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How Does Cost Affect Access to Health Care?

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How Does Cost Affect Access to Health Care?



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This analysis explores trends in how the cost of health care affects access to care in the U.S. using National Health Interview Survey (NHIS) data through 2024.

In 2024, about 1 in 6 adults (17%) reported delaying or not getting healthcare due to cost, including those who delayed or did not get medical or mental health care and those who rationed prescription drugs due to cost. Uninsured adults and adults who are in worse health are twice as likely to report that they or a family member had difficulty paying medical bills.

The analysis is available through the Peterson-KFF Health System Tracker, an online information hub dedicated to monitoring and assessing the performance of the U.S. health system.



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Bronze health plan popularity surges in Marketplaces

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Bronze health plan popularity surges in Marketplaces



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As consumers face decreased access to Marketplace health insurance subsidies for 2026 plans – and higher net premiums for consumers who continue to be subsidy-eligible – one clear buying trend has emerged: a migration of buyers to Bronze-level health plans.

While details about the plans that people selected for 2026 are not yet available in most states, several state-run Marketplaces have published this information in early 2026. Data from those state-run exchanges shows a significant number of enrollees have downgraded their coverage, opting for a Bronze plan instead of a Gold or Silver plan.

What’s happening with Marketplace health plan enrollments?

Enrollment in Marketplace health plans declined in 2026 after four consecutive years of record-high enrollment. This was not surprising, given the sharp increase in net premiums for 2026 due to the expiration of federal subsidy enhancements at the end of 2025.

We don’t yet have Marketplace metal-level plan selection data for the states that use HealthCare.gov, but about half of the state-run Marketplaces have shared information about the metal levels that people selected during open enrollment. In most cases, Bronze plan selections increased significantly. (There were a couple of exceptions, which we’ll discuss in a moment.)

Why might consumers be downgrading to Bronze plans?

Lower premiums

Although all Marketplace plans cover the ACA’s essential health benefits, Bronze plans have higher deductibles and out-of-pocket limits than Silver or Gold plans. As a result, Bronze plans have lower monthly premiums.

So when consumers were faced with average net premiums that more than doubled for 2026, it’s understandable that people may have selected a different plan with a lower premium, in an effort to keep their monthly premium costs affordable.

Access to HSA contributions

The fact that Bronze plans are newly HSA-eligible may also have been a factor in some enrollees’ decisions to downgrade to a Bronze plan. As of 2026, all Bronze (and Catastrophic) Marketplace plans are HSA-eligible, meaning that people who enroll in these plans have the option to contribute pre-tax money to a health savings account (HSA).

Learn more about health savings accounts and the tax advantages they offer.

Contributions to an HSA will reduce the ACA-specific modified adjusted gross income (MAGI) that’s used to determine Marketplace subsidy eligibility. So selecting an HSA-eligible plan and making HSA contributions is a way for people to increase their subsidy amount (due to their reduced MAGI) or potentially qualify for subsidies if the HSA contribution brings their MAGI down below 400% of the federal poverty level (FPL).

This became more important in 2026, due to the return of the “subsidy cliff.” Enrollees with household income above 400% of FPL have to pay full-price for their coverage in 2026, so opting for a Bronze plan and contributing to an HSA may have been a choice that allowed some enrollees to continue to qualify for a subsidy.

Which state-run Marketplaces have reported an increase in Bronze plan selections?

Of the state-run Marketplaces that have published 2026 enrollment metrics thus far, all but two have reported an increase in the percentage of enrollees selecting Bronze plans:

  • California: Of enrollees in 2025 plans, 130,000 enrollees switched to Bronze plans for 2026. And among new enrollees, more than a third selected Bronze plans, compared with fewer than a quarter last year.
  • Idaho: Nearly 60% of enrollees picked Bronze plans, while enrollment in Silver and Gold plans declined compared to 2025 enrollment.
  • Maine: Nearly 60% of enrollees picked Bronze plans – up from 46% in 2025. (The percentage of enrollees in Bronze plans had been quite steady from 2022 through 2025.)
  • Maryland: The exchange reported that 5,743 people switched from 2025 Gold plans to Bronze plans for 2026.
  • New Jersey: Among people who actively selected a plan (not counting auto-renewals), 31% chose a Bronze plan, up from 16% the year before.
  • Pennsylvania: Bronze plan selections were 30% higher than they were the year before.
  • Rhode Island: As of mid-January 2026, about 38% of new enrollees had picked a Bronze plan, up from about 15% in previous years. There was also a trend of existing enrollees switching to Bronze plans at that point.
  • Vermont: Almost twice as many people newly selected a Bronze plan for 2026, compared with 2025. And more than 60% of the new Bronze enrollees had previously been enrolled in Gold plans.
  • Virginia: Bronze plan selections increased, although not as significantly as they did in most of the other states listed above. For 2026 coverage, 42% of enrollees selected Bronze plans, up from 38% in 2025.

Four of those nine states (California, Maryland, New Jersey, and Vermont) offer state-funded subsidies in addition to federal subsidies, in an effort to make Marketplace coverage more affordable. But despite this additional assistance, a significant number of enrollees still downgraded their coverage for 2026.

Which state-run Marketplaces reported a reduction in Bronze plan selections?

Two state-run Marketplaces have reported a decrease in Bronze plan selections for 2026. In both cases, the state had taken action to make more robust coverage more affordable for residents:

New Mexico

Very few Marketplace enrollees in New Mexico have Bronze plans. Enrollment in Bronze plans dropped slightly – from 3.4% in 2025 to 3.1% in 2026.

New Mexico offers additional state-funded subsidies that result in robust “Turquoise” plans being available to enrollees with household incomes up to 400% of the federal poverty level. These are by far the most popular plans in the New Mexico Marketplace, selected by nearly eight out of ten enrollees buying 2026 plans.

New Mexico is also the only state that used state funding to fully backfill the reduction in federal premium subsidies for 2026. So while consumers in many states responded to higher net premiums (stemming from the expiration of the federal subsidy enhancements) by downgrading their coverage to a plan with a lower premium, there was no need for New Mexico residents to do that.

Washington

About 87,000 Washington Marketplace enrollees selected Bronze plans for 2026, versus about 96,000 who had picked Bronze plans for 2025. (In both cases, this was roughly three out of ten enrollees, since total enrollment declined for 2026.)

But Gold plan selections increased significantly in Washington, increasing from 18% of plan selections in 2025 to 53% in 2026.

This migration to Gold plans happened because Washington adopted premium alignment for 2026, requiring insurers to add a 43% load to the premiums for Silver plans. This is because most Silver plans actually have benefits that are similar to those of Platinum plans, as a result of cost-sharing reductions (CSR).

Because Silver plans became more expensive, premium subsidies also increased, as subsidy amounts are based on the cost of a Silver plan. These larger subsidies made Gold plans more affordable, leading to a substantial increase in Gold plan selections for 2026.

What does a shift to Bronze plans mean for consumers?

Bronze plans have average deductibles of nearly $7,500 in 2026, which is more than double the overall weighted average deductible across all Marketplace plans. Plan designs vary considerably, but some Bronze plans count all non-preventive care toward the deductible (and deductibles can be as high as $10,600 in 2026, depending on how the plan is designed).

So consumers who select Bronze plans will generally have deductibles that are quite a bit higher than the average Marketplace plan deductible. Their total out-of-pocket exposure is often as high as the allowable maximum, which is $10,600 for a single individual in 2026. And depending on how the plan is designed, it might pay very little until the enrollee has met the deductible.

This means Bronze plan enrollees should be prepared for the possibility of having to pay several thousand dollars in out-of-pocket costs if they end up needing medical care during the year.

Unfortunately, a person who downgraded to a Bronze plan because of premium affordability might struggle to come up with the money to pay their deductible. Or they might avoid getting necessary medical care because of the cost.

Options for Bronze plan buyers facing higher out-of-pocket costs

If you’re enrolled in a Bronze plan and worried about higher out-of-pocket costs, there are several tips to keep in mind:

  • Comparison shop for your care whenever possible. Although your health plan might have a wide range of in-network hospitals, medical offices, and pharmacies, that doesn’t mean your out-of-pocket costs will be the same at all of them. If you need a prescription, you can check with various in-network pharmacies (including mail-order options) to see if there are price differences. The same is true for other medical care, and there are transparency tools that can help you determine what your costs will be.
  • Discuss your financial situation with your medical providers. You may find that they can offer a payment plan that fits within your budget.
  • If at all possible, consider opening and funding an HSA. All Bronze plans are HSA-eligible as of 2026. The money you contribute to an HSA is pre-tax. And if you need to use it to pay your deductible or other medical expenses, it will continue to be tax-free when you make the withdrawal. If you don’t end up needing to use the money in your HSA, it will remain in the account in future years until if and when you need it.
  • If your income isn’t more than 200% of the federal poverty level, you might be eligible for reduced out-of-pocket costs if you use a federally qualified health center (FQHC) that’s in your plan’s provider network. Depending on your income, these clinics can reduce the amount that you’d otherwise have to pay out-of-pocket under the terms of your health plan.
  • Consider supplemental coverage, such as a critical illness policy or an accident insurance policy, that could reimburse some of your out-of-pocket costs if you were to face unexpected medical costs for a covered illness or injury.
  • Some people with high-deductible health insurance choose to enroll in a local doctor’s direct primary care (DPC) membership program, to have unlimited access to various primary care services. And as of 2026, having a DPC membership no longer prohibits a person from making HSA contributions if they also have an HSA-eligible health plan, as long as the DPC membership meets certain parameters.

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written hundreds of opinions and educational pieces about the Affordable Care Act for healthinsurance.org.



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What Medicare’s Temporary Program Covering GLP-1s for Obesity Means for Beneficiaries

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What Medicare’s Temporary Program Covering GLP-1s for Obesity Means for Beneficiaries



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The Centers for Medicare & Medicaid Services (CMS) has released a memo fleshing out the design of a short-term program providing Medicare coverage of GLP-1s for obesity in 2026 ahead of a multi-year demonstration program beginning in 2027. Medicare is statutorily prohibited from covering drugs used for weight loss, and these demonstration programs are designed to fill that gap.

Under the short-term program, called the “Medicare GLP-1 Bridge,” Medicare will cover GLP-1s approved for weight reduction – Wegovy and Zepbound – for eligible beneficiaries enrolled in Medicare Part D for a $50 copayment. Eligibility is based on BMI of 35 or more alone, or 27 or more plus other clinical criteria. Although beneficiaries must be enrolled in Part D to participate, the short-term program will operate outside the Part D benefit for its duration from July 1 to December 31, 2026. Instead, providers will submit GLP-1 prescriptions and prior authorization requests to a central processer managed by CMS.

CMS’s efforts to provide Medicare coverage of GLP-1s for obesity could offer substantial benefits to millions of Medicare beneficiaries, given the high demand for these medications. The number of beneficiaries eligible for the Medicare GLP-1 Bridge is unknown, but a previous KFF analysis estimated that close to 14 million Medicare beneficiaries had a diagnosis of overweight or obesity in 2020 (BMI of 25-29.9 and 30 or more, respectively), though applying the specific criteria that determine eligibility for the Medicare GLP-1 Bridge would reduce that number.

There are potential drawbacks to the short-term program, however. Because it will operate outside the Part D benefit, the $50 copayment won’t count towards the Part D deductible or the $2,100 out-of-pocket spending cap. Part D enrollees using a GLP-1 for type 2 diabetes, sleep apnea, or other Medicare-covered uses will continue accessing the drug through their Part D plan and paying their plan’s cost-sharing requirement, even if it’s more than the $50 copayment for GLP-1s for obesity under the Medicare GLP-1 Bridge. And low-income Medicare beneficiaries who qualify for reduced cost sharing through the Part D Low-Income Subsidy can’t use those subsidies for GLP-1 prescriptions filled under the short-term program. For low- and modest-income individuals, the $50 copayment could be a barrier to participation.

Another potential issue is that beneficiaries who participate in the short-term program will need to be enrolled in a Part D plan that participates in the longer-term demonstration, called the BALANCE Model, to continue accessing Medicare coverage of GLP-1s for obesity starting in 2027. CMS is aiming for robust Part D plan participation in the BALANCE model, which is voluntary for plans, but this is still uncertain. Transitioning Medicare coverage of GLP-1s for obesity from the mandatory Medicare GLP-1 Bridge to the voluntary BALANCE model sets up the possibility that beneficiaries with coverage under the short-term program may need to switch Part D plans during the 2027 open enrollment period, with potential cost and coverage implications for other medications they use.



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Medicaid Workers and Job-Based Insurance: Who Is Offered, Eligible, and Enrolled?

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Medicaid Workers and Job-Based Insurance: Who Is Offered, Eligible, and Enrolled?



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Passage of the 2025 reconciliation law, also known as the “One Big, Beautiful Bill,” in July 2025 and the inclusion of new work requirements for certain Medicaid enrollees in the law focused attention on the work status of adults enrolled in the program as well as their access to job-based insurance. Most adults who will be subject to the new Medicaid work requirements are already working. These adult workers rely on Medicaid because most work in jobs that do not offer health coverage or are not eligible for the offered coverage. While employer-sponsored insurance is the main source of coverage for working-age adults in the United States, access to job-based coverage is more limited for low-wage workers, those who work in certain industries, part-time workers, and those who work at smaller firms. Many employers— small and large— report that Medicaid provides important access to health care to their employees.

New work requirements are unlikely to increase employment (as most Medicaid adults are working or face barriers to work). Given the limited offers and eligibility for job-based coverage for low-wage workers, the new requirements are also not likely to substantially reduce reliance on Medicaid as a source of coverage for those workers. However, these requirements will likely reduce Medicaid enrollment because even some enrollees who are working will be unable to verify their work status.

Using data from the 2025 Current Population Survey Annual Social and Economic Supplement (CPS ASEC), this analysis examines the availability of job-based insurance in 2024 for adult Medicaid workers ages 19 to 64 and explores the reasons why Medicaid adults who are working are not eligible for employer coverage, and if eligible, why they do not take up the offer. The analysis excludes Medicaid adults who are self-employed, are also enrolled in Medicare, receive disability-related payments from Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI) and focuses on states that have adopted the Medicaid expansion and Wisconsin, which has adopted a partial expansion. Medicaid adults enrolled through the expansion, or partial expansion in Wisconsin, will be subject to the new work requirements. Georgia is excluded from the analysis because enrollment in the Pathways to Coverage Program is too small to be captured in the data. This analysis does not attempt to identify adults who would be subject to work requirements. It covers a broader group of Medicaid enrollees, including adults with dependent children, some of whom may be exempt.

Most Medicaid adult workers work for an employer that does not offer job-based insurance or are not eligible if their employer offers coverage. For workers to enroll in job-based insurance, they need to work for an employer that offers coverage and be eligible to enroll in that coverage. Nearly two-thirds (65%) of Medicaid adult workers in expansion states and Wisconsin either work for an employer that does not offer health coverage (52%) or are not eligible for coverage that is offered by their employer (13%) (Figure 1). In contrast, about one in five (21%) adult workers who are not covered by Medicaid in the same states are not offered (16%) or eligible (5%) for coverage offered by their employer.

About a quarter (26%) of adult Medicaid workers decline coverage when they are eligible compared to 17% of adult workers not covered by Medicaid. Many adult workers who are eligible for job-based insurance do not take up the offer because the coverage is unaffordable (Appendix Table 1). For adult Medicaid workers who did not enroll in job-based coverage, Medicaid likely provides coverage that is more affordable, and in some cases, more comprehensive than the health insurance available through their employer.

About one in ten (9%) adult Medicaid workers take up coverage offered by their employer and are covered by both Medicaid and the employer plan. In these cases, Medicaid provides wrap-around coverage, covering premiums and cost sharing, as well as providing coverage for benefits not included in the employer plan.

Even when adult Medicaid workers in low-wage jobs have access to job-based insurance, the employee share of the costs can be unaffordable. Workers in firms with many lower-wage workers (where at least 35% earn $37,000 or less annually) have higher average contribution rates toward their premium for family and single coverage compared to workers at firms with fewer low-wage workers (31% vs 26% for family coverage and 19% vs 16% for single coverage). These higher contributions likely mean low-income families with job-based coverage spend a greater share of their income on health costs overall (premium contributions and out-of-pocket expenses) than those with higher incomes, which may contribute to decisions not to enroll in the offered coverage.

Most Medicaid Adults Work for an Employer That Does Not Offer Job-Based Insurance or Are Not Eligible if Their Employer Offers Coverage

Medicaid adults who work part time are less likely to be eligible for job-based insurance than those who work full time. About one-third (32%) of adult Medicaid workers work part time, and among these part-time workers, one in five (21%) are eligible for coverage from their employer compared to 42% of those who work full time (Figure 2). Under the Affordable Care Act’s shared responsibility mandate, employers with at least 50 full-time equivalent employees are required to provide minimum essential coverage to employees, but that requirement only extends to employees who work an average of at least 30 hours per week. As a result, among firms that offer health benefits, relatively few offer benefits to part-time workers.

Medicaid Adults Who Work Part Time Are Less Likely to be Eligible For Job-Based Insurance Than Full-Time Workers

Eligibility for job-based insurance among adult Medicaid workers varies by industry. The share of adult Medicaid workers eligible for job-based insurance varies from 56% in the mining industry to 20% in the agricultural and forestry industry (Figure 3). Medicaid adults working in educational and health services industry represent nearly a quarter (23%) of adult Medicaid workers and 41% are eligible for job-based insurance. On the other hand, about one in six (16%) adult Medicaid workers have jobs in the leisure and hospitality industry where only 22% are eligible for employer-based insurance.

Eligibility for Job-Based Insurance Among Adult Medicaid Workers Varies by Industry

Among adult Medicaid workers who are offered insurance by their employer, most are not eligible because they do not work enough hours. About one in eight (13%) adult Medicaid workers work for an employer that offers health insurance but are not eligible (Figure 1). Nearly seven in ten (69%) of these workers reported they were not eligible because they did not work enough hours per week or weeks per year to qualify (Figure 4). About one in ten (13%) Medicaid workers were not eligible because they had not worked for the employer long enough, and another 5% said they were not eligible because contract and temporary employers were not allowed in the employer’s health plan.

Among Adult Medicaid Workers Who Are Offered Insurance by Their Employer, Most Are Not Eligible Because They Do Not Work Enough Hours

Reasons for Not Taking Up Job-Based Coverage Among Adult Workers Covered By Medicaid and Those Not Covered by Medicaid



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How Do Health Expenditures Vary Across the Population?

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How Do Health Expenditures Vary Across the Population?



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In a given year, a small portion of the population is responsible for a very large percentage of total health spending. This collection of charts explores the variation in health spending across the population through an analysis of 2023 Medical Expenditure Panel Survey (MEPS) data. The analysis finds that five percent of the population accounted for nearly half of all health spending, spending an average of $72,918 annually in 2023. People with health spending in the top one percent spent an average of $150,467 per year.

The analysis also examines spending variation by age, gender, race, insurance coverage status and presence of certain health conditions. Adults who have been diagnosed with a serious or chronic disease have significantly higher out-of-pocket spending.

The chart collection is part of the Peterson-KFF Health System Tracker, an online information hub dedicated to monitoring and assessing the performance of the U.S. health system.



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Your guide to early retirement health insurance options

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Your guide to early retirement health insurance options



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If you’re retiring before age 65 and your employer doesn’t offer retiree health benefits, you’ll need a plan for your health coverage until you become eligible for Medicare at 65. Let’s take a look at your early retirement health insurance options and what you need to know about each one.

Can early retirees get health insurance through the ACA Marketplace?

Yes. The ACA Marketplace / exchange can be a great option for early retirees to find coverage. ACA-compliant coverage is guaranteed-issue regardless of medical history, and if you lose access to your employer’s health plan when you retire, the loss of coverage will trigger a special enrollment period for individual-market coverage.

Depending on your household income, you might be eligible for premium tax credits (subsidies) that cover some or all of the premiums for a Marketplace plan.

Here’s what you need to know about Marketplace health coverage for early retirees:

  • Premiums do not vary based on gender or medical history, but they do vary based on age. In most states, a 52-year-old will have a premium that’s roughly double the premium for a 21-year-old, and a 64-year-old’s premium will be three times as high as a 21-year-old’s.
  • If you qualify for a premium subsidy, the subsidy is based on your premium for the second-lowest-cost Silver plan (benchmark plan). So the premium subsidy is also larger for older enrollees, as it’s based on a larger benchmark plan premium.
  • To qualify for a premium subsidy, you must have a household income in the subsidy-eligible range, as described below. Here’s how household income is calculated under the ACA.
  • Marketplace subsidy eligibility is based on your total household income for the full year, even if that income isn’t evenly spread across the year.

How can early retirees find out if they’re eligible for Marketplace subsidies?

Let’s take a closer look at how Marketplace subsidy eligibility works for early retirees, since the subsidies can make a big difference in terms of how affordable a Marketplace plan will be.

The subsidy-eligible income range depends on where you live and how many people are in your household. On the lower end of the income spectrum, your household income must be at least 100% of the federal poverty level (FPL) to qualify for subsidies, but in most states, it actually needs to be above 138% of FPL because Medicaid is available below that level.

On the upper end of the income spectrum, you wouldn’t be eligible for federal premium subsidies if your household income exceeds 400% of FPL. (State-funded subsidies are available to enrollees with household incomes above 400% of FPL in Connecticut, New Jersey, and New Mexico.)

Here are the income ranges that make a single Marketplace enrollee eligible for federal premium subsidies in 2026 (using the 2025 federal poverty guidelines). (The income limits are higher if your household includes additional people.)

  • In Alabama, Florida, Georgia, Kansas, Mississippi, South Carolina, Tennessee, Texas, Wisconsin, and Wyoming (states that have not expanded Medicaid under the ACA), your income must be between $15,650 and $62,600.
  • In Hawaii, your income must be between $24,827 and $71,960.
  • In Alaska, your income must be between $26,980 and $78,200.
  • In the rest of the country, your income must be between $21,598 and $62,600.

Your household income used to calculate subsidy eligibility includes total earnings from employment, capital gains, investment income, a pension, rental income, and Social Security. (Retirement benefits can begin as early as age 62.)

But if, for example, you’re planning to live off of savings and the income (dividends, interest, capital gains, etc.) from those savings isn’t enough to put you in the subsidy-eligible range, you would not be eligible for Marketplace subsidies.

On the other end of the spectrum, if your income will decline significantly when you retire, your pre-retirement income from earlier in the year could make you ineligible for subsidies for the remainder of that year, depending on how much you earned.

For example, consider a person who earns $100,000 per year (about $8,333 per month), who is planning to retire at the end of August. By that point in the year, they will have earned nearly $67,000. Unless they’re in Alaska or Hawaii, that means they will be ineligible for Marketplace subsidies for the whole year – even if they don’t earn anything at all for the final four months of the year.

You may want to have a discussion with a financial advisor before you retire, to ensure that you have a plan in place for managing your income in retirement if you’re hoping to qualify for Marketplace subsidies. And when determining the timing of your retirement, be sure you understand what your total household income will be during the year you retire – including money you earned before your retirement date and any severance pay you might receive – as well as future years.

Just for perspective in terms of how much difference a subsidy can make, here are 2026 Marketplace premiums for a single 60-year-old in Mobile, Alabama, which is fairly mid-range in terms of premium costs:

  • Household income of $60,000: Lowest-cost Bronze plan is $0/month (because the household receives a subsidy of $827 per month).
  • Household income of $63,000: Lowest-cost Bronze plan is $827/month (because the household is ineligible for subsidies, due to the “subsidy cliff”).

Note: You can reduce your ACA-specific household income by contributing to a health savings account (HSA) if you select an HSA-eligible health plan. And if you continue to have earned income during retirement (from a part-time job, self-employment, consulting, etc.), you can contribute to a pre-tax retirement account, which will also lower your household income under ACA rules.

Use a subsidy calculator to see if your retirement income makes you subsidy-eligible.

Can early retirees get Medicaid if they’re in an expansion state?

In 40 states and Washington, DC, Medicaid eligibility has been expanded under the ACA. This means that adults under age 65 are eligible for Medicaid if their household income doesn’t exceed 138% of FPL.

If you’re under 65, your eligibility for Medicaid in an expansion state is based solely on your income, so assets aren’t taken into consideration. (Individuals age 65 and older face both income limits and asset limits when applying for Medicaid.)

And unlike eligibility for Marketplace subsidies, your Medicaid eligibility can be determined based on annual income or current monthly income. This can make Medicaid coverage possible even if the person had a higher income earlier in the year.

But there are a couple of important points to understand about using expanded Medicaid as your early retiree health coverage:

Medicaid expansion states will soon have a work requirement

Starting in 2027, Medicaid expansion enrollees will face a work requirement, due to federal legislation enacted in 2025. Unless they qualify for an exemption, Medicaid expansion enrollees will be required to spend at least 80 hours per month participating in “community engagement” activities.

These “community engagement” activities can include employment, community service, education, or a combination these activities. Enrollees will be required to provide proof of these activities to their state Medicaid agency in order to keep coverage in force.

Some early retirees who plan to volunteer extensively or return to school or hold a part-time job (that doesn’t push their income out of the Medicaid-eligible range) will continue to be eligible for Medicaid expansion coverage in those states that expanded Medicaid. But those who do not plan to have at least 80 hours per month of community engagement are unlikely to be eligible for Medicaid in 2027 and future years.

Medicaid estate recovery

Under federal rules, states are required to use estate recovery (recouping funds after a Medicaid beneficiary has died) for Medicaid-funded long-term care that was provided after a person was 55 years old. But states also have the option to use estate recovery to recoup any Medicaid expenses that were incurred after a person was 55 years old, so states vary in their approach to this.

If you’re planning to use Medicaid as your early retiree coverage, make sure you understand how your state handles estate recovery, so that there are no eventual surprises for your heirs. (Here’s Medicaid contact information for each state.)

Is COBRA or state continuation a good option for early retirees?

When you retire, you may have access to COBRA or state continuation (“mini COBRA,” which is offered in many states to people whose employers weren’t large enough to be subject to COBRA). These federal and state provisions allow early retirees to continue their employer-sponsored coverage temporarily. Here’s what you need to know about this option:

  • If your employer’s health plan is subject to COBRA and you retire, COBRA allows you to continue your existing coverage for up to 18 months.
  • If your employer’s health plan is subject to state continuation, the length of time you can keep your plan will depend on the rules in your state.
  • You’ll be responsible for the full premium cost (including the portion your employer was paying), plus an administrative fee. For COBRA, the fee is 2% of the premiums. For mini-COBRA, the fee varies by state.

COBRA can be a good solution if you’ll be eligible for Medicare within 18 months of retirement, as it means you won’t have to switch to new  coverage for the gap between your retirement date and the start of your  Medicare coverage. But it’s a good idea to compare Marketplace plans to your COBRA offer to see which makes more sense for your circumstances, as each option has pros and cons.

You can use COBRA even if you still have several years before you’ll be eligible for Medicare. Just know that once you exhaust your COBRA benefit, you’ll need to pick a new plan at that point, to cover the rest of your early retirement years.

Early retirement health insurance through a spouse’s coverage

If you’re retiring early but your spouse is still working, you may both have access to your spouse’s employer-sponsored health plan. There is no federal law requiring group health plans to offer coverage to spouses, but almost all of them do.

If your spouse is enrolled in their employer’s plan and you’re enrolled in your own employer’s plan, your loss of coverage will trigger a special enrollment period that will allow you to be added to your spouse’s plan (assuming the plan is offered to employees’ spouses).

If you and your spouse are both covered under your plan, the loss of coverage when you retire will trigger a special enrollment period that will allow both of you to enroll in your spouse’s plan (assuming your spouse is an eligible employee and the plan allows employees’ spouses to enroll).

Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written hundreds of opinions and educational pieces about the Affordable Care Act for healthinsurance.org.

 



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Constrained Budgets Lead States to Restrict HIV Drug Access Through Ryan White

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Constrained Budgets Lead States to Restrict HIV Drug Access Through Ryan White



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States are facing constrained budgets, putting pressure on HIV care and prevention programs, including the Ryan White HIV/AIDS Program. Ryan White, the nation’s HIV safety-net, is funded each year through discretionary federal appropriations, state dollars, and other sources. However, funding does not necessarily match the number of people who need support or the cost of services.

The largest component of Ryan White provides grants to states, including for their AIDS Drug Assistance Programs (ADAPs), which provide HIV treatment and insurance assistance for people with HIV. In the past, ADAPs have used waiting lists and other cost-containment measures when programs could not meet the needs of all those eligible, and in the early 2000s, waiting lists were common. Significant waiting lists were last cleared with an influx of emergency federal funding in 2013 and then were used occasionally for a few years. They have not been used for over a decade and, to date, have not returned. However, several states facing budget pressures have recently moved to institute other cost-containment measures, including restricting eligibility and scope of services, and some are considering waiting lists for the future.  This represents the first time such broad cost-containment measures have been taken since the waitlist era.

Ultimately, such changes could result in people with HIV losing access to care and treatment, which could worsen health outcomes (increasing morbidity and mortality) and leading to new HIV infections (four in ten new HIV transmissions are associated with someone who is aware of their HIV status but not in care).

State ADAPs Respond to Strain by Limiting Enrollment and Services Offered

Florida recently annoucned changes to its ADAP, which would dramatically limit eligibility and scope of assistance. Specifically, the state plans to reduce income1 eligibility for the program from 400% of the federal poverty level (FPL) to 130% FPL (for an individual, which is the equivalent of eligibility decreasing from a maximum income of $63,840 to $20,748 annually).

Additionally, the state plans to remove Biktarvy from its formulary. Biktarvy is the most widely prescribed antiretroviral (ARV) medication nationally (accounting for 52% of the U.S. ARV market) and the only single tablet regimen (STR) included among the national HIV treatment guidelines list of recommended initial treatment regimens. Some studies have shown that STRs improve adherence by reducing pill burden.

The state also plans to roll back its insurance assistance program. ADAPs can help cover insurance costs in addition to directly purchasing medications. Ending insurance assistance poses unique challenges, as insurance coverage allows individuals to meet both HIV-related and other health care needs and helps protect clients in the face of unexpected medical costs (e.g. through out-of-pocket maximums).2 With expiration of enhanced Affordable Care Act premium tax credits, out-of-pocket premiums for people in ACA plans are increasing substantially this year.

The changes in Florida have received significant push back from advocates, patients, and providers, and the state was sued for proceeding with these changes without formal rule making. (The state then issued a proposed rule which it followed with emergency rulemaking. Litigation continues seeking to block implementation).

Florida, however, is not alone. New data from the National Association of State and Territorial AIDS Directors (NASTAD) indicate that 23 states (including Washinton, D.C.) have implemented or are considering ADAP cost-containment measures.3 Eighteen (18) ADAPs, including Florida‘s, have already made or are making changes and five additional states report that they are considering introducing such measures in the future. Further, 12 of the 19 states already implementing cost-containment measures are considering additional changes for the future.

For example, in addition to Florida, Pennsylvania, Kansas, Delaware, and Rhode Island have also reduced income eligibility for their programs (though to a lesser degree). Other changes states are exploring or implementing include reducing formularies (though, so far, none as consequential as removing Biktarvy), reducing funding for medical and support services, making recertification more stringent (which can create churn and lead to program disenrollment), implementing annual client spending caps, and restricting or ending health insurance assistance.

At Least 19 ADAPs Have Taken Cost-Containment Actions, 5 More Are Considering Future Action

To date, no state has implemented a waiting list, a measure widely seen as a last resort. However, Arkansas, Louisiana, and New Jersey report considering implementing one as a future cost-containment measure.

Multiple Factors Are Exerting Budget Pressures on ADAP

There are a range of factors affecting ADAP budgets. These include, but are not limited to, the following:

Federal ADAP Funding Not Keeping Pace With Inflation

Since 1996, Congress has allocated (or “earmarked”) a set amount of funding for ADAPs during the annual appropriations process. After modest funding levels in the late 1990s, followed by significant growth in the early 2000s, ADAP inflation-adjusted appropriations have declined by 31% since 2005.4 The decline is largely attributable to more than a decade of flat funding in nominal dollars. When adjusted to 1996 dollars, the FY25 appropriation ($438.8 million) has similar purchasing power as the program’s FY1999 funding level ($434.0 million).5 In other words, in the last 20 years, ADAP funding has not kept pace with inflation, even before accounting for enrollment growth and increased costs (discussed below).

ADAP Earmark in Nominal Dollars and Adjusted for Inflation (1996 dollars)

In the NASTAD report ADAPs identified growing client enrollment, growing drug costs, and rising insurance costs as the top three drivers of budget concerns. These concerns are explored further below:

Increased Client Enrollment

While modern era federal ADAP funding has not kept pace with inflation, the number of ADAP clients served has increased significantly. The number of clients served increased by 56% from 2007 (the first year with available data for the full year) to 2024 (the most recent year with available data), rising from 165,3826 to 257,644 clients served. Adjusted for inflation, appropriations per client served dropped from about $3,600 in 2007 to approximately $1,700 in 2024. Additionally, the national HIV treatment guidelines have evolved to recommend HIV treatment at the time of diagnosis -as opposed to starting at signs of disease progression- which has led to more people with HIV having an indication for treatment.

Rising HIV Drug Costs

Another factor impeding the reach of ADAP dollars is the increasing cost of drugs for HIV treatment. A recent analysis found that the average wholesale price (AWP) of recommended initial antiretroviral regimes in 2012 ranged from an AWP of $24,970 to $35,160, increasing to $36,080 to $48,000 in 2018. Costs have generally increased since then. Data in the treatment guidelines show that the AWP for Biktarvy (again the number one treatment regimen for people with HIV and only STR recommended by the treatment guidelines start list) was $61,000 in 2025. The 2025 AWP for other recommended (two-pill) regimens ranged from $34,320 to $65,196. While ADAPs do not pay the full AWP because they have access to price discounts through the 340B drug pricing program and supplemental manufacturer rebates, increasing drug prices may still affect them; it is a main concern cited by ADAPs regarding cost challenges. Additionally, ADAPs ability to generate rebates (which make up a growing share of their budgets) through Medicare have diminished due to programmatic changes, including adoption of the out-of-pocket cap in Part D – by introducing the cap, ADAPs and other 340B entities, have less opportunity to generate rebates on claims because they make fewer cost-sharing payments.

Increased Insurance Premium Costs and Expiration of Enhanced Tax Credits

As mentioned above, ADAPs can also purchase health insurance for eligible clients. However, the cost of individual market coverage is on the rise, with the expiration of the enhanced premium tax credits being a particular driver and premium increases also playing a role.

ACA premium tax credits help make marketplace plans more affordable for people with low to moderate incomes. They were first enhanced as part of the American Rescue Plan Act in 2021 and extended by Congress through 2025, but have since expired due to the lack of a bipartisan Congressional agreement to continue them. The enhanced tax credits had improved insurance affordability for ADAPs purchasing coverage on behalf of clients, including for those previously eligible for the less generous ACA subsidies and, newly, for those with incomes over 400% FPL, a group for whom premium costs were limited to 8.5% of income. Without the enhanced credit those 100-400% FPL revert to the original, less generous, ACA tax credits and those over 400% FPL have lost financial assistance altogether. For enrollees keeping the same plan, expiration of the enhanced premium tax credits is estimated to more than double what subsidized enrollees previously paid annually for premiums—a 114% increase from an average of $888 in 2025 to $1,904 in 2026.

Additionally, after holding relatively steady since 2020, premiums increased steeply between 2025 and 2026, with the average premium cost for benchmark plans increasing by 26%7, with significant variation across states. Some southern states with high HIV prevalence saw especially large average increases (e.g. 33% in Florida and 35% in Texas). These premium increases occurred for a range of reasons including, but not limited to, higher health care costs, use of expensive GLP-1 drugs, the threat of tariffs, and the expiration of the enhanced premium tax credits. While the vast-majority of ADAP clients have modest incomes, these costs will be borne out most acutely for the 7% of clients served by insurance purchasing who have incomes over 400% FPL, a group who lost the enhanced tax credits that previously capped premium costs as a share of their income. ADAPs covering individuals in this higher income group face a two-fold setback – loss of enhanced tax credits and no protections against rising premiums. 

Additionally, individuals who lose ADAP insurance coverage due to cost-containment measures may find financing coverage independently more challenging due to reduced tax credit generosity and increases in premiums.

Looking Ahead

While ADAPs have sought to leverage additional state funds, drug rebates, and capture limited emergency and supplemental funding, these efforts have not remedied budget shortfalls, leading many to institute cost-containment measures. ADAPs may increasingly face budget pressures that could lead to additional such measures in the future. This could leave growing numbers of people with HIV ineligible for safety-net services, particularly if states further lower income eligibility limits or institute waiting lists. The expiration of enhanced tax credits amplifies these challenges, both increasing costs for programs and leaving those who are ineligible for ADAPs with fewer affordable alternatives. Limiting access to Ryan White services will in turn affect the ability of people with HIV to stay engaged in HIV treatment, a cornerstone of national efforts to address the HIV epidemic.

Endnotes



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The Midterms Lurk Behind Every Health Policy Move Now

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The Midterms Lurk Behind Every Health Policy Move Now



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Look for the midterms to play a role in every health policy decision until November, as both Republicans and Democrats maneuver for advantage with voters. That’s the case with two recent Trump administration moves to strengthen the hand of Republicans in the midterm elections. Democrats start out with a significant advantage on health in the midterms, but rather than cut and run to other issues, Trump wants Republicans to try to erode that advantage where they can.

One example is the shake-up at Health and Human Services, surrounding Secretary Robert F. Kennedy, Jr. with a new cadre of advisers, deposing others and installing the Director of the National Institutes of Health as Acting Director of the Centers for Disease Control & Prevention at the same time. This augments a controversial secretary with administration appointees placed there to deliver on policies the administration wants Republicans to trumpet, such as their initiatives to lower drug costs, including “most favored nation” (MFN) drug pricing and Trump Rx. Keeping the secretary in place rather than replacing him also appeases Make America Healthy Again (MAHA) supporters in the Republican base and may appeal to other voters who support MAHA ideas.

Four in 10 adults say they are MAHA supporters—the amorphous cause RFK Jr. champions—including 22% of Democrats and 38% of Independents. We don’t know if many of them will vote in the midterms for that reason, but some may if they feel strongly about MAHA-related issues or a candidate who champions them. Make America Great Again (MAGA), Independent and Democratic MAHA adherents almost certainly have different elements of MAHA-ism they care about, from vaccines to healthier food to environmental chemicals, to general distrust of government—and not all of these issues will be in play in the midterm races they vote in. Anti-vax views can be strongly held but notably, 31% of MAHA adherents disapprove of RFK Jr.’s handling of vaccines. The secretary sometimes takes heat from the more extreme MAHA groups for not going far enough, but overall, he holds down a lot of the MAHA flank for Trump and Republicans while the newly installed advisors pursue policy deliverables.  

Four in Ten Adults Say They Support the Make America Healthy Again (MAHA) Movement, With Support Closely Tied to Republicans and MAGA Republicans

Saying the quiet part about underlying political strategy out loud as he often does, Trump recently linked the drug cost policies he wants to advance directly to the midterms, calling on Republican candidates to emphasize efforts to bring down drug costs as a midterm campaign message. It’s an effort to play offense and blunt attacks from Democrats focusing on affordability and rising premiums, especially in the Affordable Care Act (ACA) Marketplaces. Politically, the goal for Trump and Republicans is not to “win” the health care issue but to erode the Democratic advantage on it by talking a lot about drug costs and villainizing drug companies. (Lately, adding insurance companies to the mix of villains as well.) Of course, Democrats also have advanced drug cost policies they can talk about if they choose to fight on that terrain rather than health care affordability generally.

Overall, as the chart shows, Democrats still have a sizable advantage on health heading into the midterm campaigns, including a modest one on drug costs despite the administration’s initiatives. Their primary strategy is to link health care costs to the public’s broader concerns about affordability at a time when paying for health care has emerged as voters’ top economic worry. 

Among Voters, Democrats Have an Edge Over Republicans on Most Health Issues

It remains to be seen if Republican candidates in close races will want to go head-to-head with Democrats on health care, despite Trump’s urging them to do so. They may feel they have other cards to play, and some will not want to highlight decisions they made to cut Medicaid and double people’s ACA premium payments in a general election.

Policies have declared and undeclared purposes. We analyze the pros and cons of policies like Trump Rx or MFN when the primary purpose of the policy is to signal to voters that “I care about your drug costs” and “I am doing something about it.” The political strategy behind them is usually undeclared but almost everything in health policy between now and November will be substantially about the midterms. 

View all of Drew’s Beyond the Data Columns



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TrumpRx: What’s the Value for Customers?

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TrumpRx: What’s the Value for Customers?



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Evaluating the impact of TrumpRx requires a closer look at how most Americans access prescription medication. Sixty-six percent of people under age 65 have private health insurance, including 58% with employer-sponsored coverage and 8% with individual insurance purchased on or off ACA Marketplaces. Nearly all (99%) workers with employer-sponsored coverage are at a firm that provides prescription drug coverage to enrollees in its largest health plan. 

The discounts currently advertised on TrumpRx are only available to those purchasing medications without using insurance. The “Frequently Asked Questions” at the bottom of the TrumpRx landing page explicitly state that the discounted pricing is only available for “cash-paying” patients. The webpage for each TrumpRx drug notes that patients with insurance should check what their copay would be if using insurance, as it may be even lower than the TrumpRx price.

Due to the complexity of prescription drug pricing and the variation in private insurance plan designs, several factors need to be considered to evaluate the usefulness of TrumpRx for individual consumers. Three illustrative scenarios are provided below.

Patient has private insurance for a TrumpRx drug, and a generic equivalent is not available

Medication covered by an individual’s private insurance may be less expensive when purchased through insurance. Because TrumpRx coupons are for self-pay consumers, dollars paid for a TrumpRx medication will not count toward a consumer’s insurance deductible or out-of-pocket maximum. In contrast, individuals using private health insurance to purchase the drug instead of the TrumpRx coupon or other manufacturer discount will have their out-of-pocket payments count toward their plan’s deductible and out-of-pocket maximum. Since many of these drugs are used by individuals with chronic illnesses who need their medication throughout the year, the out-of-pocket expenditure may contribute significantly to the deductible and out-of-pocket maximum amounts for the plan, affecting the out-of-pocket costs for other services billed to insurance.

Individuals purchasing through insurance will also have access to a negotiated price through their insurer or employer plan. The “savings” listed on TrumpRx for each drug are based on the manufacturer’s list price for drugs sold to wholesalers or direct purchasers (“wholesale acquisition cost,” or WAC) and typically do not directly reflect what consumers pay. The negotiated prices vary across private plans but are typically lower than the WAC. In such a case, consumers could pay less over the year with their insurance, even having to meet a deductible. Specific cost-sharing arrangements, copay or coinsurance, for the drug depend on the plan formulary, but may also be cheaper than the TrumpRx price.

But deductibles matter. While many patients with private insurance could come out ahead in terms of their annual out-of-pocket costs by using their insurance instead of a TrumpRx coupon or other manufacturer discount for a specific medication, growing insurance deductibles for those with private insurance factor into patient choices and might steer people who have insurance to discounted self-pay options via direct-to-consumer (DTC) manufacturer websites or TrumpRx. 

According to the annual KFF Employer Health Benefits Survey (EHBS), among workers covered by employer-sponsored insurance, the average deductible for single coverage was $1,663 in 2025 (including those whose plan does not have a general annual deductible), 23% higher than the average general annual deductible in 2020 ($1,350), and 54% higher than in 2015 ($1,078). Average deductibles are higher for Affordable Care Act (ACA) Marketplace plans sold on HealthCare.gov, though growth over the past decade has increased more slowly than for employer-sponsored plans. In 2025, the average annual individual combined deductible (medical services and drugs) for ACA Marketplace coverage was $2,759. While this is lower than the average deductible in 2020 ($2,962), it is an increase from $1,987 in 2015.3

At least one study has found that for employer-sponsored insurance, out-of-pocket prices for branded retail drugs, on average, increased nearly 6% annually between 2007 and 2020, driven by large increases in deductible and coinsurance payments.

TrumpRx may be an economical option for those who face high out-of-pocket costs for prescription drugs before they meet their plan’s deductible, especially those who do not reach their annual deductible at all. If a consumer, for instance, must pay the retail price for an expensive medication prior to meeting their plan’s deductible, they might look to Trump Rx or DTC self-pay options to reduce their monthly payment for a medication. Self-pay expenses won’t count toward their deductible, but some consumers may choose this option if their monthly income and other household expenses will only allow them to afford the medication at a self-pay discounted price.

Example 1

Terry has a prescription for Prempro to help manage symptoms of menopause. The self-pay discounted price on TrumpRx is $98.84 per month, but she has private health insurance. It is the beginning of the year, though, and Terry has not met any of her plan’s $1,500 annual deductible. If her monthly cost for Prempro is $250 and she has a $30 copay after meeting her deductible, she would pay the full price from January through June, at which point she would have met her $1,500 deductible, then she would just pay the $30 copay from July through December. Assuming no other deductible spending during the year, her total annual out-of-pocket cost for this drug would be $1,680 if she uses her insurance. In this example, she would pay less over the year ($1,186) using the self-pay TrumpRx discount instead of her insurance, though the amount she spends using the discount would not count toward her plan’s deductible or out-of-pocket maximum.

However, some employer plan designs effectively mitigate the impact of high deductibles on prescription drugs. According to the 2025 KFF EHBS, 61% of workers enrolled in an employer-sponsored health plan with a general annual deductible do not have to meet the deductible before prescription drugs are covered. Formularies with a tier for “preferred” brand-name drugs may require a relatively small copay even before the deductible is met. Additionally, 45% of covered workers in firms with 50 or more workers are enrolled in a plan that reduces or waives cost sharing for at least some maintenance drugs for chronic conditions, such as insulin for diabetes. 

Example 2

Using the previous example, now assume that Terry’s insurance covers prescription drugs before meeting the deductible, meaning that she is just responsible for the $30 copay for a month of Prempro. Using her insurance to purchase the drug, she would spend $360 over the year, far less than the $1,186 she would spend if she were to pay using the TrumpRx coupon and bypass insurance.

People who are enrolled in a high-deductible health plan (HDHP) paired with a health savings account (HSA) must pay all medical costs until they meet their high deductible (at least $1,700 for an individual in 2026), or else they cannot contribute new funds to their HSA.4 There are exceptions that allow plans to cover certain prescription drugs that are ACA-required preventive services, certain insulin products, and other medications deemed preventive for certain chronic conditions before the deductible is met. However, beginning this year, people in bronze and catastrophic Marketplace individual plans can contribute to their HSAs even if they have coverage for a prescription drug before meeting the annual minimum deductible.

For privately insured patients with chronic disease, copay assistance could also be a factor. Manufacturer “copay assistance programs” specifically for consumers using private health insurance are available for over half of the drugs currently available on TrumpRx, which may lower enrollees’ copay and coinsurance payments to as little as $0/month for some drugs, without TrumpRx discounts. Many health plans (group and individual), however, do not count the value of manufacturer copay coupons toward the enrollee’s deductible or out-of-pocket maximum, a feature known as a “copay adjustment program.” As of 2026, at least 25 states and the District of Columbia prohibit or restrict the use of at least some of these types of programs in certain health insurance plans sold in those states.5 These laws do not apply to those in employer self-insured plans regulated only under federal law. Consumers may need to consult their plan documents to find out whether manufacturer copay assistance can be used and, if so, whether their expenses will count toward their plan’s out-of-pocket obligations.

Patient takes a prescription drug that is discounted on TrumpRx, and a generic equivalent is available

According to one analysis, 90% of all prescriptions filled in the U.S. in 2024 were generics. Regardless of the form of payment (private insurance or self-pay), generic equivalents are often cheaper than brand-name drugs, sometimes even after discounts offered through TrumpRx. About half (22) of the drugs on TrumpRx have generic equivalents available in the U.S., at least three-quarters (17) of which are less expensive via GoodRx discounts or direct purchase from Cost Plus Drugs than the TrumpRx coupon price for the brand-name version. *Five brand-name drugs on TrumpRx are less expensive on TrumpRx than their generic equivalents on the other two websites. Generic drugs generally have more favorable cost-sharing arrangements than brand-name drugs through insurance, decreasing patient out-of-pocket responsibility for patients using private insurance. Since usual and customary retail prices for these generic drugs are so much lower than their brand-name equivalents, they are cheaper for self-pay patients as well. There is no disclaimer on TrumpRx stating that consumers could pay less than the TrumpRx price by purchasing a generic alternative.

Example 3

Jo has a prescription for Diflucan for an infection. Her insurance has substituted generic fluconazole instead of the brand-name product, with a $10 copay (before deductible) for one bottle. In this case, even with the coupon, it would be cheaper to use her private insurance instead of self-paying with the coupon, which prices Diflucan at $14.06. Additionally, she finds out that the $10 copay will count toward her plan’s out-of-pocket maximum.

If a generic version is available, pharmacists may substitute the generic equivalent for the brand-name drug (and as of 2022, 17 states and the District of Columbia7 required this) unless the prescriber indicates to “dispense as written” on the prescription or the patient specifically requests the brand-name. In these states, a consumer who presents a TrumpRx coupon at the pharmacy for a brand-name drug might automatically end up paying less without using the coupon when the prescription is filled with a generic. Indeed, the “Frequently Asked Questions” at the bottom of the TrumpRx landing page indicates that pharmacies are not required to dispense the TrumpRx discounted drug.

Example 4

Patrick’s physician has written him a prescription for Farxiga for his diabetes. He is uninsured and goes to a pharmacy to fill the prescription. Although the self-pay price is $700, the pharmacist provides a generic equivalent at around half the price. TrumpRx advertises the discounted brand-name drug for a yet lower price of $181.59.

Example 5

Patricia has rheumatoid arthritis and gets a prescription for Azulfidine. She is uninsured and goes to a pharmacy to fill the prescription. Although the self-pay price is $350, the pharmacy only stocks the generic equivalent at $60 a month. This price is lower than the discounted price for the brand-name product advertised on TrumpRx, $99.60.

Patient does not have insurance, or the TrumpRx drug is not covered by their insurance

Those who have already been paying out-of-pocket for certain drugs may see savings from TrumpRx. Some of the drugs on TrumpRx are typically not covered by private health insurance. For example, the KFF Employer Health Benefits Survey found that just one in five (19%) large employers offering health benefits to workers say they cover costly GLP-1 drugs such as Wegovy and Zepbound when used primarily for weight loss in 2025, and fewer than two in five (37%) reported covering fertility medications in 2024. However, some drug discounts on TrumpRx reflect limited-time offers for lower initial doses for new patients. For example, Wegovy pills start at $149/month but increase to $299/month after two monthly fills (for a higher dose).

Example 6

Carol has a prescription for the fertility drug Cetrotide. Her insurance doesn’t cover this drug at all, so she has been buying it from a direct-to-consumer online pharmacy. She pays $49.50 for the generic version, which is more expensive than the brand-name drug with the TrumpRx coupon, at $22.50.

Example 7

Rob receives a prescription to start using Wegovy, which does not have a generic version. He doesn’t have insurance but is able to afford the drug with the one-time introductory offer via TrumpRx of $149 for a month of pills. After that, the monthly price for the drug goes up to $299, making it unaffordable to Rob for continued use even with the discount.

Other patients who could potentially benefit (at least temporarily) from TrumpRx include those who have a gap in insurance coverage, those whose plan formulary has removed coverage for a needed drug, or those whose insurance has utilization management requirements, such as quantity limits or step therapy. As mentioned above, though, since TrumpRx currently only includes 43 drugs, patients will likely find discounts for a much larger selection of drugs using other self-pay discount platforms or from online pharmacies.



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Hospital Spending Accounted for 40% of the Growth in National Health Spending Between 2022 and 2024

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Hospital Spending Accounted for 40% of the Growth in National Health Spending Between 2022 and 2024



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Introduction

National spending on health has increased rapidly over time—rising to $5.3 trillion and 18% of GDP in 2024—and is projected to continue to do so into the future. Growth in health spending contributes to higher costs for families, employers, Medicare, Medicaid, and other payers. In 2025, average annual premiums for employer-sponsored family coverage reached $26,993, with workers paying $6,850 for their coverage, according to KFF’s annual survey of employers.  Hospital care accounted for nearly one-third of national health expenditures in 2024, and more than doubled in nominal terms over the preceding two decades, making hospitals a major driver of health spending growth over time.

This data note analyzes the extent to which hospital spending has contributed to the growth in national health expenditures in recent years (2022-2024) and over the long term (2005-2024) using data from the Centers for Medicare & Medicaid Services (CMS) National Health Expenditures Accounts (NHEA). (See Key Facts About Hospitals for more information about hospital spending and the Peterson-KFF Health System Tracker for more on national health expenditures).

Hospital Spending Accounted for 40% of the Growth in National Health Spending Between 2022 and 2024, A Far Larger Share Than Any Other Health Spending Category  

National health expenditures increased by $692 billion between 2022 and 2024, from $4.6 trillion to $5.3 trillion. During this period, spending on hospital care alone accounted for $277 billion of spending growth, or 40% of the total increase in national health spending (Figure 1). The large contribution of hospital care to overall health spending growth reflects the fact that hospital spending accounted for nearly a third of national health expenditures in 2022 (30%) and grew more quickly than national health expenditures overall in both 2023 (10.6% versus 7.4%) and 2024 (8.9% versus 7.2%).

Hospital Spending Accounted for 40% of the Growth in National Health Spending Between 2022 and 2024, A Far Larger Share Than Any Other Health Spending Category

The growth in hospital spending in 2023 and 2024 was primarily due to a “rebound in nonprice factors, such as the use and intensity of services, that were somewhat depressed during the [COVID-19] public health emergency,” according to CMS. Nonetheless, hospital prices, which grew by 2.7% in 2023 and 3.4% in 2024, also played a role. In fact, according to CMS, 2024 saw the fastest hospital price growth since 2007. Hospital price growth includes Medicare and Medicaid as well as commercial prices; hospital prices in these public programs have grown more slowly than commercial prices over time.

The contribution of hospital care to overall spending growth was larger than that of other major spending categories. Physician and clinical services accounted for the second-largest share at 22% of the growth. Retail prescription drug spending, which grew at about the same rate as hospital spending during the period between 2022 and 2024, accounted for 11% of the growth during this period (Appendix Table 1). Spending on non-medical insurance expenditures, other professional services, home health care, nursing care and continuing care retirement communities, dental services, and government administration accounted for smaller shares. Spending on government public health activities declined by 7% during this period, likely due to the winding down of activities related to the COVID-19 pandemic. Spending on all other goods and services, which includes some long-term services and supports, accounted for 13% of the growth in total spending.

Hospital spending grew at a faster rate (20%) than total health spending (15%) from 2022 to 2024.  Retail prescription drugs (20%), other professional services (25%), home health care (23%) and government administration (24%) also grew more quickly than total health spending, although these categories contributed less to overall growth than hospitals because they had lower baseline spending in 2022. 

Over a longer period, 2005-2024, hospital spending accounted for 32% of the overall increase in national health spending growth, while spending on physician and clinical services accounted for 22% and spending on retail prescription drugs accounted for 8% (Appendix Table 2). CMS projects that hospitals will return to a similar share of spending growth through 2033 (32%), down from the 40% share that hospitals have accounted for in recent years.

Hospital Spending Per Year Increased by $1 Trillion Over the Past Two Decades and by $277 Billion Between 2022 and 2024

Hospital spending grew from $609 billion in 2005 to $1.6 trillion in 2024, a $1.0 trillion increase (Figure 2). During this period, total health spending grew $3.3 trillion, from $2.0 trillion to $5.3 trillion. In more recent years, hospital spending increased from $1.4 trillion in 2022 to $1.6 trillion in 2024, a $277 billion increase.

Hospital Spending Per Year Increased by $1 Trillion Over the Past Two Decades

Hospital spending growth over the past two decades was greater than the spending growth for physician and clinical services (the second-largest increase), and substantially greater than the growth in retail prescription drugs (the third-largest increase).

Spending on hospital care specifically and national health expenditures generally have both exceeded overall economic growth over time. Hospital spending increased from 4.7% to 5.6% of GDP from 2005 to 2024, while total health care spending increased from 15.5% to 18.0% of GDP over the same period. By 2033, CMS projects that hospital spending will rise to 6.4% of GDP, with national health expenditures increasing to 20.3% of GDP.

Hospital spending growth over the past two decades is primarily due to increases in both prices and quantity of services provided, particularly when outpatient care is taken into account. From 2005 to 2024, hospital prices increased by 61% based on KFF analysis of the Producer Price Index (PPI). In terms of volume, although total hospital inpatient days decreased 5% (17% per 1,000 population), outpatient visits increased by 44% (25% per 1,000 population), based on KFF analysis of the AHA Trendwatch Chartbook and the AHA Annual Survey Database. The continued growth in hospital spending will contribute to higher costs for public programs like Medicare and Medicaid, employers and families, and exacerbate ongoing concerns about health care affordability.

This work was supported in part by Arnold Ventures. KFF maintains full editorial control over all of its policy analysis, polling, and journalism activities.

Appendix

US National Health Spending Growth by Type of Spending, 2022-2024

US National Health Spending Growth by Type of Spending, 2005-2024



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