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Examining LGBTQ+ Adults’ Experiences with Health Care Costs and Access
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Key Takeaways
- LGBTQ+ adults face significantly greater challenges accessing and affording health care compared to their non-LGBTQ+ peers. They are more likely to postpone or skip needed care (58% vs. 38%), forgo prescription medications due to cost (22% vs. 12%), and struggle to pay medical bills (30% vs. 21%).
- Cost-related barriers to care are especially pronounced among certain segments of the LGBTQ+ population, most notably trans adults, younger LGBTQ+ adults, those with lower incomes, and those without health coverage. Eight in ten (82%) trans adults, three-quarters (77%) of LGBTQ+ adults without health coverage, and two-thirds (68%) of those under age 30 report not getting needed health care in the past 12 months either because they couldn’t get an appointment, couldn’t afford the cost, or for another reason. Additionally, larger shares of LGBQ+ women than men report skipping or delaying care in the past year (63% vs. 46%).
- While trans adults represent a small share of the total LGBTQ+ population, they experience outsized barriers to affording care and other access issues. Compared with other LGBQ+ groups, trans adults report the highest rates of difficulty finding providers with available appointments (53%), not taking prescription medications because of cost (39%), worsening health from postponed care (45%), struggling with medical bills (42%), and experiencing insurance delays or denials (61%). Trans adults experience these greater barriers to health cost and access even when controlling for other demographic variables such as age, income, and insurance status.
- Health care costs create significant financial strain for many LGBTQ+ adults. Three in ten (30%) report problems paying medical bills in the past year, and one in five (19%) say they cut back on household necessities such as food or clothing to pay for health care costs. Financial burdens are particularly common among younger adults, those with lower incomes, and those without health coverage.
- Having health insurance does not guarantee timely access to care. About three in ten LGBTQ+ insured adults report that their insurance delayed or denied coverage for recommended care in the past two years, a more widespread experience than among non-LGBTQ+ insured adults, with particularly high rates among trans adults and those covered by Medicaid or those with ACA marketplace coverage.
Understanding the Challenges LGBTQ+ Adults Face Affording Health Care
LGBTQ+ adults in the U.S. are a growing population who have historically faced health disparities in terms of both wellbeing and health care access and affordability. Previous research has found that LGBTQ+ adults are more likely than their non-LGBTQ+ peers to experience barriers to obtaining needed care, to struggle to afford health care costs, and to delay or forgo care because of cost. These affordability challenges often intersect with and may even be a driver of broader health disparities, including poorer mental and physical health outcomes, particularly among trans adults.
Understanding the financial challenges LGBTQ+ adults face when accessing health care can help identify persistent gaps in affordability and inform efforts to improve access to needed care and coverage.
LGBTQ+ definition and demographics
The LGBTQ+ sample included in this analysis is comprised of 2,640 adults, including 52% who identify as bisexual, 21% as gay men, 9% as lesbian women, 9% as transgender, and 9% who use some other term to identify themselves. The analysis is broken out by transgender (trans) adults (9%), lesbian, gay, bisexual or other queer identifying men (39%), and lesbian, gay, bisexual, or other queer identifying women (50%).
The LGBTQ+ community is not a monolith and beyond differences related to sexual orientation and gender identity, health care experiences can vary widely depending on age, income, and insurance status, among other factors. This analysis also examines differences by these factors. For example, regardless of LGBTQ+ identity, women tend to have more interactions with the health care system than men and therefore, may have more cost or access issues. In addition, trans adults are more likely than other groups to face barriers in health care, including discrimination and lack of providers trained to handle the health needs of trans adults. Subgroups of the LGBTQ+ population, including trans adults or older adults usually make up too small a share of national survey samples to allow for statistically reliable analysis. The large sample size of this survey provides a unique opportunity to examine these differences.
This report also compares the experiences of LGBTQ+ adults with their non-LGBTQ+ counterparts. A caveat to these comparisons is that there are key demographic differences between LGBTQ+ and non-LGBTQ+ adults that may contribute to differences in measures of health care cost and access between these populations. LGBTQ+ people are generally younger than the U.S. population overall, have lower incomes, and are somewhat more likely to be uninsured. Therefore, some findings might be more reflective of income or coverage differences, for example, than LGBTQ+ identity, though those factors are certainly intertwined. See appendix for a more detailed analysis of the demographic characteristics of the LGBTQ+ community.
Delays in Health Care for LGBTQ+ Adults
Six in ten LGBTQ+ adults (58%) say they have skipped or postponed needed health care in the past year, greater shares than their non-LGBTQ+ counterparts (38%). This includes more than four in ten (43%) LGBTQ+ adults who say they’ve skipped or delayed getting needed care because of the cost and about three in ten who said it was due to their inability to get an appointment (28%) or for some other reason (29%). LGBTQ+ adults are nearly twice as likely as non-LGBTQ+ adults (26%) to say they’ve skipped or delayed getting needed care because of the costs.
Compared to other LGBQ+ adults, trans adults are more likely to report they have put off care in the past year because of cost or other issues (82%). At least half of trans adults say they skipped or postponed getting needed health care because of the cost (56%), because they couldn’t find a doctor or health care provider with appointments available (53%), or they skipped or postponed for any other reasons (48%). There may be many reasons why trans adults are more likely to skip or delay care, but a recent KFF/Washington Post Trans Survey found significant barriers for trans adults in getting needed health care, including providers not being properly educated to provide appropriate care.
Beyond trans adults, larger shares of LGBQ+ women than men report skipping or postponing care in the past year (63% vs. 46%). This includes half of LGBQ+ women who say they skipped or postponed needed care because of the cost (compared to a third of LGBQ+ men), and roughly a third of LGBQ+ women who say they skipped or postponed care because they couldn’t get an appointment (31% vs. 19% of LGBQ+ men) or for any reason besides cost or not being able to get an appointment (32% vs. 21% of LGBQ+ men). Across all LGBTQ+ groups, non-LGBTQ+ adults less commonly reported skipping or postponing care.
Many socioeconomic and demographic factors can predict delaying or skipping care, but LGBTQ+ adults are more likely to skip or delay care even when controlling for race and ethnicity, insurance coverage, age, income, and education, suggesting this population group may have unique struggles in accessing needed health care. The differences reported in this analysis between LGBTQ+ adults and non-LGBTQ+ adults hold even when controlling for these demographic characteristics.
Among all LGBTQ+ adults, two-thirds (68%) of those under age 30 report having put off needed care in the past year, higher than the shares of older LGBTQ+ adults who report this. While age is a significant predictor of putting off care regardless of sexual identity, LGBTQ+ adults under age 30 are twenty percentage points more likely to report putting off care than non-LGBTQ+ adults in the same age range (48%). In fact, across most age groups, LGBTQ+ adults are more likely to report putting off or postponing needed care than their non-LGBTQ+ counterparts, except for those 65 and older. The difference between LGBTQ+ and non-LGBTQ+ adults levels out among those age 65 and older, which may be due to several factors, such as increased medical care among older adults and Medicare eligibility.
Insurance and income also play a role in accessing care. Three in four (77%) LGBTQ+ adults without health insurance report having missed or delayed care in the past year for any reason, compared to six in ten LGBTQ+ adults with health insurance. Fewer non-LGBTQ+ adults than LGBTQ+ adults without health insurance report experiencing any of the following in the past year (65% vs. 77% of uninsured LGBTQ+ adults).
Similarly, about six in ten LGBTQ+ adults with household incomes under $40,000 a year (59%) or between $40,000 and $99,999 a year (63%) say they skipped or postponed needed care, compared to half of those with annual incomes of $100,000 or more. Even among the highest income groups or those with health insurance, LGBTQ+ adults are more likely than non-LGBTQ+ adults to say they skipped or delayed needed care in the past year.
Substantial shares of LGBTQ+ adults report postponing their care worsened their health, and that number is especially pronounced among trans adults. Three in ten (29%) LGBTQ+ adults say their health got worse because they skipped or delayed care, which is about twice the share of non-LGBTQ+ adults who report the same (14%). This experience is more common among LGBQ+ women (34%) than LGBQ+ men (20%). Almost half (45%) of trans adults say they delayed or skipped care and their health got worse as a result.
The share who say their health got worse due to postponing care also rises to roughly a third of uninsured LGBTQ+ adults (35%) and those under age 30 (35%). One-third (33%) of LGBTQ+ adults with household incomes of less than $40,000 report that their health got worse because of postponed care.
Impacts of Cost on Prescription Medications
Cost barriers also affect prescription medication behavior, including among LGBTQ+ adults, with about a fifth of LGBTQ+ adults (22%) saying they’ve cut pills in half, skipped doses of a medication, or decided not to fill a prescription because they couldn’t afford the cost (compared to 12% of non-LGBTQ+ adults). Trans adults (39%), LGBTQ+ adults without insurance (28%), LGBQ+ women (25%), and younger LGBTQ+ adults (23% of those under age 30), are the most likely to report that they didn’t take their prescription medication as prescribed due to cost.
In addition, around a quarter of LGBTQ+ adults with lower incomes report cutting pills in half, skipping doses of medications, or not filling a prescription in the past year due to cost, including 27% of those with a household income of less than $40,000 a year, and 24% of those with incomes between $40,000 and $99,999 a year, compared to around one in ten (12%) of LGBTQ+ adults with incomes of $100,000 or more a year.
Difficulty Paying Medical Bills
Substantial shares of LGBTQ+ adults also report struggling with medical bills. Three in ten LGBTQ+ adults say they have had problems paying for or were unable to pay a medical bill, including bills for doctors, tests or labs, or medication in the past 12 months, higher than the 21% of non-LGBTQ+ adults who say the same. This includes four in ten (42%) trans adults, over a third (36%) of LGBQ+ women and two in ten (21%) LGBQ+ men.
Problems with bills can lead to important financial consequences for many LGBTQ+ adults. Two in ten (19%) LGBTQ+ adults, including two in ten (22%) LGBQ+ women and roughly one in ten (13%) LGBQ+ men say they’ve had to cut back on household expenses like food, clothing, or other basic household items in order to pay for health care costs. This experience is more common among trans adults, over one quarter of whom (28%) report the same. Overall, LGBTQ+ adults report they have cut back on necessities to pay for health care costs more commonly than non-LGBTQ+ adults (13%).
Younger LGBTQ+ adults and those with lower household incomes, two groups with considerable overlap, are among the most likely to report problems paying medical bills in the past year, with around a third of those under age 30 (33%), between 30 and 49 (34%), those with incomes of less than $40,000 a year (35%) or between $40,000 and $99,999 (35%) reporting they had problems paying or an inability to pay for any medical bills in the past year. Individuals earning over $100,000 annually and those 65 and older, who are largely covered by Medicare, are less likely to report such problems.
Younger LGBTQ+ adults and those with lower incomes are also more likely to report cutting back on expenses because of their problems paying medical bills. Overall, a quarter (24%) of LGBTQ+ adults with household incomes less than $40,000 a year say they have cut back on household expenses like food, clothing or other basic household items to pay for health care costs, compared to two in ten (19%) LGBTQ+ adults with incomes between $40,000 and $99,999 and one in ten (11%) of those with incomes of $100,000 or more a year.
Younger LGBTQ+ adults are also more likely to report cutting back on expenses because of trouble paying medical bills, including two in ten LGBTQ+ adults under age 30 and between ages 30 to 49 (21% for each) compared to one in ten (13%) LGBTQ+ adults ages 50 to 64 and one in twelve (8%) of those ages 65 and older.
Insurance Delays or Denials
Treatments or medications recommended by a provider may be delayed, and in some cases, an insurance company may deny coverage for the recommended medication or treatment after or during the care process. While insurance coverage helps some LGBTQ+ adults deal with access and cost issues, many face other challenges such as delayed or denied care.
Roughly one-third of insured LGBTQ+ adults say their insurance company denied coverage (32%) or delayed (30%) their ability to get a health care service, treatment, or medication that their doctor prescribed in the past two years. Four in ten say coverage has either been delayed or denied. These shares are substantially higher than among non-LGBTQ+ adults, about a quarter (26%) of whom say they’ve experienced a denial of service (21%) or delay (17%) in the past two years.
These experiences are particularly common among trans adults, roughly six in ten (61%) of whom say they’ve been delayed (53%) or denied (45%) coverage by their insurance for a service, treatment, or medication prescribed by their doctor in the past two years.
Delays and denials of coverage for LGBTQ+ adults vary based on what type of insurance they have. Individuals with either self-purchased plans or Medicaid report experiencing these most often. Roughly half (48%) of LGBTQ+ adults under age 65 who have Medicaid (48%) or self-purchased insurance (46%) say their insurance company has denied or delayed health care services, treatments, or medications in the past two years. Given that Medicaid plays a larger role in covering LGBTQ+ people, this coverage difference may in partially explain some of the disparate challenges this group faces with delays and denials.
Roughly four in ten (39%) LGBTQ+ adults under age 65 with employer-sponsored insurance say the same while just three in ten (28%) LGBTQ+ adults ages 65 and older with Medicare report experiencing recent delays and denials.
The share of LGBTQ+ adults with various types of health insurance who report delays or denials of needed care is larger than the share of non-LGBTQ+ adults who say the same. Roughly a third of those non-LGBTQ+ adults with Medicaid (33%) or self-purchased insurance (31%), around a quarter (26%) of those with employer-sponsored coverage, and around two in ten (18%) of non-LGBTQ+ adults who have Medicare and are ages 65 or older report these issues.
How Much and Why Premiums Are Going Up for Small Businesses in 2027
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Small businesses that offer health insurance to their employees could see health costs rise in 2027, according to an analysis of preliminary rate filings from all 50 states and DC. Nearly 300 insurers offering small group coverage reported a median proposed premium increase of 14% for next year.
Small group insurers say rising medical prices, including for hospitalizations, physician care, and prescription drugs, and increased utilization are major drivers of the premium increases. Among the other drivers, insurers point to the continued decline in small group plan enrollment, as more small businesses shift to alternative coverage options like self-insurance or stop offering health coverage altogether to lower costs.
The full analysis and other data on health costs are available on the Peterson-KFF Health System Tracker, an online information hub dedicated to monitoring and assessing the performance of the U.S. health system.
ACA Marketplace Insurers Are Proposing a Median Premium Increase of About 15% in 2027
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ACA Marketplace insurers’ proposed rate filings for 2027 are now available from all 50 states and the District of Columbia. According to KFF’s analysis, the 15% median increase would be the second consecutive year of double-digit premium hikes (last year’s median finalized premium increase was 20%.)
How Much and Why ACA Marketplace Premiums Are Going Up in 2027
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Note: This brief was originally published on July 8 and updated on August 3, 2026 to include proposed 2027 rates from all 50 states and the District of Columbia.
ACA Marketplaces insurers are proposing a median premium increase of 15% in 2027, according to KFF’s updated analysis of 276 insurers with publicly available filings across all 50 states and the District of Columbia. This is the second consecutive year of double-digit premium hikes. Last year’s median nationwide proposed rate change was 18%, and the median finalized rate change was 20%. While this proposed rate change is lower than last year, it represents the second-highest requested rate change since 2018, as premium growth had been relatively flat in this market for several years.
Based on detailed filings from 16 states and DC, rising healthcare prices—as in prior years—remain the primary driver of 2027 premium increases. Insurers cite higher costs for health services, general economic inflation, and labor shortages. They also point to factors unique to the individual market: the expiration of enhanced premium tax credits at the end of 2025 and a related increase in the risk pool’s morbidity, as contributing to rising rates for 2027.
The full analysis and other data on health costs are available on the Peterson-KFF Health System Tracker, an online information hub dedicated to monitoring and assessing the performance of the U.S. health system.
Medicare’s Proposed Cut to 340B Drug Payments Would Hit Safety-Net Hospitals While Benefiting For-Profit Hospitals
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The recently proposed 2027 Medicare Hospital Outpatient Perspective Payment System (OPPS) rule from the Centers for Medicare & Medicaid Services (CMS) includes a proposal to reduce Medicare’s reimbursement for 340B drugs. The proposal would reduce reimbursement for 340B drugs from average sales price (ASP) plus 6% (what Medicare generally pays for Part B outpatient drugs administered by providers) to ASP minus 33.4%, a 37% reduction. CMS indicated that this change would better align Medicare reimbursement with hospitals’ costs of acquiring 340B drugs.
The 340B Drug Pricing Program requires drug manufacturers participating in Medicaid to sell outpatient drugs to eligible nonprofit and government providers at a substantial discount, allowing providers to earn larger profits when being reimbursed for 340B drugs. The intent of the program is to support providers, such as certain disproportionate share hospitals and federally qualified health clinics, that care for low-income and other underserved populations. Critics have raised concerns that the 340B program, which has grown substantially over time, is not well-targeted; that savings from the program are not shared with patients; and that the program incentivizes hospitals to acquire clinics and physician practices in order to extend 340B discounts to those settings, enabling them to generate more revenue. Supporters of the program say that revenues generated by the difference between Medicare (and other payer) reimbursement for 340B drugs and the discounted price help 340B providers care for underserved populations and invest in operations.
CMS based the amount of the proposed payment reduction on a cost acquisition survey of 340B drugs completed by hospitals in early 2026. This proposed change revives an earlier effort by CMS to reduce Medicare payments for 340B drugs that was implemented in 2018 under the first Trump administration, but the Supreme Court overturned that rule in 2022 because the agency had not first conducted a cost acquisition survey. If finalized, CMS’s proposed Medicare 340B payment reduction would take effect on January 1, 2027, and would have disparate effects on different types of hospitals, as described more below.
CMS’s proposed cut to 340B drug reimbursement would reduce Medicare spending on 340B drugs by an estimated $4.85 billion in 2027, while increasing spending on non-drug outpatient services by the same amount because of budget neutrality requirements. Under federal law, CMS is generally required to maintain the same amount of aggregate spending through OPPS regardless of reimbursement changes (i.e., maintain budget neutrality). Based on this requirement, CMS proposed an 8.44% across-the-board increase in payments for non-drug outpatient services covered under the OPPS, which the agency estimates will offset the impact of cuts to spending on 340B drugs in 2027.
The budget neutrality requirement means that savings from reductions in 340B payments to 340B hospitals would be redistributed to both 340B and non-340B hospitals through higher payments for non-drug outpatient services. Similarly, Medicare beneficiaries would face lower cost sharing on 340B drugs (e.g., based on 20% coinsurance applied to a lower amount) but higher cost sharing for non-drug outpatient hospital services. CMS estimates that Medicare beneficiaries who use 340B drugs would save $1.15 billion in total in 2027, but cost sharing would increase for beneficiaries who use non-drug outpatient hospital services based on Medicare’s proposed 8.44% payment increase.
Proposed cuts would reduce revenues among safety-net hospitals while increasing revenues among for-profit hospitals, among other differences. For 340B hospitals, total Medicare revenues would decrease or increase depending on how reliant they are on revenues from 340B drugs versus non-drug outpatient services, but non-340B hospitals would experience revenue increases only based on the higher payment rate for non-drug outpatient services. CMS’s proposal to reduce reimbursement for 340B drugs would exempt rural sole community hospitals (SCHs) (rural hospitals that are the only source of short-term, acute inpatient care in a region), children’s hospitals, and PPS-exempt cancer hospitals. Changes would not affect hospitals that are not reimbursed under the OPPS, including critical access hospitals (CAHs), which make up the majority of rural hospitals.
In the aggregate, some types of hospitals would lose or benefit more from these changes than others, based on estimates from CMS (Figure 1):
- Safety-net hospitals would face a 5.8% net reduction of OPPS revenue under this proposal (see figure notes for definition of “safety-net hospitals”). Other types of hospitals would also see net reductions in OPPS revenue in the aggregate, including large urban hospitals (with 500 beds or more) (-5.2%), major teaching hospitals (-4.3%), government hospitals (-3.0%), and nonprofit hospitals (-0.5%). Some hospitals that would see the largest decrease in revenue likely fall into more than one of these categories (e.g., major teaching hospitals tend to be large urban hospitals).
- For-profit hospitals would see a 7.4% net increase in OPPS revenues. For-profit hospitals are not eligible for the 340B program and so would only see increases in reimbursement for non-drug outpatient services. Other types of hospitals would also face net increases in Medicare OPPS reimbursement in aggregate, including rural SCHs (5.7%), small urban hospitals (with 0 to 99 beds) (4.8%), and non-teaching hospitals (3.5%).
Reductions in 340B payments could add to the financial challenges facing safety-net hospitals while increasing margins of for-profit hospitals. Safety-net hospitals have lower operating margins than average and so could have an especially difficult time absorbing any revenue losses from the 340B payment cut, while for-profit hospitals have much higher operating margins than the average hospital. Additionally, safety-net hospitals, which are particularly dependent on Medicaid revenues, are likely to be disproportionately affected by the 2025 reconciliation law, as it achieves most of its health care savings through federal Medicaid spending reductions.
The substantial growth of the 340B program in recent years has led hospitals, pharmaceutical companies, and policymakers to focus on whether and how to change the program. At the federal level, lawmakers have proposed options that would preserve or narrow the scope of the program and have proposed increasing transparency around the program, such as by requiring hospitals to report 340B savings. At the state level, some states have passed laws that would preserve the ability of hospitals to use multiple contract pharmacies to dispense 340B drugs, among other things. Other states have implemented requirements for hospitals to disclose the amount of savings generated from the 340B program (as required by Minnesota) or how those savings are spent.
Some pharmaceutical companies have attempted to start providing 340B drug discounts through a rebate model, an approach that would require hospitals to purchase 340B drugs at a non-discounted price and receive post-sale rebates after submitting claims information. These efforts have been halted by the courts due to lack of authorization from HHS, the agency that administers the 340B program. In 2025, the Trump administration attempted to implement the 340B Rebate Model Pilot Program, but a court halted the pilot after a lawsuit was filed by the hospital industry. HHS has recently requested information from stakeholders on a revised rebate model pilot.
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
Are Health Care Costs THE Top Issue for Voters?
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No matter which way pollsters ask the question, health care costs emerge as a top concern for voters. It’s at the top of the list of worries for voters, and one of several problems they say are affecting their family budgets, along with gas and food prices, housing costs and the cost of utilities. But it’s probably over-reading polls to say health care costs are the number one issue for voters, or that there is any single top issue. Health costs are part of a stew of affordability worries and problems driving voters now, which candidates can address separately or together. Depending on the poll and the question, one or the other may be at the top of the list. And worries and problems are not the same thing. Health care costs register most on the worries list.
The big thing driving health care costs as an issue is voters’ worries about getting hit with big health care bills. That makes sense. Only 1 in 10 people are hospitalized each year but far more worry about incurring major medical bills if they get sick. Health care costs provoke special anxiety because they are less predictable than other household expenses. On the other hand, everyone has to buy food and gas (except a few of us EV owners) and pay their monthly housing costs, and people have a pretty good fix on what those costs are. This is why people are upset about drug prices, too—it’s the health cost they see almost as often as they pay for food or pay the rent. Two thirds of adults take a prescription drug and 3 in 10 take four or more.
You can see this in our polling:
- In June, we asked voters: “How WORRRIED [my emphasis] are you about being able to afford each of the following for you and your family,” and gave them a list to choose from including health care costs, gas, rent and mortgage, food, utilities, and so forth. Health care costs were clearly the number one worry, as we reported at the time, followed by gas and rent and the mortgage, but worries about everything were reasonably closely clumped together:
Gallup asked a similar worries question and got a similar result: the “availability and cost of health care” was the public’s top worry, followed by the economy and inflation.
- On other hand, in late spring, CNN asked voters to say in their own words what “the biggest economic PROBLEM [my emphasis] was facing their family.” General cost of living was named most often, with food, gas and housing well ahead of health costs. People see these costs more frequently but may worry about them less than they do a big health care bill. However, when gas prices and food costs or housing costs rise, it can also make it tougher for families to pay their health care bills, underscoring that a family budget is made up of interconnected parts and a bottom line, even as pollsters often try to rank them on a scorecard.
- We also asked a different question in our polls: What issues do you want to hear the candidates talk about in health? Health care costs emerged as number one, followed by the future of Medicare, fraud in government health programs, and then the future of Medicaid.
Why does this matter?
First, be alert that the various polls are asking different things about health care when you see issue rankings: worries, problems facing people, problems facing the nation or for government to address, and what candidates should be talking about, are all different things that will get different answers and rankings from the public.
Second, both worries about unexpected health care costs and problems paying health care bills are motivating voter concern about health care. For candidates, appealing to worries is likely the smarter course that broadens the net of concerned voters.
Finally, voters clump health costs with a series of other problems and worries about their family budgets. I have come to the conclusion that the search for a single top issue through polling questions—whether it’s health costs, or gas prices, or the cost of food—is artificial. People worry about and experience these costs together. There is no top issue, unless that issue is the catchall, “cost of living.”
How Has ACA Marketplace Enrollment Changed Across States in 2026?
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Following several years of rapid enrollment growth in the Affordable Care Act (ACA) Marketplaces that corresponded with temporary enhanced premium tax credits, enrollment fell for the first time in seven years in 2026, when those tax credits expired. The Assistant Secretary for Planning and Evaluation (ASPE) of the Department of Health and Human Services reported that enrollment declined by nearly three million people between 2025 and 2026.
Earlier federal data and analysis had focused on plan selections, or sign-ups, which decreased by about one million (5%) from last year, but plan selections do not account for enrollees who ultimately do not make their premium payments and are not covered. Effectuated enrollment is different from selection or sign-up data in that it accounts for who paid their premiums. Consumers who canceled their coverage or did not make their premium payments, resulting in termination of coverage, do not contribute to effectuated enrollment totals.
This analysis uses data from the Centers for Medicare and Medicaid Services (CMS) on effectuated enrollment in addition to Open Enrollment plan selections to examine how enrollment in the ACA Marketplaces has changed in 2026.
Key Findings
- Every state except for New Mexico saw a drop in ACA Marketplace enrollment from 2025 to 2026. New Mexico is the only state to fully replace the expired federal enhanced premiums tax credits with state-funded subsidies.
- State-based Marketplaces that run their own enrollment platforms, including those that partially offset the expiring federal enhanced tax credits, generally saw lower drops in enrollment (a 6% decline versus a 15% decline for states that use the federal marketplace).
- The effectuation rate (the rate at which people who initially signed up for a plan kept their coverage by making their premium payments) was lower in 2026 than in recent years.
- States that run their own Marketplaces, and particularly those that offered state-funded subsidies, generally saw higher-than-average effectuation rates.
February effectuated enrollment declined in 2026 to 19.2 million people (as of May 5, 2026), down from 21.8 million people in 2025, a record high enrollment (see note in Methods about 2025 total enrollment). This represents a 12% decline in enrollment year-over-year. Similarly, KFF polling indicated about one in ten 2025 Marketplace enrollees (9%) said they became uninsured for the 2026 plan year. The decline in enrollment coincides with the expiration of the enhanced premium tax credits at the end of 2025.
While effectuated enrollment data do not capture the reasons coverage lapsed, these significant declines in enrollment correspond with rising premium payments after the expiration of enhanced premium tax credits. Without the enhanced credits, premium payments increased substantially for most subsidized enrollees, and some middle-income enrollees who previously qualified for subsidies faced the full cost of coverage for the first time. On average, premium payments net of tax credits increased by 58% for people who signed up for 2026 coverage. A 2026 KFF follow-up survey of people who had been enrolled in ACA Marketplace coverage in 2025 found that eight in 10 enrollees who made changes to their ACA coverage or became uninsured cited cost as a reason, with 17% of returning Marketplace enrollees stating they worried about being able to pay their premiums for the entirety of 2026.
As shown in Figure 2, 2026 was the first year of widespread increases in premium payments. In prior years, including before the implementation of enhanced premium tax credits, people receiving a subsidy were largely sheltered from increases in the premiums charged by insurers. This may at least in part explain why the effectuation rate in 2026 was lower than some years preceding the enhanced premium tax credits. While the drop in enrollment from 2025 to 2026 is the largest drop since the Marketplaces opened, there are still more ACA Marketplace enrollees now than there were before the enhanced premium tax credits were passed.
Effectuated enrollment declined in nearly every state from 2025 to 2026, though the size of the decline varied substantially. New Mexico was the only state to see an increase in effectuated enrollment, growing 14% between 2025 and 2026, coinciding with the state’s premium assistance program that fully replaced the expiring federal enhanced tax credits with state-funded subsidies. Effectuated enrollment in Illinois, Connecticut, Pennsylvania, Idaho, the District of Columbia, Massachusetts, and Texas held relatively flat or fell by less than 5%. Of these states, Texas is the only state that is not a state-based Marketplace. Enrollment in Texas may have been buoyed by a state rule that mandates substantial silver loading, which can lead to more subsidized people being eligible for a bronze plan, or in some cases a gold plan, with little or no premium payment.
At the other end of the spectrum, effectuated enrollment fell by just over 32% in Ohio and Oklahoma, and by more than a quarter in Arizona (30%), South Carolina (29%), Indiana (28%), Michigan (27%), Minnesota (27%), Mississippi (26%), and Louisiana (26%). Of these states, Minnesota is unlike the others in that it offers a Basic Health Program covering low-income people who would otherwise sign up on-exchange. With a relatively higher-income group of Marketplace enrollees, Minnesota enrollees may have been disproportionately affected by the return of the subsidy cliff as enhanced tax credits expired.
A sortable table in the appendix shows the change in enrollment for each state, alongside other information about the type of Marketplace, whether state subsidies are available, and the effectuation rate.
States that run their own enrollment platforms, and particularly those that offered state-funded subsidies, generally saw a smaller drop in enrollment (or an increase, in the case of New Mexico). When weighted by enrollment in each state, those that use theHealthCare.gov platform (and do not offer state-specific subsidies) saw a decline in effectuated enrollment of 15% from 2025 to 2026. However, state-based Marketplaces experienced a 6% decline during the same period. States that offered state-funded subsidies all saw below-average declines in enrollment, or an increase in the case of New Mexico.
Of the 26 states with effectuated enrollment drops smaller than the national average, 18 were state-based Marketplaces, including all nine that offered their own state-funded subsidies. These differences across states suggest that the availability of state-level premium assistance helped cushion the effect of expiring enhanced premium tax credits on enrollees’ ability to maintain coverage, though enrollment changes likely also reflect broader differences in state populations and Marketplace administration.
Changes in both plan selections and effectuated enrollment from 2025 to 2026 varied considerably among states. However, changes in effectuated enrollment were not always well predicted by earlier reported changes in plan selections. In most states (37), both plan selections and effectuated enrollment declined, and the gap between the two widened, meaning that drops in plan selections underpredicted the change in effectuated enrollment. This pattern was particularly pronounced in states such as South Carolina, where plan selections fell 7% but effectuated enrollment fell 29%; Michigan, where plan selections fell 6% but effectuated enrollment fell 27%; and Minnesota, where plan selections fell 8% but effectuated enrollment fell 28%.
For nine states, plan selections rose from 2025 to 2026 but effectuated enrollment fell, reflecting a declining effectuation rate. Louisiana saw the largest divergence: plan selections increased by about 1% but effectuated enrollment fell by 27%. Texas showed the largest difference by number of enrollees: about 206,000 more people signed up this year (a 5% increase in sign-ups), with effectuated enrollment ultimately falling by about 146,000 people (a 4% decrease). Connecticut, Idaho, Massachusetts, Maryland, Pennsylvania, and Rhode Island saw smaller versions of this trend, with modest increases in plan selections alongside slight declines in effectuated enrollment.
Nationwide, the February effectuation rate fell from 90% in 2025 to 83% in 2026. This means a larger share of the people who signed up for coverage during open enrollment did not maintain their coverage, perhaps because they did not pay the first month’s premium, canceled after enrolling, or fell behind on payments and had their coverage terminated. Since 2019, the effectuation rate (measured past the end of the three-month grace period for February premium payment) has been above 90% but was lower in the early years of Marketplace coverage.
This year, Mississippi had the lowest effectuation rate (61%), meaning nearly two in five consumers who signed up during open enrollment did not maintain coverage past January. Similarly, South Carolina, Louisiana, Indiana, and Oklahoma also saw effectuation rates below 70% in 2026. By contrast, New Mexico, California, Nevada, Vermont, and Idaho each had effectuation rates of 95% or more.
States that run their own Marketplaces generally maintained higher effectuation rates than states that use HealthCare.gov. The ten states with the lowest effectuation rates all use the Healthcare.gov platform, while the ten states with the highest effectuation rates are all state-based Marketplaces. These differences may reflect variation in state populations, subsidy structures, or outreach and enrollment assistance efforts. Of state-based Marketplaces, Minnesota and the District of Columbia were the only ones to see lower-than-average effectuation rates. Both markets skew relatively higher-income, as both offer Basic Health Programs that cover lower-income enrollees who would otherwise sign up on exchange.
As with smaller drops in effectuated enrollment, states that implemented state-based subsidy programs to help offset the expiration of the enhanced premium tax credits through their state-based Marketplaces saw higher effectuation rates. Of the nine states offering state-based premium subsidies, seven saw effectuation rates higher than 90%, and all saw effectuation rates higher than the U.S. average. New Mexico, which, as mentioned earlier, fully replaced the lost enhanced premium tax credits through state funds, had the highest effectuation rate among all states at 96%.
These patterns suggest that state policies designed to blunt the effect of rising premiums may be associated with higher rates of enrollees maintaining active coverage, though other factors—such as income levels, Marketplace type, and state outreach efforts—likely also play a role. All states that offered state subsidies to backfill some portion of the expired enhanced premium tax credits were above the median change in effectuated enrollment.
Appendix
Methods
Open enrollment plan selections and monthly effectuated enrollment were collected from Centers for Medicare & Medicaid Services (CMS) sites. Effectuated enrollment in this current analysis refers to enrollees with any coverage in February. For 2025, effectuated enrollment is as of March 15, 2026; for 2026, as of May 5, 2026. Both of these dates are past end of the February premium payment grace period for consumers who had effectuated coverage. State-based subsidy information was obtained from state government websites; see Figure 3 for links to source data. States that operate their own exchanges but use the HealthCare.gov platform are included in the HealthCare.gov category; none of them provide state-funded premium assistance. Weighted average enrollment changes by platform type were calculated using the above described categorizations. Illinois, which switched from using HealthCare.gov in 2025 to its own state-based Marketplace platform in 2026, is counted as a state-based Marketplace for change in effectuated enrollment.
An analysis by ASPE reported the 2025 February effectuated enrollment total to be 22.1 million, but the CMS monthly effectuated enrollment data report a total of 21.8 million enrollees in February 2025. Effectuated enrollment totals may differ across data sources, potentially due to the date of measurement. This KFF analysis is based on CMS monthly effectuated enrollment data (linked above) which indicated a total of 21.8 million effectuated enrollees.
Health insurance premium increases for 2027: Proposed rates by state and what consumers should know
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Proposed individual market premium increases for 2027 have been published in about a third of the states as of mid-July, with a median proposed increase of about 14%.
Basic details of initial 2027 rate filings will be available for every state on ratereview.healthcare.gov starting on July 31, 2026.
After last year’s increases, another round of double-digit rate increases may sound alarming. But proposed rate increases do not necessarily reflect what Marketplace enrollees will ultimately pay, and several key factors make the outlook for 2027 very different than what we saw for 2026.
Here are the proposed weighted average health insurance rate increases that are available at this point:
Proposed 2027 individual market rate increases by state |
|
|---|---|
| State | Average proposed increase |
| Vermont | 6.5% |
| Iowa | 6.7% |
| Washington, DC | 9.5% |
| Hawaii | 11.1%* |
| Minnesota | 11.9% |
| Massachusetts | 12.9% |
| Maryland | 13.7% |
| Illinois | 14.1% |
| Connecticut | 16.2% |
| Maine | 16.8% |
| Oregon | 17.5% |
| Indiana | 19.3% |
| Kentucky | 19.6%* |
| Rhode Island | 20.1% |
| Georgia | 20.7% |
| New York | 20.7% |
| Washington | 22.4% |
Federal subsidy enhancements expired last year, driving up the average net (after-subsidy) Marketplace premiums by 58% in 2026, even though many people downgraded to lower-priced Bronze plans.
Had the subsidy enhancements had been extended, premium subsidies would have been larger, offsetting the last year’s underlying premium growth – which was significantly larger than we had seen for the last several years.
(Premium subsidies are actually larger in 2026 than they were in 2025. In 2026, the average premium subsidy is $650/month, up from $550/month in 2025. But the average full-price premium grew by even more: It was $619/month in 2025, and increased to $741/month in 2026, despite all the people who downgraded their coverage.)
Here’s why 2027 will be different, despite the double-digit rate increase proposals that we’re seeing so far:
- Most Marketplace enrollees still get premium subsidies, even after the subsidy enhancements expired. During the open enrollment period for 2026 coverage, 87% of enrollees qualified for premium subsidies.
- The subsidies are designed to keep pace with the cost of the benchmark (second-lowest-cost) Silver plan in each area. So as premiums rise, so should subsidies. The reason people are paying much higher premiums this year, even if they’re still getting a subsidy, is because the expiration of the subsidy enhancements resulted in a significant increase in the percentage of income that people have to pay for their coverage.
- For 2027, the percentage of income that people have to pay themselves will be indexed just the way it was each year from 2015 to 2021, but it won’t be the sort of drastic change that we saw for 2026.
The short story: For most Marketplace enrollees, larger subsidies will likely offset some or all of the premium increases for 2027. But the full brunt of the premium increases will mostly impact Marketplace enrollees who aren’t eligible for a subsidy, plus anyone who buys individual market coverage outside the Marketplace, where subsidies aren’t available.
Why Marketplace premiums are increasing
The factors driving full-price premiums higher for 2027 include some usual culprits and some that stem from recent federal changes. As is typically the case, the largest driver of higher premiums is the ever-increasing cost of healthcare. This includes a variety of factors, including higher hospital and drug costs (including the cost of GLP-1 medications), higher labor costs, and increased utilization of medical services.
Insurers also point to general economic inflation as a factor that has pushed prices higher across the board in recent years, including the price of healthcare.
Insurers also note that the expiration of the federal subsidy enhancements is expected to result in continued deterioration of the health of the overall risk pool in 2027, as healthier enrollees drop their coverage, leaving a sicker risk pool that costs more to insure on a per-person basis. Insurers also point to some other recent federal rule changes that are projected to result in lower enrollment (and thus a sicker risk pool), including the 2025 Marketplace Integrity rule, the “One Big Beautiful Bill,” and the 2027 Notice of Benefit and Payment Parameters.
Will I qualify for a subsidy in 2027 if I don’t qualify in 2026?
Because the subsidy enhancements were allowed to expire, the “subsidy cliff” returned in 2026. This means subsidy eligibility ends abruptly if household income goes above 400% of the federal poverty level (FPL), regardless of how much the household has to spend on health insurance.
During the open enrollment period for 2025 coverage, 92% of Marketplace enrollees qualified for a subsidy, but that dropped to 87% in 2026, largely because of the return of the subsidy cliff.
The subsidy cliff will still exist in 2027, so subsidies will not be available if household income is more than 400% FPL. But because of annual increases in the FPL, the income level at which subsidy eligibility ends will be a little higher in 2027:
- A single person in the continental U.S. will qualify for a subsidy with an income as high as $63,840, up from $62,600 in 2026.
- A household of four in the continental U.S. will qualify for a subsidy with a household income as high as $132,000, up from $128,600 in 2026.
Make sure you understand how household income is calculated under the ACA, as it’s a unique version of MAGI. And keep in mind that contributions to a health savings account or pre-tax retirement account will reduce your ACA-specific MAGI.
If I get a premium subsidy, will my subsidy increase in 2027?
If the cost of the benchmark plan in your area increases, your subsidy amount will generally increase too, assuming your income remains fairly steady.
But the benchmark plan is just one plan, and there are dozens of plans available in most areas. So it’s important to understand that the size of your subsidy is tied to the price of the benchmark plan, not the price of your specific plan.
Depending on the discrepancy between how much your plan’s premium changes and how much the benchmark plan’s premium changes, you may find that your subsidy doesn’t keep pace with your premium. But it’s also possible for the subsidy amount to increase by more than the premium increase for your plan, making your plan more affordable in the coming year.
Either way, it’s always a good idea to carefully comparison shop during open enrollment, which starts on November 1 in most states.
Should I switch to a different Marketplace plan for 2027?
Renewing your current plan for 2027 – if it’s still available – might be the best option, or you might be better served by switching to a different plan. You won’t know until you compare the plans available in your area during open enrollment.
Pay close attention to any notifications you get from your health plan and the Marketplace as we get closer to the start of open enrollment. If your net health insurance premium is increasing for 2027, you might prefer a different plan. But choosing a health insurance policy involves a lot more than just premiums, so be sure you consider all aspects of the various plans before picking the one you want for 2027.
Note: Roughly 700,000 people will need to select new plans for 2027 because of carriers exiting the Marketplace at the end of 2026. If your carrier is leaving the Marketplace and you pick a new plan by December 31, it will take effect on January 1, ensuring that you have seamless coverage.
Final rates could differ from proposed rates
The proposed rate increases listed above are initial proposals, so they could change before they’re finalized. In nearly all states, the rate review process is done by the state, and there’s significant variation in terms of how much approved rates tend to differ from the rates that the insurers initially file.
Last year, for example, New York regulators approved an overall average rate increase of 7.1% for 2026 individual market plans, which was significantly smaller than the 13.5% average rate increase the insurers had proposed.
But in Idaho, the approved health insurance rates were nearly identical to the insurers’ proposals, except for two carriers, one of which ended up with a larger-than-proposed rate increase, and one of which ended up with a smaller-than-proposed rate increase.