The House-passed reconciliation bill includes only a few provisions that directly affect Medicare spending. It includes no provisions related to Medicare Advantage, the private plan alternative to traditional Medicare, even though analysis by the Medicare Payment Advisory Commission (MedPAC) estimates payments to Medicare Advantage plans are $84 billion (or 20%) more than spending for similar beneficiaries in traditional Medicare. In contrast, the bill instead focuses on major changes to Medicaid and the Affordable Care Act (ACA), which would reduce federal spending by over $1 trillion and increase the number of uninsured people by an estimated 10.9 million. (When combined with the effects of allowing the ACA’s enhanced premium tax credits to expire, CBO estimates 16 million more people will be uninsured in 2034.) Despite some reports last week that Senate Republicans were considering including changes to how the federal government adjusts payments to Medicare Advantage plans based on the health status of their enrollees, those now appear unlikely to be included in the Senate version.

The Medicare Advantage quality bonus program, established by the Affordable Care Act, increases Medicare payments to Medicare Advantage plans based on a five-star rating system. Plans may, but are not required to, use the additional payments to cover the cost of supplemental benefits, including reduced cost sharing, extra benefits not covered by traditional Medicare (e.g., vision, hearing and dental), and lowering Part B and/or Part D premiums. The star ratings are intended to help consumers make informed decisions when choosing among Medicare Advantage plans and the bonus payments are intended to encourage plans to compete based on quality. However, MedPAC and others have observed that the star ratings incorporate too many measures, do not adequately account for social risk factors, and may not be a useful indicator of quality because star ratings are reported at the contract rather than the plan level. Medicare Advantage contracts typically include multiple plans, which may have different benefits, costs, networks, service areas, and enroll different populations (i.e., plans that are open for general enrollment and special needs plans that limit enrollment to dual-eligible individuals).

Critiques of the quality bonus program have led to calls to replace, reform or end the program. In 2018, the Congressional Budget Office estimated that eliminating the quality bonus program would lower federal spending by almost $100 billion over ten years. Given the sharp increase in both actual and projected Medicare Advantage enrollment since CBO’s analysis, the savings from eliminating bonuses could be substantially higher. For example, 33 million people were enrolled in Medicare Advantage in 2024, which was 5 million more than CBO projected at the time of the analysis, and CBO’s most recent projections for future Medicare Advantage enrollment are nearly 30% higher than previously projected. The degree to which changes to the quality bonus program would impact plan quality or the availability of supplemental benefits would depend on the specifics of any proposal and how insurers modified plan offerings in response. Though the proposal that had reportedly been under consideration by the Senate, the No UPCODE Act, does not directly address the quality bonus program, to the extent the changes in the legislation results in lower risk scores of Medicare Advantage enrollees, spending under the quality bonus program would also be lower.

This analysis examines trends in bonus payments to Medicare Advantage plans, enrollment in plans in bonus status (plans that qualify for a benchmark increase based on their quality star rating), and how these measures vary across plan types using publicly available information on Medicare Advantage enrollment, payment rates, and quality ratings.

Key Takeaways:

• Federal spending on Medicare Advantage bonus payments will total at least $12.7 billion in 2025, similar to spending in 2023, and more than four times higher than in 2015. Since 2015, Medicare has spent at least $87 billion on quality bonus program payments.
• Most Medicare Advantage enrollees (75%) are in plans that are receiving bonus payments in 2025. Since 2019, at least 7 in 10 Medicare Advantage enrollees have been in a plan receiving a bonus payment.
• The average bonus payment per enrollee is highest for employer- and union-sponsored Medicare Advantage plans ($438) and lowest for special needs plans ($332), raising questions about the implications of the quality bonus program for high-need beneficiaries.

Medicare Advantage plans will receive at least $12.7 billion in bonus payments in 2025.

Estimated bonus payments to Medicare Advantage plans will total at least $12.7 billion in 2025, similar to 2023. Bonus payment spending had decreased slightly in 2024 following a decline in star ratings after the expiration of COVID-19 pandemic-era policies. Those policies prevented individual measures that go into calculating the star ratings from declining between 2021 and 2022 and temporarily increased star ratings for certain plans. Bonus payments have increased sharply since the program started, more than quadrupling from $3.0 billion in 2015 to $12.7 billion in 2025 (Figure 1). The total spending on the quality bonus program is less than 2.5% of the projected payments to Medicare Advantage plans in 2025 ($540 billion).

Medicare spending on bonus payments has grown faster than enrollment in Medicare Advantage, which has doubled since 2015. This spending comes at a time when the Medicare program is facing growing fiscal pressures. Medicare Advantage benchmarks (and corresponding spending) have grown faster than traditional Medicare spending in part because of the increase in bonus payments.

These estimates are a lower bound because bonus payments are risk adjusted, which is likely to increase bonus payments. The estimates also do not include additional spending that results if plans increase their bids when their benchmark is higher because of being in bonus status. For example, a plan might increase its bid to increase payments to providers, add more expensive providers to its network, or retain a larger amount as profit, provided they meet medical loss ratio requirements.

The distribution of bonus spending across plan types is similar to the distribution of enrollment in 2025, though employer plans comprise a slightly larger share of bonus spending than enrollment. Individual plans account for 61% ($7.8 billion) of bonus spending and 62% of enrollment, employer plans account for 20% ($2.5 billion) of bonus spending and 17% of enrollment, and special needs plans account for 19% ($2.4 billion) of bonus spending and 21% of enrollment in 2025 (Appendix Table 1).

Most Medicare Advantage enrollees (75%) are in plans that receive bonus payments.

In 2025, nearly 26 million people, or 75% of Medicare Advantage enrollees, are in plans that are receiving bonuses. That compares to just under 9 million people (55%) in 2015 (Figure 2). The share of enrollees in plans that receive bonus payments in 2025 is slightly higher than the previous year (72%).

Average annual bonus payments are highest for enrollees in employer- and union-sponsored plans.

In 2025, Medicare Advantage plans receive an average annual bonus of $372 per enrollee, more than double the $184 average bonus per enrollee in 2015 (Appendix Table 2). Average bonuses in group employer- and union-sponsored plans have consistently been higher than for other plans. The average bonus per enrollee in a group employer- or union-sponsored Medicare Advantage plan is $438 in 2025, compared to $368 for individual plans and $332 for special needs plans (SNPs) (Figure 3).

Bonuses are higher per enrollee in employer plans because these plans have higher average star ratings, resulting in a larger share of enrollees receiving coverage from plans that qualify for bonuses. Across the entire period of 2015 to 2025, the share of all enrollees in employer- or union-sponsored plans that received a bonus never went below 80%. In contrast, at least 80% of enrollees in individual and special needs plans were in a plan that received a bonus in only one year – 2023 (Figure 4).

Relatively low bonus payments for special needs plans, raises questions about the implications for higher need beneficiaries, including people who are dually eligible for Medicare and Medicaid.

On May 22, 2025, the U.S. House of Representatives passed a budget reconciliation bill—called the One Big Beautiful Bill Act (OBBBA)—that includes significant reductions in federal Medicaid spending to help offset the cost of tax cuts, along with changes to the Affordable Care Act (ACA), immigration reforms and  other provisions. Together, the combination of policies that increase the number of uninsured, policies that limit the ability of states to raise revenues to increase provider payments, and other changes are expected to have financial consequences for hospitals, affecting some hospitals more (or less) than others. Financial pressure on hospitals could affect patient care to the extent that hospitals respond by cutting certain expenses—such as by offering fewer services, laying off staff, or investing less in quality improvements—or close altogether, especially in rural areas. This is in addition to the direct impact of losing coverage on individuals, who would be less likely to obtain needed care as a result.

According to the Congressional Budget Office (CBO), the bill is projected to cut federal Medicaid spending by $793 billion and reduce spending related to the ACA Marketplaces by $268 billion over a decade, totaling $1.04 trillion in cuts after accounting for the indirect effects on federal revenues. CBO projects that the number of uninsured Americans would increase by 10.9 million as a result of the OBBBA—7.8 million due to changes to Medicaid and 3.1 million due to changes to the ACA exchanges—and by 16.0 million when combined with the expected expiration of the ACA enhanced premium tax credits and the implementation of proposed rules for the ACA exchanges. The substantial increase in uninsured Americans would likely lead to more uncompensated care, putting an additional strain on hospital finances. The bill would also restrict states’ future ability to raise the state share of Medicaid revenues through provider taxes, which often support higher payments for hospitals, and would limit the ability of states to create new state directed payments to increase payments to hospitals. The impact of the OBBBA on hospital finances would vary across hospitals. For example, it is likely that the OBBBA would have a disproportionate impact on hospitals caring for a relatively large number of Medicaid patients and other patients with low incomes.

Because the OBBBA is projected to increase the deficit, CBO projects it would trigger about $500 billion in mandatory reductions in Medicare spending between 2026 and 2034, including a 4% reduction in payments to hospitals, unless Congress takes action to circumvent them (which Congress has historically done).

This issue brief discusses the potential implications of the OBBBA for hospitals and explains how some hospitals (such as rural hospitals as well as urban hospitals that serve a large share of Medicaid patients) may be less well positioned than others (such as hospitals that serve a large share of commercial patients) to absorb revenue losses given their current financial status. Analyses of hospital operating margins are based primarily on RAND Hospital Data and reflect 2023 numbers.

About 4 in 10 hospitals had negative operating margins, and 12% had margins below -10%, but 24% had margins at or above 10%, suggesting some will have greater capacity than others to absorb any losses

About four in ten (39%) hospitals had negative operating margins in 2023 (Figure 1). Operating margins are a measure of financial standing that indicate the extent to which hospitals profit or lose money on patient care and other operating activities. Hospitals with negative operating margins could have a particularly hard time absorbing any losses resulting from the reconciliation bill. This could especially be the case for the more than one in ten (12%) hospitals with operating margins below -10%.

However, the remaining three fifths (61%) of hospitals had positive margins, though some of these hospitals had relatively modest margins (e.g., 22% had positive margins of less than 5%).  Roughly a quarter of all hospitals (24%) had relatively high margins of at least 10%. These hospitals may be most likely to withstand major spending reductions in the OBBBA.

Rural hospitals were more likely to have negative margins than urban hospitals

A larger share of rural versus urban hospitals had negative margins (44% versus 35%) (Figure 2). The share with negative margins was especially high among hospitals in the most remote rural areas (49%), defined here as rural areas not adjacent to a metropolitan area.

Rural hospitals have a unique set of financial challenges and could have an especially hard time adjusting to any losses resulting from the OBBBA. For example, rural hospitals tend to be smaller facilities with lower volume. Operating at a smaller scale can lead to a higher cost of providing care on average—e.g., to the extent that the fixed costs of operating a hospital, such as maintaining a minimum number of staff, are spread across fewer patients—and may limit the ability of rural hospitals to offer specialized services.

The ability to absorb any losses resulting from the reconciliation bill would likely vary across rural hospitals, as is true of hospitals overall. More than four in ten (44%) rural hospitals had negative margins, and about one in seven (15%) had margins of less than -10%. Negative margins were more common among rural hospitals in states that had not expanded Medicaid (especially those in the most rural areas) and among sole community, Medicare-dependent, and low-volume hospitals, among other differences. A major provision in the reconciliation bill – a work and reporting requirement in Medicaid – would only apply to the Medicaid expansion. However, other provisions, such as cutbacks on the ACA Marketplaces, would likely disproportionately affect states that have not expanded Medicaid.

At the same time, more than half (56%) of all rural hospitals had positive margins. Nearly a quarter (23%) of rural hospitals had relatively modest margins (less than 5%) while about one fifth (19%) had margins of at least 10%. Positive margins were more common among rural hospitals with more beds, with higher occupancy, that were affiliated with a health system, and that were not government-owned.

Hospitals that serve a large share of Medicaid patients in urban and rural areas were more likely than others to have negative margins, and they could be disproportionately affected by the House-passed bill

Hospitals where Medicaid covered a high share of stays—a group that could also have an especially hard time absorbing any losses resulting from the OBBBA—were more likely than others to have negative margins. For example, 45% of hospitals with high shares of Medicaid patients had negative margins versus 35% among hospitals with low shares. The share with negative margins was relatively high among hospitals with high Medicaid shares in both urban and rural areas (44% and 48%, respectively). Relatedly, operating margins were lower than average among hospitals with high Medicaid shares (e.g., they were 2.3% among hospitals with high shares versus 7.0% among those with low shares).

Hospitals caring for a disproportionate share of Medicaid patients and other patients with low incomes have unique financial challenges. For example, Medicaid and other public payers tend to reimburse at lower rates than private insurance, and it may be more expensive to treat patients with low incomes in ways that are not captured in reimbursement rates.

Further, it is likely that hospitals caring for a relatively large share of Medicaid patients and other patients with low incomes would take the biggest hit under the OBBBA, since the bill achieves much of its savings through Medicaid cuts along with changes to the ACA exchanges that would increase the number of uninsured individuals.

Hospitals with for-profit ownership, high commercial shares, and high commercial-to-Medicare price ratios were more likely to have positive margins than other hospitals, among other differences

While about six tenths (61%) of hospitals had negative operating margins, the share was higher among for-profit hospitals (71%), hospitals where commercial payers cover a relatively large share of stays (73%), hospitals with high commercial-to-Medicare price ratios (75%), hospitals that were part of a broader health system (66%), and hospitals with high market shares (73%) (Figure 4). These hospitals may have an easier time than others in absorbing any losses related to the OBBBA.

In most states (29), at least four in ten hospitals had negative margins in 2023

The share of hospitals with negative margins varied across states, but in more than half of all states (29 states), at least four in ten hospitals had negative margins (Figure 5). At least half of hospitals had negative margins in 14 states. This includes a mixture of red states (such as Kansas and Oklahoma) and blue states (such as Massachusetts and New York). At least 60% of hospitals had negative margins in four states: Kansas, Mississippi, Vermont, and Washington.

Differences in hospital finances across states may be attributable to variations in demographics, hospital ownership and type, commercial reimbursement rates, and state and local health and tax policy. For instance, the share of hospitals in the red may have been relatively low in Texas in part because the state has a relatively large number of for-profit hospitals (which are less likely to have negative margins) among other factors. The relatively low share of hospitals with negative margins in Florida may be at least partly due to relatively high commercial prices as a percent of Medicare rates.

Some states with a relatively large share of hospitals with negative margins may be disproportionately affected by the OBBBA and other policy changes. For instance, three fifths (60%) of hospitals in Mississippi had negative margins. If the OBBBA were enacted, the ACA enhanced tax credits expired, and the proposed rules for the ACA Marketplaces were implemented, then the share of people who are uninsured is expected to increase, putting a particular strain on hospitals in states that experience large increases in the number of uninsured.  The uninsured rate in Mississippi would increase by 6 percentage points—one of the highest increases in the country—based on KFF estimates. As another example, in Washington, where more than three fifths (63%) of hospitals had negative margins, the reduction in federal Medicaid as a share of baseline spending resulting from the OBBBA would be the largest of all states (17% over ten years) according to KFF estimates.

The bill could trigger about $500 billion in mandatory Medicare cuts, including cuts in payments to hospitals and other providers, unless Congress intervenes

Because the bill is expected to increase the federal deficit, CBO projects it would trigger about $500 billion in mandatory cuts to Medicare spending between 2026 and 2034—including a 4% cut in payments to hospitals and other providers—unless Congress intervened. The automatic reductions in Medicare payments to hospitals and other health care providers and plans, known as “sequestration,” would be required under the Statutory Pay-As-You-Go (PAYGO) Act. If these cuts did go into effect, they would come at a time when the Medicare Payment Advisory Commission has recommended that Congress increase Medicare payment rates in 2026 relative to current law and could raise concerns about the adequacy of Medicare reimbursement. Historically, Congress has voted to waive automatic Medicare payment reductions due to sequestration under statutory PAYGO rules.

DEERFIELD, Ill. & SAN FRANCISCO, June 12, 2025 –  Walgreens and Greater Than HIV/STDs, a public information campaign from KFF, are joining with health departments and community organizations to provide free rapid HIV, syphilis and hepatitis C testing at more than 575 Walgreens stores on June 27 for the nation’s largest National HIV Testing Day (NHTD) event. 

With more than 415 local testing partners in nearly all states, Washington, D.C. and Puerto Rico, this year’s activation marks a record level of participation in the partnership’s 15-year history. Since 2011, KFF’s Greater Than HIV and Walgreens National HIV Community Partnership has provided more than 93,000 free HIV/STD tests through the in-store NHTD program.

“This year’s record-breaking National HIV Testing Day activation shows the power of public-private partnership,” KFF Senior Vice President Tina Hoff said. “Together with Walgreens and hundreds of community organizations from across the nation, we’re reaching more people than ever with free, fast HIV and STD testing—and expanding awareness about powerful new prevention tools like PrEP and doxy-PEP, along with advances in treatment.”

“The Greater Than campaign plays a vital role in reaching those in need with accessible information about the latest in HIV and STD testing, prevention and treatment,” said Rick Gates, chief pharmacy officer, Walgreens. “All Walgreens pharmacists receive HIV prevention and destigmatization training, and about 3,000 of our specialty and community pharmacists have completed advanced training in HIV treatment and prevention. Partnering once again with KFF strengthens our ability to help patients access the care and support they need most.”

HIV and STD testing will be available on-site in a private area of the store or mobile unit administered by trained counselors with results available in 20 minutes or less. Information about the latest in prevention, including PrEP and doxy PEP, and advances in treatment will also be available.

With ongoing high rates of syphilis, including congenital syphilis (transmission during pregnancy or delivery), along with other STDs in the U.S., the activation expanded last year to include additional testing offerings.More than 22,000 rapid HIV, syphilis and hepatitis C tests have been donated to support this year‘s activation by leading manufacturers, including Diagnostics Direct, NOWDiagnostics, OraSure Technologies, Chembio Diagnostics, and bioLytical Laboratories.Click here for a list of participating Walgreens stores and testing hours. Appointments are not required.To get out the word about the importance of HIV/STD testing throughout June, Mesmerize, a national advertising network, is donating time on 1,200 screens in 750 clinics and community organizations for Greater Than videos.

About WalgreensFounded in 1901, Walgreens (www.walgreens.com) has a storied heritage of caring for communities for generations and proudly serves nearly 9 million customers and patients each day across its approximately 8,500 stores throughout the U.S. and Puerto Rico, and leading omni-channel platforms. Walgreens has approximately 220,000 team members, including nearly 90,000 healthcare service providers, and is committed to being the first choice for retail pharmacy and health services, building trusted relationships that create healthier futures for customers, patients, team members and communities.

Walgreens is the flagship U.S. brand of Walgreens Boots Alliance, Inc. (Nasdaq: WBA), an integrated healthcare, pharmacy and retail leader. Its retail locations are a critical point of access and convenience in thousands of communities, with Walgreens pharmacists playing a greater role as part of the healthcare system and patients’ care teams than ever before. Walgreens Specialty Pharmacy provides critical care and pharmacy services to millions of patients with rare disease states and complex, chronic conditions.

About KFF

KFF is the independent source for health policy research, polling, and journalism. Its mission is to serve as a nonpartisan source of information for policymakers, the media, the health policy community, and the public. KFF’s Greater Than HIV initiative is a leading public information response focused on HIV in the U.S. Through localized Greater Than HIV campaigns, KFF works with health departments and community partners to reach those most affected and in need with the latest on testing, prevention and treatment. This public-private partnership model helps extend the reach of limited resources in high need areas.

Over the years, policymakers have expressed ongoing concern about barriers to medical care in rural areas, due to workforce shortages, long travel times to medical facilities, and rural hospital closures. For the more than 10 million people with Medicare who live in rural areas, both older adults and younger beneficiaries with permanent disabilities, these issues may pose particular challenges to the extent they are more likely than other people to have medical conditions that require frequent visits to health care providers. Compounding existing challenges to the delivery of health care in rural areas, current proposals by the GOP-led Congress to cut billions in Medicaid spending and discontinue enhanced subsidies for Marketplace coverage could impact the financial stability of rural hospitals and other health care providers, which could heighten concerns about access to care for rural residents, including millions of people with Medicare.

Over the years, federal and state lawmakers have taken steps to improve rural health care for Medicare beneficiaries, including support for Rural Health Clinics (RHCs), preservation of rural hospitals at risk of closure under the Rural Emergency Hospital (REH) and Critical Access Hospital (CAH) programs, and increased training opportunities for medical residents at sites that serve rural communities. Additionally, the House-passed 2025 reconciliation bill proposes to expand the definition of a rural emergency hospital under the Medicare program. However, the Trump administration is proposing $1 billion in cuts to HRSA’s Health Workforce Programs, which support training for providers in rural and underserved areas, as part of the President’s FY 2026 budget. While budget decisions ultimately rest with Congress, these proposed changes could also affect the health care of people living in rural communities.

To help inform current policy discussions, this brief analyzes various data sources to highlight key facts about Medicare beneficiaries living in rural areas, including their demographic and health characteristics, access to care, and satisfaction with care. The analysis compares Medicare beneficiaries living in rural areas, including those that are not adjacent to any urban areas (referred to as the “most rural areas”) and those that are adjacent to an urban area (“rural adjacent areas”), and urban areas (see Methods for further details). More than 10 million Medicare beneficiaries lived in rural areas in 2024, 3.4 million of whom were in the most rural areas.

Key Takeaways

• A larger share of Medicare beneficiaries living in the most rural areas than beneficiaries living in urban areas had annual incomes of less than $20,000 per person in 2022 (34% vs. 27%).
• Rural Medicare beneficiaries are more likely to also be enrolled in Medicaid than those in urban areas (23% and 18% respectively).
• About one-third (32%) of Medicare beneficiaries living in the most rural areas had 5 or more chronic health conditions, as compared to 25% of beneficiaries living in urban areas.
• The majority (58%) of Medicare beneficiaries living in the most rural areas are covered by traditional Medicare instead of Medicare Advantage, while in rural adjacent and urban counties, traditional Medicare is less common (48% and 44%, respectively).
• While more than 9 in 10 Medicare beneficiaries living in the most rural areas were satisfied with the quality of their medical care and fewer than 1 in 10 reported trouble getting needed care, larger shares reported food insecurity (21%) and health care cost-related problems (13%) than beneficiaries in urban areas (16% and 10%, respectively).
• A smaller share of Medicare beneficiaries living in the most rural areas reported that their usual provider offers telehealth services than beneficiaries in urban areas (57% vs.67%).

More than 10 million Medicare beneficiaries live in rural areas, including 3.4 million who live in the most rural areas

Among the 61 million Medicare beneficiaries with both Parts A and B in 2024, 3.4 million, or 6%, lived in the most rural areas of the country (Figure 1). Another 7.3 million lived in rural adjacent areas and 50.4 million lived in urban areas. The share of Medicare beneficiaries living in the most rural areas varied across states, ranging from 61% in Wyoming to less than 5% in 17 states, including Florida, New York, and California (Figure 1, Appendix Table 1).

Medicare beneficiaries in the most rural areas are more likely to have lower incomes than beneficiaries in urban areas

More than one-third of Medicare beneficiaries living in the most rural areas had annual incomes of less than $20,000 per person in 2022 (34% vs. 27% in urban areas) (Figure 2). Likewise, nearly three-quarters of beneficiaries living in the most rural areas had annual incomes of less than $40,000 per person (72% vs. 56% in urban areas). Having a relatively low income can pose a barrier to access to care for Medicare beneficiaries who may need to pay for costly or unanticipated medical care, as well as services not covered by Medicare, including dental services and long-term services and supports.

Medicare beneficiaries living in rural areas are more likely to rely on Medicaid than beneficiaries in urban areas

In 2022, a larger share (23%) of Medicare beneficiaries living in rural areas (including the most rural counties and rural adjacent counties) also had Medicaid coverage (i.e., “dual-eligible individuals”) than beneficiaries in urban areas (18%) (Figure 3). For these individuals, Medicare is their primary source of health insurance coverage, and Medicaid wraps around their Medicare coverage by paying Medicare premiums, and in most cases, cost sharing. Many dual-eligible individuals also have Medicaid coverage of benefits not covered by Medicare, including long-term services and supports. Dual-eligible individuals generally have low incomes, modest assets, and are more likely to be in poorer health and have greater health needs than Medicare beneficiaries without Medicaid.

Medicare beneficiaries living in the most rural areas have higher rates of chronic conditions and are more likely to be under 65 with permanent disabilities than beneficiaries in urban areas

Roughly one-third of Medicare beneficiaries living in the most rural areas had 5 or more chronic health conditions (32% vs. 25% in urban areas) (Figure 4). The share of beneficiaries in the most rural areas with specific chronic conditions included 66% with hypertension (vs. 61% in urban areas), 36% with heart disease (vs. 30% in urban areas), and 22% with a pulmonary condition (vs. 18% in urban areas) (Appendix Table 2).

More than one in five Medicare beneficiaries living in the most rural areas had a cognitive impairment (21% vs. 16% in urban areas), which may present additional challenges when navigating the health care system, particularly for those who must travel long distances to reach their health care appointments and may need to rely on family members or caregivers for transportation.

A larger share of Medicare beneficiaries in living in the most rural areas and in rural adjacent areas were under age 65 with permanent disabilities, relative to those living in urban areas (13%, 16% and 11%, respectively). People under age 65 typically qualify for Medicare once they have received Social Security Disability Insurance benefits for at least 24 months. Medicare beneficiaries under age 65 are more likely than older beneficiaries to experience problems with their health insurance, including cost-related problems and difficulty accessing needed health services.

A majority of Medicare beneficiaries in the most rural areas get their coverage from traditional Medicare than Medicare Advantage

In 2024, nearly 6 in 10 (58%) Medicare beneficiaries living in the most rural areas were in traditional Medicare and 42% were enrolled in a Medicare Advantage plan (Figure 5). This pattern is in contrast to beneficiaries living in other areas, where more than half of eligible beneficiaries (52% in rural adjacent areas and 56% in urban areas) were in Medicare Advantage, and the remaining 48% and 44%, respectively, were in traditional Medicare. This pattern is driven in part by the fact that fewer Medicare Advantage plans are available to people living in the most rural areas. More limited participation of local providers in Medicare Advantage plan provider networks in rural areas is also likely to factor into lower Medicare Advantage enrollment in the most rural areas.

Among traditional Medicare beneficiaries in rural areas, most had some form of additional coverage—including 4 in 10 with a Medigap policy—but a larger share had no form of supplemental coverage compared to beneficiaries in urban areas. In 2022, similar shares of traditional Medicare beneficiaries in rural and urban areas (40% vs 43%) had a Medicare supplement insurance policy, also known as Medigap, to supplement their traditional Medicare coverage (Figure 6). Medigap policies, sold by private insurance companies, limit the financial exposure of Medicare beneficiaries by partially or fully covering Medicare’s cost-sharing requirements, but premiums for these policies can be costly and vary by state and policy type. Additionally, similar shares had some employer-sponsored insurance in addition to their traditional Medicare coverage.

However, a larger share of traditional Medicare beneficiaries in rural areas, including both the most rural counties and rural adjacent counties (14%), had no supplemental coverage than beneficiaries in urban areas (10%). These beneficiaries are fully exposed to Medicare’s cost-sharing requirements, and for those under age 65 in rural areas, getting a Medigap policy may be particularly challenging due to the lack of guaranteed issue rights for this group.

A small share of rural Medicare beneficiaries report difficulty accessing medical care, but they are more likely than beneficiaries in urban areas to report economic struggles, including health care cost-related problems and food insecurity

Most Medicare beneficiaries, including those in rural areas, report being satisfied with the quality of their medical care and few report difficulty accessing care. More than 9 in 10 Medicare beneficiaries living in the most rural areas, rural adjacent areas, and urban areas reported being satisfied or very satisfied with the quality of their medical care. Likewise, fewer than 1 in 10 beneficiaries in the most rural areas, rural adjacent areas, or urban areas reported difficulty accessing needed health care (Figure 7).

Medicare beneficiaries living in rural areas were more likely to report economic struggles, however, including food insecurity and health care cost-related problems (Figure 8). In 2022, more than one in five beneficiaries living in the most rural areas (21%) and rural adjacent areas (22%) reported some type of food insecurity in the past year compared to 16% of beneficiaries in urban areas. This includes running out of food and not having money to buy more, cutting the size of meals or skipping meals because there wasn’t enough money for food, eating less because there wasn’t enough money for food, or feeling hungry and not eating because there wasn’t enough money for food.

Additionally, larger shares of Medicare beneficiaries in the most rural areas (13%) and rural areas adjacent to urban areas (15%) reported having at least one of the following health care cost-related problems than beneficiaries in urban areas (10%): trouble getting needed health care due to cost, delays in health care due to cost, or problems paying medical bills.

Medicare beneficiaries in rural areas are less likely to be offered telehealth services by their usual providers than beneficiaries in urban areas

Among Medicare beneficiaries with a usual source of care, a lower share of beneficiaries in the most rural areas (57%) and areas adjacent to urban areas (51%) reported that their usual provider offers telehealth services compared with beneficiaries in urban areas (69%) (Figure 9). Lower rates of telehealth offerings by rural providers may reflect differences in provider capacity and health system infrastructure challenges in rural areas relative to urban areas.

Additionally, among traditional Medicare beneficiaries, 10% of those in rural areas used Medicare-eligible telehealth services compared to 14% of those in urban areas as of the third quarter of 2024, based on fee-for-service claims data. While telehealth use has the potential to improve access to care in areas with a shortage of health care providers or where people must travel farther to access medical care, lower use of telehealth services in rural areas could be partly due to more limited broadband access. According to the Federal Communications Commission, in 2022, 28% of Americans in rural areas lacked broadband internet coverage compared to just 2% of people in urban areas.

During the COVID-19 public health emergency, Congress enacted several Medicare telehealth flexibilities that were initially set to expire at the end of the public health emergency. However, these flexibilities have been extended multiple times, with the latest extension set to expire on September 30, 2025, unless Congress takes further action.

Appendix

Update: On June 17^th, 2025, SAMHSA announced that it would end the 988 LGBTQI+ specialty service stating “The 988 Suicide & Crisis Lifeline will no longer silo LGB+ youth services, also known as the “Press 3 option,” to focus on serving all help seekers, including those previously served through the Press 3 option.”  

Since taking office, the Trump administration has pursued various policy actions that could limit health services and access for LGBTQ+ people, including those related to mental health. LGBTQ+ people experience elevated stigma, discrimination, and mental health challenges, along with greater unmet mental health needs. Dedicated services tailored specifically to LGBTQ+ individuals aim to address these distinct needs and experiences.

988, the federal suicide and crisis line, supported by the Substance Abuse and Mental Health Services Administration (SAMHSA), includes a specific service to meet the needs of LGBTQI+¹  youth and young adults under the age of 25.²  This specialty service, initially launched in pilot form in October 2022 and expanded nationwide in July 2023, has experienced increasing demand. The Trump administration’s FY 2026 budget request includes level funding for 988 overall, including its Spanish language service, but eliminates dedicated funding for the LGBTQI+ service. Additionally, promotional materials for 988’s LGBTQI+ service were removed from SAMHSA’s website in early February 2025.³  With this exclusion from the proposed budget, removal of materials, along with other actions, the future of the 988 LGBTQI+ service is uncertain. (For additional history of the LGBTQI+ service and, 988 more broadly, see our earlier analyses.)

This brief reviews the latest data on the 988 LGBTQI+ service.

Since its launch (including the pilot phase) the 988 LGBTQI+ service has received nearly 1.3 million contacts from LGBTQI+ youth and young adults seeking support, and usage has risen substantially. Like the broader 988 service, the 988 LGBTQI+ service is available via call, text, or chat. Between July 2023, when the LGBTQI+ service fully launched following the pilot program, and February 2025 (the latest available data):

• Service utilization has steadily increased with contacts to the LGBTQI+ service rising by 46% over this period.
• The service has averaged about 50,000 contacts per month, with most occurring by call (60%), followed by text (25%), and chat (15%). More recently, from October 2024 to February 2025, average monthly contacts have remained steady at about 60,000.
• Contacts to the 988 LGBTQI+ service represented 10% of all 988 contacts, including 13% of all texts, 12% of all chats, and 9% of all calls.
• People contacting the 988 LGBTQI+ service experienced slightly higher disconnection rates than 988 users overall (13% v. 10%). According to SAMHSA, disconnections may be due to a technical reason (e.g. internet or mobile connection strength or service interruptions, etc.) or because the person ends the contact before a counselor responds.

The 988 LGBTQI+ service offers specialized crisis care tailored to LGBTQI+ youth and young adults, who experience higher rates of serious suicidal thoughts and suicide attempts compared to their peers. This dedicated service addresses the specific challenges commonly facing LGBTQI+ young people and their associated higher unmet need for mental health services. In 2023, 41% of LGBTQ+ high school students reported having seriously considered suicide during the past year, and 20% reported a suicide attempt, compared to 13% and 6%, respectively, among non-LGBTQ+ students (Figure 2).

The President’s budget request is only a proposal, with Congress ultimately determining appropriations, and Congress has historically provided specific funding for the LGBTQI+ service. Most recently, Congress appropriated $520 million for 988, including 6% ($33 million) for this service. However, recent administrative actions, and the President’s budget request, have created uncertainty about the future of the program.

1. SAMHSA uses the acronym “LGBTQI+” in describing and discussing this service. In other contexts, SAMHSA has defined “LGBTQI+” as “people identifying as lesbian, gay, bisexual, transgender, queer, questioning, intersex, two-spirit, and other diverse sexual orientations, gender identities, and expressions.” ↩︎
2. 988 also has specialty services for veterans and Spanish speakers, and operators trained to meet the needs of people who are deaf or hard of hearing. ↩︎
3. Previously, LGBTQI+ people were identified as a “resource population,” a designation for groups receiving specifically tailored promotional materials   ↩︎

This brief has been updated to reflect Secretary of Health and Human Services Kennedy’s announcement dismissing all members of the Advisory Committee on Immunization Practices , issued on June 9, 2025.

The federal government routinely relies on external advisory committees to inform policy across multiple areas. In the context of vaccines, these include several committees that assist in informing the government on vaccine policy, vaccine approvals, and vaccine recommendations for use among the public. Still, while advisory committees have served an important function in this regard for years, members of the Trump administration have raised critiques and questions about the role of these committees and taken actions in the past few weeks that have bypassed their input altogether. For example, Secretary of Health and Human Services (HHS) Robert F. Kennedy, Jr. has long raised concerns about conflicts of interest and a lack of transparency on federal vaccine advisory committees, and has recently said he intends to make changes to these committees.  On June 9, 2025, Kennedy took a major step in this direction, dismissing all members of the Advisory Committee on Immunization Practices (ACIP), a key external advisory committee for the Centers for Disease Control and Prevention (CDC). In addition, in recent days officials at HHS and FDA announced a number of changes to policies regarding the review, approval, and recommendations for COVID-19 vaccines, which were implemented without any input from advisory committees. These statements and actions raise questions about the roles external vaccine advisory committees will play going forward, and whether and how federal health agencies will tap into their advice when making policy decisions.

Given this context, this brief provides an overview of key federal vaccine advisory committees and discusses policy issues and questions they currently face.

Background

External advisory committees are established by Congress, federal departments, and agencies as tools for “furnishing expert advice, ideas, and diverse opinions.” Almost all federal external advisory committees are governed by the Federal Advisory Committee Act (FACA), and operate under a common set of rules and guidelines. Each advisory committee under FACA is required to have a charter, which outlines key processes and procedures such as how members are selected, how long members serve, the number of members and voting privileges, meeting schedules, reporting, and other aspects.

External advisory committees are typically comprised of the following types of members:

• Special Government Employee (SGE) members are subject matter experts drawn from outside the U.S. government. SGEs are expected to provide independent input and judgment on behalf of the government and to be free of conflicts of interest – U.S. Code prohibits SGEs from serving on a committee if doing so has a “direct and predictable effect” on their financial interests.
• Ex-officio members are federal employees who represent relevant federal offices.
• Representative members are individuals from non-government entities that represent points of view from particular groups or interested parties. For example, there may be representatives present on advisory committees from interested professional associations and/or patient groups.

Committees are overseen by and report to staff from associated federal departments or agencies. For the most part, federal external committees are advisory only – they do not set federal policy and instead only provide input and recommendations for consideration. However, some committees, such as the Advisory Committee on Immunization Practices, have certain statutory roles related to federal vaccine programs (see more below).

In the context of federal vaccine policy, there are four main advisory committees that have been established: the Vaccines and Related Biological Products Advisory Committee (VRBPAC) at the Food and Drug Administration (FDA); the Advisory Committee on Immunization Practices (ACIP) at the Centers for Disease Control and Prevention (CDC); the National Vaccine Advisory Committee (NVAC) at the Department of Health and Human Services (HHS); and the Advisory Commission on Childhood Vaccines (ACCV) at HHS.

Vaccines and Related Biological Products Advisory Committee (VRBPAC)

Overview and governance: The Vaccines and Related Biological Products Advisory Committee (VRBPAC) at FDA reviews and evaluates scientific data on the safety and effectiveness of vaccines and provides independent advice on these issues to the FDA Commissioner. It was initially established in 1979 under U.S. code (21 U.S.C 394) and is subject to the provisions of the FACA. It is managed by the FDA’s Center for Biologics Evaluation and Research (CBER). Its most recent charter was approved in July 2024; the charter must be renewed every two years or the committee will be terminated, so charter renewal will be due by July 2026.

Membership: There are 15 voting members of VRBPAC, including a Chair. Committee members are selected by the FDA Commissioner from individuals outside the government with expertise in relevant areas and serve for up to four-year terms. One voting member, as selected by the Commissioner or designee, can be selected to represent “consumer interests” while one non-voting member can be selected to represent “industry interests.” There are two ex-officio voting members: one representing the CDC and one representing the National Institutes of Health (NIH). Voting members are subject to FDA and federal government conflict of interest standards and safeguards.

Responsibilities and process: According to its current charter, VRBPAC is meant to be convened approximately six times a year, with meetings open to the public except as determined by the FDA Commissioner or their designee. Each VRBPAC meeting is announced in advance, with an agenda of topics for review by committee members. Typically, the committee is convened to consider one or more candidate vaccines under review by the FDA, which can be new vaccines or updates to existing vaccines. Committee members review background materials and receive presentations that summarize information on the safety and efficacy of the candidate vaccine(s). There is time allotted for questions and deliberation, including public comments and questions. Voting members are typically asked to vote on specific questions, such as whether the candidate vaccine should or should not be approved by the FDA. The vote results and other information from the meeting are then reviewed and considered by FDA staff and the Commissioner as they make final decisions regarding vaccine approval or authorization, but the FDA Commissioner is not required to follow the recommendations of the committee.

Recent and upcoming meetings & topics: In 2024, the committee met four times. Since taking office, the Trump Administration has convened one VRBPAC meeting, which was held May 22, 2025 and focused on formula selection for COVID-19 vaccines for the 2025-2026 season. Earlier this year, there had been a VRBPAC meeting scheduled for March to review influenza vaccine composition for the 2025-2026 season, but it was cancelled with no reason given. Instead, FDA announced it held a closed-door interagency meeting of government experts to discuss this topic and that group agreed on a set of recommendations for influenza vaccine composition for the coming season without external input from VRBPAC.

Advisory Committee on Immunization Practices (ACIP)

Overview and governance: The Advisory Committee on Immunization Practices (ACIP) provides the CDC Director with expert opinion and recommendations about the use of vaccines. ACIP was established in 1964 under section 222 of the Public Health Service Act (42 U.S.C. §2l7a), and has a Secretariat composed of CDC staff, including an Executive Secretary from the CDC’s National Center for Immunization and Respiratory Diseases (NCIRD) who is responsible for overall management and compliance with federal law. The ACIP Secretariat is responsible for renewing the charter every two years (or the committee will be terminated), and any revisions to the charter are subject to review and approval by the Secretary of HHS. The current ACIP charter was approved in April 2024, with renewal due by April 2026.

Membership: There are up to 19 voting members of ACIP including a Chair and Vice Chair. Currently, membership on the committee is in flux because on June 9, 2025, Secretary Kennedy dismissed 17 members that had been sitting on the committee. Replacements for those dismissed have not yet been announced. According to its charter, committee members are meant to be selected from technically qualified people from outside government trained in a clinical medical field with knowledge of vaccines and immunization. Also, ACIP must include a consumer representative as one of the voting members of the committee. ACIP members are selected by the Secretary of HHS and serve for up to four year terms. Voting members are considered SGEs subject to federal government conflict of interest standards and safeguards. In addition, ACIP voting members cannot be directly employed (or have an immediate family member who is directly employed) by a vaccine manufacturer and cannot hold a patent on a vaccine or related product. Further, members disclose sources of research funding at the beginning of every committee meeting and cannot vote on decisions where they are conflicted. ACIP also has six ex-officio members who are non-voting representatives from related U.S. government agencies such the FDA, the National Institutes of Health, and the Centers for Medicare and Medicaid services. In addition, there are 31 liaison (non-voting) representatives primarily representing professional organizations such as the American Academy of Pediatrics, the American Academy of Family Physicians, and the American College of Physicians.

Responsibilities and process: ACIP responsibilities include generating recommendations for the CDC Director regarding who should get a vaccine (e.g., specifying age or other criteria), what dose of the vaccine should be given, and what the timing of vaccine doses should be. In addition to generating recommendations for the CDC Director, ACIP also has certain statutory roles assigned by Congress. For example, ACIP has the responsibility to establish the list of vaccines, number of doses, schedule and contraindications for the Vaccines for Children (VFC) program, which provides vaccines to children whose parents or guardians may not be able to afford them. In addition, the Affordable Care Act and subsequent laws have indicated that health insurance plans must cover ACIP-recommended immunizations after those recommendations have been formally adopted by the CDC Director. ACIP also recommends which vaccines are required for individuals immigrating to the United States.

According to its charter, ACIP holds three regular meetings each year, though additional meetings may be scheduled as needed. Meetings are open to the public, except as otherwise determined by the CDC Director or their designee. The ACIP Steering Committee, which is comprised of representatives from each of the major centers at CDC, plans the agenda for ACIP meetings. Before meetings, each new or modified use of an existing vaccine on the agenda is reviewed by a work group consisting of ACIP members and CDC staff, which then proposes questions for consideration by the full committee. During meetings the full committee reviews this and other background information, listens to presentations, and engages in discussion and debate. In its deliberations, ACIP considers disease epidemiology and burden of disease, efficacy and effectiveness, safety, the quality of evidence reviewed, economic analyses, and implementation issues for each vaccine. The committee then votes on specific proposals or the wording of recommendations, the results of which are submitted to the CDC Director for consideration, but the CDC Director is not required to follow these recommendations.

Recent and upcoming meetings & topics: A February 2025 ACIP meeting was initially postponed and subsequently held in April 2025. That meeting covered topics that included meningococcal, respiratory syncytial virus, and chikungunya vaccines. There is another ACIP meeting scheduled starting June 24, 2025, which is expected to focus on COVID-19 vaccines for the 2025-2026 season, coming after the May 22 VRBPAC meeting on that topic. The June meeting also comes on the heels of an announcement by HHS Secretary Kennedy on May 27 that the CDC will no longer recommend COVID vaccines for healthy children or healthy pregnant women, a policy change that was reported to be a surprise to CDC staff and which was made without any input from ACIP. Further, it is unclear how many new ACIP members will be announced, vetted, and participating prior to the upcoming June 24-25 meeting now that all prior members have been dismissed.

National Vaccine Advisory Committee (NVAC)

Overview and Governance: The National Vaccine Advisory Committee (NVAC) serves an advisory role, providing peer review, consultation, advice, and recommendations to the Assistant Secretary for Health at HHS, in their capacity as the Director of the National Vaccine Program. A senior staff member of the Office of Infectious Disease and HIV/AIDS Policy (OIDP) with the Assistant Secretary of Health at HHS serves as the federal officer responsible for NVAC. The committee was established in 1986 by Congress under Section 2105 of the Public Health Service Act, and its charter was renewed in July 2023 and is due for renewal every two years or will be terminated; its next renewal would be July 2025.

Membership: NVAC consists of 17 voting members, comprised of 15 public members who are SGs, including the chair, and two members designated to serve as official representatives of the vaccine manufacturing industry. The committee also includes non-voting ex-officio representatives from federal agencies, as well as non-voting liaison representatives from other groups such as state and local health departments or non-governmental public health organizations. Members are appointed by the Assistant Secretary of Health at HHS in consultation with the National Academy of Sciences; vaccine industry groups are consulted for selection of the two voting representative members.

Responsibilities and process: NVAC advises the Assistant Secretary for Health at HHS on how to close gaps in immunization coverage and makes recommendations for how the U.S. vaccine enterprise broadly can improve the prevention of infectious diseases through vaccination. The committee’s advice and recommendations cover areas such as: barriers in the immunization delivery system, public trust in vaccines, immunization infrastructure, support for providers of immunization services, demand for immunization, vaccine safety, and fostering vaccine development and innovation. NVAC’s advice is presented to the Assistant Secretary for Health, who by law serves as the Director of the U.S. National Vaccine Program. NVAC is the only federal advisory committee that considers and makes recommendations across the entire U.S. immunization system broadly.

According to its charter, NVAC meets three times per year, and meetings are open to the public except as otherwise determined by the HHS Secretary or their designee. Meetings can cover recent and timely topics affecting the vaccines and immunizations broadly in the U.S.

Recent and upcoming meetings & topics: NVAC has not met since September 2024. At that meeting, the committee focused on areas such as Hepatitis B vaccine recommendations and implementation, approaches to equity in immunizations, provider payments for vaccination, and a review of HIV vaccine development. No NVAC meetings have been held under the Trump administration, and none have been publicly scheduled for future dates.

Advisory Commission on Childhood Vaccines (ACCV)

Overview and Governance: The Advisory Commission on Childhood Vaccines (ACCV) advises the Secretary of HHS on matters related to the implementation of the National Vaccine Injury Compensation Program (VICP). VICP is a federal program established by Congress in 1986, that provides financial compensation to individuals found to have been injured by a vaccine covered by the program (primarily childhood vaccines). The ACCV was established in 1986 under Title 42 of U.S. Code (42 U.S.C. 300aa-19). The committee is managed by the Health Systems Bureau of the Health Resources and Services Administration (HRSA). The current AACV charter was renewed in July of 2024; the charter is meant to be renewed every two years or will be terminated; the next renewal would be before July 2026.

Membership: Nine voting members appointed by the Secretary as follows: “three health professionals who are not employees of the federal government with expertise in health care of children, the prevention of childhood diseases, and the adverse reactions associated with vaccines, of whom at least two are pediatricians; three members from the general public, of whom at least two shall be legal representatives of children who have suffered a vaccine-related injury or death; and three attorneys, of whom at least one is an attorney whose specialty includes representation of persons who have suffered a vaccine-related injury or death and one who is an attorney whose specialty includes representation of vaccine manufacturers.” Voting members are considered SGEs. In addition, the Director of the National Institutes of Health, the Assistant Secretary for Health, the Director of the CDC, and the FDA Commissioner (or designees of these officials) participate as ex-officio, non-voting members.

Responsibilities and process: According to its charter, ACCV is meant to meet four times a calendar year to advise the Secretary of HHS on matters related to the implementation of the VICP. The committee does not make final decisions about individual claims (the United States Court of Federal Claims is responsible for resolving claims for compensation under the VICP) but instead makes observations about and recommendations for improvements to the VICP program. Meetings are open to the public, except as determined otherwise by the Secretary of HHS or their designee.

Recent and upcoming meetings & topics: The most recent ACCV meeting took place in July 2024, where the committee reviewed and discussed topics such as the finding from a National Academy of Medicine review of the adverse effects of COVID-19 vaccination, the latest information from CDC’s Immunization Safety Office and updates from other federal agencies on vaccine injury information. No meetings of ACCV have been held under the Trump administration, and none have been publicly scheduled for future dates. An ACCV meeting that had been scheduled for January 29, 2025 was postponed indefinitely.

Issues to Watch

Committee composition and membership. The June 9, 2025 announcement from Secretary Kennedy dismissing all sitting members of ACIP indicates that Trump Administration officials are willing and able to make significant changes to the composition of these committees, and re-fashion their membership to reflect their priorities. No changes to the membership of VRBPAC, NVAC, or ACCV have been announced so far, even as the same concerns used to justify dismissal of ACIP members – conflicts of interest – have been raised for the membership of these other committees. While FDA Commissioner Makary said he had no plans to rearrange or remove experts on FDA external advisory committees such as VRBPAC, Secretary Kennedy, who has the authority to remove members, continues to raise concerns about corruption at FDA and the committee members’ independence.

Handling of alleged conflict of interests. The primary concerns expressed by Secretary Kennedy and others in relation to external advisory committees – especially VRBPAC and ACIP – revolves around accusations of conflicts of interest. Commissioner Makary, for example, has said the FDA under his leadership will have to “review the ethics policy” because of a “cozy relationship between industry and the regulators.” Regarding ACIP, one of the first steps Kennedy took to address transparency concerns was launching a new online tool to allow the public to search for conflicts of interest among ACIP committee members. The rationale given for the dismissal of all ACIP members on June 9 was to promote trust and address conflict of interest concerns. However, there is little evidence of major conflicts of interest for current VRBPAC and ACIP committee members that have served recently, and all federal vaccine advisory committee members are already required to comply with federal regulations regarding disclosing potential conflicts of interest. For example, FDA says it “screens all advisory committee members carefully” for current financial interests and any other interests and relationships that could create the appearance that a member lacks impartiality.” In addition, VRBPAC members cannot be directly employed (or have an immediate family member who is directly employed) by a vaccine manufacturer and cannot hold a patent on a vaccine or related product. Likewise, ACIP members file annual financial disclosures, cannot work for or own vaccine manufacturer stock (nor can their family members), and cannot accept gifts from vaccine companies. Even so, more changes to committees may be coming in the future based on perceived conflicts of interest.

Uncertainty about meeting frequency and cancelations. Under the Trump administration, the pace of convenings for these committees has been relatively slow compared to the recommended frequencies noted in their charters, and compared to past years. For example, VRBPAC has met once since President Trump took office this year, even though the frequency has been four to six meetings in previous years. A VRBPAC meeting initially scheduled for March 2025 was cancelled, and a February 2025 ACIP meeting was postponed for over a month. No meetings have been scheduled for either NVAC or ACCV, which according to their charters are meant to have three and four meetings a year, respectively. NVAC, for example, met at least twice and usually three times in each of the previous six years, while ACCV met four times a year over that time frame.

Officials bypassing or ignoring committee input on key policy decisions. In the past, FDA and CDC have typically sought input from VRBPAC and ACIP when considering key vaccine policy questions. Furthermore, final policy decisions coming from these agencies regarding vaccine approvals and recommendations have typically aligned with the input provided by these committees. However, this year has seen Trump administration health officials make several vaccine policy changes without seeking committee input or doing so while ignoring committee recommendations. For example, seasonal influenza vaccine composition this year was decided without external input, in contrast to previous years. Also, FDA leaders announced that updated COVID-19 vaccines would have to undergo new placebo-controlled trials to be approved in some cases, without any input on this change from VRBPAC. In addition, HHS Secretary Kennedy recently announced CDC would no longer be recommending COVID-19 vaccines for healthy children and pregnant women, a change that was instituted without ACIP consultation and which goes against existing committee recommendations. Further, Kennedy has thus far not acted on issuing new CDC guidance expanding the recommended age range for meningitis and respiratory syncytial virus vaccinations in the U.S., even though these changes were recommended by ACIP in its April 2025 meeting (CDC guidance regarding the chikungunya vaccine, however, was updated following ACIP recommendations from the same meeting). While there is past precedent for FDA and CDC ignoring or breaking with advisory committee recommendations, it has been rare. Ultimately, the leadership of these agencies has authority to take unilateral action, and in fact the Secretary of HHS has ultimate authority over vaccine approvals and recommendations. Therefore, further changes to federal vaccine policy changes that bypass or ignore these committees may be coming.

As Congress weighs spending cuts and other changes to Medicaid, more than half (54%) of the public say they are worried significant reductions in federal Medicaid spending would negatively affect their family’s ability to obtain and afford health care, a new KFF Health Tracking Poll finds. This includes about three in 10 (29%) who say they are “very worried” about such an outcome. 

Democrats (69%) and independents (68%) are much more likely to say they are worried about the impact of potential Medicaid cuts on their families compared to Republicans generally (31%) and supporters of President Trump’s Make America Great Again (MAGA) movement specifically (26%). 

Among Medicaid enrollees themselves, a large majority (86%) worry about the impact of cuts on their families, including six in 10 (60%) who say they are very worried. Three- quarters (76%) of MAGA supporters and other Republican Medicaid enrollees say they are worried about the potential impact of federal spending reductions on their families, as are about half (53%) of Republicans with household incomes less than $40,000. 

About seven in 10 people overall also say they are worried federal Medicaid spending reductions would lead to more adults and children becoming uninsured (72%, including 46% who are “very worried”) and would negatively impact hospitals, nursing homes, and other health care providers in their communities (71%, including 42% who are “very worried”). 

These concerns are shared by residents of rural communities, where providers often rely heavily on funding from Medicaid and other government health care programs. 

Among rural residents, about half (52%) say they are worried that Medicaid funding reductions would impact their or their family’s ability to get or pay for care. A sizeable majority of rural residents also worry that spending reductions would lead to more adults and children becoming uninsured (69%) and would negatively impact health care providers in their communities (66%).  

Nearly Half of Marketplace Enrollees Identify as MAGA Supporters and Other Republicans  

With Congress and the Trump administration weighing changes to the Affordable Care Act (ACA), the poll shows that ACA Marketplace enrollees represent a diverse group. 

Nearly half (45%) of those who purchase their own health insurance plans – the vast majority of which are ACA Marketplace plans – identify as or lean Republican, including three in 10 (31%) who identify as MAGA supporters. Smaller shares identify as Democrats or Democratic-leaning independents (35%), or do not lean toward either party (20%). 

Among Medicaid enrollees, about a quarter (27%) identify as MAGA supporters or other Republicans.  

Partisans Split on Trump Administration’s Impact on Medicaid and Medicare 

About six in 10 adults say the Trump administration’s policies will weaken Medicaid (59%) and Medicare (57%), more than twice the share who say the policies will strengthen each program (19% and 23%, respectively). Half of adults (49%) say the Trump administration’s policies will weaken health care services for veterans, a larger share than say the policies will strengthen care for veterans (32%). 

Unsurprisingly, there are dramatic differences in how partisans view the Trump administration’s impact in each of these areas.  

For example, much larger shares of Democrats (91%) and independents (70%) than Republicans (22%) expect the administration’s policies to weaken Medicaid. In contrast, more Republicans (42%) than Democrats (3%) or independents (7%) say that the administration’s policies would strengthen Medicaid. Among Republicans who get their insurance from Medicaid, roughly as many expect Trump’s policies to weaken the program (34%) as expect them to strengthen it (35%). 

Designed and analyzed by public opinion researchers at KFF, this survey was conducted May 5-26, 2025, online and by telephone among a nationally representative sample of 2,539 U.S. adults in English and Spanish. The margin of sampling error is plus or minus 3 percentage points for the full sample. For results based on other subgroups, the margin of sampling error may be larger. 

President Trump released the FY 2026 budget request, the first of his second term, on May 30, 2025, following a preliminary release with topline information earlier this month. A budget request lays out presidential administration priorities both in terms of the policy issues identified 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. Congress may also pass temporary “continuing resolutions” rather than a full budget. Those appropriations can differ from levels proposed by the administration. At the same time, since taking office in January, the Trump administration has taken several executive actions to terminate or limit already appropriated funding – – including delaying and cancelling HIV-related grants – leading to litigation and creating some uncertainty regarding future spending even if funds continue to be appropriated. In addition, the administration has plans to use the recission process, whereby the president asks Congress to rescind appropriated funds, which, if approved by Congress, would reduce funding.

The FY 2026 request marks a significant change in approach for domestic HIV programs and funding levels. It eliminates or transforms several core programs, while maintaining others. Additionally, past proposals to bolster PrEP uptake were not included in this request. Notably, an OMB document leaked earlier this year indicated that the administration was considering eliminating the “Ending the HIV Epidemic” (EHE) initiative, an effort created by the first Trump administration, but the final budget request retains funding for EHE (at least for accounts where funding levels are available). While detailed funding information is not available for all accounts, where levels are known for both years, the FY 2026 budget request for domestic HIV programs represents a $1.5 billion (35%) decline compared to FY 2025 levels.

If these cuts are enacted, it could make addressing HIV more challenging at a time when Congress debates other changes to the health policy landscape, changes that could also have an impact on how people with, and at increased risk for, HIV receive access to 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 Health Resources and Services Administration’s (HRSA) Ryan White HIV/AIDS and Health Center Programs, programs that the budget moves to the new Administration for Healthy America (AHA). The request states that AHA “will prioritize prevention” and includes HIV/AIDS, among other named areas, as a focus. Funding previously provided to other departments/agencies for HIV activities is moved to AHA. This includes funding previously at 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 CDC. At the same time, the request eliminates a range of historical HIV programs including funding for domestic HIV prevention at the Center for Disease Control and Prevention’s (CDC), the Housing Opportunities for People with AIDS (HOPWA) program, 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.

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 funding previously provided to the CDC for EHE activities ($220 million) is 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 FY25 level ($1 billion, including the EHE) in 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 $77 million below the sum of these individual accounts in FY 2025. These accounts were not traditionally part of the HIV prevention budget and it is unclear whether HIV activities would be allowable activities in the reorganized account.

Ryan White HIV/AIDS Program

The Ryan White HIV/AIDS Program, the nation’s safety net for HIV care and treatment (formerly housed at HRSA, now at AHA), receives $2.5 billion in the FY 2026 request, a $74 million (3%) decrease over the FY 2025 enacted level. The request includes $165 million for EHE activities within Ryan White, the same as in FY 2025. 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) which provide 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.

Community Health Center HIV Funding

The FY 2026 budget request includes $157 million in HIV funding for the Health Center Program (formerly housed at HRSA, now at AHA), all of which is for the EHE initiative, and is the same amount as the FY 2025 level.

Administration for Healthy America (AHA) – EHE Coordination

The budget provides funding to support coordination and leadership of “EHE and other HIV/AIDS related activities, formerly carried out by OASH’s Office of Infectious Disease and HIV/AIDS Policy” (OIDP). It appears this is accompanied by $8 million in funding and may inlcude funding to support work related to other infectious diseases. Previously, these funds resided at OIDP for HIV and other activities.

Housing Opportunities for Persons with AIDS (HOPWA)

The Department of Housing and Urban Development’s HOPWA Program is eliminated in the budget. In FY 2025, HOPWA was funded at $505 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.

National Institutes of Health – Domestic HIV Research.

Historically, the National Institutes of Health (NIH) has carried out almost all federally funded HIV research activities. However, the budget proposes significant cuts to NIH overall, including to the National Institute of Allergy and Infectious Disease (NIAID) which would be cut by $2.4 billion (36%), from approximately $6.6. billion to $4.2 billion. While the amount of funding for domestic HIV research at NIH is not yet known, in FY 2025, it was $2.7 billion (amount provided to KFF via data request). The Office of AIDS Research, which sits in the Office of the NIH Director is mentioned in the budget’s technical appendix, although a specific funding amount is not provided. suggesting some level of funding may be retained. Notably though, the administration has reportedly decided not to renew core NIH funded HIV vaccine research.

Indian Health Service (IHS)

In the IHS budget justification, EHE is mentioned but no funding level is provided, nor is it described as eliminated. In FY 2025, IHS received $5 million for EHE activities to support ending HIV and hepatitis C in Indian Country.

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), aimed at “improving the health of people of color who have or are at risk for HIV” is eliminated in the proposal. In FY 2025 SAMHSA received $119 million for the MAI. Another $60 in MAI funding is eliminated from the Secretary’s Minority HIV/AIDS. In addition, as noted, MAI Ryan White funding in Part F is also eliminated in the proposal.

The tables below compare federal funding levels for domestic HIV, where specified, in the FY 2026 request to the FY 2025 continuing resolution (CR) levels. EHE funding is included in the overall table (Table 1) and in a dedicated table (Table 2).

Sources:

HHS FY26 Budget in Brief: https://www.hhs.gov/sites/default/files/fy-2026-budget-in-brief.pdf

HHS FY26 Budget Technical Appendix: https://www.govinfo.gov/content/pkg/BUDGET-2026-APP/pdf/BUDGET-2026-APP.pdf

Indian Health Services Congressional Budget Justification: https://www.ihs.gov/sites/ofa/themes/responsive2017/display_objects/documents/FY_2026_IHS_Congressional_Justification_Plan.pdf

Centers for Disease Control and Prevention Congression Budget Justification: https://www.cdc.gov/budget/documents/fy2026/fy-2026-cdc-cj.pdf

Department of Housing and Urban Development Congressional Budget Justification https://www.hud.gov/stat/cfo/cj-fy26

Consolidated Appropriations Act, 2024 (basis for FY25 continuing resolution): https://www.govinfo.gov/content/pkg/CPRT-118HPRT55008/pdf/CPRT-118HPRT55008.pdf