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%.

Ahead of Medicare’s annual mid-year announcement about the national average premium for Part D prescription drug coverage in 2026 and other plan details, two questions loom large for the insurers that sponsor Part D stand-alone prescription drug plans (PDPs) and the 23 million people in traditional Medicare who are currently enrolled in these plans: Will the Trump administration continue Medicare’s Part D premium stabilization demonstration for a second year, and what will the PDP market look like in 2026 and in subsequent years? The answer to the first question could determine whether monthly PDP premiums remain at a relatively affordable level and whether PDP availability remains stable in 2026. The answer to the second question has larger implications for the viability of traditional Medicare as an option for beneficiaries nationwide but especially for beneficiaries who live in rural areas. This is because rural Medicare beneficiaries are more likely to be enrolled in traditional Medicare and rely more on drug coverage from stand-alone PDPs than Medicare Advantage plans.

Why does the stability of the PDP market matter?

For Medicare beneficiaries who are enrolled in traditional Medicare, which is just under half of all people with Medicare, getting Medicare Part D prescription drug coverage means enrolling in a stand-alone PDP. For Medicare beneficiaries who qualify for the Part D Low-Income Subsidy (LIS), enrolling in certain PDPs provides the only guaranteed option for premium-free drug coverage and lower cost sharing. In recent years, the overall number of PDPs has declined, with the number of PDPs available to the average beneficiary decreasing from 30 in 2021 to 14 in 2025 (Figure 1). The number of premium-free (“benchmark”) plans for LIS enrollees is even lower and decreased from 8 benchmark PDPs in 2021 to 2 in 2025. Over this period, the average number of Medicare Advantage drug plans (MA-PDs) increased from 27 to 34.

Ultimately, the erosion of the PDP market – fewer plans coupled with rising premiums – could diminish the ability of Medicare beneficiaries in traditional Medicare to obtain affordable Medicare Part D drug coverage, leaving them with little choice but to enroll in Medicare Advantage, a choice that comes with tradeoffs. While Medicare Advantage plans typically charge zero premium beyond the standard Part B premium and offer extra benefits than what is covered under traditional Medicare, they also have more limited provider networks and greater use of prior authorization than in traditional Medicare. The erosion of the PDP market could also further reduce premium-free stand-alone drug plan choices for low-income Medicare beneficiaries.

Why is PDP market stability an issue for rural Medicare beneficiaries in particular?

While most people with Medicare live in urban areas, a majority of Medicare beneficiaries who live in the nation’s most rural areas are enrolled in traditional Medicare, not Medicare Advantage, and six in 10 of these beneficiaries are enrolled in stand-alone PDPs in 2025 (Figure 2).

If rural Medicare beneficiaries in traditional Medicare are unable to obtain affordable Medicare drug coverage through PDPs, they could be left with no option but to enroll in Medicare Advantage if they want Part D coverage. However, beneficiaries living in rural areas have far fewer Medicare Advantage plan options than those in urban areas, often with more limited provider networks.

What was the impetus for the Part D premium stabilization demonstration?

The Part D premium demonstration was established in 2024 ahead of a major redesign of the Part D benefit that took effect in 2025, including a new $2,000 out-of-pocket drug spending cap and changes that significantly shifted benefit costs from the federal government to Part D plan sponsors. Sponsors of Part D stand-alone drug plans projected greater variability in the impact on their benefit costs than sponsors of Medicare Advantage drug plans, and the voluntary demonstration, established under the federal government’s Section 402 demonstration authority, provided additional premium subsidies to stand-alone PDPs to prevent substantial premium increases along with other measures designed to help stabilize the PDP market.

What was the effect of the PDP stabilization demonstration in 2025?

The demonstration worked as intended to stabilize premiums, with the average monthly PDP premium holding steady at under $40 in 2025, despite monthly premium increases in some PDPs of up to $35, the maximum increase allowed for plans participating in the premium stabilization demonstration. Even as the number of PDPs dropped from 709 to 464, enrollment in stand-alone PDPs remained stable for 2025, suggesting that the demonstration helped to minimize disruption in the PDP market that might otherwise have occurred.

How much did the PDP stabilization demonstration cost the federal government?

The Congressional Budget Office (CBO) estimated that the demonstration would cost $5 billion in 2025. Some GOP members of Congress criticized these additional subsidies to PDPs as shifting costs from plan sponsors and enrollees to taxpayers. However, these subsidies are being offered to PDPs on a temporary demonstration basis. By comparison, through the existing statutory Medicare Advantage payment system, the government is providing additional Part D subsidies to Medicare Advantage plans in the form of rebates that total more than $500 per year for each MA-PD enrollee in 2025. This amounts to close to $11 billion in additional federal subsidies that MA-PD sponsors are using to lower or eliminate their Part D premiums and offer Part D supplemental benefits in 2025. As a result, most MA-PD enrollees pay no premium for their Medicare Advantage Part D drug coverage.

Is the PDP stabilization demonstration legal?

In response to a 2024 request from members of the House and Senate GOP, the U.S. Government Accountability Office (GAO) recently issued a legal decision that the Part D premium stabilization demonstration is consistent with the authority granted to the HHS Secretary under Section 402 of the Social Security Act to conduct Medicare payment demonstrations. GAO’s official assessment of the legality of the demonstration may take some of the wind out of the sails of its critics, but it doesn’t bind the Trump administration to continuing the demonstration beyond 2025.

What comes next?

The Trump administration has not provided a clear signal as to whether it will continue the PDP premium stabilization demonstration for 2026 and if so what the specific parameters will be. That announcement is expected at the end of July. For Medicare beneficiaries in traditional Medicare, and rural Medicare beneficiaries in particular, continuation of the Part D premium stabilization demonstration could be key to ensuring access to relatively affordable Part D coverage through PDPs in 2026.

Plan-level Part D premiums for 2026 are not yet known and will be announced in the fall. Premiums are expected to vary across plans, with lower monthly premiums for MA-PDs than PDPs, on average. If so, this would be consistent with 2025, when average monthly premiums are $7 for MA-PDs and $39 for PDPs. The lower average MA-PD premium is heavily weighted by zero-premium plans, with MA-PD sponsors using rebates to reduce their Part D premiums.

The premium differential in 2026 could be even greater, however, if the Trump administration decides to scale back or terminate the PDP premium stabilization demonstration. Doing so could also result in further reductions in PDP availability, which would have implications for access to Part D drug coverage among Medicare beneficiaries enrolled in PDPs. If PDP options become less numerous and more expensive, that could hasten the shift of enrollees from traditional Medicare to Medicare Advantage. With the federal government spending more per beneficiary in Medicare Advantage than traditional Medicare, that would mean even higher federal spending over time.

Note: This brief was updated on July 15, 2025 to incorporate new data on abortion statistics.

• In the two years since the Supreme Court ruling that overturned Roe v. Wade, the total number of abortions nationally has slightly increased. The most recent data from the Society for Family Planning’s #WeCount project show that there were 1.14 million abortions in 2024, up from 1.05 million abortions in 2023. For most of the decade prior to the Dobbs ruling, there was a steady decline in abortion rates nationally, with a slight uptick in the years just before the ruling.
• The upward trend in abortion volume is likely due to multiple reasons, including expanded telehealth capacity, the ability to mail medication abortion pills to patients, and the lower costs for telehealth abortions through virtual clinics compared to in-person care. Medication abortion via telehealth now accounts for 25% of all abortions.
• In contrast to the abortion bans, several states have passed laws to protect abortion access for their residents and expand access to people seeking abortions from other states which have contributed in part to the increased the number of abortions in those states compared to pre-Dobbs time frame. Twelve (12) states require state-regulated private plans to cover abortion, many without cost-sharing, and 20 Medicaid programs use state-only funds to cover nearly all medically necessary abortions. Twenty-three (23) states passed shield laws intended to reduce the legal risks for clinicians who provide abortion care to patients who live in states where abortion is banned or restricted.
• The upward trend in abortion volume can also be attributed to increased interstate travel. The travel rate for abortion care across state lines nearly doubled from 2020 to 2024, with Illinois, North Carolina, New Mexico, and Kansas experiencing the highest volume of out-of-state abortion patients last year.

Following the 2022 ruling in Dobbs v. Jackson Women’s Health Organization, it was generally expected that the abortion rate would drop due to the number of states that rapidly adopted abortion bans (12 states) and early gestational restrictions (6 states). There is no doubt these policies have made abortion access much more challenging or even impossible for those seeking abortion who live in restrictive states; yet, contrary to expectations, recent data show that the number of abortions in the U.S. overall has slightly increased in two years following the Supreme Court ruling. The combination of growth in telehealth availability for abortion care, lower telehealth costs, increased legal reproductive health care protections through state efforts, and higher rates of interstate travel, all likely contributed to the unexpected trajectory in abortion volume. However, the possibility of more state bans and restrictions combined with the ongoing legal challenges seeking to further restrict access may reverse this trend. Additionally, future actions that the Trump administration could take at the federal level could further limit abortion availability and access even in states that have enshrined the right to abortion, particularly if the administration restricts the distribution of medication abortion pills through the Comstock Act or targets the provision of telehealth abortions through regulatory revisions at the Food and Drug Administration.

This brief reviews the different sources of abortion data in the U.S., the factors that have affected abortion rates across the country before and after Dobbs, and what we may see as the Trump administration, Republican majorities in the House and Senate, and a conservative federal judiciary shape policy in the coming years.

How is abortion tracked at the state and federal level?

Three major organizations collect and report national and state-level data on abortion volume and rates: the federal Centers for Disease Control and Prevention (CDC), the Guttmacher Institute, and most recently, the Society of Family Planning through its (SFP) #WeCount project.

For decades, the federal CDC Abortion Surveillance System has requested data from the central health agencies of the 50 states, D.C., and New York City to document the number and characteristics of women obtaining abortions. Reporting to the CDC is voluntary and not all states participate in the surveillance system. Notably, California, Maryland, and New Hampshire have not reported data on abortions to the CDC system for years. Most states collect and report data on the demographic characteristics of patients, gestational weeks, and type of abortion procedure. CDC publishes data from the surveillance system annually, with the most recent data on abortions in 2022, reflecting a 2-year lag. As of April 2025, following the termination of federal staff from the Reproductive Health Division, it is unclear whether the CDC will continue to update its Abortion Surveillance System which currently presents data from 2022 that was released in November 2024.

Prior to the Dobbs ruling, the Guttmacher Institute, an independent research and advocacy organization, periodically conducted the Abortion Provider Census (APC), collecting data on abortion incidence, abortion facilities, and patient characteristics. Data from the APC are based primarily on questionnaires completed by known facilities that provide abortion in the country, information from state health departments, and Guttmacher estimates for a small portion of facilities. The most recent APC reports data from 2020. Following the Dobbs ruling, the Guttmacher Institute established an additional data collection initiative, the Monthly Abortion Provision Study, to track abortion volume within the formal U.S. health care system. This ongoing effort collects data on and provides national and state-level estimates on abortions while also tracking the changes in national abortion volume since 2020.

While the CDC and Guttmacher APC data differ in terms of collection methods, timeframe, and completeness, both have shown similar trends in abortion rates over the past decade. One notable difference is that Guttmacher’s survey has included continuous reporting from all states, which explains at least in part the higher abortion volume in their data.

Society of Family Planning’s (SFP) #WeCount is a newer national reporting initiative that measures changes in abortion access following the Dobbs ruling. The project provides semiannual reports on the monthly number of abortions by state and includes data on abortions provided through in-person health care settings and through telehealth. The #WeCount report started collecting data in April 2022 and has published two full years of abortion data since Dobbs.

How has the abortion rate changed over time?

For most of the decade prior to the Dobbs ruling, there was a steady decline in abortion rates nationally, but there was a slight increase in the years just before the ruling.

The most recent CDC data are from 2022, the same year as the Dobbs decision, and show that abortion rates declined from 2013 through 2017 and remained steady in the years leading up to the court decision (Figure 1). CDC reported 609,360 abortions in 2022 and a rate of 11.2 abortions per 1,000 women (excludes CA, DC, MD, NH, and NJ). In contrast, the Guttmacher Institute reported 930,160 abortions in 2020 and a rate of 14.4 abortions per 1,000 women. Guttmacher’s study showed a slight upward trend in abortion from 2017 to 2020 whereas CDC’s report showed a stable rate in abortions from 2017 to 2022 except for a slight uptick in 2019 and 2021.

Experts generally attribute the long-term decline in abortion rates to increased use of more effective methods of contraception. The slight increase in the years leading up to the Dobbs decision could be due to greater state-level coverage of Medicaid enrollees that made abortion access more affordable in some states as well as broader financial support from abortion funds to help individuals pay for the costs of abortion care.

Even prior to the Dobbs ruling, abortion rates varied widely between states.

National averages can mask local and more granular differences. Some of the variation in abortion volume and rates has been due to the wide differences in state policies that have shaped the availability of abortion, with some states historically placing restrictions on abortion (such as targeted regulations of abortion providers, requirements for multiple visits, and mandatory waiting periods), that constrained abortion access and availability. In some states, there were only one or two abortion providers even before Dobbs.

What has happened to abortion volume since Dobbs?

The SFP and Guttmacher Institute data both find that while the number of abortions in the U.S. dropped immediately following Dobbs, the total number of abortions nationally has increased two years following the ruling. However, the consistency observed at the national level obscures wide state-level variation and sharp declines in the number of abortions in states with bans and early gestational restrictions.

The latest SFP’s #WeCount data show that in 2024, there were an estimated 1.14 million abortions, slightly up from 1.05 million in 2023. The monthly average number of abortions increased from 88,000 abortions per month in 2023 to 95,200 in 2024 (Figure 3).

Why did the number of abortions increase after states instituted bans?

While it was not a total surprise that states without abortion bans had an increase in abortions following the Dobbs ruling, the reasons behind this increase are complex. The upward trend is likely due to a combination of increased interstate travel for abortion access by people coming from abortion ban states, the presence of state-level laws in states that protect providers who offer abortion services, lower costs associated with telemedicine medication abortions, and expanded virtual/telehealth capacity and the ability to mail medication abortions pills to patients among both bricks-and-mortar and telemedicine-only providers.

The Rise of Medication Abortion, Telehealth, and Virtual Clinics

While procedural abortions are only performed in a clinical setting, medication abortion can be provided either in a clinical setting or remotely via telehealth. Medication accounts for nearly two thirds (63%) of abortions nationally. Approved by the U.S. Food and Drug Administration (FDA) in 2000, medication abortion has a solid safety and effectiveness record regardless of whether the pills are dispensed in person by a clinician (either medical doctor or advanced practice clinician) or via telehealth and mailed or dispensed through a retail pharmacy. Medication abortion successfully terminates the pregnancy 99.6% of the time, with a 0.4% risk of major complications, and an associated mortality rate of less than 0.001 percent (0.00064%). The latest Guttmacher data show that in states without bans, medication accounted for the majority of abortions in 2023 (Figure 4). In five states (MT, WY, NE, GA, and VT), more than eight in ten abortions were medication abortions.

Access to medication abortion via telehealth had been historically limited by an FDA policy (Risk Evaluation Mitigation Strategy or REMS) that had permitted only physicians in a health care setting to dispense mifepristone in person. This resulted in a restriction on the ability to mail the pills or for retail pharmacies to dispense. In December 2021, the FDA revised this policy lifting the requirement that clinicians dispense the drug only in-person. This was done, in part, to alleviate the burden placed on the health care delivery system during the COVID-19 public health emergency. In January 2023, the FDA finalized a policy change that allows retail pharmacies to dispense medication abortion pills to patients with a prescription. These changes opened the door to greater use of telehealth for medication abortions.

The increase in telehealth abortions has also been driven in part by the rise in the number of virtual abortion clinics. The number of virtual clinics began to rise after the FDA revised its in-person dispensing requirement in 2021 and now accounts for a quarter (24%) of facilities that offer medication abortion services.

SFP’s #WeCount study breaks out monthly averages for telehealth abortions, and the most recent report shows that telehealth abortions accounted for 25% of all abortions in the last quarter of 2024 (Figure 5). The latest #WeCount reports distinguish between telehealth abortions provided by brick-and-mortar facilities from those provided under shield laws that give some legal protections to clinicians who provide abortion care via telehealth to people living in states with bans and restrictive policies. More than half of these telehealth abortions were performed under shield laws (53%), 7% of abortions were from online services offered by clinics that traditionally operate from physical locations (brick-and-mortar facilities), and four in ten (41%) were from virtual-only clinics. The provision of telehealth abortions varies widely across states, ranging from 7% of all abortions in some states and reaching 40% of all abortions in other states.

Costs for Telemedicine Abortions

The median price of medication abortion offered through brick-and-mortar clinics increased from $580 in 2021 to $600 in 2023. In contrast, the median price of medication abortions via virtual clinics decreased from $239 in 2021 to $150 in 2023, which is 75% less than the cost of in-person care (Figure 6). Virtual clinics do not incur many of the costs of a physical clinic, such as building maintenance, meeting regulations for surgical centers, and security to handle protesters. The increased availability of telehealth and virtual clinics has lowered the costs of care and reduced financial barriers resulting from abortion services as well as travel and other related expenses.

Costs for some have also been offset by the availability of financial assistance and logistical support from national and local networks of abortion funds. Since Dobbs, these networks received a reported 39% more requests for abortion support and financially supported more than 100,000 individuals seeking abortion care. While donations to these networks increased immediately following Dobbs, the frequency of donations has slowed, and funds have begun to taper. Some organizations recently reported suspending operations altogether, signaling that abortion volume may consequently dwindle as demand outpaces donations.

State-Level Protections

Over the past several years, some of the states where abortion remains legal have passed laws to protect abortion access for their residents and expand access to people seeking abortions from other states. For example, residents in California are protected from civil liabilities for providing or receiving abortion services, and providers are protected from professional discipline. Policies that have been implemented include using state funds to cover abortions under Medicaid beyond federal limitations, raising Medicaid reimbursement rates for abortion services, requiring state-regulated private plans to cover abortion, and enacting shield laws to protect clinicians who provide abortions in their states either in person or via telemedicine.

Today, 12 states require state-regulated private plans to cover abortion, some without any cost-sharing (Figure 7).

State actions to use their own revenues to pay for abortions have also expanded access to abortion services. States are not restricted by the federal Hyde Amendment (which bans the use of federal funds for abortion in Medicaid, Medicare and other public programs unless the pregnancy is a result of rape, incest, or if it endangers the woman’s life) and have the option to use state-only funds to cover abortions under other circumstances for women on Medicaid, which 20 states do currently.

A growing number of states passed shield laws to reduce the legal risks for clinicians who provide abortion care to patients who live in states where abortion is banned or restricted. While the details of these laws vary state to state, some policies protect clinicians from professional discipline for offering health care that is criminalized in another state, and others protect clinicians who provide care to patients across state lines, such as by prescribing and mailing abortion pills via telehealth services to patients in their state of residence. Some states also passed broader shield laws to protect patients and people assisting with reproductive services from civil and criminal consequences. As of February 2025, 22 states and Washington D.C. have enacted shield laws, with 8 states extending explicit protections to clinicians regardless of patient location or state of residence (Figure 8).

Interstate Travel

The Guttmacher Institute Monthly Abortion Provision Study is the only data source so far to provide in-depth information on interstate travel pre- and post-Dobbs. Guttmacher estimates that prior to Dobbs, nearly one in ten people obtained an abortion by traveling across state lines in 2020. Even though abortion was legal, there were considerable restrictions in many states that made abortion access very limited, which led to the need for interstate travel for abortion care for some people. The latest data show that 155,000 patients traveled out of state for abortion care in 2024, a slight drop from 170,000 in 2023 but nearly double the number of travelers in 2020 (81,000). The states with the highest number of people traveling inbound for abortion care border at least one state where abortion is banned, including Illinois (35,470 patients), North Carolina (16,640 patients), Kansas (15,930 patients), and New Mexico (12,730 patients) (Figure 9).

The volume of interstate travel into Florida and North Carolina is especially notable as they were two of the last southern states in 2023 where abortion was legal beyond six weeks of gestation. However, the policies in these two states became more restrictive. North Carolina went from a 20-week ban to a 12-week ban in July 2023, and Florida’s 15-week ban changed to a 6-week ban in May 2024. The volume of interstate travel into Florida declined from 9,100 travelers in 2023 to 4,010 travelers in 2024 (data not shown). Conversely, the volume of interstate travel into North Carolina increased from 14,860 in 2023 to 16,640 in 2024 (data not shown). This is largely due to Florida’s stricter gestational stage ban, which curtailed abortion access in the region and has resulted in patients in southern states having to travel elsewhere for abortion care.

While the data show that abortions slightly increased one full year after Dobbs, ongoing and impending legal challenges, state legislative efforts, and federal executive actions could further alter the reproductive care landscape and have impacts beyond abortion counts. A recent JAMA study, for instance, found that fertility rates have increased in states with complete or 6 week abortion bans, namely among populations with the greatest structural disadvantages and barriers to obtaining abortion care. A concurrent study showed infant mortality rates have also risen in these states, many of which are already experiencing some of the worst maternal, infant, and child health outcomes in the U.S. The findings from these studies underscore the widespread repercussions of policy efforts aimed at restricting abortion access.

On July 16, 2022, the federally mandated crisis number, 988, became available to all phone users at no charge. This three-digit number connects users–via phone, text, or chat–to a network of over 200 local and state-funded crisis call centers that provide access to crisis counseling, resources, and referrals through the 988 Suicide & Crisis Lifeline. The introduction of 988 came against the backdrop of rising suicide rates. Between 2013 and 2023, more than half a million lives (509,115) were lost to suicide, with increases observed nationally and across most states. Firearms have been the predominant suicide method, accounting for over half of all suicide deaths and contributing to a record high number of suicides in 2022.

988 enters its third year amid significant legislative changes to Medicaid and other health programs, projected by the CBO to reduce federal Medicaid spending by $1 trillion dollars and result in 11.8 million people losing health coverage (from Medicaid and Marketplace changes) over the next 10 years. These changes could disrupt access to mental health care and create ripple effects across the broader mental health system. The HHS budget has proposed maintaining current 988 funding levels, much of which supports 988’s federal infrastructure. At the same time, the substantial federal Medicaid spending reductions in the recently-passed 2025 tax cuts and domestic policy bill could lead states to scale back spending, including on behavioral health services. The recent elimination of the specialized 988 service for LGBTQ+ young people—which previously handled about 10% of all 988 contacts—raises concerns about the mental health support for LGBTQ+ youth, a population already experiencing high rates of suicidal ideation and attempt.

Taken together, these changes could simultaneously increase mental health needs and reduce available support, potentially leading to higher rates of suicide attempts or deaths in coming years. This policy watch examines 988 on its third anniversary, drawing from the latest Lifeline data available through May 2025 and suicide death data from CDC WONDER for the period 2013 to 2023.

988 received 16.5 million contacts since its launch in July 2022, including 11.1 million calls, 2.9 million texts, and 2.4 million chats. Monthly contact volume has steadily increased, consistently surpassing 500,000 contacts per month over the past year and approaching or exceeding 600,000 per month since early 2025—double the contacts recorded before launch (303,332 in May 2022). Public awareness of the 988 service was low in 2023 but may have since improved, potentially contributing to the increases in contact volume. These 988 metrics do not include suicide hotline contacts from centers operating outside of the 988 network. As of 2022, fewer than half of all hotline call centers (about 200 of 544) participated in the 988 network.

Most states now answer 80% or more of 988 calls in-state, a significant improvement compared to before 988’s launch. In May 2025, 42 states answered at least 80% of calls locally, up from 23 states just before 988’s launch. In-state answer rates in May 2025 ranged from 58% (Arkansas) to 99% (Rhode Island). Calls not answered in-state are redirected to national backup centers, where counselors answer the crisis call but may be less familiar with local resources. Nationally, 91% of 988 calls, texts, and chats are answered, while 9% are disconnected—for reasons that may include the person ending the contact or technical issues. This compares to a 30% disconnection rate before 988’s launch in May 2022. Federal funds supported 988’s launch, including some initial funding to support state infrastructure and local call centers, but ongoing funding for these call centers largely falls to states. Currently, 12 states passed legislation to help fund 988 through telecom fees (similar to 911 funding), with early-adopting states raising between $8 and $44.3 million in CY2023. Several other states have appropriated funds for 988, related crisis services, or efforts to improve interoperability across crisis response systems—and Medicaid, along with other payers in some cases, may also help finance 988 and related crisis services.

The overall number of suicide deaths remained stable from 2022 to 2023 (49,476 to 49,316), though it is too soon to fully determine the impact of 988. This stability was driven by small declines in non-firearm (other) suicides, while firearm suicides increased slightly (Figure 3). These patterns were generally consistent across demographic groups, including several of those previously experiencing increases over longer periods. Provisional CDC data suggest this stabilization may be continuing into 2024 (48,796), though these data are preliminary and may be incomplete. While there is no direct way to measure the effect of 988 on these rates, it could be a factor.

Enrollment in Medicare Advantage, the private plan alternative to traditional Medicare, has increased steadily since 2010. The average beneficiary has access to 34 Medicare Advantage plans with prescription drug coverage in 2025, double the number available in 2018. On average, Medicare beneficiaries have access to plans offered by 8 firms, a slight increase from 2018. One goal of offering Medicare coverage through private plans is to leverage competition with the idea that insurers will compete to provide better benefits and lower costs to attract and retain enrollees. However, recent analysis finds that Medicare Advantage markets are highly concentrated, suggesting that the growth in enrollment and plan availability has not occurred in the context of a competitive market.

Higher market concentration in Medicare Advantage insurance markets may lower the incentive for insurers to compete for potential enrollees by making plans more appealing through more comprehensive benefits or lower costs. However, the competitiveness, or lack thereof, of Medicare Advantage markets has not been a priority of policymakers or regulators, especially in recent years. The most recent activity at the federal level occurred in 2017 when the Department of Justice blocked a merger between insurers Aetna and Humana, arguing if it went through it would significantly raise market concentration in the Medicare Advantage market. More recently, the conversation regarding competition in health care has revolved around increased consolidation in provider markets, especially hospitals and health systems.

To examine the competitiveness of Medicare Advantage markets, this analysis uses publicly available, county-level Medicare Advantage plan information and enrollment data for all 50 states, D.C., and Puerto Rico, published by the Centers for Medicare and Medicaid, to calculate the Herfindahl-Hirshman Index (HHI) for each market (a county is considered a Medicare Advantage market because plans are offered at the county level). The HHI uses the relative market shares of all Medicare Advantage insurers offering plans in a county to create a measure of market concentration. Counties are then classified as unconcentrated, moderately concentrated, highly concentrated, or very highly concentrated markets. These categories align with guidelines published by the Federal Trade Commission and U.S. Department of Justice, except in that a fourth category (very highly concentrated) is added to further discern differences within the most concentrated markets. This analysis also examines how often one or two Medicare Advantage insurers enrolled at least half of all enrollees within a county, which provides an alternative illustration of market concentration (See Methods for more details).

Key Takeaways

• Virtually all counties were highly concentrated (79%) or very highly concentrated (18%) in 2024. Less than 1% were moderately concentrated and 0% of counties were unconcentrated. (2% of counties had low or no Medicare Advantage enrollment.)
• Most (89%) Medicare Advantage enrollees were in highly concentrated markets, with another 4% of Medicare Advantage enrollees in very highly concentrated markets.
• Medicare Advantage markets were more concentrated in rural counties than in urban counties: 39% of the most rural counties were very highly concentrated in 2024 compared with 15% of rural counties that were near urban areas and 6% of urban counties.
• Nine in ten (90%) Medicare beneficiaries lived in a county where at least half of all Medicare Advantage enrollees were in plans sponsored by one or two insurers in 2024.
• UnitedHealthcare (41%) or Humana (25%) had the highest enrollment in two-thirds of counties, which comprised 59% of all Medicare Advantage enrollment, in 2024. Among all Medicare Advantage insurers, UnitedHealthcare was the dominant insurer in the largest share of highly concentrated markets (41%) and very highly concentrated markets (50%) in 2024.
• In more than four in ten counties (44%), comprising 22% of all Medicare Advantage enrollment, a single Medicare Advantage insurer had at least 50% of enrollment in 2024, including 22% of counties where UnitedHealthcare had at least 50% of enrollment and 10% of counties where Humana had at least 50% of enrollment. Some large counties where one insurer had at least 50% of enrollment include Dallas County, Texas (55%), Salt Lake County, Utah (52%), and Milwaukee County, Wisconsin (64%).

Virtually all Medicare Advantage insurance markets were highly concentrated (79%) or very highly concentrated (18%) in 2024.

In 2024, virtually every county was a highly concentrated or very highly concentrated market for Medicare Advantage (Figure 1). A total of 2,524 counties (79%) were highly concentrated markets and 574 counties (18%) were very highly concentrated markets (Figure 2). Just 30 counties (<1%) were moderately concentrated markets. No counties were unconcentrated. (In 2024, 72 counties (2%) did not have sufficient Medicare Advantage enrollment to have a market concentration classification.)

Most Medicare Advantage enrollees were in a highly concentrated (89%) or very highly concentrated market (4%) in 2024.

Most Medicare Advantage enrollees lived in a highly concentrated or very highly concentrated market: 28.9 million out of 32.3 million Medicare Advantage enrollees (89%) lived in a highly concentrated market, while 1.1 million lived (4%) lived in a very highly concentrated market in 2024 (Figure 2). Of the remaining Medicare Advantage enrollees, 2.3 million (7%) lived in moderately concentrated markets. No Medicare Advantage enrollees were in unconcentrated markets.

Since 2010, the share of counties that were either highly concentrated or very highly concentrated Medicare Advantage markets has changed little (94% of counties in 2010 compared to 97% in 2024). However, there have been shifts within markets at the highest levels of concentration. Specifically, the share of counties that are very highly concentrated markets declined from 36% in 2010 to 18% in 2024, while the share of counties that are highly concentrated has increased from 58% in 2010 to 79% in 2024 (Appendix Table 1).

Medicare Advantage markets were more concentrated (and less competitive) in rural than urban counties.

On average, Medicare Advantage markets in rural areas were more concentrated than those in urban areas in 2024 (data not shown). Consistent with this finding, substantially more counties were very highly concentrated in the most rural areas (39%), compared with rural counties near urban areas (15%), and counties in urban areas (6%) (Figure 3).

A much larger share of Medicare Advantage enrollees living in the most rural counties were in very highly concentrated markets than either rural adjacent or urban counties: 16% of Medicare Advantage enrollees in the most rural counties lived in very highly concentrated markets, compared to 6% of Medicare Advantage enrollees in rural counties near urban areas and approximately 3% of Medicare Advantage enrollees in urban areas.

Nine in ten (90%) Medicare beneficiaries lived in counties where more than half of all Medicare Advantage enrollees were in plans sponsored by one or two firms in 2024.

In 2024, 90% of eligible Medicare beneficiaries – 54.3 million out of 60.5 million – lived in a county where at least 50% of Medicare Advantage enrollees in that county were in plans sponsored by one or two insurers (Figure 4). This represents a small decrease since 2010, when 96% of eligible beneficiaries – 41.4 million out of 43.5 million – lived in a county where at least half of Medicare Advantage enrollees were in plans sponsored by one or two insurers.

There has been a sharper decline in the share of Medicare beneficiaries living in counties where at least 75% of Medicare Advantage enrollment was in plans sponsored by one or two insurers. In 2010, 50% of Medicare beneficiaries lived in counties where the two largest firms comprised at least 75% Medicare Advantage enrollment compared with 25% in 2024.

UnitedHealthcare or Humana was the largest Medicare Advantage insurer in over half of counties in 2024.

UnitedHealthcare had the highest market share in more counties (41%) than any other Medicare Advantage insurer in 2024 – meaning that for 38% of all Medicare Advantage enrollees nationwide, UnitedHealthcare was the largest insurer in their county (Figure 5). Humana was the largest insurer in 25% of all counties in 2024; for 21% of all Medicare Advantage enrollees nationwide, Humana was the largest insurer in their county. UnitedHealthcare and Humana have consistently been the two largest insurers in the Medicare Advantage market, and comprised nearly half (47%) of all Medicare Advantage enrollment across the country in 2024.

UnitedHealthcare and Humana’s dominance was especially prominent in the least competitive markets: UnitedHealthcare was the largest Medicare Advantage insurer in 50% of all very highly concentrated counties and in 41% of highly concentrated counties in 2024, while Humana was dominant in 22% of very highly concentrated counties and in 26% of highly concentrated counties.

Other insurers enrolled the largest number of Medicare beneficiaries in a smaller number of counties. BlueCross BlueShield (BCBS) affiliates were the largest Medicare Advantage insurer in 11% of all counties, followed by CVS Health (8%), and Elevance Health (4%). In 2% of counties there was not sufficient Medicare Advantage enrollment to examine enrollment by insurer.

A single insurer comprised at least half of Medicare Advantage enrollment in 44% of counties in 2024.

In 44% of counties, comprising 22% of all Medicare Advantage enrollment, a single insurer enrolled at least 50% of all Medicare Advantage enrollees in 2024. In half of these counties (22%), UnitedHealthcare was the single insurer with a market share of at least 50%, including in Dallas County, Texas (55%), Salt Lake County, Utah (52%), Milwaukee County, Wisconsin (64%), Boulder County, Colorado (52%), and the District of Columbia (64%) (Appendix Table 2).

Humana enrolled at least half of all Medicare Advantage enrollees in 10% of counties, BCBS affiliates in 5% of counties, CVS Health in 3% of counties, and Elevance Health in less than 1% of counties (Appendix Table 3). Other insurers had at least 50% of Medicare Advantage enrollment in 3% of counties.

Appendix

This brief was updated on July 11, 2025 to include the latest KFF polling data.

For many years, KFF polling has found that the high cost of health care is a burden on U.S. families, and that health care costs factor into decisions about insurance coverage and care seeking. These costs and the prospect of unexpected medical bills also rank as the top financial worries for adults and their families. This data note summarizes recent KFF polling on the public’s experiences with health care costs. Main takeaways include:

• Just under half of U.S. adults say it is difficult to afford health care costs, and one in four say they or a family member in their household had problems paying for health care in the past 12 months. Black and Hispanic adults, those with lower incomes, and the uninsured are particularly likely to report problems affording health care in the past year.
• The cost of health care can lead some to put off needed care. About one-third (36%) of adults say that in the past 12 months they have skipped or postponed getting health care they needed because of the cost. Notably three in four (75%) uninsured adults under age 65 say they went without needed care because of the cost.
• The cost of prescription drugs prevents some people from filling prescriptions. About one in five adults (21%) say they have not filled a prescription because of the cost while a similar share (23%) say they have instead opted for over-the-counter alternatives. About one in seven adults say they have cut pills in half or skipped doses of medicine in the last year because of the cost. A third of all adults say they have taken at least one of these cost saving measures in the past year, including larger shares of women and those with lower incomes.
• Health care debt is a burden for a large share of Americans. In 2022, about four in ten adults (41%) reported having debt due to medical or dental bills including debts owed to credit cards, collections agencies, family and friends, banks, and other lenders to pay for their health care costs, with disproportionate shares of Black and Hispanic adults, women, parents, those with low incomes, and uninsured adults saying they have health care debt.
• Those who are covered by health insurance are not immune to the burden of health care costs. Almost four in ten insured adults under the age of 65 (38%) worry about affording their monthly health insurance premium and large shares of adults with employer-sponsored insurance (ESI) and those with Marketplace coverage rate their insurance as “fair” or “poor” when it comes to their monthly premium and to out-of-pocket costs to see a doctor.
• Notable shares of adults say they are worried about affording medical costs such as the cost of health care services (including out-of-pocket costs not covered by insurance, such as co-pays and deductibles) or unexpected bills. About six in ten adults say they are either “very” or “somewhat worried” about being able to afford the cost of health care services (62%) or unexpected medical bills (61%) for themselves and their families.

Difficulty Affording Medical Costs

Many U.S. adults have trouble affording health care costs. While lower income and uninsured adults are the most likely to report this, those with health insurance and those with higher incomes are not immune to the high cost of medical care. Just under half of U.S. adults say that it is very or somewhat difficult for them to afford their health care costs (44%). Uninsured adults under age 65 are much more likely to say affording health care costs is difficult (82%) compared to those with health insurance coverage (42%). Additionally, a slight majority of Hispanic adults (55%) and half of Black adults (49%) report difficulty affording health care costs compared to about four in ten White adults (39%). Adults in households with annual incomes under $40,000 are more likely than adults in households with higher incomes to say it is difficult to afford their health care costs. (Source: KFF Health Tracking Poll: May 2025)

When asked specifically about problems paying for health care in the past year, about one in four (23%) adults say they or a family member in their household had problems paying for care, including three in ten Hispanic adults (33%) and Black adults (30%). Over half (55%) of uninsured adults under age 65 say they or a family member in their household had problems paying for health care, compared to just one in five (22%) insured adults. (Source: KFF Health Tracking Poll: May 2025)

The cost of care can also lead some adults to skip or delay seeking services, with one-third (36%) of adults saying that they have skipped or postponed getting needed health care in the past 12 months because of the cost. Women are more likely than men to say they have skipped or postponed getting health care they needed because of the cost (38% vs. 32%). Adults ages 65 and older, most of whom are eligible for health care coverage through Medicare, are much less likely than younger age groups to say they have not gotten health care they needed because of cost.

Three-quarters of uninsured adults say they have skipped or postponed getting the health care they needed due to cost. Having health insurance, however, does not offer ironclad protection as about four in ten adults with insurance (37%) still report not getting health care they needed due to cost. (Source: KFF Health Tracking Poll: May 2025)

Skipping care due to costs can have notable health impacts. Nearly two in ten adults (18%) report that their health got worse because they skipped or delayed getting care. Among adults under age 65, those who are uninsured are twice as likely as those with health coverage to say that their health worsened due to skipped or postponed care (42% vs. 20%). About four times as many adults under age 65 (23%) say their health got worse after skipping or postponing care as adults ages 65 and older (6%), most of whom have Medicare coverage. (Source: KFF Health Tracking Poll: May 2025)

A 2022 KFF report found that people who already have debt due to medical or dental care are disproportionately likely to put off or skip medical care. Half (51%) of adults currently experiencing debt due to medical or dental bills say in the past year, cost has been a probititor to getting the medical test or treatment that was recommended by a doctor. (Source: KFF Health Care Debt Survey: Feb.-Mar. 2022)

Prescription Drug Costs

The high cost of prescription drugs also leads some people to cut back on their medications in various ways. About one in four adults (23%) say in the past 12 months they have taken an over-the-counter drug instead of getting a prescription filled because of cost concerns and about one in five (21%) say they have not filled a prescription due to the cost. Additionally, about one in seven adults (15%) say that in the past 12 months they have cut pills in half or skipped doses of medicine due to cost.

One-third of the public (33%) say they have taken any of these cost saving measures in the past 12 months. Four in ten women (39%) say they have taken any of these prescription medication measures compared to one-quarter (26%) of men. Additionally, just under half of Hispanic adults (46%) say they’ve either taken an over-the-counter drug, skipped doses, or not filled prescriptions because of the cost, compared to three in ten (29%) White adults who say the same. Similarly, larger shares those with lower incomes report having taken a cost-saving measure in the last year compared to those with higher incomes (41% of those with a household income of less than $40,000 a year vs. 29% of those with an income of $40,000 or more). (Source: KFF Health Tracking Poll: May 2025)

Notably, adults with chronic conditions, who tend to have higher health care and medication needs, can often face challenges affording prescriptions. In KFF’s 2023 Survey of Consumer Experiences with Health Insurance, insured adult with a chronic condition were twice as likely as those without a chronic condition to say they had delayed or gone without prescription drugs due to the cost (18% vs. 9%).

Health Insurance Cost Ratings

Health insurance provides some financial protection, but premiums and out-of-pocket costs can still present a financial burden for many individuals. Overall, most insured adults rate their health insurance as “excellent” or “good” when it comes to the amount they have to pay out-of-pocket for their prescriptions (61%), the amount they have to pay out-of-pocket to see a doctor (53%), and the amount they pay monthly for insurance (54%). However, at least three in ten rate their insurance as “fair” or “poor” on each of these metrics, and affordability ratings vary depending on the type of coverage people have.

Adults who have private insurance through employer-sponsored insurance or Marketplace coverage are more likely than those with Medicare or Medicaid to rate their insurance negatively when it comes to their monthly premium, the amount they have to pay out of pocket to see a doctor, and their prescription co-pays. About one in four adults with Medicare give negative ratings to the amount they have to pay each month for insurance and to their out-of-pocket prescription costs, while about one in five give their insurance a negative rating when it comes to their out-of-pocket costs to see a doctor.

Medicaid enrollees are less likely than those with other coverage types to give their insurance negative ratings on these affordability measures (Medicaid does not charge monthly premiums in most states, and copays for covered services, where applied, are required to be nominal). (Source: KFF Survey of Consumer Experiences with Health Insurance)

Health Care Debt

In June 2022, KFF released an analysis of the KFF Health Care Debt Survey, a companion report to the investigative journalism project on health care debt conducted by KFF Health News and NPR, Diagnosis Debt. This project found that health care debt is a wide-reaching problem in the United States and that 41% of U.S. adults currently have some type of debt due to medical or dental bills from their own or someone else’s care, including about a quarter of adults (24%) who say they have medical or dental bills that are past due or that they are unable to pay, and one in five (21%) who have bills they are paying off over time directly to a provider. One in six (17%) report debt owed to a bank, collection agency, or other lender from loans taken out to pay for medical or dental bills, while similar shares say they have health care debt from bills they put on a credit card and are paying off over time (17%). One in ten report debt owed to a family member or friend from money they borrowed to pay off medical or dental bills.

While four in ten U.S. adults have some type of health care debt, disproportionate shares of lower income adults, the uninsured, Black and Hispanic adults, women, and parents report current debt due to medical or dental bills.

Vulnerabilities and Worries About Health Care and Long-Term Care Costs

KFF’s May 2025 Health Tracking Poll shows the cost of health care services and unexpected medical bills are at the top of the list of people’s financial worries, with about six in ten saying they are at least somewhat worried about affording the cost of health care services (62%) or unexpected medical bills (61%) for themselves and their families. These are larger than the shares who say they worry about affording housing costs (51%), transportation expenses (50%), utilities (49%), and food (48%) for their families.

Notably, eight in ten uninsured adults under age 65 say they are worried about affording the cost of health care services or unexpected medical bills (82% and 80%, respectively). About four in ten (38%) insured adults under the age of 65 say they are worried about affording their monthly health insurance premium. (Source: KFF Health Tracking Poll: May 2025)

Many U.S. adults may be one unexpected medical bill from falling into debt. About half of U.S. adults say they would not be able to pay an unexpected medical bill that came to $500 out of pocket. This includes one in five (19%) who would not be able to pay it at all, 5% who would borrow the money from a bank, payday lender, friends or family to cover the cost, and one in five (21%) who would incur credit card debt in order to pay the bill. Women, those with lower household incomes, Black and Hispanic adults are more likely than their counterparts to say they would be unable to afford this type of bill. (Source: KFF Health Care Debt Survey: Feb.-Mar. 2022)

Among older adults, the costs of long-term care and support services are also a concern. Almost six in ten (57%) adults 65 and older say they are at least “somewhat anxious” about affording the cost of a nursing home or assisted living facility if they needed it, and half say they feel anxious about being able to afford support services such as paid nurses or aides. These concerns also loom large among those between the ages of 50 and 64, with more than seven in ten saying they feel anxious about affording residential care (73%) and care from paid nurses or aides (72%) if they were to need these services. See The Affordability of Long-Term Care and Support Services: Findings from a KFF Survey for a deeper dive into concerns about the affordability of nursing homes and support services.

In this article in the Journal of Health Politics, Policy and Law, KFF’s Tricia Neuman, Jeannie Fuglesten Biniek and Juliette Cubanski examine three isssues facing Medicare’s future: privatization, affordability and spending/financing.

They write that as Medicare approaches its 60th anniversary, it almost goes without saying that the program is both popular and successful. Medicare provides health insurance coverage to 67 million older adults and people with disabilities. Medicare is viewed favorably by Democrats, Republicans, and independents. Medicare has also helped to extend life expectancy and, in conjunction with the Civil Rights Act of 1964, narrow disparities in care. It is a vital source of revenue for hospitals, physicians and other health care providers, and health insurers, and it is an essential component of health and retirement security in the United States. These are among the reasons why Medicare is often considered a third rail in politics.

The authors also note that Medicare also faces challenges stemming from the growing role of private plans, demographic shifts, and rising health care costs. They examine these challenges by focusing on three fundamental questions: What are the implications of the transformation taking place such that private insurers are playing a more dominant role in providing Medicare benefits? What changes may be important for addressing the gaps in covered benefits and related affordability challenges? And how can Medicare be sustained to finance care for current and future generations?

OB-GYNs provide a range of care for women throughout their lifespan, including diagnosis and treatment of gynecological conditions such as endometriosis, polycystic ovary syndrome, and cervical cancer; contraceptive care; prenatal and postpartum care; and menopause management. Access to care depends on several factors, including the availability of providers and, for people with insurance, whether the provider is in their plan’s network. When there are few providers in an area, local providers are not taking new patients, or a patient needs to see a provider who is not in their plan’s network, their ability to get care, how long they have to wait for an appointment, and potentially how much they have to pay out-of-pocket can all be impacted.

This brief examines the supply of OB-GYNs in the U.S. and the share of OB-GYNs participating in the provider networks of Qualified Health Plans (QHPs) offered in the individual market in the federal and state Affordable Care Act (ACA) Marketplaces in 2021. This analysis uses multiple data sources; see the Methods section for details. While many more women are covered by employer-sponsored health plans than ACA Marketplace plans, there is no publicly available data to analyze the networks for employer plans.

Key Takeaways

• There were 38 practicing OB-GYNs per 100,000 women in the United States, with higher ratios in metro counties (41) than in rural counties (13) in 2021-2022. 38 practicing OB-GYNs per 100,000 women is equivalent to one OB-GYN per about 2,600 women.
• Nearly half (48%) of counties did not have any practicing OB-GYNs and 7% of women lived in a county with no OB-GYN. The share of women with no OB-GYN in their county was substantially higher in rural counties than in metro counties (58% vs. 3%).
• In 2021, enrollees in ACA Marketplace plans had in-network access to 55% of practicing OB-GYNs in their area on average. By comparison, Marketplace enrollees had in-network access to 43% of primary care physicians.
• Marketplace enrollees in metro counties, on average, had in-network access to 53% of the OB-GYNs near their home compared to 70% in rural counties. However, as noted above, there are relatively few OB-GYNs practicing in rural counties.
• On average, Marketplace enrollees in counties with the highest shares of people of color had in-network access to 43% of area OB-GYNs while those in counties with the lowest shares of people of color had in-network access to 69%.

OB-GYN Workforce

OB-GYNs play an important role in ensuring women have access to comprehensive health care. There are many factors that can create barriers to accessing obstetric and gynecological care, including the size of the OB-GYN workforce and the ratio of OB-GYNs to patients. Although there is no established “adequacy” ratio of OB-GYNs to patients, OB-GYN shortages could be considered in the context of longer appointment wait times and increased travel distances, among others. The U.S. Department of Health and Human Services projects a shortage of 7,980 OB-GYNs by 2037 based on the supply of OB-GYNs in the workforce and the demand for OB-GYNs (based on the population of adolescent girls and women).

According to KFF analysis of the HRSA Area Health Resource Files for 2021-2022, there were 38 OB-GYNs per 100,000 women ages 15-64 (hereafter collectively referred to as “women”) in the United States, with wide variation by county (Figure 1). The workforce data analyzed here is from the year that Roe v. Wade was overturned (and the year before), so that decision’s specific impacts on the OB-GYN workforce are largely not reflected in this data.

In 2021-2022, nearly half (48%) of U.S. counties did not have any OB-GYNs, and 7% of women lived in a county with no OB-GYN. Three-quarters (74%) of all counties had fewer than five OB-GYNs, and 17% of women lived in a county with fewer than five OB-GYNs.

The number of OB-GYNs per 100,000 women was higher than the national average in 28 of the top 30 Core-Based Statistical Areas (CBSAs) with the largest number of women (Figure 2). Among these 30 CBSAs, the CBSAs with the highest ratios were San Francisco-Oakland-Berkeley, CA; Baltimore-Columbia-Towson, MD; and Portland-Vancouver-Hillsboro, OR-WA, with 61, 53, and 53 OB-GYNs per 100,000 women, respectively. The CBSAs with the lowest ratios were Columbus, OH; Los Angeles-Long Beach-Anaheim, CA; and Virginia Beach-Norfolk-Newport News, VA-NC, with 39, 38, and 33 OB-GYNs per 100,000 women, respectively.

CBSA is the umbrella term for Metropolitan and Micropolitan Statistical Areas as defined by the Office of Management and Budget (OMB). CBSAs consist of the county or counties or equivalent entities associated with at least one urban core (urbanized area or urban cluster) of at least 10,000 population, plus adjacent counties having a high degree of social and economic integration with the core as measured through commuting ties with the counties containing the core.

County Classification Differences in Provider Availability

In 2021-2022, eight in ten (79%) rural counties had no OB-GYNs and nearly six in ten (58%) women in rural counties lived in a county without an OB-GYN (Table 1). There were approximately three times more OB-GYNs per 100,000 women in metro counties (42) than in rural counties (13).

County classifications are based on USDA’s 2013 Rural-Urban Continuum Codes and KFF categorized these classifications into metro counties, small urban counties, and rural counties. See the Methods section for more details. Using this taxonomy, 85% of women lived in metro counties, 11% lived in small urban counties, and 4% lived in rural counties.

Race/Ethnicity Differences in Provider Availability

Counties with an above-average share of White non-Hispanic people had almost half the number of OB-GYNs per 100,000 women as counties with an above-average share of Black non-Hispanic people (24 vs. 46). There were 41 OB-GYNs per 100,000 women in counties with an above-average share of Hispanic people of any race. On average, about 58% of the U.S. population was White non-Hispanic, 12% was Black non-Hispanic, and 19% was Hispanic (any race) during that timeframe.

Other Implications

Provider shortages can also play a role in hospital and clinic staffing. For example, one study found that more than 35% of counties are considered “maternity care deserts,” meaning that there is no access to birthing hospitals, birth centers offering obstetric care, or obstetric providers. Maternity care deserts affected maternity care for more than 2.3 million women of reproductive age in 2022, resulting in poorer health outcomes, less prenatal care, and higher rates of pre-term births. Additionally, another study found that the share of hospitals in the U.S. without obstetric services increased from approximately 35% in 2010 to 42% in 2022, with even higher percentages for rural hospitals. Studies have identified that workforce challenges are one of the primary reasons for labor and delivery units closing in rural hospitals.

Although it is not clear how, precisely, OB-GYN workforce shortages impact the use of obstetric and gynecological care, the overall disparities in maternal and infant health for women of color are well-documented. While increased attention to these disparities has contributed to a range of federal and state efforts to reduce disparities in maternal and infant health, it is unclear how, or if, these efforts will continue in a political landscape characterized by rolling back efforts aimed at identifying and addressing disparities in historically marginalized groups and eliminating agencies and committees that lead these efforts. Additionally, state abortion bans and restrictions may exacerbate poor maternal and infant health outcomes, especially for people of color.

Additionally, it is reported that 1.2 million reproductive-age women live in a county without a single health center offering the full range of contraceptive methods, referred to as a “contraceptive desert.” A 2023 KFF survey of OB-GYNs following the overturning of Roe v. Wade found that just three in ten (29%) OB-GYNs provide all contraceptive methods, and that share is substantially lower in states that had banned abortion (13%). Although most OB-GYNs do not provide abortion services, abortion bans could also exacerbate provider shortages in some areas and impact access to other types of care that OB-GYNs provide.

OB-GYN Provider Networks in Marketplace Plans

The breadth of provider networks in the Affordable Care Act (ACA) Marketplaces has been the subject of significant policy interest. As insurers seek to offer lower-premium plans, one mechanism for controlling costs is to limit their physician networks to providers with lower payment rates. While the Centers for Medicare and Medicaid Services (CMS) establishes minimum standards for the adequacy of physicians, including OB-GYNs, in Marketplace plan networks, insurers retain considerable flexibility in how they design networks.

While many more women are covered by employer-sponsored health plans than ACA Marketplace plans, there is no publicly-available data to analyze the networks for employer plans.

The 2023 KFF Survey of Consumer Experiences with Health Insurance found that 24% of adult women with Marketplace coverage said that in the past year, a particular doctor (not specific to obstetric or gynecological care) or hospital they needed was not covered by their insurance. Among women Marketplace enrollees who experienced this problem, 32% said that needed care was delayed, and 42% said they ended up paying more out of pocket for care than expected as a result of problems they had with their health insurance.

This section analyzes OB-GYN provider networks of Qualified Health Plans (QHPs) offered in the individual health insurance Marketplaces in 2021. (At the time of analysis, 2021 was the most recent data available for calculating the total number of active OB-GYNs. See the Methods section for more details.) In total, 12 million consumers selected a plan for the 2021 plan year, roughly 55% of whom were women. Due to missing or incomplete demographic data for some states, this analysis presents data for Marketplace enrollees of all genders.

On average, Marketplace enrollees had in-network access to more than half (55%) of the practicing OB-GYNs near their homes in 2021 (Figure 3). By comparison, Marketplace enrollees had in-network access to 43% of primary care physicians and 37% of psychiatrists near their homes. One-quarter of enrollees were enrolled in plans with fewer than 34% of the local OB-GYNs in-network, while another quarter were in plans with at least 78% of local OB-GYNs in-network.

Geographic Differences in Marketplace Provider Networks

While metro counties had more practicing OB-GYNs overall, smaller shares of them participated in Marketplace plan networks compared to OB-GYNs in small urban and rural counties (Figure 4). Eighty-eight percent of Marketplace enrollees lived in a metro county. Marketplace enrollees in metro counties, on average, had access to 53% of the OB-GYNs within five to ten miles of their county through their plan networks, with one-quarter enrolled in a plan whose network included no more than 33% of local OB-GYNs.

Marketplace enrollees in rural counties (e.g., Knox County, ME; Anderson County, TX; Macon County, NC), on average, had access to 70% of OB-GYNs in their local area (within 30 miles) through their plan networks. The higher OB-GYN participation rates in these counties, however, should be considered in the context of the small number of OB-GYNs practicing in these areas. For example, 98% of rural counties had fewer than five practicing OB-GYNs. It is possible that not all of these providers are accepting new patients, and an enrollee’s choice may be even more limited than the number of OB-GYNs who participate in the plan network. (See the OB-GYN Workforce section for county classification definitions.)

The 30 counties with the highest enrollment in the Marketplaces in 2021 collectively represented 34% of all Marketplace enrollees and 21% of the U.S. population. Most of them are urban and some are home to large cities (e.g., Seattle in King County, WA). On average, Marketplace enrollees in almost all of these counties were in plans that included fewer than half of local OB-GYNs, though there was significant variation across these 30 counties (Figure 5). For example, Marketplace enrollees in Cook County, IL (Chicago) had access to fewer than two in ten (20%) OB-GYNs in their area on average. In contrast, enrollees in Gwinette County, GA (outside Atlanta) had in-network access to seven in ten (71%) practicing OB-GYNs on average.

Race/Ethnicity Differences in Marketplace Provider Networks

On average, Marketplace enrollees living in counties with a higher share of people of color were in networks that included a smaller share of OB-GYNs than counties with a smaller share of people of color (Figure 6). The quarter of Marketplace enrollees living in the counties with the highest share of people of color had access to 43% of OB-GYNs in-network, on average, compared to 69% in counties with the smallest share of people of color. These differences may reflect the higher concentrations of these people of color in large metro counties, where plans typically had narrower provider networks. ‘People of color’ include those who identify as Hispanic (of any race), multi-racial (Hispanic or non-Hispanic), or a race other than White (Hispanic or non-Hispanic).

Numbers of Practicing and In-Network OB-GYNs

The share of providers participating in a network is just one component of access and may not always gauge how well enrollees are served. High network participation rates matter little if there are few local providers to begin with. For example, in 2021, about one-quarter (23%) of Marketplace enrollees lived in a county with fewer than 25 practicing OB-GYNs in the local area (Figure 7). One in ten (10%) Marketplace enrollees had fewer than 10 practicing OB-GYNs in the local area, and 4% lived in a county with fewer than five OB-GYNs in the area (0% of Marketplace enrollees lived in a county with no local OB-GYNs). Sixty-three percent of Marketplace enrollees live in a county with 25 or more practicing OB-GYNs.

When it comes to network breadth, more than one-third (36%) of Marketplace enrollees were in a plan that included fewer than 25 local OB-GYNs, either because there weren’t 25 OB-GYNs in the market, or because available OB-GYNs were not included in the network. Nearly two in ten (18%) were in a plan that included fewer than ten OB-GYNs and one in ten (10%) were in a plan that had fewer than five local OB-GYNs (including 1% who were in a plan with no OB-GYNs). Thirty-five percent of Marketplace enrollees were in a plan with 25 or more OB-GYNs.

Although this OB-GYN network analysis is just among ACA Marketplace plans, employer-sponsored plans, which cover more people than Marketplace plans, also have provider networks. While many employers describe their plan’s provider networks as “very broad” or “somewhat broad,” nearly 1-in-5 (18%) firms with 5,000 or more workers characterize their plan as “somewhat narrow” or “very narrow.” The extent to which provider networks reduce the availability of OB-GYN services for those with employer coverage, and for which enrollees, remains unclear.

Methods

OB-GYN Workforce Analysis:

Information on the OB-GYN workforce is available in HRSA Area Health Resource File (AHRF) for 2021-2022. Data on the OB-GYN workforce is derived from the American Medical Association Physician Masterfiles. Data on the share of the population that is Black non-Hispanic, White non-Hispanic, or Hispanic is based on the 2010 Census Redistricting Data. Data on the share of the population that is foreign-born or that has limited English proficiency is based on the American Community Survey 2016-2020.

County classifications are based on USDA’s 2013 Rural-Urban Continuum Codes, which was the version in use for the 2021-2022 AHRF. This analysis defines metro counties as those in metro areas with any size population; small urban counties as those with a population of 20,000 or more, adjacent or not adjacent to a metro area or that have a population of 2,500-19,999 adjacent to a metro area; and rural counties as those with populations of 2,500-19,999 not adjacent to a metro area or that have a population of less than 2,500, adjacent or not adjacent to a metro area.

It should be noted that clinicians other than OB-GYNs, such as nurse practitioners, physician assistants, and midwives, also provide obstetric and gynecological care and are included in this dataset. However, the dataset does not indicate the specific field in which they practice, so we are unable to include them in this analysis. Doulas, who provide non-clinical support to pregnant and postpartum people, are not generally included in the dataset and so are also not represented in this analysis.

Provider Network Analysis:

This analysis of ACA Marketplace plan networks uses similar methodology as a 2024 KFF analysis. In total, 12 million enrollees selected or were automatically re-enrolled in a plan on either HealthCare.gov (8.3 million) or a state-based Marketplace (3.8 million) during open enrollment for the 2021 plan year. Approximately 55% of enrollees were female and 45% were male. Gender counts for some state-based Marketplaces are incomplete due to unknown or missing gender data; therefore, the data presented in this analysis is representative of Marketplace enrollees of all genders. This analysis estimates the share of OB-GYNs included in individual Marketplace plans in 2021. The data include only physicians (which includes OB-GYNs) and not other providers of obstetric and gynecological care.

Information on plan provider directories was compiled by Ideon through an API with insurers as well as other data including the National Plan and Provider Enumeration System (NPPES). Data for carriers not participating in the Ideon API were supplemented with carriers’ public filings.

Local OB-GYNs are defined as those who practice within the same county as an enrollee or are within the distance thresholds specified as part of CMS’s network adequacy standards for HealthCare.gov plans. See mileage thresholds in Table 1 here for defining “local” areas.  While the mileage standards in network adequacy regulations are based on the proximity to plan enrollees, this analysis measures the distance from the population-weighted center of the county. County classifications (e.g., rural, small urban, metro) were derived from the data source and approach listed in the OB-GYN Workforce Analysis methods section above.

To estimate the total number of OB-GYNs who are in active practice, we relied on Medicare Data on Provider Practice and Specialty (MD-PPAS), a federal database of physicians who submitted at least one Medicare Part B claim in 2021 and therefore saw at least one Medicare patient in the year. Virtually all OB-GYNs participate in Medicare, with only about 1% formally opting out altogether. In total, 34,945 OB-GYNs were included in MD-PPAS in 2021.

Although MD-PPAS provides a list of physicians known to be working, one concern is that a disproportionate share of OB-GYNs may not have treated a Medicare patient in 2021. To assess the representativeness of OB-GYNs in MD-PPAS compared to other physician types, we examined the share of individual providers by specialty in the National Plan and Provider Enumeration System, a federal registry that assigns health care providers unique National Provider Identifiers (but that is not intended to serve as a census of the active health care workforce), who also filed a Medicare Part B claim in MD-PPAS. On average, 61% of OB-GYNs filed a Part B claim—a rate comparable to adult primary care physicians (57%) and all designated physician specialties (58%).

A central challenge in analyzing provider networks is determining the size of the physician workforce. While the vast majority of physicians engaged in active practice accept Medicare, some physicians may be inadvertently missed, including those in closed-network HMOs serving exclusively commercial populations or those specializing in services not typically used by Medicare enrollees. Telehealth providers whose addresses are not within the local market are also excluded. Further, this analysis only considers individual-level physicians enumerated in the plan directory. In some cases, plans may include group health practices in their networks and not individually list providers.

Conversely, this analysis may exaggerate the breadth of provider networks. “Phantom providers,” or physicians who are listed in the plan directory but no longer accept the plan, may artificially increase the breadth of some plans.

Click here to read the full methodology, scope, and limitations of this analysis.