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Since its inception in 1999, the Employer Health Benefits Survey has tracked trends in employer-sponsored health insurance. Each year, private and non-federal public employers with three or more employees participate in the survey. Among various topics, the survey inquires about the premium (or total per-person cost) of their health coverage and the contributions made by workers (the portion of the premium paid by employees). The graphing tool below illustrates the changes in premiums and worker contributions over time for covered workers across different types of employers.
The findings from the 2024 survey, along with supplementary information, can be accessed here. For further details regarding the survey methodology, please refer to the Survey Design and Methods section. If you have additional questions concerning the Employer Health Benefits Survey or this tool, please visit the Contact Us page and select “TOPIC: Health Costs.”
Standard Errors (SE): Like all surveys, every estimate within the Employer Health Benefits Survey carries a degree of uncertainty. Estimates for smaller or more targeted groups generally exhibit higher uncertainty. Standard Errors (SEs) quantify the uncertainty surrounding an estimate. They are utilized in statistical tests to assess if the difference between two estimates is significant. Frequently, even considerable discrepancies between two groups may not be statistically significant. Standard errors are provided for each data point in the “Export Table Data” download link above.
Not Sufficient Data (NSD): The abbreviation NSD is employed when there are insufficient firms in a sub-population to yield a reasonable estimate and/or safeguard respondent confidentiality.
Weights: To guarantee that estimates are representative at the national level, firms are selected randomly and weights are assigned to each firm’s data. Premium and worker contribution estimates are weighted according to the number of workers covered by health benefits. These weights are further adjusted based on the number of employees within specific industry and firm size categories. For more insights, please check the Survey Design and Methods section.
Variable Definitions: Family coverage refers to a household of four. Firms that offer self-funded or partially self-funded plans assume some or all of the financial risk associated with covering their employees’ medical claims directly. These employers typically contract with a third-party administrator or insurer for administrative services for these plans. In certain instances, these employers may also purchase stop-loss insurance from a third-party insurer to mitigate the risk of incurring very large claims. For more information on self-funding, see Section 10. Firms that provide various plan types are categorized as self-funded or fully insured based on the attributes of their largest plan type; however, premiums are calculated as a weighted average of up to two plan types. Consequently, the premiums from both self-funded and fully insured plans may be included in the average premium and worker contribution for certain firms.
Industry classifications are determined based on a firm’s primary Standard Industrial Classification (SIC) code as established by Dun and Bradstreet. A firm’s region is ascertained by the location of its primary establishment according to the U.S. Census Bureau definitions. Ownership classifications are reported by the survey respondent.
Firms with a Significant Proportion of Lower-Wage or Higher-Wage Workers: Since 2013, the thresholds for higher- and lower-wage workers are based on the 25th and 75th percentiles of national worker earnings as reported by the Bureau of Labor Statistics’ (BLS) Occupational Employment Statistics (OES) (2020). These cutoffs are adjusted for inflation and rounded to the nearest thousand. From 2007 to 2012, wage thresholds were derived using the now-defunct National Compensation Survey. Higher-wage firms are defined as those where at least 35% of workers earn above the 75th percentile cutoff. Conversely, lower-wage firms are those where at least 35% of workers earn below the 25th percentile cutoff. To minimize the survey burden on respondents, certain years only included questions concerning higher-wage workers.
|
35% of Workers Earn … or less |
35% of Workers Earn … or more |
|
|
1999 |
$20,000 |
$75,000 |
|
2000 |
$20,000 |
$75,000 |
|
2001 |
$20,000 |
Not Available |
|
2002 |
$20,000 |
Not Available |
|
2003 |
$20,000 |
Not Available |
|
2004 |
$20,000 |
Not Available |
|
2005 |
$20,000 |
Not Available |
|
2006 |
$20,000 |
Not Available |
|
2007 |
$21,000 |
$50,000 |
|
2008 |
$22,000 |
$52,000 |
|
2009 |
$23,000 |
Not Available |
|
2010 |
$23,000 |
Not Available |
|
2011 |
$23,000 |
Not Available |
|
2012 |
$24,000 |
$55,000 |
|
2013 |
$23,000 |
$56,000 |
|
2014 |
$23,000 |
$57,000 |
|
2015 |
$23,000 |
$58,000 |
|
2016 |
$23,000 |
$59,000 |
|
2017 |
$24,000 |
$60,000 |
|
2018 |
$25,000 |
$62,000 |
|
2019 |
$25,000 |
$63,000 |
|
2020 |
$26,000 |
$64,000 |
|
2021 |
$28,000 |
$66,000 |
|
2022 |
$30,000 |
$70,000 |
|
2023 |
$31,000 |
$72,000 |
|
2024 |
$35,000 |
$77,000 |
An updated collection of charts examines the anticipated growth in health spending over the next few years, focusing on trends in prescription drug costs, out-of-pocket expenses, and other related factors.
In 2024, the growth in per capita health spending is projected to slow down to 4.5%. Expectations indicate a further decline in growth rates for 2025 and 2026, anticipated at 4.2% and 4.3%, respectively. From 2027 to 2032, average annual growth in per capita spending is expected to stabilize at around 5.0%. Throughout this timeframe, national health expenditures are likely to exceed GDP growth, primarily due to rising medical prices.
The insights presented in this chart collection utilize the 2022 National Health Expenditure (NHE) projections provided by federal actuaries. For more analyses and information, visit the Peterson-KFF Health System Tracker, a resource hub focused on monitoring and evaluating the U.S. health system’s performance.
KFF research has consistently highlighted prescription drug costs as a critical health policy issue that captures public interest and concern. Our surveys reveal that the majority of individuals take at least one prescription medication and recognize their societal benefits; however, a significant portion believes these drugs are too costly, with three in ten struggling to afford their medications. The public has historically backed various strategies to reduce prescription drug prices, including allowing Medicare to negotiate prices, a key element of the Inflation Reduction Act (IRA) enacted in 2022. Nonetheless, over two years after the IRA’s passage, a large majority of the public remains unaware of the drug pricing measures included in the legislation.
Here are some key insights regarding the public’s experiences and perceptions regarding prescription medications and their costs.
Prescription drugs impact the lives of most Americans. Approximately six in ten adults report currently taking at least one prescription drug, while one-quarter state they are on four or more medications.
In addition to using prescription drugs, a majority of the public acknowledges the advantages these medications provide. About six in ten (63%) adults believe that prescription drugs developed over the last two decades have generally improved life for people in the U.S., whereas a much smaller portion (21%) feels they have worsened it.
Despite their perceived benefits, around eight in ten adults (82%) deem the cost of prescription drugs to be unreasonable. The public identifies profits made by pharmaceutical companies as the chief factor in these high prices. Over 80% of adults from all political affiliations consider pharmaceutical company profits to be a “major factor” in prescription drug pricing, followed by more than half who attribute costs to research and development expenses and nearly half who cite marketing and advertising costs as significant contributors.
More than half (55%) of adults express concern about their family’s ability to afford prescription drug costs, with a quarter (26%) being “very” worried. A greater percentage of Black (61%) and Hispanic (69%) adults report worries about affording the costs compared to White adults, half of whom share this concern. Additionally, 67% of uninsured adults under 65 report worries about affording prescription drugs, while over half (54%) of insured adults also express concerns about these costs.
While about two-thirds (65%) of adults overall find it very or somewhat easy to cover their prescription drug costs, affordability becomes a larger issue for those taking four or more medications. Nearly four in ten (37%) individuals on four or more prescriptions report challenges in affording their medications, compared to one in five (18%) adults taking three or fewer prescriptions. Adults earning less than $40,000 annually are also more likely to experience difficulties in affording their prescription medications compared to those with higher incomes.
Approximately three in ten adults reported not taking their medications as prescribed at some point in the past year due to financial constraints. This includes about one in five who either did not fill a prescription (21%) or opted for an over-the-counter alternative (21%), with 12% indicating they cut pills in half or skipped doses because of costs. The rates of not filling prescriptions, using over-the-counter drugs instead, or skipping doses increase to roughly four in ten among adults aged 18-29 (40%), Hispanic adults (39%), those taking four or more prescriptions (37%), and individuals in households earning less than $40,000 (37%).
The July 2023 KFF Tracking Poll shows that three in four adults believe there is “not enough regulation” to control the pricing of prescription drugs. While partisan views can differ regarding the extent of government regulation in other sectors, a majority across party lines—including 82% of Democrats, approximately 68% of Republicans, and around 67% of independents—agree that there is “not as much regulation as there should be” concerning prescription drug pricing.
For decades, lawmakers have debated drug pricing reform, with the Inflation Reduction Act, or IRA, being the first significant piece of recent legislation aimed at lowering prescription drug prices. Prior to the IRA’s passage in 2022, majorities from both parties supported various initiatives, including allowing the federal government to negotiate lower medication prices for Medicare recipients, which is a central aspect of the IRA. Traditionally, majorities have also backed measures such as increasing taxes on pharmaceutical companies that refuse to negotiate drug prices with the government, capping price increases based on annual inflation rates, permitting Americans to import drugs from Canada, setting annual limits on out-of-pocket drug expenses for Medicare beneficiaries, and facilitating the entry of generic drugs into the market.
As of September 2024, many voters remain unaware of the Medicare drug pricing measures in the IRA, which was passed by Congress and ratified by President Biden in 2022. Awareness of some provisions is notably higher among older voters, the demographic most affected by these changes. Four in ten voters know that a federal law exists limiting insulin costs for Medicare recipients to $35 per month, while approximately a third (35%) are aware of the law mandating federal negotiations for some prescription drugs for Medicare. About a quarter (27%) are informed about the law introducing an annual limit on out-of-pocket costs for Medicare recipients, and one in eight (12%) are aware of penalties for drug companies increasing prices faster than inflation for Medicare patients. Notably, a higher percentage of older voters (61%) recognize the $35 cap on insulin as part of existing law.
Overall, nearly nine in ten (85%) voters favor the federal government having the authority to negotiate drug prices for Medicare beneficiaries as outlined in the IRA, with only one in seven (14%) opposing it. This provision enjoys support from 92% of Democratic voters, 89% of independent voters, and 77% of Republican voters.
Majorities of voters, both overall and across party affiliations, support two proposals aimed at expanding the IRA’s provisions beyond Medicare’s scope. Approximately three-quarters (77%) favor a proposal that extends the $35 cap on out-of-pocket insulin costs to those without Medicare, including majorities from both parties—84% of Democrats, 79% of independents, and 70% of Republicans. Additionally, about seven in ten (69%) voters support a proposal to broaden the $2,000 annual cap on out-of-pocket prescription drug expenses to individuals not covered by Medicare, including 83% of Democrats, 70% of independents, and 58% of Republicans.
National health expenditure reached $4.5 trillion in 2022, accounting for 17% of the gross domestic product (GDP), and is expected to outpace GDP growth through 2032. This growing expenditure is likely to increase costs for families, employers, states, and the federal government. As policymakers explore various strategies to enhance health care affordability, they are paying close attention to the effects of market consolidation in health care and its potential impact on costs and quality of care. Hospital consolidation is a primary focus because nearly one third of all health care spending is directed towards hospital services. While consolidation could enable providers to function more efficiently and assist struggling providers in underserved areas, it frequently results in diminished competition. A wealth of evidence indicates that consolidation can lead to increased prices, with ambiguous effects on quality.
This analysis investigates the competitiveness of hospital care markets by using RAND Hospital Data, a refined version of cost reports from Medicare-certified hospitals, along with American Hospital Association (AHA) survey data. For conciseness, the terms “independent hospitals” and “health systems” will both be referred to as “health systems.” Competition is quantified in three different ways: the proportion of metropolitan statistical areas (MSAs) dominated by a limited number of health systems, the level of market concentration in MSAs using the Herfindahl-Hirschman Index (HHI), and the evolving share of hospitals associated with health systems. This analysis concentrates on general short-term or general medical and surgical hospitals based on 2022 data, excluding federal hospitals (see Methods for more information).
A single health system controlled nearly one in five (19%) metropolitan statistical areas (MSAs), while over one in four (27%) markets were governed by two systems in 2022 (see Figure 1). In more than four out of five metropolitan areas (82%), one or two health systems ruled over more than 75 percent of the market. All these markets classified as highly concentrated according to current antitrust guideline definitions (outlined below). One health system held at least half the market share in three out of four MSAs (75%) and at least a quarter of the market in almost every MSA (98%).
The number of health systems within an MSA generally increases in line with the region’s population. For instance, in 79% of MSAs with populations under 200,000, one or two health systems controlled the market for inpatient hospital care in 2022, as seen in locations such as Muncie, IN; Napa, CA; and Amherst Town-Northampton, MA (Figure 2). MSAs with one or two health systems represent nearly half (47%) of all MSAs but only 12% of the U.S. metropolitan population.
On the other hand, almost all (53 out of 54) MSAs with populations of one million or more had at least four health systems, as is the case for Detroit, Miami, and Phoenix. These MSAs with four or more health systems make up 35% of all MSAs and 79% of the U.S. population residing in metropolitan areas.
However, in nine of these relatively large MSAs with four or more systems, the two largest health systems had control over at least 75% of the market. Moreover, in 37 of these markets, they accounted for at least 50%. For instance, in the MSA encompassing Austin, TX, with a population of 2.4 million, two systems (HCA Healthcare and Ascension Health) dominated 85% of the inpatient hospital care market, even though Austin hosts more than four health systems. The metropolitan area covering Portland, OR, with a population of 2.5 million and also more than four health systems, showcases a slightly less concentrated market compared to Austin’s; however, the two largest systems (Legacy Health and Providence) still collectively hold 56% of the market. (Refer to Methods for a discussion regarding MSAs as hospital market geographies).
Another approach to evaluating market competitiveness involves analyzing concentration through the Herfindahl-Hirschman Index (HHI), which gauges the number of competitors in a market and their market shares. The scale ranges from 0 (indicating perfect competition) to 10,000 (indicating a monopoly). According to current merger guidelines from the Federal Trade Commission (FTC) and Department of Justice (DOJ), markets are categorized as: not concentrated (HHI < 1,000), moderately concentrated (1,000 – 1,800), and highly concentrated (HHI > 1,800). This analysis calculates HHIs for MSAs and classifies these regions accordingly, although alternative market boundary definitions can yield different competition levels (see Methods).
In 2022, nearly all (97%) MSAs showed high market concentration for inpatient hospital care, based on HHI thresholds from current merger guidelines (Figure 3). These guidelines reflect 2023 updates that lowered the HHI thresholds for moderately and highly concentrated markets. Under previous guidelines, a large proportion—though marginally smaller (93%)—of MSAs were classified as highly concentrated markets, corroborating an estimation from a previous study (90%) using 2016 data.
Similar to the findings regarding the number of health systems in MSAs, more populated metropolitan areas generally tended to be less concentrated and more competitive than those with smaller populations, though this wasn’t universally true. All 13 MSAs identified as either not concentrated or moderately concentrated had populations exceeding one million, including places like Cincinnati, Oklahoma City, and Miami. Nevertheless, 41 MSAs with populations greater than one million—including Houston, Denver, and Atlanta—exhibited highly concentrated hospital markets. Overall, 70% of individuals residing in metropolitan areas lived in highly concentrated hospital markets.
As of 2022, approximately two-thirds of hospitals (67%) are affiliated with larger systems, a rise from 56% in 2010 (Figure 4). A lower percentage of rural hospitals than nonrural ones were part of a health system in 2022 (52% vs. 83%), though both rural and nonrural areas have seen an upward trend: from 43% in 2010 to 52% in 2022 among rural hospitals, and from 69% in 2010 to 83% in 2022 among nonrural hospitals.
As of 2022, the majority of system-affiliated hospitals (53%) belonged to systems with at least 15 hospitals, while 22% were part of systems with 50 or more hospitals. Systems with at least 100 hospitals accounted for 13% of system-affiliated hospitals.
Hospital consolidations into larger systems do not always result in diminished local market competition, especially if an independent hospital is absorbed by a larger system that lacks existing facilities in that locality. Nonetheless, mergers across hospitals that serve distinct geographic markets for patient care—termed “cross-market” mergers—may still lead to escalated prices in certain instances.
This work received partial support from Arnold Ventures. KFF retains complete editorial independence over all of its policy analysis, polling, and journalism efforts.
Methods |
| Market share and HHI analyses (e.g., Figures 1 through 3) were based on RAND Hospital Data, which represents a cleaned and processed dataset from annual cost reports submitted by Medicare-certified hospitals to the federal government. While this data applies only to Medicare-certified hospitals, it covered the vast majority (97%) of non-federal general medical and surgical hospitals included in US metropolitan areas for our AHA Annual Survey Database analysis (detailed below). Cost reports were assigned to specific years based on the reporting period’s conclusion and adjusted to align with a 365-day period, as needed.
Market share and HHI calculations were confined to non-federal, general short-term hospitals. Market shares were determined by the proportion of inpatient discharges in an MSA attributed to a particular health system or independent hospital. One percent of hospitals meeting our sample restrictions had missing inpatient discharge data and were omitted. Hospitals were organized into health systems based on the 2022 AHRQ Compendium of US Health Systems. MSAs reflect the 2023 geographic definitions established by the Census Bureau, derived from data from the 2020 decennial census. HHIs were calculated by squaring the market shares of all health systems in a given MSA (e.g., if an MSA were evenly divided between two systems, the HHI would be 502 + 502 = 5,000). We retrieved 2022 MSA population estimates from the Census Bureau. MSAs were utilized as proxies for hospital markets, a common method followed by other studies analyzing hospital market competition nationwide. Alternate market definitions may result in different competition assessments. For example, some recent reports have also focused on MSAs but emphasized the locations where residents received care, which can include hospitals outside the MSA. Other market definitions might utilize Hospital Referral Regions (HRRs) or USDA Commuting Zones. However, more precise market definitions, such as those used in antitrust cases, were not practical. This study did not exclude MSAs with populations of three million or more, as some analyses have done, because this investigation aimed to describe competition across all metropolitan areas. The share of hospitals affiliated with systems is analyzed based on the AHA Annual Survey Database, which includes a system affiliation measure. This analysis was restricted to nonfederal, general medical and surgical hospitals. Hospitals were classified as rural if located in ZIP codes qualifying for Rural Health Grants via the Federal Office of Rural Health Programs. |
Minneapolis, MN – The open enrollment period for Affordable Care Act (ACA) health plans is set to begin on Nov. 1, with several updates that could enhance enrollment numbers. Healthinsurance.org outlines the upcoming changes, including expanded eligibility for DACA recipients, state-specific adjustments, and new limits on the duration of short-term health insurance plans.
For most states, the open enrollment period for 2025 Marketplace coverage runs from Nov. 1, 2024, to Jan. 15, 2025.
“Open enrollment is approaching quickly, and there are important changes that people should be aware of,” stated Louise Norris, a health policy analyst at healthinsurance.org.
Thanks to a recent rule change by the Biden administration, approximately 100,000 DACA recipients—individuals within the Deferred Action for Childhood Arrivals program—will now qualify for ACA Marketplace plans and federal premium subsidies, starting Nov. 1. This new regulation also makes DACA recipients eligible for Basic Health Program (BHP) coverage, although two of the three states currently with BHPs allow DACA recipients to enroll already.
Nonetheless, 19 attorneys general are pursuing efforts to delay and reverse the DACA eligibility adjustment. Oral arguments are anticipated for mid-October, and a decision could be announced shortly before the open enrollment period begins, creating some uncertainty regarding DACA recipients’ eligibility for 2025 Marketplace coverage.
A new federal regulation imposes limits on the duration of all short-term health insurance plans—effective from Sept. 1, 2024, onwards—to a maximum of four months, including renewals. This is a significant reduction from the previous allowance of up to 36 months across most states.
This means consumers might purchase a short-term plan on or after Sept. 1 and possibly extend it through to the year’s end. However, open enrollment is the first chance for many of these consumers to secure replacement coverage through the Marketplace for 2025.
“The new federal regulation prevents consumers from relying on short-term health insurance policies for extended periods,” explained Norris. “Failing to participate in open enrollment this fall could result in limited or no full-year coverage options for 2025.”
Last year, 93 percent of Marketplace participants received federal premium tax credits, which help reduce coverage costs. Enhanced federal premium subsidies from the American Rescue Plan (ARP) will remain available for 2025 due to the Inflation Reduction Act (IRA).
Nine states also offer state-funded subsidies, which will see increases in California and New Mexico for 2025. Additionally, New York will introduce a new subsidy program for 2025 coverage.
Conversely, Colorado is scaling back its subsidy program. Starting in 2025, the eligibility threshold for Colorado state subsidies will revert to 200% of the federal poverty level (FPL), down from 250% in 2024.
Several insurance carriers are entering state Marketplaces for 2025 coverage. Notably, WellPoint will now provide services in Texas, Florida, and Maryland. Other expanding insurers include Simply Healthcare Plans in Florida, UnitedHealthcare in Indiana, HAP CareSource in Michigan, and WellSense in New Hampshire.
On the other hand, states experiencing insurance carrier exits from Marketplaces include Indiana, Kansas, New Mexico, Pennsylvania, South Carolina, Tennessee, Texas, Utah, and Washington.
In July, the federal government updated its guidelines to safeguard consumers from unauthorized alterations to their health coverage. The new policy mandates that consumers confirm brokers’ authorization to assist with their enrollments on HealthCare.gov or through an approved enhanced direct enrollment platform. The required steps may differ based on the broker. States handling their own exchanges will implement their specific protocols to ensure that enrollments and plan modifications occur with enrollee consent.
“This new requirement aims to safeguard consumers against fraudulent enrollments or unintended plan changes,” Norris notes. “However, it means consumers must plan in advance to ensure they have enough time to receive enrollment assistance from a broker.”
Healthinsurance.org offers online resources to help consumers understand individual and family health insurance options. Owned by HealthInsurance.org, LLC, the site has been a provider of health insurance information and health reform education for over 25 years.
Contact:
In 2022, nearly half (47%) of metropolitan areas across the nation had only one or two hospitals or health systems offering general inpatient hospital care, according to a recent KFF analysis.
The analysis explores the level of competition among hospitals amidst a surge of hospital consolidations that has garnered the attention of both state and federal regulators. Approximately one in five (19%) metropolitan statistical areas are served by just one hospital or health system, while more than a quarter (27%) are under the control of two hospitals or systems.
In a vast majority of metropolitan areas (82%), one or two hospitals or health systems accounted for at least three-quarters of all inpatient hospital discharges, thus fulfilling the criteria for highly concentrated markets as outlined by current federal antitrust standards.
The quantity of hospitals or health systems in a metropolitan area commonly increases with the population size of the region. A significant majority of smaller metropolitan areas (fewer than 200,000 residents) have only one or two hospitals or health systems providing inpatient care, while almost all of the largest areas (with at least one million residents) host a minimum of four hospitals or health systems.
Additional findings include:
Immigrant adults represent a diverse segment of the population, constituting 16% of adults in the United States and significantly contributing to the nation’s workforce and communities. As we approach the 2024 election, anti-immigrant sentiment has surged, with immigration becoming a focal issue for various candidates. The Trump campaign has frequently labeled immigrants as contributors to crime, a financial burden on taxpayers, and a liability for government programs such as Medicare and Social Security. Meanwhile, the Harris campaign has centered its immigration narrative around her strong law enforcement background as a former attorney general in a border state, while also emphasizing her family’s immigrant heritage. Certain states have enacted restrictive measures aimed at immigrants, including mandates for hospitals to gather patient immigration status.
In light of this rhetoric and recent state actions, information on immigrants’ health care utilization and costs, as well as their economic contributions, particularly in the health care sector, is essential. This brief presents important data on these subjects, utilizing KFF analysis from various sources, including the KFF/LA Times Survey of Immigrants, the largest nationally representative survey of immigrants conducted to date, along with other studies.
The 2023 KFF/LA Times Survey of Immigrants reveals that, despite experiencing lower household incomes and encountering financial difficulties, immigrant adults are just as likely as U.S.-born adults to state that they or someone in their household received government assistance for food, housing, or health care in the last year. In fact, approximately one-quarter (28%) of both immigrant adults and U.S.-born citizen adults reported receiving such assistance within the past 12 months (Figure 1).
Lawfully present immigrants face eligibility restrictions for federal programs like Medicaid and the Children’s Health Insurance Program (CHIP). Generally, lawfully present immigrants must possess a “qualified status” to access Medicaid or CHIP. Many, including most lawful permanent residents or green card holders, must wait five years after achieving qualified status before enrolling, provided they meet all other eligibility criteria. Some lawfully present immigrants, such as refugees and asylees, are exempt from this five-year waiting period. Additionally, states can expand coverage to lawfully residing immigrant pregnant individuals and children without this waiting period. Lawfully present immigrants can also purchase coverage through the Affordable Care Act (ACA) Marketplace and qualify for tax credits to help lower their costs immediately. Those meeting the work requirements can enroll in Medicare, while others may purchase Medicare Part A after maintaining legal residence in the U.S. for five consecutive years.
Undocumented immigrants cannot enroll in federally funded programs like Medicaid, CHIP, or Medicare, nor can they buy coverage through the ACA Marketplaces. Medicaid can cover emergency services for individuals eligible for Medicaid but for their immigration status. Emergency conditions encompass those that threaten the individual’s health or result in serious bodily impairment, although states hold discretion regarding what services qualify for Emergency Medicaid reimbursement.
Some states have initiated fully state-funded programs to extend coverage to immigrants regardless of status, although the eligibility criteria and benefits provided vary. Studies indicate that expanding health coverage for immigrants can lead to decreased rates of uninsurance, increased health care utilization, reduced costs, and improved health outcomes.
Research indicates that immigrants, both lawfully present and undocumented, engage less with health care services than U.S.-born citizens. The KFF/LA Times Survey of Immigrants shows that undocumented immigrants are less likely to seek or receive care in the U.S. compared to lawfully present immigrants and naturalized citizens. Approximately 63% of likely undocumented immigrant adults report having a health care visit in the past year, compared to 74% of lawfully present immigrant adults and 82% of naturalized citizen adults.
This lower health care utilization among immigrants can be attributed to their overall healthier and younger demographics, along with increased barriers such as language access issues, confusion, and fears related to immigration. Analysis from KFF indicated that policies from the Trump administration intensified these fears and led to increased hesitance in seeking care.
Reflecting their reduced health care utilization, immigrants exhibit lower health care expenditures than their U.S.-born counterparts. KFF’s analysis of 2021 medical expenditure data indicates that the average annual per capita health care expenditures for immigrants are about two-thirds that of U.S.-born citizens ($4,875 vs. $7,277) (Figure 3). This includes lower spending across various health care services such as office visits, prescription medications, inpatient and outpatient care, and dental services. These findings support other research revealing that immigrants’ overall health expenditures range from half to two-thirds compared to those of U.S.-born individuals, irrespective of immigration status, with lower per capita expenses noted across private and public insurance sources, especially among undocumented immigrants. A particular study highlighted that undocumented immigrants tend to be uninsured and have significantly reduced yearly health care expenditures compared to U.S.-born individuals, with no substantial differences in rates of uncompensated care between the two groups.
Immigrants play a crucial role in addressing the nation’s labor shortages by occupying unmet manufacturing and service needs, with research indicating they do not displace U.S.-born workers. Their contributions are particularly evident in essential sectors such as construction and agriculture, which are vulnerable to health risks and injuries, including climate-related hazards. Furthermore, immigrants, alongside their adult children, significantly enhance the health care workforce, serving as physicians, surgeons, nurses, and long-term care workers (Figure 4). With ongoing projections of shortages in health care employment and a growing population aged 65 and older, immigrants could be pivotal in alleviating these workforce deficits.
Studies show that undocumented immigrants contribute billions yearly in federal, state, and local taxes, with more than a third attributed to payroll taxes funding programs they cannot access, such as Social Security and Medicare. Additional research indicates that immigrants contribute more to the health care system than they use through taxes and premiums, effectively subsidizing health care for U.S.-born citizens. Earlier studies found that without the input of undocumented immigrants into the Medicare Trust Fund, it would face insolvency sooner, and demonstrably, undocumented immigrants positively impact the financial health of Social Security.
Starting Nov. 1, 2024, Georgia residents will use a state-run health insurance enrollment platform, Georgia Access, to shop for and enroll in Marketplace health coverage for 2025. Here’s a look at the changes that consumers can expect:
From 2014 through 2023, Georgia relied fully on the federally run health insurance Marketplace, HealthCare.gov, for enrollment. For 2024, the state transitioned to a state-based Marketplace on the federal platform.
This meant Georgia was responsible for some aspects of running the Marketplace, including operating and funding a Navigator program, and certifying the plans offered for sale via the Marketplace. But residents have continued to use HealthCare.gov to enroll in coverage with a 2024 effective date.
That changes for 2025 coverage, as Georgia will be running all aspects of their Marketplace, including the enrollment platform.
No. Georgia residents who have a special enrollment period this fall and are using it to sign up for coverage that takes effect before the end of 2024 will still use HealthCare.gov to do that – even after Nov. 1. But then they will need to renew or change their coverage for 2025 using the Georgia Access platform.
To clarify, the Georgia Access platform cannot be used for enrollment with an effective date prior to Jan. 1, 2025, as it’s been approved by the federal government for enrollments starting with plan year 2025. The state-run enrollment platform will be operational as of Nov. 1, 2024, but only for coverage effective in 2025.
If you’re enrolling in 2025 individual/family health coverage in Georgia, you’ll be using the Georgia Access enrollment platform instead of HealthCare.gov this fall. Existing HealthCare.gov accounts for Georgia residents will be transferred to Georgia Access. The Marketplace will send enrollees instructions for logging into the new Marketplace portal and accessing their accounts so that they can renew or change their coverage for 2025.
Georgia Access will also be operating the state’s Marketplace call center, as all state-run exchanges are required to do. So Georgia residents will no longer use HealthCare.gov’s call center if they need phone assistance with the enrollment process.
Those are the primary changes from a consumer perspective. But there will also be the same sort of changes that enrollees see every year, in terms of adjustments to plan designs, provider networks, and premiums – including changes to subsidy amounts that can affect net premiums.
Although Georgia residents will no longer use HealthCare.gov to enroll in coverage for 2025, many aspects of the Marketplace will remain the same:
Open enrollment start date
Open enrollment in Georgia will begin Nov. 1, 2024, for coverage effective in 2025. This is the same schedule used by HealthCare.gov. Georgia residents will need to complete their enrollment by Dec. 16, 2024 to have coverage effective Jan. 1, 2025. (This is one day later than the Dec. 15, 2024 deadline for a Jan. 1 effective date on HealthCare.gov.)
According to the Georgia Office of the Commissioner of Insurance, the end date for open enrollment had not yet been finalized as of late August 2024. In most states, including all of the states that use HealthCare.gov, it will end on Jan. 15, 2025. Georgia could opt to extend it beyond that, but cannot end it any earlier, under federal rules that were finalized in 2024.
Subsidy eligibility
After the transition to Georgia Access, enrollees will continue to have access to the same federal premium tax credits (premium subsidies) and cost-sharing reductions that are available via HealthCare.gov. Eligibility for these subsidies is the same regardless of whether a state runs its own exchange or uses the federal platform.
Participating Marketplace carriers
Georgia’s health insurance Marketplace has nine participating carriers offering coverage in 2024, with varying coverage areas. All nine will continue to offer Marketplace coverage in 2025 (including one that will be offering plans under two separate entities).
As is always the case – regardless of whether a state runs its own Marketplace – carriers can change their coverage areas from one year to the next. So although all of Georgia’s 2024 Marketplace insurers will continue to offer coverage in 2025, the specific plans and participating insurers in each area might change. Enrollees should carefully consider all of their available options before selecting a plan or renewing their coverage for 2025.
Georgia residents can continue to use an EDE
This is a significant difference between Georgia’s Marketplace and other state-run Marketplaces. Georgia is the first state-run Marketplace that will partner with enhanced direct enrollment (EDE) entities the way HealthCare.gov does.
The enhanced direct enrollment process allows consumers in states that use HealthCare.gov to enroll in an on-exchange / Marketplace health plan through approved web brokers’ and insurers’ sites, without having to visit HealthCare.gov.
Georgia Access is requiring its EDE partners to be certified as EDEs with HealthCare.gov. (An entity that doesn’t pass the federal Marketplace EDE certification requirements cannot serve as an EDE in Georgia.)
So if you’re already accustomed to using an EDE to enroll in your Georgia Marketplace coverage – as opposed to going directly through HealthCare.gov – you’ll be able to continue to use that approach for 2025.
“The partnership between Georgia Access and private enrollment sites gives consumers the option of shopping and choosing Marketplace coverage through a third-party web site they may already be accustomed to using or with the assistance of a trusted insurance broker or agent,” says Dave Keller, president of INSXCloud, Inc., one of the participating enhanced direct enrollment platforms Georgia residents can use.* “We’re convinced the added enrollment flexibility will further increase enrollment in an already growing Georgia market.”
Georgia’s reinsurance program
The Georgia Access model is part of a 1332 waiver that was approved by CMS in 2020. Another part of that same 1332 waiver included a reinsurance program that took effect in Georgia in 2022.
Georgia’s reinsurance program will continue to operate in 2025 the same way it does now. Reinsurance programs are in use in 17 states, including Georgia. Some of these states use HealthCare.gov while others run their own Marketplaces.
Reinsurance operates in the background, helping to keep premiums lower than they would otherwise be. Reinsurance primarily helps enrollees who don’t get premium subsidies (about 4% of Georgia Marketplace enrollees) and thus have to pay the full cost of their coverage. Georgia’s reinsurance program will continue to do this in 2025, as it is currently authorized through 2026, and can be extended after that.
(The effects of reinsurance on subsidized enrollees are mixed; some pay higher net premiums as a result of the reinsurance program, since lower overall premiums result in smaller premium subsidies. But this is not affected by whether a state runs its own Marketplace or uses the federally run platform.)
If you need to obtain your own health coverage for 2025, you’ll be using the Georgia Access platform or an approved enhanced direct enrollment entity.
If you already have coverage through the Georgia Marketplace in 2024, keep an eye out for any communications from HealthCare.gov, Georgia Access, and your health plan. You’ll receive instructions for claiming your account on Georgia Access, as well as information about how your current plan’s benefits and premium will change for 2025. And if you’re receiving a premium subsidy, you’ll also receive a notification of how much your subsidy will be in 2025.
As long as your current plan will still be available in 2025, it will auto-renew if you take no action during open enrollment. But it’s in your best interest to actively compare your plan options and decide whether you’d like to renew your existing plan or pick a different one.
If you worked with a broker or Navigator to enroll in your 2024 coverage, you can reach out to them to confirm that they’ll be certified with Georgia Access and will be able to help you with your 2025 coverage.
If you aren’t currently enrolled in a Georgia Marketplace plan, you’ll be able to use Georgia Access starting Nov. 1, 2024, to select a plan for 2025 – with income-based subsidies if you’re eligible.
* HealthInsurance.org, LLC and INSXCloud, Inc. indirectly share common corporate ownership.
Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org.
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Most voters continue to be unaware of the Medicare drug pricing provisions in the Inflation Reduction Act, or IRA, that was passed by Congress and signed into law by President Biden more than two years ago, though awareness of some of the provisions is higher among older voters – the group most impacted by the provisions.
Four in ten voters are now aware there is a federal law in place that caps the cost of insulin for people with Medicare at $35 per month, while another third (35%) are aware of the law that requires the federal government to negotiate the price of some prescription drugs for people with Medicare. A quarter of voters (27%) are aware of the federal law that places a limit on out-of-pocket prescription drug costs for people with Medicare, and one in eight (12%) are aware that there is a law in place that penalizes drug companies for increasing prices faster than the rate of inflation for people with Medicare.
Larger shares of voters ages 65 and older are aware of some of these drug pricing provisions of the IRA. For example, six in ten (61%) voters ages 65 and older are aware of the law that caps the cost of insulin for people with Medicare and about a third (34%) of older voters are aware of the provision that places an out-of-pocket limit on prescription drug costs. Similar shares of older voters compared to younger voters are aware of the provision that requires the government to negotiate the price of some prescription drugs and that penalizes drug companies for increasing prices faster than the rate of inflation for people with Medicare.
While awareness of the Medicare drug pricing provisions increased, especially among older voters, from November 2023 to May 2024, awareness has remained steady over the past several months.
The Biden administration recently announced that the lower prices negotiated for some prescription drugs would have saved the federal government $6 billion in 2023 with an estimated $1.5 billion reduction in out-of-pocket costs for older adults when lower prices take effect in 2026. Large majorities of voters have not heard about these projected savings, with almost half (45%) who say they have heard “nothing at all” about the negotiations, while a quarter (25%) have heard “a lot” or “some.” Another three in ten (30%) have heard “a little” about the negotiations.
Larger shares of older voters, those ages 65 and over, say they’ve heard “a lot” or “some” about these savings, with a third (32%) who say so, compared to one in five (22%) of those under age 65.
Similarly, larger shares of Democratic and independent voters have heard about the projected savings, with about a third (34%) of Democrats and a quarter (27%) of independents who have heard at least “some,” compared to about one in six (16%) Republican voters.
Overall, almost nine in ten (85%) voters support authorizing the federal government to negotiate drug prices, while one in seven (14%) oppose. This provision is supported by 92% of Democratic voters, 89% of independent voters, and 77% of Republican voters. While support for the law is lower among Republicans, most Republican voters support it.
In addition to supporting the federal government negotiations, a slight majority (55%) of voters ages 65 and older think Medicare negotiations will lower their own prescription drug costs, while four in ten (43%) older voters think negotiating won’t have any impact on their prescription drug costs. Expectations that Medicare negotiations won’t lower drug costs seem to be partisan, with two-thirds (64%) of older Democratic and Democratic-leaning voters thinking it will lower their drug costs, while about half (52%) of older Republican and Republican-leaning voters thinking it won’t have any impact on their drug costs.
The Inflation Reduction Act was enacted under President Biden without any Republican support in Congress. Six in ten voters say President Biden had a “major” or “minor” role in passing the recent law aimed at lowering drug prices for people on Medicare, including four in ten (37%) who say he had a “major” role. Similar shares of voters say the same about Democrats in Congress, with six in ten (60%) who say they played a “major” or “minor” role. Another four in ten (42%) voters say Vice President Harris played a role. Credit for the recent law could be key as she picks up these issues on her own platform for president.
Almost half (46%) of voters think that Republicans in Congress played a role in passing the recent law, with a small share saying they played a “major” role (14%). About a quarter of voters credit former President Trump for the passage of the law aimed at lowering drug prices for those on Medicare, with a quarter (28%) who say he played a “major” or “minor” role, while 41% say he had no role in passing the recent law. Between a quarter and a third of voters aren’t sure how big of a role these groups played in the health care legislation.
Partisans are more likely to give their own party leaders credit for passing legislation aimed at lowering the price of prescription drugs for people on Medicare, though Republican voters are less enthusiastic about their party leaders’ roles. Larger shares of Democratic voters than Republican voters say President Biden, Vice President Harris, and the Democrats in Congress played a “major” or “minor” role in passing legislation for lowering drug prices for people on Medicare. While Republican voters are more likely than Democratic voters to say former President Trump and the Republicans in Congress played a role, only about a quarter of Republican voters said either (23% and 24%, respectively) played a “major role.” In fact, a similar share of Republican voters give former President Trump credit for passing the legislation as give credit to President Biden.
Overall, eight in ten (81%) Democratic voters say Biden played a role in passing the legislation, four in ten (39%) of Republican voters say the same about Trump. Another eight in ten Democratic voters say Democrats in Congress played a “major” or “minor” role in passing the legislation, while over half (54%) of Republicans say the same about Republicans in Congress.
Vice President Harris’ campaign has announced that, if elected, her administration hopes to expand some of the drug pricing legislation beyond just those with Medicare, allowing others to benefit from the cap on monthly out-of-pocket costs for those with insulin and the annual limit on out-of-pocket prescription drug costs. Former President Trump has remained silent on some of these issues, though his administration implemented a program under which Medicare plans voluntarily lowered insulin copays to $35 per month. Majorities of voters, overall and across partisanship, support these proposed provisions, though smaller shares of Republicans are on board. Three-quarters (77%) of voters support the proposal to expand the $35 cap on out-of-pocket costs for insulin beyond those with Medicare, including majorities of Democratic voters (84%), independent voters (79%), and Republican voters (70%). Seven in ten (69%) voters support the proposal to expand the $2,000 annual limit on out-of-pocket prescription drug costs beyond those with Medicare, including 83% of Democrats, 70% of independents, and 58% of Republicans.