An Afghan refugee caresses her 9-day-old infant inside the pediatric ward of a medical treatment facility in 2021 at Joint Base McGuire-Dix-Lakehurst, N.J. Refugees are among the lawfully present noncitizens facing the loss of federally funded health care coverage. (Photo by Barbara Davidson/Pool/Getty Images)

An estimated 1.4 million immigrants who are in the country legally but are not citizens stand to lose their government-subsidized health care coverage under the sweeping tax and spending bill President Donald Trump signed into law this summer, according to estimates from the nonpartisan Congressional Budget Office.

The One Big Beautiful Bill Act cuts federal spending on Medicaid, the joint federal-state health insurance program for low-income people. It also places new eligibility restrictions on lawfully present immigrants, including refugees and asylees, who are enrolled in a variety of government-subsidized health programs: Medicaid, the Children’s Health Insurance Program (CHIP), Medicare and Affordable Care Act marketplaces.

Immigrants who are in the country illegally have long been ineligible for federally funded health coverage.

But seven states — California, Colorado, Illinois, Minnesota, New York, Oregon and Washington — plus the District of Columbia have extended state-funded coverage to some income-eligible noncitizen adults regardless of their immigration status. Fourteen states plus the district provide state-funded coverage to noncitizen children whether they are here legally or not.

The new restrictions in the One Big Beautiful Bill Act, combined with other Trump policies limiting public benefits for immigrants, put those states in a financial bind. With less federal money to provide health benefits to immigrants who are here legally, states will be hard-pressed to maintain their programs that offer coverage to all immigrants, regardless of their legal status.

“We’re taking a giant step backwards from that public health and preventive health measure by excluding more people and draining federal resources from states that need it,” said Tanya Broder, a senior counsel specializing in immigrant health policy at the National Immigration Law Center, an advocacy group.

“And the result will be that our health — individually, as families and as communities — will be in jeopardy, and the health care infrastructure that serves all of us will also be compromised,” Broder said.

Already, some states that had offered health coverage aid to all immigrants — regardless of status — have been pulling back.

To help close a $12 billion deficit, California Democratic Gov. Gavin Newsom in June signed a state budget that bars immigrants who are here illegally from enrolling in the state’s Medicaid program, known as Medi-Cal. Current enrollees between the ages of 19 and 59 will have to pay a new $30 monthly premium beginning in 2027. In July 2026, the state will eliminate dental care for noncitizens.

Illinois in July ended its state-funded health coverage program for all immigrants ages 42 to 64. The state still operates a state-funded plan for residents 65 and older regardless of immigration status, but enrollment has been paused. And Minnesota also plans to exclude adult immigrants who are here illegally from a program that used to provide coverage regardless of immigration status.

New York is in an especially tough spot, since its state constitution prohibits discrimination against lawfully present immigrants in providing public benefits.

“States have had some type of leeway to fund resources for migrant communities if they want to,” said Medha Makhlouf, a law professor and the founding director of the Medical-Legal Partnership Clinic at Penn State Dickinson Law who studies immigrants’ access to health care. “But now this [federal] law makes it difficult for them to do that.”

Making it less attractive to stay

Jessica Vaughan, director of policy studies at the Center for Immigration Studies, a nonprofit group that backs stricter immigration policies, said these efforts are part of both Trump’s larger anti-immigration stance and “Congress’ interest in getting rid of any incentive or benefit for people who are in the country illegally.”

“It’s a way of making it less attractive for people to stay here illegally, right?” Vaughan said. “They’re trying to give people reasons to leave rather than reasons to stay.”

As noncitizens who are here legally lose access to federally funded benefits, the demand for state-funded coverage is “likely to increase,” Drishti Pillai, director of immigrant health policy at KFF, a health policy research group, told Stateline.

“However, at the same time, states are facing increasing budget pressures, especially with the Medicaid cuts,” Pillai said. “So it’s almost a double whammy, where there will likely be increased demand for state-funded coverage programs, but also states will have fewer resources to cover people.”

Makhlouf said the Trump administration’s policy changes reflect a broader strategy of stripping public benefits from marginalized and poor communities.

“Everyone who cares about access to health care needs to pay attention to what’s happening to immigrants,” she said. “When it becomes normalized to be able to sacrifice certain people’s humanity or their vulnerability, or to minimize their contributions to society, and say, ‘You don’t deserve access to health care,’ then that can be turned on to any group.”

Under Trump’s domestic policy law, California expects to lose at least $28.4 billion in federal Medicaid funding, according to Newsom’s office.

On the California Senate floor June 27, Democratic state Sen. María Elena Durazo expressed her sorrow at the state’s decision to deny coverage to immigrants.

“I can’t express how much joy I felt when we expanded basic health care,” Durazo said. “Today, that joy that I was so happy about, that joy has turned into pain, that joy has turned into shame.”

Democratic Senate Pro Tem Mike McGuire, however, said the state had little choice.

“We are a state of immigrants, 10.6 million strong. And we will never turn our backs on those who are part of the heart of the largest economy in the United States of America,” McGuire said during the debate. “So we’ve had to make some tough decisions. I know we’re not going to please everyone.”

Obligated in New York

One state, New York, is particularly in a bind, because its constitution requires it to provide coverage to lawfully present noncitizens.

Roxana, 27, has been living in the U.S. under the Deferred Action for Childhood Arrivals program, known as DACA, since she was 8 years old and is using her first name only out of fear she will be targeted. At the end of 2019, she experienced a range of debilitating symptoms, including pelvic pain and chronic fatigue, and discovered a noncancerous lump on her breast.

“Chronic illness has impacted my career trajectory with a lot of fatigue and chronic pain,” said Roxana, who lives in the Bronx, New York.

Roxana cannot get federally funded Medicaid. But she qualified for state-funded public health coverage in New York. A 2001 court case, Aliessa v. Novello, requires the state to offer publicly funded health coverage to all lawfully present residents under the state constitution. So, she could afford to go to the doctor, where she learned that she had a hormonal condition called polycystic ovary syndrome, or PCOS, and she was able to get the lump removed.

New York mostly picked up the tab for immigrants and other lawfully residing immigrants until 2016, when it launched coverage it called the Essential Plan under the 2010 Affordable Care Act, also known as Obamacare. Under the ACA, the plan has no deductibles or monthly premiums for patients, and the federal government has picked up almost the entire cost — 90% — of the plan, a huge economic relief for the state.

Now, New York faces an annual loss of $13.5 billion in federal Medicaid and Affordable Care Act funds. Additionally, the phasing out of premium tax credits for noncitizens under Trump’s law would lead to a loss of $7.5 billion in annual funding to the state’s Essential Plan, which covers 1.7 million New Yorkers.

“These are billions of dollars that are being taken away and out of New York’s delivery system,” Amir Bassiri, director of Medicaid at the New York State Department of Health, said at a United Hospital Fund conference on July 30.

It’s unclear whether and how the state will afford to cover people like Roxana, even though it’s required under the state’s constitution. Like other immigrants, she is terrified that in the face of cuts and shrinking safety net access for noncitizens, she will lose continuous health care coverage and that her condition will get worse.

“My PCOS symptoms have just been getting worse over the years. I really want to try my best with the health access that I have to get it under control.”

Stateline reporter Shalina Chatlani can be reached at schatlani@stateline.org.

U.S. Sen. Raphael Warnock, a Georgia Democrat, speaks at a Senate hearing earlier this month. Warnock and several other lawmakers commissioned a Government Accountability Office report which found that Georgia spent $54.2 million in less than five years to administer the country’s only Medicaid program with work requirements (Photo by Andrew Harnik/Getty Images)

Georgia spent $54.2 million in less than five years to administer the country’s only Medicaid program with work requirements – more than twice as much as it spent to provide health care to enrollees, according to an analysis released earlier this month by the Government Accountability Office.

The report suggests it will be expensive to implement the Medicaid work requirements included in the broad tax and spending law President Donald Trump signed on July 4.

Under that law, the 40 states plus the District of Columbia that expanded Medicaid under the Affordable Care Act must require the expansion population – low-income adults under 65 with incomes up to 138% of the federal poverty level – to either work or engage in other activities such as job training or higher education for at least 80 hours per month.

The law is projected to cut federal Medicaid spending by an estimated $911 billion over the next decade, largely because the new work requirements will push people off the rolls. The new rules take effect on Jan. 1, 2027.

Supporters say the work requirements will encourage people to get jobs that offer health care coverage. But critics argue that most Medicaid recipients already work, and that most people who lose coverage will be dropped because they fail to meet the reporting requirements.

In October 2020, Georgia received federal approval to test Medicaid work requirements for an initial 5-year period. Its program, called Georgia Pathways to Coverage, is available to people between the ages of 19 and 64, with incomes at or below the federal poverty level, who would not otherwise qualify for Medicaid. Georgia originally planned to begin enrollment in July 2021, but legal challenges delayed implementation until July 2023.

As of May 2025, Georgia reported that 7,463 people were enrolled, far fewer than the 25,000 the state had expected to enroll during the first year of the program.

Between 2021 and June 2025, Georgia spent $54.2 million on administrative costs, compared with $26.1 million on providing medical care, according to GAO. About $50.8 of the administrative spending went toward changing the state’s system for determining people’s eligibility and enrolling them. In addition, the state used $20 million it received under the American Rescue Plan Act of 2021 to advertise the program.

Georgia officials told GAO that the pause in implementation forced them to do some things twice, raising administrative costs by between 20% and 30%. This included IT system changes, coordination with other agencies, and staff training.

“Every state Medicaid program is different, and so the amount or proportion of administrative costs that states may have to upgrade their systems and implement the new work requirements can vary by state,” Michelle Rosenberg, the GAO health care director, said in an interview.

“I suspect some states may require less administrative spending, and other states may require more. But I do think this is the best information we have available on what states’ experiences may be like.”

The Georgia Department of Community Health, which oversees Georgia Pathways to Coverage, did not respond to multiple Stateline requests for comment.

U.S. Sen. Raphael Warnock of Georgia, one of the lawmakers who requested the GAO report, said it proves that Medicaid work requirements are a waste of taxpayer dollars.

“This report shows that Pathways is incredibly effective at barring working people from health coverage and making corporate consultants richer,” the Democrat said in a news release. “If Republican politicians were serious about getting people to work, they would have closed the coverage gap nationwide and cut out the government bureaucracy.”

Stateline reporter Shalina Chatlani can be reached at schatlani@stateline.org

A patient goes to a physical therapy session at Lake Charles Memorial Hospital in Lake Charles, La. Without congressional action, more than 7 million people who buy their health insurance on Affordable Care Act marketplaces will pay much higher premiums next year. (Photo by Mario Tama/Getty Images)

Without congressional action, more than 7 million people who buy their health insurance on Affordable Care Act marketplaces would pay much higher premiums next year. Close to 5 million of them wouldn’t be able to absorb the price hike – nor would they be able to afford to buy coverage anywhere else, according to a new analysis.

The study by the Urban Institute, a left-leaning research organization, estimates that in eight states (Georgia, Louisiana, Mississippi, Oregon, South Carolina, Tennessee, Texas, and West Virginia) the number of people buying subsidized insurance from the marketplace would drop by at least half. Non-Hispanic Black people, non-Hispanic white people, and young adults would see the largest increases in the number of insured.

Enrollment in marketplace coverage surged from 11.4 million people in 2020 to 24.3 million this year, largely because of enhanced federal subsidies first made available by the American Rescue Plan Act in 2021 and later extended through the end of 2025 by the Inflation Reduction Act.

Unless Congress extends the subsidies, they will expire at the end of this year.

The Urban Institute projects that in 2026, the average premium paid by individuals or households with incomes below 250% of the federal poverty level (250% of the federal poverty level is $39,125 for an individual) would be $919, up from $169. Premiums would more than double, from $1,171 to $2,455, for people with incomes from 250% to 400% of the federal poverty level. And they would nearly double, from $4,436 to $8,471, for people with incomes above 400% of the federal poverty level.

Jessica Banthin, a senior fellow at the Urban Institute, said in an interview that the expiration of the tax credits would leave millions without access to any affordable health care options. She also noted that it likely would raise the cost of insurance for those who do remain on the marketplaces.

“People who are sicker will make the effort or find the money to stay enrolled,” Banthin said. “People who are healthier are more likely to leave the marketplace and either find another source of coverage or stay uninsured — they’re more likely to risk it.”

“And so what that means is the people remaining in the marketplace are a little bit sicker on average than they were before, and that means the risk pool is more costly, and premiums go up across the board.”

Last week, Democratic governors from 18 states sent a letter to congressional leaders of both parties, urging them to extend the subsidies.

“The timing couldn’t be more urgent. Insurers are already setting 2026 rates. If Congress acts quickly, states can lock in lower premiums and spare families a wave of sticker shock this fall,” the letter said. “If not, the damage will be felt for years.”

Congressional Republicans recognize the political peril in allowing the credits to expire less than a year before the midterm elections. Earlier this month, 10 GOP representatives introduced legislation that would extend the subsidies for one year. Senate Majority Leader John Thune, a South Dakota Republican, told reporters last week that GOP leaders are open to addressing the issue of the expiring credits but not until later this year.

A child receives a COVID-19 shot in Annandale, Va., in 2021. Virginia is among the states that have parted ways with new federal guidance restricting access to the vaccine. (Photo by Chip Somodevilla/Getty Images)

At least 17 states have taken steps to ensure broader access to the COVID-19 vaccine since last month, when the federal government significantly restricted eligibility for the shot.

Arizona, California, Colorado, Connecticut, Delaware, Hawaii, Maine, Massachusetts, New Mexico, New York, North Carolina, Oregon, Pennsylvania, Rhode Island, Virginia, Washington and Wisconsin have issued orders that aim to make it easier for people to get the COVID-19 vaccine. All but Virginia have Democratic governors.

Together, the moves represent an extraordinary state rebellion against the public health authority of the federal government.

For decades, states have followed the lead of the U.S. Food and Drug Administration and the federal Centers for Disease Control and Prevention on which vaccines Americans should get, and when they should get them. Now, rejecting the antivaccine stance of U.S. Health and Human Services Secretary Robert F. Kennedy, Jr., an increasing number of states say they will rely instead on their own public health experts and professional medical organizations for that advice.

Previously, the FDA recommended that the COVID-19 vaccine booster be available to anyone 6 months or older. But in August, the federal agency said the booster shot should be limited to two specific groups: people who are 65 and older, and anyone who is at least six 6 months old and has an underlying health condition, such as asthma or obesity, that increases the risk of a COVID-19 infection becoming severe.

Under the new guidelines, children under 18 without an underlying condition can only get the shot if a health care provider is consulted first, meaning parents can’t simply take their kids to a vaccination clinic or pharmacy.

“The American people demanded science, safety, and common sense. This framework delivers all three,” Kennedy wrote on the social media platform X on Aug. 27.

In June, Kennedy ousted the entire vaccine advisory committee at the CDC, replacing some of them with vaccine skeptics. The previous month, he announced that the federal government would no longer recommend that pregnant women get the vaccine.

Currently 43 states — all but Arizona, Florida, Georgia, Louisiana, Oregon, Utah and West Virginia, along with the District of Columbia — allow pharmacies to administer FDA-approved shots without a prescription, according to Amy Thibault, a spokesperson for CVS Health.

But the federal government’s new COVID-19 recommendations have sown confusion. Many people are unsure whether their local pharmacy will give them the shot without a prescription — and if so, whether their health insurance will pay for it.

In the 17 states that have acted thus far, governors and state public health officials are trying to clear up that confusion, empower pharmacists to administer the shot and, in some cases, mandate that insurers pay for it.

The latest state to act is Wisconsin. Democratic Gov. Tony Evers signed an executive order Monday directing state health officials to create policies that ease vaccine restrictions, and requiring insurers to keep covering the COVID-19 shot.

“Vaccines save lives, folks. Spreading fear, distrust, and disinformation about safe and effective vaccines isn’t just reckless, it’s dangerous,” Evers said in a news release. “RFK and the Trump administration are inserting partisan politics into health care and the science-based decisions of medical professionals and are putting the health and lives of kids, families, and folks across our state at risk in the process.”

In addition to Wisconsin, Colorado, Massachusetts and Rhode Island have required insurers to cover the shot, and Arizona Democratic Gov. Katie Hobbs’s executive order calls on state insurance regulators to “encourage” insurers to do so.

In many of the states, including Arizona, Colorado, Maine, Massachusetts, New Jersey, New Mexico and Rhode Island, the governor or the chief public health officer issued a standing order clarifying that pharmacies can administer the vaccine without a prescription.

Earlier this month, New York Democratic Gov. Kathy Hochul issued an executive order allowing pharmacies in her state to administer the shot to anyone 3 or older through October 5. The order can be renewed, pending action by the legislature.

And in Connecticut, Delaware and Pennsylvania, state authorities directed pharmacists to follow the vaccine recommendations issued by professional groups such as the American Academy of Pediatrics, the American Academy of Family Physicians and the American College of Obstetricians and Gynecologists.

North Carolina Democratic Gov. Josh Stein issued an order stating that pharmacies can administer the COVID-19 vaccine without a prescription to all adults over 65 and anyone over 18 with a broad range of underlying health conditions. Virginia’s top public health official issued a similar order.

Earlier this month, the Democratic governors of California, Hawaii, Oregon and Washington announced the formation of the West Coast Health Alliance to coordinate vaccine recommendations for their states. The states pledged to use guidelines based on advice from leading medical organizations.

Meanwhile, Republican-controlled Florida doubled down on Kennedy’s antivaccine stance, announcing plans to become the first state to phase out all vaccine mandates, including ending requirements that kids be vaccinated against dangerous diseases before enrolling in schools.

At a news conference earlier this month, Florida Surgeon General Joseph Ladapo said vaccine mandates are “immoral.”

“Every last one of them is wrong and drips with disdain and slavery,” Ladapo said of such requirements.

In Louisiana, Republican U.S. Sen. Bill Cassidy, who is a physician, suggested last week that state Surgeon General Ralph Abraham should issue a blanket prescription for anyone who wants the COVID-19 shot, the Shreveport Times reported.

Republican Gov. Jeff Landry responded angrily on X.

“The last time I checked you have a prescription pad, why don’t you just leave a prescription for the dangerous Covid shot at your district office and anyone can swing by and get one! I am sure big pharma would love you for that one!” Landry wrote.

Stateline reporter Shalina Chatlani can be reached at schatlani@stateline.org