Over the past decades, Puerto Ricans living in the United States have experienced persistently higher poverty rates than the overall population, even as conditions have improved over time. In 2000, 25.8% of Puerto Rican individuals lived below the federal poverty line, compared to 12.4% of the total United States population (U.S. Census Bureau, 2000 Decennial Census). By 2010, these rates were 25.1% and 13.8%, respectively. More recently, in 2021, the poverty rate among stateside Puerto Ricans declined to 20.6%, while the overall poverty rate in the United States stood at 12.6% (U.S. Census Bureau, 2010 and 2021 American Community Survey 5-Year Estimates). Although these figures from the Census Bureau reflect meaningful progress, Puerto Ricans remain disproportionately represented among lower-income individuals. Eligibility for public health coverage programs such as Medicaid and for subsidies to the Health Insurance Marketplace is largely determined by income. Thus, these disparities have direct implications for access to affordable healthcare: recent federal policy changes have begun to reshape the structure of health coverage in ways that may disproportionately affect Puerto Ricans living in the United States by making them more vulnerable to losing health insurance coverage altogether.
On July 4, 2025, President Donald J. Trump signed H.R. 1, known as the “One Big Beautiful Bill”, into law. The bill, which became Public Law 119-21, pairs tax cuts and spending reductions with stricter eligibility rules across major means-tested programs, including Medicaid and the Supplemental Nutrition Assistance Program (SNAP), reversing key pandemic-era expansions in health coverage and income support. Enhanced tax credit subsidies to buy private health insurance through state Marketplaces expired, original income-based insurance premium contribution caps were reinstated, subsidies to buy insurance through the Marketplace were eliminated for households earning incomes above 400% of the federal poverty line, and statutory federal work requirements were imposed for Medicaid expansion enrollees. PL 119-21 also eliminated financial incentives for states to adopt Medicaid expansion and expanded work and eligibility requirements for SNAP. Changes to public health coverage and SNAP threaten to deepen the affordability crisis that affects much of the population in the United States, in particular population groups, like Puerto Ricans, who are highly dependent on public assistance.
The changes in healthcare policy put in place by Public Law 119-21 do not explicitly target Puerto Ricans or any other population group. Rather, they restructure health insurance eligibility and affordability along income lines and across state-level Medicaid expansion decisions. Formally neutral policy shifts, such as the introduction of Medicaid work requirements and the expiration of enhanced Marketplace subsidies, are likely to have uneven consequences for Puerto Ricans living in the United States, since Puerto Ricans in many states experience higher poverty rates and lower median household incomes than the overall state populations, and are disproportionately represented in the income ranges most affected by these changes, exposing them to inaccessibility to health insurance, whether public or private.
This is the first of a series of posts that explore the impact PL 119-21 could have on the Puerto Rican population living in the United States. In this first blog we examine the impact that changes to Medicaid expansion and Marketplace health insurance subsidies could have on Puerto Ricans in the United States. To assess the impacts PL 119-21 may have, we estimate the number of Puerto Ricans most likely to be affected by the changes contained in this law. We do this by estimating the number of Puerto Rican adults that fall within the income thresholds most directly affected by changes in these policies. The analysis is carried out using 2023 American Community Survey (ACS) one-year estimates and Public Use Microdata Sample (PUMS) data. We limit our analysis to the 15 states with the largest Puerto Rican populations for which selected population profile data is available in the 2023 1-year American Community Survey.
We find that Puerto Ricans are disproportionately vulnerable to the changes in Medicaid expansion policy in PL 119-21 given the greater share of Puerto Rican non-elderly adults that are eligible for Medicaid expansion relative to the overall population. As of 2023, nearly 219,000 non-elderly Puerto Rican adults would be eligible for Medicaid expansion coverage if their states of residence adopted Medicaid expansion. Within this population of Puerto Ricans in non-expansion states, the majority are ineligible for Marketplace subsidies because their incomes fall below the poverty level, while those who are eligible for Marketplace subsidies in non-expansion states are now faced with non-$0 premium healthcare plans. Pressure from new Medicaid expansion work requirements and from increased private health insurance premium costs could lead these individuals to forgo insurance altogether. Changes affecting the higher end of the private health insurance Marketplace subsidy structure also negatively impact middle-income Puerto Ricans, who, absent any tax credit help, are faced with paying higher insurance premiums or joining the ranks of the uninsured.
What does PL 119-21 undo?
To understand what PL 119-21 altered, it is important to first examine the health coverage framework that existed prior to its enactment. The Affordable Care Act (ACA), enacted in 2010 during the presidency of Barack H. Obama, reduced the number of uninsured Americans by expanding Medicaid eligibility and by creating subsidized Marketplace healthcare coverage for individuals purchasing private health insurance via state insurance exchanges. Medicaid expansion extended Medicaid eligibility to non-elderly adults (aged 19 to 64 years old) with incomes below 138% of the federal poverty line, while subsidies in the form of premium tax credits reduced the cost of private insurance for households with incomes at or above the federal poverty line. Subsidies to buy insurance in the Marketplace were originally made available to those with incomes up to 400% of the federal poverty line (FPL). Those with incomes above 400% FPL fell into a “subsidy cliff”, as they were ineligible to receive tax credits to buy private health insurance through the Marketplace. Together, these policies contributed to a drastic decline in the number of uninsured people nationwide. In 2012, a Supreme Court decision made the ACA’s Medicaid expansion optional for states, creating a “coverage gap” in states without Medicaid expansion, where many non-elderly adults with incomes below 100% of the federal poverty line are ineligible for both Medicaid and subsidized Marketplace coverage.
During the COVID-19 pandemic, federal policy further expanded access to health insurance coverage. Beginning in March 2020, the Families First Coronavirus Response Act passed by Congress required states to suspend annual Medicaid eligibility redeterminations in exchange for additional federal funding. As a result, Medicaid enrollment increased from 71.4 million individuals in early 2020 to 94.6 million by April 2023. At the same time, enhanced premium tax credits (ePTCs), introduced under the American Rescue Plan Act in 2021 and extended through 2025 by the Inflation Reduction Act of 2023, expanded Marketplace insurance affordability. These enhancements eliminated the “subsidy cliff” above 400% of the federal poverty line, capped health insurance premium contributions at 8.5% of income, and allowed individuals at or below 150% of the federal poverty line to qualify for $0 premium benchmark plans. Benchmark plans are defined as the second lowest cost Silver plan offered through a state’s healthcare insurance Marketplace.
In 2023, Congress ended the continuous Medicaid enrollment requirement for states, allowing them to resume eligibility redeterminations in what became known as the “Great Medicaid Unwinding”. Temporary expansion in Medicaid enrollment, combined with growth in per-enrollee spending, increased total federal government expenditures in Medicaid during this period. As eligibility redeterminations resumed, millions were disenrolled, and national Medicaid enrollment declined to 76.8 million by October 2025. This unwinding was the first large-scale contraction of pandemic-era healthcare coverage expansions, and signaled a pivot away from increases in federal health spending. It also set the stage for Public Law 119-21, which formalized and extended these policy changes through permanent modifications to Marketplace subsidy structure and Medicaid policy.
The Congressional Budget Office estimates that Public Law 119-21 will increase the number of uninsured individuals by 10 million by the end of fiscal year 2034, specifically due to a return to the pre-pandemic tax subsidy structure to the ACA state Marketplaces and the implementation of statutory Medicaid work requirements. (In order to remain eligible for Medicaid, able-bodied non-elderly adults without children must now meet an 80-hour-per-month work or community engagement requirement.) The CBO also estimates that cuts to federal Medicaid spending will add up to over $900 billion by fiscal year 2034. By early 2026, individuals and families all across the United States were experiencing increased health care costs, including increased Marketplace health insurance premiums, and national enrollment in the Marketplace had declined by more than one million people, according to federal administrative data analyzed by the Kaiser Family Foundation. Rising health insurance premiums increase out-of-pocket healthcare costs and may lead people to forgo insurance or select plans with higher deductibles and cost-sharing requirements. These increases in healthcare costs are occurring in parallel with sustained cost-of-living increases, where household expenses have risen faster than earnings in recent years. This intensifies affordability constraints for many working- and middle-income households in the United States.
How will Puerto Ricans fare?
The effects of Public Law 119-21 depend on policy design and on how populations are distributed across states and income thresholds that govern eligibility for Medicaid expansion and Marketplace subsidies. To identify the groups most exposed to these changes, we first examine key economic and demographic characteristics of Puerto Ricans relative to the overall population, including income, poverty, and health insurance coverage patterns. We then relate these patterns to policy structure by analyzing Medicaid expansion, which determines coverage for lower-income adults, and by commenting on changes in Marketplace subsidies that also impact higher-income groups.
Economic and Health Coverage Profile of Puerto Ricans in the United States
In 2023, over 5.8 million Puerto Ricans lived in the United States, of which over 3.3 million were non-elderly adults; that is, adults aged 19 to 64 years. The largest total and non-elderly adult population of Puerto Ricans lived in Florida, with other large populations concentrated in New York, Pennsylvania, New Jersey, and Massachusetts (Figure 1). Puerto Ricans experience poverty at higher rates than the overall United States population. In 2023, the federal poverty level for an individual was $14,850 a year and $30,000 for a 4-person household (See Figure 2). According to estimates derived from the 2023 ACS 1-year Public Use Microdata Sample, the poverty rate of Puerto Rican individuals was more than 50% higher than for the poverty rate for the population as a whole in 2023: 12.4% of the total population had incomes under 100% of the federal poverty level compared to 19.6% of stateside Puerto Ricans. That same year, 41.8% of the total population had incomes above 400% of the federal poverty level, compared to 30.4% of the Puerto Rican population (see Figure 3). Thus, median household incomes also differed substantially: $61,597 for Puerto Rican households compared to $77,719 for all households in the United States.
A majority of Puerto Ricans living in the United States in 2023 obtained private health insurance, either through their employer or directly purchased from insurance companies, which was also the case for the overall population in the country (Figure 4). According to estimates derived from the ACS Public Use Microdata Sample, a larger share of the U.S. overall population relative to the Puerto Rican population obtained private health insurance via their employer (54.8% vs 47.3%) or directly purchased from health insurance companies (13.8% vs 10.0%). The share of Puerto Ricans with subsidized private health insurance bought through state Marketplaces was the same as for the overall population (2.5%). On the other hand, a greater proportion of Puerto Ricans had public health insurance coverage than the total overall population. Nearly thirty eight percent (37.5%) of the total civilian noninstitutionalized population was covered by public health insurance, and 45.3% of the Puerto Rican civilian noninstitutionalized population had health insurance via public coverage. Puerto Rican overrepresentation in public health insurance was driven by Medicaid coverage: 35.5% of Puerto Ricans were covered by Medicaid in 2023, compared to 21.2% of the overall population in the United States. The Puerto Rican population in the United States is, at a national level, younger than the overall population of the United States, and thus less reliant on Medicare, an age-based public health insurance program. Whereas 17.7% of the overall population in the United States was 65 years and older, 11.2% of the Puerto Rican population was in this age group. The median age of Puerto Ricans in the U.S. was 33.0 years in 2023, compared to 39.2 years for the overall population. Nearly 28% of the total Puerto Rican population (27.9%) in the U.S. was under 18 years, versus 21.4% for the overall population.
These patterns vary across states. Poverty rates among Puerto Ricans exceed those of the overall population in most states with large Puerto Rican populations. States with long-established, older Puerto Rican populations (i.e., Massachusetts, New York, Connecticut, and Pennsylvania) exhibit high poverty, public insurance coverage, and Medicaid coverage rates among Puerto Ricans relative to the total state population (Figure 5). Puerto Ricans in Ohio and Wisconsin also follow this pattern. On the other hand, Maryland and Virginia, states with smaller Puerto Rican populations with higher median household income, are two states where the Puerto Rican population has a lower poverty rate than that of the overall population as well as lower rates of public insurance coverage compared to the overall population (Figure 6).
In Florida, Texas, North Carolina, and Georgia, Puerto Ricans experience higher rates of lack of health insurance coverage than Puerto Ricans in other states where there is a more generous approach to state health policies. These four states had not adopted Medicaid expansion for their non-elderly adult eligible populations as of 2023. Although Wisconsin is also a non-expansion state, it covers those with incomes below the federal poverty line through a state program (BadgerCare) and therefore does not have a coverage gap problem. Overall, the rate of uninsured Puerto Ricans in the fifteen states analyzed are similar to the rates of uninsured people for the population as a whole in those states (Figure 5).
The patterns described above, in particular the higher reliance of Puerto Ricans on public coverage, determine how recent policy changes translate into differential exposure and vulnerability across populations. The effects of PL 119-21 operate through two main channels: changes to Medicaid expansion eligibility and changes to Marketplace subsidies. We begin with Medicaid expansion, which shapes access to coverage for lower-income adults.
Medicaid Expansion, Non-expansion states, and the Coverage Gap
Under the original Affordable Care Act, Medicaid expansion extended eligibility to all non-elderly adults with incomes less than or equal to 138% of the federal poverty line. However, because expansion was made optional for states in 2012, eligibility for Medicaid expansion varies across the country. In non-expansion states, many non-elderly adults with incomes below 100% FPL fall into a “coverage gap”, as they are ineligible for both Medicaid and subsidized Marketplace coverage. As a result, non-expansion states have a higher percentage of uninsured individuals compared to expansion states (see Figure 5). Of the fifteen states we obtained data for, Florida, Texas, North Carolina, and Georgia (four of five non-expansion states under consideration in 2023) had higher uninsured rates for both their overall and Puerto Rican population compared to the remaining states. To make matters more precarious, some Medicaid expansion states have enacted trigger laws that would automatically end Medicaid expansion coverage if the federal matching rate for the expansion population declines, introducing additional uncertainty into the long-term stability of coverage.
To evaluate how these policy structures translate into exposure to Medicaid expansion policy changes, we examine the share of non-elderly adults with incomes at or below 138% of the federal poverty line in all of the United States; that is, the Medicaid expansion-qualifying population that is vulnerable to lose access to Medicaid if they don’t satisfy new eligibility and work requirements. In 2023, there were over 193 million non-elderly adults living in the United States, 16.4% of which had incomes at or below 138% FPL. These 31.6 million non-elderly adults would be eligible for Medicaid expansion under the original ACA, prior to the 2012 SCOTUS decision that made expansion optional to states. There were over 3.3 million non-elderly Puerto Rican adults living in the United States in 2023, and 23.4% of them had incomes at or below 138% FPL. Thus, an over 40% greater share of non-elderly Puerto Rican adults in all of the United States would be eligible for Medicaid expansion under the original ACA than in the overall population (Figure 7).
However, since Medicaid expansion is optional to states, state policies shape the exposure of the population to changes in Medicaid. When considering only Medicaid expansion states, 25.7% of all Puerto Rican non-elderly adults in those states qualify for Medicaid expansion, compared to 15.9% of all non-elderly adults in those same states; therefore, given their greater share of eligibility under Medicaid expansion, the Puerto Rican Medicaid expansion eligible population is proportionally at greater risk of losing public health coverage compared to the overall Medicaid expansion population in expansion states (Figure 8). Connecticut, Massachusetts, New York, and Pennsylvania are Medicaid expansion states with relatively higher Medicaid coverage rates (see Figure 4), where a large share of their Puerto Rican non-elderly adult population has incomes at or below 138% FPL (Figure 9). Thus, non-elderly Puerto Rican adults in these states are relatively overexposed to the negative impacts of new Medicaid expansion eligibility requirements.
Among non-elderly adults living in Medicaid expansion states, 11.3% of the total population, or around 15 million people, had incomes below the federal poverty line, compared to an 18.9% poverty rate among Puerto Rican non-elderly adults in those states. In non-expansion states, 12.0% of the total non-elderly population and 12.9% of the Puerto Rican non-elderly adult population had incomes below the federal poverty line. Individuals in non-expansion states with incomes below the poverty line fall into what is known as the coverage gap, as they are largely ineligible for their state’s Medicaid programs and barred from Marketplace subsidies. (As previously mentioned, Wisconsin, a non-expansion state, avoids the coverage gap by offering healthcare to state residents that live under the federal poverty level.) In addition, 5.4% of all non-elderly adults and 6.2% of Puerto Rican non-elderly adults in non-expansion states had incomes between 100% and 138% of the poverty line. These individuals would qualify for Medicaid under expansion but instead must rely on federal subsidies to access relatively affordable private health insurance through their states’ ACA Marketplace.
The interaction between income distribution and state-level policy decisions creates uneven exposure to changes in health coverage policy in PL 119-21. In non-expansion states, low-income Puerto Rican non-elderly adults are excluded from Medicaid expansion coverage despite meeting the ACA’s original income criteria. In total, around 219,000 Puerto Rican adults aged 19 to 64 years living in non-expansion states in 2023 had incomes at or below 138% of the poverty line, including nearly 148,000 with incomes below 100% FPL that placed them in the coverage gap (Figure 8). Florida alone accounted for the majority of Puerto Rican individuals in the coverage gap, with an estimated 88,902 Puerto Rican non-elderly adults with incomes below the federal poverty line in 2023. The remaining 71,000 Puerto Rican non-elderly adults in non-expansion states, with incomes between 100% and 138% of the federal poverty line, could access subsidized private health insurance via the ACA Marketplace. Changes in the ACA Marketplace subsidy structure brought upon by PL 119-21 will also impact this population, as explained below.
Marketplace Subsidies and the End of Enhanced Premium Tax Credits
While Medicaid expansion determines coverage for those with incomes at or below 138% FPL, individuals in non-expansion states and those at higher income levels rely on subsidized private health insurance bought in state Marketplaces to access affordable private health insurance. The effects of changes to Marketplace subsidies differ depending on whether a state has adopted Medicaid expansion (Figure 10). In expansion states, non-elderly adults with incomes at or below 138% of the federal poverty line are eligible for Medicaid and therefore ineligible for subsidized Marketplace coverage. In non-expansion states, subsidized Marketplace coverage is available to individuals with incomes at or above 100% of the federal poverty line. As a result, individuals with incomes between 100% and 138% of the federal poverty line rely on Marketplace coverage in non-expansion states but would generally be covered by Medicaid in expansion states.
Beginning in 2026, the Affordable Care Act’s original sliding income scale for Marketplace insurance premium payment caps returned, increasing the share of income that individuals must contribute towards premiums across all income categories. Individuals with incomes between 100% and 150% of the federal poverty line no longer qualify for $0 premium benchmark plans, while those with incomes above 400% FPL face the return of the “subsidy cliff”: they do not have access to subsidies to purchase private insurance through the Marketplace. For older adults in this income group, whose premiums are already higher, the return of the subsidy cliff results in especially large increases in out-of-pocket costs. These changes have happened amid rising premiums, increasing out-of-pocket health insurance costs for all individuals. Estimates from the Kaiser Family Foundation show that many households with incomes below 400% of the federal poverty line will see their payments for insurance increase by hundreds of dollars. As insurance premiums increase, healthy individuals may forgo coverage, which leads to an increase in the number of the uninsured and to higher insurance premium costs for those who remain covered.
Puerto Rican Marketplace Enrollees
Over 140,000 Puerto Ricans of all ages living in the United States were enrolled in subsidized Marketplace private health insurance plans (see Figure 4). Nearly 15,000 Puerto Ricans enrolled in subsidized Marketplace plans had incomes between 100% and 150% of the federal poverty line as of 2023, and qualified for zero-premium benchmark plans that have been lost with the passing of the Big Beautiful Bill. Over 23,000 Puerto Ricans with incomes above 400% of the federal poverty line (so called “middle-income” individuals) obtained subsidies to buy private health insurance in the Marketplace in 2023, including over 10,000 in Florida alone. With the return of the subsidy cliff, these individuals are no longer eligible to obtain any tax credits towards their health insurance premiums. Thus, Puerto Ricans are exposed to Marketplace policy changes through two distinct pathways: lower-income (100% to 138% FPL) individuals in non-Medicaid expansion states who depend more on Marketplace subsidies to access private health insurance, and middle-income households who face the subsidy cliff and have lost all eligibility for subsidies under restored ACA Marketplace income thresholds. Both changes increase the likelihood of health insurance coverage instability among Puerto Ricans living in the United States, simultaneous to changes in Medicaid expansion. This will likely lead to an increase in the population of Puerto Ricans living in the United States without private or public health insurance.
Conclusion
Public Law 119-21 restructures health coverage eligibility and affordability across income thresholds that Puerto Rican households disproportionately occupy. Non-elderly, working-age Puerto Rican adults are significantly more likely than the overall population to fall below the Medicaid expansion income threshold of 138% of the federal poverty line. With the expiration of enhanced Marketplace subsidies and work requirements taking effect for those who have access to Medicaid expansion, low-income Puerto Rican adults face increased risk from both sides of the coverage system, and are vulnerable to either becoming uninsured via new eligibility requirements or by forgoing health insurance coverage due to its increased cost. The latter is also true for middle-income (over 400% FPL) households who are no longer eligible for any tax credits to buy private health insurance.
Income vulnerability, geographic concentration in non-expansion states, and reliance on subsidized private health insurance coverage mean that formally income-based policy changes are likely to produce uneven effects across Puerto Ricans living in the United States. Monitoring ACS PUMS data in subsequent years will be essential to assess how these structural shifts translate into changes in health insurance coverage and uninsurance among Puerto Rican communities.