Domestic violence is a health and health policy issue. Intimate partner violence (IPV) can result in a range of adverse health outcomes or behaviors, including physical injuries, mental health and substance use challenges, missed work or school, and other circumstances that require specialized care and support. For survivors, health coverage is an important part of the safety net that protects them from such harms, helping them access the care they need while navigating the challenges of leaving an abusive relationship.
A 2025 study found that 62 percent of nearly 10,000 IPV hotline respondents reported current health needs related to their abusive experience. And in a 2022 survey, 46 percent of respondents said their partner had controlled or restricted their access to health care, identifying finances, health insurance coverage, and transportation as just some of the barriers they faced.
Health care can play a key role in responding to both the immediate and long-term effects of violence on survivors. Yet accessing that care can itself be difficult when someone is financially dependent on an abusive partner or loses insurance when they leave them. Without affordable, stable coverage, the cost of medical care can become another obstacle for someone already navigating safety, housing, employment, and financial instability.
These challenges are becoming more consequential as federal health policy changes make coverage more expensive and harder to maintain, adding to the instability survivors may already face when seeking access to care.
A changing coverage landscape could create new barriers for survivors
Recent federal policy changes are reshaping the health coverage landscape. Marketplace coverage has become more expensive following the expiration of the Affordable Care Act (ACA) enhanced premium tax credits, while Medicaid eligibility changes are expected to cause additional coverage losses beginning in 2027.
The effects of these changes are beginning to emerge. Marketplace enrollment fell from 22.1 million people in February 2025 to 19.2 million in February 2026, a 13 percent decline. Medicaid enrollment has also fallen: The Center on Budget and Policy Priorities (CBPP) found that 4.8 million fewer people enrolled in Medicaid in June 2026 than in June 2025, a decline of about 7 percent. And the largest Medicaid changes have not even happened yet, as the CBPP estimates that enrollment declines are likely to grow beginning in 2027 as new eligibility and renewal requirements take effect.
These trends could have particularly dire consequences for survivors who rely on marketplace and Medicaid coverage to access health care and other supports. Depending on the state, Medicaid may cover many of the services survivors need—including emergency and other medical care, mental and behavioral health services, substance use treatment, prescription drugs, and preventive and reproductive health care. Some state Medicaid programs also connect people to services that address other conditions affecting health, such as housing and food insecurity.
These health coverage changes are occurring as other parts of the broader safety net on which survivors rely face increasing strain. Domestic violence service providers have faced proposed changes to federal funding and other disruptions to the very systems that support survivors. Worse yet, these changes come as Medicaid and ACA marketplace coverage have also become less accessible.
While it is unclear exactly how many people experiencing intimate partner violence will lose coverage, the enrollment trends highlighted above do show that the coverage landscape is already changing—and that changes in the cost and stability of coverage could affect people’s ability to afford and maintain access to care. For survivors, that matters, particularly when leaving an abusive partner can itself disrupt coverage.
When leaving means losing coverage
Leaving an abusive relationship can itself create a coverage transition. An individual covered through a spouse’s employer-sponsored insurance, for example, may need to find coverage independently, while also dealing with the financial and logistical challenges of leaving.
The federal marketplace already recognizes this problem. The Centers for Medicare and Medicaid Services provides a special enrollment period (SEP) for victims of domestic abuse or spousal abandonment, as well as their dependents. The SEP allows eligible individuals to enroll in ACA coverage outside the regular open enrollment period and obtain coverage separately from an abuser or abandoner.
However, a coverage pathway is only part of the challenge. Survivors often need support applying for coverage, choosing a plan, maintaining enrollment, and accessing care. Support from health care providers and other professionals can help survivors navigate these processes and connect with other resources they may need. Health care providers specifically offer one of the few private settings where survivors can receive referrals, though some state reporting requirements may limit confidentiality.
States have options to reduce barriers to care
Even within a constrained Medicaid environment, states can make policy choices that affect survivors. In fact, states have several mechanisms available to address IPV through their health programs.
Many states have begun exploring ways to use Medicaid to address IPV more directly. One approach is “universal education,” such as Confidentiality, Universal Education and Empowerment, and Support (CUES), which encourages health care providers to discuss IPV and provide information and resources to all patients, rather than trying to determine in advance which patients are experiencing abuse. The model gives providers tools to have conversations with patients and connect them with resources for safety planning, health promotion, and counseling.
Ultimately, state policymakers have power to determine whether survivors encounter a health care system that helps them recover or one that makes an already difficult transition harder.
States can use Medicaid demonstration projects to support community-based organizations. North Carolina’s Section 1115 Healthy Opportunities Pilots, for example, allows Medicaid to pay participating community-based organizations for services such as case management, violence intervention, and parenting support—including home visiting services and child care and after-school programs. Such models demonstrate one way Medicaid can connect health coverage with services that address the circumstances affecting a person’s health outside the clinical setting.
States can also take steps to make Medicaid enrollment and renewal easier for people experiencing abuse, including by partnering with IPV service organizations for outreach and reducing paperwork requirements. For survivors who lose Medicaid coverage, states can strengthen connections to marketplace coverage by ensuring they receive clear information about their options, including special enrollment opportunities, and have access to navigators and other enrollment assisters who can help them understand their eligibility and enroll in coverage. Ultimately, state policymakers have power to determine whether survivors encounter a health care system that helps them recover or one that makes an already difficult transition harder.
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Conclusion
As federal policy reshapes Medicaid and marketplace coverage, states have policy options to protect access to care for survivors of intimate partner violence. Reducing enrollment barriers and improving coordination can help survivors maintain coverage and connect with the supports they need.
The author would like to thank Natasha Murphy, Haley Norris, and Topher Spiro for their review and Brian Keyser for his fact-checking.