Health insurance plays a pivotal role in improving health outcomes and ensuring broader quality of life. Despite that fact and DC’s longtime commitment to near universal health coverage in the District, thousands fewer immigrants in DC have access to affordable health insurance under drastic changes that District lawmakers approved to the Health Care Alliance program (the Alliance) that began to take effect in October 2025.
Nearly 25 years ago, DC leaders created the Alliance—a program that served about 23,000 residents per month in fiscal year (FY) 2024—with the belief that everyone should have access to health care, regardless of immigration or economic status, and that widespread coverage is good for residents’ health and less costly than the alternative.[1] But facing a tight budget, District lawmakers halted new enrollment in the Alliance for adults over age 25 starting in October 2026, and ended eligibility entirely for all adults over 21 in October 2027. Lawmakers also added greater administrative barriers to enrollment and reduced covered benefits.[2]
These program changes, among others, will harm immigrant residents who will struggle to pay for health care, may avoid or delay needed care, and may even die from diseases that could have been successfully treated if they had received timely care.[3] These changes come as the federal government escalates deportations and targets immigrants for other benefits cuts. Congress has recently excluded more lawfully present immigrants from Medicaid, and federal agents are targeting Black and brown people for arrest, including citizens and those with documented statuses.[4][5] District leaders should be working to increase protections and stability rather than intensifying hardship for communities already under attack.
Instead of making drastic cuts to a program that serves people ineligible for Medicaid, many of them immigrants, District lawmakers should restore the program and form an advisory council of experts, including current Alliance enrollees, to identify potential areas for savings and improvements. It will take nothing short of this to restore DC’s promise as a place that values immigrants and treats health care as a basic human right.
DC Has Been a National Leader on Health Coverage, Including Through the Alliance
A large body of research finds that insurance coverage prevents death and leads to better general health outcomes as well as outcomes for those suffering from specific diseases.[6] Analysis of the Affordable Care Act’s (ACA) Medicaid expansion has shown other positive effects including medical debt reduction, better credit, lower eviction rates for renters with low incomes, and reduced uncompensated care costs.[7] Expanded health coverage under the ACA has contributed to a healthier workforce and higher productivity, all of which is good for people, businesses, and the economy. [8] It’s also been shown to support entrepreneurship. In fact, in the District, 30 percent of residents aged 21-64 who are covered by ACA marketplace insurance are small business owners or self-employed persons.[9]
Recognizing the many benefits that health insurance brings, DC has been a national leader in promoting access to health care.[10] DC has made investments over the last two decades in the adoption and expansion of the Alliance, administration of the District’s health care exchange, and Medicaid expansion. DC went a step further than other states and used the ACA’s additional state plan authority to provide insurance to childless adults between 139 and 215 percent of the poverty line and parents between 139 and 221 percent.[11][12][13] These actions have contributed to DC’s very low uninsured rate of 2.7 percent—the second lowest rate in the nation (Figure 1).[14] Created in 2001, the Alliance is critical in these efforts, providing coverage to nearly 23,000 adult residents per month who did not qualify for Medicaid. [15] And because of Medicaid and expansion and ACA marketplace efforts over time, it became a program mostly serving immigrants with low incomes.[16]
Figure 1.
Alliance Cuts Ended Coverage for Adults by FY 2028, Due to Cost Drivers That Are Unclear
In 2025, DC Council limited Alliance eligibility and covered benefits in addition to making enrollment and recertification more difficult. This led to about 2,200 residents losing the Alliance in FY 2026, more adults losing coverage in FY 2027, and then all adults aged over losing coverage at the start of FY 2028. [17]
Deputy Mayor for Health and Human Services Wayne Turnage has argued that Alliance costs are increasing too fast but for reasons that are not entirely clear to agency leaders.[18] He testified in the summer of 2025 that the budget would have more than doubled since 2011 from an inflation-adjusted $74.3 million to a projected $247 million in 2026, if lawmakers made no changes to the program.[19] However, the projection for FY 2026 is far higher than both the approved FY 2025 budget for the Alliance and the Immigrant Children’s Program (ICP) together, which totaled about $150 million, and actual spending in FY 2025 which totaled $184 million.[20][21]
Assumptions behind the cost increase seemed to be based on enrollment despite the fact that enrollment grew just over 2 percent annually between FY 2011 and FY 2025.[22] Turnage testified that he anticipated enrollment growth in FY 2026 to be a significant spending pressure, estimating that the combined adult and child caseloads would rise to 37,000.[23] With the child caseload remaining fairly flat at around 6,000, this would have translated into an adult caseload of about 31,000.[24] This did not come to pass. After peaking at 27,619 in the fourth quarter of FY 2025, enrollment has now in fact fallen to about 19,000 in the first quarter of FY 2026.[25] In February of 2026, Turnage said that 2,600 enrollees lost Alliance coverage because of reduced income eligibility, which means that the earlier projection for FY 2026 was off-base. He also reported that another 6,000 likely did not attempt to recertify due to “the chilling effect” of Immigration and Customs Enforcement Activity (ICE) presence and deportations.[26]
Inaccurate projections aside, increasing Alliance costs are not outside of the norm for the nation. Health care costs typically grow faster than inflation and have sharply increased in the United States over the last several decades.[27] National health expenditures more than doubled from $2.2 trillion in 2000 to $4.9 trillion in 2023 after adjusting for inflation.[28] Matching the national trend, part of the budget growth is likely due to an increase in the average age of Alliance enrollees, whose medical needs became more complex and expensive.[29]
Rather than determining with certainty the primary cost drivers and finding ways to curb them, DC lawmakers made severe cuts to the program by dramatically narrowing eligibility based on age and income over three years and then ultimately fully phasing out Alliance coverage for adults over the age of 20 in FY 2028 (Table 1).
Table 1.
DC lawmakers adopted several other program changes that will lead to fewer enrollees and fewer benefits for those who are still eligible.
Former Immigrant Children’s Program Enrollees Will Have Fewer Covered Benefits Under the Alliance
Lawmakers ended the ICP and shifted its enrollees to the Alliance. ICP provided health coverage to District residents who were 20 years old and younger and didn’t qualify for Medicaid. For children up to age 18, family income had to be at or below 319 percent of the federal poverty line (FPL) and for 19- and 20-year-olds at or below 216 percent of FPL (Table 1).[30] Lawmakers did not change the income thresholds for these age groups.
The DC Council’s Health Committee also reported that the Department of Health Care Finance (DHCF) assured them that “children’s services will remain essentially the same [under the Health Care Alliance] as those they received through ICP.[31] But the agency is also claiming that benefits will be limited to primary care services, inpatient and outpatient acute-care hospital services, emergency medical transportation services, and prescription drugs. That means that ICP enrollees no longer have access to specialty care, including home health services, services, and services provided by an inpatient psychiatric hospital.
New Age Limits Dramatically Narrow Eligibility for the Alliance
Beginning in October 2025, or FY 2026, individuals over the age of 26 were no longer allowed to newly enroll in the program. Enrollment will be further restricted in October 2026, when only individuals under age 21 will be allowed to newly enroll. Existing enrollees have a 90-day grace period to renew their coverage, or they will be dropped from the program. Mayor Bowser initially proposed a moratorium for all individuals over 21, but the DC Council Committee on Health found funding to restore eligibility up to age 25 for FY 2026 only. Unless lawmakers act, the moratorium on new enrollments will drop to age 21 in FY 2027.
Individuals Must Now Have Much Lower Incomes to Be Eligible for the Alliance
For adults over the age of 20, the threshold drops from 210 percent of FPL in FY 2025 to 138 percent of FPL in FY 2026 and then all the way down to 19 percent of FPL in FY 2027 before eliminating the program for adults over the age of 20.
In 2026, if an adult is 64 or younger, is documented, and has an annual income between 100 and 200 percent of FPL ($15,650 to $31,300 for a single adult), they may be eligible for the new Healthy DC Plan, also known as the Basic Health Plan (BHP) if they meet new, narrowed eligibility criteria.[32] [33] [34] Like the Alliance, this plan has no monthly premiums and no out-of-pocket costs for covered care. However, this plan does not cover dental or vision care as the Alliance did prior to FY 2026.
The Alliance Will No Longer Cover a Range of Benefits Including Vision and Dental
The Council originally voted to limit the Alliance benefit package, no longer covering vision, dental, non-emergency transportation, podiatry, and home health care services. The mayor proposed cutting durable medical equipment, such as inhalers, glucose monitors, and blood pressure cuffs, as well, but the Council Committee on Health restored this coverage for both adults and young people.
Recognizing the harm of the approved benefit cuts, the DC Council added a provision in the FY 2026 budget that directed a portion of FY 2025 revenue growth to restore the benefit package for FY 2026 as long as the additional revenues exceed actual expenditures, as estimated by the Chief Financial Officer (CFO).[35] In December, the CFO certified the additional revenue was available and District leaders are now considering whether to implement this restoration of benefits.[36][37] District leaders must find funding in the FY 2027 budget to continue the restoration past October 1, 2026.
Lawmakers Made it More Difficult for Program Applicants to Prove Residency
Previously, Alliance applicants and enrollees were able to prove DC residency with just one form of proof. Applicants will now have to provide two forms of evidence of residency, and the types of proof DC will accept are now more limited.[38] Previously a DC One Card—the consolidated credential designed to give residents access to DC government facilities and programs—was sufficient to prove residency. But now the District is moving away from the One Cards as a form of identification because the card is valid for five years and there were concerns that former DC residents were using them after moving to another jurisdiction.[39] The District will also no longer accept voter registration cards, auto, homeowner’s or renter’s insurance policies, or an official government form that verifies residency.[40] Those with exceptional circumstances, including people experiencing homelessness or domestic violence, or dealing with a noncustodial parent who refuses to release verification documentation, will not be required to provide two proofs of residency.[41] The Committee on Health added public school enrollment as an allowable single proof of residence.
Lawmakers Shifted the Program’s Reimbursement Model
The Alliance was previously a managed care organization (MCO) program and is now a fee-for-service (FFS) program. Under MCO, the District paid a monthly payment per Alliance enrollee, a set amount of money to cover the predicted monthly costs of covered care for a specific patient.[42] Now the District will pay health care providers for each service performed.[43] During FY 2026 budget deliberations, the agency predicted they would save $66 million by switching to FFS but the Deputy Mayor recently reported that there might not be any savings.[44] MCOs are tasked with coordinating care to reduce unnecessary emergency room visits, hospital admissions, and hospital readmissions.[45] If enrollees use more of these very expensive services than they did under MCOs, costs may end up higher than they were under MCO.[46]
Alliance Cuts Reflect an Enduring Legacy of Racism and Xenophobia
These policy changes will primarily hurt DC’s Hispanic and Black residents, especially immigrants who are undocumented and documented.[47] In FY 2020, 50 percent of Alliance enrollees were Hispanic, 20 percent were Black, and just over 2 percent of enrollees were white (Figure 2).[48]
Figure 2.
In FY 2020, approximately 59 percent of Alliance enrollees were female, and 40 percent were male, suggesting that the cuts could also cause outsized harm to women.[49] (While reported Alliance data has only “male” and “female” categories, sex and gender span beyond those binaries. These individuals are served by the Alliance as well.)
And the Alliance served residents in all wards but were more concentrated in Ward 4 (45 percent of all enrollees), Ward 1 (nearly 26 percent), and in Ward 5 (11 percent).
The current federal policy shift on immigration and local changes to the Alliance are part of a long, racist history of restrictions on immigrant access to public benefits. Prior to 1965, immigrants to the United States primarily came from Northern and European countries and federal law did not exclude immigrants from public benefit programs.[50] When federal lawmakers created Medicaid in 1965, they required states to cover everyone in all mandatory coverage groups regardless of their citizenship or immigration status.[51] Then the immigration system also changed in 1965, leading to greater numbers of immigrants coming from Asia and Latin America.[52]
Starting in the early 1970s, Congress and some states began restricting immigrants from public benefit programs due to xenophobia and racism. Political leaders and the press promoted disproven stereotypes to justify exclusion. They used similar stereotypes to make it harder for Black Americans to access benefits as well.[53]
The Nixon administration barred undocumented immigrants from Medicaid but a federal court overturned that policy.[54] In response, Congress passed a law in 1986 barring federal reimbursement of Medicaid services to states for undocumented residents, except for life-threatening medical emergencies.[55] As a result of racist stereotypes and a desire to cut spending on programs that benefited people with low incomes, federal lawmakers excluded many documented immigrants and all undocumented immigrants from Medicaid.
Earlier this year, federal lawmakers cut Medicaid coverage for immigrants who are lawfully present under humanitarian protections, including asylees, refugees, and certain domestic violence and sex trafficking survivors.[56] Federal lawmakers also ended access to marketplace tax credits that make health care more affordable for immigrants with documented status but who are still ineligible for Medicaid and earning less than 100 percent of the federal poverty level.[57]
Even in the District, policymakers have at times enacted program changes designed to erect barriers and deny health coverage to residents. For example, in 2011 they required in-person interviews every six months to redetermine eligibility, which immediately led to a sharp drop in participation, with thousands of eligible residents losing coverage.[58] Lawmakers didn’t restore funding for annual and electronic recertification until the FY 2023 budget.[59] For more than a decade, DC had two sets of rules for people participating in publicly funded health care and with the more restrictive rules falling largely on immigrant residents.
Alliance Cuts Will Harm Immigrant Residents Who Are Particularly in Need With Ripple Effects for All of DC
Immigrants, even those with documented status, have limited health coverage options and thus are in particular need of programs like the Alliance. Many have long been excluded from Medicaid coverage, and some are newly prohibited from Medicaid or no longer eligible for coverage on the ACA marketplace due to actions adopted by Congress in 2025.[60] In addition, noncitizen immigrants regardless of status are more likely to be employed in jobs that have lower wages and lack employer-sponsored health insurance.[61] They are also more likely to work in sectors with higher adverse health risks.[62][63]These conditions lead many immigrant residents in DC to rely on the Alliance to access affordable and life-saving health care coverage. Taking away this vital safety net will likely make it harder for some immigrants to stay healthy and remain on the job, harming them and DC’s economy, among other ripple effects.
More Uninsured DC Residents Will Put Additional Pressure on Federally Qualified Health Centers with Fewer Resources
Federally Qualified Health Centers (FQHCs) are “safety net” providers, including community health centers and programs serving migrants and people experiencing homelessness.[64] Their main purpose is to improve primary care services in underserved urban and rural communities.[65] FQHCs are obligated to serve patients even if they cannot pay, but they are limited in the services they can provide.[66] They do not provide cancer treatment, dialysis, or durable medical equipment such as wheelchairs, for example.[67]
While they will care for patients regardless of their ability to pay, FQHCs will face a critical funding gap due to the increase in uninsured patients following Alliance cuts. The DC Primary Care Association, the membership organization of local health centers, reports that FQHCs will lose $12.4 million annually when the Alliance is eliminated for adults in FY 2028.[68] FQHC directors report that they will not be able to absorb this loss and that they will have to lay off staff. They fear remaining staff will burn out as a result and the reduced capacity will force patients to rely on expensive emergency room visits that are not designed for helping patients manage diseases like hypertension and diabetes. [69]
Without Insurance, Individuals Increasingly Rely on Costly Emergency Room Visits
Individuals without insurance often skip preventive care and postpone routine care until they have an emergency.[70][71] By law, emergency rooms must provide patients with life-saving care even if they lack health insurance. But hospitals can charge these patients higher prices than insured patients.[72] Insurance companies negotiate with hospitals for reduced prices for their clients, but the uninsured do not have the same negotiating opportunities and can be charged thousands of dollars more than insurance companies pay. [73] [74]
The Centers for Medicare & Medicaid report that unnecessary emergency room visits should be avoided as “they are costly and consume resources that other individuals with more acute needs may need.”[75] DC emergency rooms already have the longest wait times in the country, averaging 5 hours and 29 minutes, and now many former Alliance patients will seek care in the emergency room, making this wait time increase.[76]
Residents With Low Incomes Will Take on More Medical Debt
Hospitals often use harmful debt collection practices on uninsured patients. And, although District law actually requires hospitals to provide uncompensated care for uninsured people with low incomes (at no less than 3 percent of their operating expenses), they are allowed to count bad debt toward that requirement, which they can later write-off. [77] Because of that loophole, private, nonprofit hospitals in the District spent just 0.80 percent of their operating expenses on free or reduced price care in 2021, for example.[78] Additionally, the District does not require hospitals to inform patients of the availability of financial assistance.[79]
Medical debt negatively affects an individual’s ability to obtain a job, housing, and other lines of credit.[80] The American Cancer Society reports that it is “associated with more days of poor physical and mental health, more years of life lost and higher mortality rates for all-cause and leading causes of death.”[81] Medical debt is also the leading cause of bankruptcy, which harms the broader economy. Fear of medical debt may lead some residents to delay or forego care. Polling has found that 28 percent of respondents delayed or did not receive health care due to cost. [82]
Residents Will Lose Access to Needed Behavioral Health Services
The Alliance has never covered outpatient mental health services, but individuals with severe mental illness were able to receive assessments, outpatient therapy, medication, or specialty in-home services through the Department of Behavioral Health (DBH). Despite the Council Committee on Health’s stated commitment to working with the DHCF and DBH to maintain these services until the Alliance sunsets for adults completely, the District eliminated these services for residents who now exceed the Alliance’s new income eligibility limits.[83][84]
Pregnant People Will Lose Health Coverage Just Two Months After Delivery
The District will provide pregnancy-related care through the federal Children’s Health Insurance Program (CHIP), which allows states to cover parents regardless of immigration status as part of covering low-income citizen children from conception to birth. CHIP covers prenatal care, labor, and delivery, but only offers two months of postpartum services. This is inadequate because pregnancy-related complications can develop up to a year after childbearing.[85] Nationally, nearly 12 percent of pregnancy-related deaths occur between 43 to 365 days postpartum.[86] For this reason, the Alliance and Medicaid both offer 12 months of postpartum care. However, as eligibility for the Alliance shrinks, people also ineligible for Medicaid will be left with insufficient postpartum services through CHIP.
The District Should Restore Alliance Coverage and Form an Advisory Council to Identify Cost Savings
The District should restore the Alliance program because health coverage is good for residents, communities, and DC’s economy. The District can, at the same time, form a task force of experts, including current Alliance enrollees, to identify cost drivers and potential areas for savings, with the goal of offering recommendations by January 2027.
The task force could evaluate, for example, the benefit of the District requiring Alliance beneficiaries who use FQHCs to fill their prescriptions there because FQHCs are able to purchase medications at a ed price. An inhaler that costs more than $500 at a retail pharmacy is less than $30 at an FQHC.[87] Long-acting insulin is more than $100 at a retail pharmacy and less than $50 at an FQHC.[88]
The advisory council should also examine enrollment and recertification practices and aim to reduce administrative burden on residents. For example, the advisory council could look at the new proofs of residency and see how many individuals have not been able to apply or recertify successfully. The council can also ensure implementation of any changes is smooth. When the Alliance moved from MCOs to FFS, there was confusion about what medications are covered and which providers are covered.[89]
Neither national research nor evidence from DC justifies the adoption of these harsh policies, which would cause the Alliance’s reach to plummet, leaving fewer residents with the affordable health care coverage they need to stay healthy. Evidence compiled by the advisory council would offer the promise of a better path forward that both identifies reasonable savings while also restoring DC’s promise as a place that values immigrants and treats health care as a basic human right.
