On July 4, President Trump signed into law a budget and tax bill that includes significant changes to the Medicaid program including new requirements for states to implement work requirements for individuals enrolled through the Affordable Care Act (ACA) Medicaid expansion pathway or certain state waivers. The Congressional Budget Office (CBO) estimates that this requirement will have the largest effect on spending and coverage compared to other provisions, reducing federal Medicaid spending by $326 billion over ten years and resulting in 5.3 million more people who are uninsured.

In the summer of 2025 while the new law was under debate in Congress and shortly after enactment, the 25^th annual budget survey of Medicaid officials in all 50 states and the District of Columbia conducted by KFF and Health Management Associates (HMA), in collaboration with the National Association of Medicaid Directors (NAMD) was in the field. To better understand how states are preparing for Medicaid work requirements, the survey asked states to discuss anticipated challenges to implementing work requirements by the end of 2026, including related system changes and data matching. KFF anticipates that work requirements will apply to 43 states (41 expansion states including the District of Columbia plus Georgia and Wisconsin, which have expanded Medicaid through waivers). We received responses to this question from 42 of these states.

Because the survey question asked specifically about challenges pertaining to systems, nearly all states described system changes they expect to make; however, they identified other challenges as well. These challenges include how quickly the requirements must be implemented, staff capacity concerns, cost concerns, and issues for applicants and enrollees (Figure 1). In many cases, states described multiple, interrelated challenges. For example, the compressed implementation timeframe and need for federal guidance often factored into state responses detailing other challenges. Some states expressed more challenges than others. A few states that had already been pursuing 1115 waivers to implement work requirements reported fewer anticipated implementation challenges. Understanding state challenges can help inform the content and timing of forthcoming federal guidance. 

States cited the need to make major changes to eligibility systems in a short timeframe and the need for enhanced data sharing infrastructure as major challenges. States will need to make significant changes to eligibility systems to be able to verify compliance with work, school, and other qualifying activities as well as to identify individuals who qualify for mandatory exemptions and optional exceptions. States expressed concern over having to make such major system changes in a very short timeframe, noting the long lead times typically needed to design, procure, and build new systems. Adding to the challenge will be the need to make key system design and workflow decisions before CMS releases guidance. Another priority many states mentioned is enhancing capabilities to collect and match data from multiple agencies and external sources (e.g., SNAP, Medicaid claims data, state education enrollment data) to reduce the burden on applicants and enrollees for documenting their work or exemption status (Figure 2). However, some states acknowledged that data sharing infrastructure is limited and establishing interfaces to accurately share data will take time to put in place. 

According to several states, other policy changes in the law, including restrictions on eligibility for lawfully present immigrants, 6-month eligibility redeterminations for expansion enrollees, and limits to retroactive Medicaid coverage, also require significant systems changes. Increasing this complexity, some states also mentioned the challenge of aligning different work requirements across Medicaid, SNAP, and TANF, as well as having to make complex systems and eligibility policy changes for SNAP as required by the new law. These changes may be particularly complicated for states with integrated Medicaid and SNAP eligibility systems. In addition, a few states noted that they are currently involved in multiyear IT systems projects and that it will be challenging to complete those projects successfully while also simultaneously adding new systems redesigns.  All of these systems challenges are further exacerbated by limited state staff capacity and financial resources.

According to many states, the short implementation timeline means they will need to move quickly with key systems changes and policy decisions before clear federal guidance is available. States have just over a year to prepare to implement work requirements on January 1, 2027, and have less than a year before they will need to begin outreach to notify individuals of the new requirements in September 2026 (Figure 3). The law directs the Secretary of HHS to issue an interim final rule on implementing work requirements by June 1, 2026, leaving little time between when the guidance is released and when outreach begins. For many states, this short timeline intensifies the pressure to move quickly with system upgrades, particularly given the often lengthy vendor procurement process, and other key decisions. However, several states emphasized the risks of moving forward in the absence of clear guidance, noting that if state decisions are not aligned with the federal expectations, the resulting rework would increase costs and potentially delay meeting important deadlines. Some states described the implementation deadline as unrealistic, noting that it increases the risk of errors that could lead to unnecessary coverage losses. In light of these risks, some states said early and clear guidance from CMS would be helpful, especially on issues such as the definition of medical frailty and other exemptions or the permissibility of self-attestation that could affect systems decisions.

A small number of states explicitly mentioned interest in the option for states to pursue good faith waivers to delay implementation of work requirements, noting that additional guidance would be needed to understand the criteria to obtain a “good faith waiver” and the state application process.

Figure 3

Several states reported workforce challenges, including the need to hire or reallocate staff in anticipation of increased workloads and the need for additional staff training. Many states reported that they will need to hire additional staff or reallocate existing staff to handle increased workloads from verifications, appeals, and enrollee outreach. States also anticipate the need for additional staff training, including training staff across departments and agencies (e.g., SNAP), to ensure eligibility workers understand the new rules and requirements, exemption criteria, and documentation requirements. A few states called out the additional workforce resources that will be necessary to conduct comprehensive and multi-modal outreach efforts and respond to the expected increase in enrollee inquiries.

A few states noted that staff are already managing major multiyear projects that are underway, such as eligibility system modernization projects, forcing staff and leadership to juggle competing demands. Similarly, limited staff capacity could cause spillover effects and result in less timely eligibility determinations for enrollees not subject to work requirements.

Even with implementation funds and federal matching payments for administrative costs, some states cited the increased costs of implementing work requirements as a concern. A number of states explicitly mentioned the fiscal implications tied to systems changes, hiring additional staff, and conducting outreach to enrollees. One state noted that, given the tight timeframe coupled with the enormity and complexity of the new requirements tied to system changes, interagency agreements, state rulemaking, and enrollee outreach, states may need to move forward on multiple parallel tracks, which could increase implementation costs and the risk for errors. Contracts for systems changes or new components are costly, and states noted that accelerated timelines often increase those costs. Some states also reported that the increased costs will further strain already constrained state budgets. In addition, some states discussed that new financial penalties for error rates in SNAP and Medicaid may potentially affect how they move forward with system changes. The new law provides $200 million in funding to states for systems development, with states able to access federal matching funds. The federal government generally provides 50 percent of the funds for administrative activities but pays for up to 90 percent of certain administrative costs, including for certain IT system changes.

While not asked directly about enrollee issues, several states cited concerns for applicants and enrollees, including anticipated confusion over the new requirements and possible coverage losses. States anticipate confusion among enrollees and applicants about the new work requirements and listed educating individuals among the challenges they will face. While states noted the importance of outreach to consumers, a few reported that efforts to move forward with communication and outreach without federal guidance could result in more enrollee confusion if CMS guidance does not align with state assumptions related to documentation requirements, exemption definitions, or data matching. Some states also expressed concern over possible coverage loss stemming from the accelerated implementation timeline and indicated that they plan to investigate ways they can minimize any coverage losses. One state noted particular concerns for enrollees in rural areas with limited internet access and those with jobs with fluctuating work hours.

Adolescents face unique challenges accessing reliable health information and education. This has become even more difficult in a post-Roe landscape where publicly available health information on government webpages continue to be suppressed, federal and state level reproductive policy changes and legal challenges persist, and mis- and dis- information about health—particularly, reproductive health issues like abortion and contraception—are widespread. Over the last several years, teen pregnancy and birth rates have fallen; however, rates of sexually transmitted infections (STIs) remain high among teens and young adults. Many schools and community groups have adopted a broad spectrum of programming that ranges from curricula aimed at reducing teen pregnancy and STI rates—which can include topics like contraception as well as broader aspects of adolescents’ reproductive health such as forming healthy relationships—to curricula that emphasize abstinence and avoidance of all sexual risks. The content of these programs varies considerably and is shaped by policies at the school, district, state, and federal level.

Over the years, Congressional, legislative, and executive agency actions have both hindered and expanded access to federal funding for comprehensive sex education depending on the administration and partisanship. Most recently, the Trump administration’s executive order officially recognizing only two sexes—male and female—has far-reaching implications for the LGBTQ+ community and education. The proclamation has affected how federal agencies run health programs, collect data, share health information, and will also shape whether state and local sex education programs supported by federal grants like the Teen Pregnancy Prevention program, will continue to qualify for support. 

This issue brief reviews the major sex education models and funding streams that are most commonly used, highlights state policies on sex education, and summarizes what is known about the impact of these programs and policies on teen sexual behavior and health outcomes.

Sources of Sex Education

Adolescents receive sex education information from a wide array of sources including informal channels such as parents, friends, online or social media, or through formal settings such as school or health care professionals. For example, while most teens learn about condoms—the most commonly used contraceptive among teens—in formal educational settings and through their parents—a 2024 study on youth health access found, not surprisingly, that many teens also get their contraceptive information from friends and online through websites and social media.

Most youth use social media and nearly half are online almost constantly on platforms like YouTube, TikTok, and Instagram. While social media can be an effective tool to spread reliable and trustworthy health-related information to young people, it can and has been used to spread mis- and dis-information. Anecdotally, a growing number of young women have reportedly stopped using hormonal oral contraceptive pills after viewing TikTok content describing negative experiences with the pill.

Parents can be another source of information for adolescents. Most female adolescents say they discussed “how to say no to sex,” birth control methods, and STIs/STDs with their parents. Most male adolescents discussed STIs/STDs with their parents (55%), but fewer than half say they discussed any other sex education topics. While most adolescents aged 15 to 19 say they received some sex education from their parents, one in five adolescents say they did not (Figure 1).

Parental involvement also plays a role how or whether students receive sex education from schools. Most states (45 states and D.C.) have “opt-in” and/or “opt-out” policies for sex education, meaning that parents can choose to remove their student from classes that include sexual content or must approve their participation in classroom education on the topic. Nonetheless, many teens say they received sex education in formal settings such as schools and churches. Most reported getting information about STIs/STDs and HIV/AIDS prevention and “how to say no” to sex in a formal setting (Figure 1). Far fewer adolescents, however, say they learned about birth control methods or waiting until marriage in classroom settings. Fewer than half of adolescents say they received education on where to get birth control.

State Policies and Sex Education Models:
Impact on Youth Reproductive Health

Most states and D.C. require some aspect of sex education be taught in public schools (Figure 2). However, the decision-making process over implementation of sex education varies on both the state and local level, resulting in different interpretations of program models and content, as well as the timing and overall quality of the sex education provided to children and adolescents. 

In most states (43), local school districts and sometimes individual schools develop their own curricula, but state-level officials play a role in curriculum development in seven states (North Carolina, Rhode Island, Iowa, Minnesota, South Carolina, Texas, and Washington). State-level education officials—such as state boards, state departments, state commissioners, and superintendents—develop educational content standards that, depending on state statutes, are either required or recommended in curriculum development. Funding availability may also determine if and how schools implement sex education.

There are two main approaches towards formal sex education: sexual risk avoidance and comprehensive sex education. These categories are broad, and the content, methods, and targeted populations can vary widely between programs.

Sexual Risk Avoidance Education: The foundation of these programs is to emphasize the benefits of abstaining from non-marital sexual activity as a means of reducing risky behaviors, STIs, and teen pregnancy.

• Abstinence-only: In general, abstinence-only programs teach adolescents how to voluntarily refrain from non-marital sexual activity, and stress that abstinence is the only safe and effective way to prevent unintended pregnancy and STIs. They generally do not discuss contraceptive methods or condoms other than to emphasize their failure rates.
• Abstinence-plus: Some programs stress abstinence as the best way to prevent pregnancy and STIs and include information on contraception. Other abstinence-plus programs emphasize safer-sex practices and often include information about healthy relationships and lifestyles.

Comprehensive sex education: These programs include medically accurate, evidence-based information about both sex and abstinence, contraception, and the use of condoms to prevent STI transmission. Comprehensive programs also usually include information about healthy relationships, sexual consent, sexual orientation, and gender identity.

Proponents of sexual risk avoidance education (SRAE) argue that teaching abstinence to youth will delay teens’ first sexual encounter and will reduce the number of partners they have, leading to a reduction in rates of teen pregnancy and STIs. However, there is a limited body of evidence to support that SRAE programs have these effects on the sexual behavior of youth, and some studies have documented no impacts on pregnancy and birth rates.

There is, however, considerable evidence that comprehensive sex education programs can be effective in delaying sexual initiation among teens and increase the use of contraceptives, including condoms, among sexually active youth. Studies repeatedly show that comprehensive sex education is associated with lower pregnancy rates, more consistent condom use, and lower rates of unprotected sex. Despite this growing evidence, 34 states require schools to stress abstinence, or emphasize that abstinence is preferable to sexual activity, if sex education is taught.

Research also shows that comprehensive sex education programs improve students’ health outcomes and understanding, knowledge, and attitudes of a wide range of health topics, including gender and sexual diversity, violence, and healthy relationships.

Gender and Sexual Diversity

For years, research has found that comprehensive sex education with LGBTQ-inclusive curricula is associated with reduced victimization among sexual minority youth as well as reduced adverse mental health outcomes among all youth. Despite the demonstrated effectiveness in improved outcomes, instruction on sexual orientation and/or gender identity (SOGI) is required in only nine states and D.C. and optional in 13 states—if sex education is taught (Figure 3). Among these states, eight require instruction to portray non-heterosexual and non-cisgender identities as unacceptable. In other states, there is either no explicit policy or instruction on SOGI is banned altogether.

Historically, heterosexual and cisgender identities have been the central focus of sex education, but in recent years, advocates have increasingly called for more representation of sexual and gender diversity in curricula. In 2021, approximately 3 in 10 (29.6%) LGBTQ+ students who received any kind of sex education reported that LGBTQ+ representation was positive, while over half (57%) reported receiving sex education without “LGB or transgender/non-binary” topics.

Although sex education content is typically determined by states and school districts, recent actions by the Trump administration may further impede access to SOGI instructional material. In January 2025, the administration issued an executive order officially recognizing only 2 sexes: male and female, which does not account for the complexity of sex and human beings and excludes recognition of gender expansive identities including transgender and non-binary people. In July 2025, the U.S. Department of Health and Human Services (HHS) issued a policy notice restricting the use of federal funding from the Teen Pregnancy Prevention (TPP) program, meaning grantees of this program would no longer receive funding if their educational materials reflected “radical gender ideology” and encouraged “discriminatory equity ideology.” These actions have raised concerns about how gender and sexual diversity may be included in sex education, if at all.

Concern over educational content, particularly sex education, has long been a point of contention for parents. Parents may choose to opt their children out of sex education classes due to personal or religious beliefs. In recent years, parental involvement has evolved into a national debate over how much influence parents should be allowed to have when it comes to their student’s education and personal health decisions, with some calling for a “Parental Bill of Rights.” This movement has gained traction in several politically conservative states and is increasingly reshaping educational curricula in school districts across the nation.

Healthy Relationships and Violence

It is not uncommon for adolescents to experience dating violence (DV). An estimated 1 in 12 teens in 2021 report experiencing physical DV, which can include being hit, injured with an object or weapon, or slammed into something. An estimated 1 in 10 teens report experiencing sexual DV, which includes unwanted physical advances such as kissing, touching, or forced intercourse. Some adolescents, such as female teens and those who identify as LGBTQ, report higher rates of physical and sexual dating violence.

Studies have long shown that comprehensive sex education is associated with lower rates of DV among adolescents and increased knowledge, attitudes, and skills to form healthy relationships. School-based programs that teach DV and intimate partner violence (IPV) prevention have been proven to reduce both DV and IPV among students, with some programs yielding long-term outcomes. Research also shows that comprehensive school-based programs improve students’ knowledge and attitudes towards forming healthy relationships and improve communication skills and intention/consent. 

Schools are required to have curricula on healthy relationships in 34 states and D.C., but fewer states (17 and D.C.) are mandated to teach students on sexual consent (Figure 4).

Abortion Knowledge

Abortion is a safe and common medical service that an estimated one in four women will obtain at some point in their life. In 2022, 9% of abortion patients were younger than 20-years-old.

Since the Dobbs decision, 12 states have banned abortion, and another 6 states have implemented early gestational limits between 6 and 12 weeks. The confluence of mis- and dis- information, litigation on abortion access, and policy changes at the state and federal level has made accessing reliable and accurate information on abortion difficult for many. Small shares of 15- to 17-year-olds say they received information about abortion in the past year, primarily through sources like social media, websites, and friends. Fewer than four in ten say they are confident in their ability to get information about abortion services or methods.

Abortion is largely absent from school curricula, including in sex education class. Only California, Colorado, and D.C. require sex education programs to teach about abortion. Six other states—Arkansas, Connecticut, Louisiana, Michigan, Mississippi, and South Carolina—restrict what can be taught regarding abortion. One third of states discourage abortion curricula in sex education programs, and five of these states—Idaho, Indiana, Kansas, North Dakota, and Tennessee—require schools to show students a medically inaccurate depiction of fetal development beginning at fertilization, known as the Meet Baby Olivia video. These “Baby Olivia” laws have been introduced in several other states, including Ohio, West Virginia, and Missouri.

Federal Funding Streams for Sex Education

Although decisions regarding if and how sex education is taught are ultimately left to individual states and school districts, Congress and the executive branch also play a role by providing financial support to programs that focus on preventing adolescent pregnancy. Federal dollars go toward programs that focus on sexual risk avoidance education/abstinence education, comprehensive sex education, or a combination of the two approaches.

Four major programs provide the majority of federal dollars towards education on teen pregnancy prevention: the Teen Pregnancy Prevention (TPP) program, the Personal Responsibility Education Program (PREP), the Title V Sexual Risk Avoidance Education Program (SRAE), and the General Departmental (GD) Sexual Risk Avoidance Education (SRAE) program. These programs primarily fund school programs but can also fund churches, juvenile justice programs, and other entities. Other federal programs, including the Centers for Disease Control and Prevention’s (CDC) Division of Adolescent School Health (DASH), also provide varying amounts of funding toward sex education initiatives each year.

The four major programs differ in several ways, including by scope and educational approach (Table 1). Notably, the TPP program and PREP use evidence-based, comprehensive sex education models proven to be effective at preventing teen pregnancy, whereas the two SRAE programs stress refraining from nonmarital sexual activity and have historically focused on abstinence-only approaches. While grant announcements and notices from the two SRAE programs required grantees to adopt “evidence-based” interventions and “medically accurate” curricula during the Biden administration, Project 2025’s agenda—which the Trump administration has been closely mirroring in their recent policy proposals—specifically notes that “any [sex education program] lists with ‘approved curriculum’ or so-called evidence-based lists should be abolished.”

The TPP program, established in 2010, is a national grant program that funds organizations to educate adolescents in making healthy decisions to improve their sexual and reproductive health outcomes. The large majority of TPP program participants were served in school settings, and some participants were served in community-based settings, or other places such as juvenile justice centers and clinics. Compared to the pre-pandemic era, larger shares of participants in recent years were served in technology-based and virtual settings.

Also established in 2010, PREP awards grants to state agencies to educate adolescents on both abstinence and contraception, focusing on those who experience homelessness, are in foster care, live in areas with high teen birth rates, or are from minority groups. Like the TPP program, most of the implemented programming took place in school settings during school hours, with a smaller share taking place after school.

Formerly known as the Title V Abstinence Education Grant program established in 1996, the Title V SRAE awards funds to grantees focused on sexual risk avoidance or abstinence until marriage. The GD SRAE program similarly funds programs that exclusively teach abstinence, with a focus on teens experiencing homelessness, teen pregnancy, and domestic violence. An evaluation of the two SRAE programs show that most SRAE programming took place in middle and high schools (74%), while others took place in settings such as community-based organizations, faith-based institutions, and detention centers.

The four programs are appropriated different amounts of federal funding per fiscal year (FY). The TPP program is a discretionary grant program and received $101 million in FY2024. PREP and the Title V SRAE programs, both mandatory spending programs, received $75 million each. The GD SRAE program, a discretionary grant program, received $35 million in funding in FY2024. Of the $286 million of federal dollars dedicated to teen pregnancy prevention programs from these four programs, 38% goes towards programs that focus exclusively on sexual risk avoidance/abstinence education, which has been demonstrated to be less effective at preventing pregnancy in adolescents compared to comprehensive sex education (Figure 5).

Funding for the SRAE programs had only small fluctuations between FY2019 and FY2024 ($100-$110 million), but this has more than doubled since FY2014 when the programs were funded at $51.4 million in total (Figure 6). Federal funding towards comprehensive sex education, on the other hand, has remained steady in the last 10 years, ranging between $170.6 and $176 million.

While federal funding for sex education and other reproductive health services for adolescents has been appropriated by Congress for decades, there have been recent efforts from the Trump administration to cancel or withhold these federal dollars from grantees. The Trump administration recently announced the cancellation of a $12.3 million PREP grant to California after state officials refused to revise curricula in compliance with the president’s 2025 executive order on gender. This executive order refuted the concept of “gender ideology,” and—without scientific evidence—argued that only two sexes exist. Shortly after, the administration sent letters to 46 additional states and territories demanding that all references to “gender ideology” (generally taken to mean reference to transgender people) be removed from PREP sex educational materials. States that fail to comply may also risk losing federal funding like California’s program. As of September 2025, 16 states and D.C. have sued HHS, alleging that these current grant conditions are unlawful, unconstitutional, and harmful to gender diverse youth.

Similar policy changes were also made to the TPP program earlier this summer, but the Trump administration’s actions were blocked by a judge in October 2025. Previous iterations of the House Republican’s 2026 funding bill would have likewise eliminated funding for the TPP program altogether and increased funding for abstinence-only education by $5 million. These actions mirror previous efforts to dismantle comprehensive sex education in the classroom from the first Trump administration, which unsuccessfully tried to cut over $200 million in federal funding for TPP program grantees. The first Trump administration also shifted the TPP focus and funding away from comprehensive sex education and towards abstinence-only education.

The recent policy proposals from the second Trump administration closely align with Project 2025’s agenda, which claims comprehensive sex education promotes sex, prostitution, and abortion. Project 2025’s agenda prioritizes curricula that emphasizes sexual risk avoidance, arguing that any other program should not be eligible for federal funding. President Trump’s proposed 2026 discretionary budget, which is both a funding request to Congress and documentation of administrative priorities, would eliminate support for the TPP program as well as the GD SRAE program, claiming that both are “duplicative” of PREP and Title V SRAE, respectively.

Each year, there are multiple infectious disease outbreaks (defined as the occurrence of cases of disease in excess of what is expected) throughout the world. Some of these become severe and have global and domestic implications, including, most notably, the COVID-19 pandemic, but also the 2002-2004 SARS outbreak in China and eventually 28 other countries and the 2014 Ebola outbreak in West Africa. Since outbreaks are an ongoing reality and threat to human health, understanding the current status and scope of global disease outbreaks is important for stemming further spread to other geographic areas and populations, providing advice to travelers, and identifying the types of medical countermeasures that might be needed. While historically the U.S. government has played a key and often lead role in responding to outbreaks throughout the world, particularly in low- and middle-income countries, understanding the extent of outbreaks takes on added importance now, given changes made by the Trump administration. These changes include reduced funding, reductions in the number of U.S. staff supporting international outbreak response efforts, and elimination of some offices and functions, actions which collectively have diminished current U.S. government capacity to respond to outbreaks at home and abroad, even as experts believe another costly pandemic may strike the world within 25 years. There may a renewed opportunity, however, to mitigate some of these risks with the release of the State Department’s new U.S. global health strategy, which includes global health security as one of its three pillars.

To better understand the current outbreak landscape around the world, and because there is no single database of all global outbreaks, we analyzed data from multiple official sources to develop a snapshot of the number, type, and location of disease outbreaks, with human transmission, that have occurred thus far in 2025. Based on this analysis, we identified more than 100 outbreaks, including some that have affected multiple countries and impacted large populations. This finding is broadly similar to an estimate from a prior study of the 1996-2023 period that identified an average of 108 outbreaks that occurred each year. However, given that 2025 is not yet over, there could be more outbreaks in the weeks and months ahead. Our finding is also likely an underestimate due to delays in reporting and other factors (see methods for more information).

Findings

Our analysis finds that thus far in 2025 (see Table 1):

• We identified 102 reported disease outbreaks with human transmission in 66 countries as of October 10, 2025; this is likely an undercount due to delays in reporting, the multiplicity of outbreaks that may be captured in this analysis as a single outbreak (e.g., the United States has identified 44 distinct outbreaks of measles as of Oct. 7 this year), and other factors.
• These outbreaks are due to 20 different infectious diseases spanning a wide variety of disease types (including respiratory, vector-borne, food or waterborne, and direct contact infections) and including avian influenza (H5N1), Chikungunya, cholera, Ebola, Marburg, measles, mpox, Nipah, Rift Valley fever, yellow fever, and Zika, among others.
• There is significant geographic variation in the occurrence of outbreaks by region. The greatest number of reported outbreaks have been in sub-Saharan Africa (33 countries), followed by the Western Hemisphere (15), East Asia and the Pacific (7), South and Central Asia (6), and the Near East (Middle East and North Africa, 5).
• A third of these countries (23) countries have experienced more than one outbreak this year, often of varying scales. For example, the Democratic Republic of the Congo has reported outbreaks of anthrax, cholera, cVDPV1, Ebola virus disease, mpox, and one outbreak due to an unexplained cause but described now as “acute febrile illness,” and the United States has reported outbreaks of dengue – which is not endemic in the continental U.S. but has caused localized transmission from travel-related imported cases – and measles, which had long been considered eliminated in the U.S., a status that is now at risk due to increasing cases.
• Outbreaks have ranged in size, as measured by number of cases as well as the number of affected countries. For example, a single case of Chapare hemorrhagic fever constituted an outbreak in Bolivia, while the largest this year has been the cholera outbreak across 34 countries, which has approached a half million cases and been declared a health emergency by the World Health Organization.
• Similarly, the number of deaths resulting from these outbreaks has also varied widely, as some virulent infectious diseases have led to high mortality, such as deaths among all suspected cases of Marburg virus disease (10 of 10) and deaths among two-thirds of suspected cases of Ebola virus disease (43 of 64). Others have resulted in few deaths but spread rapidly and can have important health impacts, such as chikungunya and mpox.

Table 1

Disease Outbreaks, 2025

With the onset of the COVID-19 pandemic, deaths due to drug overdose among adolescents more than doubled, primarily driven by the synthetic opioid, fentanyl. National survey data show that while the percent of adolescents (ages 12-17) with a past year substance use disorder decreased from 2021 to 2024, the share of adolescents with a past year opioid use disorder remained stable over the same period. Additionally, less than one-third of adolescents with a past year opioid use disorder reported receiving any treatment. In recent years, many schools have incorporated measures to address the fentanyl crisis. Further, nearly 7 in 10 adolescents reported receiving substance use disorder and prevention education at school and over 480,000 adolescents received substance use treatment at school in 2023, underscoring how schools can serve as an access point for these services among youth.

This analysis examines trends in drug overdose deaths among adolescents from the latest data from the Centers for Disease Control and explores the steps public schools took in the 2024-2025 school year to combat drug overdose due to fentanyl by drawing upon survey data from the School Pulse Panel.¹ The School Pulse Panel is a study by the National Center for Education Statistics and the U.S. Census Bureau that surveys schools monthly on a variety of topics, including drug overdose prevention services.

Total drug overdose death rates among adolescents sharply increased alongside the COVID-19 pandemic, before slowing in 2023; with the fastest increases in these deaths seen among children of color (Figure 1). In 2019, 1.1 per 100,000 adolescents (or 282 adolescents total) died by drug overdose, before increasing to 2.8 in 2022 (or 721 adolescents total). Although there has been a recent decline, drug overdose death rates remain higher than pre-pandemic rates (1.7 in 2024 or 441 adolescents total). White adolescents continue to account for the largest share of adolescent drug overdose deaths (50% in 2024); however, Black and Hispanic adolescents have experienced the fastest increase in these deaths in recent years.

Among public schools in the 2024-2025 school year, nearly 3 out of 4 public school administrators reported that some or all of their staff are trained to recognize a drug overdose. Specifically, 30% of administrators reported that all of their teachers and staff are trained and 44% of administrators reported that some of their teachers and staff are trained (Figure 2). However, 16% of administrators reported that none of their staff are trained.

Fifty-two percent of public schools reported offering fentanyl education to students in the 2024-2025 school year using several methods (Figure 3). The most common type of fentanyl education is provided through classroom instruction (30%), followed by school assemblies (22%) and events held for school families (22%).

Seventy-seven percent of public schools reported storing naloxone – a nasal spray to reverse opioid overdose – on campus (Figure 4). In light of the fentanyl crisis, measures were taken to improve access to naloxone. An analysis of large school districts across the U.S. found that by 2023, there was an increase in the percent of districts stocking naloxone; however, some districts did not have plans to do so. Currently, several states, including Illinois, Rhode Island, Washington, and Arkansas, have mandates for schools to stock naloxone. California’s Department of Health Care Services provides naloxone for free to schools through an application process. Many other states recommend or at least allow schools to stock naloxone on campus and administer if needed.

Some schools are more likely than others to store naloxone – for example, schools with fewer students of color were more likely to store naloxone than schools with a higher population of students of color (Figure 4). Specifically, schools in which less than 25% of students were students of color were more likely to store naloxone than schools in which more than 75% of students were students of color (79% vs. 71%). This is consistent with research that suggests that compared to White people, Black people may have limited access to naloxone. Similar trends in schools storing naloxone were seen with schools in lower poverty neighborhoods compared to higher poverty neighborhoods (78% vs. 72%), middle and high schools compared to elementary schools (82% and 89%, vs. 69%), and schools with 1,000 or more students compared to smaller-sized schools.   

Among school staff, nurses, security personnel, and administrative staff are most likely to be trained to administer naloxone in the case of an emergency (Figure 5). In the 2024-2025 school year, 1% of public schools reported that naloxone was administered at school or during a school event.

1. The School Pulse Panel utilizes a random stratified sample of the Common Core of Data, a universe of public schools. This stratified sample includes public and public charter schools, schools with magnet programs, alternative schools, special education schools, and vocational schools. Approximately 4,000 schools were included in the sample for the 2024-2025 school year. Approximately 1,600 schools responded to the March survey – findings from this survey are included in this brief. There has been some variation in the number of schools that respond each month. While school principals are the initial point of contact to complete the survey, they may invite other school and district staff to assist with completion. Published data is weighted and adjusted to account for non-response. ↩︎

The Affordable Care Act (ACA) Marketplace Open Enrollment season starts November 1, 2025 in most states. The premiums insurers charge are increasing. And, with enhanced premium tax credits set to expire at the end of the year, out-of-pocket premiums are expected to increase drastically. Additionally, changes to Marketplace enrollment and eligibility rules in this year’s budget reconciliation law and in the Trump Administration’s “Marketplace Integrity and Affordability” regulation (program integrity regulation) include other changes to open enrollment.

Here are the eight things to know for the 2026 Open Enrollment period.

1. Enhanced premium tax credits are set to expire.

Currently, enhanced premium tax credits provide extra financial assistance to ACA Marketplace enrollees who are eligible for subsidies, and make middle-income enrollees (those with incomes above four times the poverty level) eligible for financial help, unlike in the original ACA. These enhanced tax credits will expire at the end of the year unless Congress acts to change the law.

Looking ahead to 2026, the future of the enhanced premium tax credits remains uncertain. Without enhanced tax credits, KFF estimates that subsidized Marketplace enrollees’ out-of-pocket premium payments will be 114% higher, on average.

These increases in enrollees’ monthly premium payments will vary from person to person. If enhanced tax credits expire, people with incomes below four times poverty ($62,600 for an individual, $128,600 for a family of four) will continue to receive a tax credit, but the amount of financial help they receive could be significantly less. People with incomes above four times poverty will no longer be eligible for financial help and will be hit by a double whammy of lost tax credits and rising costs from insurers if enhanced tax credits expire. A KFF calculator allows users to input a zip code, income, and age to see 2026 premium payments with or without an extension of the enhanced tax credits.

While these tax credits do not expire until the end of 2025, if Congress does not extend the subsidies at least a few days before the enrollment window opens, Marketplace enrollees will log on and see these higher premiums as soon as open enrollment starts on November 1. The Congressional Budget Office projects significant coverage losses, and insurers expect younger, healthier enrollees to be more likely to drop their Marketplace plans, which will in turn push premium increases even higher than they otherwise would be. 

2. Marketplace enrollees could have to repay more at tax time.

Currently, an enrollee who makes less than 400% of the federal poverty level and whose income ends up being higher than they had estimated at the time they signed up must repay some of the excess premium tax credit on their taxes the following year, up to a repayment limit.

Starting in the 2026 plan year, due to changes made in the 2025 budget reconciliation law, tax credit repayment limits will be eliminated, and Marketplace enrollees will be expected to repay the full amount of any excess tax credits when they file their 2026 taxes.

Additionally, if enhanced premium tax credits expire, and the “subsidy cliff” returns for people with incomes over four times the federal poverty level, enrollees who start out with expected incomes below four times poverty but end up with actual incomes above four times poverty will have to pay back the entire tax credit, which could be thousands or even tens of thousands of dollars.

Marketplace enrollees, who are often self-employed, shift, or gig-workers, tend to have high income volatility, potentially leaving them subject to significant repayments. If an enrollee experiences a mid-year change in their expected earnings, they can notify the Marketplace to adjust their coming months’ tax credit to minimize repayments at tax time.

3. Program changes might result in more Marketplace enrollees selecting higher deductible plans.

With the expiration of enhanced premium tax credits, many ACA Marketplace enrollees facing higher monthly premium payments next year may decide to switch from a silver or gold plan to a bronze or catastrophic plan to keep a lower premium payment, but the tradeoff would be a much higher deductible.

The Trump administration announced plans to expand access to catastrophic health plans on the Federally Facilitated Marketplaces and some State-Based Marketplaces. Citing a “significant rise in health insurance premiums,” CMS will streamline the process for individuals to receive a “hardship exemption” if they are not eligible for premium tax credits or cost sharing help because their projected income is below the federal poverty level or above 250% of the federal poverty level. These individuals will be allowed to enroll in a catastrophic plan where they are available on or off the Marketplace. These plans have lower premiums than bronze plans but have an annual deductible of $10,600 for an individual or $21,200 for a family in 2026.

Additionally, the budget reconciliation law included changes to health savings account (HSA) rules that will automatically treat all Marketplace bronze and catastrophic plans as high-deductible health plans (HDHP), making them eligible to be paired with an HSA. In the past, not all bronze or catastrophic plans with high deductibles available on the Marketplace could be used with an HSA. This change could increase use of HSAs in the Marketplace. The budget reconciliation law also now allows all HDHPs with an HSA to cover telehealth and other remote services before the enrollee meets the deductible.

4. Premium tax credit eligibility will be eliminated for certain lawfully present immigrants.

Currently, lawfully present immigrants with incomes below 100% FPL who are ineligible for Medicaid because they have been in the U.S. less than five years are eligible for subsidized ACA Marketplace coverage.

Starting in 2026, lawfully present immigrants who are not eligible for Medicaid due to their immigration status and who have incomes below 100% FPL will no longer be eligible for subsidized Marketplace coverage.

Additionally, starting in 2027, the budget reconciliation law further restricts eligibility for subsidized Marketplace coverage only to certain lawfully present immigrants. These individuals include:

• Lawful permanent residents
• Cuban and Haitian entrants, as defined in section 501(e) of the Refugee Education Assistance Act of 1980
• Any lawful residents living in the U.S. under the Compact of Free Association

This means other lawfully present immigrants such as refugees, asylees, and survivors of human trafficking will no longer be eligible for premium tax credits starting in 2027.

5. Consumers with lower incomes can no longer sign up year-round.

In recent years, consumers with estimated incomes less than or equal to 150% of the federal poverty level (FPL) ($23,475 for an individual, and $48,225 for a household of 4 in 2026) could enroll in Marketplace coverage at any point throughout the year, not just during Open Enrollment, in what was called the “low-income special enrollment period” (low-income SEP). Insurers had expressed concern that this year-round opportunity to enroll in and switch plans was leading to adverse selection as lower-income people could wait until they were sick to sign up or switch to a more generous plan.

Starting August 25, 2025, a consumer can no longer qualify for an SEP just because they have a low income. This change, included in the program integrity regulation, will expire at the end of plan year 2026; however, a provision of the budget reconciliation law that takes effect in 2026 will effectively end the low-income SEP permanently. This change will prohibit most consumers from receiving a premium tax credit if they enroll in Marketplace coverage through an income-based SEP, such as the low-income SEP.

6. Loss of federal Navigator funding could make it harder for some consumers to find help during open enrollment.

In February 2025, the Centers for Medicare & Medicaid Services (CMS) announced a 90% reduction in federal Navigator funding, reducing funding from $100 million last year to $10 million for the 2026 plan year. This cut will significantly reduce the resources available to nonprofit and community organizations that help consumers with navigating coverage changes, selecting plans, and applying for premium tax credits, among other services. For example, Navigators in the state of Louisiana were awarded $2,467,867 last year. This year they were awarded $250,000. In North Carolina, funding was reduced from $7,434,368 in 2025 to $750,000 in 2026.

While agents and brokers have facilitated an increasing number of enrollments for HealthCare.gov, unlike Navigators, agents and brokers are financially compensated by private insurers for enrolling people in plans. Recent Department of Justice indictments have involved allegations that some brokers have fraudulently enrolled consumers or switched their Marketplace coverage to obtain commission payments from insurance companies.

7. Deferred Action for Childhood Arrivals (DACA) recipients will be unable to sign up for Marketplace coverage.

A Biden administration regulation from 2024 allowed DACA recipients to enroll in Marketplace or Basic Health Program (BHP) coverage and access premium tax credits and cost-sharing reductions.

As of August 25, 2025, due to the Trump Administration program integrity rule, DACA recipients are no longer eligible for Marketplace coverage, premium tax credits, cost-sharing reductions, or BHP coverage in states that operate one. No DACA recipients can enroll after that date, and, in most states, those already enrolled in Marketplace coverage lost this coverage effective September 30, 2025.

8. Several planned regulatory changes to ACA Marketplace coverage have been temporarily blocked by a federal court.

The Trump Administration issued a program integrity rule that makes substantial changes to Marketplace enrollment processes and eligibility for premium tax credits, aimed in part at reducing fraudulent enrollment. These changes were scheduled to go into effect for the 2026 plan year. However, many of these changes have been temporarily halted by a federal court in Maryland.

In a case called City of Columbus et. al v. Kennedy, plaintiffs question the authority of the Trump Administration to make many of these changes, alleging that the Administration either exceeded their authority under the ACA or failed to make the case that these new eligibility and enrollment restrictions were warranted. The court granted a preliminary injunction in August blocking the implementation of several parts of the program integrity rule, including additional paperwork requirements for certain consumers to verify their income to be eligible for premium tax credits. Also, the court temporarily blocked a requirement that returning Marketplace enrollees who would otherwise be automatically reenrolled into a zero-premium plan pay a new five-dollar monthly premium until they actively reenroll. A list of the stayed provisions is available here.

It is expected that this case (and a related one) will take several months to be resolved, so consumers may not see these stayed provisions in effect soon, if at all.

Assistance with fertility care, a stated priority of President Trump, is an urgent need for many people. Rarely considered a “medically necessary” health service by health plans, only a minority of employers offer fertility benefits; and IVF is typically never covered by Medicaid or Medicare. The nationally representative KFF Women’s Health Survey finds that one in eight (13%) women ages 18 to 49 say they or their partner needed fertility assistance services at some point. While there are many obstacles to receiving fertility care, cost is by far the single largest barrier. Among those who reported needing fertility services at some point, 12% say they did not receive these services with cost cited as the leading reason.

During the 2024 campaign, Donald Trump pledged to make IVF free, and many have been waiting for the Administration to fulfill this promise. Following an executive order earlier this year, the October 16th White House announcement proposes to offer a discount on certain drugs that are used in IVF treatments through a new government website, TrumpRx.gov, and to develop additional options for employers to voluntarily offer assistance with fertility and family formation costs for their workers and their dependents. The impact of this plan, however, will be limited to either those covered by an employer that opts to cover these benefits or those who will be able to get discounts through the TrumpRx website once it is fully operational in 2026 and who can afford to pay the other costs associated with IVF that are not being made available at lower prices.

What are the features of Trump’s announcement on IVF?

The White House announcement focused on reducing the cost of some IVF drugs and clarifying options for employers to offer standalone fertility benefits for their employees and their dependents.  Here are some key takeaways about the Trump IVF plan:

IVF drug costs:  The Trump Administration says it will decrease the price of IVF drugs, Gonal-F, Ovidrel, and Cetrotide. People who use TrumpRx.gov will be connected to manufacturers who will sell them the drugs directly. This is based on a deal that the Administration made with the manufacturer, EMD Serono, to provide their medications to patients at Most Favored Nation (MFN) pricing, which would tie drug prices to the lowest price paid in a set of other developed nations. It is difficult to know precisely what the cost savings for IVF drugs specifically will be, both because of uncertainty around exactly what the MFN price level will be, and because the TrumpRx website is not yet operational. CMS estimates that women can save up to $2,200 per cycle of fertility drugs as a result of this deal on drugs that often cost over $5,000. While any reduction in the price of IVF drugs could be helpful, these are just a few of the many drugs that individuals may take throughout their IVF treatment. Gonal-F and Ovidrel are gonadotropins used to stimulate the ovaries and Cetrotide is a GnRH antagonist that prevents premature ovulation. Other medications involved in IVF cycles are oral contraceptive pills to control the timing of the menstrual cycle, as well as drugs that help prepare the uterine lining for implantation, stimulate egg growth, and prevent infections prior to embryo implantation. IVF treatment plans are very individualized to the person and not everyone going through IVF uses these specific discounted drugs. There are currently websites that already offer self-pay patients with discounts on fertility drugs, so the impact of the TrumpRx discount may depend on how it compares to existing discount programs. The White House announcement also states that the FDA will include a lower cost fertility drug in the initial round of recipients for the National Priority Review Voucher program, and that the review timeline will be expedited.

Fertility benefits: The administration states that they have created a new benefit option that makes it easier for employers to offer stand-alone fertility benefits–should they choose to. However, the pathway for these benefits was originally created in 1996 as part of the federal Health Insurance Portability and Accountability Act (HIPAA), which established the categories of “excepted benefits.” The Trump announcement does not create a new benefit category, rather it clarifies by explicitly stating that employers can offer fertility benefits under two subtypes of excepted benefits. Some employers have already been offering standalone fertility benefits without this level of regulatory specificity. In recent years, a number of companies, such as Carrot Fertility, Maven, and Progeny, have been established to offer such a product. Employers who offer comprehensive health insurance can use these programs to extend fertility benefits to their workers using a “group coverage” health reimbursement account (HRA) which allows employers to decide how much they want to spend on these benefits and does not have a federal spending cap. The White House plan clarifies that employers can use the following additional approaches to extend fertility benefits to their workers:

• Independent, non-coordinated excepted benefit: Employers can currently offer standalone benefits for some specific services such as coverage for only a specified disease (such as cancer-only policies) and hospital indemnity insurance. The Trump announcement clarifies employers can voluntarily choose to also offer standalone insured fertility benefits, regardless of whether the employer also offers comprehensive health insurance. The Administration intends to do future rulemaking that would allow employers to offer standalone “self-insured” fertility benefits.  A freestanding fertility plan, however, would be of limited utility to people who are currently uninsured for fertility care unless it is offered along with comprehensive insurance that covers prenatal care and other costs associated with childbirth. The range and costs of services that such a plan might cover could be as comprehensive or narrow as the employer defines since it is an optional benefit. 
• Limited excepted benefits: These plans include “excepted benefit health reimbursement accounts” (HRAs) that reimburse employees for their out-of-pocket fertility expenses, but employer contributions are capped at $2,150 for these accounts. This could be an option for employers who want to offer fertility benefits but want to limit their financial exposure to this relatively small amount, as it would only cover, on average, one -tenth of the cost of one IVF cycle. This might also include an Employee Assistance Program that provides coaching and navigator services related to fertility benefits. The Trump Administration is proposing future rulemaking to expand the ways employers can provide fertility benefits as limited excepted benefits, but do not outline these options in the announcement.  

What will be the impact of Trump’s IVF plan?

While many people are not insured for IVF, without a subsidy, mandate or some type of employer incentive, the President’s proposal is not likely to make a significant dent to the current gaps in access to IVF services,  as it essentially offers a discount for a limited set of drugs and clarifies that employers have pathways to offer a limited benefit without running afoul of ACA and HIPAA regulations. For people who lack coverage for IVF services, the discount on drugs through TrumpRx.gov could lower out of pocket costs for people who rely on those drugs as part of their treatment plan, but alone it does not address the majority of IVF costs, such as egg retrieval and embryo transfer.

The President’s announcement also encourages employers to offer IVF and other fertility benefits, but there is no mandate, nor are there any federal subsidies nor new tax incentives to encourage employers to offer these benefits to their workers. To implement a new mandate or tax incentive, Congressional action would be required. Employers already have the option to offer fertility benefits either as part of their insurance plan or as a standalone benefit. The KFF Employer Health Benefits Survey finds that one in four (27%) larger employers (200 or more workers) offers IVF coverage to their workers as do half (53%) of employers with at least 5000 workers. These benefits can vary greatly and may not cover the full cost of an IVF cycle, which on average ranges from $15,000 to $20,000, and many individuals struggling with infertility may need more than one IVF treatment cycle. 

Private insurance coverage for IVF has grown over the past decade, particularly as more states have enacted laws requiring plans in their state to cover services. These laws vary widely in scope and who is eligible for benefits. Some are limited to those who have a diagnosis of infertility, which effectively excludes single individuals and same sex couples. The White House announcement does not address any of these limitations. State laws, however, do not apply to self-funded plans, which cover about two-thirds (67%) of workers with employer-based insurance.

The plan also does not address gaps in fertility coverage faced by the nearly 16 million reproductive age women who are currently enrolled in Medicaid. Even with a discount through the TrumpRx website for some medications, the costs of the rest of IVF-related services would be prohibitive for most people on Medicaid who must have a low income to qualify for the program. A 2020 review of Medicaid programs conducted by KFF found that the vast majority of state programs did not cover fertility services, and among those who had limited coverage, no state provided comprehensive IVF services to Medicaid enrollees.

What are the chances for greater expansion of assistance with IVF costs and coverage?

IVF moved to the policy spotlight right after a 2024 ruling of the Alabama Supreme Court categorized embryos created through IVF as “unborn children”, bringing media attention to the potential implications of fetal personhood laws, which give rights to embryos. Fetal personhood is embedded in some state abortion bans and a variety of other public policies. The language is also widely promoted in conservative circles. For example, the Project 2025 blueprint refers to embryos as “aborted children” and opposes research using embryonic stem cells (which can be obtained through the IVF process). Many influential conservative groups, including the Southern Baptist Convention and Catholic Church, expressly oppose IVF.

This announcement comes at a time when the Trump Administration has laid off the staff of the Centers for Disease Control Division of Reproductive Health, including those who worked on the Assisted Reproductive Technology Surveillance team that ran the National Assisted Reproductive Technology (ART) Surveillance System, which collected data from assisted reproductive technology clinics in the U.S. and calculated and reported success rates for each clinic to monitor clinic outcomes. More recently, the majority of staff at the Office of Population Affairs under which the administration had proposed starting an Infertility Training Center was also let go. It is not clear what staff are left at HHS or CDC to track the provision of infertility treatment and to regulate the services.

To assist all people with coverage who want or need fertility care as the President promised during his campaign, Congress would need to approve a new law to either require or subsidize fertility and IVF coverage. In 2024, Congressional bills that would have established a national right to IVF failed as a result of opposition from nearly all Republican Senators. In May 2025, Representative Lauren Underwood introduced the Health Coverage for IVF Act of 2025, which would require small and non-group plans to offer comprehensive fertility coverage including IVF, but there has been no congressional movement on this bill to date.

Enrollment in Medicare Advantage, the private plan alternative to traditional Medicare, has increased steadily over time. The growth in enrollment has been accompanied by an increase in the number of Medicare Advantage plans, with the average beneficiary having the option to choose among 42 plans in 2025, including 34 with prescription drug coverage. Most Medicare Advantage insurers use provider networks, along with other tools, such as prior authorization, to help manage utilization and lower costs. While these practices may contribute to insurers’ ability to offer extra benefits and reduce cost sharing, they may also impose barriers to care by restricting choice of physicians, hospitals, and other providers, introducing additional complexity in comparing and choosing plans, and creating potential for disruption in care arrangements for patients when their hospitals and physicians are no longer in-network.

Despite the wide range of Medicare coverage options available, there are limited decision-support tools for beneficiaries wishing to compare Medicare Advantage provider networks to each other and to traditional Medicare. While Medicare beneficiaries say that physician availability is an important factor in selecting their coverage, it can be challenging to assess which physicians are in-network across all available plans. In 2025, as with prior years, the Medicare Plan Finder did not include Medicare Advantage provider network information. Beneficiaries have been directed to each plan’s website to obtain information about the provider network, and typically, the network directories are not available in a uniform, easy-to-compare format. Further compounding the problem, these directories are often inaccurate. As of October 2025, in advance of the 2026 plan year, CMS will post provider directory information on the Plan Finder using information aggregated by a third party, and beginning in 2027, Medicare Advantage insurers will be required to submit provider information directly to CMS for publication online.  

To understand how much provider networks vary across Medicare Advantage plans, this brief examines the share of physicians available to Medicare Advantage enrollees as a share of physicians available to traditional Medicare beneficiaries, by county, plan characteristics, and physician specialties, using 2022 Medicare Advantage provider directories. (See Methods.) The analysis finds wide variation in network breadth across plans and compared to traditional Medicare The size of a Medicare Advantage plan’s network does not necessarily indicate whether it includes enough physicians with the right expertise who are available when patients need care, or whether those physicians are accepting new patients, though smaller networks increase the chances that enrollees pay more for going out of network or experience some disruption in their care arrangements.

Key Findings:

• Medicare Advantage enrollees were in a plan that included just under half (48%) of all physicians available to traditional Medicare beneficiaries in their area in 2022, on average. Narrower networks limit which doctors, specialists, and other health care providers are available to Medicare Advantage enrollees, unless they are willing and able to pay more to go out-of-network. Narrower networks can also be disruptive for patients who need to switch doctors or hospitals to stay within the network for their care.
  • For the one-fifth of Medicare Advantage enrollees in plans with the narrowest network, two out of three physicians available to beneficiaries in traditional Medicare in their area were out-of-network.
  • Conversely, for the one-fifth of Medicare Advantage enrollees in plans with the broadest networks, fewer than one-third of physicians available to traditional Medicare beneficiaries were out of their plan’s network.
• The breadth of Medicare Advantage networks varied widely across counties. Among the 30 counties with the largest Medicare Advantage enrollment, the share of physicians available to Medicare Advantage enrollees as a share of physicians available to traditional Medicare beneficiaries ranged from an average of 18% in San Diego, CA to an average of 58% in Pima, AZ (Tucson). This variation across geographic areas means that some Medicare Advantage enrollees have more choice among health care providers than others.
• In counties where larger shares of the population were people of color, a smaller share of physicians available to traditional Medicare beneficiaries were in-network, on average, than in other counties (37% vs 52%).
• Even within the same county, physician networks often varied widely across plans. One third (32%) of all Medicare beneficiaries lived in a county where at least one plan had less than one-quarter of physicians available to traditional Medicare beneficiaries and at least one plan included at least two-thirds of physicians available to traditional Medicare beneficiaries, though these variations are difficult for beneficiaries to decipher and not obvious when potential enrollees are comparing their Medicare coverage options.
• The share of physicians available to Medicare Advantage enrollees varied by specialty. Generally, larger shares of outpatient medical and surgical specialists were in plan networks than primary care physicians, with as many as 72% of ophthalmologists available to traditional Medicare beneficiaries in plan networks compared to only 55% of primary care physicians, on average.
• Medicare Advantage plan quality star ratings were not correlated with the breadth of the physician network. Though star ratings were intended to help beneficiaries choose a plan that best meets their needs, they do not convey the information needed for potential enrollees who prioritize the breadth of the provider network. 

Medicare Advantage Enrollees had Access to About Half of the Physicians Available to Traditional Medicare Beneficiaries.

Traditional Medicare beneficiaries may see any physician who participates in Medicare, as long as the physician is taking new patients. According to a separate KFF analysis, just 1% of non-pediatric physicians have formally opted out of the Medicare program nationwide, and the vast majority of office-based physicians accept new Medicare patients. In contrast, enrollees in Medicare Advantage must see providers who participate in their plan’s network or potentially pay higher cost-sharing. On average, Medicare Advantage enrollees were in a plan that included about half (48%) of physicians available to traditional Medicare beneficiaries in their area in 2022 (Figure 1).

Some physicians are substantially less likely to participate in a Medicare Advantage network, such as hospital-based emergency medicine doctors and anesthesiologists. When these providers deliver certain services, such as care in an emergency room or anesthesia during surgery at an in-network facility, patients will not be liable for additional costs because the doctor is out-of-network. If hospital-based physicians are excluded from the analysis, the share of physicians available to traditional Medicare beneficiaries who participate in Medicare Advantage networks increases to 62%, on average. This analysis considers all individual-level physicians who billed traditional Medicare, including hospital-based physicians.  Based on available data is not possible to identify which physicians, under what circumstances, would not lead to higher costs for patients if the physician were out-of-network.

Many Medicare Advantage enrollees were in plans with narrower networks that included substantially fewer physicians. One in five Medicare Advantage enrollees were in plans with 32% or fewer of the physicians serving traditional Medicare beneficiaries. This means that for these Medicare Advantage enrollees, more than two out of three physicians available to traditional Medicare beneficiaries were out-of-network. At the same time, many Medicare Advantage enrollees were in plans with broader networks, with one in five Medicare Advantage enrollees in plans that included at least 63% of the physicians available to traditional Medicare (Figure 1).

The share of physicians included in Medicare Advantage plan networks varied widely across counties.

Medicare Advantage plans are offered at the county level. Like other characteristics of the Medicare Advantage market, such as plan availability, the average breadth of Medicare Advantage plan networks varied widely across counties, ranging from an average of just 15% of physicians available to traditional Medicare beneficiaries in Charles County, MD (outside Washington, D.C.) to 88% of physicians available to traditional Medicare beneficiaries in Redwood, MN (in southern Minnesota).

Among the 30 counties with the largest Medicare Advantage enrollment, the share of physicians included in plan networks ranged from an average of 18% in San Diego, CA, to an average of 58% in Pima, AZ (Tucson).

Just 30 counties are home to more than 20% of all Medicare Advantage enrollees. In these counties, the share of physicians available to traditional Medicare beneficiaries included in plan networks ranged from an average of 18% in San Diego, CA to 58% in Pima, AZ (Tucson). At least half of physicians were in-network in just 10 of these 30 counties. Conversely, in 20 of these 30 counties, fewer than half of all physicians available to traditional Medicare beneficiaries were in-network for Medicare Advantage enrollees, on average (Figure 2).

Counties with relatively larger populations of people of color had smaller Medicare Advantage networks, on average

Medicare Advantage enrolls Black, Hispanic, and Asian and Pacific Islander Medicare beneficiaries at higher rates than White Medicare beneficiaries. Across dozens of measures examined in the literature, people of color, particularly Black Medicare Advantage enrollees, often fare worse than White Medicare Advantage enrollees.

Plans in counties with a disproportionate share of residents who are people of color tended to have narrower networks. More specifically, Medicare Advantage enrollees living in counties with the largest share of people of color had access to just 37% of the physicians available to traditional Medicare beneficiaries, on average, compared with 52% in counties where people of color made up a smaller share of the population (Figure 3).

The differential access to physicians persists when looking only within metropolitan counties (36% vs. 51%), which have narrower networks on average (see below) and often larger populations of people of color.

Counties with a larger number of insurers had smaller physician networks, on average.

In 2022, the average Medicare beneficiary could choose from plans offered by nine firms, and one-quarter of beneficiaries had access to plans from 11 or more firms. On average, Medicare Advantage enrollees in counties where more firms offered plans were in plans with smaller networks. Specifically, Medicare Advantage enrollees in counties with 11 or more firms were in plans that included less than 4 in 10 (39%) physicians available to traditional Medicare beneficiaries in the area, compared to 54% among Medicare Advantage enrollees in counties with five or fewer firms (Figure 4). The share of physicians who were in-network on average was similar when examining all Medicare Advantage enrollees and just those in large counties.

In rural counties, more than half (53%) of physicians available to traditional Medicare beneficiaries were in-network, on average, slightly more than the national average.

A larger share of Medicare beneficiaries living in rural areas get their Medicare coverage through traditional Medicare rather than Medicare Advantage, though enrollment in Medicare Advantage has grown substantially in rural areas in recent years. On average, Medicare Advantage enrollees in rural areas have a slightly larger share of physicians available to traditional Medicare beneficiaries in the network than those in metropolitan areas, 53% compared with 47%. A substantially smaller share of physicians practice in rural areas than in metropolitan areas, so broader networks in rural areas may not translate into better access to physicians.

The size of physician networks varied widely within most counties.

Most Medicare beneficiaries can choose from dozens of Medicare Advantage plans offered in their county. The plans vary across many dimensions, such as premiums, cost sharing, out-of-pocket limits, prescription drug coverage, use of prior authorization, and the availability and generosity of benefits for non-Medicare covered services. Additionally, the breadth of physician networks varies widely.

Nearly two-thirds of Medicare Advantage enrollees lived in a county with at least one plan that had fewer than 25% of physicians available to traditional Medicare beneficiaries in-network and, conversely, at least one plan with nearly two-thirds (64%) of the physicians available to traditional Medicare beneficiaries in-network. Such a large variation in the breadth of physician networks means that plan choice has substantial implications for which doctors someone can see without incurring additional cost-sharing.

Figure 5 shows the share of physicians available to traditional Medicare beneficiaries who are in network for plans offered in the 30 counties with the largest Medicare Advantage enrollment (which represents 23% of all Medicare Advantage enrollment). For example, in Hennepin County, MN (which includes Minneapolis), the share of physicians available to traditional Medicare beneficiaries who were in network ranged from 14% to 88%. In Clark County, NV (which includes Las Vegas) the difference across plans was smaller, but still substantial, ranging from 12% to 43%. 

Some doctors did not participate in any Medicare Advantage plan network. On average, approximately 1 in 7 (14%) physicians who submitted Medicare claims were not included in any Medicare Advantage plan network. A large share of the doctors who do not participate in any Medicare Advantage network are hospital-based physicians, such as emergency medicine doctors and anesthesiologists (21% and 19% of all physicians who are not in any Medicare Advantage network, respectively). While obtaining care from a non-network provider generally results in higher costs for patients, that is not always the case. Specifically, emergency care is covered regardless of the provider’s network status. Additionally, patients are protected against out-of-network charges for certain services provided during a hospital stay or procedure that occurs in a hospital setting, when specific conditions are met, such as when the facility or primary provider (e.g., a surgeon) is in network. Otherwise, beneficiaries who see other types of physicians who are not in any Medicare Advantage plan network would either pay more to maintain continuity of care or need to find a new doctor.

There were differences in the size of Medicare Advantage networks across some Medicare Advantage plan characteristics, but not others.

Medicare Advantage plans with high-quality star ratings did not have larger physician networks.

One of the pieces of information that Medicare beneficiaries have when selecting a plan is the quality star rating. Medicare Advantage plans are rated on a scale of 1-to-5 stars, which reflect performance on a large set of indicators, including customer service, consumer satisfaction, the share of enrollees who receive vaccines and screenings, and management of certain conditions, among others. Both plan availability and enrollment are skewed towards plans with higher stars, with more than 80% of enrollees in this analysis in a plan with at least 4 stars in 2022.

On average, enrollees in plans with 4.5 or 5 stars had a network that included 49% and 43% of physicians available to traditional Medicare beneficiaries, respectively, compared to 51% for plans with 4 stars and 50% for plans with 3.5 stars (Figure 6). While star ratings do not incorporate any measures of network breadth, they are one of the more salient measures available to potential enrollees.

PPOs had broader physician networks, on average, than HMOs.

In recent years, preferred provider organization (PPO) plans have comprised a growing share of the available Medicare Advantage plans. For example, between 2017 and 2025, the share of plans that were local PPOs increased from 24% to 43%. In 2025, more than half of Medicare Advantage enrollees were in HMOs. While PPOs and health maintenance organizations (HMOs) both use provider networks, PPOs have some out-of-network coverage, while typically HMOs do not, except in the case of emergencies. In 2022, just over half (54%) of physicians available to traditional Medicare beneficiaries were in-network in PPO plans, on average, compared with 45% in HMO plans. However, the size of the networks varied, particularly for HMOs, and many included more physicians than the average PPO plan (Figure 7).

On average, Medicare Advantage plans offered by BlueCross Blue Shield affiliates, UnitedHealthcare, and Centene included at least half of the physicians available to traditional Medicare beneficiaries.

The average share of in-network physicians varied across Medicare Advantage insurers. Enrollees covered by UnitedHealthcare and Blue Cross Blue Shield affiliated organizations included 58% and 59% of the physicians available to beneficiaries in traditional Medicare, respectively. Conversely, enrollees in Humana and CVS covered less than half (44% and 46% respectively), on average (Figure 8).

At the same time, there is considerable variation across plans offered by the same insurer. For example, among enrollees in Humana Medicare Advantage plans, 6% percent had 25% or fewer physicians available to traditional Medicare beneficiaries in-network, and 34% had at least half of physicians available to traditional Medicare beneficiaries in-network (data not shown).

In many cases, a single insurer may offer multiple networks in the same area. For example, in Maricopa, AZ (Phoenix), UnitedHealthcare offered 12 plans with 12 different networks, ranging from 37% to 61% of physicians available to traditional Medicare beneficiaries. In Broward, FL (Fort Lauderdale) Humana offered 19 plans with three networks, ranging from 26% to 44% of physicians (data not shown).

The share of physicians included in Medicare Advantage networks ranged across specialties

CMS has network adequacy rules that require Medicare Advantage plans to contract with a certain number of primary care physicians, as well as physicians with specific specialties. Many of the specialties that are included in the network adequacy regulation participate at a higher rate on average than physicians without specific requirements.  Nearly three-in-ten physicians who submitted a Part B claim for a traditional Medicare beneficiary were hospital-based physicians. These physicians were less likely to be included in Medicare Advantage directories  (21%). Hospital-based physicians may have less incentive to participate in Medicare Advantage networks because the services they most frequently provide are likely to be covered regardless of network status. For example, emergency medicine doctors were among the most common types of doctors to not participate in a Medicare Advantage network. When a person receives emergency services, coverage of those services is not subject to network restrictions, so it would not matter that the physician providing the service is not in network.

Generally, Medicare Advantage plans included a larger share of outpatient medical and surgical specialists subject to network adequacy rules than primary care providers, with access ranging from 61% for neurology to 72% for ophthalmology on average (Figure 9).  The specific specialties and distance requirements established by these rules are listed in the Appendix. These physician categories do not represent all physicians or specialists an enrollee may need, but highlight some of the key capabilities that older Americans often require.

An ongoing challenge in assessing network breadth is the lack of up-to-date, reliable data. As detailed in the Methods, this analysis has several limitations: it includes only individual physicians listed in plan directories who submitted at least one Part B claim during the year. “Phantom” providers those in the directory but not actually accepting the plan in the place and specialty listed, can overstate network size, while participating providers missing from directories can make networks appear narrower than they are.

Appendix

Medicare Advantage plans are generally required to include a minimum number of providers across various specialties and facility categories. Within Medicare Advantage network adequacy standards, plans may still include a tiny fraction of the providers working in or near the county. These regulations act as a floor and grant plans considerable latitude. This brief considers the share of available physicians around an enrollee’s home who are listed in their plan’s network directory. Available physicians are those who practice within the county or are within the distance standards specified in the Medicare Advantage network adequacy standards (Table 1).

In total, CMS designates 78 “Large Metro” counties based on their population and population density, and 720 “Metro” counties. For example, Large Metro areas are classified as counties with at least a million people and a population density of at least 1,000 people per square mile, or counties with between 500,000 to 999,999 people and a population density of at least 1,500 people per square mile, or counties with a population density of at least 5,000 people. The county classifications follow the definitions used in the Medicare Advantage network adequacy rules (Table 3-1). Most Medicare Advantage enrollees live in one of these urban county-designations, including 29% in “Large Metro” counties and 53% in “Metro” counties.