UNFPA Funding and Kemp-Kasten: An Explainer

Name: U.S. Funding for UNFPA, FY 1985 - FY 2025
Creator: KFF

Published: Apr 17, 2026

Editorial Note: Originally published in April 2017, this resource is updated as needed to reflect the latest developments.

Key Points

On May 8, 2025, the Trump administration invoked the “Kemp-Kasten amendment” in order to withhold FY 2025 funding for the United Nations Population Fund (UNFPA, the lead U.N. agency focused on global population and reproductive health); the same determination was made during President Trump’s first term. FY 2025 funding for UNFPA was expected to total $32.5 million in core support and potentially millions more for other project activities.
While under current law any U.S. funding withheld from UNFPA is to be made available for other family planning, maternal health, and reproductive health activities, Congress rescinded (permanently canceled) FY 2025 funding appropriated for UNFPA as part of a broader foreign aid rescission package requested by the President. Although Congress again appropriated $32.5 million in core support for UNFPA for FY 2026, it is expected that President Trump will again withhold the funds from the organization.
The Kemp-Kasten amendment is a provision of U.S. law, first enacted by Congress in 1985 and included in appropriations language annually, that states that no U.S. funds may be made available to “any organization or program which, as determined by the president of the United States, supports or participates in the management of a program of coercive abortion or involuntary sterilization.”
Kemp-Kasten has often been used, as determined by presidents along party lines, to withhold U.S. funding to UNFPA. While framed broadly, Kemp-Kasten was originally intended to restrict funding to UNFPA specifically, after concerns arose about China’s population control policies and UNFPA’s work in China; to date, it has only been applied to UNFPA. Evaluations by the U.S. government and others have found no evidence that UNFPA directly engages in coercive abortion or involuntary sterilization in China, and more generally, UNFPA does not promote abortion as a method of family planning or fund abortion services.
Kemp-Kasten has been used to withhold funding from UNFPA in 20 of the past 41 fiscal years.

What is the Kemp-Kasten Amendment?

The Kemp-Kasten amendment, first enacted in 1985, is a provision of U.S. law that states that no U.S. funds may be made available to “any organization or program which, as determined by the [p]resident of the United States, supports or participates in the management of a program of coercive abortion or involuntary sterilization.”¹ It was the congressional response to a Reagan administration decision in 1984 to temporarily withhold some funding from UNFPA and to begin conditioning its funding on assurances that the agency did not engage in or provide funding for abortion or coercive family planning. This policy change was made after concerns arose about whether UNFPA supported China’s coercive population policies.² It was announced by the Reagan administration at the 2nd International Conference on Population in 1984, in conjunction with the “Mexico City Policy.”³ The Mexico City Policy originally required foreign NGOs to certify that they would not “perform or actively promote abortion as a method of family planning” with non-U.S. funds as a condition of receiving U.S. family planning assistance; the Trump administration recently expanded this restriction to encompass more funding, more organizations, and more policy areas (see the KFF explainer on the policy).

Box 1: The Original Language Regarding UNFPA in the U.S. Policy Statement at the 2nd International Conference on Population, 1984

“With regard to the United Nations Fund for Population Activities [UNFPA], the US will insist that no part of its contribution be used for abortion. The US will also call for concrete assurances that the UNFPA is not engaged in, or does not provide funding for, abortion or coercive family planning programs; if such assurances are not forthcoming, the US will redirect the amount of its contribution to other, non-UNFPA, family planning programs.”⁴

What U.S. funding does Kemp-Kasten apply to?

Kemp-Kasten applies to all funds appropriated under the State and Foreign Operations appropriations act as well as any unobligated balances from prior appropriations. This includes all funding provided to the State Department and the now-dissolved USAID, which, in turn, includes the vast majority of U.S. global health funding.⁵

When has Kemp-Kasten been in effect?

The Kemp-Kasten amendment has been in effect for 41 years. First enacted in 1985,⁶ its language has been included in the State and Foreign Operations appropriations act every fiscal year since then. (Although the provision is present in current law, language similar to Kemp-Kasten was also included in President Trump’s presidential memorandum reinstating the Mexico City Policy on January 24, 2025.⁷) While Congress has kept the amendment in place annually, it remains up to the president to determine whether or not to invoke Kemp-Kasten as a reason to withhold funding from an organization (see below).⁸

Though Kemp-Kasten technically could apply to funding provided to any organization or program (including U.S. NGOs, non-U.S. NGOs, multilateral organizations, and foreign governments), the U.S. government has issued determinations about only one organization, UNFPA, thus far. The U.S. played a key role in the launch of UNFPA in 1969 and was, until 1985, the largest government donor to the agency.⁹ However, the U.S. has withheld funding from UNFPA due to presidential determinations that it violated Kemp-Kasten as often as it has provided funding since 1985 (in 20 of the past 41 fiscal years, to date), and in some years, funding was also withheld from UNFPA based on other provisions of the law, such as the dollar-for-dollar withholding requirement¹⁰ (see below). These determinations have been made along party lines with only one exception – the first year of President George W. Bush’s administration (see Figure 1 and Table 1).

How much funding does the U.S. provide to UNFPA?

In 2024, the U.S. was the largest donor to UNFPA, having provided 17% of all contributions. Total funding from the U.S. for UNFPA was $231.8 million – $30.5 million in core support and $201.3 million for other projects – in FY 2024 (see Box 2).¹¹ See Figure 1 and Table 1 for historical funding data.

Box 2: Core and Non-Core Support to UNFPA

According to UNFPA, contributions to core resources allow the agency to support any activity, while contributions to non-core resources – funds earmarked for a specific purpose – may only be used for the stated project or activity.¹² Governments provide contributions toward UNFPA core and non-core resources on a voluntary basis, since UNFPA does not assess a required contribution from governments.

U.S.
Funding for UNFPA, FY 1985 - FY 2025 (Bar Chart)

Kemp-Kasten and U.S. Funding for UNFPA (Core Support Only), FY 1985–FY 2027 (Table)

How is a determination about Kemp-Kasten made?

By law, it is up to the president to determine whether any organization or program should be ineligible for funding due to a violation of the Kemp-Kasten amendment (in practice, this authority has generally been delegated to the State Department). In most recent years, legislative language has also specified that this determination must be: 1) made no later than six months after the date of enactment of the law that includes the provision and 2) accompanied by the evidence and criteria used to make the determination.¹³

Most recently, on January 24, 2025, at the beginning of his second term, President Trump directed the Secretary of State to begin the process of making a Kemp-Kasten determination by taking “all necessary steps,” and in May 2025, the United States again invoked Kemp-Kasten to withhold funding from UNFPA. These determinations are usually made after the annual appropriations process is completed. For example, in 2017, the Trump administration’s determination was made on March 30, 2017, at the six month mark after the passage of the FY 2017 continuing resolution appropriations bill and was accompanied by a two-page justification memorandum.¹⁴

Has there ever been evidence that UNFPA supports coercive abortion or involuntary sterilizations?

To date, there has been no evidence that UNFPA supports coercive abortion or involuntary sterilizations. Several evaluations by the U.S. government (including one by an assessment team sent to China by the State Department in 2002) as well as other groups, such as the British All-Party Parliamentary Group on Population, Development, and Reproductive Health (in 2002) and the Interfaith Delegation (in 2003), have found no evidence of direct engagement by UNFPA in such activities in China or elsewhere.¹⁵ In addition, UNFPA does not promote abortion as a method of family planning or fund abortion services.¹⁶ In years when a determination has been made that UNFPA violated Kemp-Kasten, the U.S. government has stated that the determination was based on its conclusion that UNFPA support to or partnering with the Chinese government for other population and reproductive health activities was sufficient grounds for invoking the amendment to withhold funding. In the March 30, 2017, determination by the Trump administration, for example, the justification memorandum stated that: “While there is no evidence that UNFPA directly engages in coercive abortions or involuntary sterilizations in China, the agency continues to partner with the NHFPC [China’s National Health and Family Planning Commission] on family planning, and thus can be found to support, or participate in the management of China’s coercive policies for purposes of the Kemp-Kasten amendment.”

What other legislative requirements apply to U.S. funding for UNFPA?

In addition to Kemp-Kasten, there are several other provisions of law that Congress has enacted in recent years to set conditions on U.S. funding for the agency.¹⁷ These provisions:

require UNFPA to keep U.S. funding to the agency in a separate account, not to be commingled with other funds;
prohibit UNFPA from funding abortion;
prohibit UNFPA from using any U.S. funds for their programming in China;
reduce the U.S. contribution to UNFPA by one dollar for every dollar that UNFPA spends on its programming in China (“dollar-for-dollar withholding”); and
in some years, state that not more than half of funding designated for the U.S. contribution to UNFPA is to be released before a particular date, which varies by fiscal year (this provision is not currently in effect).

What happens to funding that is withheld from UNFPA?

For several years, including FY 2025 and FY 2026, Congress has required that funding withheld from UNFPA be reallocated to U.S. global family planning, maternal, and reproductive health activities. (However, despite this requirement, the withheld FY 2025 contribution to UNFPA will not be reallocated to those purposes since shortly after the Trump administration made its Kemp-Kasten determination that year, Congress rescinded, or permanently canceled, the funding as part of a larger foreign aid rescission package requested by the President.¹⁸) The enactment of this provision first affected reallocation of FY 2002 funds.¹⁹ It is now typically included in the State and Foreign Operations appropriations act each year.²⁰

U.S. Congress, FY 2017 Consolidated Appropriations Act (P.L. 115-31), May 5, 2017; KFF, The U.S. Government and International Family Planning & Reproductive Health: Statutory Requirements and Policies, fact sheet. ↩︎
Congressional Research Service (CRS), The U.N. Population Fund: Background and the U.S. Funding Debate, RL32703, July 2010; “Policy Statement of the United States of America at the United Nations International Conference on Population (Second Session), Mexico City, Mexico, August 6-14, 1984,” undated. ↩︎
“Policy Statement of the United States of America at the United Nations International Conference on Population (Second Session), Mexico City, Mexico, August 6-14, 1984,” undated; United Nations Division of Economic and Social Affairs/Population Division, “United Nations Conferences on Population,” webpage, undated, http://www.un.org/en/development/desa/population/events/conference/index.shtml. ↩︎
“Policy Statement of the United States of America at the United Nations International Conference on Population (Second Session), Mexico City, Mexico, August 6-14, 1984,” undated. ↩︎
KFF, The U.S. Congress and Global Health: A Primer; and KFF U.S. Global Health Budget Tracker, available at: https://www.kff.org/interactive/u-s-global-health-budget-tracker/. ↩︎
Via FY 1985 supplemental appropriations, per CRS, The U.N. Population Fund: Background and the U.S. Funding Debate, RL32703, July 2010. ↩︎
Specifically, in this memorandum, President Trump stated, “I further direct the Secretary of State to take all necessary actions, to the extent permitted by law, to ensure that U.S. taxpayer dollars do not fund organizations or programs that support or participate in the management of a program of coercive abortion or involuntary sterilization.” ↩︎
However, after UNFPA ended its program in China in 1997 but then began a new program there in 1999, this resulted in Congress withholding funding from UNFPA that year. ↩︎
CRS, The U.N. Population Fund: Background and the U.S. Funding Debate, RL32703, July 2010; PAI, Why the United States Should Maintain Funding for UNFPA, May 2015. ↩︎
In FY 1999, Congress prohibited UNFPA funding in response to the initiation of a new UNFPA program in China (this was unrelated to Kemp-Kasten), and in some other years when the U.S. made a contribution to UNFPA, UNFPA’s China program meant some UNFPA funding was withheld under the “dollar-for-dollar withholding” provision. ↩︎
KFF analysis of data from State Department, U.S. Contributions to International Organizations: Reports to Congress, available at: https://www.state.gov/u-s-contributions-to-international-organizations https://bidenwhitehouse.archives.gov/briefing-room/presidential-actions/2021/01/28/memorandum-on-protecting-womens-health-at-home-and-abroad/https://www.whitehouse.gov/briefing-room/presidential-actions/2021/01/28/memorandum-on-protecting-womens-health-at-home-and-abroad/. ↩︎
UNFPA, Annual Report 2013, 2014. ↩︎
Typically included in annual State and Foreign Operations appropriations since FY 2008, including in FY 2017 under the terms of the continuing resolution. CRS, The U.N. Population Fund: Background and the U.S. Funding Debate, RL32703, July 2010; KFF analysis of appropriations bills. ↩︎
State Department: Letter to Bob Corker, Chairman, Committee on Foreign Relations, from Joseph E Macmanus, Bureau of Legislative Affairs, State Department, dated April 3, 2017, and accompanying “Determination Regarding the ‘Kemp-Kasten Amendment,’” dated March 30, 2017, and “Memorandum of Justification for the Determination Regarding the “Kemp-Kasten Amendment,” undated. Available online (follows the article) at: https://www.buzzfeednews.com/article/jinamoore/the-us-wont-give-any-more-money-to-the-un-population-fund. ↩︎
CRS, The U.N. Population Fund: Background and the U.S. Funding Debate, RL32703, July 2010. ↩︎
UNFPA, “Frequently Asked Questions,” webpage, updated January 2025, http://www.unfpa.org/frequently-asked-questions#abortion. ↩︎
KFF, The U.S. Government and International Family Planning & Reproductive Health: Statutory Requirements and Policies, fact sheet. ↩︎
KFF analysis of Congressional Appropriations Bills. ↩︎
“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,” per KFF, The U.S. Government and International Family Planning & Reproductive Health: Statutory Requirements and Policies, fact sheet. ↩︎
The activities to which Congress directs reallocated funds varies by fiscal year; in FY 2003, for example, reallocated funding supported assistance to vulnerable children and victims of trafficking in persons. CRS, The U.N. Population Fund: Background and the U.S. Funding Debate, RL32703, July 2010. ↩︎

What Are the Recent Trends in Employer-Based Health Coverage?

Authors: Gary Claxton, Matthew Rae, and Aubrey Winger

Published: Apr 17, 2026

Employer-sponsored health insurance is the largest source of health coverage for people under 65, covering 165.6 million people in March 2025, but its reach is uneven. About four in five (80%) adult workers under age 65 work for an employer that offers health insurance to at least some employees—a share that falls to 60% for lower-paid workers. Additionally, some workers do not enroll even when coverage is offered: employer-sponsored health insurance covered only 22.5% of people under 65 with incomes below 200% of poverty—compared to 82.5% of people with incomes of at least 400% of poverty.

This analysis examines who among people under 65 have employer coverage and which workers are offered and eligible for coverage at their jobs, using the Annual Economic and Social (March) Supplements of the Current Population Survey.

The analysis of part of the Peterson-KFF Health System Tracker, an online information hub dedicated to monitoring and assessing the performance of the U.S. health system.

Americans’ Challenges with Health Care Costs

Authors: Grace Sparks, Lunna Lopes, Alex Montero, Marley Presiado, and Liz Hamel

Published: Apr 16, 2026

Editorial Note: This brief was updated on April 16, 2026, to include the latest KFF polling data. It was originally published on December 14, 2021.

For many years, KFF polling has found that the high cost of health care is a burden on U.S. families, and that health care costs factor into decisions about insurance coverage and care seeking. These costs also rank as the top financial worry for adults and their families. This data note summarizes recent KFF polling on the public’s experiences with health care costs. Main takeaways include:

Just under half of U.S. adults say it is difficult to afford health care costs, and about three in ten say they or a family member in their household had problems paying for health care in the past 12 months. Hispanic adults, young adults, and the uninsured are particularly likely to report problems affording health care in the past year.
The cost of health care can lead some to put off needed care. About one-third (36%) of adults say that in the past 12 months they have skipped or postponed getting health care they needed because of the cost. Notably three in four (75%) uninsured adults under age 65 say they went without needed care because of the cost.
The cost of prescription drugs prevents some people from filling prescriptions. About four in ten (43%) U.S. adults say they have not taken their medication as prescribed in the past year due to costs. This includes three in ten who say they have taken an over-the-counter drug instead of getting a prescription filled (31%), a quarter (27%) who have not filled a prescription, and one in five (19%) who have cut pills in half or skipped doses of medicine because of the cost. Larger shares of lower-income, uninsured, women, Black, and Hispanic adults report taking these measures.
Health care debt is a burden for a large share of Americans. In 2022, about four in ten adults (41%) reported having debt due to medical or dental bills including debts owed to credit cards, collections agencies, family and friends, banks, and other lenders to pay for their health care costs, with disproportionate shares of Black and Hispanic adults, women, parents, those with low incomes, and uninsured adults saying they have health care debt.
Those who are covered by health insurance are not immune to the burden of health care costs. Almost four in ten insured adults under the age of 65 (38%) worry about affording their monthly health insurance premium and large shares of adults with employer-sponsored insurance (ESI) and those with Marketplace coverage rate their insurance as “fair” or “poor” when it comes to their monthly premium and to out-of-pocket costs to see a doctor.
Notable shares of adults say they are worried about affording medical costs such as the cost of health care services (including the cost of health insurance and out-of-pocket costs for things like office visits and prescription drugs). About two-thirds of adults say they are either “very worried” (32%) or “somewhat worried” (34%) about being able to afford the cost of health care for themselves and their families. The cost of health care ranks at the top of the list when it comes to things that people worry about affording, followed by food, utilities, and other household expenses.

Difficulty Affording Medical Costs

Many U.S. adults have trouble affording health care costs. While lower income and uninsured adults are the most likely to report this, those with health insurance and those with higher incomes are not immune to the high cost of medical care. Just under half of U.S. adults say that it is very or somewhat difficult for them to afford their health care costs (44%). Uninsured adults under age 65 are much more likely to say affording health care costs is difficult (82%) compared to those with health insurance coverage (42%). Additionally, a slight majority of Hispanic adults (55%) and half of Black adults (49%) report difficulty affording health care costs compared to about four in ten White adults (39%). Adults in households with annual incomes under $40,000 are more likely than adults in households with higher incomes to say it is difficult to afford their health care costs. (Source: KFF Health Tracking Poll: May 2025)

Mirrored bar chart showing shares who say it is easy or difficult to afford their health care costs by total, insurance status, race/ethnicity, and household income.

When asked specifically about problems paying for health care in the past year, about three in ten (28%) adults say they or a family member in their household had problems paying for care, rising to four in ten among Hispanic adults (41%) and young adults ages 18 to 29 (40%). Among those under age 65, six in ten (59%) uninsured adults report problems paying for health care in the past year, about twice the share of insured adults who say the same (30%). (Source: KFF Health Tracking Poll: November 2025)

Single bar showing the percent who say, in the past 12 months, they or a family member living with them had problems paying for health care by total, age, gender, race/ethnicity, household income, and insurance status.

The cost of care can also lead some adults to skip or delay seeking services, with one-third (36%) of adults saying that they have skipped or postponed getting needed health care in the past 12 months because of the cost. Women are more likely than men to say they have skipped or postponed getting health care they needed because of the cost (38% vs. 32%). Adults ages 65 and older, most of whom are eligible for health care coverage through Medicare, are much less likely than younger age groups to say they have not gotten health care they needed because of cost.

Three-quarters of uninsured adults say they have skipped or postponed getting the health care they needed due to cost. Having health insurance, however, does not offer ironclad protection as about four in ten adults with insurance (37%) still report not getting health care they needed due to cost. (Source: KFF Health Tracking Poll: May 2025)

Single bar chart showing percent who say they have skipped or postponed getting needed health care in the past 12 months because of the cost by total, age, gender, race/ethnicity, household income, and insurance status.

Skipping care due to costs can have notable health impacts. Nearly two in ten adults (18%) report that their health got worse because they skipped or delayed getting care. Among adults under age 65, those who are uninsured are twice as likely as those with health coverage to say that their health worsened due to skipped or postponed care (42% vs. 20%). About four times as many adults under age 65 (23%) say their health got worse after skipping or postponing care as adults ages 65 and older (6%), most of whom have Medicare coverage. (Source: KFF Health Tracking Poll: May 2025)

Single bar chart showing the share who say their health got worse because they didn't get care or postponed their care by total, age, and insurance status.

A 2022 KFF report found that people who already have debt due to medical or dental care are disproportionately likely to put off or skip medical care. Half (51%) of adults currently experiencing debt due to medical or dental bills say in the past year, cost has been a probititor to getting the medical test or treatment that was recommended by a doctor. (Source: KFF Health Care Debt Survey: Feb.-Mar. 2022)

Prescription Drug Costs

The high cost of prescription drugs also leads some people to cut back on their medications in various ways. About three in ten adults (31%) say in the past 12 months they have taken an over-the-counter drug instead of getting a prescription filled because of cost concerns, while about a quarter (27%) say they have not filled a prescription and about one in five (19%) say they have cut pills in half or skipped doses of medicine due to cost. Overall, four in ten (43%) adults report taking at least one of these measures in the past year, continuing an upward trend from a third (33%) in 2025 and about three in ten (31%) in July 2023.

Larger shares of adults in households with lower and middle incomes report resorting to these cost-saving prescription medication solutions compared to those with higher incomes. About half of adults in households with annual incomes under $40,000 (52%) or between $40,000 and $90,000 (47%) say they have not taken their medication as prescribed due to the cost in the last year, compared to three in ten adults in households with incomes of $90,000 or more. Uninsured adults under the age of 65 are more likely than their counterparts to also report not taking their medicine as prescribed due to costs (58% compared to 43% of insured adults under age 65). Additionally, half of women (49%) say they have taken any of these prescription medication measures compared to about a third (36%) of men. Over half (55%) of Black adults say the same, compared to half (47%) of Hispanic adults and four in ten White adults. (Source: KFF Health Tracking Poll: March 2026)

Multiple split bars showing the percent who have taken steps to reduce the cost of care including taking an over-the-counter drug instead of getting a prescription filled, not filled a prescription for medicine, or cut pills in half or skipped doses of medicine.

Health Insurance Cost Ratings

Health insurance provides some financial protection, but premiums and out-of-pocket costs can still present a financial burden for many individuals. Overall, most insured adults rate their health insurance as “excellent” or “good” when it comes to the amount they have to pay out-of-pocket for their prescriptions (61%), the amount they have to pay out-of-pocket to see a doctor (53%), and the amount they pay monthly for insurance (54%). However, at least three in ten rate their insurance as “fair” or “poor” on each of these metrics, and affordability ratings vary depending on the type of coverage people have.

Adults who have private insurance through employer-sponsored insurance or Marketplace coverage are more likely than those with Medicare or Medicaid to rate their insurance negatively when it comes to their monthly premium, the amount they have to pay out of pocket to see a doctor, and their prescription co-pays. About one in four adults with Medicare give negative ratings to the amount they have to pay each month for insurance and to their out-of-pocket prescription costs, while about one in five give their insurance a negative rating when it comes to their out-of-pocket costs to see a doctor.

Medicaid enrollees are less likely than those with other coverage types to give their insurance negative ratings on these affordability measures (Medicaid does not charge monthly premiums in most states, and copays for covered services, where applied, are required to be nominal). (Source: KFF Survey of Consumer Experiences with Health Insurance)

Split bar chart showing shares of adults by main insurance coverage who rate specific aspects of their current health insurance as either fair or poor.

Health Care Debt

In June 2022, KFF released an analysis of the KFF Health Care Debt Survey, a companion report to the investigative journalism project on health care debt conducted by KFF Health News and NPR, Diagnosis Debt. This project found that health care debt is a wide-reaching problem in the United States and that 41% of U.S. adults currently have some type of debt due to medical or dental bills from their own or someone else’s care, including about a quarter of adults (24%) who say they have medical or dental bills that are past due or that they are unable to pay, and one in five (21%) who have bills they are paying off over time directly to a provider. One in six (17%) report debt owed to a bank, collection agency, or other lender from loans taken out to pay for medical or dental bills, while similar shares say they have health care debt from bills they put on a credit card and are paying off over time (17%). One in ten report debt owed to a family member or friend from money they borrowed to pay off medical or dental bills.

While four in ten U.S. adults have some type of health care debt, disproportionate shares of lower income adults, the uninsured, Black and Hispanic adults, women, and parents report current debt due to medical or dental bills.

Single bar chart showing the percent who say they have different types of debt due to medical or dental bills for themselves or someone else in their care.

Vulnerabilities and Worries About Health Care and Long-Term Care Costs

At the start of 2026, health care costs are at the top of the list of people’s financial worries, with two-thirds (66%) saying they are at least somewhat worried about affording the cost of health care, including the cost of health insurance and out-of-pocket costs for things like office visits and prescription drugs for themselves and their families. This is larger than the shares who say they worry about affording food and groceries (57%), utilities (57%), housing costs (52%), and gas or other transportation expenses (52%) for their families.

Notably, about nine in ten uninsured adults under age 65 say they are worried about affording the cost of health care (88%), but a large share of insured adults are also worried (68%). Health care costs are at the top of household cost worries across insurance types and partisans. (Source: KFF Health Tracking Poll: January 2026)

Stacked bar chart showing the public's levels of worry when it comes to affording living necessities. Shown among total adults.

Many U.S. adults may be one unexpected medical bill from falling into debt. About half of U.S. adults say they would not be able to pay an unexpected medical bill that came to $500 out of pocket. This includes one in five (19%) who would not be able to pay it at all, 5% who would borrow the money from a bank, payday lender, friends or family to cover the cost, and one in five (21%) who would incur credit card debt in order to pay the bill. Women, those with lower household incomes, Black and Hispanic adults are more likely than their counterparts to say they would be unable to afford this type of bill. (Source: KFF Health Care Debt Survey: Feb.-Mar. 2022)

Split bar chart showing how adults would handle an unexpected medical bill of 0, if they'd be able to pay the bill without going into debt, go into debt to pay the bill, or would not be able to pay the bill.

Among older adults, the costs of long-term care and support services are also a concern. Almost six in ten (57%) adults 65 and older say they are at least “somewhat anxious” about affording the cost of a nursing home or assisted living facility if they needed it, and half say they feel anxious about being able to afford support services such as paid nurses or aides. These concerns also loom large among those between the ages of 50 and 64, with more than seven in ten saying they feel anxious about affording residential care (73%) and care from paid nurses or aides (72%) if they were to need these services. See The Affordability of Long-Term Care and Support Services: Findings from a KFF Survey for a deeper dive into concerns about the affordability of nursing homes and support services.

Employer-Sponsored Health Insurance 101

Published: April 15, 2026

Health Policy 101:

Introduction

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KFF Authors:

Gary Claxton ,

Matthew Rae , and

Aubrey Winger

Introduction

Employer-sponsored health insurance (ESI) is the largest source of health coverage for U.S. residents under age 65. Unlike many other nations, the U.S. relies on voluntary, private health insurance as the primary source of coverage for residents who are not elderly, poor or disabled. Providing health insurance through workplaces is an efficient way of offering coverage options to working families, and the tax benefits of employer-based coverage further enhance its attractiveness. Yet ESI often results in uneven coverage, especially for those with low wages or those working at smaller firms. Overall, 60% of people under age 65, or about 165.6 million people, had employment-sponsored health insurance in 2025. The level of coverage varies significantly with income and other factors, even among working families.

Editorial Note: The estimate for the number of people with employer-sponsored health insurance includes all people under age 65, regardless of whether they report multiple types of coverage. A KFF analysis of the American Community Survey (ACS) found that 154 million people under age 65 are covered by employer-sponsored health insurance in the United States. To produce this estimate, coverage is assigned using a hierarchy, so each person reporting more than one type of insurance is counted under a single category.

What Is Employer-Sponsored Health Insurance?

There are several ways people get private health insurance. One is by purchasing coverage directly from an insurer, often with the help of an insurance agent or through an online platform such as Healthcare.gov. Income-based premium assistance is available under the Affordable Care Act (ACA). This is called individual or non-group health insurance. The second is coverage under a policy or plan offered by a sponsoring group, such as an employer, union or trade association. This is called group health insurance. When an individual is sponsored specifically by an employer (or sometimes jointly by one or more employers and a union or by a group of employers), it is often referred to as employer-sponsored health insurance, or ESI.

The word “insurance” is something of a misnomer here. An employer providing health benefits for workers and their families (“plan enrollees”) can fund them in one of two ways. Employers may purchase a health insurance policy from a state-licensed health insurer, which is referred to as an insured plan. Alternatively, the employer can pay for health care for the plan enrollees directly with its own assets, referred to as a self-funded plan. Employers with self-funded plans often protect themselves from unexpected high claim amounts or volume by purchasing a type of insurance referred to as stop-loss coverage. As discussed below, most ESI plan enrollees are covered by large employers, and most large employers self-fund their health benefit plans.

Another confusing set of phrases used in conjunction with health insurance, including ESI, is “health plan” or just “plan”. The terms can refer to an entity offering coverage (e.g., Aetna) or a particular coverage option offered by an insurer or employer (e.g., the PPO plan option). However, the terms “employee benefit plan” and “plan” have specific meanings in federal law, and invoke several legal obligations for employers when they offer certain benefits to their workers and their family members. Under the Employee Retirement Income Security Act, or ERISA, an employee benefit plan, or plan, is created when a private employer creates a plan, fund or program to provide certain benefits, including health benefits, to employees. ERISA creates a structure of disclosure, enforcement and fair dealing regarding the promises made by employers to enrollees in employee benefit plans. However, ERISA does not apply to the health benefit plans created by public plans or churches, although the word plan is often still used to describe benefits offered in these settings.

ESI plans can be differentiated across several dimensions.

Comprehensive or limited benefits

Employers offer different types of health benefit options to employees. These include comprehensive benefit plans, which cover a large share of the cost of hospital, physician and prescription costs that a family might incur during a year; service-specific benefits, such as dental or vision care plans; and supplemental benefit plans, which may provide a limited additional benefit to enrollees if certain circumstances occur (e.g., $100 per day if hospitalized). The discussion here will be limited to comprehensive benefit plans.

Open or closed provider networks

Health plans contract with hospitals, physicians, pharmacies and other types of health providers to provide plan enrollees with access to medical care at a predetermined cost. Plan enrollees receiving services from one of these providers know that their financial liability is limited by their deductible and other cost-sharing amounts specified in their benefit plan. A closed-network plan is one where, absent special circumstances, an enrollee is only covered if they receive care from a provider in their plan’s network of contracted providers. In an open-network plan, an enrollee still has some coverage if they receive care from a provider not in the plan network, although they will likely face higher cost sharing under their benefit plan, and the provider may ask them to pay an additional amount (known as balance billing). Health maintenance organization (HMO) and exclusive provider organization (EPO) plans are two types of closed network plans. Preferred provider organization (PPO) and point of service (POS) plans are two types of open network plans.

Small and large group markets

Federal and state laws divide ESI into the small group and the large group market, based on the number of full-time equivalent employees (FTEs) working for the employer sponsoring the plan. Federal regulation states that employers with fewer than 50 FTEs are often in the small group market and employers with at least 50 FTEs are in the large group market. However, states have the option to raise the small group market limit to fewer than 100 FTEs. The regulatory requirements for the small and large group markets differ somewhat. Generally, the small group insured market is subject to more extensive rules about benefits and ratings. Large employers are potentially subject to financial penalty under the ACA if they do not offer health insurance coverage meeting certain requirements to their full-time employees.

Are Employers Required to Offer Health Benefits?

The drafters of the ACA intended to provide coverage options to those without access to employer-sponsored coverage without encouraging employers to drop coverage. To achieve this balance, the ACA requires that employers with at least 50 FTEs offer health benefits which meet minimum standards for value and affordability or pay a penalty. The so-called ‘employer mandate’ constitutes two separate penalties.

First, employers are taxed if they do not offer minimum essential coverage to 95% of their full-time employees and their dependent children. This generally requires that employers offer major-medical coverage and not a limited benefit plan. Employers face this penalty when at least one of their employees receives an advance premium tax credit (APTC) to purchase coverage on the health insurance exchange markets or Marketplaces. In 2025, this penalty stipulates that employers will be assessed a tax of $2,900 for each full-time employee after their first 30 employees.

Secondly, employers are penalized if the coverage they offer is not affordable or does not provide minimum value. Plans are considered to meet the minimum value standard if they cover 60% of the health spending of a typical population. In 2025, coverage was deemed to be affordable if the employee premium contribution was less than or equal to 9.02% of their household income. Employers may be charged $4,350 for each employee enrolling in subsidized Marketplace coverage.

Defining what constitutes ‘affordable’ has been the focus of considerable attention in recent years. The Obama administration initially issued rules that workers and their dependents would be considered to have an affordable offer if self-only coverage met the affordability test. With many employers requiring much larger premium contributions to enroll dependents, this meant that as many as 5.1 million people were in households where they had to pay a larger share of their income to enroll in the plan offered by their employers without being eligible for premium tax credits. Recent rules have addressed the so-called “family glitch” by considering the cost of family coverage when assessing affordability. While most large employers offer health benefits, many may encourage spouses and other dependents to enroll in other plans if possible. For more information on eligibility for premium credits see the Affordable Care Act chapter.

Why Is Employer-Sponsored Health Insurance So Dominant?

ESI is by far the most common source of private health insurance. There are two primary reasons for this. The first is that providing health insurance through the workplace is efficient, with advantages relating both to risk management and to the costs of administration. The second is that contributions towards premiums by employers and (in most cases) by employees are not subject to income or payroll taxes, providing a substantial federal and state subsidy towards the costs of ESI.

ESI Efficiencies

When people have choices about whether to buy insurance and the amount of coverage to buy, it is natural that people with the highest need for coverage (e.g., people in poorer health) will be more likely to purchase and be more willing to pay higher prices. This is called adverse selection. If insurers do not address these tendencies, their risk pools will become dominated by a relatively small share of people with the highest needs, and premiums will increase to levels that only make sense for those with very high expected costs.

There are several ways insurers seek to manage the risk profile of potential enrollees to avoid adverse selection. One is by examining the health profile of each applicant, which typically includes the applicant’s health history and pre-existing conditions. This strategy is reasonably effective, but an expensive and time-consuming process. A much lower-cost approach is to provide coverage to groups of people who are grouped together for reasons other than their health or their need for health insurance. Providing coverage through the workplace is a common way of doing this. Mostly, people choose a job because of the work, not because they need health insurance. Therefore, providing coverage through workplaces provides insurers with a fairly normal mix of healthy and less healthy enrollees if certain conditions are met. These conditions include enrolling a large share of the eligible workers in coverage (typically achieved by the employer paying a large share of the cost) and limiting the range of coverage options (to avoid adverse selection among plan types). Further, as the number of employees grows, the ability to predict future costs based on prior experience also increases, reducing the uncertainty in setting premiums for the group. As uncertainty decreases, insurers can reduce what they charge for insuring the group. Overall, the same scenario generally applies to situations where employers choose to offer a self-funded plan. Therefore, these advantages occur regardless of whether an insurer or an employer is taking on the risk.

In addition to the risk management advantages, ESI has many administrative advantages. Providing coverage through a workplace adds many employees to a risk pool through a single transaction, with no need to examine their health in most cases. Employers also provide and collect enrollment information to workers and collect the employee share of premiums, dramatically reducing the number of transactions and reducing the amount of unpaid premiums that typically occur when individuals purchase insurance directly from insurers.

Tax Advantages

Federal and state tax systems provide significant tax preferences for ESI. Generally, wages and other things of value employers provide as compensation to their workers are subject to federal and state taxes. The federal government taxes wages and other forms of income through a series of marginal rates that vary with income and the marital and filing status of the taxpayer. For example, the lowest marginal rate in 2024 for a single taxpayer was 10% for income below $11,601 and the highest rate was 37% for income above $609,350. Additionally, wages are subject to federal payroll taxes to support the Social Security and Medicare programs; employers and employees are each assessed 6.2% of wages up to a maximum wage for Social Security and 1.45% of wages with no wage limit for Medicare. Wages are also subject to state income and payroll taxes for unemployment, which vary considerably.

Unlike wages, ESI provided by employers as part of their compensation to employees is not considered income under the federal income tax code, nor are they considered wages subject to federal payroll taxes (See 26 USC sections 105 and 106). Federal law also permits employers to establish programs that exclude employee contributions towards ESI from these taxes. These exclusions lower the cost of health insurance for employees. For example, just considering the federal tax advantages, if an employee earns annual wages of $100,000, an employer can provide the employee with a $20,000 family policy for an additional $20,000 in compensation. However, if ESI were subject to federal taxes, that same employee would need to earn an additional $27,460 in wages to be able to buy a $20,000 family policy with after-tax dollars, assuming a 22% marginal federal income tax rate and a combined 15.3% payroll tax for Social Security and Medicare. Looked at another way, for this employee, for every dollar that the employer raises the employee’s compensation, the employee can get a dollar of health benefits or just under 63 cents in wages after taxes. State tax laws, which follow federal definitions of income and wages in this situation, further lower the cost of ESI for workers, although the impacts are much smaller.

The exclusion of ESI from federal income tax is a long-standing and somewhat controversial part of federal tax policy, first appearing due to a decision by the War Labor Board in 1942, which in turn allowed employers to use fringe benefits to attract workers during the war. In 1954, ESI exclusion was enacted in the tax code. This tax policy, combined with the risk management and administrative advantages of group coverage, contributed to the rapid growth and continued market dominance of commercial hospital and medical insurance during this period. Detractors of the tax exclusion have argued that it encourages workers to over-consume health insurance by demanding health benefits that are richer than what they would want under a tax-neutral approach (e.g., if health benefits were taxed in the same way as wages). Richer benefits, it is argued, contribute to higher health care costs because people with better insurance use more health care than they otherwise would, since they are not facing the actual costs of care (sometimes called moral hazard). Another criticism is that the income tax exclusion favors higher-paid employees because they have higher marginal tax rates: the effective income tax benefit for a dollar of ESI is only 10 cents for a worker with very low wages but can be up to 37 cents for those with the highest wages.

In contrast, the exclusion of health benefits from payroll taxes has the same dollar benefit for workers at all wage levels (up to the Social Security earnings limit), which results in a higher percentage exclusion (share of wages) for those with lower wages. The tax exclusion was estimated to cost the federal government $312 billion (about $940 per person in the U.S.) in income and payroll taxes in 2022.

Who Is Covered by Employer-Sponsored Health Insurance?

Share of individuals under 65 with employer-sponsored health insurance (ESI), overall and by poverty level, March 2025 (Bar Chart)

As of March 2025, 60.0% of people under age 65, or about 165.6 million people, had ESI. Of these, 85.7 million had ESI from their own job, 73.6 million were covered as a dependent by someone within their household, and 6.3 million were covered as a dependent by someone outside of their household.

A relatively small share of these people also held other coverage at that time: 3.0% were also covered by Medicaid or other public coverage and 0.8% were also covered by non-group coverage.

ESI coverage varies dramatically with income. In March 2025, more than 4 in 5 (82.5%)adults under age 65 with incomes at least 400% of the federal poverty level (FPL) had ESI, compared to 57.2% with incomes between 200% and 399% of the FPL and 22.5% with incomes below 200% of the FPL. ESI also varies with age, as well as other worker characteristics. Among people under the age of 65 in March of 2025, people in younger age groups were less likely than those in older age groups to have ESI, and U.S. citizens were much more likely than non-citizens to have ESI. ESI coverage also varied across race and ethnic categories: compared to non-Hispanic White people, Hispanic people and non-Hispanic people who are Black, American Indian or Alaskan Native, Native Hawaiian or other Pacific Islander, or of mixed race were less likely to have ESI.

Share of individuals under 65 with employer-sponsored health insurance (ESI), by select characteristics, March 2025 (Bar Chart)

How Many Workers Have Access to Employer-Sponsored Health Insurance at Their Job?

For people in working families to have ESI, one or more workers must work for an employer that makes coverage available to them. For workers to access ESI, they need to work for an employer that offers ESI and be eligible to enroll in coverage offered at their job. About 4 in 5 (80.4%) adult workers under age 65 worked for an employer that offered ESI to at least some employees as of March 2025. Most (92.8%) of these workers were eligible for the ESI offered at their job. Overall, in 2025, about 3 in 4 of all workers were eligible to enroll in the ESI offered at their job.

Among workers ages 18-64 years, share working for an offering employer and share eligible for employer-sponsored health insurance (ESI) at job, overall and by poverty level, March 2025 (Grouped Bars)

Both the share of workers working for employers offering coverage and the share of workers eligible for coverage at their jobs vary significantly with income. Among adult workers under age 65, the share working for an employer offering ESI ranged from 60.4% for workers with incomes under 200% of the FPL to 87.5% for workers with incomes at least 400% of the FPL. Similarly, the share eligible for coverage ranged from 48.9% for workers with incomes under 200% of the FPL to 83.4% for workers with incomes of at least 400% of the FPL.

Both working for an offering employer and being eligible for the offered coverage are dependent on a combination of characteristics. As of March of 2025, workers under age 65 working in construction, service, sales, and farm, fishing and forestry-related occupations were less likely to be working for an employer offering ESI and to be eligible for ESI at their jobs. Full-time workers were much more likely to be working for an employer offering ESI and to qualify for coverage at their job. There also was significant variation in offer rates and eligibility within sex, age group, race and ethnicity, and citizenship.

Among workers ages 18-64 years, share working for an offering employer and share eligible for employer-sponsored health insurance (ESI) at job, By occupation and full-time/part-time status, March 2025 (Grouped Bars)

How Many Workers Take Employer-Sponsored Health Insurance Available at Their Job?

Among workers ages 18-64 years eligible for employer-sponsored health insurance (ESI) at work, share covered from own job or other sources, March 2025 (Bar Chart)

Among adult workers under age 65 eligible for ESI at their jobs in March 2025, 75.5% were ESI policyholders. Of those who did not have ESI from their own job, 13.6% were covered by ESI as a dependent, 3.9% had Medicaid or other public coverage, 2.2% had non-group coverage, 1.1% had some other coverage, and 4.1% were uninsured. A small share of workers with ESI from their job also had other coverage at the same time: 2.2% also had Medicaid or other public coverage and 0.7% also had non-group coverage.

What Are the Premiums for Employer-Sponsored Health Insurance?

Average Annual Worker and Employer Premium Contributions for Family Coverage, 2015, 2020 and 2025 (Stacked column chart)

Employer health insurance premiums are the total of what employers and employees pay to providers for health coverage through employment. Generally, premiums are the estimated cost of health spending for the covered population, as well as the administrative costs and fees associated with the plan. Therefore, premiums usually increase when a covered population either uses more health services or the prices for health care increase. In 2025, the average total premiums for covered workers were $9,325 for single coverage and $26,993 for family coverage (for a family of four). Employer contributions to an employee’s health insurance premium are a sizeable share of an employee’s overall compensation (6.9% for private industry as of June 2025).

Premiums varied around these averages due to factors such as the age and the health of the workforce, the cost of the providers included in the network, and the generosity of the coverage. In 2025, 23% of covered workers worked at a firm with an average annual premium of at least $31,500 for family coverage. The robustness of plan offerings varies across firms, with some employers offering generous benefits to attract new employees, while others prioritize more affordable plan options. Some employers sponsor limited-benefit plans, which may cover a limited number of services but have lower costs. The average family premium for covered workers at firms with a relatively large share of lower-wage workers (firms where at least 35% of the workers earn $31,000 annually or less) is lower than at firms with fewer lower-wage workers. On the other hand, the average premiums for single and family coverage are relatively higher in the Northeast and in private not-for-profit firms. There is additional discussion of how premiums vary with firm characteristics here.

During the late 1990s and early 2000s, health insurance premiums grew at a rate considerably faster than inflation and workers’ wages. Recently, the rate of growth has moderated. For example, over the last five years, family premiums have grown 26%, roughly comparable to the rate of inflation (23.5%) and the change in wages (28.6%). When faced with higher premium costs, employers can adjust their plan offerings, increase cost sharing, drop high-cost providers, or change how benefits are covered in other ways.

How Much Do Workers Contribute Towards the Premiums for Employer-Sponsored Health Insurance?

Workers contribute to health insurance in two ways. First, through a premium contribution, which is typically deducted from an employee’s paycheck. Then, secondly, through cost-sharing such as copays, coinsurance, and/or deductibles, which are paid when the employee utilizes services covered by their plan. While all workers enrolled in the plan must pay their premium (or have it paid by the employer), overall cost sharing is higher for workers who use more services.

Workers with health coverage in 2025, on average, were responsible for 16% of the premium for single coverage and 26% of the premium for family coverage. In dollar terms, the average annual contribution for covered workers was $1,440 for single coverage and $6,850 for family coverage.

Over time, the average premium contribution for covered workers has increased. For example, over the last 10 years, the single coverage average contribution has increased 31% and the family coverage average contribution increased 37%. At the same time, the share of the premium paid by workers has remained relatively consistent. In 2025, covered workers contributed, on average, 16% of the premium for single coverage and 26% of the premium for family coverage, which was similar to these averages a decade ago. This is because as premiums have increased over time, both employers and employees have faced similar increases on average.

There remains a lot of variation in how much workers are required to contribute to their health plan across firms, particularly within firm size. In 2025, 29% of covered workers at small firms were enrolled in a plan where the employer paid the entire premium for single coverage. This was only the case for 7% of covered workers at large firms. However, 29% of covered workers at small firms were in a plan where they must contribute more than half of the premium for family coverage, compared to 5% of covered workers at large firms. The family average contribution rate for covered workers in firms with fewer than 200 employees was 36%, which is higher than the average contribution rate of 23% for covered workers in larger firms. Small firms often approach the cost of health insurance differently than large firms, sometimes making the same employer contribution regardless of whether the employee enrolls any dependents. Similarly, some large employers encourage spouses and dependents to enroll in other plans, if they have access, through spousal surcharges.

Distribution of Percentage of Premium Paid by Covered Workers for Single and Family Coverage, by Firm Size, 2025 (Stacked Bars)

In addition to any required premium contributions, most covered workers must pay a share of the cost of the medical services they use. The most common forms of cost-sharing are deductibles (an amount that must be paid before most services are covered by the plan), copayments (fixed dollar amounts), and coinsurance (a percentage of the charge for services). Some plans combine cost-sharing forms, such as requiring coinsurance for a service up to a maximum amount or requiring either coinsurance or a copayment for a service, whichever is higher. The type and level of cost sharing may vary with the kind of plan in which the worker is enrolled. Cost sharing may also vary by the type of service, with separate classifications for office visits, hospitalizations, and prescription drugs. Plans often structure their cost sharing to encourage enrollees to reflect on their use, reducing overall utilization.

Among Covered Workers Who Face a Deductible for Single Coverage, Average General Annual Deductible for Single Coverage, by Firm Size, 2006-2025 (Line chart)

In recent years, general annual deductibles have grown in prominence in plan design. In 2025, 88% percent of covered workers were enrolled in a health plan which required that an enrollee met a deductible before the plan covered most services. As of 2025, the average deductible amount for workers with single coverage and a general annual deductible was $1,886. On average, covered workers at smaller firms face higher deductibles than those at large firms ($2,631 vs. $1,670). Generally, a substantial share of workers faced relatively high deductibles. Fifty-three percent of workers at small firms and 28% of workers at large firms had a general annual deductible of $2,000 or more. Over the last five years, the percentage of covered workers with a general annual deductible of $2,000 or more for single coverage has grown from 26% to 34%.

While average deductibles have not grown over the last few years, the growth over the last 10 years outpaces the increases in premiums, wages and inflation. The rise in deductible costs has focused attention on consumerism in health care. Some believe that increasing deductibles will place a greater incentive on enrollees to shop for services, therefore reducing total plan spending. Alternatively, deductibles are less common in Health Maintenance Organization (HMO) plans, which use forms of gatekeeping to dissuade utilization. The growth of deductibles has had important consequences for the financial protection that health insurance provides. A multitude of plans require deductibles well in excess of the financial assets of many of their enrollees. As opposed to coinsurances and copays that accumulate throughout the year, deductible spending may require enrollees to finance relatively high expenses all at once.

Cumulative Increases in Family Coverage Premiums, General Annual Deductibles, Inflation, and Workers' Earnings, 2015-2025 (Line chart)

In addition to looking at the average obligations enrollees face under their health plan, we can look at the actual spending incurred by enrollees in large group plans. In 2021, deductibles accounted for more than 58% of an enrollee’s cost-sharing liability, which is significantly greater than 35% of enrollee liability 10 years prior.

The amount of cost sharing large group enrollees face varies, particularly around how many health services a person uses. Individuals who have a hospitalization, or a chronic condition that requires ongoing management, often incur higher cost-sharing over the year. For example, large group enrollees faced an average of $779 in cost sharing, but individuals with a diabetes diagnosis (even without complications) incurred costs of $1,585 in 2017.

Distribution of out-of-pocket spending for people with large employer coverage, 2003-2021 (Stacked Bars)

While some employer health plans have relatively generous benefits, there remains a concern about affordability, particularly for lower-wage workers who do not have the assets to meet the cost-sharing required under their plan, as well as for individuals enrolling in family coverage at smaller firms. Overall, individuals in families with employer coverage spend 2.4% of their income on the worker contribution required to enroll in an employer-sponsored health plan, and another 1.4% of their income on typical out-of-pocket spending on cost-sharing. Individuals covered by employer-sponsored plans in households at or below 199% of the FPL contribute 9.6% of their income on average towards their premiums and cost-sharing.

A key component of plan design is the out-of-pocket maximum, which caps the amount of money an enrollee spends on in-network covered benefits within a year.

The ACA requires that almost all plans have an out-of-pocket (OOP) maximum below a federally determined limit. In 2025, 12% of covered workers in plans with an OOP maximum had an OOP maximum of less than $2,000 for single coverage, while 21% of these workers had an OOP maximum above $6,000.

What Types of Employer-Sponsored Health Insurance Plans Do Workers Have?

Today virtually all plans have preferential cost sharing for enrollees to visit providers participating in a preferred provider network. Some plans require enrollees to visit a primary care physician or other gatekeeper before they are referred to a specialist. Plans are often categorized based on these characteristics.

Preferred Provider Organization (PPO)

PPO plans are the most common plan type. These plans typically have broader provider networks and do not require gatekeeping for specialist services. However, insurers may still use utilization management tools, such as prior authorization, to determine appropriate use and which services will be paid for under the plan. Point-of-service (POS) plans have a provider network like a PPO plan but require gatekeeping for referrals. POS plans are more common in the Northeast and among smaller firms.

Health Maintenance Organization (HMO)

HMO plans represented 12% of covered workers in 2025. HMO enrollment has decreased over the past few decades, compared to nearly 3 in 10 workers who were enrolled in HMOs in the late 1990s. HMOs do not cover non-emergency out-of-network services, and some integrate health care financing and services delivery. Since providers in these plans are not paid on a fee-for-service basis, they are designed to encourage lower utilization to reduce costs.

High Deductible Health Plan with a Savings Option (HDHP-SO)

HDHP-SO is a relatively new plan type. This plan pairs a high deductible with either a Health Reimbursement Arrangement (HRA) or Health Savings Account (HSA). HSA-qualified plans were first authorized in the Medicare Modernization Act of 2003 and grew precipitously until 2015. HDHP-SO plans now represent almost 3 in 10 covered workers, including almost a quarter enrolled in an HSA-qualified plan. These plans may be an HMO, PPO, or POS, meeting specified federal guidelines. HSA-qualified plans allow both employers and enrollees to contribute to a tax-preferred savings account, which enrollees can use to meet their cost-sharing requirements or save for future health spending. On average, HSA-qualified health plans have higher deductibles than other plan types and lower premiums. The growing enrollment in HSA-qualified plans has led to a growth in general annual deductibles overall. While having a higher deductible in other plan types generally increases enrollee out-of-pocket liability, this is not necessarily true for HDHP-SO plans. Many HDHP-SO enrollees receive an account contribution from their employers, reducing the higher cost-sharing in these plans. In 2025, 62% of employers offering single coverage and 61% of employers offering family coverage, as well as an HSA-qualified health plan, contributed to the enrollee’s account. On average, employers contributed $690 to single coverage HSA-qualified HDHPs and $1,296 to family coverage HSA-qualified HDHPs. Some employers may make their account contribution contingent on other factors, such as completing wellness programs.

Distribution of Health Plan Enrollment for Covered Workers, by Plan Type, 1988-2025 (Stacked Bars)

Average Annual Premiums and Contributions for Covered Workers in HDHP/SOs and Non-HDHP/SOs, for Family Coverage, 2025 (Stacked column chart)

What Types of Network Strategies Do Employer-Sponsored Health Insurance Plans Use?

Employer plans typically include provider networks, in which enrollees face lower out-of-pocket expenses if they receive care from a designated provider. Firms and health plans structure their networks of providers to ensure access to care to encourage enrollees to use providers who are lower cost or who provide better care. Employees generally prefer broad network plans, and job-based plans are typically broader than those offered on the Marketplaces. Even so, some employers offer a health plan with a relatively small network of providers. These narrow network plans limit the number of providers that can participate to reduce costs and are more restrictive than standard HMO networks. In 2025, 9% percent of firms offering health benefits reported that they offer at least one narrow network plan to their employees.

More frequently, firms use tiered or high-performance networks in which providers are selected and then grouped within the network based on the quality, cost, and/or efficiency of care they deliver. Enrollees then receive lower cost sharing by choosing a provider in a lower tier.

Another way plans designate preferred providers is through “Centers of Excellence”, which are facilities or providers that health plans and employers single out as suppliers of exceptionally high-value specialty care for specific conditions. Plans and employers may encourage or require enrollees to use these designated providers to receive coverage for certain types of care.

As major purchasers of health care, many view employers as having considerable leverage in health care markets based on their network design. This leverage is dampened by a combination of factors, including the prevalence of highly concentrated provider markets, employees’ preferences for broad network plans, and the challenges of building networks capable of delivering timely access.

One specific concern is the availability of mental health providers. Most firms (92%) reported that they believed their largest plan offered timely access to primary care providers. However, only 70% of firms believed there were enough mental health providers in their largest plan’s network to provide timely access to services. As plan costs continue to rise for employers, these networks may be further limited as high-cost providers are removed to mitigate costs.

One policy intended to promote employers’ ability to construct lower-cost networks is the new price transparency rules, which require hospitals and health plans to disclose the prices for services. Employers may use this information to identify high-cost providers or if providers charge lower prices to other payers. This could lead to more active shopping or the development of networks that encourage the use of lower-priced providers. However, even with this additional price information, employers may still face constraints in how they design their networks, particularly in highly consolidated provider markets or in areas where maintaining adequate access remains a concern.

Additional Strategies to Improve Health and Control Cost

In addition to cost-sharing requirements and network design, many employers use other strategies to influence both the health of their workforce and the cost of their health plans.

One such strategy is utilization management, where insurers evaluate enrollees’ health care use. A common tool is prior authorization, where an insurer reviews the appropriateness of certain services or prescriptions before covering them. Plans may use prior authorization to limit the use of services they believe are often used inappropriately or to encourage lower-cost alternatives. In recent years, prior authorization has come under public scrutiny for delaying care and adding complexity for patients. Among large employers (those with 200 or more workers), 12% believe their employees have a high level of concern about the complexity of prior authorization requirements, and another 32% believe employees’ concern is moderate. In early 2025, many insurers pledged to voluntarily expedite their prior authorization processes and improve enrollee communication. How these changes will affect enrollees’ access to timely care remains to be seen, or if ultimately prior authorization becomes the target of new legislation. While loosening restrictions could improve access, it may also lead to higher plan costs and premiums if more services are used.

Another approach is to promote population health in order to improve the health and productivity of workers and their family members while also potentially reducing health care spending. Many employers try to achieve this through wellness programs, which may include initiatives such as exercise programs, health education classes, health coaching, and stress management counseling. Among large firms offering health benefits, 68% offer programs to help employees stop smoking or using tobacco, 63% offer programs to support weight loss, and 74% offer other forms of lifestyle or behavioral coaching. Overall, 83% of large firms offer at least one of these programs. Some wellness programs are tied to financial incentives or penalties, which can increase costs for enrollees who choose not to participate in wellness activities, decline health screenings, or, in some cases, fail to meet biometric targets.

Future Outlook

While ESI seems likely to remain the dominant source of health insurance for working families, employers and working families each face challenges relating to affordability and access to care. These include:

Ultimately, health care is expensive, and the cost of good ESI coverage can place a strain on employers and employees, particularly for workers with lower wages. Additionally, only about half of workers with incomes below 200% of the FPL are even eligible for ESI at their workplace. Can ESI be a source of affordable coverage for all working families, or are novel approaches to providing affordable coverage options needed for these families?

Many ESI policies have significant deductibles and other out-of-pocket costs to keep the premium costs down, while increasing the cost of obtaining care for enrollees. Can and will employers continue to increase out-of-pocket costs, and, if not, how will they control the costs of ESI going forward?

What avenues are available to employers to increase access to care for people with mental health and substance use care needs? Is telehealth a sufficient response?

Can employers and health plans develop provider networks that provide quality health care at lower costs?

Resources

2025 Employer Health Benefits Survey

2025 Employer Health Benefits Chart Pack

Long-Term Trends in Employer-Based Coverage – Peterson-KFF Health System Tracker

Long-Term Trends in Employer-Based Coverage

Many Workers, Particularly at Small Firms, Face High Premiums to Enroll in Family Coverage, Leaving Many in the ‘Family Glitch’

How many people have enough money to afford private insurance cost sharing?

The burden of medical debt in the United States

How affordability of employer coverage varies by family income

Increases in cost-sharing payments continue to outpace wage growth

What do we know about people with high out-of-pocket health spending?

Preventive services use among people with private insurance coverage

Many Workers, Particularly at Small Firms, Face High Premiums to Enroll in Family Coverage, Leaving Many in the ‘Family Glitch’

Out-of-pocket spending on insulin among people with private insurance

Employer Responsibility Under the Affordable Care Act

Citation

Claxton, G., Rae, M., & Winger, A., Employer-Sponsored Health Insurance 101. In Altman, Drew (Editor), Health Policy 101, (KFF, April 2026) https://www.kff.org/health-policy-101-employer-sponsored-health-insurance/ (date accessed).

Global COVID-19 Tracker

Published: Apr 15, 2026

Editorial Note: The Policy Actions tracker will no longer be updated as the data source has ceased tracking government responses to COVID-19. For more information, please visit the Oxford Covid-19 Government Response Tracker.

Section:

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Cases and Deaths

This tracker provides the cumulative number of confirmed COVID-19 cases and deaths, as well as the rate of daily COVID-19 cases and deaths by country, income, region, and globally. It will be updated weekly, as new data are released. As of March 7, 2023, all data on COVID-19 cases and deaths are drawn from the World Health Organization’s (WHO) Coronavirus (COVID-19) Dashboard. Prior to March 7, 2023, this tracker relied on data provided by the Johns Hopkins University (JHU) Coronavirus Resource Center’s COVID-19 Map, which ended on March 10, 2023. Please see the Methods tab for more detailed information on data sources and notes. To prevent slow load times, the tracker only contains data from the last 200 days. However, the full data set can be downloaded from our GitHub page. While the tracker provides the most recent data available, there is a two-week lag in the data reporting.

Note: The data in this tool were corrected on March 18, 2024, to clarify that they represent new cases and deaths over a full week rather than the average per day over a seven-day period.

Policy Actions

This tracker contains information on policy measures currently in place to address the COVID-19 pandemic. Policy categories currently being tracked include social distancing & closure measures, economic measures, and health systems measures. Policies are tracked at the country-, income-, and region-level. Please see the Methods tab for more detailed information on data sources and notes.

As countries continue to implement policies to prevent the transmission of SARS-CoV-2, the virus that causes COVID-19, these tables and charts show which social distancing and closure measures are currently in place by country.

Economic Measures

The COVID-19 pandemic has placed an unprecedented strain on country economies. These tables and charts show which economic-related measures, namely income support and debt relief, are currently in place by country.

Health Systems Measures

The COVID-19 pandemic continues to strain and disrupt global health systems. These tables and charts show which health systems measures are currently in place by country.

Methods

Cases and Deaths

SOURCES

As of March 7, 2023, all data on COVID-19 cases and deaths are drawn from the World Health Organization’s (WHO) Coronavirus (COVID-19) Dashboard. Prior to March 7, 2023, this tracker relied on data provided by the Johns Hopkins University (JHU) Coronavirus Resource Center’s COVID-19 Map, which ends on March 10, 2023. Population data are obtained from the United Nations World Population Prospects using 2021 total population estimates. Income-level classifications are obtained from the latest World Bank Country and Lending Groups. Regional classifications are obtained from the World Health Organization.

Policy Actions

NOTES

Policy actions data include the measure that was in place for each indicator at the country-level as of the end of 2022. Policy actions data will no longer be updated as the data source has ceased tracking government responses to COVID-19. For more information, please visit the Oxford Covid-19 Government Response Tracker.

Social Distancing and Closure Measures

Under ‘Stay At Home Requirements’, exceptions for leaving the house may include anything from being able to leave for daily exercise, grocery shopping, and essential trips, to only being allowed to leave once a week, or one person may leave at a time, etc. Under ‘Workplace Closing’, partial closing includes instances in which a country recommends closing the workplace (or working from home); businesses are open but with significant COVID-19-related operational adjustments; or when workplaces require closing for only some, but not all, sectors or categories of workers. Under ‘School Closing’, partial closing includes instances in which a country has recommended school closures; all schools are open but with significant COVID-19-related operational adjustments; or some schools, but not all, are closed; full closing includes schools that are in session but operating virtually. Under ‘Restrictions On Gatherings’, partial restrictions include restrictions on gatherings of more than 10 people; full restrictions include restrictions on gatherings of 10 people or less. Under ‘International Travel Controls’, partial restrictions include screening and quarantine requirements for those entering the country. Values for ‘Cancel Public Events’ were not recodified.

Economic Measures

Under ‘Income Support’, narrow support includes instances in which a country’s government is replacing less than 50% of lost salary (or if a flat sum, it is less than 50% median salary); broad support includes instances in which a country’s government is replacing 50% or more of lost salary (or if a flat sum, it is greater than 50% median salary). Under ‘Debt/Contract Relief’, narrow support includes instances in which a country’s government is providing narrow relief, such as relief specific to one kind of contract.

Health Systems Measures

Under ‘Vaccine Eligibility’, partial availability includes availability for some or all of the following groups: key workers, non-elderly clinically vulnerable groups, and elderly groups, or for select broad groups/ages. Under ‘Facial Coverings’, recommend/partial requirement includes instances in which a country’s government recommends wearing facial coverings, requires facial coverings in some situations, and requires facial coverings when social distancing is not possible.

SOURCES

Data on and descriptions of government measures related to COVID-19 provided by the Oxford Covid-19 Government Response Tracker (OxCGRT). For more detailed information on their data collection and methodology, please see their codebook and interpretation guide.

The Business of Health with Chip Kahn

Podcast Trailer:
KFF’s The Business of Health

April 15, 2026

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About this Episode

In advance of the launch of KFF’s new podcast, “The Business of Health with Chip Kahn,” the host, KFF’s Senior Visiting Fellow Chip Kahn, explains that for the caring to work in health care, the business of health care has to work and deliver for the patients who depend on it. “This podcast is about that business,” Kahn explains.

The Host

Chip Kahn

Sr. Visiting Fellow

Charles N. Kahn III is a senior visiting fellow at KFF. He is also a visiting senior fellow at the American Enterprise Institute (AEI) and a nonresident senior scholar at the University of Southern California’s Schaeffer Center for Health Policy & Economics. He serves as co-chair of the international Future of Health collaborative.

SERIES

The Business of Health with Chip Kahn

This weekly podcast features insightful conversations between host Chip Kahn and his guests, who discuss the business of health care, connecting the dots between the health care business, policy, and patients.

The podcast’s first series on AI in health care illuminates how AI is changing health care, and features guests who are deploying this technology, managing its consequences, and designing policy around it.

Implementing Medicaid Work Requirements: Lessons from Unwinding

Authors: Amaya Diana and Robin Rudowitz

Published: Apr 14, 2026

The 2025 reconciliation law requires states to condition Medicaid eligibility for adults in the Affordable Care Act (ACA) Medicaid expansion group and enrollees in partial expansion waiver programs (Georgia and Wisconsin) on meeting work requirements starting January 1, 2027, with the option for states to implement requirements earlier. To implement Medicaid work requirements, states will need to make policy and operational decisions, develop new outreach and education strategies, implement system upgrades or changes, and hire and train staff, all within a relatively short timeframe.

As states begin the process of implementing new Medicaid work requirements, they may draw on lessons from their recent experience with “Medicaid unwinding.” In April 2023, states began the process of unwinding the Medicaid continuous enrollment provision, a pandemic-era policy that generally stopped disenrollment in return for extra federal funds provided to states. During the unwinding, states conducted eligibility redeterminations for everyone on the program and disenrolled those who were no longer eligible or who did not complete the renewal process.

State experience with Medicaid unwinding illustrated the complexity of Medicaid eligibility processes and that outcomes reflect federal and state policy decisions, implementation and systems. KFF interviews with state officials, managed care plans, primary care associations, and advocacy organizations involved with the Medicaid unwinding in 2023, as well as interviews from the 23rd annual budget survey of Medicaid officials, provided lessons about outreach and engagement and renewal processes. This brief highlights lessons from unwinding that could help inform work requirement implementation. Key takeaways include:

Successful outreach and communication generally utilize an array of strategies and partnerships to reach and educate enrollees about changes to the program. Managed care organizations (MCOs) can help identify enrollees and provide outreach.
Streamlined renewal processes and increases to ex parte, or automated, renewals help to maintain enrollment for those eligible and reduce state burdens; however, implementing multiple policy changes in tight timeframes can result in significant challenges for systems and staff.
While states can draw on their experiences from the Medicaid unwinding, they will face new challenges unique to implementing work requirements. These include the need to collect and incorporate new information when making eligibility determinations, conduct targeted rather than broad outreach, and implement complicated system changes and integrate new data, as well as the inability to replicate certain flexibilities that were available during unwinding.

What lessons from unwinding could inform implementation of work requirements?

Successful outreach and communication generally utilize an array of strategies to reach and educate enrollees about changes to the program. During unwinding, many states expanded the number of touchpoints before renewal and engaged in multi-modal communication strategies. These included broad efforts (e.g., traditional communication campaigns, paid advertising, press conferences, and toolkits for partner organizations), direct outreach to enrollees (e.g., mailers and text messaging), and targeted outreach to certain populations such as people with limited English proficiency. States also used new strategies to update contact information, such as using the National Change of Address database and accepting updated contact information from managed care organizations (MCOs), with reductions in returned mail. Groups reported that finding the correct balance of frequency of outreach and ensuring clear messaging is key to not overwhelm or confuse enrollees.

Partnerships can amplify outreach and provide feedback loops. During the Medicaid unwinding, most states worked with a wide range of groups to reach Medicaid enrollees, including managed care organizations (MCOs), providers (such as community health centers, other primary care providers, and pharmacies), community-based organizations, navigator/assister organizations, and faith-based groups to amplify state outreach efforts. State officials and groups working directly with affected enrollees found local marketing and word of mouth to be effective methods for reaching enrollees. Many states also held regular meetings to provide updates and review data with others involved in unwinding. Feedback loops with community partners helped identify early problems; conversely, limited state engagement and communication contributed to frustration and more reports of problems.

Managed care organizations (MCOs) can help identify enrollees and provide outreach. During unwinding, some MCOs were able to take on new roles with enrollees as a result of certain waivers and flexibilities (post-unwinding, states have the option to permanently adopt many renewal strategies). State officials and managed care representatives reported that MCOs providing direct outreach to enrollees and sharing updated contact information for enrollees with the state were both helpful. Other innovative approaches MCOs took included virtual renewal training events and coordination between MCOs and primary care providers so providers could work with individuals due for renewal.

Implementing multiple policy changes in tight timeframes can result in significant challenges for systems and staff. A number of states reported that their systems were old or difficult to use and not set up to produce real-time analytics. Respondents also cited staffing shortages as an ongoing challenge contributing to slower processing of renewals and backlogs. Several mentioned that their staff was not experienced enough to handle the large workload, mostly due to high turnover among eligibility workers. States mentioned taking steps to increase ex parte renewal rates to reduce the burden on eligibility staff and enrollees and providing additional staff training. Leading up to the implementation of Medicaid work requirements, states have reported workforce challenges, including the need to hire or reallocate staff in anticipation of increased workloads and the need for additional staff training.

Streamlined renewal processes and increases to ex parte, or automated, renewals help to maintain enrollment for those eligible and reduce state burdens. Heading into unwinding, two-thirds of states reported taking steps to improve the share of renewals processed on an ex parte basis, such as by improving system programming rules or expanding data sources. The ability to perform ex parte renewals varied by state system. Some were able to add data sources and prioritize automating eligibility processes more easily, which in turn reduced the burden on staff.

States reported both benefits and drawbacks to having Medicaid eligibility systems that are integrated with other benefit programs. Integrated eligibility systems allow people to apply for and renew coverage for multiple benefit programs at once. States with Medicaid eligibility systems that were integrated with the Children’s Health Insurance Program (CHIP) and social benefit programs like the Supplemental Nutrition Access Program (SNAP) and the Temporary Assistance for Needy Families (TANF) program reported that data sharing across programs helped improve ex parte renewal rates and simplify renewal processes. State officials also reported that it can be more challenging to make changes to integrated systems because of the need to reconcile complex eligibility rules across programs. Waivers allowing use of SNAP data to renew Medicaid were helpful during unwinding and using SNAP data may be helpful in assessing if individuals meet work or exemption criteria for new requirements.

How will implementing work requirements differ from unwinding experiences?

New work requirements represent a major change to Medicaid eligibility policy and will require states to collect and incorporate new information when determining eligibility. While the volume of renewals posed challenging for states during unwinding, there was no change to enrollee eligibility policy. New work requirements will affect both existing enrollees and new applicants, and will require collecting new information to verify compliance or exemption status. For example, states will likely need to add new questions to Medicaid applications and renewal forms, as well as incorporate new data sources (see more below). States will also have to train staff on new eligibility policy and verification requirements. Instead of doing traditional point-in-time determinations, states will have to consider historical information and confirm that an individual was meeting requirements in one or more months prior to application.

While states can draw on their experiences conducting outreach during the Medicaid unwinding, educating enrollees about work requirements may pose unique challenges. While unwinding affected the entire Medicaid population, work requirements affects only a subset of Medicaid adult expansion enrollees. Compared to the broad outreach conducted during unwinding, states will need to provide more targeted outreach to reduce confusion among Medicaid enrollees and applicants who are not affected by the new work requirements. For those who are affected, states will need to educate individuals on the new requirements, the list of exemptions, how to document compliance, and how to know that you need to submit information. States will likely want to work with a narrower subset of community partners than during unwinding that primarily work with or serve Medicaid expansion adults.

Some flexibilities made available during unwinding will not be helpful for verifying compliance with work requirements. CMS encouraged states to adopt a range of waivers and flexibilities to increase ex parte rates and streamline renewals during unwinding. States reported that streamlining renewals for those with zero and low income were among the most helpful waivers. However, these waivers will be less helpful going forward since determining compliance with work requirements may require income documentation and exemptions will not be based on income. Some states also received waivers that allowed MCOs to help their members complete renewals. The new federal reconciliation law prohibits MCOs from being able to determine beneficiary compliance, but states may be able to engage with MCOs to assist with identification and outreach to enrollees and assist members with completing renewals when implementing work requirements.

Implementing work requirements may require more complicated system changes than states experienced during unwinding, due to the need to integrate various data from agencies and external sources. While states will be able to build on system improvements made during unwinding, implementing work requirements will require more varied data to automate verification of exemptions and qualifying activities, such as meeting minimum education hours or participating in substance use disorder treatment. States may need to identify and establish linkages with new sources, such as gig work platforms, student databases, and claims data to increase the share of applicants and enrollees who can be automatically determined to meet the requirements. In addition, when implementing work requirements, states will have to simultaneously implement other forthcoming changes such as changes to eligibility renewal frequency for expansion adults and changes to retroactive eligibility. States also needed to complete work requirement changes for SNAP that went into effect at the end of 2025, which may have delayed the initiation of work on the Medicaid changes for states with integrated Medicaid and SNAP eligibility systems.

KFF Tracker: America First MOU Bilateral Global Health Agreements

Published: Apr 13, 2026

Editorial Note: Originally published on January 13, 2026, this resource will be updated as needed, most recently on April 13, 2026, to reflect additional developments.

On September 18, 2025, the U.S. government (USG) released its new America First Global Health Strategy, which details how the U.S. will engage in global health efforts moving forward. As part of this new strategy, the U.S. has announced that it will be establishing bilateral health cooperation agreements with countries that receive U.S. global health assistance. These agreements, or Memorandums of Understanding (MOUs), between the U.S. and partner countries represent five-year plans (for the period 2026-2030) outlining U.S. engagement in each country’s health efforts with the goal of “helping countries move toward more resilient and durable health systems.” Central to these plans is transitioning country programs from U.S. assistance to long-term country ownership, with a pledge from each partner country to increase its domestic health spending, or co-investment in health, over the next five years as the U.S. decreases its health assistance. The U.S. began signing these agreements in late 2025 and this process is ongoing. Implementation is slated for later this year.

This tracker provides an overview of the MOUs signed to date. Data are based on press releases issued by the State Department, U.S. embassies, and partner country Ministries of Health, as well as MOU documents (if publicly available). See Methods for more information. This tracker will be updated as agreements are signed and more data become available.

USG Global Health MOUs by Country (Table)

Signed USG Global Health MOUs by Country (Choropleth map)

Global Health MOU Funding by Country (Bar Chart)

USG Global Health MOU Co-Financing Share by Country (Stacked Bars)

USG Global Health MOU Program Areas by Country (Table)

Historical vs. Proposed 5-Year USG Global Health MOU Funding by Country (Grouped Bars)

Methods

This tracker provides information on U.S. MOU bilateral global health agreements to date. Information is sourced from publicly available U.S. Department of State, U.S. embassies, and partner country Ministries of Health press release statements and MOU texts, and will be updated as more information becomes available and when additional agreements are signed. Currently, MOU text, which contains the most detailed information of these sources, is publicly available for only a limited number of countries; for these countries, data were sourced directly from these MOU documents. For countries with available MOU documents, overall totals are based on the sum of annual amounts presented in the text.

Program areas are captured using keyword searches; for global health security (GHS) specifically, country agreements were categorized as targeting GHS if they specifically mentioned GHS, or if they included descriptions of outbreak preparedness and response activities and containing health threats. Due to the limited nature of press release statements, this tracker may not comprehensively capture the global health program areas targeted in each country’s agreement.

Overview of President Trump’s Executive Actions Impacting LGBTQ+ Health

Authors: Lindsey Dawson and Jennifer Kates

Published: Apr 10, 2026

Editorial Note: This resource was originally published on February 24, 2025, and will be updated as needed to reflect additional developments.

Starting on the first day of his second term, President Trump began to issue numerous executive actions, several of which directly address or affect health programs, efforts, or policies to meet the health needs of LGBTQ+ people. This guide provides an overview of these actions, in the order in which they were issued. The “date issued” is date the action was first taken; subsequent actions, such as litigation efforts, are listed under “What Happens/Implications.” It is not inclusive of administrative actions that impact LGBTQ+ people that are not directly related to health and health care access, such as efforts related to participation in sport even though those actions might have an impact on well-being. In addition, within the actions examined, only provisions directly related to health and health access are described in table.

Initial Rescissions of Harmful Executive Orders and Actions, January 20, 2025

Purpose: Initial rescissions of Executive Orders and Actions issued by President Biden.

Among these orders are several that addressed LGBTQ+ equity including “Preventing and Combating Discrimination on the Basis of Gender Identity or Sexual Orientation” (Executive Order 13988) and “Advancing Equality for Lesbian, Gay, Bisexual, Transgender, Queer, and Intersex Individuals” (Executive Order 14075). The order establishing the White House Gender Policy Council (Executive Order 14020) and several Orders related to diversity, equity, and inclusion were also rescinded, as were orders related to nondiscrimination and equity in schools.

Implications: This order could lead to less oversight, reduced health programing, and fewer policies protecting LGBTQ+ people, which could negatively impact access to care and well-being. Of particular note:

• Rescinds orders that had called for LGBTQ+ people’s health equity, the national public health needs of LGBTQ+ people, LGBTQ+ data collection, and nondiscrimination protections, including in health care.

• Rescinds orders that had called for nondiscrimination protections for LGBTQ+ young people in school, which could contribute to stigma and worsened mental health.

Executive Order: Defending Women From Gender Ideology Extremism and Restoring Biological Truth to The Federal Government, January 20, 2025

Purpose: To define sex as an immutable binary biological classification and remove recognition of the concept of gender identity, including in sex protections and in agency operations.

The order states that “It is the policy of the United States to recognize two sexes, male and female” and directs the Executive Branch to “enforce all sex-protective laws to promote this reality”. Elements of the order that may affect LGBTQ people’s health are as follows:

• Defines sex as “an individual’s immutable biological classification as either male or female.” States that “’sex’ is not a synonym for and does not include the concept of ‘gender identity’” and that gender identity “does not provide a meaningful basis for identification and cannot be recognized as a replacement for sex.”

• Defines male and female based on reproductive cell production. Introduces the term “gender ideology” which is defined to include “the idea that there is a vast spectrum of genders that are disconnected from one’s sex” and “maintains that it is possible for a person to be born in the wrong sexed body.”

• Directs the Secretary of Health and Human Services (HHS) to provide the U.S. government, external partners, and the public guidance expanding on the sex-based definitions set forth in the order within 30 days.

• Directs each agency and all federal employees to “enforce laws governing sex-based rights, protections, opportunities, and accommodations to protect men and women as biologically distinct sexes,” including “when interpreting or applying statutes, regulations, or guidance and in all other official agency business, documents, and communications.”

• Directs each agency and all Federal employees, “when administering or enforcing sex-based distinctions,” to “use the term ‘sex’ and not ‘gender’ in all applicable Federal policies and documents.”

• Directs agencies to “remove all statements, policies, regulations, forms, communications, or other internal and external messages that promote or otherwise inculcate gender ideology, and shall cease issuing such statements, policies, regulations, forms, communications or other messages.”

• Directs agency forms to exclude gender identity and directs agencies to “take all necessary steps, as permitted by law, to end the Federal funding of gender ideology.”

• Requires that federal funds “not be used to promote gender ideology” and directs agencies to ensure “grant funds do not promote gender ideology.”

• Directs the Attorney General to ensure the Bureau of Prisons revises policies to prohibit federal funds from being expended “for any medical procedure, treatment, or drug for the purpose of conforming an inmate’s appearance to that of the opposite sex.”

• Rescinds multiple executive orders issued by President Biden, including: “Preventing and Combating Discrimination on the Basis of Gender Identity or Sexual Orientation” (13988), “Establishment of the White House Gender Policy Council” (14020) (which is also dissolved), and “Advancing Equality for Lesbian, Gay, Bisexual, Transgender, Queer, and Intersex Individuals” (14075).

• Also directs agencies to rescind certain guidance documents, including, “The White House Toolkit on Transgender Equality”; “The Attorney General’s Memorandum of March 26, 2021 entitled “Application of Bostock v. Clayton County to Title IX of the Education Amendments of 1972,” and range of orders related to LGBTQ+ students in schools.

Implications: This order is broad, directed to all federal agencies and programs. Because federal health programs reach LGBTQ+ people, and some are specifically designed to be inclusive of the LGBTQ+ community, or account for gender identities in addition to biological sex, this Order could widely affect program funding, guidance, and access. It has several possible implications:

The terms used in the Order include several biological and social inaccuracies which could perpetuate misinformation about LGBTQ+ people and transgender people’s health needs. It also takes steps towards ban gender care in certain area, most explicitly in prisons.

Requiring that federal funds are not used to “promote gender ideology” has caused significant confusion. Since this order was issued, there have been multiple reports of HIV programs and community health centers that have lost funding as a result of supporting programs inclusive of transgender people. In addition, there have been reports that some health care facilities paused providing youth with gender affirming care, fearing that federal funding would be withheld according to this and another Order relating to youth access to gender affirming care (see separate entry). (See court decisions below.) Withholding care could lead to negative health outcomes for those that require it.

Data collection and data presentation/distribution have been impacted. At first some data was removed from federal websites, though due to court order this appears to have been restored. If public health messaging and services related to the health needs of transgender people, or other specific populations, are unavailable, this may result in adverse health outcomes such increased disease prevalence, greater difficulty with care engagement, and poor mental health outcomes. There have been reports that gender identity questions will be removed from federal surveys which makes tracking the experiences and well-being of LGBTQ+ people more difficult.

The order directs the HHS Secretary to take action to end gender affirming care through Section 1557 of the Affordable Care Act (ACA), the law’s major nondiscrimination provision, which includes protections on the basis of sex. While the Biden administration interpreted sex protections to include sexual orientation and gender identity, it is expected that the Trump administration will seek to remove these protections, as was the approach during his first term. Despite the Executive Orders and any future guidance, courts could continue to rule that such protections exist in statute.

On March 17^th the VA announced that it would phase out providing gender affirming care to comply with this Executive Order. Exceptions include Veterans already receiving hormone therapy from the VA or Veterans “receiving such care from the military as part of and upon their separation from military service” who are eligible for VA health care. The VA will not provide other gender affirming medical services.

The statement writes that historically the VA had provided a range of gender affirming services and “letters of support encouraging non-VA providers to perform sex-change surgeries on Veterans.” These services had been authorized under the now rescinded Veterans Health Administration Directive 1341(4).

There have been multiple legal challenges to this Order with some judicial actions that have paused aspects of implementation:

• On February 4, 2025 a lawsuit was filed in federal court challenging the Order on the grounds that it usurps Congressional power, violates Sec. 1557 of the ACA, and is unconstitutional and on February 11 a temporary restraining order and memorandum opinion was issued requiring restoration of webpages, datasets, and any other resources needed to provide medical care, identified by the Plaintiffs.

• On February 4, 2025, a separate federal lawsuit was filed challenging this Order and the Executive Order on “Protecting Children from Chemical and Surgical Mutilation” (see separate entry), asserting they are openly discriminatory, unlawful, and unconstitutional. On February 13, a federal judge issued a temporary restraining order preventing the federal government from withholding or conditioning funding on the basis of providing this care.

• An additional suit was filed on February 19, 2025 by the National Urban League, National Fair Housing Alliance, and AIDS Foundation of Chicago challenging three Executive Orders: “Ending Radical and Wasteful DEI Programs and Preferencing”, “Defending Women From Gender Ideology Extremism and Restoring Biological Truth to the Federal Government” and the “Ending Illegal Discrimination and Restoring Merit-Based Opportunity” as usurping the power of Congress, violating the Constitution and the Administrative Procedures Act, and, seeking declaratory and injunctive relief. In their complaint, plaintiffs highlight the potential harm this Order could bring to people with HIV and LGBTQ+ communities and the programs that serve them.

• On February 20, a separate case was filed in federal court by multiple LGBTQ+ health care and service organizations, challenging the “Ending Radical and Wasteful DEI Programs and Preferencing”, “Defending Women From Gender Ideology Extremism and Restoring Biological Truth to the Federal Government” and the “Ending Illegal Discrimination and Restoring Merit-Based Opportunity” Orders claiming they usurp the power of Congress and violate the Constitution. In their complaint, plaintiffs highlight the potential harm this Order could bring to people with HIV and LGBTQ communities and the programs that serve them. On June 9^th, 2026, the court issued a preliminary injunction, blocking in part key provisions in this EO and in the DEI EO including those that instruct agencies to remove and cease to issue materials and “communications…that promote or otherwise inculcate gender ideology” and instructing agencies to “end the Federal funding of gender ideology”; prohibit federal funds from being “used to promote gender ideology,”; and direct agencies and departments to terminate DEI offices and positions, materials, initiatives, performance requirements, and grants or contracts.

• On March 12, 2025 two physician and academic plaintiffs filed a lawsuit challenging the Order and related OPM memo when their articles were removed from HHS’ Agency for Healthcare Research and Quality (AHRQ)’s Patient Safety Network (PSNet), a federal online patient-safety resource. The reason for the removal articles was for their inclusion of passing references to transgender patients. On May 23, a MA district court found the plaintiffs would likely succeed on their constitutional 1^st amendment claims and granted a preliminary injunction requiring HHS to republish the censored content.

Exective Order: Ending Radical and Wasteful Government DEI Programs and Preferencing, January 20, 2025

Purpose: To limit diversity, equity, inclusion, and accessibility (DEIA) activities in government and by government contractors and grantees.

Directs each agency, department, or commission head to take the following actions (among others):
• terminate, to the maximum extent allowed by law, all DEI, DEIA, and “environmental justice” offices and positions…; all “equity action plans,” “equity” actions, initiatives, or programs, “equity-related” grants or contracts…
• provide the Director of the OMB with a list of all “federal grantees who received Federal funding to provide or advance DEI, DEIA, or “environmental justice” programs, services, or activities since January 20, 2021,” among other actions.

Implications: As with the other DEIA related Order (see separate entry), these efforts could make reaching populations with unique health needs in culturally competent ways more challenging, including in programs related to LGBTQ+ health and HIV. It could also jeopardized programs and funding for agencies reaching these communities.
There have been multiple legal challenges to this Order:

• On February 3, a lawsuit was filed by four diverse plaintiffs challenging the constitutionality of this Order and the Order, “Ending Illegal Discrimination and Restoring Merit-Based Opportunity”.

• An additional suit was filed in federal court on February 19, 2025 by the National Urban League, National Fair Housing Alliance, and AIDS Foundation of Chicago challenging this order as well as the “Defending Women From Gender Ideology Extremism and Restoring Biological Truth to the Federal Government” and the “Ending Illegal Discrimination and Restoring Merit-Based Opportunity” ” as usurping the power of Congress, violating the Constitution and the Administrative Procedures Act, and, seeking declaratory and injunctive relief. In their complaint, plaintiffs highlight the potential harm this Order could bring to people with HIV and LGBTQ communities and the programs that serve them.

• On February 20, a separate case was filed in federal court by multiple LGBTQ+ health care and service organizations, challenging the “Ending Radical and Wasteful DEI Programs and Preferencing”, “Defending Women From Gender Ideology Extremism and Restoring Biological Truth to the Federal Government” and the “Ending Illegal Discrimination and Restoring Merit-Based Opportunity” orders claiming they usurp the power of Congress and violate the Constitution. In their complaint, plaintiffs highlight the potential harm this Order could bring to people with HIV and LGBTQ communities and the programs that serve them. On June 9^th, 2026, the court issued a preliminary injunction, blocking in part key provisions in this EO and in the “gender ideology” EO including those that instruct agencies to remove and cease to issue materials and “communications…that promote or otherwise inculcate gender ideology” and instructing agencies to “end the Federal funding of gender ideology”; prohibit federal funds from being “used to promote gender ideology,”; and direct agencies and departments to terminate DEI offices and positions, materials, initiatives, performance requirements, and grants or contracts.

Executive Order: Ending Illegal Discrimination and Restoring Merit-Based Opportunity, January 21, 2025

Purpose: Order seeks to end federal “preferencing” through DEIA efforts within government and through contracting to the extent that they do not comply with the Administration’s view of civil rights law.

The order is broad and non-specific but includes the following directives:

• Orders all executive departments and agencies “to terminate all discriminatory and illegal preferences, mandates, policies, programs, activities, guidance, regulations, enforcement actions, consent orders, and requirements. I further order all agencies to enforce our longstanding civil-rights laws and to combat illegal private-sector DEI preferences, mandates, policies, programs, and activities.”

• Orders agency heads to include in every contract or grant award “a term requiring the contractual counterparty or grant recipient to agree that its compliance in all respects with all applicable Federal anti-discrimination laws is material to the government’s payment decisions for purposes of section 3729(b)(4) of title 31, United States Code; and…A term requiring such counterparty or recipient to certify that it does not operate any programs promoting DEI that violate any applicable Federal anti-discrimination laws.”

There have been multiple legal challenges to this Order:

• On February 20, a separate case was filed in federal court by multiple LGBTQ+ health care and service organizations, challenging the “Ending Radical and Wasteful DEI Programs and Preferencing”, “Defending Women From Gender Ideology Extremism and Restoring Biological Truth to the Federal Government” and the “Ending Illegal Discrimination and Restoring Merit-Based Opportunity” orders claiming they usurp the power of Congress and violate the Constitution. In their complaint, plaintiffs highlight the potential harm this Order could bring to people with HIV and LGBTQ communities and the programs that serve them. On June 9^th, 2026, the court issued a preliminary injunction, blocking in part key provisions in this EO and in the “gender ideology” EO including those that instruct agencies to remove and cease to issue materials and “communications…that promote or otherwise inculcate gender ideology” and instructing agencies to “end the Federal funding of gender ideology”; prohibit federal funds from being “used to promote gender ideology,”; and direct agencies and departments to terminate DEI offices and positions, materials, initiatives, performance requirements, and grants or contracts.

Exective Order: Protecting Children From Chemical and Surgical Mutilation, January 28, 2025

Purpose: Order directs agencies and programs to work towards significantly limiting access to gender affirming care for young people (defined as those under age 19) nationwide.

• Directs agencies to rescind and amend policies that rely on guidance from the World Professional Association for Transgender Health (WPATH).

• Directs the HHS Secretary to conduct and publish a review of existing literature and best practices related to gender affirming care and gender dysphoria and to “increase the quality of data to guide practices“ in this area.

• Directs executive department and agency heads “that provide research or education grants to medical institutions, including medical schools and hospitals”, “in coordination with the Director of the Office of Management and Budget” to “immediately take appropriate steps to ensure that institutions receiving Federal research or education grants end the chemical and surgical mutilation of children” (which is how the Order defines gender affirming care).

• Directs the HHS Secretary to take action to end gender affirming care for children “including [through] regulatory and sub-regulatory actions, which may involve the following laws, programs, issues, or documents:
– Medicare or Medicaid conditions of participation or conditions for coverage
– clinical-abuse or inappropriate-use assessments relevant to State Medicaid programs
– mandatory drug use reviews
– section 1557 of the Patient Protection and Affordable Care Actquality, safety, and oversight memoranda
– essential health benefits requirements; and
– the Eleventh Revision of the International Classification of Diseases and other federally funded manuals, including the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.”

• Withdraws Biden Administration “HHS Notice and Guidance on Gender Affirming Care, Civil Rights and Patient Privacy” and directs the Secretary of HHS “in consultation with the Attorney General [to] issue new guidance protecting whistleblowers who take action related to ensuring compliance with this order.”

• Directs the Secretary of the Department of Defense to “commence a rulemaking or sub-regulatory action” restrict access to gender affirming care for children in the TRICARE program.

• Directs the Director of the Office of Personnel Management to limit access to care in coverage for federal employees’ families by requiring “provisions in the Federal Employee Health Benefits (FEHB) and Postal Service Health Benefits (PSHB) programs call letter for the 2026 Plan Year” that would require eligible carriers to exclude “coverage for pediatric transgender surgeries or hormone treatments…”

• Directs the Attorney General to review Department of Justice laws on female genital mutilation and “prioritize enforcement of protections” and “to convene States’ Attorneys General and other law enforcement officers to coordinate the enforcement of laws against female genital mutilation.”

• Directs the Attorney General to “prioritize investigations and take appropriate action to end deception of consumers, fraud, and violations of the Food, Drug, and Cosmetic Act by any entity that may be misleading the public about long-term side effects of chemical and surgical mutilation.”

• Directs the Attorney General “in consultation with the Congress” “to draft, propose, and promote legislation to enact a private right of action for children and the parents” who have received gender affirming care “which should include a lengthy statute of limitations.

• Directs the Attorney General to “prioritize investigations and take appropriate action to end child-abusive practices by so-called sanctuary States that facilitate stripping custody from parents who support the healthy development of their own children, including by considering the application of the Parental Kidnapping Prevention Act and recognized constitutional rights.”

• Directs agency heads included in this executive order to “submit a single, combined report to the Assistant to the President for Domestic Policy, detailing progress in implementing this order and a timeline for future action” within 60 Days of its issuance.

Implications: If fully implemented, the Order would broadly and extensively limit access to gender affirming care for young people, across a range of payers and providers. Access to gender affirming care is associated with improved mental health outcomes for transgender people and limiting this care with negative ones, including poorer mental health outcomes. Additional impact includes:

• The executive order includes details about sex, gender identity, gender affirming care, and transgender people that conflict with science and evidence. These inaccuracies include suggesting that large shares of youth are seeking gender affirming medical care, that regret rates among those seeking care are high, and conflating “female genital mutilation” and gender-affirming care. This has the potential to promote hostility, stigma, and discrimination, and can lead to care denials.

• It seeks to remove Federal reference to one of the standards of evidence-based care for transgender people in the US. Directing the HHS Secretary to develop new guidance without this standard, and in accordance with this and other orders, could limit agency ability to identify standards that adequately meet the needs of transgender people.

• It also seeks to condition federal research and education grants on grantees not providing young people with gender affirming care.

• There has already been some confusion with certain states and providers looking to preemptively comply with the order and another Order relating to “gender ideology” (see separate entry).

• The order lays groundwork for the Administration remove explicit protects for LGBTQ+ people in health care, including with respect to accessing gender affirming care. Specifically, the Order suggests a reinterpretation of sex protections in Section. 1557 of the Affordable Care Act void of explicit protections on the basis of sexual orientation and gender identity.

• The order leans on laws and policies unrelated to gender affirming care in an effort to limit access to those services including by erroneously conflating gender affirming care and female genital mutilation, using the FDA regulatory process to limit access, and suggesting kidnapping protections be applied to parents in certain circumstance.

On January 31, 2025. FEHB issued a letter to carriers stating that begining plan year 2026, carriers should not covre surgical or hormonal gender affirming care.

On February 19, 2025, additional guidance was released relating to this order, providing new and refined definition of terms “ which directs the Department of Health and Human Services (the Department) to promulgate clear guidance to the U.S. Government, external partners, and the public, expanding on the sex-based definitions set forth in the Executive Order.”

On February 20, 2025, pursuant to this Order, HHS issued a “Recession of ‘HHS Notice and Guidance on Gender Affirming Care, Civil Rights, and Patient Privacy’ issued by the Biden Administration” which had stated the Administration “stands with transgender and gender nonconforming youth” and that medically necessary for gender affirming care for minors improves physical and mental health. It also reiterated that administration’s view that Sec. 1557 of the ACA includes protections on the basis of sexual orientation and gender identity.

There have been multiple legal challenges to this Order with some judicial actions that have paused aspects of implementation:

• On February 4, 2025, a federal lawsuit was filed challenging this Order and the Executive Order on “Defending Women From Gender Ideology Extremism and Restoring Biological Truth to The Federal Government,” asserting they are openly discriminatory, unlawful, and unconstitutional. On February 13, a federal judge issued a temporary restraining order preventing the federal government from withholding or conditioning funding on the basis of providing this care. On March 4th, the court issued a preliminary temporary injunction.

• An additional federal lawsuit was filed on February 7^th challenging this executive order with a separate temporary restraining order being issued on the 14^th preventing the conditioning of federal funds and also applying to a condition linking gender affirming care to female genital mutilation. The restraining order was extended through March 5th on February 26th.

• In March a class action lawsuit was filed in federal district court challenging the Bureau of Prisons (“BOP”) implemention of the order. In June a preliminary injunction blocking BOP officials from providing hormone therapy and accommodating transgender people was granted.

On June 1, the FBI posted on social media urging the public to “report tips of any hospitals, clinics, or practitioners performing these surgical procedures on children,” despite pediatric gender affirming care being permitted in about half of states and not prohibited by the federal government.

Ending Radical Indoctrination in K-12 Schooling, January 29, 2025

The order is broad and non-specific but includes the following directives:

Implications: Should the federal government proceed with conditioning federal funding for schools on whether or not they support transgender students, it could exacerbate existing mental health disparities, contribute to stigma and discrimination, and reduce school connectedness. For example, the policies detailed in the Order could prevent schools from recognizing transgender students’ identities (e.g. their names and pronouns), allow schools to withhold mental health services, to out students to (potentially unsupportive) families, and to restrict facility use and activity participation.

Memorandum For The Heads Of Executive Departments And Agencies, February 6, 2025

Purpose: The memorandum seeks to “stop funding Nongovernmental Organizations that undermine the national interest and administration priorities.”

The memorandum states:

• It is Administration policy “to stop funding [Nongovernmental Organizations] NGOs that undermine the national interest.”

• Direct heads of executive departments and agencies to review all funding that agencies provide to NGOs and “to align future funding decisions with the interests of the United States and with the goals and priorities of my Administration, as expressed in executive actions; as otherwise determined in the judgment of the heads of agencies; and on the basis of applicable authorizing statutes, regulations, and terms.”

Implications: This memo aligns with other administrative efforts to stop current and future funding from being provided to NGOs that do not align with administrative priorities and could impact funding to health organizations or programs aimed at serving transgender people or research funding inclusive of trans and gender diverse people. It could also potentially impact care for LGBTQ+ people more broadly if services aimed directly at this population are considered DEIA efforts.

DOJ Letter to the Supreme Court: United States v. Jonathan Skrmetti, Attorney, February 7, 2025

Purpose: “To notify the Court that the government’s previously stated views” on a case challenging a state’s ban on gender affirming care “no longer represents the United States’ position.”

• Notifies the Court that “following the change in Administration, the Department of Justice has reconsidered the United States’ position in” the case brought by the Biden Administration challenging Tennessee’s ban on gender affirming care for minors. The letter states, that their view is that the Tennessee law being challenged “does not deny equal protection on account of sex or any other characteristic,” which is the question before the Court.

• Despite this change in perspective, the Trump Administration encouraged the Court to resolve the questions presented without granting certiorari to the original plaintiffs.

Implications: There are 26 states with bans on gender affirming care for minors and litigation challenging these bans is ongoing. At the request of the Biden Administration, who brought the plaintiff’s case from the lower courts, the Supreme Court agreed to examine whether the Tennessee ban violates Equal Protection constitutional protections under the 14^th Amendment. The case was briefed and argued prior to the administration change. Upon taking office, the Trump Administration wrote this letter to the Court stating that the Biden Administration position no longer represented that of the U.S. government but nevertheless asked the court to decide the case. The court will likely issue a decision in the case and technically, the Trump Administration letter should not have bearing on the court’s decision. The court is expected to issue a decision in the case this summer (2025).

Quality and Safety Special Alert Memo on Provision of Gender Affirming Care to Children, March 5, 2025

Purpose: To alert providers to the administration’s approach to children’s access to gender affirming care and serve as notice “that CMS may begin taking steps in the future to align policy, including CMS-regulated provider requirements and agreements…” to limit such care.

The memorandum states:

• That “CMS renews its commitment to promoting evidence-based standards through health quality and safety improvement activities, and reminds hospitals and other applicable facilities and providers of the obligation to prioritize the health and safety of their patients, especially children.” It questions evidence around gender affirming care for young people and states “CMS may begin taking steps in the future to adjust its policies to reflect this…”

Implications:

• The CMS memo aligns with policies put forward in the Executive Order, “Protecting Children From Chemical and Surgical Mutilation,” related to limiting young people’s access to gender affirming care, provisions of which are subject to a nationwide preliminary injunction (described in above entry). However, this is not explicitly stated in the memo.

• On March 6^th the Health Resources & Services Administration (HRSA) and Substance Abuse and Mental Health Services Administration (SAMHSA) released additional guidance stating that they would review policies, grants, and programs for consistency with the CMS memo (SAMHSA letter unavailable but described in this filing). HRSA also specifically notes the agency will review its Children’s Hospitals Graduate Medical Education (CHGME) Payment Program for consistency with the memo.

• While the memo does not specifically refer to the Executive Order, on March 7^th, plaintiffs in a case challenging the order sought enforcement of the preliminary injunction claiming that the CMS memo and HRSA/SAMHSA guidance violate its terms because by “threatening to withhold federal funding, the Executive Orders coerced hospitals into immediately shutting down gender affirming medical care for people under nineteen to avoid potential loss of funds.”

• Depending on how future policy is implemented, CMS could seek to significantly limit access to gender affirming care for young people.

National Child Abuse Prevention Month, 2025 April 3, 2025

Purpose: Issued to proclaim April as National Child Abuse Prevention Month. Describes “the sinister threat of gender ideology” as “one of the most prevalent forms of child abuse facing our country today.”

Erroneously conflates youth access to gender affirming care with child abuse.
References other efforts (see above) aimed at “prohibiting public schools from indoctrinating our children with transgender ideology” and “taking action to cut off all taxpayer funding to any institution that engages in the sexual mutilation of our youth.”
Promises legal action against those perpetrating child abuse.

Implications: The proclamation includes details about gender affirming care and transgender people that conflict with science and evidence, including that children are being “indoctrinated” “with the devastating lie that they are trapped in the wrong body,” referring to gender affirming surgery (which is very rare among young people) as “sexual mutilation surgery,” and suggesting that such care inhibits “happiness, health, and freedom,” for young people and creates “heartbreak” for parents and families.

• By erroneously conflating gender affirming care and abuse, potentially threatens those providing or facilitating access by stating, “we affirm that every perpetrator who inflicts violence on our children will be punished to the fullest extent of the law.”

Ryan White Letter to Awardees and Stakeholders Relating to Gender Affirming Care, April 7, 2025.

Purpose: Reverses a Biden Administration policy that had permitted the Ryan White HIV/AIDS Program to cover certain gender affirming care services as a part of whole person care to transgender people with HIV.

• Referring to a policy on gender affirming care from the Biden administration, the letter states that “under the previous administration, certain interpretations of RWHAP’s allowable uses…co-opted the program’s patient centered mission in favor of radical ideological agendas and policies.”

• The letter further states “that RWHAP funds shall be marshaled exclusively toward evidence-based interventions proven to combat HIV, sustain viral suppression, and improve the quality of life for those living with the disease” and reaffirms the prohibition on funding services outside the scope of outpatient care, including “surgeries and inpatient care, irrespective of setting or anesthesia”

Implications:

• Previously, Ryan White funds were permitted to be used to support gender affirming care within core medical and support service categories, including through the provision of hormones via ADAP programs. Additionally, funds could be used to “provide behavioral and mental health services to clients experiencing gender dysphoria and social and emotional stress related to transgender discrimination, stigma, and rejection.” The policy under the prior Administration prohibited surgery, as does the new one, so that does not represent a change.

• Prohibiting use of funds to support certain gender affirming care services may make care engagement more challenging for transgender Ryan White clients. In some cases, gender affirming care may have helped to connect clients with HIV services and thus improve HIV outcomes.

Nondiscrimination on the Basis of Disability in Programs or Activities Receiving Federal Financial Assistance; Clarification, April 11, 2025.

Purpose: HHS issued this notice “to clarify the non-enforceability of certain language that was included in the preamble to—but not the regulatory text of” the final rule on Section 504, “titled ‘Nondiscrimination on the Basis of Disability in Programs or Activities Receiving Federal Financial Assistance.’ The clarification states that language in the preamble concerning gender dysphoria, which is not in the regulatory text, does not have the force or effect of law and cannot be enforced.

Implications:

• Section 504 prohibits recipients of federal funding, including publicly-subsidized health payers and health care providers who accept Medicare or Medicaid, from discriminating against people on the basis of disability. The Biden Administration’s final rule on Sec. 504 included in the preamble that HHS would “approach gender dysphoria as it would any other disorder or condition. If a disorder or condition affects one or more body systems, or is a mental or psychological disorder, it may be considered a physical or mental impairment.”

• This new interpretation could weaken certain protections for transgender and gender non-conforming people.

State Medicaid Director Letter “Re: Puberty blockers, cross-sex hormones, and surgery related to gender dysphoria,” April 11, 2025.

Purpose: “The purpose of this letter is to ensure that state Medicaid agencies are aware of growing evidence regarding certain procedures offered to children, and to remind states of their responsibility to ensure that Medicaid payments are consistent with quality of care and that covered services are provided in a manner consistent with the best interest of recipients.”

States that “medical interventions for gender dysphoria in children have proliferated” and that “several developed countries have recently diverged from the U.S. in the way they treat gender dysphoria in children.”

CMS reminds states of the following federal Medicaid requirements:

• Program “responsibility to ensure that payments are consistent with ‘efficiency, economy, and quality of care.’”

• Requirement for states to “provide such safeguards as may be necessary to ensure covered care and services are provided in a manner consistent with the best interests of recipients.”

• Prohibition on “federal funding for coverage of services whose purpose is to permanently render an individual incapable of reproducing. Federal financial participation (FFP) is strictly limited for procedures, treatments, or operations for the purpose of rendering an individual permanently incapable of reproducing and…prohibited for such procedures performed on a person under age 21.”

• Drug utilization review (DUR) program requirements “to assure that prescribed drugs are appropriate, medically necessary, and are not likely to result in adverse results.”
– CMS encourages “states to review their DUR programs to ensure alignment with current medical evidence and federal requirements, including the evidence outlined above.
– Notes that “additional guidance on DUR approaches is forthcoming.”

Implications:

• Letter appears to encourage states to take steps to limit gender affirming care for youth within their state Medicaid programs and suggests that not doing so could put them out of compliance with federal law. It does not immediately change policy.

• Letter misrepresents certain information about gender affirming care including its frequency and the approach in international settings.

• Letter leverages a law aimed at addressing discrimination/unwanted sterilizations among people with disabilities to limit gender affirming care.

• The letter could lead to changes in state policy-making or make providers and/or employers less likely to cover services which could ultimately lead to more limited access to GAC.

• CMS issued a press release along with the letter. The letter stated “Medicaid dollars are not to be used for gender reassignment surgeries or hormone treatments in minors.”

Department of Justice Memorandum “Preventing the Mutilation of American Children,” April 22, 2025.

Purpose: An internal Department of Justice (DOJ) memorandum seeks to implement, in part, an executive order aimed at limiting minor’s access to gender affirming care (GAC) (see above).

The memo is an internal document that was leaked. It is not law but provides guidance relating to an earlier executive order aimed at limiting minor access to gender affirming care (see above). The memo reportedly:

• The internal document was leaked and is not law but provides guidance relating to an earlier executive order aimed at limiting minor access to gender affirming care.

• Puts providers “on notice” that “it is a felony to perform, attempt to perform, or conspire to perform female genital mutilation (“FGM”*) on” minors and states that the FBI “alongside federal, state, and local partners, will pursue every legitimate lead on possible FGM cases.”

• States DOJ “will investigate and hold accountable medical providers and pharmaceutical companies that mislead the public about the long-term side effects of chemical and surgical mutilations.”

• Directs “investigations of any violations of the Food, Drug, and Cosmetic Act by manufacturers and distributors engaged in misbranding by making false claims about the…use of puberty blockers, sex hormones, or any other drug” in GAC.

• Directs “investigations under the False Claims Act of false claims submitted to federal health care programs for any non-covered services related to radical gender experimentation.” Gives example of prescribing puberty blockers to a minor for GAC but reporting the service as being for early onset puberty. States Department will work with whistleblowers “with knowledge of any such violations” under The False Claims Act.

• Following prior direction “that Department employees shall not rely on”… the World Professional Association for Transgender Health (WPATH)… “guidelines, and that they should withdraw all court filings” doing so, “expressly extend[s] that direction to all Department employees.” Directs department to “purge all…policies, memoranda, and publications and court filings based on WPATH guidelines.”

• Launches “the Attorney General’s Coalition Against Child Mutilation” to “partner with state attorneys general to identify leads, share intelligence, and build cases against…” providers “…violating federal or state laws banning female genital mutilation and other, related practices…[and] support the state-level prosecution of medical professionals who violate state laws “prohibiting gender affirming care.

• Instructs Office of Legislative Affairs to draft legislation “creating a private right of action for children and the parents of children” who have had gender affirming care with “a long statute of limitations and retroactive liability” and work with Congress “to bring this bill to President Trump.”

Implications:

• The memo directs action but is not law. It seeks to implement an executive order that is, in part, currently enjoined in court.

• The memo includes inaccuracies relating to gender identity, gender affirming care, and transgender people that conflict with science and evidence. These inaccuracies include suggesting that being transgender is a harmful medical condition, that large shares of youth are seeking gender affirming medical care, that regret rates among those seeking care are high, and conflating “female genital mutilation” and gender-affirming care. This has the potential to promote hostility, stigma, and discrimination, and can lead to care denials.

• Seeks to discredit WPATH’s widely relied on standard of care guidelines which providers look to deliver best practices gender affirming care and is regularly referenced by major medical associations including the American Psychological Association.

• While nothing in the memo prohibits provision of gender affirming care, its emphasis on litigation and enforcement of existing law that do not necessarily implicate this care, could have a chilling effect on providers.

HHS Report “Treatment for Pediatric Gender Dysphoria: Review of Evidence and Best Practices,” May 1, 2025.

Purpose: To develop an evidence review around pediatric gender affirming medical care as commissioned by the executive order on Protecting Children From Chemical and Surgical Mutilation (see above entry).

“This Review of evidence and best practices was commissioned pursuant to Executive Order 14187, signed on January 28, 2025. It is not a clinical practice guideline, and it does not issue legislative or policy recommendations. Rather, it seeks to provide the most accurate and current information available regarding the evidence base for the treatment of gender dysphoria in this population, the state of the relevant medical field in the United States, and the ethical considerations associated with the treatments offered. The Review is intended for policymakers, clinicians, therapists, medical organizations and, importantly, patients and their families.” Among the report’s findings:

• Report concludes that the quality of evidence on the effects of gender affirming intervention is low but also that evidence on harms is “sparse.”

• Cites “significant risks” of medical transition, departing from most medical associations and widely used guidelines in the U.S.

• In addition to a focus on medical intervention (e.g. surgery, puberty blockers, and hormones) report discusses role of psychotherapy in gender affirming care, supporting the use of psychotherapeutic approaches, including an approach termed “exploratory therapy”, which can include conversion therapy. Conversion therapy is a practice that seeks to change an individual’s sexual orientation or gender identity. These practices contrast with recommendations from major medical associations, which criticize conversion efforts for their lack evidence, ineffectiveness, and because they can cause harm. Additionally, many states ban these practices for the same reasons.

Implications:

• Review could be used as support for other actions the administration seeks to take (some described here) aimed at limiting minor access to gender affirming care. Outside experts, including from the American Academy of Pediatrics, have raised concerns that the “report misrepresents the current medical consensus and fails to reflect the realities of pediatric care.”

• With respect to therapeutic practices, it could shift how some practitioners approach gender affirming care or potentially provide support to those using conversion related approaches.

• The report could also fuel misinformation in other areas, particularly around regret rates (which the report states are high when they are actually very low) and the share of young people seeking a medical transition (which the report states is large, when the share is small).

On May 28, 2025, HHS sent a letter to an unspecified group of providers, state medical boards, and health risk managers urging providers to update treatment protocol to align with the review’s findings and avoid relying on the WPATH Standards of Care (which are seen by gender affirming care providers as valuable and trusted source of guidance.) The letter points to risk but not benefits of gender affirming medical care and highlights the report’s promotion of psychotherapy as an alternative to other medical care.

HHS Letter “Urgent Review of Quality Standards and Gender Transition Procedures” May 28, 2025

Purpose: The letter from the Center for Medicare and Medicaid Services (CMS) is directed at “select hospitals” providing minors with gender affirming care services including puberty blockers, hormones, and surgeries. The aim of the letter is to collect information on the delivery of these services and their associated costs and revenue. CMS states they are collecting this data to “ensure quality standards at institutions participating in the Medicare and Medicaid programs” and because “CMS has an obligation to be a good steward of taxpayer dollar.”

In the letter CMS asks for information on the following within 30 days:
• consent protocols for children with gender dysphoria, including when parental consent is required
• changes to clinical practice guidelines and protocols in light of the HHS Review (see above entry)
• adverse events, particularly children who later look to detransition
billing codes utilized for gender affirming care
• facility and provider-level revenue and profit margins data related to these services

Implications: If facilities or providers believe HHS is excessively engaged in oversight of their practice of this area of medicine, it could have a chilling effect on willingness to provide these treatments. Depending on what the Administration does with data collected, this effort could represent a significant step in the administration’s aim to limit GAC for minors.

The effort to collect this level of information is likely burdensome for providers, particularly within a 30-day period.

The letter appears to stoke misinformation in its suggestion that there is a lack of parental involvement or consent in the practice of gender affirming care and that regret is a serious problem in this field.

It also appears to question the validity of using federal dollars to provide this care and possibly that delivering these services to minors is a significant cost-burden to the federal government. Because just a small share of the population is transgender, and not all trans people seek medical intervention, costs are likely very low.

CMS Informational Bulletin “Rescission of Guidance on Adding Sexual Orientation and Gender Identity Questions to State Medicaid and CHIP Applications for Health Coverage” June 5, 2025

Purpose: To rescind a bulletin from the Biden administration that provided state Medicaid programs with guidance on implementing optional sexual orientation and gender identity (SOGI) questions on their applications for coverage.

The Trump administration bulletin states that “CMS no longer intends to collect this information from state Medicaid and Children’s Health Insurance Program (CHIP) agencies as part of Transformed Medicaid Statistical Information System (T-MSIS) data submissions.”

Implications: Collection of SOGI health data plays a role in documenting the health experiences and status of LGBTQ+ people. Data collection can reveal disparities and gaps in access, which can, in turn, inform policy making to address these challenges. Without this data, addressing these disparities is more challenging. SOGI Data collection expanded under the Biden administration and has retracted under the Trump administration.

Final Rule Changing ACA Coverage of Gender-Affirming Care, June 25, 2025.

Purpose: The rule prohibits gender affirming care services from being covered as an Essential Health Benefit (EHB) in ACA plans.
CMS changes how ACA complaint individual and small group plans cover gender affirming care services, which the rule calls “coverage for sex-trait modification.” Beginning plan year 2026, insurers are prohibited from covering gender affirming care as an essential health benefit (EHB).

Differing from the proposed rule, which offered no definition, HHS defines “sex-trait modification” services to mean “any pharmaceutical or surgical intervention that is provided for the purpose of attempting to align an individual’s physical appearance or body with an asserted identity that differs from the individual’s sex.”
If a state mandates coverage for gender affirming care, the state would be required to defray the cost.

The preamble to the rule clarifies that CMS finds that as non-EHB services, EHB non-discrimination in the ACA do not apply.

Implications: The aim of the final rule aligns with policies expressed in Executive Orders on gender and limiting access to gender affirming care (discussed above), though the agency states the rule does not rely on these orders or their enjoined sections. The agency writes that the purpose of the rule is to ensure that health plans meet the ACA’s “typicality requirement,” that is that EHBs be “equal to the scope of benefits provided under a typical employer plan.” The preamble to the rule discusses debate among commenters about whether inclusion of these services is typical.

The rule does not mean that plans cannot cover gender affirming care services but excluding certain services from coverage as EHBs means that enrollees would not be assured the same cost-sharing and benefit design protections as for services included in the EHB package. Costs accrued for gender affirming care would not be required to count towards deductibles or out-of-pocket maximums and would not be protected from annual or lifetime limits, increasing out-of-pocket liability. Additionally, the portion of premiums attributable to specified gender affirming services would not be eligible for premium tax credits or cost-sharing reductions for low- and moderate-income enrollees.

While CMS does not believe the impact will be significant, some commenters expressed concern that the policy change, particularly its near implementation date for 2026 plan year, could create challenges for issuers, which have already been engaged in (and some completed) rate setting for 2026. They also stated that change would require plans that cover gender affirming care outside of the EHB to complete the necessary backend activities (e.g. changes to claims and utilization management programs and policies) to implement the change, activities that could be more burdensome for smaller issuers.

While HHS states that this rule does not violate various statues (e.g. ACA’s nondiscrimination provisions at Sec. 1557 or typicality requirements, ADA’s Section 505 protections, constitutional equal protections, etc.) and disagrees with those who commented on the proposed rule that HHS lacks legal authority to make these policy changes, the rule could ultimately face legal challenges on these or other grounds.

Federal Trade Commission Request for Information on Gender Affirming Care Practices, July 28, 2025.

Purpose: The Federal Trade Commission (FTC) issued a request for public comment on “how consumers may have been exposed to false or unsupported claims about ‘gender-affirming care’(GAC), especially as it relates to minors, and to gauge the harms consumers may be experiencing.”

Arguing that GAC has been subject to “potential deceptive or unfair practices involved in this type of medical care,” the agency “seeks to evaluate whether consumers (in particular, minors) have been harmed by GAC and whether medical professionals or others may have violated Sections 5 and 12 of the FTC Act by failing to disclose material risks associated with GAC or making false or unsubstantiated claims about the benefits or effectiveness of GAC.”

As discussed in the RFI, this action comes on the heels of a recent workshop the agency held on the same topic and the agency now seeks comment related to:

• Experiences of individuals and families seeking GAC, including on recommendations made by providers, whether providers described risks/benefits/effectiveness, and whether providers discussed the current policy environment and debates related to GAC, among other issues.

• Whether GAC was obtained and whether individuals experienced benefits/side effects/adverse events, among other issues.

• Detail related to whether providers “made false representations regarding the benefits or effectiveness.”

• Information related to providers making “false representations regarding the benefits or effectiveness” related to GAC

Implications: This activity is likely to have a chilling effect on provider willingness to offer GAC. In addition to the workshop and RFI described above, more than 20 providers have received subpoenas from the DOJ for investigations related to GAC that “include healthcare fraud, false statements, and more.”

The RFI (and surrounding actions) also have the potential to promote misinformation around the risks and benefits of GAC and suggests that providers are using deceptive and unethical positions in delivering GAC on a significant scale, something that has not been demonstrated. Additionally, the RFI states that there is “widespread concern about the harms” related to GAC but does not acknowledge the broad clinical support GAC has as medically necessary treatment for gender dysphoria, including from major U.S. medical associations.

Improving Oversight of Federal Grantmaking, August 5, 2025

Purpose: The Executive Order seeks reform “the process of Federal grantmaking while ending offensive waste of tax dollars.”

The EO aims to overhaul the federal grantmaking and grant review process “to strengthen oversight and coordination of, and to streamline, agency grantmaking to address these problems, prevent them from recurring, and ensure greater accountability for use of public funds more broadly.” One section of the EO requires agencies to “ensure that…[grants] are consistent with agency priorities and the national interest.” In addition to other actions, agencies are directed to ensure that awards are not “used to fund, promote, encourage, subsidize, or facilitate” certain themes including, “denial by the grant recipient of the sex binary in humans or the notion that sex is a chosen or mutable characteristic” and “racial preferences or other forms of racial discrimination by the grant recipient, including activities where race or intentional proxies for race will be used as a selection criterion for employment or program participation,” among others.

Implications: This approach to grantmaking could further chill research and grantmaking related to and aimed to supporting transgender and gender diverse people, including that related to health and healthcare. This could impact access to and availability of culturally competent services at the individual level and reduce research and data on transgender and gender diverse communities more broadly. Such research in turn could have been used to inform service delivery and policy making and to address health disparities.

CDC Priorities Statement, September 17, 2025.

Purpose: CDC updated its priorities statement on the agency’s “about” website to include discussion of gender affirming care, parental rights, and DEI (among a range of other topics) not previously included on the site.

With respect to gender affirming care, the agency refers to its “comprehensive review of the evidence and best practices for promoting the health of children and adolescents with gender dysphoria” (see above entry) and states it is “a CDC priority to protect children from …” gender affirming care “and, to the extent allowable by applicable federal law and any relevant court orders, CDC programs will deprioritize programs that engage in these practices where permissible. CDC funds will also not support the costs of such practices where not required by the law or court order.” Further, CDC states it is an agency “priority to recognize that a person’s sex as either male or female is unchangeable and determined by objective biology, and to ensure CDC programs accurately reflect science, including the biological reality of sex.”

Another stated priority is that “CDC believes parents are the primary decision-makers in their children’s education and should have full authority over what their children are taught” and that school policies “and curricula should emphasize knowledge…without imposing ideas that may conflict with parents’ political, religious, or social beliefs.”
With respect to DEI the statement reads, “to the extent permitted by law, CDC will deprioritize diversity, equity, and inclusion (DEI) initiatives that prioritize group identity over individual merit” and that “CDC has previously invested substantially in ideologically-laden concepts like health equity—mainly on identifying and documenting worse health outcomes for minority populations.”

Implications: The new priorities statement represents are departure from the previous CDC “about” page which was much broader in its description and referenced the agency strategic plan stating that the plan “advances science and health equity and affirms the agency’s commitment to one unified vision— equitably protecting health, safety, and security.”

The new statement could potentially inform grant making and other agency activities such as reporting, recommendations/guidance, data collection, and data presentation. It may also impact CDC research ability to conduct research related to gender affirming care, transgender people, and health disparities. It also may limit the ability of grantees to use CDC resources to provide LGBTQ students with certain types of support or for the agency to provide resources to support LGBTQ youth. Targeting public health approaches to hard hit populations may be more difficult, including for conditions that disproportionately impact LGBTQ+ people, like HIV.

In its description of the HHS report findings on GAC, the CDC statement appears to go beyond what the review itself stated which was that the quality of evidence to support interventions was low and the evidence on harms was “sparse.” The CDC statement writes the review found that provision of gender affirming care to minors is “unsupported by the evidence and have an unfavorable risk/benefit profile.” Neither the report nor the CDC statement reference the well documented benefits associated with gender affirming care.

Proposed Rule Seeking to Amend CMS Hospital Condition of Participation to Prohibit Provision of Certain Gender Affirming Care Services for Young People, December 18, 2025.

Purpose: The proposed rule wouldchange the hospital Conditions of Participation (CoPs) to prohibit most Medicare and Medicaid enrolled hospitals from providing specified gender affirming medical care for youth.

The proposal would prohibit most hospitals (i.e. those covered by section 42 CFR part 482) that accept payments from the Medicare or Medicaid programs (the majority of hospitals in the U.S.) from providing pharmaceutical and surgical services related to gender affirming care to young people under age 18. Prohibited services would include puberty blockers (which delay the onset of puberty), hormone therapy, and surgery (which is very rare among young people). While these services would be prohibited for the purposes of providing gender affirming care, the rule would permit hospitals to provide them to youth when the service is not intended to affirm a person’s gender.

The proposal does not take immediate effect. There is a 60-day comment period from the date of publication in the federal register.

The rule applies to facility type (not payer) and therefore, if adopted, would prohibit hospitals from offering gender affirming services to all patients under 18 years old regardless of payer, including youth with private insurance or other coverage and those paying cash, not just those covered by Medicare and Medicaid.

If finalized, the proposed rule would further limit access to gender affirming care nationwide. To the extent that academic research hospitals discontinue provision of care, this could also have implications for research being conducted in these institutions.

See KFF’s overview of this proposed rule: https://www.kff.org/lgbtq/new-trump-administration-proposals-would-further-limit-gender-affirming-care-for-young-people-by-restricting-providers-and-reducing-coverage/

Proposed Rule Seeking to Prohibit Federal Medicaid/CHIP Funds from Covering Gender Affirming Care Services for Young People, December 18, 2025.

Purpose: The proposed rule would prohibit the use of federal Medicaid of CHIP funds from covering pharmaceutical and surgical gender affirming services for young people (under age 18 for those covered by Medicaid and under age 19 for those covered by CHIP). Prohibited services would include puberty blockers (which delay the onset of puberty), hormone therapy, and surgery (which is very rare among young people). Federal funds would be permitted to cover the same services when the service is not intended to affirm a person’s gender. Under the proposal, states would be permitted to use state-only funds to cover the prohibited services.

The proposal does not take immediate effect. There is a 60-day comment period from the date of publication in the federal register.

Implications: The aim of the proposed rule aligns with earlier actions (e.g. the Executive Order aimed at limiting access to gender affirming care, letters from HHS to providers/states, etc. (discussed above)).
The rule applies to federal Medicaid as a payer and therefore restrict reimbursement for care regardless of provider type (e.g. hospitals, primary care providers, endocrinologists, etc.). However, it does not prohibit providers from offering these services
If finalized, the proposed rule would further limit access to gender affirming care nationwide and impact families with lower incomes the hardest. While young people with Medicaid and CHIP coverage could theoretically seek care outside of hospitals without using their insurance, the cost of doing so would likely be prohibitive.
See KFF’s overview of this proposed rule: https://www.kff.org/lgbtq/new-trump-administration-proposals-would-further-limit-gender-affirming-care-for-young-people-by-restricting-providers-and-reducing-coverage/

Proposal to Amend Regulations Implementing Section 504 of the Rehabilitation Act of 1973, to exclude protections related to gender dysphoria, December 18, 2025.

Purpose: The proposed rule seeks to amend federal regulations implementing Section 504 of the Rehabilitation Act of 1973, which prohibits discrimination on the basis of disability in federal and federally funded programs, as it applies to recipients of funding from the Department of Health and Human Services (HHS). It would revise a Biden Administration final rule which, in the preamble, stated that HHS would be willing to view gender dysphoria as covered by Sec. 504 “as it would any other disorder or condition. If a disorder or condition affects one or more body systems, or is a mental or psychological disorder, it may be considered a physical or mental impairment.” The proposed rule would do the opposite, and clarified that the current administration interprets statutory exclusions related to ‘‘gender identity disorders not resulting from physical impairments’’ to encompass ‘‘gender dysphoria not resulting from a physical impairment.’’

The proposal does not take immediate effect. There is a 30-day comment period from the date of publication in the federal register.

Implications: This new interpretation could weaken certain protections for transgender and gender non-conforming people.
(See related April 11, 2025 Notice above.)

Declaration of the Secretary of the Department of Health and Human Services, December 18, 2025.

Purpose: HHS Sec. Kennedy issued a declaration stating certain gender affirming care procedures are “neither safe nor effective as a treatment modality for gender dysphoria, gender incongruence, or other related disorders in minors, and therefore, fail to meet professional recognized standards of health care.” It further stated that “the Secretary ‘may’ exclude individuals or entities from participation in any Federal health care program if the Secretary determines the individual or entity has” delivered services that fail “to meet professionally recognized standards of health care.” However, HHS notes the “declaration does not constitute a determination that any individual or entity should be excluded from participation in any Federal health care program.”

Implications: The declaration was issued on the same day that proposed rules aiming to restrict youth access to gender affirming care in the Medicaid program and by hospitals participating in Medicare and Medicaid were released. (See more on the proposed rules in a separate entry below).

The declaration seeks to discredit widely used U.S. standards of care for gender affirming care (i.e. WPATH and Endocrine Society guidelines) and recommendations by major medical associations, instead relying on HHS’s evidence review relating to gender affirming care for minors (see above entry). It seeks to develop a Secretary-defined standard that would instead find that certain gender affirming services fail to meet professional recognized standards of care and therefore provide a basis for HHS to restrict federal funding to providers offering this care. This diverges from current recommendations which support access to this care and deem it a medical necessity.

While the declaration states that it does not determine that specific individuals or entities “should be excluded from participation in any Federal health care program” and that “any such determination…[would be]…subject to further administrative and judicial review,” it represents an additional effort aimed at restricting federal funding from reimbursing for gender affirming care for minors. As with other efforts, the declaration excepts the same services used in gender affirming care for other medical purposes.

Should the declaration be further implemented, it could increase the limitations on youth access to gender affirming care. The declaration is not limited to payer (as the Medicaid proposed rule is) or to a specific facility type (as the Conditions of Participation rule is). It could apply to any provider receiving federal funds. Even if the declaration is not implemented, it could stoke additional fear among providers who may choose to continue to or newly stop offering these services out of retaliatory fear.

On December 24, 2025, a lawsuit was filed in which 20 states challenged the administration’s authority to issue the declaration, claiming it violates the Administrative Procedures Act and the Medicare and Medicaid statutes and that “the Secretary has no legal authority to substantively alter the standards of care and effectively ban, by fiat, an entire category of healthcare.” In March 2026, a federal judge ruled that HHS had overstepped its authority, offering temporary relief for the (now 21) plaintiff states.

HHS has since referred mulitple providers to the Office of Inspector General based on the declaration.

Assistant Sec. for HHS Public Health Message on “Evidence-Based Care for Children and Adolescents with Gender Dysphoria”, December 18, 2025.

Purpose: To “inform healthcare providers, families, and policymakers about evidence-based approaches to caring for children and adolescents experiencing gender dysphoria.”

It reviews findings from the HHS review of gender affirming care for youth (see above entry) and summarizes elements of other reviews before recommending that providers refuse to provide pharmaceutical and surgical gender affirming care for young patients, prioritizing instead psychosocial assessment and care. It also recommends providers share with families the administration’s view that there is “weak evidence for medical interventions” and “substantial documented harms” in medically treating gender dysphoria in young people.

Implications: The recommendations made are not binding but add to administrative efforts to reduce access to gender affirming care for young people. They ignore widely recognized benefits associated with gender affirming care access and recommendations of dominant US medical associations and guidelines.

FDA Warning Letters Related to the Sale and Manufacturing of Chest Binders, December 16-18, 2025.

Purpose: To issue warning letters to retailers and manufacturers of chest binders which include marketing language about their use to help alleviate gender dysphoria. The FDA letters, issued to 12 retailers and manufacturers, state the binders are “misbranded” and that they are medical devices that must be registered with the FDA. In a press release HHS wrote “Breast binders are Class 1 medical devices used for purposes such as assistance in recovery from cancer-related mastectomy.”

FDA states that these companies “should take prompt action to address any violations identified in this letter. Failure to adequately address this matter may result in regulatory action being initiated by the FDA without further notice. These actions include, but are not limited to, seizure and injunction.” FDA states “if you believe that your products are not in violation of the FD&C Act, include your reasoning and any supporting information for our consideration as part of your response.”

Implications: The FDA efforts could create financial and logistical challenges for retailers and manufactures of chest binders used by transgender and nonbinary people. These challenges could result in access challenges for consumers, such as those relating to supply and cost.

Federal Bureau of Prisons Guidance on evaluation and treatment of inmates with Gender Dysphoria, February 19, 2026.

Purpose: “To establish professional guidelines for the mental health evaluation and treatment of inmates meeting the diagnostic criteria’ for Gender Dysphoria (GD) to assist their progress toward recovery, while reducing or eliminating the frequency and severity of symptoms and associated negative outcomes.” Restricts the Bureau of Prisons (BOP) from providing surgical and hormonal medical services related to gender affirming care and offering accommodations. Specifically, the guidance:

Prioritizes mental health care in the treatment of gender dysphoria, emphasizing assessment of comorbid psychiatric conditions, and collection of past medical records.
Connects guidance to the gender ideology Executive Order (described in above entry) which “prohibits the Bureau from expending federal funds for ‘any medical procedure, treatment, or drug for the purpose of conforming an inmate’s appearance to that of the opposite sex’” unless prohibited by court order. While referencing the Executive Order, it also states that the policy is being adopted independent of the Order.
States that treatment plans should be individualized and address all identified medical and psychiatric concerns but prohibits BOP from providing gender affirming surgeries and hormone therapy for those not currently receiving hormones.
Requires a “rapid discontinuation” tapering plan for those already but recently receiving hormones as a part of gender affirming care and an “appropriately paced” discontinuation plan for those who have received hormones for “extended periods.” States that for those who have had gender affirming surgeries and have been on hormones for an extended period, “it may not be appropriate…for the initial tapering plan to include cessation of hormones. But tapering plans should be reevaluated regularly.”
Prohibits BOP from providing (and says BOP may confiscate items related to) “social accommodation,” defined to include clothing, cosmetics, and other items like binders to help an inmate’s appearance align with their gender identity.

Implications:

Marks an area where federal restrictions around gender affirming care extend to adults.
Suggests that GD may be the result of, and addressed by, treatment of comorbid psychiatric conditions and prioritizes mental health interventions to the exclusion of other medical interventions that are widely considered best practice and not seen as interchangeable. As such, the policy could stand to negatively impact the well-being of transgender and nonbinary inmates in federal prisons seeking medically necessary gender affirming care. In addition, unwanted physical and emotional symptoms can occur because of hormone discontinuation.
By restricting and/or confiscating “social accommodation” this policy puts up barriers to social transition and goes beyond medical restrictions.
Uses the definitions section to reject the existence of transgender people’s identities stating that gender identity “does not provide a meaningful basis for identification.”
The Gender Ideology Executive Order is being challenged in court, parts of which are subject to preliminary injunctions. This includes a case in which a federal judge temporarily enjoined federal prisons from withholding gender affirming care from inmates as a result of the order. It is yet to be seen how the new policy will intersect with the existing injunction but the judge has ordered the administrative record for the BOP policy be filed with the court.

Domestic HIV Funding in the White House FY2027 Budget Request

Author: Lindsey Dawson

Published: Apr 10, 2026

President Trump’s FY 2027 budget request, the second of his second term, was released on April 3, 2026, and proposes significantly reduced funding for some domestic HIV programs. A budget request lays out presidential administration priorities both in terms of policy issues and the level of funding requested (or proposed for elimination). Congress then considers the request but ultimately has “the power of the purse” and is responsible for appropriating funding for discretionary programs. Those appropriations can, and often do, differ from levels proposed by the administration. Indeed, while President Trump also called for reduced HIV funding in his budget request for FY 2026, Congress appropriated funding similar to prior year levels.

Beyond the traditional budget process, the Trump administration has taken several executive actions to terminate or limit already appropriated funding by delaying or cancelling funding, including for accounts and grants related to HIV. In some cases these actions have led to litigation, sometimes resulting in grants being reinstated. In addition, the administration has used the recission process, whereby the president asks Congress to rescind appropriated funds, which reduces funding if approved by Congress, though to date, recissions have not impacted domestic HIV accounts. These administrative actions have led to uncertainty regarding availability of federal dollars, including for HIV programs, grantees, and sub-grantees, even after funds are appropriated.

The FY 2027 request for domestic HIV, like the FY 2026 request, calls for the elimination or transformation of several core programs, while maintaining others. As with the FY 2026 request, proposals to bolster PrEP uptake that had become a feature of Biden Administration HIV requests, were not included. Funding for the Ending the HIV Epidemic Initiative, an effort born during the first Trump Administration, has been maintained. While detailed funding information is not available for all accounts, where levels are known, the FY 2027 budget request for domestic HIV programs represents a $1.6 billion (35%) decline compared to final FY 2026 funding levels.

If these cuts are enacted, it could make addressing HIV more challenging at a time when other changes to the health policy landscape could negatively impact access to HIV care and prevention services.

A summary of the request for domestic HIV programs is below.

Overview

The request includes discretionary funding for key programs aimed at addressing the domestic HIV epidemic, including for the Ryan White HIV/AIDS and Health Center Programs, programs that the budget moves from the Health Resources and Services Administration (HRSA) to the proposed new agency, the Administration for Healthy America (AHA). Congress rejected the FY26 request’s proposal to create and fund AHA during the appropriations process. The FY27 request states that AHA will prioritize HIV/AIDS programs (among other areas), “aligning with the Administration’s priorities”. Other funding that has been provided to other departments/agencies for HIV activities is also moved to AHA. This includes funding for the Office of Infectious Disease and HIV/AIDS Policy (OIDP) for HIV and other infectious disease related activities, as well as all EHE funding previously allocated to Centers for Diseases Control and Prevention (CDC).

At the same time, the request eliminates a range of historical HIV programs including funding for domestic HIV prevention at the CDC, Part F of the Ryan White HIV/AIDS Program, and at least some parts of the Minority AIDS Initiative (MAI). Additionally, large cuts are proposed for the National Institute of Allergy and Infectious Diseases (NIAID) at the National Institutes of Health, which has been the largest source of HIV research funding in the world. The request also proposed cutting the Housing Opportunities for People with AIDS (HOPWA) program which is a program of Department of Housing and Urban Development.

Specific, known funding levels are as follows:

Centers for Disease Control and Prevention (CDC)- Domestic HIV Prevention

Funding for core HIV prevention programs at the CDC is eliminated in the budget request and only funding previously provided to the CDC for EHE activities ($220 million) is preserved but moved to AHA. Historically, CDC has accounted for almost all (91%) federal funding for domestic HIV prevention. This cut would represent a $794 million decrease (78%) over the FY26 level ($1 billion, including the EHE) for HIV funding, but a total elimination of funding for the division.

While CDC’s HIV prevention funds are eliminated in the proposal, some funding for infectious diseases has been retained and combined into one account. Previously, CDC funding for viral hepatitis, sexually transmitted infections, and tuberculosis prevention had separate funding lines. The request proposes to group those accounts into a single $300 million line. The $300 million funding level is $70 million below the sum of these individual accounts in FY 2026.

These changes at CDC were also proposed in the FY26 budget request but rejected by Congress.

Ryan White HIV/AIDS Program

The Ryan White HIV/AIDS Program, the nation’s safety-net for HIV care and treatment (now housed at HRSA, and would be moved to AHA), receives $2.5 billion in the FY 2026 request, a $74 million (3%) decrease over the FY 2026 enacted level. The request includes $165 million for EHE activities within Ryan White, the same as in FY 2026. The overall program decrease of $74 million is attributed to the elimination of funding for Part F of the program which has included the following components:

AIDS Education and Training Centers (AETCs) whichprovide education and training for health care providers who treat people with HIV.
Dental Programs: The “Dental Reimbursement Program” reimburses dental schools and providers for oral health services. The “Community-Based Dental Partnership Program” supports dental provider education and expands access to oral care for people with HIV.
Minority AIDS Initiative (MAI): Created in 1998 to address the impact of HIV on racial and ethnic minorities, MAI provides funding to strengthen organizational capacity and expand HIV services in minority communities. (See additional discussion of MAI below.)

Community Health Center HIV Funding

The FY 2027 budget request includes $157 million in HIV funding for the Health Center Program (now housed at HRSA and would be moved to AHA), all of which is for the EHE initiative; the same amount as the FY 2026 level. EHE funding in health centers “support efforts to reduce new HIV infections through outreach, routine and risk-based testing, and increased access to Pre-Exposure Prophylaxis for patient.”

Office of Infectious Disease and HIV/AIDS Policy (OIDP)

The FY27 budget provides $7.6 million in funding to the Office of Infectious Disease and HIV/AIDS Policy (OIDP) (now housed at the Office of the Assistant Secretary of Health, it would be moved to AHA). OIDP plays a coordinating role, including historically for EHE effort and national HIV, STI, and hepatitis strategies. Funding for OIDP is provided in the request to “drive progress [in] MAHA priorities by implementing innovative, evidence-based interventions to prevent, diagnose, and treat HIV/AIDS, STIs, viral hepatitis, nosocomial infections/hospital – acquired infections (HAIs), and antibiotic-resistant organisms.” It also supports OIDP to “coordinate national strategies, support data-driven program development, and engage communities most affected by these conditions.”

National Institutes of Health – Domestic HIV Research

Historically, the National Institutes of Health (NIH) has carried out almost all federally funded HIV research activities. The budget proposes significant cuts to NIH overall, including to the National Institute of Allergy and Infectious Disease (NIAID) which would be cut by $1.8 billion (27%), from approximately $6.5. billion to $4.8 billion. While the amount of funding for domestic HIV research at NIH is not yet known, in FY 2025, it was $3.3 billion (amount provided to KFF via data request). The Office of AIDS Research, which sits in the Office of the NIH Director and plays a coordinating role withing NIH is mentioned in the budget’s technical appendix, although a specific funding amount is not provided.

Indian Health Service (IHS)

In the FY27 budget, $5 million for IHS EHE activities to support ending HIV and hepatitis C in Indian Country is continued, the same as the FY26 final level. (Funding information provided to KFF via data request.)

The Minority AIDS Initiative (MAI)

As noted above, the MAI was created in 1998 to address the disparate impact of HIV on racial and ethnic minority communities and to build resources and organizational capacity within these communities. The status of the Minority AIDS Initiative is unclear. Funding that has been provided for MAI activities at the Substance Abuse and Mental Health Services Administration (SAMHSA) which the budget would move to AHA, aimed at “improving the health of people of color who have or are at risk for HIV” is eliminated in the proposal. In FY 2026 SAMHSA received $119 million for the MAI. Another $56 in MAI funding is eliminated from the Secretary’s Minority HIV/AIDS. In addition, as noted, Ryan White funding for Part F, which includes a funding line for MAI, is also eliminated in the proposal.

Housing Opportunities for Persons with AIDS (HOPWA)

The Department of Housing and Urban Development’s HOPWA Program is eliminated in the budget. In FY 2026, HOPWA was funded at $529 million. HOPWA, which was established in 1992, has provided housing assistance and supportive services to low-income people with HIV facing housing insecurity and is the only federal program centered on the housing needs of people with HIV. Its funding supports grants to localities, states, and community-based organizations.

The tables below compare federal funding levels for domestic HIV, where specified, in the FY 2027 request to the FY 2026 enacted levels. EHE funding is included in the overall table (Table 1) and in a dedicated table (Table 2).

Key Discretionary Accounts in the Domestic HIV Budget Request, FY 2027 Budget Request and FY 2026 Final (in Millions) (Table)

EHE funding in the FY27 Domestic HIV Budget Request and FY 2026 Final (in Millions) (Table)

Sources:

HHS FY27 Budget in Brief: https://www.hhs.gov/sites/default/files/fy-2027-budget-in-brief.pdf
HHS FY27 Budget Technical Appendix: https://www.whitehouse.gov/wp-content/uploads/2026/04/hhs_fy2027.pdf
Indian Health Services Congressional Budget Justification: https://www.ihs.gov/sites/ofa/themes/responsive2017/display_objects/documents/IHS%20Draft%20CJ%20FY%202027.pdf
Centers for Disease Control and Prevention Congression Budget Justification: https://www.cdc.gov/budget/documents/fy2027/fy-2027-cdc-cj.pdf
Department of Housing and Urban Development Congressional Budget Justification: https://www.hud.gov/sites/dfiles/CFO/documents/2027-Congressional-Justifications.pdf
Administration for a Healthy America Budget Justification (includes accounts formerly at HRSA, SAMHSA, and OASH, among others): https://www.hhs.gov/sites/default/files/fy-2027-aha-cj.pdf
Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriations Act, 2026: https://www.congress.gov/bill/119th-congress/senate-bill/2587
Transportation, Housing and Urban Development, and Related Agencies Appropriations Act, 2026: https://www.congress.gov/bill/119th-congress/house-bill/4552

UNFPA Funding and Kemp-Kasten: An Explainer

Key Points

What is the Kemp-Kasten Amendment?

What U.S. funding does Kemp-Kasten apply to?

When has Kemp-Kasten been in effect?

How much funding does the U.S. provide to UNFPA?

How is a determination about Kemp-Kasten made?

Has there ever been evidence that UNFPA supports coercive abortion or involuntary sterilizations?

What other legislative requirements apply to U.S. funding for UNFPA?

What happens to funding that is withheld from UNFPA?

Also of Interest

What Are the Recent Trends in Employer-Based Health Coverage?

Also of Interest

Americans’ Challenges with Health Care Costs

Difficulty Affording Medical Costs

Prescription Drug Costs

Health Insurance Cost Ratings

Health Care Debt

Vulnerabilities and Worries About Health Care and Long-Term Care Costs

Also of Interest

Employer-Sponsored Health Insurance 101

KFF Authors:

Comprehensive or limited benefits

Open or closed provider networks

Small and large group markets

ESI Efficiencies

Tax Advantages

Preferred Provider Organization (PPO)

Health Maintenance Organization (HMO)

High Deductible Health Plan with a Savings Option (HDHP-SO)

Global COVID-19 Tracker

Cases and Deaths

Policy Actions

Social Distancing and Closure Measures

Economic Measures

Health Systems Measures

Methods

Cases and Deaths

Policy Actions

Podcast Trailer: KFF’s The Business of Health

About this Episode

The Host

Implementing Medicaid Work Requirements: Lessons from Unwinding

What lessons from unwinding could inform implementation of work requirements?

How will implementing work requirements differ from unwinding experiences?

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KFF Tracker: America First MOU Bilateral Global Health Agreements

Methods

Related Content

Overview of President Trump’s Executive Actions Impacting LGBTQ+ Health

Domestic HIV Funding in the White House FY2027 Budget Request

Overview

Centers for Disease Control and Prevention (CDC)- Domestic HIV Prevention

Ryan White HIV/AIDS Program

Community Health Center HIV Funding

Office of Infectious Disease and HIV/AIDS Policy (OIDP)

National Institutes of Health – Domestic HIV Research

Indian Health Service (IHS)

The Minority AIDS Initiative (MAI)

Housing Opportunities for Persons with AIDS (HOPWA)

Related Content

Podcast Trailer:
KFF’s The Business of Health