This resource provides data on global health funding awards by U.S. state and congressional district in FY 2024. Data were obtained from USAspending.gov, the official source of spending across the U.S. government. While the resource allows users to see how much funding for global health projects was channeled to organizations in the U.S., it only provides information on the prime awardee of funding, not sub-awardee, and should not be used to assess how much funding ultimately went to other countries (other analyses¹  show that most funding does go to support health activities in recipient countries). Rather, the analysis can be used to indicate that some funding goes to U.S.-based organizations and companies who in turn work on behalf of the U.S. government on global health.

Some key take-aways are as follows:

• In FY 2024, the U.S. obligated more than $10 billion for global health activities.
• Most of this funding (75% or $7.9 billion) was designated for work primarily to be performed in other countries, whether or not the prime awardee was a U.S. or foreign implementer.
• U.S.-based prime awardees received $4.6 billion (44%) of FY 2024 global health funding (foreign implementers received $5.9 billion or 56%).
• Of the $4.6 billion provided to U.S.-based implementers:
  • Funding was provided to organizations in 45 states and the District of Columbia and 151 of 436 congressional districts.² 
  • The top 10 states accounted for $4.5 billion, or 97%. D.C.-based organizations received the largest amount of funding ($2 billion), primarily because the global health supply chain contractor is based on D.C., followed by Maryland ($661 million), North Carolina ($555 million), Virginia ($386 million), Massachusetts ($294 million), New York ($283 million), Washington ($217 million), Georgia ($61 million), Tennessee ($43 million), and California ($37 million).
  • The top 10 congressional districts accounted for $4.2 billion, or 90%. Again, D.C. received the largest amount of funding ($2 billion), followed by NC-04 ($553 million), MD-08 ($384 million), MD-07 ($274 million), WA-07 ($188 million), VA-08 ($188 million), VA-11 ($180 million), NY-13 ($157 million), MA-05 ($142 million), and MA-08 ($141 million).

Detailed data are provided below.

States

Congressional Districts

1. See: Center for Global Development, “No, 90 Percent of Aid Is Not Skimmed Off Before Reaching Target Communities,” https://www.cgdev.org/blog/no-90-percent-aid-not-skimmed-reaching-target-communities; WLRN Public Radio and Television, “PolitiFact FL: Does as little as 10% of USAID go to help people in need? What that claim gets wrong,” https://www.wlrn.org/government-politics/2025-02-07/politifact-florida-usaid; PEPFAR, “PEPFAR 2022 Country and Regional Operational Plan (COP/ROP) Guidance for all PEPFAR-Supported Countries”, https://modern.kff.org/wp-content/uploads/2022/02/PEPFAR-2022-COP-ROP-Guidance-Final.pdf#page=97; Washington Post, “Vance, Rubio peddle fiction that 88 percent of foreign aid doesn’t go overseas,” https://www.washingtonpost.com/politics/2025/06/11/usaid-vance-rubio-fact-checker/. ↩︎
2. Excludes congressional districts in U.S. territories; includes D.C.’s congressional district. ↩︎

Most people with Medicare are required to pay a monthly premium for enrollment in Medicare Part B, which provides coverage for physician visits and other outpatient services. In 2025, the standard Part B premium is $185 per month, up from $174.70 in 2024. People with relatively low incomes and limited financial resources can qualify for the Medicare Savings Programs, through which state Medicaid programs provide financial assistance with Medicare premiums and cost sharing. However, provisions in the GOP’s budget reconciliation bill currently moving through Congress would make it harder for people to enroll in these programs. The Congressional Budget Office estimates 1.3 million Medicare beneficiaries would lose access to these Medicaid benefits, meaning some low-income Medicare beneficiaries would lose Part B premium assistance. Many people with Medicare are facing a relatively high financial burden associated with paying Part B premiums, and the reconciliation bill could drive that number higher.

Over one in ten (12% or 7.4 million) of the 61 million Medicare beneficiaries enrolled in Part B in 2024 spent more than 10% of their annual per capita income on Part B premiums. Another 5 million spent between 8% and 10% of their income on Part B premiums, meaning that altogether, over one in five (21% or 12.5 million) people with Medicare Part B spent more than 8% of their annual per capita income on Part B premiums in 2024 (Figure 1). For roughly half of Medicare beneficiaries enrolled in Part B in 2024 (30.7 million), the Part B premium accounted for a smaller share of their annual per capita income – 6% or less. These estimates, which are based on income data from the Dynamic Simulation of Income Model (DYNASIM), highlight the burden of Part B premiums for the many Medicare beneficiaries living with modest means.

The monthly Part B premium imposes a relatively large financial burden on lower-income Medicare beneficiaries who are not enrolled in the Medicare Savings Programs. The 7 million beneficiaries who spent at least 10% of their annual income on Part B premiums in 2024 by definition had per capita income of $21,000 or less per person, based on the 2024 monthly Part B premium of $174.70 (or $2,100 for the year). An individual with income of this amount would have been just above the upper threshold to qualify for the Medicare Savings Programs in 2024, which was around $20,600 (135% of the federal poverty guidelines that year).

Delaying implementation of the rules intended in part to streamline enrollment in the Medicare Savings Programs, as proposed in the House-passed budget reconciliation bill, or prohibiting their implementation, as proposed by the Senate, would result in the loss of valuable financial protections under Medicaid for some low-income Medicare beneficiaries, who would then be responsible for paying Part B premiums (and possibly also Medicare deductibles and cost sharing). These costs would represent a relatively substantial share of their income, as illustrated in another KFF analysis showing that in 2025, the $185 monthly Part B premium would represent nearly 20% of the monthly $967 Supplemental Security Income (SSI) benefit for a low-income Medicare beneficiary receiving SSI. This individual would be automatically enrolled in a Medicare Savings Program under the federal rule proposed for delayed implementation in the reconciliation bill.

Factoring in Medicare cost-sharing requirements, such as the annual Part A and Part B deductibles ($1,676 and $257 in 2025), the same individual, if they paid those full cost-sharing amounts, would have costs consuming at least one-third or more of their SSI benefit for the year. With Medicare Part B premiums projected to increase to nearly $2,500 in 2026 and more than $4,000 by 2034, the financial burden on Medicare beneficiaries associated with paying for Part B coverage is likely to grow.

Changes to Marketplace plans recently finalized by the Centers for Medicare and Medicaid Services (CMS) may incentivize insurers to make their plans less generous. With less generous plans, consumers could face higher out-of-pocket costs. However, these changes could also lower premiums for those who don’t qualify for premium assistance (roughly 8% of Marketplace enrollees). Plans sold on the Affordable Care Act (ACA) Marketplaces and sold in the small group market are grouped into metal tiers—bronze, silver, gold, and platinum—based on their actuarial value (AV), or the average share of health care costs the plan covers for a standard population. Bronze plans require the highest cost sharing, paying only 60% of expected costs, followed by silver plans (70%), gold plans (80%), and platinum plans (90%). “Expanded” bronze plans have a somewhat higher actuarial value and are required to cover some services before the deductible is met.

Issuers are given flexibility in meeting these actuarial value targets. In rules issued in effect from the 2023 plan year, standard on-exchange bronze (except expanded bronze), silver, gold, and platinum plans are required to be within +2/-2 percentage points of their AV targets, a range known as the de minimis range. Individual market standard silver plans have an allowable range of +2/0 percentage points; silver plans offered with cost-sharing reductions for lower-income enrollees are required to have a narrower range (+1/0 percentage points).

CMS has finalized expanding the de minimis range as part of a broader Program Integrity Rule starting in plan year 2026. The finalized rule reverts to the range used between 2018-2022 and gives issuers more flexibility to lower the AV of plans while maintaining their metal level. Individual and small-group market plans may vary from the target AV by up to +2/-4 percentage points (except for expanded bronze plans). For silver plans that include cost-sharing reductions, the allowable range is expanded to +1/-1 percentage points. The One Big Beautiful Bill Act, as passed by the House of Representatives, would codify these ranges into law.

An illustrative silver plan can be used to illustrate the potential impacts of widening the allowable range of AVs. Under current rules, a silver plan with 15% coinsurance for enrollees across all services and a $4,000 combined medical and drug deductible has an actuarial value of 70%. That calculation is based on the actuarial value calculator issued by the federal government. Under the new finalized rule, a plan with a deductible $1,750 higher or a coinsurance 25 percentage points higher could still be classified as silver, with an AV of just over 66%. How much more any given consumer would pay out-of-pocket would depend on their use of services.

Insurers may choose to configure plan designs in this wider range by some combination of increased copays, coinsurance, maximum out-of-pocket amounts, or cost sharing for specific services to decrease the AV. Many Marketplace plans currently have AVs near the lower end of the allowed range: In 2025, the average AV for silver plans was 70.3%.

Standardized plans (designated “easy pricing” plans on HealthCare.gov) were created to simplify cost-sharing arrangements and allow consumers to easily compare plans. For the 2026 plan year, standardized plans have an actuarial value of 70.0% in most states. Allowing a wider range of actuarial values to be classified as the same metal level may increase the challenges of shopping. If insurers choose to offer non-standardized plans with lower AVs, consumers may have difficulty identifying the decreased coverage provided by these plans compared to standardized ones.

While insurers are not required to lower AVs, the finalized rule could create an incentive to do so—effectively reducing the value of coverage for Marketplace enrollees. The finalized rule cites increased cost sharing as a potential benefit, lowering overall premiums, and encouraging more people without a subsidy to purchase coverage. However, those who are eligible for premium tax credits – which make up the vast majority of Marketplace enrollees – would not pay lower premiums and may face higher cost sharing.

The House recently passed a budget reconciliation bill that includes national Medicaid work requirements for adults in the Affordable Care Act (ACA) expansion group, which the Congressional Budget Office (CBO) estimates would reduce federal Medicaid spending by $344 billion over ten years and increase the number of people without health insurance by 4.8 million. On June 16, the Senate Finance committee released proposed reconciliation language with some substantive changes to the Medicaid work requirement provisions, but this language may change as the Senate debates the bill. Under the House-passed bill, adults enrolled through ACA Medicaid expansion must complete 80 hours of work (or other qualifying activities) per month or meet specific exemption criteria (such as having a substance use disorder (SUD) or “disabling” mental disorder). States must verify compliance (at least) at application, renewal, and every six months thereafter, starting no later than December 31, 2026 or individuals could be denied or disenrolled from coverage. For additional details about this process, see KFF’s explainer.

Medicaid plays a large part in coverage and treatment of behavioral health conditions, covering nearly one-third of all adults with mental health disorders and one-fifth of all adults with substance use disorders; among Medicaid expansion enrollees specifically, 24% have a diagnosed behavioral health condition. Continuous Medicaid coverage supports ongoing treatment for mental health and substance use disorders, and disruptions may negatively affect individuals’ mental and physical health. Additionally, many adults with mild or moderate conditions already work or engage in qualifying activities but rely on Medicaid-covered medications and treatments to maintain steady employment. This brief describes key challenges that Medicaid work requirements may pose for adults with mental health or substance use disorders.

Medicaid expansion is the primary coverage pathway for people with mental health or substance use disorders. Among Medicaid-covered adults diagnosed with a substance use disorder, 59% qualify through ACA expansion, similar to those with opioid use disorders (61%), any mental health disorder (51%), and serious mental illness (45%, defined here as schizophrenia, other psychotic disorders, and bipolar disorders). These shares are higher when limited to ACA Medicaid expansion states (Figure 1). Others qualify for Medicaid by receiving Supplemental Security Income (SSI) for a disability, as a low-income parent, or pregnant/postpartum individual. Although certain serious mental illness diagnoses may qualify for SSI, the disability determination process is lengthy and complex, and overall two-thirds of Medicaid enrollees with disabilities qualify through non-disability pathways, such as Medicaid expansion. Substance use disorders alone do not qualify individuals for SSI.

The House-passed bill (and language proposed by the Senate Finance Committee) specifies exemptions for individuals with substance use disorders or “disabling” mental disorders from Medicaid work requirements under the “medically frail” designation. Participation in a SUD treatment program is also listed as an exemption in the bill. However, the bill does not explicitly define which diagnoses constitute “disabling” mental disorders. Mental health disorders that substantially impair daily functioning—such as schizophrenia, other disorders involving psychosis, or bipolar disorder—might be among those considered “disabling” mental disorders under the medically frail designation. However, the exact diagnoses qualifying for this exemption have not yet been clarified and will depend on forthcoming federal guidance and state decisions.

Federal and state decisions about implementing work requirements may be particularly impactful for adults with mental health or substance use disorders. However, the extent of the impact may depend heavily on how these requirements are defined and operationalized, and many details currently remain unclear. Upcoming federal guidance may provide some clarification, but processes could still vary by state. For example, the House bill does not specify how states would be expected to identify individuals who are exempt or whether/when individuals may be required to self-report or provide documentation to confirm they meet exemption criteria. Potential challenges include:

• The House bill does not specify states will be required to use available data to automatically verify exemptions, and even states using data may miss some individuals due to data limitations. While states could cross-reference Medicaid enrollment records with other data sources, such as Medicaid claims, to identify exemption-qualifying conditions like substance use disorders or certain mental disorders, there is often a delay of weeks or months between a service being delivered and claims being fully processed. The length of this delay may also differ by state and Medicaid managed care organization, the primary way most enrollees receive care. Claims further delayed due to disputes, denials, or bundling with other services can further obscure specific diagnoses. These data limitations could leave some exempt individuals unidentified, requiring them to initiate and navigate the state’s exemption process. States with outdated or less integrated data systems may face additional challenges, potentially increasing reliance on manual reporting—particularly difficult for individuals with mental health or substance use disorders. For example, when Arkansas implemented Medicaid work requirements, data-matching identified about two thirds of enrollees, exempting them from reporting work hours or exemption status. Among those who had to actively report, about 70% did not obtain an exemption or report compliance with the work requirements, ultimately resulting in over 18,000 people losing coverage. Arkansas is among a subset of states that already makes “medically frail” determinations because they opt to provide an “alternative benefit package” to ACA expansion adults, enrolling them in Marketplace health plans (while individuals designated “medically frail” may receive the “traditional” Medicaid benefit package). As a result, the state may be better positioned to conduct data matching for exemptions relative to other states; but still Arkansas highlighted (in its new waiver request) that limitations with “data matching” led to some individuals with medical conditions or disabilities that prevented them from working to “fall through the cracks” when the state implemented its work policies in 2018.

Common behavioral health symptoms would make it more challenging for individuals with these conditions to self-report work or exemption status. Behavioral health symptoms can include challenges with concentration, planning, energy levels, anxiety, feelings of overwhelm, and difficulties managing stress, all of which may make it harder for enrollees to understand requirements, navigate complex submission processes, and troubleshoot issues that arise. Individuals experiencing severe or acute behavioral health symptoms may find it particularly difficult to provide documentation, especially for those whose disorders are compounded by unstable employment, housing instability, or homelessness—which is more common among those with serious mental health disorders or severe substance use disorders. Therefore, mental health and substance use disorders themselves could increase the risk of Medicaid coverage loss under proposed requirements. Provider burden may increase if provider documentation is required to obtain an exemption. Under New Hampshire’s work requirement waiver, adults who self-attested to being medically frail were still required to obtain certification from a medical professional of their medical frailty exemption, which was reportedly difficult for enrollees to navigate and complicated for providers.

• Mild and moderate mental health disorders may not qualify adults for exemptions from work requirements; however, symptoms could lead to employment gaps, making compliance with new requirements more difficult. People with mild or moderate disorders can experience episodic symptoms, such as depressive episodes or severe anxiety, which can disrupt consistent employment. The House bill allows states to provide short-term hardship exceptions, such as during inpatient psychiatric stays; however, these exceptions are not federally required and must be requested by the enrollee. Additionally, variation in work requirement implementation could further affect compliance. For instance, states that require verification of work history over three consecutive preceding months may present greater compliance challenges compared to states with less stringent criteria.

• Individuals with new or undiagnosed behavioral health disorders may struggle to qualify or maintain Medicaid coverage without sufficient work history or formal diagnoses. Adults experiencing sudden symptoms, such as a first episode of psychosis, may face significant difficulties navigating exemption processes quickly, particularly at the onset of a disorder, which can be confusing and difficult in itself. Additionally, many adults have undiagnosed behavioral health disorders, an issue especially common among people with substance use disorders. If enrollees are required to submit an official diagnosis to receive an exemption, individuals without an official diagnosis remain subject to work and reporting requirements, potentially leading to coverage loss if symptoms disrupt employment. Even in states that use Medicaid claims data to identify exemptions, there is typically processing time between service dates and when the visit appears in claims data, which can delay states’ identification of individuals with new diagnoses. In addition, applicants with recent employment gaps due to mental health or substance use symptoms may face additional barriers documenting compliance or exemption status at enrollment. For example, Georgia—the only state currently requiring work compliance at Medicaid application—experienced significantly lower enrollment than anticipated due to these requirements, though it did not allow any exemptions.

Being in poor health is associated with an increased risk of job loss, while access to affordable health supports obtaining and maintaining employment. Regular access to care, including mental health and substance use disorder treatment, can help stabilize behavioral health symptoms. However, disruptions or losses in coverage can interrupt treatment, exacerbating these conditions. For instance, stopping medication for opioid use disorder significantly increases mortality risk, with individuals facing a six-fold greater risk of death in the four weeks immediately following treatment discontinuation.

According to the Associated Press, the Trump administration recently shared the personal and health data of millions of noncitizen Medicaid enrollees living in California, Illinois, Washington, and D.C. with immigration enforcement officials, despite concerns reportedly raised by some officials from the Centers for Medicare and Medicaid Services (CMS) about violations of data privacy protections. This policy watch discusses the data privacy protections in Medicaid and the implications of breaches or violations of those protections.

State Medicaid agencies collect and maintain personal and health information for applicants and beneficiaries to determine eligibility for coverage and provide care. This information includes personal identifying data, such as names, birth dates, and contact information; social security numbers; citizenship and immigration status; income; and health information. State Medicaid agencies cannot require applicants to provide information about the citizenship or immigration status of any family or household members not applying for coverage. Medicaid is jointly administered by the federal government and states, and states are required to share certain information with the federal government to administer the program.

Federal and state laws and regulations provide protections designed to safeguard applicant and enrollee data that limit the use and sharing of personal information for administering the program. For example, the Social Security Act and accompanying regulations require that the “the use or disclosure of information concerning applicants and beneficiaries” must be restricted to “purposes directly connected” with administering state health coverage programs and that states safeguard the information so that it is “protected against unauthorized disclosure for other purposes.” At a minimum, safeguarded information must include names and addresses, medical services provided, social and economic circumstances, agency evaluation of personal information, medical data, information for verifying eligibility and medical assistance payments, social security numbers, and any information received in connection with identification of legally liable third party resources. Consistent with these laws and regulations, prior guidance issued in 2013 clarified that Immigration and Customs Enforcement does not use these data to pursue civil immigration enforcement. Medicaid data are also subject to Health Insurance Portability and Accountability Act (HIPAA) standards that protect sensitive health information from disclosure without a patient’s consent. Some states also have their own data privacy laws that apply to Medicaid data.

Federal regulations also require states to publicize the confidential nature of information applicants and beneficiaries submit to them. Reflecting this requirement, many states have information on their websites specifying that data shared with the Medicaid agency will be protected. For example, the California Department of Health Care Services notes that, “When someone applies for state-funded benefits, their information is only used to determine if they qualify. State laws protect the privacy of their information.” Similarly, the Illinois Healthcare and Family Services indicates that, “Information you put on a Medicaid application will NOT be shared with U.S. Immigration and Customs Enforcement for any purpose.”

Breaches or sharing of Medicaid enrollees’ information for purposes other than the provision of health coverage and care pose risks for individuals and may jeopardize confidence in the security of data held by agencies. For example, data breaches may lead to identify theft and subsequent financial losses for individuals. Sharing of data with other entities for purposes other than administering the program without authorization may violate the privacy of individuals’ information and pose other risks. Specifically, the sharing of data with immigration enforcement officials may make individuals easier to identify for enforcement activity. Data breaches and/or privacy violations may also make individuals more reluctant to submit information to Medicaid agencies, particularly those who have immigration-related fears, which could contribute to individuals or their children going without coverage even if they are eligible.

Note: KFF’s analysis was updated on July 1, 2025 to include Wisconsin in the allocation of spending reductions due to the work requirement provision and to include Delaware in the allocation of spending reductions due to changes in state-directed payments (see KFF’s analysis of the House-passed bill for more information).

The House passed budget reconciliation package, the One Big Beautiful Bill Act, is estimated to reduce federal Medicaid spending by $793 billion, decrease Medicaid enrollment by 10.3 million people, and increase the number of uninsured people by 7.8 million. While the debate has not centered on repeal and replace of the Affordable Care Act (ACA) like the debate in 2017, several provisions in the House-passed reconciliation bill specifically target states that have adopted the ACA Medicaid expansion in various ways. Additionally, the bill would make substantial changes to how the ACA marketplaces function, and allowing enhanced ACA premium tax credits to expire would result in 4.2 million more people uninsured, according to the Congressional Budget Office (CBO). Prior KFF analysis allocated CBO’s federal Medicaid spending reductions and enrollment losses across the states, and this policy watch builds on that analysis to examine the potential impacts in expansion states compared with non-expansion states.

Provisions that would only apply to states that have adopted the ACA expansion account for roughly half ($427 billion) of the total amount of federal spending reductions in the House-passed reconciliation bill (Figure 1). These provisions include mandating that adults who are eligible for Medicaid through the ACA expansion meet work and reporting requirements ($344 billion), increasing the frequency of eligibility redeterminations for the ACA expansion group ($64 billion), imposing a federal match rate penalty for states that have expanded coverage for immigrants using state-only funds ($11 billion), and requiring additional cost-sharing for some expansion enrollees ($8 billion).

Expansion states would experience larger federal spending reductions and enrollment losses under the House-passed reconciliation bill (Figure 2). Prior KFF analysis found that federal cuts to states in the House-passed reconciliation bill would represent 12% of federal spending on Medicaid over a 10-year period and 12% of projected enrollment by FY 2034, though the shares varied by state. Expansion states would be disproportionately impacted, with federal spending cuts across expansion states representing 13% of federal Medicaid spending over the period compared with 7% across non-expansion states. Estimated enrollment losses in expansion states represent 14% of projected FY 2034 enrollment compared with 5% in non-expansion states.

Although the CBO has not yet estimated the effects of the Senate Finance Committee’s Medicaid language, there are changes to the House bill that would amplify the effects on states that have adopted the ACA expansion. The House bill prohibited states from increasing the rate of existing provider taxes, a key source of state revenues to finance Medicaid. The Finance Committee language expanded on that provision, proposing to reduce existing provider taxes, but only in states that have adopted the ACA expansion. This change could potentially reduce federal Medicaid spending in 22 states by tens of billions or hundreds of billions of dollars. Effects on hospitals would be in addition to reductions in supplemental hospital payments made by managed care organizations. The Finance Committee language would reduce those payments across a broader set of states, but the new limit would be lower in expansion states than in non-expansion states (100% and 110% of Medicare respectively). The Finance Committee language also includes a new provision to limit federal matching payments for Emergency Medicaid for individuals who would otherwise be eligible for expansion coverage except for their immigration status as well as makes changes to the federal work requirement for ACA expansion enrollees. These changes apply to expansion states only and will likely increase the total cuts that apply to ACA expansion states alone, which reached $427 billion in the House-passed bill. It is possible that new estimates of federal Medicaid cuts to ACA expansion states alone would be in the range of prior KFF estimates of federal spending reductions from eliminating the enhanced federal match rate for ACA Medicaid expansion ($626 billion).

In this research article released online by The Journal of Health Policy, Politics and Law, KFF’s Elizabeth Hamel, Alex Montero and Mollyann Brodie reflect on 30 years of public opinion data to offer perspectives on how the public accesses, evaluates, and uses health information, and what recent trends may suggest about the future of the health information (and misinformation) environment. The article examines public knowledge gaps on health and the role of partisanship in national health debates, how sources of health information have changed over time, declines in trust of information from government health agencies, and the current era of health information, including widespread uncertainty among the public and increasing use of social media and emergent technologies.

On June 18, 2025, the U.S. Supreme Court ruled (6-3) in United States v. Skrmetti, upholding the lower court’s ruling that a Tennessee law (SB1) banning gender affirming care for minors does not violate the U.S Constitution’s 14^th amendment equal protection clause. The Tennessee law, along with other states’ laws restricting gender affirming care, may stand. Access to gender affirming care in states without bans is not impacted by this decision.

As explained in the KFF brief, What to Know Ahead of the Supreme Court Case on Youth Access to Gender Affirming Care, the Supreme Court granted review for Skrmetti to resolve a split among circuits, and the ongoing questions about the constitutionality of these bans (see that brief for more background on the case). The question the Court considered was whether Tennessee’s ban on gender affirming care for minors violates the Equal Protection Clause of the Fourteenth Amendment. Embedded in its assessment, the Court considered whether the law results in sex-based classification and therefore should be reviewed with “heightened scrutiny” – that is, to show that the law is substantially related to achieving an important government objective – as opposed to the looser standard of “rational basis,” which only requires the state to show the law has a rational relation to the state’s legitimate objective.

What did the Court decide?

The Court found that because the Tennessee law classifies people based on age and medical diagnosis, it therefore does not discriminate on the basis of sex or transgender status and as such does not trigger heightened scrutiny and does not violate Constitutional Equal Protections guarantees. “SB1 satisfies rational basis review. Under that standard, the Court will uphold a statutory classification so long as there is “any reasonably conceivable state of facts that could provide a rational basis for the classification.”

Justice Sotomayor dissented, joined by Justice Jackson stating that because SB 1 does classify individuals based on sex, the Court should use heightened scrutiny, and SB 1 would fail under heightened scrutiny. Justice Kagan joined most parts of Justice Sotomayor’s decision except she filed a separate dissent to clarify she has no conclusion about whether SB 1 would satisfy heightened scrutiny.

What is the impact?

The result of the Court’s ruling means that most of the bans on gender-affirming care enacted by other states may stand as well. As of June 2025, 27 states that have enacted gender affirming care bans for minors. Bans in 25 states remain in place as a result of the ruling. Bans in Montana and Arkansas are currently permanently blocked by court order. The challenge in Montana relates to the state constitution and not federal law, and is therefore not directly impacted by the decision and the law remains blocked. A federal court blocked the Arkansas law, finding it unconstitutional based on both the Equal Protection and Due Process clauses. The Due Process claim was brought by parents stating the law took away their ability to make decisions regarding their child’s healthcare. This injunction remains in place given its basis on Due Process claims. The bans in Arizona and New Hampshire restrict only surgical care, which was not at issue before the Supreme Court, and remain in effect. Ultimately, this case leaves the patchwork of access to gender affirming care for young people in the United States in place. If a minor lived in a state without access before the decision, that access remains barred. If a minor had access to gender affirming care prior to the decision, that access remains.

There was some question as to whether the Court would apply the reasoning in Bostock, an earlier case which found that in the employment setting, sex discrimination protections apply to gender identity and sexual orientation in hiring and firing. But the Court did not do so, stating, “The Court declines to address whether Bostock’s reasoning reaches beyond the Title VII [employment] context—unlike the employment discrimination at issue in Bostock, changing a minor’s sex or transgender status does not alter the application of SB1.”

Notably, the Supreme Court heard this case narrowly on the basis of Equal Protection claims and many cases challenging state laws have been argued on multiple other grounds (including this case at the district and appellate courts). As noted, a federal district court has permanently blocked a similar ban on gender affirming care for minors in Arkansas, finding the ban violates the due process rights of parents of transgender minors. It is likely that additional cases will be filed against other state bans on due process grounds, and ultimately the Supreme Court could review a case in a future term raising 14^th Amendment Due Process, Section 1557 (the Affordable Care Act’s major non-discrimination protections), or other claims. Additionally, as noted, the Montana Supreme Court has blocked its state ban on gender affirming care for minors based on provisions in the state constitution. Litigation challenging gender affirming care based on provisions in state constitutions will also continue in state courts, , and will likely result in varying interpretations of state constitutional protections for transgender minors.

As a result of the decision, minors across the US will continue to see their access to gender affirming care determined at least in part based on where they live. However, access to these services is being debated in venues beyond the judiciary, including in Congress and by the Trump Administration. The Trump Administration has taken a range of actions aimed at limiting access to gender affirming care, especially for minors and Congress too has taken up the issue. The reconciliation bill still being finalized includes a prohibition on Medicaid covering gender affirming care in Senate and House-passed versions. These efforts will likely face, and some cases already have faced, litigation. While the ruling on this case is quite limited (narrowly focused on equal protection claims and Tennessee’s ban), it could have some bearing on the outcome of future challenges.

On May 22, the House passed the One Big Beautiful Bill Act, which the Congressional Budget Office (CBO) estimated would reduce federal Medicaid spending by $793 billion over 10 years. Over 10% of those savings came from a provision that would place a moratorium on provider taxes, keeping current taxes in place but prohibiting states from establishing any new provider taxes or from increasing the rates of existing taxes. On June 16, the Senate Finance Committee released reconciliation language expanding on that provision by also reducing existing provider taxes in states that have adopted the Affordable Care Act (ACA) Medicaid expansion. Specifically, the Finance Committee language would reduce the safe harbor limit (currently 6.0% of revenues) for states that have adopted the ACA expansion by 0.5% annually until they are within a lower safe harbor limit of 3.5%. The moratorium applies to all provider taxes, while the reduction in existing taxes would exempt nursing facilities and intermediate care facilities.

If Congress passes the reconciliation bill with the Finance Committee provision, 22 states could be required to reduce their provider taxes on either hospitals or managed care organizations, cutting a key source of state Medicaid funding in those states (Figure 1). Affected states include Arizona, California, Colorado, Connecticut, Illinois, Indiana, Iowa, Louisiana, Michigan, Minnesota, Missouri, Nevada, New Hampshire, New Jersey, New York, Oklahoma, Oregon, Pennsylvania, Rhode Island, Utah, Vermont, and Virginia.

The new restriction on states’ funding sources would apply only to states that have adopted the ACA expansion, adding another financial penalty on expansion states—in the House bill, over half of the federal spending cuts stem from provisions that only apply to expansion states. This policy watch explains how the Finance Committee provision would reduce Medicaid spending, and the implications for expansion states.

All states except for Alaska use provider taxes to help finance the state share of Medicaid spending, and those provider taxes are set in accordance with federal laws. Among other requirements, provider taxes may not hold taxpayers (providers) “harmless,” meaning that states are prohibited from directly or indirectly guaranteeing that providers will receive the taxes they pay back in the form of higher Medicaid payments, unless the provider tax comprises 6% or less of net patient revenues. The 6% limit is referred to as a “safe harbor” limit, and many states set their provider taxes below that limit so they may use provider tax revenues as a source of increased funding for hospitals and other safety net providers.

CBO’s older estimates suggest that reducing the safe harbor limit to 3.5% in expansion states could generate federal savings that are tens of billions or even hundreds of billions of dollars. Specifically, CBO estimated that reducing the safe harbor limit to 5% would reduce federal Medicaid spending by $48 billion over ten years while reducing the threshold to 2.5% would reduce federal spending by $241 billion over ten years. Those estimates apply to all states and would be somewhat lower if restricted to states that have adopted the ACA expansion.

The new limits on provider taxes in states that have adopted the ACA expansion could lead to lower hospital payment rates or reductions in Medicaid eligibility and coverage. States often use hospital provider taxes to finance higher payment rates for hospitals that serve disproportionate numbers of Medicaid or uninsured patients; some states fund the state share of the ACA Medicaid expansion or other increases in Medicaid eligibility and coverage. The House-passed version of the One Big Beautiful Bill Act is estimated to increase the number of uninsured people by 10.9 million (including 400,000 more uninsured from the provider tax provisions). CBO assumes that with limited access to provider tax financing, states would make programmatic decisions that could affect coverage. Imposing more stringent limits to provider taxes in expansion states could result in additional federal spending reductions but also could amplify negative implications for provider reimbursement rates and for coverage loss.

On May 22, the House passed a budget reconciliation bill that includes significant changes to the Medicaid program designed to reduce federal spending and enrollment, and on June 16, the Senate Finance Committee released language that could result in more significant reductions in Medicaid spending and enrollment. The Congressional Budget Office (CBO) estimated that the House bill would reduce federal Medicaid spending by $793 billion and reduce the number of people covered by Medicaid in 2034 by 10.3 million. The two largest sources of spending cuts in CBO’s estimates are establishing work requirements for adults eligible for Medicaid through the Affordable Care Act (ACA) Medicaid expansion (estimated to save $344 billion) and repealing the Biden Administration’s rules simplifying Medicaid enrollment and renewal processes (estimated to save $167 billion). Many of the reductions in coverage will be among Medicaid enrollees ages 50 and older.

The reconciliation bill could also affect access to and quality of care among older Medicaid enrollees because it includes provisions that would limit the ability of states to raise revenues to increase provider payments, limit some supplemental payments for hospitals, and pause implementation of a Biden-era rule on nursing facility staffing (although key elements of that rule were also overturned in court). Beyond the loss of Medicaid coverage, the reduction in federal Medicaid spending could spur states to make additional spending reductions by reducing covered benefits or cutting workforce payment rates that can affect care for adults ages 50 and older. This issue brief examines Medicaid coverage for the 22 million Medicaid enrollees who are ages 50 and older and implications of the provisions in the House reconciliation bill for these enrollees.

1. The 22 million adults ages 50 and older comprise 23% of Medicaid enrollees and 42% of Medicaid spending.

Adults ages 50 and older comprise 23% of Medicaid enrollment and 42% of federal and state Medicaid spending (Figure 1). The higher spending relative to enrollment is consistent with the greater health and functional needs of people as they age. Nearly half of Medicaid enrollees ages 50 and older rely on Medicaid alone for their coverage, while just over half (known as dual-eligible individuals) have Medicare as their primary source of health coverage because they are either age-eligible for Medicare (65+) or qualify due to having a long-term disability (data not shown). For dual-eligible individuals, Medicaid wraps around Medicare, paying Medicare premiums and, in most cases, cost sharing, and often pays for supplemental benefits that are not covered by Medicare, most notably, long-term care.

Even with Medicaid as the secondary payer, Medicaid spending is high for dual-eligible individuals. Dual-eligible individuals ages 50 and older account for 12% of all Medicaid enrollees but 25% of spending. Enrollees ages 50 and older with only Medicaid coverage account for 10% of Medicaid enrollment and 17% of Medicaid spending.

Relatively higher Medicaid spending among dual-eligible individuals reflects their higher rates of long-term care use. Among Medicaid enrollees who use long-term care, 63% are also enrolled in Medicare, compared to only 8% among Medicaid enrollees who don’t use long-term care. On average, Medicaid per person spending for enrollees using long term care was 8-times greater than average Medicaid spending for enrollees who did not use any long term care.

2. Over 90% of older adults with Medicaid enroll through pathways that would be affected by reconciliation provisions making it harder to enroll in and maintain Medicaid.

Among Medicaid enrollees ages 50 and older, 92% are eligible for Medicaid either through the ACA expansion pathway (27%) or through pathways that are specifically for older adults and people with disabilities (65%), both of which are disproportionately affected by the House and Senate versions of the reconciliation bill (Figure 2). In the House-passed reconciliation bill, about half of the federal spending reductions, accounting for $427 billion over 10 years, stem from provisions that only apply to states that have adopted the ACA Medicaid expansion. The biggest reductions in enrollment for expansion enrollees stem from work requirements and a new requirement for states to redetermine eligibility for expansion enrollees at least twice per year. Those changes are likely to reduce Medicaid enrollment among adults ages 50-64.

The second largest source of spending cuts in the reconciliation bill ($167 billion) stem from delaying implementation of two rules that streamline Medicaid enrollment and renewal processes until 2035. The delayed rules were expected to disproportionately increase enrollment among Medicaid enrollees eligible because they were ages 65 and older or because of a disability, who account for 65% of all older Medicaid enrollees. The first rule helps eligible Medicare beneficiaries more easily access Medicaid coverage of Medicare premiums and cost sharing while the second rule streamlines application and enrollment processes in Medicaid, including requiring states to renew eligibility only every 12 months for older adults and people with disabilities. CBO estimates that eliminating those rules would reduce the number of Medicaid enrollees by 2.3 million in 2034, 1.3 million of whom also have Medicare (dual-eligible individuals).

3. The share of adults ages 50 and older who have Medicaid coverage nationally is 14% and varies across states.

Nationally, 14% of adults ages 50 and older have Medicaid, with more than 20% of people 50 and older having Medicaid in four states and the District of Columbia (Louisiana, New Mexico, California and New York, Figure 3). Medicaid enrollees include those for whom Medicaid is their only source of health insurance and those who have Medicaid in addition to another source of coverage, including Medicare. The percentage of adults ages 50 and older covered by Medicaid tends to be higher in the 41 states that expanded Medicaid under the ACA (15%), than in states that did not expand Medicaid under the ACA (12%). Additionally, rates of Medicaid coverage among those ages 50 and older are higher in states with lower average incomes and lower rates of health insurance offered through employers.

4. More than 8 in 10 older adults on Medicaid are working or face barriers to work.

The CBO estimates that Medicaid work requirements in the House reconciliation bill, which would apply to adults ages 19-64, would reduce the number of people with Medicaid by 5.2 million. Medicaid enrollees ages 50 and older typically have lower rates of employment and increased barriers to work compared to all Medicaid enrollees ages 19-64. Among adults ages 50 to 64 with Medicaid who do not receive benefits from the Social Security disability programs, Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI), and who are not also covered by Medicare, 37% reported working full-time and 15% were working part-time. Others reported not working due to caregiving responsibilities (9%), illness or disability (20%), or school attendance (1%, Figure 4). The remaining 17% of Medicaid adults ages 50-64 reported that they are retired, unable to find work, or are not working for another reason. A 2022 CBO report found that Medicaid work requirements were unlikely to increase employment rates but would be likely to result in loss of Medicaid.

Even though both reconciliation bills provide exemptions for people based on caregiving responsibilities and illness or disability, those people still must comply with reporting requirements, increasing the risk of losing Medicaid. The provisions in the bills apply to individuals in the ACA Medicaid expansion group, so it would not include individuals who have Medicare or SSI; however, many who are enrolled in the expansion group may have a disability, despite not receiving SSI or SSDI benefits. In Arkansas, which implemented work requirements from June 2018-March 2019, about 70% of the population that had to actively report work hours lost coverage primarily due to failure to regularly report work status or document eligibility for an exemption.

5. Provisions in the House and Senate reconciliation bills could result in loss of coverage and SNAP benefits for Medicaid enrollees ages 50 and older who already report higher rates of household food insecurity compared to those without Medicaid.

The House and Senate reconciliation bills would create work requirements for the Supplemental Nutrition Assistance Program (SNAP), which could exacerbate financial challenges for older Medicaid enrollees. Medicaid enrollees ages 50 and older are over two and a half times more likely to experience household food insecurity than those not enrolled in Medicaid. Among Medicaid enrolled adults ages 50 and older, 28% live in households with food insecurity compared to 10% of those not enrolled in Medicaid (Figure 5). Among Medicaid enrollees 50 or older, nearly half (45%) were enrolled in SNAP for at least one month compared to 3% of their counterparts who were not enrolled in Medicaid. This pattern primarily reflects the significant overlap in eligibility requirements for Medicaid and SNAP, though this may vary by state and coverage population. Beyond the direct reductions proposed to SNAP, loss of Medicaid coverage may increase barriers to enrolling in SNAP as many states use Medicaid enrollment to determine eligibility for other public benefit programs, including SNAP.