Enrollment in Medicare Advantage, the private plan alternative to traditional Medicare, has increased steadily over the past two decades, with more than half of eligible beneficiaries enrolled in Medicare Advantage since 2023. The growth in enrollment has implications for federal spending, because according to the Medicare Payment Advisory Commission (MedPAC), Medicare payments to private plans are higher than spending for similar beneficiaries in traditional Medicare. In 2026, payments are 14% more per person, which translates into an additional $76 billion in federal spending this year. While payments per person relative to traditional Medicare are similar to a decade ago (15% higher), the impact on federal spending was substantially lower at $24 billion because enrollment was substantially lower with about one-third of eligible beneficiaries enrolled in a Medicare Advantage plan at that time.

Given the enrollment and spending trends, policymakers have become increasingly focused on how Medicare pays private plans, though without broad agreement on how or when to move forward with any changes to how Medicare Advantage plans are paid. In part, the difficulty stems from concerns about the effects of payment changes on beneficiaries’ choice among plans and access to supplemental benefits, such as coverage of dental, vision and hearing.

To better understand trends in the growth of the Medicare Advantage program, this brief provides current information about enrollment, including by plan type and firm. A second, companion analysis describes Medicare Advantage premiums, out-of-pocket limits, supplemental benefits offered, and prior authorization requirements in 2026.

Highlights for 2026:

• More than half (55%) of eligible Medicare beneficiaries are enrolled in Medicare Advantage in 2026. While a growing share of Medicare beneficiaries are enrolled in a Medicare Advantage plan, the pace of the increase in enrollment continued to slow in 2026.
• In 2026, nearly one quarter (23%) of Medicare Advantage enrollees are in a special needs plan (SNP), reflecting a steady increase in recent years. Most (85%) of the net increase in Medicare Advantage enrollment between 2025 and 2026 across all plan types was among SNPs, up from 48% in the prior year.
• More than three-quarters of SNP enrollment (78%) is in plans designed for people who are dually eligible for Medicare and Medicaid (D-SNPs), with plans for people with certain chronic conditions (C-SNPs) continuing to see a surge in enrollees in 2026 as in 2025. Enrollment in C-SNPS increased by 45% between 2025 and 2026, rising to 20% of SNP enrollment.
• Medicare Advantage enrollment is highly concentrated among plans owned by a small number of parent organizations, with UnitedHealth Group leading the market, and, together with Humana, accounting for nearly half (46%) of all Medicare Advantage enrollees nationwide, the same as in 2025, and consistent with the pattern in prior years. However, market shares for the leading parent organizations changed with UnitedHealth Group dropping to 26% (down from 29%), and Humana increasing to 20% (up from 17%). In absolute numbers, Humana had the largest growth in enrollment, with 1.3 million more enrollees in 2026 than in 2025. In contrast, enrollment in UnitedHealth Group plans decreased by nearly 647,000 from 2025 to 2026. 

More than half of eligible Medicare beneficiaries are enrolled in Medicare Advantage in 2026.

In 2026, more than half (55%) of eligible Medicare beneficiaries – 35 million out of about 64 million Medicare beneficiaries with both Medicare Parts A and B – are enrolled in Medicare Advantage plans. Medicare Advantage enrollment as a share of the eligible Medicare population has jumped from 19% in 2007 to 55% in 2026 (Figure 1).

Between 2025 and 2026, total Medicare Advantage enrollment grew by about 1.1 million beneficiaries, or 3% – a similar growth rate to the prior year (4%). The Congressional Budget Office (CBO) projects that the share of all Medicare beneficiaries enrolled in Medicare Advantage plans will rise to 63% by 2034 and remain at 63% for 2035 and 2036 (Figure 2).

In 2026, about six in ten Medicare Advantage enrollees are in individual plans that are open for general enrollment.

About 6 in 10 Medicare Advantage enrollees (61%), or 21.4 million people, are in plans generally available to all Medicare beneficiaries for individual enrollment (Figure 3). That is an increase of 0.2 million enrollees compared to 2025, though individual plans comprised a slightly smaller share of total Medicare Advantage enrollment in 2026 (61%) compared to 2025 (62%), and their share of enrollment has declined since 2010 when they comprised 71% of all enrollees. The decline in the share of enrollment in individual plans is due to faster enrollment growth in special needs plans (SNPs), especially since 2018.  

Special needs plans (SNPs) comprise a growing share of Medicare Advantage enrollment.

Nearly 8.2 million Medicare beneficiaries are enrolled in special needs plans (SNPs), an increase of more than 900,000 enrollees since 2025, and accounted for 85% of the net increase in Medicare Advantage enrollment over the last year. SNPs restrict enrollment to beneficiaries with significant or relatively specialized care needs, or who qualify because they are eligible for both Medicare and Medicaid. SNPs comprise a growing share of Medicare Advantage enrollment, accounting for 23% of enrollees in 2026 compared with 21% of enrollees in 2025 (Figure 4).

The increase in SNP enrollment is consistent with the increasing number of SNP plans available on average and more dual-eligible individuals having access to these plans since the Bipartisan Budget Act of 2018 made SNPs a permanent part of the Medicare Advantage program. Growth in SNP enrollment may also stem from the sharp increase in rebate payments, which have more than doubled since 2017 and are higher than for individual plans, which enables SNPs to offer extra benefits that are attractive to dual-eligible individuals.

Further, the Medicare Advantage Value-Based Insurance Design Model (VBID), which launched in 2017, gave plans the ability to provide additional interventions to enrollees such as reduced cost sharing and extra benefits based on their socioeconomic status (e.g., LIS eligibility), along with other targeting criteria. This meant many enrollees in SNPs, including those dually eligible for Medicare and Medicaid, may have been eligible for additional benefits. For example, plans enrolled in the model were able to offer benefits such as food and produce, assistance with utilities, and transportation for non-medical needs, among others, to a broader group of enrollees, when many of those benefits were typically reserved for enrollees who met the stricter definition of eligibility for Special Supplemental Benefits for the Chronically Ill (SSBCI). However, CMS discontinued this model in 2025 due to the “unprecedented cost” of this model, including increased rebates and increased Part D expenditures.

D-SNPs. Most SNP enrollees (78%) are in plans for beneficiaries dually enrolled in both Medicare and Medicaid (D-SNPs), a decline from 83% in 2025. While D-SNPs are designed specifically for dually-eligible individuals, among the 3.9 million dually-eligible enrollees with full benefits enrolled in Medicare Advantage plans, 28% were enrolled in Medicare Advantage plans that are generally available to all beneficiaries (not designed specifically for the dually-eligible population).

C-SNPs. Another 20% of SNP enrollees are in plans for people with severe chronic or disabling conditions (C-SNPs) – an increase from 16% in 2025. C-SNP enrollment in 2026 (about 1.7 million people) is 45% higher than it was in 2025 – an increase of about 518,000 enrollees. Nearly all (97%) C-SNP enrollees are in plans for people with diabetes or cardiovascular conditions in 2026, the same as in 2025.

I-SNPs. And 2% of SNP enrollees in 2026 are in plans for beneficiaries requiring a nursing home or institutional level of care (I-SNPs), the same as 2025. Enrollment in I-SNPs increased slightly in 2026 124,000 enrollees, an increase of about 9,000 enrollees since 2025.

SNP enrollment varies across states. In the District of Columbia and Puerto Rico, SNP enrollees comprise about half of all Medicare Advantage enrollees (51% in DC and 49% in PR). In eleven states, SNP enrollment accounts for at least a quarter of Medicare Advantage enrollment: 46% in MS, 40% in AR, 37% in NY, 36% in LA, 33% in FL, 32% in SC, 30% in GA, 27% in OK and AL, 26% in CT, and 26% in RI. In the remaining 39 states, fewer than a quarter of Medicare Advantage enrollees are in SNPs, including Alaska and Vermont, which have no SNP enrollment.

Enrollment in a D-SNP comprises the largest share of enrollment in SNPs in all states except New Hampshire where C-SNP enrollment is higher, though overall SNP enrollment only represents 2% of Medicare Advantage enrollment in New Hampshire. C-SNP enrollment represents a relatively large share of Medicare Advantage SNP enrollment in Illinois, Utah, South Carolina, Delaware, Nevada, and Oregon, where 40% or more of SNP enrollment is in C-SNPs.

Slightly less than one in five (16% or about 5.7 million) Medicare Advantage enrollees are in a group plan offered to retirees by an employer or union.

Group enrollment as a share of total Medicare Advantage enrollment is 16%, the lowest share since 2010, though it has generally fluctuated between 17% and 20% of enrollment. At the same time, the number of enrollees has increased from 1.8 million in 2010 to 5.7 million in 2026. The 2026 enrollment in group plans is a slight decrease from 2025 (a decrease of about 31,000 enrollees), the first time since 2010 that enrollment in this type of plan has declined year-to-year (Figure 5). With a group plan, an employer or union contracts with an insurer and Medicare pays the insurer a fixed amount per enrollee to provide benefits covered by Medicare. For example, 13 states provided health insurance benefits to their Medicare-eligible retirees exclusively through Medicare Advantage plans in 2024.

As with other Medicare Advantage plans, employer and union group plans may provide additional benefits and/or lower cost sharing than traditional Medicare and are eligible for bonus payments if they obtain required quality scores. The employer or union (and sometimes the retiree) may also pay an additional premium for these supplemental benefits. Group enrollees comprise a quarter or more of Medicare Advantage enrollees in seven states: 100% in AK, 60% in VT, 34% in MI, 31% in NJ, 28% in MD and WV, and 25% in IL.

Medicare Advantage enrollment is highly concentrated among a small number of parent organizations.

The average Medicare beneficiary is able to choose from Medicare Advantage plans offered by 8 parent organizations in 2026, the same as in 2025 and 2024, and nearly three in ten (29%) can choose among Medicare Advantage plans offered by 10 or more parent organizations.

UnitedHealth Group and Humana account for nearly half of all Medicare Advantage enrollees nationwide in 2026.

Despite most beneficiaries having access to plans operated by several parent organizations, Medicare Advantage enrollment is highly concentrated among a small number of parent organizations (Figure 6). UnitedHealth Group Inc. accounts for 26% of all Medicare Advantage enrollment in 2026 (a decline from 29% in 2025), or 9.3 million enrollees. Humana Inc. accounts for 20% of all Medicare Advantage enrollment in 2026 (an increase from 17% in 2025), or 7 million enrollees. Together, UnitedHealth Group Inc. and Humana Inc. account for nearly half (46%) of all Medicare Advantage enrollees nationwide, the same share as in 2025. In more than a quarter of counties (28% or 889 counties), these two organizations account for at least 75% of Medicare Advantage enrollment. These counties include East Baton Rouge (Baton Rouge), LA (81%), Travis County (Austin), TX (78%), Jackson County (Kansas City), MO (76%), and Palm Beach, Florida (75%).

Three other parent organizations comprise more than 5% of Medicare Advantage enrollment: CVS Health Corporation (12%), Kaiser Foundation Health Plan Inc. (6%), and Elevance Health Inc, (5%). (In contrast, as of 2025, CVS Health and Centene Corporation dominate the market for stand-alone prescription drug plans (PDP) that supplement traditional Medicare, with both organizations accounting for just over half of enrollment in PDPs).

Humana and Kaiser Permanente were the only large insurers to increase enrollment from 2025 to 2026.

In absolute numbers, Humana had the largest growth in enrollment, with 1.3 million more beneficiaries enrolled in a plan sponsored by Humana in March 2026 than in March 2025 (Figure 7). Of the largest insurers (5% of enrollment or more), Kaiser Permanente had the second largest growth in enrollment, with an increase of nearly 87,000 beneficiaries between March 2025 and March 2026. However, some smaller insurers had even larger growth – Devoted Health had an increase of nearly 258,000, SCAN Group had an increase of 136,000, and Aware Integrated had an increase of 89,000 beneficiaries between March 2025 and March 2026 (data not shown).

In contrast, enrollment in UnitedHealth plans declined, decreasing by nearly 647,000 beneficiaries between March 2025 and March 2026, and Elevance had the second largest enrollment drop, losing 346,000 beneficiaries, while enrollment in CVS plans declined by nearly 29,000.

Methods

This analysis uses data from the Centers for Medicare & Medicaid Services (CMS) Medicare Advantage Enrollment, Benefit and Landscape files for the respective year. KFF uses the Medicare Enrollment Dashboard for enrollment data for March 2024-2025, and the CMS Chronic Conditions Data Warehouse Master Beneficiary Summary File (MBSF) for March for earlier years. For overall Medicare Advantage penetration for 2026, we are using February data from the Medicare Enrollment Dashboard and will update to March when available. For other analyses of enrollment in this brief, KFF uses March data; enrollment data is only provided for plan-county combinations that have at least 11 beneficiaries; thus, this analysis excludes approximately 400,000 individuals who reside in a county where county-wide plan enrollment does not meet this threshold. Trend analysis begins in 2007 because that was the earliest year of data that was based on March enrollment. Data from the Medicare enrollment dashboard (used to calculate penetration rates) may change retroactively as CMS updates and reconciles administrative enrollment records. As a result, historical enrollment counts and penetration rates may differ from earlier downloads of the same data.

KFF calculates the share of eligible Medicare beneficiaries enrolled in Medicare Advantage, meaning they must have both Part A and B coverage. In previous years, KFF calculated the share of Medicare beneficiaries enrolled in Medicare Advantage by including Medicare beneficiaries with either Part A and/or B coverage. We modified our approach in 2022 to estimate the share enrolled among beneficiaries eligible for Medicare Advantage who have both Medicare Part A and Medicare B.

Additionally, in previous years, KFF had used the term Medicare Advantage to refer to Medicare Advantage plans as well as other types of private plans, including cost plans, PACE plans, and HCPPs. However, cost plans, PACE plans, and HCPPs are excluded from this analysis in addition to MMPs. In this analysis, KFF excludes these other plans as some may have different enrollment requirements than Medicare Advantage plans (e.g., may be available to beneficiaries with only Part B coverage) and in some cases, may be paid differently than Medicare Advantage plans. These exclusions are reflected in all data displayed trending back to 2007.

Beginning with the analysis of 2025 Medicare Advantage enrollment, KFF has relied on the parent organization field reported to CMS to identify plans sponsored by the same insurer. Previously, KFF had supplemented these data with publicly available information about acquisitions, mergers, and business relationships. The previous approach led to fewer total plan sponsors.

Medicare projections for 2027-2036 are from the February Congressional Budget Office (CBO) Medicare Baseline for 2026. Using the CBO baseline, Medicare enrollment is based on individuals who are enrolled in Part B, which is designed to include only individuals who are eligible for Medicare Advantage and exclude those who only have Part A only (~5.7 million people in 2026) and cannot enroll in Medicare Advantage. However, it may include some individuals who have Part B only and also are not eligible for Medicare Advantage.

Enrollment counts in publications by firms operating in the Medicare Advantage market, such as company financial statements, might differ from KFF estimates due to inclusion or exclusion of certain plan types, such as SNPs or employer group health plans.

People with Medicare have the option of receiving their Medicare benefits through the traditional Medicare program administered by the federal government or through a private Medicare Advantage plan, such as an HMO or PPO. In Medicare Advantage, the federal government contracts with private insurers to provide Medicare benefits to enrollees. Medicare pays insurers a set amount per enrollee per month, which varies depending on the county in which the plan is located, the health status of the plan’s enrollees, the plan’s quality star rating, and the plan’s estimated costs of covering Medicare Part A and Part B services.

The plans use the payments from the federal government to pay for Medicare-covered services, and in most cases, to also pay for supplemental benefits and reduced cost sharing, which are attractive to enrollees. Plans are able to offer these additional benefits, often without charging an additional premium for Part D prescription drugs or supplemental benefits, because in 2026, they receive an additional $2,664 per enrollee above their estimated costs of providing Medicare-covered services, according to the Medicare Payment Advisory Commission (MedPAC). This portion of plan payments, also called the rebate, has increased substantially in the last several years, more than doubling since 2018.

Plans are also able to lower costs, which help finance these supplemental benefits, through cost management tools, such as prior authorization requirements and provider networks. Prior authorization requirements are used to assess whether health care services are medically necessary before they are covered to reduce unnecessary costs, though they may also impose barriers to receiving care. Medicare Advantage plans often have a limited network of providers, which can restrict beneficiary choice of physicians and hospitals. More than half of Medicare Advantage beneficiaries are enrolled in HMO plans that typically do not cover out-of-network services.

This brief provides information about Medicare Advantage plans in 2026, including premiums, out-of-pocket limits, supplemental benefits, and prior authorization, as well as trends over time. A companion analysis examines trends in Medicare Advantage enrollment.

Highlights for 2026:

• In 2026, three quarters (75%) of enrollees in individual Medicare Advantage plans with prescription drug coverage pay no premium other than the Medicare Part B premium, which is a selling point for enrollees, particularly those living on modest incomes. The average supplemental premium, including Medicare Advantage enrollees who pay no supplemental premium, is $15 a month. Individual Medicare Advantage plans are available to all beneficiaries with Medicare Part A and Part B, unlike special needs plans (SNPs) or group plans offered to retirees by an employer or union.
• More than 6 in 10 enrollees in individual Medicare Advantage plans with prescription drug coverage are in HMOs (61%), 38% are in local PPOs, and less than 1% are in regional PPOs in 2026. HMOs generally only cover services provided in-network, but tend to have lower supplemental premiums, which were $12 a month, on average, in 2026. PPOs cover services received out-of-network, typically for higher cost sharing, and tend to charge higher supplemental premiums, which were $18 a month, on average, in 2026.
• The average out-of-pocket limit for Medicare Advantage enrollees is $5,421 for in-network services and $9,825 for in-network and out-of-network services combined in 2026. The average out-of-pocket limit for in-network services is higher for PPOs ($6,592) than HMOs ($4,636). Traditional Medicare does not have an out-of-pocket limit, but Medicare Advantage plans are required to cap patient costs.
• Most Medicare Advantage enrollees are in plans that offer supplemental benefits not covered by traditional Medicare, such as vision, hearing and dental. From 2025 to 2026, access to dental, vision, and hearing benefits for Medicare Advantage enrollees remained stable. However, there were decreases in the share of individual plan enrollees in plans providing over-the-counter benefits, meal benefits, remote access technologies, transportation benefits, and bathroom safety devices. The share of SNP enrollees in plans that offered in-home support services increased, while the share of SNP enrollees in plans that offered transportation benefits, bathroom safety devices, and remote access technologies decreased.
• About one third of enrollees (31%) are in plans that also reduce the Part B premium ($202.90 per month in 2026), most often by less than $10 a month. Among enrollees in individual Medicare Advantage plans, nearly a third (32%) received a reduction in their Part B premium in 2026, the same as in 2025. Among enrollees in individual plans that offer reduced Part B premiums as a supplemental benefit, 39% are in plans that reduce premiums by less than $10 a month, while about 32% are in plans that reduce Part B premiums by $100 or more per month.
• Nearly all Medicare Advantage enrollees (99%) are in plans that require prior authorization for some services, which is rarely used in traditional Medicare. Prior authorization is most often required for relatively expensive services, such as inpatient hospital stays (acute: 97%; psychiatric: 93%), skilled nursing facility stays (95%), Part B drugs (94%), and home health services (90%) and is rarely required for preventive services (6%).

In 2026, three quarters of Medicare Advantage enrollees (75%) are in plans with no premium other than the Part B premium.

In 2026, most people (75%) enrolled in individual Medicare Advantage plans with prescription drug coverage (MA-PDs) pay no premium other than the Medicare Part B premium ($202.90 in 2026) (Figure 1). The MA-PD supplemental premium includes both the cost of Medicare-covered Part A and Part B benefits and Part D prescription drug coverage. In 2026, 96% of Medicare Advantage enrollees in individual plans open for general enrollment are in plans that offer prescription drug coverage.

Altogether, including those who do not pay a supplemental premium, the average enrollment-weighted supplemental premium in 2026 is $15 per month, and averages $8 per month for just the Part D portion of covered benefits, substantially lower than the average premium of $36 for stand-alone prescription drug plans (PDP) in 2026. Higher average PDP premiums compared to the MA-PD drug portion of premiums is due in part to the ability of MA-PD sponsors to use rebate dollars from Medicare payments to lower their Part D premiums. When a plan’s estimated costs for Medicare-covered services are below the maximum amount the federal government will pay private plans in an area (known as the benchmark), the plan retains a portion of the difference, known as the “rebate” (See How Medicare Pays Medicare Advantage Plans: Issues and Policy Options for additional information on how Medicare sets payment rates). According to MedPAC, rebates average nearly $2,400 per enrollee in 2026 for individual plans, with individual plans allocating $600 or 26% of these rebates for Part D benefits, including reducing Part D premiums.

For the 25% of beneficiaries in plans that charge a MA-PD premium (5.0 million), the average premium is $59 per month, and averages $40 for the Part D portion of covered benefits.

Supplemental premiums paid by Medicare Advantage enrollees steadily declined between 2015 and 2025 but increased slightly in 2026.

Average supplemental MA-PD premiums declined from $36 per month in 2015 to $13 per month in 2025, but increased to $15 per month in 2026 (Figure 2). Average supplemental MA-PD premiums have declined markedly for local PPOs, falling from $65 per month in 2015 to $15 per month in 2025, but increased to $18 per month in 2026. Supplemental premiums for HMOs have also declined steadily from $28 per month in 2015 to $11 per month in 2025, increasing slightly to $12 per month in 2026. Only regional PPOs, which represent a very small and declining share of enrollment, have seen an increase in plan premiums over this time from $36 per month in 2015 to $75 in 2025, increasing again to $89 per month in 2026.

More than 6 in 10 individual Medicare Advantage enrollees in plans with prescription drug coverage are in HMOs (61%), 38% are in local PPOs, and less than 1% are in regional PPOs in 2026. The reduction in supplemental premiums for nearly all plans is driven in part by the decline in supplemental premiums for local PPOs and HMOs, that account for a rising share of enrollment over this time period, as well as the increase in rebates paid by Medicare to these plans.

Since 2015, a rising share of plans estimate that their cost of providing Medicare Part A and Part B services (the “bid”) is below the benchmark, and as plan bids have declined, the rebate portion of plan payments has increased. Additionally, because rebates are adjusted for the health status of enrollees, rebates have increased as risk scores have increased. (A risk score is a measure that reflects an enrollee’s expected health care costs based on their health status and demographic characteristics, with higher risk scores translating to higher payments to plans.) As mentioned above, plans are allocating some of these rebate dollars to lower the Part D portion of the MA-PD premium. According to MedPAC, rebates for individual plans have increased from an average of about $924 per enrollee in 2015 to nearly $2,400 per enrollee in 2026. This trend contributes to greater availability of zero-premium plans, which brings down average premiums.

The average out-of-pocket limit for Medicare Advantage enrollees is $5,421 for in-network services and $9,825 for both in-network and out-of-network services (PPOs) in 2026.

Since 2011, federal regulation has required Medicare Advantage plans to provide an out-of-pocket limit for services covered under Parts A and B. In contrast, traditional Medicare does not have an out-of-pocket limit for covered services.

In 2026, the out-of-pocket limit for Medicare Advantage plans may not exceed $9,250 for in-network services and $13,900 for in-network and out-of-network services combined, though plans can offer lower limits than the maximum. These out-of-pocket limits apply to Part A and B services only, and do not apply to Part D spending, which has a separate out-of-pocket limit of $2,100 in 2026. The size of Medicare Advantage provider networks for physicians vary greatly across counties and across plans in the same county, with beneficiaries having access to about half of the physicians available to traditional Medicare beneficiaries in their area, on average.

In 2026, the average out-of-pocket limit for Medicare Advantage enrollees is $5,421 for in-network services, including those enrolled in both HMOs and PPOs. The average out-of-pocket limit both in-network and out-of-network services combined, which applies to just PPOs, is $9,825 (Figure 3).

HMOs generally only cover services provided by in-network, and the average out-of-pocket (in-network) limit is $4,636. Enrollees in HMOs are generally responsible for 100% of costs incurred for out-of-network care, so typically do not have a limit for out-of-network services. These numbers also include about 6 million Medicare Advantage enrollees that are in HMO Point-of-Service plans (HMO-POS), which generally operate the same as HMOs, but give enrollees the option of receiving specified services outside of the HMO plan's provider network, though these services typically cost more than services received in-network and may require prior approval. PPOs cover services delivered by out-of-network providers but charge enrollees higher cost sharing for this care. The average out-of-pocket limit for in-network services for PPOs is $6,592.

Average out-of-pocket limits for in-network services generally declined between 2017 and 2023 but have increased since then, with average limit for in-network services decreasing by nearly $600 from 2017 ($5,253) to 2023 ($4,685), before increasing by about $700 from 2023 to 2026 ($5,421).

Most Medicare Advantage enrollees, including enrollees in special needs plans (SNPs), are in plans that offer some benefits not covered by traditional Medicare in 2026.

Virtually all enrollees in individual Medicare Advantage plans (those generally available to Medicare beneficiaries) are in plans that offer primarily health related supplemental benefits including eye exams and/or glasses (more than 99%), dental care (98%) hearing exams and/or aids (95%), and a fitness benefit (91%) (Figure 4). Similarly, most enrollees in SNPs are in plans that offer these benefits. However, benefits such as in-home support services are less common for enrollees in both individual plans (10%) and SNPs (38%). This analysis excludes employer-group health plans because employer plans do not submit bids, and available data on supplemental benefits may not be reflective of what employer plans actually offer.

Though these benefits are widely available, the scope of specific services varies. For example, a dental benefit may include preventive services only, such as cleanings or x-rays, or more comprehensive coverage, such as crowns or dentures. Plans also vary in terms of cost sharing for various services and limits on the number of services covered per year, many impose an annual dollar cap on the amount the plan will pay toward covered service, and some have networks of dental providers that beneficiaries must choose from.

SNPs restrict enrollment to beneficiaries with significant or relatively specialized care needs, or who qualify because they are eligible for both Medicare and Medicaid. Enrollees in SNPs have greater access than other Medicare Advantage enrollees to transportation (73% vs 22%), meal benefits (81% vs 65%), bathroom safety devices (60% vs 21%), over-the-counter benefits (98% vs 68%), and in-home support services (38% vs 10%). Enrollees in SNPs who are dually eligible for Medicare and Medicaid may also have access to similar benefits through Medicaid.

It is not known what share of enrollees have used these benefits because data are not yet available.

As of 2020, Medicare Advantage plans have been allowed to include telehealth benefits as part of the basic Medicare Part A and B benefit package – beyond what was allowed under traditional Medicare prior to the public health emergency, which has again been extended to December 31, 2027. Therefore, these benefits are not included in the figure above because their cost is not covered by either rebates or supplemental premiums. Medicare Advantage plans may also offer supplemental telehealth benefits via remote access technologies and/or telemonitoring services, which can be used for those services that do not meet the requirements for coverage under traditional Medicare or the requirements for additional telehealth benefits (such as the requirement of being covered by Medicare Part B when provided in-person). Less than half of enrollees in both individual plans and SNPs are in plans that offer remote access technologies (43% and 39%, respectively), and just 2% of enrollees in individual plans and 1% of enrollees in SNPs have access to telemonitoring services.

Nearly all Medicare Advantage enrollees are in plans that offer vision, dental, and hearing benefits, similar to 2025, while fewer are offered over-the-counter benefits, meals, remote access technologies, transportation, and bathroom safety devices.

In 2026, there were changes to the share of enrollees in plans that offer specific benefits compared to 2025. The same share of enrollees in individual plans are in plans that offer eye exams and/or eyeglasses, dental benefits, and hearing exams and/or aids (Figure 5). However, smaller shares of enrollees are in plans that offer over-the-counter benefits (68% in 2026 vs 79% in 2025), meal benefits (65% in 2026 vs 70% in 2025), remote access technologies (43% in 2026 vs 49% in 2025), transportation benefits (22% in 2026 vs 28% in 2025), and bathroom safety devices (21% in 2026 vs 32% in 2025).

For those in Special Needs Plans (SNPs), similar shares of enrollees are in plans that offer eye exams and/or eyeglasses, dental benefits, and hearing exams and/or aids compared to 2025. Larger shares of SNP enrollees are in plans that offer in home-support services (38% in 2026 vs 11% in 2025). However, smaller shares of SNP enrollees are in plans that offer transportation benefits (73% in 2026 vs 80% in 2025), bathroom safety devices (60% in 2026 vs 68% in 2025), and remote access technologies (39% in 2026 vs 46% in 2025).

Despite concerns that recent changes to Medicare Advantage payment may impact the availability of extra benefits, overall, Medicare Advantage enrollees have not experienced a substantial loss in access to supplemental benefits, particularly dental, vision, hearing, and fitness benefits. However, the availability of some supplemental benefits, such as those mentioned above, has decreased over the last few years, down from a peak in 2023. This analysis also does not account for any changes to the design of benefits, which could make benefits more or less generous, such as changes to eligibility for these benefits, networks of providers, required cost sharing, or the generosity coverage.

Additionally, while CMS collects data on the use and spending for supplemental benefits, these data are not currently available to researchers or consumers. Further, CMS does not collect detailed data on prior authorization requests and denials for these benefits.

Nearly one-third (31%) of enrollees are in plans that offer a rebate against the Part B premium, though the dollar values of the rebates are often small.

In 2026, about one-third (32%) of individual plan enrollees were in plans that offer a Part B rebate, the same as in 2025. Although the Part B rebate is often used in Medicare Advantage marketing (sometimes described as “money back in your Social Security check”), for most enrollees, the dollar value of the rebate is small relative to the $202.90 standard Part B premium in 2026. Among the 6.7 million beneficiaries in an individual Medicare Advantage plan that provides a Part B rebate, 39% (2.6 million) are in plans that offer rebates of less than $10 a month, though about one-third (32%; 2.2 million) are in plans that offer rebates of $100 or more per month. (Figure 6). In other words, about 12% of all Medicare Advantage enrollees in individual plans get $10 a month off their monthly Part B premium, while 10% get $100 or more off their monthly premium.

In 2026, 30% of SNP enrollees were in plans that offer a Part B rebate, down from 44% in 2025. Among all SNP enrollees, 22% are in plans with a rebate of less than $10 a month. Most SNP enrollees are dually eligible for Medicare and Medicaid, and Medicaid pays the Part B premiums on their behalf (except in Puerto Rico). When dually-eligible individuals enroll in a Medicare Advantage plan with a Part B rebate, the state Medicaid program receives the Part B premium rebate payment from the plan (except in Puerto Rico).

Enrollees in SNPs are more likely to be in plans that offer Special Supplemental Benefits for the Chronically Ill (SSBCI) than other Medicare Advantage enrollees.

Beginning in 2020, Medicare Advantage plans have also been able to offer supplemental benefits that are not primarily health related for chronically ill beneficiaries, known as Special Supplemental Benefits for the Chronically Ill (SSBCI). In addition, Medicare Advantage plans participating in the Value-Based Insurance Design Model (which was discontinued at the end of 2025) also offered these non-primarily health related supplemental benefits to their enrollees, but used different eligibility criteria than required for SSBCI, including offering them based on an enrollee’s socioeconomic status (e.g., LIS eligibility) or whether the enrollee lives in an underserved area. While this analysis provides information on the share of Medicare Advantage enrollees in plans that offer these SSBCI benefits, data on how many beneficiaries use these benefits and how often they use them are not currently available.

In 2026, the share of Medicare Advantage enrollees offered SSBCI is highest for food and produce—8% of individual plan enrollees (1.8 million), and the vast majority (93%) of SNP enrollees (7.6 million) are offered this benefit (Figure 7).

The other SSBCI benefits that are most commonly offered are:

• General supports for living (e.g., housing, utilities) (6% for individual plans vs 79% for SNPs)
• Transportation for non-medical needs (5% for individual plans vs 36% for SNPs)
• Pest control (3% for individual plans vs 26% for SNPs)
• Meals beyond a limited basis (2% for individual plans vs 12% for SNPs)
• A social needs benefit (e.g., community programs)(2% for individual plans vs 19% for SNPs)
• Indoor air quality equipment and services (e.g., air conditioning units)(2% for individual plans vs 24% for SNPs)
• Services supporting self-direction (e.g., power of attorney for health services, financial literacy classes) (2% for individual plans vs 6% for SNPs)
• Complementary therapies (those offered alongside traditional medical treatment) (1% for individual plans vs 2% for SNPs)
• Structural home modifications (0.04% for individual plans vs 5% for SNPs)

In addition to the 10 initially enumerated examples of SSBCI provided by CMS, plans are also able to offer “other” extra benefits specified by the plan, including pet care/service animal supplies (2% in individual plans and 6% for SNPs), personal care (2% in individual plans and 8% for SNPs), memory care (1% in individual plans and 4% for SNPs), and hairstyling and beauty care (1% in individual plans and 2% for SNPs). However, this is not an exhaustive list of additional benefits plans may offer.

While the share of enrollees with plans that offer some SSBCI benefits has increased since 2021, such as food and produce, growth for other benefits has been much slower.

Though the share of SNP enrollees in plans with food and produce benefits and general supports for living benefits has grown considerably since 2021, the share of enrollment in plans for other SSBCI benefits has grown much more slowly, particularly for enrollees in individual plans (Figure 8). For example, the share of SNP Medicare Advantage enrollees with food and produce benefits has more than quadrupled from 21% in 2021 to 93% in 2026—with the sharpest growth from 2024 (49%) to 2025 (94%)—while for individual plans, food and produce benefits are far less common. The share of enrollees with these benefits increased modestly from 2021 to 2023 (from 7% to 16%) but has declined back to 8% in 2026. For general supports for living benefits, the share of SNP Medicare Advantage enrollees with these benefits has also significantly increased from 10% to 79%—with the sharpest growth from 2024 (43%) to 2025 (80%)—while for individual plans, the share more than tripled to 2025, from 3% to 10%, but has declined back to 6% in 2026.

Like for other supplemental benefits, the scope of services for SSBCI benefits varies. For example, many plans offer a specified dollar amount that enrollees can use toward a variety of benefits, such as food and produce, utility bills, rent assistance, and transportation for non-medical needs, among others. This dollar amount is often loaded onto a flex card or spending card that can be used at participating stores and retailers, which can vary depending on the vendor administering the benefit. Depending on the plan, this may be a monthly allowance that expires at the end of each month or rolls over month to month until the end of the year, when any unused amount expires.

Nearly all Medicare Advantage enrollees are in plans that require prior authorization for many higher-cost services.

Medicare Advantage plans can require enrollees to receive prior authorization before a service will be covered, and nearly all Medicare Advantage enrollees (99%) are in plans that require prior authorization for some services in 2026 (Figure 9). Prior authorization is most often required for relatively expensive services, such as inpatient hospital stays (acute: 97%; psychiatric: 93%), skilled nursing facility stays (95%), Part B drugs (94%), and home health services (90%) and is rarely required for preventive services (6%). Prior authorization is also required for the majority of enrollees for some extra benefits (in plans that offer these benefits), including preventive dental services, and hearing and eye exams.

The number of enrollees in plans that require prior authorization for one or more services stayed around the same from 2025 to 2026. In contrast to Medicare Advantage plans, traditional Medicare does not generally require prior authorization for services and does not require step therapy for Part B drugs. However, the Center for Medicare & Medicaid Innovation (CMMI) is testing a new model, the Wasteful and Inappropriate Service Reduction (WISeR) Model, that uses technologies such as artificial intelligence to apply prior authorization for a limited set of services in six states in traditional Medicare.

In 2024, nearly 53 million prior authorization requests were submitted to Medicare Advantage insurers, with insurers denying 4.1 million or nearly 8% of those requests. While Medicare Advantage insurers are required to publish some data on timeliness and use of prior authorization, information is not currently available on how prior authorization requests, denials, and appeals vary by type of service, plan, or enrollee characteristics because CMS does not collect or report this information.

Methods

This analysis uses data from the Centers for Medicare & Medicaid Services (CMS) Medicare Advantage Enrollment, Benefit and Landscape files for the respective year.

In previous years, KFF had used the term Medicare Advantage to refer to Medicare Advantage plans as well as other types of private plans, including cost plans, PACE plans, and HCPPs. However, since 2022, KFF has excluded cost plans, PACE plans, HCPPs in addition to MMPs. We exclude these other plans as some may have different enrollment requirements than Medicare Advantage plans (e.g., may be available to beneficiaries with only Part B coverage) and in some cases, may be paid differently than Medicare Advantage plans. These exclusions are reflected in both current data as well as data displayed trending back to 2010.

In previous years, KFF’s analysis of average out-of-pocket limits in Medicare Advantage excluded HMOs that are Point-of-Service plans (HMO-POS), which allow out-of-network care for certain services, because they represented a relatively small share of HMO enrollment at the time (e.g., 10% in 2017). However, HMO-POS enrollment has grown substantially and now accounts for nearly half (46%) of HMO enrollment in Medicare Advantage. As a result, these plans are included in the current analysis to better reflect the experience of a substantial share of Medicare Advantage enrollees in HMOs. 

It has now been over a year since President Trump signed executive orders eliminating federal diversity, equity, inclusion, and accessibility (DEIA) programs and related initiatives, reshaping policies and priorities across federal agencies, research, and education. Additionally, the Trump administration’s workforce reshaping initiatives, including reductions in force, the Deferred Resignation Program, early retirement incentives and a hiring freeze have led to major declines in the federal workforce which have reduced resources available to support efforts to address disparities. While some efforts have been halted or modified by court rulings, the Trump administration has continued to take steps to remove staff, programs, funding, data collection, and other activities tied to concepts of diversity, equity, or disparities. Together, these actions signal a significant shift in federal approaches to addressing inequities and may have broad implications for efforts to monitor and address disparities in health and health care, as well as for the diversity of the workforce, including in health care.

This brief provides an update on the status of the administration’s actions to eliminate DEI-related initiatives one year later and examines emerging impacts and implications for racial health disparities.

Reductions to Federal Agency Staff and Programs

Federal workforce reductions have led to the elimination or scaling back of programs that support data collection, research, and interventions that have historically included a focus on addressing disparities or groups at higher risk of poor health outcomes. Since January 2025, the Trump administration’s workforce reshaping initiatives have led to significant federal workforce declines, with more than 420,000 people separating from the federal workforce as of May 14, 2026. Within the Department of Health and Human Services (HHS), staffing losses have exceeded 20,000 employees since January 2025. At the Centers for Disease Control and Prevention (CDC), an estimated 15% of the workforce, or about 3,000 employees, have departed, with some reports suggesting even larger reductions. With these reductions, many programs that support research and public health interventions appear to have been terminated. Although the full scope of program cutbacks is unclear due to the lack of a comprehensive public record, staffing reductions across agencies have left key programs understaffed or unable to maintain core functions, including efforts focused on addressing health disparities and advancing health equity. For example:

• Reporting suggests that layoffs within the CDC’s Division of Reproductive Health in late March and early April reduced the workforce by about two-thirds, disrupting multiple programs focused on maternal and infant health, an area of health with longstanding disparities. These cuts included the elimination of the Pregnancy Risk Assessment Monitoring System (PRAMS), a primary source of data on health behaviors and outcomes before, during, and after pregnancy that has been widely used to study maternal mortality, including disparities, leaving its future uncertain.
• At HHS, the Office of Climate Change and Health Equity was removed from the agency’s website, and its staff were reportedly placed on administrative leave. Staffing reductions within the CDC’s Division of Environmental Health Science and Practice also led to the elimination of the Environmental Public Health Tracking Program, which monitored data on issues such as cancer clusters and weather-related illnesses. Together, these changes may limit federal capacity to monitor and address environmental and climate-related health disparities, particularly among low-income communities and communities of color that are often disproportionately exposed to environmental hazards and extreme weather events.
• The elimination of the National Survey on Drug Use and Health team halted a key federal data source on substance use and mental health trends, while CDC staff supporting the National Youth Tobacco Survey were also eliminated. Both surveys have historically been used to assess differences in behavioral health and tobacco use across populations and to help guide prevention and treatment efforts for groups disproportionately affected by these issues.

Elimination of Grants and Research Initiatives

Efforts to eliminate DEI across the federal government have reduced support for research related to disparities, including through funding cuts, changes to grant review and award processes, and the loss of leadership and infrastructure that support clinical trials and participation. Federal agencies have reduced or eliminated funding for research initiatives that included DEI-related goals or focused on specific populations, and grant review processes have been revised to flag or exclude applications containing DEI-related terms or focus areas including discrimination, diversity, equity, and race. For example, the recently formed and now defunct Department of Government Efficiency (DOGE) was tasked with auditing and canceling DEI-related federal research grants. Recent deposition hearings indicate that staff members used ChatGPT to propose cuts to roughly 1,400 grants under the National Endowment for the Humanities, including examples that were not related to DEI. In addition to the grants reviewed under DOGE, broader administrative actions led to the termination of more than 2,300 National Institute of Health (NIH) grants by late June 2025, with nearly 1,100 grants remaining terminated as of May 4, 2026. One study found that the National Institute of Minority Health and Health Disparities lost both the largest share of grants and the largest share of funding across all NIH institutes and centers. Research shows that grant terminations were more likely to impact American Indian or Alaskan Native (AIAN), Asian, Black, Hispanic or Native Hawaiian or Pacific Islander (NHPI) researchers compared to White researchers. These actions also affected 160 NIH-funded clinical trials, more than half of which (57%) included project terms related to racial and ethnic minority populations, such as Black, Latino, Indigenous, Asian, and other historically underserved groups. At the same time, the loss of research leadership and staff has disrupted the research pipeline and contributed to additional grant terminations. HIV research has been particularly impacted. Reporting indicates that at least 145 NIH-funded HIV research grants, totaling nearly $450 million, were terminated in early 2025, including studies focused on HIV prevention, access to pre-exposure prophylaxis (PrEP), and populations disproportionately affected by HIV, which include groups of color. A newly proposed rule issued by the Office of Management and Budget (OMB) would revise federal grant requirements by increasing political review of awards, requiring alignment with presidential priorities, and creating new mechanisms for modifying or terminating existing funding, with an emphasis on prohibiting federal support for programs, funding preferences, or award requirements that advance DEI efforts. If finalized, the proposal could expand federal grantmaking agencies’ authority to review and terminate awards deemed inconsistent with the administration’s interpretation of civil rights laws and federal priorities, which may affect research and programs designed to address racial, ethnic, gender, and other disparities.

Elimination of Public Information and Resources

Efforts to eliminate DEI across the federal government have also reduced the availability and integrity of public information and data, including through the suspension of national surveys, the removal of DEI-related data elements, and changes to climate data and evidence. As previously noted, several national surveys were suspended, delayed, or scaled back, limiting the availability of timely population-level data. These include the Pregnancy Risk Assessment Monitoring System (PRAMS) and the National Survey on Drug Use and Health (NSDUH). There are also reports that the National Intimate Partner and Sexual Violence Survey and the National Youth Tobacco Survey (NYTS) may have also been eliminated, however, their official status remains unclear. These surveys have historically provided data used to identify disparities and inform public health policy and interventions. In addition, key surveys and data systems removed or modified questions and data elements related to race, ethnicity, gender identity, sexual orientation, and other demographic measures, reducing the ability to measure differences across populations. Some publicly available datasets were also modified or taken offline, limiting access for researchers, policymakers, and the public, while some federal websites removed or archived reports, dashboards, and tools that previously highlighted disparities or equity-focused analyses. Climate-related data and resources were similarly removed, reframed and misrepresented, or made more difficult to access. For example, the Trump administration determined that official government websites would no longer host national climate assessments, including the most recent assessment released in 2023, which found that climate change disproportionately affects the health, livelihoods, and security of people of color, with Indigenous populations at particular risk. In addition, concerns have been raised about the scientific rigor and peer review process of the Climate Working Group report recently released under the administration.

Education and Workforce

Amid the executive orders, threats by the Trump administration to withdraw funding from schools with DEI programs, and charges from the Equal Employment Opportunity Commission (EEOC) for discrimination against White people, concerns have grown about the potential impacts on diversity among students and the future workforce. Early last year, the Department of Education issued guidance, commonly referred to as the “Dear Colleague” letter, directing schools and other entities receiving federal education funding to stop using what it described as “racial preferences” in admissions, programming, and other activities. This followed the Supreme Court’s 2023 decision ending race-conscious admissions, which led to a shift in enrollment patterns across higher education institutions, with declines in the share of students of color at highly selective universities. Research also suggests that the ruling has already contributed to declines in the number of Black, Hispanic, and AIAN students entering medical school, raising concerns about the future diversity of the physician workforce. These trends may further exacerbate existing disparities in representation. KFF analysis shows that Hispanic, Black, AIAN, and NHPI people remain underrepresented among physicians relative to their share of the population, with the largest gap among Hispanic people, who comprise 20% of the U.S. population but only 7% of the physician workforce. More broadly, the EEOC has increasingly emphasized enforcement related to alleged discrimination against White workers, which some argue could discourage workplace diversity initiatives. In addition, broader immigration restrictions and enforcement actions may further affect workforce diversity, particularly in health care and research fields that rely heavily on immigrant workers and internationally trained professionals.

Legal Challenges and Protections

In some cases, implementation of DEI-related cuts has been temporarily halted or mitigated by lawsuits and congressional action. As of April 2026, Congress has rejected many of the Trump administration’s proposed reductions to federal health programs through the FY 2026 appropriations process. For example:

• The legislation provided HHS with approximately $116 billion in funding, about $33 billion more than proposed in President Trump’s FY 2026 budget request, including increases for several public health and behavioral health programs, such as reproductive and community health programs, that support populations disproportionately affected by poor health outcomes, including people of color and lower-income groups.
• It also maintained the Substance Abuse and Mental Health Services Administration (SAMHSA) as an independent agency and increased SAMHSA funding by $65 million to approximately $7.4 billion, despite earlier proposals to reduce funding by roughly $1 billion. The legislation also included guardrails intended to ensure that SAMHSA funds are distributed as appropriated, preserving support for mental health and substance use programs that often serve low-income and underserved communities.
• Similarly, Congress maintained CDC funding at approximately $9.2 billion, rather than the nearly 50% reduction proposed in the administration’s FY 2026 budget request, and directed HHS to maintain staffing levels needed to carry out CDC programs, although the agency’s Social Determinants of Health program was eliminated.
• The legislation also preserved funding for reproductive health programs, including Title X and the Teen Pregnancy Prevention Program, and increased investments in maternal health programs across HRSA, CDC, and NIH, which have historically focused on addressing longstanding racial disparities in maternal and infant health outcomes.
• In addition, while the administration proposed substantial reductions to NIH funding, Congress ultimately approved increased funding for the agency, and several court challenges temporarily halted some funding cuts and grant terminations, which had a noted focus on DEI-related research.

Separate legal challenges have also limited implementation of some workforce and education-related actions. Federal courts and Congress blocked or delayed aspects of the Trump administration’s workforce reduction efforts, including rulings against certain reductions in force and layoffs implemented during agency restructuring efforts. Courts also blocked implementation of the Department of Education’s “Dear Colleague” guidance related to race-conscious practices in schools, and the Department later withdrew the guidance following legal challenges and court rulings. These actions suggest that the scope and long-term effects of the administration’s policies may continue to evolve as litigation and congressional oversight proceed.

This fact sheet summarizes the major statutory requirements and policies pertaining to U.S. global family planning/reproductive health (FP/RH) efforts over time and identifies those currently in effect. These laws and policies collectively serve to direct how U.S. funds are spent, to where and which organizations funds are provided, and generally shape the implementation and define the scope of U.S. global FP/RH activities. It includes U.S. laws and annual requirements enacted by Congress through appropriations bills (statutory provisions) as well as executive branch policies and guidance specific to FP/RH (policy provisions). Each category lists provisions in chronological order.

Since early 2025, the Trump administration has frozen or eliminated funding for most FP/RH activities, although Congress has continued to appropriate funding for this work. See the KFF fact sheet of the status of FP/RH efforts.

Table 1

Statutory Requirements and Policies for U.S. Global FP/RH Efforts (as of FY 2026)

1. As noted in CRS, Abortion and Family Planning-Related Provisions in U.S. Foreign Assistance Legislation and Policy, July 2022: “No restrictions exist on funding for the medical evacuation of Peace Corps volunteers who decide to have an abortion. Under existing policy, the Peace Corps covers the cost of evacuation to a location where ‘medically adequate facilities’ for obtaining an abortion are available and where abortions are legally permissible.” ↩︎
2. In most recent years, a provision is included requiring that any Kemp-Kasten determination that is made must be accompanied by the evidence and criteria used to make the determination. ↩︎
3. USAID defines a target/quota as “a predetermined figure that a service provider or referral agent is assigned or required to affect or achieve” for the purposes of the Tiahrt Amendment. It states that “the key to interpreting ‘incentives’ is to see whether they are provided in exchange for accepting a method (in the case of a client) or linked to achievement of a predetermined target or quota (in the case of program personnel).” USAID Global Health eLearning Center, “FP Legislative & Policy Requirements (Updated),” online course, February 2009, authored by Debbie Gueye, MSI. ↩︎
4. USAID Global Health eLearning Center, “FP Legislative & Policy Requirements (Updated),” online course, Feb. 2009, authored by Debbie Gueye, MSI. ↩︎
5. Although such reallocation began in practice in FY 2002, it was first authorized by Congress in legislation beginning in FY 2004 with reference to FY 2002 and FY 2003 funds. ↩︎
6. Informed Choice: Effective access to information on family planning choices and to the counseling, services, and supplies needed to help individuals choose to obtain or decline services; to seek, obtain, and follow up on a referral; or simply to consider the matter further. Voluntarism: Decision to use a specific method of family planning or to use any method of family planning is based upon the exercise of free choice and is not obtained by any special inducements or any element of force, fraud, deceit, duress or other forms of coercion or misrepresentation. USAID Global Health eLearning Center, “FP Legislative & Policy Requirements (Updated),” online course, Feb. 2009, authored by Debbie Gueye, MSI. ↩︎
7. This policy was first instituted via presidential memorandum in 1984 by President Reagan. In 1993, it was rescinded by President Clinton, although it was briefly applied legislatively in 1999 (see “Status” column). In 2001, it was reinstated by President Bush, who expanded its applicability in 2003 to include family planning funds at the State Department (see “Applies to” column) with some exemptions. In 2009, it was rescinded by President Obama. In 2017, it was reinstated by President Trump, who expanded its applicability to include the vast majority of global health assistance furnished by all departments and agencies. In 2021, it was rescinded by President Biden. ↩︎
8. Note that, with one exception, has been applied via Executive action. The exception was in FY 2000, when President Clinton agreed to a one-year legislative codification with a partial waiver of restrictions as part of a broader arrangement to pay the U.S. debt to the United Nations. See P.L. 106-113, Sec. 599D, and PAI, Global Gag Rule Timeline, July 12, 2011. ↩︎
9. “M16. VOLUNTARY POPULATION PLANNING ACTIVITIES – MANDATORY REQUIREMENTS (MAY 2006) …
   b. Prohibition on Abortion-Related Activities:
   (1) No funds made available under this award will be used to finance, support, or be attributed to the following activities: (i) procurement or distribution of equipment intended to be used for the purpose of inducing abortions as a method of family planning; (ii) special fees or incentives to any person to coerce or motivate them to have abortions; (iii) payments to persons to perform abortions or to solicit persons to undergo abortions; (iv) information, education, training, or communication programs that seek to promote abortion as a method of family planning; and (v) lobbying for or against abortion. The term “motivate,” as it relates to family planning assistance, must not be construed to prohibit the provision, consistent with local law, of information or counseling about all pregnancy options.
   (2)No funds made available under this award will be used to pay for any biomedical research which relates, in whole or in part, to methods of, or the performance of, abortions or involuntary sterilizations as a means of family planning. Epidemiologic or descriptive research to assess the incidence, extent, or consequences of abortions is not precluded.” ↩︎
10. For example, one provision related to abortion included in the State Department Standard Terms and Conditions is:
    “AA. Prohibition on use of funds for performance or research respecting abortions or involuntary sterilization
    The recipient agrees that in accordance with 22 USC 2151b(f) Population planning and health programs no foreign assistance funds provided by the award shall be used to:
    (1) pay for the performance of abortions as a method of family planning or to motivate or coerce any person to practice abortions (Helms Amendment, 1973).
    (2) pay for the performance of involuntary sterilizations as a method of family planning or to coerce or provide any financial incentive to any person to undergo sterilizations (Involuntary Sterilization Amendment, 1978).
    (3) pay for any biomedical research which relates, in whole or in part, to methods of, or the performance of, abortions or involuntary sterilization as a means of family planning (Biden Amendment, 1981).
    Furthermore, the recipient agrees in accordance with the Department’s annual appropriation bill, that no funds provided by the award may be used to lobby for or against abortion (Siljander Amendment, 1981).” ↩︎