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How Do Health Expenditures Vary Across the Population?

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How Do Health Expenditures Vary Across the Population?



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

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

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



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Your guide to early retirement health insurance options

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Your guide to early retirement health insurance options



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

Can early retirees get health insurance through the ACA Marketplace?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Medicaid expansion states will soon have a work requirement

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

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

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

Medicaid estate recovery

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

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

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

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

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

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

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

Early retirement health insurance through a spouse’s coverage

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

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

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

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

 



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

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



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

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

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

State ADAPs Respond to Strain by Limiting Enrollment and Services Offered

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

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

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

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

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

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

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

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

Multiple Factors Are Exerting Budget Pressures on ADAP

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

Federal ADAP Funding Not Keeping Pace With Inflation

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

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

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

Increased Client Enrollment

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

Rising HIV Drug Costs

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

Increased Insurance Premium Costs and Expiration of Enhanced Tax Credits

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

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

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

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

Looking Ahead

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

Endnotes



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The Midterms Lurk Behind Every Health Policy Move Now

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The Midterms Lurk Behind Every Health Policy Move Now



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

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

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

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

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

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

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

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

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

View all of Drew’s Beyond the Data Columns



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TrumpRx: What’s the Value for Customers?

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TrumpRx: What’s the Value for Customers?



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

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

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

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

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

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

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

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

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

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

Example 1

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

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

Example 2

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

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

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

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

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

Example 3

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

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

Example 4

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

Example 5

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

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

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

Example 6

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

Example 7

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

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



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

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



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Introduction

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Appendix

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

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



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Consolidation and Integration in Health Care: What It Means for Patients, Payers, and Policy

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Consolidation and Integration in Health Care: What It Means for Patients, Payers, and Policy



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News reports across the country trumpet major mergers and consolidation involving health insurers, physician practices, pharmacy benefits managers, hospitals and health systems, and other providers, including many that integrate different services under a single umbrella. The current wave of consolidation and integration has federal and state policy makers examining how it affects competition, prices, and overall costs.

At 12 p.m. ET on Wednesday, Feb. 18, three experts will join moderator Larry Levitt for an hour-long “Health Wonk Shop” discussion about health care consolidation and integration. During the event, panelists will discuss the motivations behind horizontal and vertical consolidation in health care, its potential to lower or raise costs, the implications for patients and payers, and how policy makers could respond.

Participants

Erin Fuse Brown

Professor of Health Services, Policy, and Practice, Brown University School of Public Health



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Marketplace enrollees face return of the ‘subsidy cliff’ in 2026

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Marketplace enrollees face return of the ‘subsidy cliff’ in 2026



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It’s happened. Congress has not extended enhanced Marketplace subsidies that have  made coverage more affordable since 2021 – and hundreds of thousands of Marketplace enrollees with household incomes over 400% of the federal poverty level are now experiencing the return of the so-called “subsidy cliff,” due to the loss of their premium subsidies.

The impact of this “subsidy cliff” is causing dramatic increases in health insurance premium expenditures. Particularly hard hit are enrollees in their 50s and 60s, who – without subsidies – could well face premiums that consume half or more of their income. (Premiums are age-based; without subsidies, a person who is 52 will pay about twice as much as a person who is 21, and a person who is 64 will pay three times as much as a person who is 21).

Here’s what Marketplace buyers are facing in 2026 with the return of the “subsidy cliff”:

Many older Marketplace buyers face drastic premium hikes

With the “subsidy cliff” returning to the health insurance Marketplace in 2026, a 63-year-old couple in Charleston, West Virginia, earning $85,000/year, will pay more than 15 times as much for the lowest-cost Gold plan, compared with what they paid in 2025.

In 2025, they would have paid about $300/month for the lowest-cost Gold plan, and they even had access to a zero-premium Bronze plan.

But because Congress didn’t extend the subsidy enhancements that had been keeping coverage more affordable since 2021, this hypothetical couple has lost their subsidy altogether.

  • To buy the lowest-cost Gold plan in 2025, they would have paid $300/month. But in 2026, their premium is $4,562/month for the lowest-cost Gold plan.
  • The lowest-cost Bronze plan in 2025 had no premium at all for this couple’s demographics, as their subsidy covered the full cost. But in 2026, the lowest-cost Gold plan has a premium of $3,648/month.

If they decided keep the Gold plan, they’ll be spending two-thirds of their household income on health insurance.

And even the lowest premium Bronze plan – which they could get with no premium at all in 2025 – will cost more than half of their household income in 2026.

To illustrate this, let’s look at the ten states where average full-price Marketplace premiums are projected to be highest for plan year 2026. The following table illustrates the effect of lost or decreased subsidies, including their effect on three different buyer age bands:

State Age 2025 lowest-cost plan monthly premium (with enhanced subsidy) 2026 lowest-cost plan monthly premium (without enhanced subsidy) Percentage increase in premium
AK 45 $111 $769 593%
55 $9 $1,188 13,100%
64 $2 $1,599 79,850%
DE 45 $308 $529 72%
55 $233 $816 250%
64 $160 $1,098 586%
ME 45 $354 $623 76%
55 $304 $962 216%
64 $255 $1,295 408%
MS 45 $401 $686 71%
55 $376 $1,060 182%
64 $452 $1,426 215%
NE 45 $298 $585 96%
55 $216 $903 318%
64 $137 $1,214 786%
TN 45 $307 $617 101%
55 $231 $953 313%
64 $156 $1,282 722%
VT 45 $0.08 $824 1,029,900%
55 $0.08 $824 1,029,900%
64 $0.08 $824 1,029,900%
WI 45 $334 $472 41%
55 $273 $729 167%
64 $213 $980 360%
WV 45 $170 $674 296%
55 $18 $1,041 5,683%
64 $0 $1,400 (Infinite)
WY 45 $221 $836 278%
55 $99 $1,291 1,204%
64 $0 $1,736 (Infinite)

‘Subsidy cliff’ affects households with incomes above 400% of federal poverty level

That’s because $85,000 for a household of two is 402% of the 2025 federal poverty level (FPL). And the ACA has a so-called “cliff” where Marketplace subsidy eligibility ends abruptly if an enrollee’s household income is more than 400% of the previous year’s FPL. That’s how it worked from 2014 through 2020, when subsidies weren’t available to these enrollees, regardless of how expensive their coverage was.

The subsidy eligibility income limit was temporarily lifted from 2021 through 2025, due to the American Rescue Plan (ARP) and Inflation Reduction Act (IRA). But it returned  in 2026 because the ARP/IRA subsidy enhancements were not extended by Congress.

American Rescue Plan and Inflation Reduction Act temporarily eliminated ‘subsidy cliff’

Section 9661 of the ARP capped Marketplace health insurance premiums (for the benchmark Silver plan) at no more than 8.5% of household income. The 8.5% cap applied to people with household incomes of 400% of the federal poverty level or higher. For people with lower incomes, the  percentage of income that had to be paid for the benchmark premium was reduced across the board. These subsidy enhancements were initially applicable for 2021 and 2022, but the Inflation Reduction Act extended them through 2025.

If your household income was more than 400% of FPL and the benchmark plan’s premium would already have been no more than 8.5% of your income, you wouldn’t qualify for a premium subsidy (meaning, the ARP/IRA didn’t change anything about your situation). This is more likely to be the case for younger enrollees in areas of the country where health insurance is less costly than average.

But if the full-price cost of the benchmark plan was more than 8.5% of your income, you were eligible for a premium subsidy between 2021 and 2025.  (This assumes you met the rest of the eligibility requirements, meaning that you’re lawfully present in the U.S. and not eligible for Medicaid, premium-free Medicare Part A, or employer-sponsored coverage that’s considered affordable and provides minimum value).

So for some people, especially older enrollees in areas of the country where health insurance is particularly costly, even those with income well above 400% of FPL were receiving a premium subsidy between 2021 and 2025. But people who earn more than 400% of FPL no longer qualify for a subsidy in 2026 – no matter how expensive their health insurance is.

Why it’s called a ‘cliff’

Due to the “subsidy cliff,” a few hundred dollars in extra annual income could translate to the loss of thousands of dollars per month in subsidies, if it pushes you over the 400% FPL threshold. And as we illustrated above, some enrollees will find that even the most inexpensive health plan will have premiums that amount to more than half their annual income. For most households, that’s simply unaffordable.

It’s called a cliff because there’s a sharp and sudden spike in health insurance premiums when subsidies end abruptly at 400% of FPL. From 2021 through 2025, subsidies instead phased out slowly as income increased. But that is no longer  the case in 2026 as subsidies are once again only available to enrollees with household income up to 400% of FPL.

Let’s take another look at the 63-year-old West Virginia couple described above, but let’s assume their income in 2026 is $84,500, instead of $85,000. That puts them just over 399% of the 2025 FPL, meaning they will still qualify for a premium subsidy in 2026.

In that case, their after-subsidy premiums for the benchmark Silver plan will be capped at a little less than 10% of their household income. That means the benchmark plan will cost them a little more than $700/month in 2026. They’ll be able to apply their subsidy to any metal-level plan, meaning they’ll be able to get the lowest-cost Bronze or Gold plan for even lower premiums.

But if their income goes above $84,600 (400% of the 2025 FPL), they will lose their subsidy altogether.

Areas with higher average premiums are hit hardest by the ‘cliff’

We used West Virginia as the example here because individual/family health insurance premiums in West Virginia are much higher than the national average.

So let’s also consider Idaho, where 2025 premiums were much lower than the national average. We’ll assume we have the same 63-year-old couple, earning $85,000, but now they live in Boise instead of Charleston, WV.

  • In 2025, the lowest-cost Bronze plan cost them less than $2/month after subsidies. In 2026, that plan will cost them $1,527/month as the “subsidy cliff” returns.
  • In 2025, the lowest-cost Gold plan cost $712/month. That jumped to $2,354/month in 2026, with the return of the “subsidy cliff.”

While these amounts aren’t as extreme as the West Virginia example (because full-price health insurance premiums are lower in Idaho), this couple will still have to pay more than a fifth of their household income for the lowest-cost plan, now that the “subsidy cliff” has returned.

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





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ACA Marketplace Enrollment is Down in 2026—But All of the Data Isn’t in Yet

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ACA Marketplace Enrollment is Down in 2026—But All of the Data Isn’t in Yet



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2026 marks the first year since 2020 that enrollees in the Affordable Care Act Marketplaces do not have access to enhanced premium tax credits. The effect of the expiration on how many people will use ACA Marketplace coverage remains unclear.

New data released by CMS on plan selections show that ACA sign-ups for 2026 are down by over 1 million people compared to the same time last year, marking the first year since 2020 that sign-ups appear to have declined. A more detailed Health Insurance Exchanges Open Enrollment Report is expected in March or April that will detail demographics, income, and metal levels for people who select or are automatically renewed into a plan. Plan selection data is unable to fully capture the effects of the enhanced tax credits expiring on the number of people with coverage. As people fail to make their premium payments, actual enrollment—known as “effectuated” enrollment—will inevitably decline. With the expiration of enhanced premium tax credits, premium payments are estimated to have increased 114%, on average, for subsidized enrollees who stay in the same plan. With such steep increases, it is not yet clear how many people who have selected a plan during Open Enrollment will make a payment. 

This brief explains the limitations of early data in understanding the impact of the expiration of enhanced premiums tax credit on ACA enrollment. It also provides a timeline of when more complete data will become available. The bottom line is that it will be quite a while before we get a complete picture of how much enrollment has dropped following expiration of the enhanced premium tax credits.

What are the limitations of plan selection data?

Plan selection (or “sign-up”) data does not accurately reflect the number of people who ultimately have ACA Marketplace coverage because it does not account for premium payments. In other words, it shows how many people have selected a plan or been automatically renewed into ACA coverage, but it does not show how many people actually gain or maintain coverage.

New enrollees are generally required to submit their first premium payment (“binder” payment) within 30 days of the coverage effective date, thus “effectuating,” or beginning, their coverage. Returning subsidized customers, however, are generally given a 3-month grace period for nonpayment of premiums. This means that these returning consumers would then have until March 31, 2026, to catch up on premium payments before their coverage is retroactively terminated. The impact of enhanced subsidies expiring will therefore not be evident (even to insurers) until all applicable grace periods have been exhausted.

For 2026, nearly 20 million of the plan selections are returning customers. Plan selection data from 2025 shows that more than four in ten people in the ACA Marketplaces were automatically renewed into their coverage that year, meaning they did not actively sign up for their plan. As consumers automatically renewed for 2026 received their first premium bills for January, some may have disenrolled or stopped making a payment. Depending on what action they take and the timing, many people could be counted in preliminary plan selection data (in the “Final Snapshot” just released and the “Open Enrollment Report” in the spring) even though they may not truly have coverage.

When will we know more about ACA enrollment?

Below is a timeline of key ACA Marketplace deadlines and data releases. The data timing listed below is based on recent years’ release dates and there could be different dates in 2026. The section following the timeline explains each of these data sources in detail.

*Note: Timing is based on recent years and may change for plan year 2026.

Effectuated Enrollment

The effectuation rate is the share of people who have a plan selection during Open Enrollment who effectuate (or start) their coverage. While it is possible that some states or insurers may provide information about effectuation rates earlier, the first national data on ACA enrollments will likely come out in July 2026 with the Effectuated Enrollment Report, if the timing of past years is followed.

As shown in the chart below, the effectuation (or premium payment) rate has been quite high since 2022, meaning the vast majority of consumers who selected a plan ended up with coverage. For that reason, in recent years, plan selections and effectuated enrollment have often been discussed synonymously. However, the expiration of enhanced premium tax credits in 2026 will mark the first time that most ACA Marketplace enrollees experience a significant increase in their premium payments, making past years’ effectuation rates unreliable indicators of this year’s rate.

CMS typically releases an Effectuated Enrollment: Early Snapshot each summer. This data will provide a better picture of the impact of the expiration of enhanced tax credits on enrollment than plan selection data alone.

Based on past years, the Effectuated Enrollment: Early Snapshot report will likely be released in July 2026, and will report February 2026 effectuated enrollment, as measured on March 15, 2026. In other words, the July data release will likely show how many people had effectuated enrollment in February, based on what insurers know about premium payments by mid-March. However, as mentioned above, returning customers have until the end of March to make premium payments under the grace period. So even the data released in July of 2026 may still overstate the number of enrollees.

The effectuated enrollment data released in July of 2026 will likely not count new consumers who missed their binder payment for January or February, nor would it count consumers who were automatically renewed in December but then actively disenrolled in January. However, it wouldstill count people who were automatically renewed for January coverage and did not make a payment during the grace period—even if they eventually had their coverage retroactively terminated as of January 31.

The Effectuated Enrollment: Full Year 2026 data, likely to be released in the summer of 2027, would show the number of effectuated enrollees after all grace periods have elapsed. As a share of plan selections made during Open Enrollment, the chart below shows the final February effectuation rate from the Full Year (green) data has historically been a few percentage points lower than the Early Snapshot (blue).

Fewer Consumers Maintain Coverage than Sign Up during Open Enrollment

Another reason the Effectuated Enrollment: Early Snapshot (expected to be released in July 2026) may not give a complete picture of the effect of expiring enhanced tax credits is that there could still be additional coverage loss later in the year. If an enrollee makes an initial premium payment but then decides their premium is unaffordable and drops their coverage mid-year, they may still be counted in the Effectuated Enrollment: Early Snapshot data even though they will not have coverage after their termination.

CMS may release additional effectuated enrollment counts before the Effectuated Enrollment: Full Year report; since this additional reporting may be after the run-out of grace periods, they would reflect finalized enrollment. In 2025, effectuated enrollment counts for the first five and seven months were released. Additionally, these releases may include information on the contribution of premium tax credits to the gross premium.

While effectuated enrollment data will tell us the number of people who are covered by ACA plans, it will not provide information about who paid their premium. The Open Enrollment Report and concurrent public use files, based on plan selections, will be the earliest source of information about income and other demographics of ACA enrollees. It is likely that the demographics and income distribution of ACA enrollees could shift from between the measurement of plan selections and effectuated enrollment. Additionally, the effectuated enrollment data from the Full Year report does not typically include metal level selection. There could be differences in payment rates for people who stay in their previous plan and face large premium increases and those who switch to lower-cost plans.

Quarterly Earnings Reports: April and May 2026

Prior to the publication of the effectuated enrollment data, some data on enrollment trends may be available from the insurers that enroll large shares of the individual market, during investor earnings calls. Insurers will host their fourth-quarter and year-end 2025 earnings calls in late January or February of 2026: Centene and Oscar will host their Q4 earnings calls on February 6 and February 10, respectively.

Insurers may start releasing membership counts for 2026 during their first-quarter 2026 earnings calls, expected to happen in April or May. Centene has announced their first-quarter earnings call for April 28. Elevance and UnitedHealthcare typically have first-quarter calls in April, while Oscar and Cigna typically report earnings in May. First-quarter calls that include enrollment information may not be fully adjusted for retroactive terminations due to nonpayment grace periods.

Insurer Rate Filings: Summer 2026

Every spring and summer, individual market insurers, including those offering ACA Marketplace plans, publicly file proposed premium rate changes to state regulators. These filings offer insight into what insurers believe is driving health cost growth and changes in enrollment. These rate filings will show insight into what insurers are planning in 2027 and may provide early counts of 2026 enrollment.

National Health Interview Survey Quarterly Releases: Likely January 2027

The National Health Interview Survey (NHIS) early release data will provide early indications of changes in the uninsured rate without the enhanced tax credits. From 2021-2024, first-quarter data came out in the summer of the same year, and data for the second quarter of the year came out closer to the end of the year. The Centers for Disease Control and Prevention has transitioned to biannual releases of data and released data for the first half of 2025 at the end of January 2026. If this release schedule remains consistent, data for the first half of 2026 may become available in early 2027.

Risk Adjustment Data: July 2027

Based on past years, the CMS Risk Adjustment Program State-Specific Data for 2026 is expected to come out in July 2027. The risk adjustment data will provide a state-by-state look at how many billable member months were reported for the ACA-compliant individual market. Because it will include on- and off-Marketplace enrollment, it will capture all people in ACA compliant coverage, even if they chose to purchase it off-exchange.

Issuer Level Enrollment Data: July 2027

The issuer-level enrollment data is split between HealthCare.gov and state-based exchanges. Data for HealthCare.gov states includes more information, including average monthly effectuated enrollment and average months of enrollment for those who have disenrolled. Additionally, issuer-level enrollment across all states will be made available through the Medical Loss Ratio Data and System Resources Public Use File, released late in the following year.

Enrollee-Level External Data Gathering Environment (EDGE): 2028

Enrollment by metal tier can be determined using the Enrollee-Level External Data Gathering Environment (EDGE) dataset, but this is subject to its own limitations: sparse enrollee demographic information, incomplete longitudinal data, and no information on terminated/non-effectuated coverage prevent fine-grained analysis on how the expiration of enhanced premium tax credits affected enrollee decisions. EDGE data for 2026 will likely not be available until 2028.



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KFF Health Tracking Poll: Health Care Costs, Expiring ACA Tax Credits, and the 2026 Midterms

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KFF Health Tracking Poll: Health Care Costs, Expiring ACA Tax Credits, and the 2026 Midterms



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Key Takeaways

  • The cost of health care, including paying for health insurance and out-of-pocket expenses, tops the list of the public’s economic anxieties, rising well above other necessities. Two-thirds of the public (66%) say they worry about being able to afford health care for them and their family, ranking higher than utilities, food and groceries, housing, and gas. In addition, most adults (55%) say their health care costs have gone up in the past year, including at least one in five who say they have increased at a faster rate than food or utilities. A majority (56%) of the public say they expect health care costs for them and their families to become even less affordable in the coming year.
  • With health care costs topping the list of economic worries across partisans and key groups, voters expect the issue to play a major role in their decisions to turnout in November’s midterm elections as well as which candidates they support. Majorities across partisans say health care costs will impact their vote in November, but the issue is resonating more with Democratic voters and independent voters. More than three-quarters of Democratic voters and independent voters say health care costs will impact both their decision to vote and which party’s candidate they will vote for in the election, compared to about half of Republican voters. In fact, two-thirds of Democratic voters and more than four in ten independent voters say health care costs will have a “major impact” on their 2026 voting decisions.
  • The Democratic Party has the advantage when it comes to which party voters trust to handle most health care issues, including health care costs, on which the Democrats have a 13-point advantage over Republicans. The one exception is prescription drug prices, an issue President Trump has focused on in his second term, and on which similar shares of voters say they trust the Democratic Party (35%) and the Republican Party (30%). Among independent voters, the Democratic Party has an edge over the Republican Party on health care issues, but many independent voters also say they don’t trust either party.
  • The public’s anxiety around health care costs comes at a time when the Senate and President Trump seem unlikely to revive the ACA enhanced premium tax credits, which expired on January 1st. Most (67%) of the public say Congress did the “wrong thing” by not extending the credits, including large majorities of Democrats (89%) and independents (72%). But majorities of Republicans (63%) including MAGA supporters (64%) say Congress did the “right thing” by not extending the ACA enhanced premium tax credits. While overall popularity of the ACA and the Marketplaces is still high, given the recent debate around the ACA enhanced tax credit debates, favorability has declined among Republicans.

Health Care Costs Top Public’s Concerns During Moment of Economic Anxiety

One year into the second term of President Trump and less than ten months before the 2026 midterm elections, the public remains concerned about the top issue of the 2025 election – the economy. Eight in ten (82%) adults say their cost of living has increased in the past year, including half who say it has increased “a lot.” Very few say their cost of living has “decreased” either “a little” (4%) or “a lot” (1%) while about one in ten say their living expenses have remained stable over the past year. Many adults, regardless of partisanship, say their cost of living has increased “a lot” in the past year, including a majority of (56%) Democrats, about half (53%) independents, and four in ten (41%) Republicans. About four in ten (38%) supporters of the Make America Great Again Movement (MAGA) also say their cost of living has increased “a lot” in the past year.

About Eight in Ten Adults Say Their Cost of Living Has Increased in the Past Year

Concerns about household spending coincide with a majority (71%) of the public saying President Trump is not focusing enough on domestic affairs, such as addressing the cost of living in the U.S. The share of the public who say President Trump is not paying enough attention to domestic concerns rises to about nine in ten (89%) Democrats and three-quarters of (76%) independents. On the other hand, a majority of the public (55%) also say the Trump administration is focusing “too much” on foreign affairs, such as actions in Venezuela, Ukraine, and Gaza. Republicans and MAGA supporters are more positive about President Trump’s priorities, with many saying he is spending the “right amount” on both domestic affairs (53% and 60%), and foreign affairs (66% and 76%).

Many Say Trump Is Not Focusing Enough on Domestic Affairs Such as Addressing the Cost of Living in The U.S., Too Focused on Foreign Affairs

The latest KFF Health Tracking Poll finds health care costs top the list of what the public worries about being able to afford for themselves and their family. Two-thirds (66%) of the public say they worry about paying for health care, including the cost of health insurance and out-of-pocket costs for things like office visits and prescription drugs, ranking higher as a financial worry than other household expenses like utilities, food, and rent or mortgage – all three items on which a majority of Americans are still worried about being able to afford.  About a third of adults (32%) say they are “very worried” about affording health care expenses, while about a quarter of adults say the same about being able to afford food and groceries (24%), their rent or mortgage (23%), or utilities (22%). About a fifth of adults say they are “very worried” about affording gas and transportation costs (17%). This comes as recent reports show that health care costs are on the rise for most Americans and the Affordable Care Act (ACA) enhanced tax credits, which benefitted most people who purchased insurance through the marketplace, have expired.

Health Care Costs Are the Top Household Expense the Public Worries About

Notably, health care costs are the biggest worry compared to other household expenses for all adults, regardless of partisanship. About one third of Democrats (36%) and Independents (34%) say they are “very” worried about affording health care, as are about one in four (24%) Republicans. This includes one in four MAGA Republicans (23%) and non-MAGA Republicans (24%).

Majorities Across Partisanship Worry About Affording Health Care Costs

One reason why health care expenses may be topping the list of household worries is that most adults say their health care costs have increased in the past year, including a substantial share who say these costs have increased at a faster rate than other household expenses.

Overall, more than half (55%) of adults say their health care costs have increased in the past year. This includes about two-thirds of people with employer-based health insurance (64%) and those who purchase their own coverage (66%), as well as about half (53%) of Medicare enrollees 65 and older. Perceptions about the increase of health care costs persist across partisanship, with about half or more across partisans saying their health care costs have increased in the past year, including 58% of Democrats, 56% of independents, and 51% of Republicans, including 47% of MAGA Republicans.

Many Say Their Health Care Costs Have Increased in the Past Year

Notably, about one in five of all adults say their health care costs have increased at a faster rate than other necessities like utilities (23%) and food and groceries (21%). This includes similar shares among partisans and MAGA supporters, as well as at least one in four with employer-sponsored insurance and about a third who purchase their own insurance. Smaller shares of adults who receive health insurance through Medicaid and Medicare say their health care costs have increased at a faster rate than utilities and food and groceries, suggesting those with government coverage are more insulated from the rising cost of health care.

One in Five Adults Say Their Health Care Costs Have Increased at a Faster Rate Than Utility and Food Costs

Looking ahead to the next year, a majority (56%) of adults expect their family’s health care costs to become less affordable, while about a third (35%) expect them to stay about the same, and one in ten (9%) expect them to be more affordable. Most Democrats (62%) and independents (58%) expect health care costs to become less affordable, while Republicans, including those who identify as MAGA Republicans are split, with similar shares saying they expect them to become less affordable or expect them to say about the same. Majorities across insurance types expect their health care costs to become less affordable. This includes two-thirds of those who self-purchase (64%) or have employer-sponsored insurance (60%) and majorities of those who are uninsured (57%) or who have coverage through Medicaid (55%).

Most Expect Their Health Care Costs To Become Less Affordable in the Next Year

Democrats Have an Advantage on Health Care Issues, But No Party Has an Advantage on the Cost of Living 

With health care costs on the rise and a significant source of worry for many, a majority of voters, regardless of partisanship, say the issue will play a role in their voting decisions. The cost of health care is a particularly strong motivator for Democratic voters, of whom more than eight in ten say it will impact their decision to vote and who they will vote for, including two-thirds who say it will have a “major impact.” The cost of health care is a similarly large motivator for independents, of whom about eight in ten say it will impact their vote, including more than four in ten who say it will have a “major impact.” While Democratic and independent voters are more likely to say health care costs are a strong motivator compared to Republican voters, substantial shares of Republican voters say it will impact their decisions in November as well. Six in ten (60%) Republican voters say it will impact their decision to vote and 56% say it will impact which party’s candidate they will vote for. This includes about a fifth of Republican voters who say the cost of health care will have a “major impact.” This suggests that rising health care costs resonate with voters across the board and will be a key voting issue to watch for in this November’s elections.

Majorities of Voters Across Partisanship Say the Cost of Health Care Will Impact Their Midterm Vote

Less than ten months before the 2026 midterm elections, the Democratic Party has a strong edge over the Republican Party when it comes to health care issues, including on the cost of health care. Democrats have a double-digit advantage over the Republicans when it comes to who voters trust on determining the future of Medicaid (43% vs. 25%), addressing the future of the ACA (42% vs. 26%), determining the future of Medicare (40% vs. 26%), and addressing the cost of health care (40% vs. 27%). Voters are more divided on which party they trust to address the cost of prescription drugs, an issue that President Trump has focused on during his second term. Notably, on every health care issue asked about, at least a quarter of voters say they trust neither party to do a better job.

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

Unsurprisingly, on each health care issue polled, Democratic voters are more likely to say they trust the Democratic Party and Republican voters are more likely to say they trust the Republican Party. Among independent voters, the Democratic Party has a clear advantage over the Republican Party on each of the health care issues; however, sizeable shares of independent voters (between about one-third and four in ten) say they trust “neither” party. When it comes to addressing the cost of prescription drugs, a larger share of independent voters say they trust “neither party” than say they trust either the Democrats or the Republicans.

Among Independent Voters, Democrats Have an Edge Over Republicans On Health Care Issues, But Many Also Say They Trust Neither Party

While the Democrats have an advantage among voters overall on health care issues, voter confidence is low when it comes to both political parties and President Trump to address the cost of living. Most voters say they have “not too much” confidence or “none” in the Republicans in Congress (64%), the Democrats in Congress (63%), and President Trump (61%), to address the cost of living for people like them. Small and similar shares of voters overall say they have “a lot” or “some” confidence in President Trump (38%), Democrats in Congress (37%), or Republicans in Congress (36%) to address the cost of living.

Voters Have Equally Low Confidence in President Trump, Democrats and Republicans to Address the Cost of Living

Amid the ACA Tax Credits Debate, Favorability of the ACA and ACA Marketplace Remains High, but Has Declined Among Republicans  

While a majority of the public continues to express a favorable view of the ACA, Republicans’ views have soured recently in the wake of the debate over extending the enhanced tax credits and Republican lawmakers’ persistent attacks on the 2010 health care law. Overall favorability of the ACA has dropped in the most recent poll, with 58% now saying they have a favorable view of the law and 41% saying they have an unfavorable view (down from 64% favorable, 35% unfavorable in September 2025). The overall decline in favorability of the ACA is driven by Republicans, of whom one in five (22%) now say they have a “very” or “somewhat” favorable view, compared to one-third (36%) who said the same in September. Views of the ACA remain positive and stable among Democrats (91%) and independents (62%), as well as among individuals who buy their own health coverage (64%).

Following ACA Tax Credit Debate, Favorability of the ACA Declines Among Republicans and MAGA Supporters

Favorable views of the ACA marketplaces where people and small businesses owners can shop for health insurance have also declined from 70% in September 2025 to 62% in the latest KFF Health Tracking Poll. Similarly to views of the ACA overall, this shift is driven by Republicans (41% now vs. 59% in September 2025 who said they view the marketplace favorably). Views of the ACA marketplaces are stable and favorable among Democrats (81%), independents (64%), and among those who self-purchase their insurance (64%).

After ACA Tax Credit Debate, Favorability of the ACA Marketplaces Declined, Driven by Republicans and MAGA Supporters

Most Say Congress Did the “Wrong Thing” Not Extending the ACA Tax Credits

The public is largely critical of Congress not extending the ACA enhanced tax credits for people who buy their own health coverage. Two-thirds of the public say Congress did the “wrong thing” by not extending the ACA enhanced tax credits, compared to one-third who say Congress did the “right thing.” Majorities of Democrats (89%), independents (72%), non-MAGA Republicans (54%), and those who purchase their insurance themselves (67%) say Congress did the “wrong thing” by not extending the tax credits. While most (63%) Republicans say Congress did the “right thing” by not extending the tax credits, a sizeable share, about four in ten (37%), say Congress did the “wrong thing.” This marks a shift in views from when debates over to extend the tax credits or not were still ongoing in November, when half of Republicans said Congress should extend the tax credits, suggesting the debates have shifted opinion among the Republican base.

Most Democrats and Independents Say Congress Did the Wrong Thing Not Extending the ACA Tax Credits; Most Republicans Say It Was the Right Thing

Among those who think the enhanced tax credits should have been extended, a group that leans more Democratic, many say most of the blame either falls on President Trump (42%, 28% of total adults) or Republicans in Congress (38%, or 26% of total adults). About one in five (19%, or 13% of total adults) say Democrats in Congress deserve the most blame. Among the four in ten Republicans who say Congress did the “wrong thing” not extending the tax credits, two-thirds (64%) blame Democrats in Congress for their expiration, rising to seven in ten (72%) MAGA-supporters.

Many Blame President Trump or Republicans for Not Extending ACA Enhanced Tax Credits; One Third Say Congress Did the Right Thing Not Extending Them

There are some indications that the expiration of the enhanced tax credits will play a role in how voters make decisions in the coming November election. Among those who self-purchase their insurance, two-thirds say it will impact their decision to vote (66%) and which party’s candidate they will vote for (67%) in the upcoming election. And although the expiring enhanced premium tax credits directly affect only those who purchase their own coverage on the ACA marketplaces, among voters overall, six in ten (62%) say their expiration will have an impact on their decision to vote, including 30% who say it will have a “major impact” and 31% who say it will have a “minor impact.” An additional four in ten (38%) voters say it will have “no impact at all” on their decision to vote. The expiration of the tax credits is a stronger motivator for Democratic voters and independent voters than for Republican voters. About eight in ten Democratic and two-thirds of independent voters say it will impact their voting behavior, compared to about four in ten Republican voters.

Most Democrats, Independents Say Expiration of ACA Tax Credits Will Impact Their Midterm Vote, Majorities of Republicans Say It Will Not



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