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

Prior Policy under PRWORA

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

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

Changes under the 2025 Policy

The 2025 policy expands the list of programs considered “federal public benefits” by adding 13 additional programs, including Head Start, the health center program, the Title X family planning program, among others (Box 2). The notice further indicates that the list is not exhaustive, and additional programs may be added to in the future.

Implications of the Policy Change

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

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

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

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

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

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

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

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

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

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

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

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

The full analysis and other data on health costs are available on the Peterson-KFF Health System Tracker, an online information hub dedicated to monitoring and assessing the performance of the U.S. health system.

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

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

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

The full analysis and other data on health costs are available on the Peterson-KFF Health System Tracker, an online information hub dedicated to monitoring and assessing the performance of the U.S. health system.

Introduction

Extreme heat continues to be a pressing issue as 2024 was recognized as the hottest year ever experienced, and 2025 is slated to be one of the five warmest years on record, with experts predicting more extreme heat records over the next five years. Warm seasons have lengthened, become more frequent, and increased in intensity due to climate change. In early July 2025, communities in Texas, New Mexico, and North Carolina experienced deadly flash floods, with over 100 people dying in the Texas floods. Flash floods are primarily a summertime weather event, the combination of high humidity levels, drought, and heat create favorable conditions for torrential downpours and flash flood events. More flash floods are expected to occur in the U.S. during summer 2025 and research finds that the risk of future flash flood events will increase as the climate warms.

In recent years, there have been rising incidents of extreme heat, poor air quality, drought, and wildfire events both globally and across the country. Exposure to extreme heat poses major health risks that disproportionately affect those with limited resources. Research shows that between 1999 and 2023, the number of heat-related deaths in the U.S. increased by 117%, from 1,069 heat-related deaths in 1999 to 2,325 in 2023. Moreover, KFF analysis of data from the Centers for Disease Control and Prevention shows that American Indian or Alaska Native and Black people are at higher risk of experiencing a heat-related death compared to their White counterparts. Estimates suggest that heat events in the U.S result in approximately $1 billion in excess health care costs each year. If left unaddressed, climate change could cost the U.S. economy approximately $14.5 trillion over the next fifty years.

Prior administrations and state and local governments increased efforts to address climate change, extreme heat, and their impacts on human health in recent decades. However, more recent efforts by the Trump administration have reversed some of these prior actions. Rollbacks in federal actions to address climate change-related inequities broadly and the impacts of extreme heat specifically, may contribute to worse health outcomes, disproportionately impacting many populations that already face disparities in health, including lower income populations, people of color, and immigrants. The elimination of key offices, programs, and data tools makes it more difficult to assess and mitigate the health risks associated with environmental hazards, including extreme heat. Beyond the federal administrative actions already taken, cuts to federal funding may further erode efforts to reduce heat exposure and its health-related impacts. Some states have taken steps to mitigate exposure to extreme heat and its health impacts. However, without broader federal actions and standards, protections will vary across states. As climate change accelerates and intensifies extreme heat, the impacts of the rollbacks of environmental protections and equity initiatives will likely widen existing health disparities, reduce community resilience, and weaken the federal government’s ability to respond to extreme climate events.

This brief provides an overview of the federal and state landscape of recent policies addressing extreme heat and health equity.

Federal Efforts Related to Extreme Heat and Health

Prior administrations implemented efforts to address climate change, extreme heat, and their impacts on human health in recent decades. In 1990, President George H.W. Bush implemented the Global Change Research Act of 1990, which created the U.S. Global Change Research Program (USGCRP) and required the release of the National Climate Assessment (NCA) every four years. The USGCRP has advanced climate change research over the past 35 years, and the NCA continues to report scientific research on climate change and its impacts on the U.S., helping to inform community responses to climate-related challenges. The Clinton administration implemented an Executive Order on “Federal Actions to Address Environmental Justice in Minority Populations and Low-Income Populations”, which required federal agencies to make identifying and addressing environmental justice a key part of their missions. Federal agencies were tasked with determining whether their programs had disproportionate detrimental effects on underserved populations through exposure to environmental hazards, including heat. The Executive Order also directed the creation of an Interagency Working Group on Environmental Justice to identify the disproportionate effects of environmental hazards exposure on communities of color and low income groups, and developing an environmental justice strategy. President George W. Bush’s administration was characterized by a withdrawal from leadership in federal regulation of climate change, including the U.S.’ withdrawal from the Kyoto protocol, an international agreement to lower greenhouse emissions that contribute to global warming and climate change. The Obama administration implemented the Memorandum of Understanding on Environmental Justice, highlighting the disproportionate burden of pollution and environmental hazards on communities of color and low income groups. The Obama administration also created the National Integrated Heat and Health Information System (NIHHIS), which sought to increase community preparedness for extreme heat events. NIHHIS integrated heat and health information across the federal government to support on-the-ground efforts to reduce the impacts of extreme heat on human health.

The Biden administration took additional steps to address the impacts of climate change, extreme heat, and exposure to environmental hazards on human health. These actions included the Executive Order, “Revitalizing Our Nation’s Commitment to Environmental Justice for All”, which created the Office of Environmental Justice and External Civil Rights to identify gaps in data and the cumulative impacts of environmental justice on underserved groups. The Biden administration also implemented Executive Order, “Tackling the Climate Crisis at Home and Abroad”, to elevate climate change as a national security priority. Among other actions, it established the Office of Climate Change and Health Equity (OCCHE) within the Department of Health and Human Services, which aimed to address the impact of climate change on health and developed tools to help track heat-related illnesses. Additionally, the U.S. Department of Housing and Urban Development implemented measures, including increasing utility allowances to help mitigate the effects of extreme heat in public housing.

The Biden administration also implemented policies to specifically address the impacts of extreme heat on workers. In 2022, the Occupational Safety and Health Administration (OSHA) launched the National Emphasis Program for Outdoor and Indoor Heat-Related Hazards, an enforcement program that sought to identify and eliminate or reduce worker exposures to occupational heat-related illnesses and injuries. The program was an expansion of the agency’s heat-related illness prevention initiative. In 2021, OSHA began engaging with stakeholders to develop regulations to protect workers from heat-related hazards and established a Heat Injury and Illness Prevention Work Group, which made recommendations for heat injury and illness prevention standards. In 2024, OSHA issued a proposed rule on Heat Injury and Illness Prevention in Outdoor and Indoor Work Settings. The proposed rule would require employers to have written heat injury and illness prevention plans, heat injury precautions, trainings, and evaluations. Specifically, it would require employers to provide workers with cool drinking water, shade, and more rest breaks once the heat index reached 90 degrees. The public comment period on the rule has closed, but OSHA conducted public hearings through July 2, 2025. Beyond the proposed rule, the administration launched its heat.gov website as a source of information on heat and health. Moreover in 2024, the U.S. Department of Health and Human Services released its National Heat Strategy, a plan to coordinate federal action to address extreme heat and its impacts.

On the first day of its second term, the Trump administration began implementing policies and regulations that reverse efforts to mitigate the impacts of extreme heat on health. President Trump signed Executive Order “Initial Recissions of Harmful Executive Orders and Action” and Executive Order “Ending Illegal Discrimination and Restoring Merit-Based Opportunity”, which revoked key climate change and environmental justice policies implemented by prior administrations. As part of efforts to eliminate diversity and disparities-related initiatives, the Trump administration eliminated environmental justice programs. These actions included eliminating the Low Income Home Energy Assistance Program, which helps low income Americans, many of whom are people of color, pay their energy bills and stay cool during the summer, and terminating grants from the U.S. Department of Agriculture’s urban forestry program, which sought to increase tree canopy cover in low income communities around the country, addressing tree inequity and exposure to extreme heat. The Department of Health and Human Services also eliminated OCCHE, which had developed tools to track heat-related illnesses. The Trump administration also cut more than 90% of the National Institute for Occupational Safety and Health, including the entire heat team involved in efforts to address heat-related illnesses and deaths among workers in the farming and construction industries. In April, the Centers for Disease Control and Prevention (CDC) also fired staff from its Division of Environmental Health and Science Practice (DEHSP) who sought to protect communities from exposure to heat waves, wildfires, and other environmental hazards as well as provided grants to local and state officials to create heat wave plans and build community cooling centers. However, as of June 11^th, 2025, at least 150 staff from the National Center for Environmental Health and nearly all workers from the DEHSP were reinstated.

The Trump administration has also taken actions that block or weaken state level climate measures, including heat protection rules. On April 8^th, President Trump issued Executive Order “Protecting American Energy from State Overreach,” which directs the Attorney General to identify and block state and local laws that address climate change, environmental, social, and governance initiatives, and environmental justice. CDC’s Climate and Health Program’s Climate-Ready States and Cities Initiative, which helped state and local health departments prepare for and respond to climate-related health outcomes was among the programs cut from CDC’s DEHSP. Thirteen jurisdictions (AR, CA, CT, FL, ME, NY, NC, OR, PR, San Francisco, VT, WI, County of Santa Clara) were recipients of grants from the program. North Carolina’s Department of Health and Human Services reports that the state’s Heat Health Alert System and Heat-Related Illness Surveillance System may be at risk due to these cuts. The alert systems help monitor and identify unhealthy heat levels and heat-related illnesses.

State Actions Related to Extreme Heat and Health

In recent years, many states have enacted climate change legislation related to extreme heat and its impact on human health. Some states, including Maryland, Massachusetts, New York, Vermont, and California, have introduced Climate Superfund Bills that seek to hold fossil fuel producers and refiners responsible for their impacts on climate change, strengthen infrastructure, increase community environmental resilience, and mitigate the impacts of climate change. For example, New York’s Climate Superfund Bill, the “Polluter Pays Bill” is expected to collect $75 billion over 25 years to fund infrastructure and other projects, including the building of cooling centers to help residents stay cool during heat waves. Additionally, some states, including New Jersey, New York, North Carolina, and Arizona, have released Extreme Heat Action Plans that seek to build community resilience through coordinated government action, educating the public on extreme heat, and developing heat-ready infrastructure. The plans also direct and coordinate investments in historically disadvantaged communities that are disproportionately vulnerable to extreme heat. In North Carolina, the Heat Action Toolkit includes steps for health care providers and other leaders to care for disproportionately affected communities during heat waves. Some states are also engaging in programs to mitigate the impact of extreme heat on Medicaid enrollees. As of July 2024, 13 states have used Section 1115 Medicaid waivers to facilitate access to air conditioning. Oregon was the first state to implement this program to support vulnerable residents during extreme heat events.

California, Colorado, Maryland, Minnesota, Nevada, Washington, and Oregon are addressing the health impacts of extreme heat on workers through comprehensive heat protection standards (Figure 1). These standards aim to protect workers who are at greater risk of heat-related illnesses. For example, California’s Heat Illness Prevention Standard mandates access to shade, cool water, and training for outdoor workers. Washington’s Outdoor Heat Exposure Rules implement specific temperature thresholds that trigger safety measures for workers. Thirteen additional states are in the process of developing their own occupational heat safety standards, including New Mexico, which has a Heat Illness and Injury Prevention Rule under public comment.

In contrast, Texas and Florida implemented legislation that limit their county- and municipal-level governments’ abilities to provide certain heat protections for outdoor workers. In 2023, Texas enacted House Bill 2127, also known as the “Death Star Bill,” which preempts local laws, including heat protection standards for outdoor workers. In 2024, Florida enacted House Bill 433, which prevents city and county governments from requiring that employers, including government contractors, provide heat protections for outdoor workers outside of those required under state or federal law. These protections include requiring water breaks and other cooling measures for outdoor workers.

On July 4, 2025, President Trump signed the recent reconciliation bill into law which is expected to leave millions of low- and moderate-income people uninsured as they lose access to Medicaid. Additionally, questions remain about whether Congress will preserve enhanced Affordable Care Act (ACA) premium tax credits for those with marketplace coverage, without which millions more could find premiums unaffordable, disenroll, and become uninsured. Given LGBT adults have lower incomes and higher rates of Medicaid coverage than non-LGBT adults, these changes could disproportionately impact this community. Additionally, as LGBT people experience a wide range of health disparities, cost barriers may serve to exacerbate these differences.

This brief reviews new data from the May 2025 KFF Health Tracking Poll on LGBT adult’s experiences and concerns related to health care affordability. Overall, the survey findings show that LGBT adults face more widespread problems and concerns with health care affordability compared to non-LGBT adults. While this may reflect the lower average incomes of LGBT adults, many of these concerns cut across income, with similar shares of LGBT adults reporting concerns regardless of whether they have lower- or more moderate- income.

Findings

U.S. adults face challenges affording a range of common expenses, including those related to health care. Half (51%) of LGBT adults say that in the past year, they or a family member living with them has had problems paying for food, housing, transportation, or other necessities. This compares to three in ten non-LGBT adults. Over one-third (36%) of LGBT adults say they or a family member living with them has had problems paying for health care, compared to one in five (21%) non-LGBT adults. The differences between these groups may be due in part to LGBT adults generally being younger and having lower household incomes than non-LGBT adults. However, even when looking only at those under 35 years old, LGBT adults are still more likely than non-LGBT adults to say they or a household member had problems paying for necessities (62% vs. 38%) and health care (46% vs. 24%).

LGBT adults with household incomes under $40,000 are more likely than LGBT adults with higher incomes to say they or a household member have experienced problems paying for food, housing and other basic necessities in the past year (63% vs. 36%). Issues with health care affordability cut across income levels among LGBT adults, as 40% of lower-income LGBT adults report problems paying for health care in the past 12 months, statistically similar to the share of higher-income LGBT adults who say the same (32%).

Paying for health care can be a burden for individuals and families, including for LGBT adults who tend to have lower incomes. About half (52%) of LGBT adults say it is difficult for them to afford their health care costs, including about one in five (18%) who say it is very difficult. This experience is more common among LGBT adults than non-LGBT adults and is driven by those finding affordability very difficult.

These challenges with affordability can have an impact on access to and willingness to seek care. Half (51%) of LGBT adults report that they have skipped or postponed getting the health care they needed in the past year because of the cost compared to one-third (34%) of non-LGBT adults. About half of LGBT adults with incomes under $40,000 (50%) and about half of those with incomes of $40,000 or more (53%) say they have skipped getting needed health care because of the cost. Additionally, one in four (25%) LGBT adults say their health got worse because they skipped or postponed care because of the cost, compared to 18% of non-LGBT adults who say the same.

Similarly, costs related to prescription drugs also lead some LGBT adults to take actions to reduce their expenses in this area. About one-third (32%) have taken an over-the-counter drug instead of getting a prescription filled, a quarter (26%) have not filled a prescription because of the cost, and almost as many (23%) have cut pills in half or skipped doses. More than four in ten LGBT adults (44%) report taking at least one of these actions, compared to about a third (32%) of non-LGBT adults. Notably, similar shares of LGBT adults with incomes under $40,000 and those with incomes of $40,000 or more report taking at least one of these cost saving actions with their prescription medications (43% and 46% respectively).

Not surprisingly, these experiences translate to worry. Over half of LGBT adults express worry about being able to afford each of the following for themselves and their family: health costs, unexpected medical bills, rent/mortgage, food, gas/transportation, and utilities. Worry about affording health costs and unexpected medical bills are among the expenses of greatest concern to LGBT adults, with about two-thirds reporting they are worried about these expenses (68% and 66%, respectively). LGBT adults are more likely than non-LGBT adults to report affordability concerns related to rent/mortgage, food, and gas/transportation and similarly likely to report such concerns related to health care costs.

On April 21, 2025, the Supreme Court is hearing oral arguments in Kennedy v. Braidwood Management. In this case, Braidwood Management, Christian owned businesses and six individuals in Texas, have challenged the Affordable Care Act’s (ACA) requirement to cover preventive services. The Supreme Court is narrowly considering whether the structure of the US Preventive Services Task Force (USPSTF) — an independent entity convened by the federal government that makes recommendations for preventive services that nearly all private insurances must cover without cost-sharing — violates the U.S. Constitution’s Appointments Clause. That provision states that “officers of the United States” may only be appointed by the president, subject to the advice and consent of the Senate and the litigants are claiming that the USPSTF does not have the authority to set coverage requirements. The Supreme Court is not considering the litigants’ other claims including those that the recommendations violate the Religious Freedom Restoration Act (RFRA), or their Appointment’s Clause claims about the Advisory Committee on Immunization Practices (ACIP), or the Health Resources and Services Administration (HRSA).

Even though President Trump had supported ACA repeal in his first term, his administration is  defending the lawsuit. On its face this may seem unexpected, but the outcome of the case could give the administration broader latitude to shape the recommendations issued by the entities that were originally established with the goal of providing independent analysis and review. This brief provides an overview of the most recent ACA case under review at the Supreme Court and discusses the implications of the potential rulings by the high court.

What Is the Case?

In the original case, filed in 2022, the respondents claimed that the preventive services requirements for private health insurance are unconstitutional and also that the requirement to cover pre-exposure prophylaxis treatment (PrEP) (medication to prevent getting HIV from sex or injection drug use for those at risk) violates the Religious Freedom Restoration Act (RFRA). The respondents are six individuals and Christian-owned businesses. Braidwood Management, a for-profit closely held organization, owned by a trust, with Dr. Steven F. Hotze, as the sole trustee and beneficiary. Braidwood is self-insured and provides health insurance to its 70 employees. The other respondent is Kelley Orthodontics, who identify themselves as a “Christian professional association” owned by respondent, John Kelley. The respondents assert both economic harm for having to pay more money for a health plan that includes services they do not want or need, and religious harm for having to include services they object to.

In 2022, the District Court, agreeing with Braidwood’s arguments, ruled that the appointment of members to USPSTF violated the Appointments Clause and that the requirement to cover PrEP violates RFRA. However, the Court also found that the ACA’s delegation to ACIP and HRSA is not in violation of the Appointments Clause since the Secretary of HHS effectively has the authority to ratify or not the ACIP and HRSA recommendations. In 2023, the District Court issued a ruling striking down the ACA’s requirement for no cost coverage of preventive services recommended or updated by USPSTF on or after March 23, 2010. This ruling, however, was subsequently paused as the case made its way through the appeals process

In June 2024, the 5th Circuit Court of Appeals affirmed the district court’s ruling that the ACA’s requirement to cover without cost-sharing services recommended by United States Preventive Services Task Force (USPSTF) is unconstitutional. However, they ruled that a nationwide remedy was not proper and that only the plaintiffs are permitted to exclude USPSTF recommended services from their plans. The Appeals Court sent back to the district court the plaintiffs’ claim that the Secretary of Health and Human Services’ ratification of HRSA and ACIP recommendations violates the Administrative Procedure Act for further briefing and a judgment. The Supreme Court is considering only the arguments regarding whether the structure of USPSTF violates the Appointment’s Clause, not the other bodies that make preventive services recommendations, nor the religious harm included in the original case. However, a separate set of claims regarding HRSA and ACIP are still being considered by the district court and could be before the Supreme Court at a future date.

What Is the Supreme Court Considering?

The current case before the Supreme Court is reviewing the 5^th Circuit Court of Appeals decision holding that appointments of individuals to the USPSTF and the recommendations made by the USPSTF after the enactment of the Affordable Care Act in 2010 (see Table 1) violate the Appointments Clause of the U.S. Constitution since they were not appointed by the President and confirmed by the Senate.

Braidwood et al. contend that the requirement for health plans to cover preventive services recommended or amended by USPSTF since the enactment of the ACA in March 2010 violates the Appointments Clause of the Constitution. They argue this is unconstitutional since the ACA does not allow the Secretary of HHS to reject the recommendations made by the Task Force or require it to make specific recommendations, meaning that USPSTF members have the capacity to unilaterally determine the preventive care that private insurers must cover and act as officers of the United States. Additionally, they contend the Secretary lacks the authority to remove USPSTF members at will. They argue that for USPSTF’s structure and recommendations to be constitutional, members would have to be appointed by the president and Senate.

The federal government argues that the HHS Secretary has constitutionally appropriate oversight over USPSTF because they may remove members at will and determine when health insurance issuers must start providing coverage for new recommendations. HHS additionally argues that if the Court holds that capacity to remove members at will is not sufficient oversight, it can remedy this by construing federal law to allow the Secretary to review USPSTF recommendations directly, which would address any remaining questions of oversight. This degree of supervision by the Secretary of HHS, the agency argues, would mean that members of the Task Force are “inferior officers,” who may be appointed or removed by the Secretary and would not require appointment by the president and Senate.

Potential Impact on Coverage

If the Court rules in favor of Braidwood, private health insurers would no longer be required to cover, without cost sharing, preventive services recommended by USPSTF after 2010 when the ACA was enacted. Any new service that was recommended or updated by USPSTF after March 2010 (and is not also recommended by HRSA or ACIP) would no longer be required to be covered without out-of-pocket costs. For example, services and medications like statins to prevent heart disease, lung cancer screening, and PrEP to prevent HIV could be subject to copays, deductibles, or coinsurance, potentially deterring access to these services. This essentially means that the standards and recommendations that the federal government would be able to enforce would not reflect current or future standards and evidence, locking required preventive services in place as of the state of the science in 2010.

Although many of the friend of the court briefs presented to the Supreme Court for this case focus on the impact of coverage of USPSTF recommendations with no cost-sharing, a ruling in favor of the federal government does not guarantee that coverage will be required for these preventive services. As the federal government argues, HHS Secretary Robert F. Kennedy Jr. has the power to remove USPSTF members at will and to review the recommendations they issue. This means that the Trump administration could change the membership of the USPSTF in ways that may significantly alter the recommendations it issues. Additionally, in their briefs, the Trump Administration’s HHS contends the Secretary can direct that the implementation of recommendations issued by USPSTF can be delayed indefinitely and that the Secretary may have additional authority to supervise and veto Task Force recommendations. In their brief they state, “In addition to removing Task Force members at will, the Secretary may supervise and review their recommendations directly.”

The Supreme Court is expected to issue its ruling in June. Regardless of how the Court rules in this specific case, it will likely not be the final word on the ACA required coverage of preventive services recommended by USPSTF, ACIP and HRSA.

Since the enactment of the Affordable Care Act (ACA) in 2010, more than 2,000 legal challenges have been filed in state and federal courts contesting part or all of the ACA. The most recent challenge involves the ACA requirement that most private insurance plans cover recommended preventive care services without cost sharing. In this case, Braidwood Management v. Becerra, Christian owned businesses and six individuals in Texas assert that (1) the requirements in the law for specific expert committees and a federal government agency to recommend covered preventive services is unconstitutional, and that (2) the requirement to cover preexposure prophylaxis (PrEP), medication for HIV prevention, violates their religious rights. If the plaintiffs prevail on either the constitutional or the religious claims, the government’s ability to require insurance plans to cover evidence-based preventive services without cost-sharing may be limited.

On September 7, 2022, Judge Reed O’Connor at the US District Court in the Northern District of Texas ruled partly in favor of the plaintiffs and partly in favor of the Department of Health and Human Services (HHS), which is defending the ACA. On March 30, 2023, Judge O’Connor issued a ruling for the remedy in this case, Braidwood Management v. Becerra, striking down part of the ACA’s requirement for no cost coverage of preventive services recommended or updated by the U.S. Preventive Services Task Force (USPSTF) on or after March 23, 2010 and finding that the requirement to cover PrEP medications for HIV prevention violates the rights of the plaintiffs who have religious objections to PrEP. The federal government appealed this decision and on May 15, 2023 the 5^th Circuit Court of Appeals issued an administrative stay of the district court’s ruling. This means that the federal government can continue enforcing the preventive services requirement while the 5^th Circuit considers the Department of Justice’s motion for a stay pending appeal. This brief explains the preventive services coverage requirements, the basis of the lawsuit, next steps in the litigation, and the potential implications.

Preventive Services Provision

The ACA requires most private health insurance plans to cover a range of recommended preventive services without any patient cost-sharing. Preventive services include a range of services including screening tests, immunizations, behavioral counseling, and medications that can prevent the development or worsening of diseases and health conditions. The preventive services that private plans and Medicaid expansion programs must cover are based on those receiving an A or B level recommendation by the U.S. Preventive Services Task Force (USPSTF), vaccines recommended by the Advisory Committee on Immunization Practices (ACIP), and the Health Resources and Services Administration (HRSA) based on recommendations issued by the Women’s Preventive Services Initiative and issued by the Bright Futures for Children program. As new recommendations are issued or updated, coverage must commence in the next plan year that begins on or after exactly one year from the recommendation’s issue date.

Preventive Services Litigation

In the current case, Braidwood Management Inc. v. Becerra, the plaintiffs claim that the preventive services requirements for private health insurance are unconstitutional and the requirement to cover PrEP-specific coverage requirement violates the Religious Freedom Restoration Act (RFRA) (Table 2). The plaintiffs are six individuals and Christian owned businesses. Braidwood Management, a for-profit closely held organization, owned by a trust, with Dr. Steven F. Hotze, a religious Christian, as the sole trustee and beneficiary. Braidwood is self-insured and provides health insurance to its 70 employees. The other plaintiff is Kelley Orthodontics, a Christian professional association owned by plaintiff John Kelley. The plaintiffs are asserting both economic harm for having to pay more money for a health plan that includes services they do not want or need, and religious harm for having to include services they object to.

Plaintiff Claims

Position 1: The Preventive Services Provision violates the Appointments Clause

The plaintiffs contend that the ACA provisions violate the Appointments Clause of the US Constitution, which provides that “officers of the United States” may only be appointed by the president, subject to the advice and consent of the Senate. They claim that the members of USPSTF, ACIP and HRSA are “officers of the United States” who have not been appointed in conformity with the Appointments Clause because they were not nominated by the President and approved by the Senate. Rather, members of these bodies are appointed by the heads of agencies within HHS (Table 1). The plaintiffs are asking the court to declare all preventive-care mandates based on recommendations or guidelines issued by USPSTF, ACIP or HRSA after March 23, 2010 (the day the ACA was signed into law) as unconstitutional. The plaintiffs contend that the ACA does not allow the Secretary of HHS or the directors of the agencies within HHS to reject the recommendations made by the committees and is thus insufficient oversight.

Conversely, HHS contends that “there are numerous statutes that incorporate by reference independent recommendation without creating any requirements that the heads of the recommending bodies be appointed as officers of the United States.” They cite examples such as a public health regulation related to water standards for consumer products that outsources the development of those standards to a non-governmental organization. Similarly, they cite a law requiring states and designated database providers to use a format for an electronic database approved by an expert panel that is not subject to approval by the head of a federal agency.

Plaintiff Position 2: The Preventive Services Provision violates the Nondelegation Doctrine

The plaintiffs contend the ACA’s preventive services provisions violate the nondelegation doctrine – based on the theory that since Article I of the Constitution vests legislative power in Congress, there are limits to the authority that Congress can delegate to federal administrative agencies. The current caselaw precedent requires statutes that delegate authority to agencies to supply an “intelligible principle” to guide and provide a boundary or limit on the agency’s discretion. The plaintiffs contend that an “intelligible principle” is lacking: “Yet there is nothing in the text of section 300gg-13(a) that purports to guide the discretion of [US]PSTF, ACIP or HRSA when choosing the preventive care that private insurance must cover.” The plaintiffs contend that this constitutional nondelegation problem can be averted if the phrase “current recommendations is construed to refer to the recommendations that existed when the ACA was signed into law.”

The plaintiffs point to comments in the Supreme Court’s opinion in Little Sisters of the Poor, as evidence that the current majority believes there could be a constitutional issue with delegation to HRSA for preventive services for women, including contraception: “On its face, then, the provision grants sweeping authority to HRSA to craft a set of standards defining the preventive care that applicable health plans must cover. But the statute is completely silent as to what those “comprehensive guidelines” must contain, or how HRSA must go about creating them. The statute does not, as Congress has done in other statutes, provide an exhaustive or illustrative list of the preventive care and screenings that must be included.” While the Little Sisters case, challenging the contraceptive coverage regulations, was not decided based on the nondelegation doctrine, there is growing speculation that the Supreme Court is poised to revisit the nondelegation doctrine to make it more difficult for Congress to delegate authority to federal agencies to address major policy details.

Plaintiff Position 3: The Preventive Services Provision violates the Religious Freedom Restoration Act

The plaintiffs assert the requirements to cover PrEP violates the Religious Freedom Restoration Act. Relying on the Supreme Court’s ruling in Burwell v. Hobby Lobby, the plaintiffs contend that employers are left with a “Hobson Choice” to provide health insurance that covers these medications and services that violate their religious beliefs or refuse to offer any health insurance to its employees. Notably, the plaintiffs state the requirement to cover PrEP “imposes a substantial burden on the religious freedom of those who oppose homosexual behavior on religious grounds” claiming further that PrEP drugs “facilitate and encourage homosexual behavior, prostitution, sexual promiscuity, and intravenous drug use.” The plaintiffs also contend the provision violates individuals who have religious objections and wish to purchase health insurance without PrEP coverage.

District Court’s Decision

Finding that Braidwood has standing to pursue its claims, on September 7, 2022, Judge O’Connor ruled that that the ACA’s delegation to U.S. Preventive Services Task Force violates the Appointments Clause because the Secretary cannot direct USPSTF to give a specific preventive service an “A” or “B” rating . The Court finds that the Secretary does not have any authority to direct which services are covered under § 300gg-13(a)(1) and concludes that USPSTF members are officers of the United States and that their selection does not comply with the Appointments Clause procedures. However, the Court also found that the ACA’s delegation to ACIP and HRSA are not in violation of the Appointments Clause since the Secretary of HHS effectively has the authority to ratify or not the ACIP and HRSA recommendations.

The court rejected the plaintiff’s nondelegation doctrine claims stating that the preventive care law met the criteria set out in prior Fifth Circuit cases on when Congress has properly provided an “intelligible principle” to guide agency discretion. Judge O’Connor noted that the Supreme Court might soon “reexamine or revive” the nondelegation doctrine, but it’s too early to predict a change in the nondelegation criteria from comments made in the Little Sisters case.

Relying on the reasoning in the Supreme Court’s decision in Hobby Lobby, the District Court also found that the requirement to cover PrEP violates Braidwood’s religious rights under the Religious Freedom Restoration Act (RFRA).

On March 30, 2023, District Court Judge O’Connor issued a ruling for the remedy in the case, Braidwood Management v. Becerra, striking down part of the ACA’s coverage requirement for preventive services. Effective immediately nationwide, the ruling blocks the federal government from requiring health plans to cover services recommended or updated by the U.S. Preventive Services Task Force (USPSTF) on or after March 23, 2010. The ruling did not affect coverage requirements for USPSTF services recommended prior to that date and also did not affect the requirement for plans to cover Women’s Preventive Services recommended by Health Resources and Services Administration (HRSA) or vaccines recommended by the CDC’s Advisory Committee on Immunization Practices (ACIP). Additionally, the judge ruled that the requirement to cover PrEP medications for HIV prevention violates the rights of the plaintiffs who have religious objections to PrEP. The federal government has appealed this decision to the United States Court of Appeals for the 5^th Circuit. On May 15, 2023 the 5^th Circuit Court of Appeals issued an administrative stay of the district court’s ruling. This means that federal government can continue enforcing the preventive services requirement while the 5^th Circuit considers the Department of Justice’s motion for a stay pending appeal.

Implications for Coverage and Access to Preventive Services in Private Health Insurance

Even if the Court’s ruling upholds the authority of HRSA and ACIP, USPSTF recommendations include a broad range of services across multiple populations and health conditions. This includes cancer screenings, preventive medications for chronic conditions such as cardiovascular disease, counseling on health behaviors related to nutrition and weight management, alcohol and drug use, tobacco cessation services, screening for depression, and prenatal services, Elimination of the coverage requirements for USPSTF recommendations would invalidate the requirement to cover all of these services without cost sharing.

Religious Objections to PrEP Coverage

The ACA’s contraceptive coverage provision has been one of the most litigated parts of the law, with three cases brought by employers who object to the coverage on religious grounds reaching the Supreme Court. The Court’s ruling on the PrEP coverage requirement is the first time a court has ruled in favor of plaintiffs challenging another preventive service based on religious objections.

If employers who object to including coverage for PrEP in their plans are allowed to exclude the coverage, employees could lose coverage for a medication that could prevent the transmission of HIV and HIV related morbidity and mortality. PrEP reduces the risk of acquiring HIV by approximately 99% through sex and 74% through injection drug. Given that over 80% of PrEP users are covered by commercial insurers, this could have significant ramifications for cost and access should the ruling be applied broadly. The cash price for generic PrEP (Emtricitabine / Tenofovir), which is about 99% effective at preventing HIV through sex, is approximately $30 per month. This compares to an estimated lifetime HIV treatment cost of $420,285 ($1,079,999 undiscounted).

In addition, allowing employers to exclude PrEP because of religious objections has the potential to open the door to employers objecting to other services, such as vaccines.

Implications for Access to Preventive Services in Medicaid & Medicare

While the plaintiffs in Braidwood are only challenging the preventive services required in private health insurance plans, Medicaid and Medicare also have requirements for coverage of preventive services. States that have expanded Medicaid eligibility under the ACA must cover Essential Health Benefits (EHBs) as defined by the ACA. One of the categories of EHBs is preventive services, which CMS has defined to include the same services as required for private insurance plans. As a result, all states must cover the preventive services recommended by USPSTF, ACIP and HRSA for enrollees who qualify through the Medicaid expansion pathway. If this litigation is successful in challenging any of the preventive services required in private health insurance plans, the requirement for preventive services for enrollees who qualify through the Medicaid expansion pathway would be left to individual states to determine based on their state private insurance benchmark plan, which may not include all the services currently required.

While Medicaid relies on the same agencies to determine the recommended services as private insurance plans must cover, the process is slightly different under Medicare. In that case, under the national coverage determination process, the Secretary of HHS has the authority to determine coverage for preventive services for Medicare beneficiaries. The ACA eliminated Medicare cost sharing, including coinsurance and deductibles, for most preventive benefits that are rated A or B by the USPSTF, beginning in 2011, and authorized the Secretary of HHS to add coverage for new preventive services, using the national coverage determination process, if they are: reasonable and necessary for prevention or detection of illness; rated A or B by the USPSTF; and appropriate for Medicare beneficiaries. Coverage under Medicare for several preventive services, including some rated A or B by the USPSTF, predated the ACA and is specified in statute, and therefore would not be affected by any ruling on the current litigation.

The current litigation is brought by employers and individuals who allege economic and religious harm from the preventive services requirements in private health insurance. Any litigation challenging the preventive services requirements under Medicaid or Medicare would need to be brought by plaintiffs who suffer a tangible harm to establish legal standing.

Broader Implications

Overturning the preventive services requirement broadly would have significant implications for coverage of a broad range of clinical preventive services. Should the final decision for this case be found in favor of the plaintiffs, and applied nationwide, then millions of people may be vulnerable to loss of guaranteed coverage of preventive services without cost sharing. It will again be at the discretion of plans and employers to determine what preventive services will be covered and whether they will charge cost-sharing, lowering premiums in some cases, but likely creating a patchwork of coverage for these services. This could widen access barriers for groups that already face increased barriers dure to cost, including low-income people and people of color.

Should this case reach the US Supreme Court, the broader implications of a final decision in favor of the plaintiffs will depend on the basis for the ruling. The Court could rule in favor of the plaintiffs based on the Appointments Clause argument, similar to Judge O’Connor’s decision, finding that USPSTF members are officers of the United States who have not been properly appointed.

The potential implications are much broader, however, if the Supreme Court revisits and revises the nondelegation doctrine and restricts Congress’ ability to delegate the development of very precise standards to federal agencies. Without allowing the agencies to update the recommended preventive services, Congress would have to pass a new law every time the USPSTF recommends a new preventive service in order for it to be covered without cost-sharing. Any decision that changes the standard for Congress’ delegation could limit agency discretion to address a broad range of health and other issues through regulation.

Beyond preventive care, much of health policy and law has been developed through the delegation of authority to federal agencies to develop standards to address complex public policy and technical requirements—from the prescription drug approval process of the FDA to the apparatus set up to review and annually update the Medicare fee schedule. The ACA itself specifically left it up to the Secretary of HHS to define the essential health benefits that insurers must cover in the individual and small group insurance markets within the framework of the ten categories of items and services that Congress set out. The authority Congress gave to HHS to temporarily waive certain healthcare requirements during the COVID public health emergency is probably the best example of how delegated authority has functioned to benefit public health as well as access to public and private health insurance coverage. Any movement by the Court to restrict Congress’ authority to delegate in these areas could have a profound effect on the daily lives of Americans.

We do not know how quickly the United States Court of Appeals for the 5^th Circuit will rule on this case. Ultimately, the parties are likely to appeal to the Supreme Court.

In 2025, states have enacted or proposed a range of legislation that will impact immigrants’ access to state-funded health coverage and other public programs. Several states have proposed rolling back state-funded health coverage programs that expand coverage to immigrants regardless of status as part of broader state actions to reduce budget deficits amid economic uncertainties. At the same time, Congressional Republicans passed the budget reconciliation bill, which would reduce federal health program funding by more than $1 trillion over the next decade for states according to estimates from the Congressional Budget Office (CBO). These funding cuts could exacerbate financial pressure on states to eliminate state-funded coverage programs despite the potential for higher demand due to provisions limiting immigrants’ eligibility for Medicaid, Medicare, and Affordable Care Act (ACA) Marketplaces. States have also enacted laws expanding immigration enforcement that reflect the Trump administration’s increased interior enforcement activities to support mass deportation. More limited access to health coverage options and increased immigration enforcement activities may increase fear and uncertainty among immigrant families and have negative physical and mental health implications, including for their citizen children.

In contrast, some states have moved to limit interior enforcement activities and increase immigrants’ access to certain public benefits. While some states are seeking to enhance protections for immigrants, the Trump administration signed an executive order directing federal agencies to suspend federal grants and contracts with states or local jurisdictions identified as obstructing enforcement of federal immigration laws, or “sanctuary jurisdictions”, which may limit states’ ability to implement protections for immigrants.

This policy watch summarizes recent proposed actions by states related to state-funded health coverage for immigrants and trends in other legislation enacted during the 2025 session that have implications for immigrants. It is based on KFF analysis of publicly available materials and the National Conference of State Legislatures’ Immigration Legislation Database.

Access to State-Funded Health Coverage and Other Programs

As of June 2025, of the 14 states that offer state-funded health coverage to at least some immigrants regardless of status, three states (California, Illinois, and Minnesota) plus D.C. have proposed or enacted budgets to end or limit new enrollment of adults in these programs as part of broader efforts to reduce state budget deficits. Economic uncertainties and federal funding reductions that may reduce state revenues and the rising costs of health care and social services have driven states across the country to consider measures to reduce spending. California plans to maintain coverage for existing enrollees in their state-funded health coverage program but pause new enrollment for immigrant adults ages 19 and older starting in January 2026, end state-funded dental benefits starting in July 2026, and charge $30 monthly premiums to currently enrolled adults ages 19-59 starting in July 2027. Illinois plans to end their state-funded health coverage program for all immigrant adults ages 42 to 64 regardless of immigration status enrolled in the Health Benefits for Immigrant Adults (HBIA) program starting July 2025. This is in addition to Illinois’ previously announced pause in new enrollment in the Health Benefits for Immigrant Seniors (HBIS) program, which provides state-funded health coverage for immigrants 65 and older regardless of status. Minnesota plans to end their state-funded health coverage program for all undocumented immigrant adults ages 18 and older by 2026. The D.C. mayor’s proposed budget, subject to council approval, proposes ending coverage of immigrant adults 21 and older regardless of status in their locally-funded Healthcare Alliance program. Losing health coverage may have negative impacts on health care access and health outcomes as research suggests that coverage expansions for immigrants are associated with lower uninsured rates and improved access to care.

As of June 2025, states have also enacted legislation that would limit immigrant access to certain public benefits. In March 2025, Idaho enacted legislation that decreases the maximum income refugees in Idaho can earn to remain eligible for the Refugee Medical Assistance program from 150% to 133% of the federal poverty level (FPL). Idaho also enacted legislation in April 2025 preventing undocumented immigrants from accessing public benefits that were previously exempt from immigration status verification, including publicly-funded vaccinations, communicable disease testing, prenatal and postnatal care for women, crisis counseling, and food assistance for children. In May 2025, Tennessee enacted legislation that would hold churches and charitable organizations liable for providing housing aid to immigrants without legal status who commit crimes, which may reduce the services available to immigrants.

In contrast, several states have enacted legislation in 2025 to increase access to certain public benefits, the health care workforce, and educational opportunities for immigrants. In February 2025, Massachusetts enacted legislation requiring resettlement agencies to coordinate the provision of services to immigrant and refugee families and pregnant women. In February 2025, New York enacted legislation to direct their Military Immigrant Family Legacy Program to connect noncitizen military members and their families to immigration legal assistance. In March 2025, Utah enacted legislation to create a new Refugee Services Office to coordinate services and benefits available to refugees. Washington and Oklahoma enacted legislation in April and May 2025, respectively, that would allow international medical graduates to practice in health care facilities in certain situations. In May 2025, Oregon enacted legislation exempting asylum seekers enrolled in the state’s public universities from paying non-resident tuition and fees, and Colorado enacted legislation that removed a requirement for immigrants to attest that they have applied or will apply for lawful presence when applying for in-state tuition at the state’s public universities.

Immigration Enforcement

Several states have enacted legislation in 2025 to enhance law enforcement against undocumented immigrants and implement increased immigration verification requirements for driver’s licenses and voting. Some states have enacted legislation related to law enforcement actions against immigrants, continuing trends in recent years on immigration enforcement. For example, Indiana enacted legislation in May 2025 which would enhance criminal sentencing if the individual is an undocumented immigrant, and Missouri enacted legislation in March 2025 that would require law enforcement to submit immigration status data to a statewide database. Some states also have prohibited local level policies that would limit cooperation with federal immigration enforcement authorities. For example, legislation enacted in North Dakota in April 2025 and in New Hampshire in May 2025 prohibit state and local government entities from adopting sanctuary policies. Several states have also continued passing driver’s licensure laws impacting immigrants. For example, Wyoming enacted legislation in February 2025 limiting noncitizens’ access to driver’s licenses. Kansas and Tennessee enacted legislation in April 2025 that would create a database of noncitizens holding driver licenses. States have also enacted legislation related to voting, such as in Alabama in May 2025 that prevents foreign driver’s licenses from being used as voter identification and in Wyoming in March 2025 that would allow the state to verify immigration status during voter registration.

In contrast, some states have also enacted legislation that may limit federal immigration enforcement in certain settings. In March 2025, Connecticut and Delaware enacted legislation requiring every school to have a designated administrator and a plan for interacting with federal immigration authorities and prohibiting public schools from sharing student information without a warrant. In May 2025, Maryland enacted legislation prohibiting sensitive locations such as schools and libraries from allowing federal immigration enforcement officials entry, with some exceptions. In May 2025, Colorado enacted legislation that would limit sharing of immigration status with federal immigration authorities and increase protections for immigrants in public facilities from enforcement.

The Medicare Part D program provides an outpatient prescription drug benefit to more than 50 million older adults and people with long-term disabilities in Medicare who enroll in private plans, including stand-alone prescription drug plans (PDPs) to supplement traditional Medicare and Medicare Advantage prescription drug plans (MA-PDs) that include drug coverage and other Medicare-covered benefits. This brief analyzes Medicare Part D enrollment and costs in 2025 and trends over time, based on data from the Centers for Medicare & Medicaid Services (CMS).

Highlights for 2025

• Enrollment in Medicare Part D stand-alone PDPs remained stable at 23 million in 2025, despite monthly premium increases in some PDPs of up to $35, the maximum increase allowed for plans participating in the Part D premium stabilization demonstration, which included measures intended to stabilize the PDP market as major changes to the Part D benefit took effect in 2025, including a new $2,000 out-of-pocket spending cap.
• Medicare Advantage continues to be the primary source of Part D drug coverage for people with Medicare, with close to 32 million enrollees. Overall, Part D enrollment is concentrated in a handful of large plan sponsors, including UnitedHealth, Centene, Humana, and CVS Health.
• Enrollment in the Part D Low-Income Subsidy (LIS) decreased in 2025, from 13.7 million to 13.1 million, the first decrease in enrollment since 2007, the first full year of the Part D program. This decrease is likely related to Medicaid disenrollment among dual-eligible individuals that stemmed from the unwinding of the Medicaid continuous enrollment provision in place during the COVID-19 pandemic
• Average monthly premiums decreased for both PDPs and MA-PDs in 2025, but the average monthly premium for Part D coverage is still substantially higher for PDPs than for MA-PDs ($39 versus $7), mainly because most MA-PD enrollees are in zero-premium plans, which is related to the ability of Medicare Advantage plan sponsors to reduce their Part D premiums using rebates, which are not available to PDP sponsors.
• Median cost-sharing amounts for drugs covered on some formulary tiers are the same or similar in PDPs and MA-PDs, but PDP enrollees are more likely than MA-PD enrollees to face coinsurance for preferred brands and non-preferred drugs, while MA-PD enrollees face higher median coinsurance for specialty tier drugs.

Part D Enrollment

Medicare Advantage drug plans continue to enroll more beneficiaries than stand-alone drug plans, but PDP enrollment has stabilized

More than half (58%) of all Part D enrollees in 2025 are in Medicare Advantage drug plans, continuing a trend of increasing enrollment in Medicare Advantage plans (Figure 1). Despite some concerns about the stability of the stand-alone PDP market as changes to the Part D benefit took effect in 2025 and an overall reduction in the number of PDPs for 2025, that decline did not result in lower overall PDP enrollment in 2025. In fact, the number of PDP enrollees has increased by 1 million since 2023. MA-PD enrollment growth was more than three times larger over the same period, however, with enrollment in MA-PDs increasing by 3.3 million between 2023 and 2025.

Part D Low-Income Subsidy enrollment is tilted even more towards Medicare Advantage drug plans than overall Part D enrollment, but overall LIS enrollment decreased in 2025

The Medicare Part D Low-Income Subsidy (LIS) provides financial assistance with drug plan premiums and cost sharing for low-income enrollees. Two-thirds of LIS enrollees – 8.8 million out of 13.1 million – are enrolled in Medicare Advantage drug plans in 2025 (Figure 2). Six million LIS enrollees are enrolled in Medicare Advantage Special Needs Plans (SNPs), nearly all of whom are in plans designed specifically for dual-eligible individuals (Table 1). LIS enrollment in MA-PDs has increased over time in tandem with overall enrollment of Medicare beneficiaries in Medicare Advantage plans.

At the same time, Part D LIS enrollment overall decreased in 2025, from 13.7 million to 13.1 million – the first decrease in enrollment since 2007, the first full year of the Part D program. This decrease is likely due to Medicaid disenrollment among dual-eligible individuals that stemmed from the unwinding of the Medicaid continuous enrollment provision in place during the COVID-19 pandemic. Medicare beneficiaries with Medicaid coverage (dual-eligible individuals) automatically qualify for LIS, meaning a loss of Medicaid coverage would lead to a loss in LIS unless eligible individuals apply and enroll separately.

Five firms cover nearly three-fourths of Part D enrollees in 2025

Part D enrollment is concentrated in a handful of top plan sponsors, with 5 firms covering 73.5% of all Part D enrollees in 2025, or 40.2 million out of 54.8 million enrollees (Figure 3). Nearly 1 in 4 enrollees (12.6 million) are in Part D plans sponsored by UnitedHealth, including both stand-alone PDPs and MA-PDs. CVS, Humana, and Centene each have around 15% of the Part D market, with enrollees in both types of Part D plans.

Centene is the top firm in the PDP market, with one-third (34%) of all PDP enrollees, followed by CVS Health (18%) and UnitedHealth (15%), while UnitedHealth is the top firm in the MA-PD market, with 29% of all MA-PD enrollees, followed by Humana (17%) and CVS Health (11%).

Nearly 5 million PDP enrollees – more than 1 in 4 – are enrolled in the lowest-premium PDP in 2025

Among the 12 national PDPs available in 2025, only one – Wellcare Value Script – has an average monthly premium less than $10 and, likely for this reason, has attracted a substantial share of all PDP enrollees, with more than 1 in 4, or 5 million, PDP enrollees in 2025 (Figure 4). Between 2024 and 2025, Wellcare Value Script gained 1.2 million PDP enrollees, as several other national PDPs experienced smaller increases and some PDPs lost enrollment, even after taking plan consolidations into account (Table 2).

The number and share of LIS enrollees in national PDPs vary considerably, which is related to the fact that only 5 of these 12 plans are benchmark PDPs, meaning they are available to Part D enrollees receiving LIS for no premium. For example, a majority of all enrollees in Wellcare Classic (83% or 2.1 million) are receiving LIS; this is a benchmark plan in 33 of 34 PDP regions (Table 3). More than two-thirds of enrollees in Cigna Healthcare Assurance Rx, a benchmark plan in 12 regions, are LIS enrollees (69% or 0.7 million). In contrast, only 3% of the 5 million enrollees in Wellcare Value Script are LIS enrollees; despite its low average premium, this is an enhanced PDP and therefore does not qualify to be a benchmark plan.

Overall, 15% (0.6 million) of the 4.2 million PDP enrollees receiving LIS (excluding those in employer group plans) are enrolled in non-benchmark PDPs. LIS enrollees in non-benchmark plans are required to pay a portion of the plan’s premium for the cost of basic benefits that exceeds the LIS benchmark amount in their region or if their plan charges a premium for enhanced benefits.

Part D Premiums

Average monthly premiums decreased for both PDPs and MA-PDs in 2025, but the average monthly premium for Part D coverage is still substantially higher for PDPs than for MA-PDs

The Part D premium demonstration for stand-alone PDPs established by the Biden administration in 2024 worked as intended to stabilize PDP premiums, with the average monthly PDP premium decreasing 9% between 2024 and 2025 from $43 to $39, despite monthly premium increases in some PDPs of up to $35, the maximum increase allowed for plans participating in the premium stabilization demonstration.

The $39 average monthly PDP premium, based on current enrollment after the end of the open enrollment season for 2025, is lower than the estimated $45 monthly PDP premium for 2025, which was based on enrollment in June 2024 and did not account for plan switching by current enrollees or plan choices by new enrollees during the open enrollment period. Taking into account plan switching and new enrollment into lower premium plans resulted in the lower enrollment-weighted average monthly premium for 2025.

On average, PDP enrollees continue to pay substantially more each month for their Part D drug coverage than enrollees in Medicare Advantage drug plans. The $39 average monthly PDP premium is nearly 6 times higher than the $7 average monthly premium for drug coverage in MA-PDs (weighted by enrollment) (Figure 5). (The total average premium for MA-PDs, including all Medicare-covered benefits, is $13 per month in 2025.) The weighted average MA-PD premium decreased by 25% between 2024 and 2025 (down from $9 to $7).

The difference between average monthly premiums for drug coverage offered by PDPs and MA-PDs has been growing larger, with the average PDP premium rising and the average MA-PD premium falling. The average premium for drug coverage in MA-PDs is heavily weighted by zero-premium plans because MA-PD sponsors can use rebate dollars from Medicare payments to lower or eliminate their Part D premiums. Rebates to Medicare Advantage plans have doubled since 2018 and now exceed $2,000 per year per beneficiary.

Eight in 10 MA-PD enrollees without low-income subsidies pay no monthly premium for Part D coverage compared to 3 in 10 PDP enrollees

Nearly 80% of MA-PD enrollees without low-income subsidies (15.1 million) pay no monthly premium for Part D coverage in 2025, compared to 31% of PDP enrollees without LIS (4.3 million). For 2025, Medicare beneficiaries had access to 29 zero-premium MA-PD plans on average, whereas only 1 PDP – Wellcare Value Script – was available for zero premium for non-LIS enrollees in most PDP regions (29 out of 34), and 6 other PDPs were available for zero premium in 5 or fewer PDP regions.

Just over half of PDP enrollees without LIS (51%) pay $30 or more – including 1 in 7 PDP enrollees without the LIS (14%) who pay at least $100 per month for their Part D plan (Figure 6). In contrast, less than 10% of MA-PD enrollees pay $30 or more per month for Part D coverage, and less than 1% pay $100 per month or more.

Out-of-Pocket Costs

Most Part D enrollees are in plans that charge a deductible for drug coverage in 2025, including 60% of MA-PD enrollees and 85% of PDP enrollees

Among MA-PD enrollees, 60% (12.3 million) are in a plan that charges a deductible for drug coverage – an increase from 2024, when only 23% of MA-PD enrollees were in a plan charging a drug deductible. In 2025, 12% of MA-PD enrollees are in a plan that charges the standard deductible of $590 (up from 3% in 2024) and 49% face a partial deductible averaging $328 (Figure 7).

A large majority of PDP enrollees (85% or 15.3 million) are in a plan that charges a drug deductible in 2025, including more than three-fourths (77%) in a plan that charges the standard deductible of $590 and 8% facing a partial deductible averaging $495. (These estimates include Part D enrollees receiving Low-Income Subsidies, who do not pay a deductible regardless of whether their plan

PDP enrollees are more likely than MA-PD enrollees to face coinsurance for preferred brands and non-preferred drugs, while MA-PD enrollees face higher median coinsurance for specialty tier drugs

As in previous years, Part D enrollees face low copayments for generic drugs and higher cost-sharing amounts for preferred brands, non-preferred drugs, and specialty drugs, regardless of whether they are in PDPs or MA-PDs (Figure 8). Median copayments for drugs covered on generic tiers are the same in PDPs and MA-PDs, but for preferred brands and non-preferred drugs, PDP enrollees are much more likely than MA-PD enrollees to pay coinsurance, or a percentage of a drug’s price. Whereas most MA-PD enrollees face a median copayment of $47 for preferred brands, most PDP enrollees face median coinsurance of 21%. For non-preferred drugs, a somewhat larger share of MA-PD enrollees face median coinsurance of 42% than a copayment of $100, while all PDP enrollees face coinsurance for non-preferred drugs, with a median rate of 40%.

Median coinsurance for specialty tier drugs (those that cost over $950 in 2025) is higher for MA-PD enrollees than PDP enrollees – 30% vs. 25%. Plans that waive some or all of the standard deductible, which most MA-PDs do, are permitted to set the specialty tier coinsurance rate above 25%.

These cost-sharing amounts apply when beneficiaries fill prescriptions in the initial coverage phase of the Part D benefit. Under a provision in the Inflation Reduction Act, beneficiaries no longer face cost sharing in the catastrophic coverage phase of the Part D benefit. In 2025, Medicare beneficiaries will pay no more than $2,000 out of pocket for prescription drugs covered under Part D.

Among the 12 PDPs offered nationwide, most charge $0 for preferred generics but only 2 charge flat copayments for preferred brands and all charge coinsurance for non-preferred drugs

Part D enrollees in 8 of the 12 national PDPs face a median copayment of $0 for preferred generics, while median copays for drugs on the standard generic tier range from $0 to $10 (Figure 9). For preferred brands, 10 of 12 national PDPs charge coinsurance, with median amounts ranging from 15% to 25%, and only 2 national PDPs charge copays. All 12 national PDPs charge coinsurance for non-preferred drugs, ranging from 31% to 50% at the median, and coinsurance for specialty tier drugs ranging from 25% to 33%.