, and Molina Healthcare – are completely exiting the MA-PD market, though Molina is still offering SNPs in many counties in 2027.

In contrast, Devoted Health is expanding its MA-PD footprint, entering 342 counties and exiting none in 2027. Second to Devoted Health, CVS Health is entering a larger number of new counties in 2027 than other insurers (63 new counties), but is also exiting 186 counties.

Kaiser Foundation Health Plans, a high enrollment insurer, is maintaining its footprint, exiting three counties while entering three new ones in 2027 (data not shown).

The characteristics of markets that insurers are leaving vary. In some cases, multiple insurers are exiting more rural areas with relatively small Medicare populations, such as four counties in Minnesota (Brown, Lake of the Woods, Morrison, and Renville), in each of which three insurers who offered MA-PDs in 2026 are no longer offering MA-PDs for 2027. In other cases, individual insurers are exiting counties in more urban areas with higher Medicare Advantage penetration, such as Miami-Dade County, FL where Health Care Service Corporation is no longer offering MA-PDs in 2027 and Monroe County, New York (Rochester) where Humana left the market. The different decisions of insurers to exit certain counties suggest a combination of factors are at play, including local market characteristics, cost pressures, shifts in firm-level strategies, and ultimately the insurers’ assessment of profitability.

On September 18, 2025, the U.S. government (USG) released its new America First Global Health Strategy, which details how the U.S. will engage in global health efforts moving forward. As part of this new strategy, the U.S. has announced that it will be establishing bilateral health cooperation agreements with countries that receive U.S. global health assistance. These agreements, or Memorandums of Understanding (MOUs), between the U.S. and partner countries represent five-year plans (for the period 2026-2030) outlining U.S. engagement in each country’s health efforts with the goal of “helping countries move toward more resilient and durable health systems.” Central to these plans is transitioning country programs from U.S. assistance to long-term country ownership, with a pledge from each partner country to increase its domestic health spending, or co-investment in health, over the next five years as the U.S. decreases its health assistance. The U.S. began signing these agreements in late 2025 and this process is ongoing. Implementation is slated for later this year.

This tracker provides an overview of the MOUs signed to date. Data are based on press releases issued by the State Department, U.S. embassies, and partner country Ministries of Health, as well as MOU documents (if publicly available). See Methods for more information. This tracker will be updated as agreements are signed and more data become available.

Methods

This tracker provides information on U.S. MOU bilateral global health agreements to date. Information is sourced from publicly available U.S. Department of State, U.S. embassies, and partner country Ministries of Health press release statements and MOU texts, and will be updated as more information becomes available and when additional agreements are signed. Currently, MOU text, which contains the most detailed information of these sources, is publicly available for only a limited number of countries; for these countries, data were sourced directly from these MOU documents. For countries with available MOU documents, overall totals are based on the sum of annual amounts presented in the text. 

Program areas are captured using keyword searches; for global health security (GHS) specifically, country agreements were categorized as targeting GHS if they specifically mentioned GHS, or if they included descriptions of outbreak preparedness and response activities and containing health threats. Due to the limited nature of press release statements, this tracker may not comprehensively capture the global health program areas targeted in each country’s agreement.

Medicaid is the primary program providing comprehensive health and long-term care to 81 million people living in the U.S. (particularly those with low incomes) and accounts for nearly $1 out of every $5 spent on health care. Last year, Congress enacted the 2025 reconciliation law, which made major changes to Medicaid. Shortly after enactment, the Congressional Budget Office (CBO) estimated the new law would reduce federal spending on Medicaid by $911 billion over the 2025-2034 period and that it would increase the number of people without health insurance by 10 million in 2034. Reductions in federal Medicaid spending could leave states with tough choices on how to offset the loss of spending through cuts to Medicaid, cuts to other programs, or tax increases. The impacts of the changes will vary across states and will be especially substantial for states that have expanded Medicaid under the Affordable Care Act (ACA).

As the 2026 midterms approach, health care costs remain voters’ top health priority and economic worry. The interactive maps below illustrate how many people are enrolled in Medicaid in 2025 and what percentage of the population is enrolled in Medicaid for each congressional district. Enrollment numbers include enrollment in each of the major Medicaid eligibility groups. The analysis uses Medicaid administrative data to estimate Medicaid enrollment by eligibility group and Census data to estimate congressional district populations. Political affiliation refers to the party of the current incumbent. See Methods for more details. Key takeaways include:

• There are 52,900 or more Medicaid enrollees living in each congressional district, with enrollment as high as 496,500 in a district. In each congressional district, there are at least 3,600 Medicaid enrollees ages 65 and older, 3,900 enrollees eligible because of a disability, 7,500 child enrollees, and 6,600 other adult enrollees.
• In half of all Republican congressional districts, 20% or more of the population is enrolled in Medicaid, and in half of all Democratic districts, 25% or more of the population is enrolled in Medicaid.
• Republican districts have a higher share of Medicaid enrollees who are children or eligible because of a disability, compared with Democratic districts which have a higher share of expansion enrollees and adults ages 65 and older. However, this varies by specific district and depends on whether a state has adopted the Medicaid expansion; there are both Democratic and Republican districts with high shares of ACA expansion enrollees.
• The top 10 Republican districts with the highest number of Medicaid enrollees are: CA-22 (496,100); CA-23 (375,200); LA-05 (347,200); CA-20 (324,100); NY-11 (313,900); LA-03 (312,700); KY-05 (311,000); LA-04 (302,200); CA-01 (298,000); and WV-01 (289,000).
• The top 10 Democratic districts with the highest number of Medicaid enrollees are: NY-15 (496,500); CA-21 (450,600); CA-43 (449,400); CA-37 (431,500); CA-13 (427,900); CA-34 (426,200); NY-14 (419,200); NY-13 (404,500); CA-29 (395,800); and NY-08 (374,900).

Methods

Data: To calculate Medicaid enrollment by eligibility group and congressional district, this analysis uses the 2024 Transformed Medicaid Statistical Information System (T-MSIS) Research Identifiable Demographic-Eligibility and Claims Files, the Missouri Census Data Center’s GeoCorr 2022 data (downloaded in September 2026), the Medicaid new adult group enrollment data collected through the Medicaid Budget and Expenditure System (MBES) for June 2025 (downloaded in August 2026), the Census American Community Survey (ACS) 1-Year Estimates, 2024 (downloaded in August 2026), and the U.S. Census Bureau Vintage 2025 Population Estimates (downloaded in September 2026).

Assigning Medicaid Enrollees to Congressional Districts: This analysis used the Missouri Census Data Center’s GeoCorr tool to create a zip code-to-congressional district crosswalk. Using the crosswalk, Medicaid enrollees were assigned to congressional districts in the T-MSIS data.

In some cases, a zip code can be split among multiple congressional districts. In those cases, enrollees were randomly assigned to a congressional district based on a zip code-to-congressional district allocation factor from the GeoCorr tool that is calculated using the 2020 decennial census.

The analysis applied the T-MSIS distributions of enrollees in eligibility groups and congressional districts to the MBES administrative enrollment data. Those data report enrollment for adults eligible through the Affordable Care Act (ACA) and for all other Medicaid enrollees on a quarterly basis.

Calculating Congressional District Population: To estimate 2025 congressional district population, two approaches were used: one for states that were redistricted and another for states that did not redistrict.

Redistricted states: GeoCorr 2022’s county-to-congressional district population distributions were used to estimate the share of each county’s population in each congressional district. County crosswalks were used instead of zip code as Census data does not report population estimates at the zip code level. County population totals from the Census Bureau Vintage 2025 Population Estimates were applied to those distributions and summed to the congressional district level. The states that redistricted are Alabama, California, Florida, Louisiana, North Carolina, Ohio, Tennessee, Texas, and Utah.

Non-redistricted states: ACS 2024 congressional district populations were used to estimate the share of state population in each congressional district, and then those shares were applied to the Census Bureau Vintage 2025 state population estimates.

Assigning Political Party to Congressional Districts: The political party of the current incumbent was used to assign political party affiliation to each congressional district. For vacant congressional seats, FL-20 and TX-23, the Cook Political Report projections for the districts (accessed September 2026) were used instead. Their political affiliations are Democrat and Republican, respectively.

Enrollment in the Affordable Care Act (ACA) Marketplaces fell in 2026 for the first time in seven years, following the expiration of the enhanced premium tax credits at the end of 2025. Nationally, effectuated enrollment declined from 21.8 million people in 2025 to 19.2 million in February 2026, a 12% drop, and is expected to further decline through the remainder of 2026. A KFF survey of 2025 Marketplace enrollees found that 1 in 10 reported they had become uninsured in early 2026. For remaining enrollees, health costs have risen substantially, with premium payments rising 58% on average, and deductibles up by 37% or about $1,000 per person.

Changes in enrollment, however, were not evenly distributed across the country. Marketplace enrollment changed substantially from one state to another, and even within states. In some congressional districts, a sizable portion of the population are enrolled in ACA Marketplace plans, such as several districts in Florida in which almost 30% of the population is enrolled.

This analysis estimates how Marketplace enrollment varies both within and across states using both publicly available data on federally facilitated Exchanges (FFEs) from the Centers for Medicare and Medicaid Services (CMS) and data provided by state-based Exchanges (SBEs). Enrollment estimates are rounded to the nearest thousand. Key takeaways include:

• Marketplace enrollment varies widely by congressional district: from as low as 2,000 people to 249,000 people.
• In 12 Democratic districts and 16 Republican districts, more than 100,000 people are enrolled in an ACA plan, based on the incumbent representative. All these districts are in Florida, Texas, or Georgia.
• Marketplace enrollment fell more sharply in Republican-held congressional districts, which account for 55% of current enrollees but 67% of the enrollment decline between 2025 and 2026.
• The top 10 Republican districts with the highest number of Marketplace enrollees are: FL-27 (249,000), FL-28 (238,000), FL-26 (223,000), FL-11 (139,000), FL-21 (128,000), FL-18 (127,000), TX-15 (124,000), FL-19 (121,000), FL-05 (109,000), and FL-12 (105,000).
• The top 10 Democratic districts with the highest number of Marketplace enrollees are: FL-24 (229,000), FL-25 (192,000), FL-20 (183,000), FL-10 (182,000), FL-09 (172,000), FL-22 (155,000), FL-23 (145,000), TX-28 (132,000), FL-14 (116,000), and GA-13 (109,000).

The number of people enrolled in an ACA Marketplace plan varies widely across the country, reflecting differences in demographics, eligibility, the availability of other sources of coverage, and state Marketplace policies. Enrollment is generally highest in the South, where several states have not expanded Medicaid, leaving some low-income people eligible for subsidized Marketplace coverage instead. Florida has 21 congressional districts with more than 100,000 Marketplace enrollees, including the 11 districts with the highest enrollment nationwide. Texas and Georgia also have districts with more than 100,000 enrollees.

Marketplace enrollment is estimated to account for a large share of the population in several Florida districts, including 31% in FL-27, 30% in FL-28, 29% in FL-24, and 28% in FL-26. Districts in Georgia, Texas, and Utah also have Marketplace enrollment representing at least 10% of the population. Most ACA Marketplace enrollees (55%) live in a Republican-held congressional district. This is roughly proportionate to Republicans' share of House seats. Two-thirds of the enrollment decline between 2025 and 2026 occurred in Republican-held districts (67%).

Marketplace enrollment is much lower in states with broader public coverage options. Twenty-four of the 25 congressional districts with the lowest estimated Marketplace enrollment are in New York, each with less than 10,000 enrollees. Minnesota, Oregon, Kentucky, and Hawaii also have low ACA Marketplace enrollment. In the majority of their congressional districts, less than 3% of the population are enrolled in an ACA plan. All five states have expanded Medicaid eligibility up to 138% of the federal poverty line (FPL), and New York, Minnesota, and Oregon additionally offer Basic Health Plans that cover low-income residents.

ACA Marketplace enrollment represents a substantial share of the population in many states, but the share varies widely. Overall, the share of state populations enrolled in ACA Marketplace plans tends to be highest across the South, where several states have not expanded Medicaid, while shares are generally lower in the Northeast and Midwest. Thirteen states have greater than 5% of their population enrolled in ACA Marketplace coverage; they were all won by President Trump in 2024.

Florida has the highest share, with 16% of its population enrolled in a Marketplace plan, followed by Georgia (11%), Texas (10%), and Utah (10%). In contrast, enrollment accounts for less than 2% of the population in New York (1%), Hawaii (2%), Minnesota (2%), and the District of Columbia (2%).

Methods

To estimate effectuated enrollment by congressional district, effectuated enrollment was first determined at the county level and then allotted to congressional district.  For states operating state-based exchanges (SBE), 2026 county enrollment data provided by the exchanges directly are February or first quarter effectuated enrollment, measured as of at least March 15. When county effectuated enrollment was not available, it was estimated by multiplying county plan selection counts by the state-level effectuation rate. This method was used to estimate enrollments for all counties in 2025, and in 2026, counties in FFM states and SBE states where only plan selection data were available (California, Idaho, Maryland, and Pennsylvania). County plan selections were obtained from the CMS Open Enrollment Period (OEP) County-Level Public Use File (PUF) for FFE states or directly from the SBE; state-level effectuation rate was derived from the OEP State-Level PUF and CMS’s Monthly Effectuated Enrollment data. Allocation of county effectuated enrollment to congressional district was based on the 2020 decennial census distribution using the Census Bureau block equivalency file for the 120^th Congress for all states except Missouri, which retained the block equivalency of the 119^th Congress.

Population estimates from 2026 are not yet available so data for 2025 were used, which may slightly overestimate the share of population enrolled in Marketplace coverage in states with large recent population growth. (For reference, state population change from 2024 to 2025 ranged from -0.3% in Vermont to +1.5% in South Carolina.) To estimate the population of each congressional district, state population estimates from Vintage 2025 of the Census Bureau Population Estimates Program were allocated to congressional districts using the population distribution from the Census Bureau 2024 American Community Survey 1-year estimates. A different method was used for states that recently redistricted: Alabama, California, Florida, Louisiana, North Carolina, Ohio, Tennessee, Texas, and Utah. In these states, the Vintage 2025 county population estimates were allocated to congressional district using the distribution from the 2020 decennial census.

Congressional district maps of effectuated enrollment account for redistricting ahead of the 120^th Congress. 2024 House race vote margins were marked as NA for districts with boundary changes after the 2024 election ahead of the 120^th Congress. These were identified by comparing Census Bureau block equivalency files for the 119^th and 120^th Congress for all states other than Missouri.

Appendix