On May 30, 2025, the administration released additional details of its Fiscal Year 2026 budget request, including more specific information on funding for global health activities at the State Department, U.S. Agency for International Development (USAID), Centers for Disease Control and Prevention (CDC), and the National Institutes of Health (NIH). The proposed budget includes significant reductions in global health funding including the elimination of some programs and activities as follows:

State/USAID:

• Global Health Programs (GHP) Account: The main account that supports global health programs totals $3.8 billion in the request, $6.2 billion below the FY 2025 amount ($10.0 billion).
• Funding for Bilateral Programs:
  • Reducing Funding: The request provides funding for HIV/AIDS, tuberculosis (TB), malaria, polio, and global health security (GHS), but at significantly reduced levels (see table below), except for polio, which is maintained at the prior year level.
  • Eliminated Funding: The request eliminates bilateral funding for family planning & reproductive health (FP/RH), the Global Health Workforce Initiative (GHWI), maternal and child health (MCH; except for polio), neglected tropical diseases (NTDs), nutrition, and vulnerable children.
• Funding for Multilateral Organizations:
  • The Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund): The request does not include a specific funding amount for the Global Fund in FY 2026, but states that funding can be provided through either the GHP account or the newly created “America First Opportunity Fund” (A1OF) and that the amount provided cannot exceed 20% of total contributions during the 8th Replenishment for a total of up to $2.4 billion over the three year period.
  • Eliminated Multilateral Funding: The request eliminates funding for Gavi, the Vaccine Alliance (Gavi), the Pan American Health Organization (PAHO), the United Nations Children’s Fund (UNICEF), the United Nations Population Fund (UNFPA), and the World Health Organization.

Centers for Disease Control and Prevention (CDC):

• CDC’s Global Health Center: The request eliminates CDC’s Global Health Center and funding for most of its bilateral programs.
  • Maintained Programs & Funding: The request maintains funding for “Disease Detection & Emergency Response” at the prior year level ($293 million), but places it under CDC’s “Crosscutting Activities and Program Support”. The request also continues support for “Parasitic Diseases and Malaria,” placing it under “Emerging and Zoonotic Infectious Diseases,” but does not specify a funding amount.
  • Eliminated Funding: The request eliminates funding for global HIV/AIDS, global tuberculosis, global immunizations (which includes polio), and parasitic diseases.

National Institutes of Health (NIH):

• Fogarty International Center (FIC): Eliminates FIC, which was funded at $95 million in FY2025.
• Global Research: While detailed funding amounts are not yet available, the request proposes significant cuts to NIH research funding, which will likely affect global research.

Additional Resources:

• White House – Office of Management and Budget (OMB): “The President’s FY 2026 Discretionary Budget Request”
• Department of State/USAID: “Fiscal Year 2026 International Affairs Budget”
• Department of Health & Human Services (HHS): “Fiscal Year 2026 – Budget in Brief”

Every summer, health insurers submit rate filings to state regulators detailing expectations and justifying premium rate changes for ACA-regulated health plans for the coming year. With the enhanced premium tax credits set to expire at the end of 2025, consumers can expect increases in how much they pay for coverage.

KFF examines 23 early insurer premium filings from Vermont, Oregon, Washington, and Washington, DC, which include an additional 4 percent increase in premiums, on average, due to the expected expiration of the credits. While not a complete picture and insurer responses differ, these filings provide early insights into how insurers are expecting premiums to change in 2026.

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

Since the enactment of Medicare and Medicaid in 1965, the federal government has played a central role in providing support to older adults and people with low incomes, with health insurance coverage under Medicare for those 65 and older and Medicaid for those with low incomes, including older adults. The Older Americans Act, enacted that same year, is perhaps lesser known than Medicare and Medicaid but also provides important support for older adults through a broad range of community-based social services programs, including home-delivered and congregate meals, transportation services, caregiver support, chronic disease prevention services, and the Long-Term Care Ombudsman program. These programs and services may face some disruption, however, in light of the Trump administration’s organizational changes and staffing reductions at the Department of Health and Human Services (HHS), which houses the Administration for Community Living (ACL), the agency that has administered the programs and services authorized by the Older Americans Act.

According to a recent HHS press release, ACL is releasing over $1 billion of Fiscal Year (FY) 2025 funding for Older Americans Act programs to state, local, and Tribal grant recipients – funds that had already been appropriated by Congress but withheld by the Trump administration. At the same time, the Trump administration recently announced a restructuring within HHS, including budget cuts for several divisions and layoffs of 10,000 employees, with the stated goal of saving money and reducing inefficiencies. As part of this effort, the President’s proposed HHS FY 2026 budget outlines the Trump administration’s plans to dissolve ACL and integrate its functions within a newly established Administration for Children, Families, and Communities (ACFC).

The reorganization and staffing reductions at HHS create some uncertainty about the potential effect on older adults that could result from dissolving the agency at the center of administering programs and services authorized under the Older Americans Act. While the Trump administration generally can make organizational changes of this nature at federal agencies, Congress typically has the final say in determining agency funding levels and appropriating funds. The most recent reauthorization of the Older Americans Act in 2020 appropriated funds through FY 2024, with funding for FY 2025 provided through continuing resolutions at FY 2024 levels.

With the changes to ACL and other restructuring at HHS as context, this brief provides an overview of programs and services provided under the Older Americans Act, the role that was played by ACL in administering Older Americans Act programs, and trends in Older Americans Act program funding and service utilization by older adults.

What programs and services are provided under the Older Americans Act?

The Older Americans Act was signed into law in 1965 with the goal of providing older adults with home and community-based social services to support independent living as long as possible. Unlike Medicaid, the Older Americans Act does not have explicit income criteria used to determine who can qualify to receive services funded under the Act. Instead, the law aims to support people age 60 and older with the greatest economic or social need, including older adults with limited English proficiency and older individuals at risk for institutional placement.

The Older Americans Act authorizes grants from the federal government to states to provide community social services to older adults and established the Administration on Aging, an office within ACL, to administer these grant programs. The scope of Older Americans Act programs has been expanded over time and now includes home-delivered and congregate nutrition services, transportation services, state Long-Term Care Ombudsman programs, elder abuse prevention, caregiver support, elder rights and legal assistance, employment training, chronic disease prevention, and several other activities. Through this wide array of programs and thousands of service providers across states, territories, and Tribal organizations, the Older Americans Act serves millions of older adults each year.

The Older Americans Act statute includes seven titles that describe the administration and funding of the programs (Appendix Table 1). Most of the funding for Older Americans Act services falls under Title III of the Act, which authorizes grants for state and community programs on aging to provide:

• supportive services and senior centers, including case management, transportation, help with homemaker tasks, chores and personal care, adult day care, and legal assistance,
• nutrition services, including home-delivered and congregate meals,
• evidence-based prevention and health promotion services, and
• the National Family Caregiver Support Program, which provides counseling, support groups, and relief from caregiver duties.

Separately, the law also provides funding for grants to encourage health, independence, and longevity, including research programs and demonstration projects in the areas of chronic disease management and fall prevention, for example; grants to promote part-time community service employment opportunities for unemployed low-income older individuals; grants for the provision of nutrition, supportive services, and caregiver support services to older American Indians, Alaska Natives, and Native Hawaiians; grants for the Long-Term Care Ombudsman program and Elder Abuse, Neglect, and Exploitation Prevention Programs, and funding for Aging and Disability Resource Centers. (Most but not all of these programs have been administered by the Administration on Aging within ACL; the community service program is administered by the Department of Labor, while Aging and Disability Resource Centers have been administered by the Center for Innovation and Partnership within ACL.)

How is the Older Americans Act administered and what has been the role of ACL?

Under the organizational structure that existed prior to the Trump administration’s restructuring at HHS, the Administration on Aging within ACL was the office that authorized Older Americans Act grant funds to 56 State Units on Aging and hundreds of Tribal organizations. The State Units on Aging are state- and territorial-level agencies that use funds to carry out policy and development responsibilities and the administration of Older Americans Act activities. The State Units on Aging in turn work with and distribute funding to over 600 local Area Agencies on Aging, which operate within a designated planning area within the state or territory. The Area Agencies on Aging are local entities that either directly, or through contracts with nearly 30,000 local service providers, oversee a system for the delivery of Older Americans Act services.

While not part of the Older Americans Act, the State Health Insurance Assistance Program (SHIP) has also been administered by ACL through its Office of Healthcare Information and Counseling. The SHIPs provide local, in-depth, and objective counseling and assistance to Medicare beneficiaries and their families to help them make informed decisions about their care and benefits. There are 54 SHIPs, organized at the state and territory level, which may have different names in different areas. SHIP staff and volunteers provide unbiased one-on-one counseling, information, and education about Medicare benefits, how Medicare works, different Medicare coverage options, low-income assistance programs, and other types of information. The provision of SHIP services is free and not limited by income or other beneficiary demographic criteria.

How many people are helped by Older Americans Act programs?

Millions of older adults are helped by programs funded by the Older Americans Act each year – one in six, according to HHS. Focusing in on programs and services funded under Title III, which represent nearly three-quarters of total Older Americans Act funding in FY 2024, more than 12 million individuals were served by select Title III programs in FY 2023 (the most recent year available), according to data from ACL (Figure 1).

Among the programs funded under Title III of the Older Americans Act, the number of older adults served and services provided in 2023 include:

• Nutrition counseling and education: Nearly 2 million individuals received some type of nutrition counseling and education, including 1.9 million individuals who received nutrition education to support food and nutrition choices, with 2.8 million education sessions provided, and 23,000 individuals who received nutrition counseling, which includes one-on-one counseling provided by a registered dietitian who provides options and methods for improving nutrition, with 37,000 hours of nutritional counseling provided.
• Meals: Well over 1 million older adults benefited from home-delivered or congregate meals provided through the Older Americans Act, including 1.3 million who received home-delivered meals and 1.3 million who received congregate meals, with 181 million home-delivered meals and 57 million congregate meals provided to these individuals.
• Case management: 413,000 older adults received case management services, such as developing care plans, coordinating services among providers, and conducting follow-ups as needed, with 3 million hours of case management provided to these individuals.
• Legal assistance: 216,000 individuals received legal assistance, including legal advice and counseling, with 1 million hours of legal assistance provided.
• Homemaker services: 116,000 people received homemaker services, which include assistance with routine tasks such as preparing meals, shopping for personal items, managing money, or doing light housework, with 12.4 million homemaker hours provided.
• Personal care: 77,000 older adults received personal care services, which include services that help individuals with activities of daily living, with 11.3 million hours of personal care provided to these individuals.
• Assisted transportation services: 34,000 individuals received assistance with transportation services, which include escorts for people who have difficulties using regular transportation, with 1.2 million one-way assisted transportation trips provided.
• Chore services: 27,000 people were provided with chore services, including assistance with such activities as heavy housework, yard work, or sidewalk maintenance, with 599,000 hours of assistance provided to these individuals.
• Adult day care services: 8,300 individuals received adult day care services, which include personal care for dependent older adults in a supervised group setting, such as social and recreational activities, training, and counseling, with 2.6 million hours of adult day care services provided to these individuals.
• Caregiving services: The National Family Caregiver Support Program provides help to thousands of caregivers. According to the HHS FY 2024 Congressional Budget Justification for ACL, 779,000 caregivers were served by the National Family Caregiver Support Program in 2021 (data not shown). In addition, the National Family Caregiver Support Program provided 50,245 family caregivers with nearly 4.9 million hours of temporary relief from their caregiving responsibilities and provided an estimated 1.5 million contacts to caregivers, assisting them in locating services from various agencies. Furthermore, the program provided an estimated 92,865 family caregivers with counseling, peer support, and training to better cope with the stresses of caregiving.
• Other services: that are provided under Title III include transportation, such as to medical appointments or the grocery store; information and assistance, such as about opportunities and services that are available in the community; and outreach on how to use existing services and benefits. Data on the number of people who used each of these services are not collected but data on the number of services provided is collected. According to ACL, in 2023, 13.1 million one-way transportation trips were provided from one location to another, and nearly 11 million contacts for information and assistance were provided.

Among older adults receiving select Title III services in 2023, 39% were living below the poverty level, 33% were people of color, and 29% lived in rural areas, according to data from ACL (Figure 2).

In addition to the programs mentioned above that are provided under Title III, the Older Americans Act provides funding for other programs that help older adults, including:

• Long-Term Care Ombudsman program: Each state is required to operate a statewide Office of the Long-Term Care Ombudsman to improve the quality of life and care of residents of long-term care facilities, including individuals living in nursing homes and assisted living facilities, and advocate on behalf of residents. In 2024, paid and volunteer staff conducted nearly 380,000 visits to over 50,000 long-term care facilities, investigated over 205,000 complaints, and provided more than 710,000 instances of information and assistance to individuals and facility staff. These services help support the 6 million people on Medicaid who live in institutional settings.
• Social supports for older American Indians, Alaska Natives, and Native Hawaiians: As part of the social supports provided to older American Indians, Alaska Natives, and Native Hawaiians under the Older Americans Act, in 2022, nearly 600,000 transportation services were provided, including for visits to medical providers, picking up prescriptions, and staying active within their communities, an estimated 4 million home-delivered and 2.1 million congregate meals were provided, and nearly 780,000 hours of information, referral, and outreach services were provided including help with navigating health care systems and payers, making appointments, and coordinating access to services.

What are the trends in funding for Older Americans Act programs?

Federal funding for all Older Americans Act services was $2.37 billion for FY 2024, the most recent year of fully appropriated funding, with nearly three-quarters (72%) devoted to grants to states and community providers for nutrition services, caregiver support services, and other social services (Figure 3).

This is roughly the same as funding from the prior fiscal year ($2.38 billion in FY 2023) but an increase of 23% since FY 2014, when Older Americans Act funding totaled $1.92 billion – or average annual growth of 2.1% (not adjusted for inflation; Figure 4). (Congress provided temporary increases in supplemental funding to Older Americans Act programs due the COVID-19 public health emergency in FY 2020 and FY 2021.)

However, the growth of overall funding for Older Americans Act programs and services has not kept pace with the growth in the older adult population in the U.S. Between 2014 and 2024, the number of people ages 60 and older increased by 28% (2.5% average annual growth), from 64.7 million to 82.5 million. As a result, Older Americans Act funding per person age 60 or older decreased slightly over these years by 3%, though this reduction would be larger in inflation-adjusted dollars, with general prices rising by 33% (2.9% annually, on average) over this period.

Based on the president’s proposed FY 2026 HHS budget, the Trump administration is proposing level funding for most Older Americans Act programs and services, including home and community-based supportive services, nutrition programs, caregiver and family support services, and programs for the protection of vulnerable older adults, like the Long-Term Care Ombudsman program. This would mean another year with no funding increases for these programs, unless Congress provides funding above current levels in new appropriations legislation or in reauthorizing the Older Americans Act. The Trump administration proposes a reduction in funding for the Alzheimer’s disease program, from $32 million in FY 2025 to $17 million in FY 2026, along with the elimination of chronic disease self-management education.

The Older Americans Act has been reauthorized and amended several times since its passage in 1965, including most recently through the Supporting Older Americans Act of 2020, which authorized appropriations for Older Americans Act programs through FY 2024. On December 10, 2024, the Senate unanimously passed the Older Americans Act Reauthorization Act of 2024, which would have reauthorized the Act for another 5 years. The House introduced legislation that included the Older Americans Act reauthorization but this funding deal fell apart under pressure from then President-elect Donald Trump. Subsequent legislation passed by Congress to keep the government funded until March 14, 2025, and then again through September 30, 2025, did not include reauthorization of the Older Americans Act.

How could the Trump Administration’s reorganization of HHS affect Older Americans Act programs?

According to the HHS FY 2026 Budget in Brief, ACL is being dissolved and its functions integrated into the newly established Administration for Children, Families, and Communities (ACFC). Programs being shifted include home and community based supportive services, nutrition programs, aging network support activities, family caregiver support services, caregiver support services for American Indians, Alaska Natives, and Native Hawaiians, Alzheimer’s disease supportive services, and prevention of elder abuse and neglect. The administration has not yet released a detailed budget justification for the new ACFC, which makes it difficult to assess whether funding for any of the former ACL’s functions will be scaled back or terminated.

Staffing reductions within HHS and at the former ACL specifically could hinder the ability of remaining staff to oversee Older Americans Act programs. Staff cuts reported to have occurred within ACL’s budget office, evaluation and policy teams, and regional offices could impede the effective administration of Older Americans Act programs, the provision of grant funding to state and local entities, and the direct delivery of services to older adults.

Appendix

The No Surprises Act, which was signed into law by President Trump during his first term and took effect in 2022, aims to protect consumers from certain surprise medical bills. The law established processes to keep the patient out of the payment negotiations between the provider and the plan. In the event of an unsuccessful negotiation, providers and payers enter an independent dispute resolution (IDR) process in which a designated third-party arbitrator examines eligible evidence from both parties to decide on a final payment rate.

KFF’s analysis examines the implementation status of the IDR process and discusses some of the impacts on providers, payers, and ultimately, consumers, with some key findings, including that nearly two in three disputed services involved care that was furnished in an emergency room. The top 10 dispute-initiating parties are all providers or their billing consultants, and the top three parties (all of which are backed by private equity firms) accounted for 53% of payment disputes from the beginning of 2023 through mid-2024.

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

The 2025 federal budget reconciliation bill passed by the House aims to promote the use of health savings accounts (HSA) through a variety of changes to the HSA provisions included in the 2003 law that created HSAs. While these changes could provide more incentives for individuals to use HSAs, they would cost the federal government almost $45 billion over 10 years, according to an estimate from the Congressional Budget Office. This Policy Watch provides an overview of HSAs and examines key HSA-related provisions in the House-passed budget reconciliation bill and their costs to the federal budget.

What Are HSAs?

HSAs are tax-advantaged spending accounts designed to help enrollees in high-deductible plans (HDHPs) pay out-of-pocket medical costs. Individuals can contribute amounts and later make withdrawals to pay for unreimbursed qualified medical expenses (e.g., deductibles, copays, coinsurance, services not covered by insurance). There are annual contribution limits for individuals (for 2025, the contribution limit is $4,300 for individual coverage, $8,550 for a family). Employers are also eligible to make contributions to their employees’ HSAs, as well as family members on behalf of an individual with an HSA. HSAs are owned by the individual, not the employer. These accounts are characterized as “portable,” meaning they can be carried to a new job or retained upon retirement or loss of work.

A key feature of these accounts is that an individual must be enrolled in an HSA-eligible HDHP with a deductible of at least $1,650 for an individual or $3,300 for a family in 2025. HSA enrollees must pay all medical costs out-of-pocket until they reach the deductible, except for specified preventive services and certain insulin products, which insurance can start paying for before the deductible is met.

Also, an individual cannot have other health coverage in addition to the HDHP to be eligible for an HSA. So, receipt of medical services outside of the HDHP may jeopardize eligibility for an HSA. Additionally, once an individual is enrolled in Medicare, they can no longer contribute to an HSA (although they can still access funds in an existing HSA).

Health savings accounts are unique in offering a “triple-tax advantage”: contributions are tax deductible, growth of funds via investment is tax-free and account balances roll over, and withdrawals are tax-free if they are used for qualified medical expenses (e.g., doctor visits, prescription drugs, medical equipment) incurred after the HSA is established.

How Have HSAs Been Used?

According to the KFF 2024 Employer Health Benefits Survey, 22% of firms offering health benefits offered a high-deductible health plan (HDHP) paired with an HSA to their employees. Larger firms offering health benefits are much more likely than smaller firms to offer an HSA-qualified HDHP (50% for offering firms with 200 or more workers compared to 21% for firms with 3-199 workers). In addition to the contributions that enrollees can make to their HSA, employers are also permitted to contribute to covered workers’ HSAs. Among firms that contribute, the average employer contribution is $842 for single coverage and $1,539 for family coverage.

HSA-qualified HDHPs are also offered on the Affordable Care Act (ACA) Marketplace; however, the share of total health plans offered on the Marketplace that are HSA-eligible HDHPs has decreased from 7% in 2017 to 3% in 2023, and total enrollment in these plans has fallen from 8% in 2017 to 5% in 2022. Even though the deductibles of most HDHPs offered on the ACA Marketplace well exceed the minimum deductible requirements for HSAs, some HDHPs sold on the Marketplace cover services before the deductible in addition to the specific health service designs that the IRS does not permit for HSA-eligible plans. As a result, some Marketplace HDHPs cannot be paired with an HSA. The drop in HSA availability on the Marketplace could also be because the Centers for Medicare and Medicaid Services (CMS) limits insurers on the exchange to offering no more than two non-standardized plans for each standardized plan they offer in a metal level for a given product/network type (e.g., HMO, PPO).

There are disparities in HSA contributions and balances across race and income groups. Research has found that higher-income individuals are more likely than those with lower incomes to be enrolled in an HSA. One explanation for this difference could be that those with higher incomes have more means to pay for out-of-pocket expenses for medical care received pre-deductible. Additionally, the tax advantages of HSAs may be particularly attractive to higher-income individuals, who may have more disposable income to maximize contributions than individuals with lower-incomes, who may not be able to afford to contribute to an HSA. Because they are in a higher tax bracket, the reduction of taxable income by making HSA contributions is also of greater value to a higher-income family than to a family with a household income in a lower tax bracket (or that earns too little to file a federal tax return). For instance, a married couple with a household income of $600,000 saves 35 cents for every dollar they contribute to their HSA, while a married couple making a combined $80,000 saves 22 cents per dollar contributed to their HSA.

Research also finds that HSA enrollment is skewed more towards White HDHP enrollees than their Black and Hispanic counterparts, which might be exacerbating existing racial income disparities and financial barriers to health care. In an analysis conducted by the Employee Benefits Research Institute (EBRI) in 2022, accountholders living in disproportionately Black or Hispanic zip codes had, on average, lower HSA balances and lower contributions than accountholders living in disproportionately White zip codes.

Investing HSA balances provides a unique, untaxed wealth-building vehicle for those who are aware of this option and have the means to do so. Despite the appeal of the tax-free investment option though, only 9% of HSA holders in 2024 invested a portion of their funds, according to a Devenir report. However, investments made up a more substantial portion of HSA assets that same year, representing a little over two-fifths of total assets. Separately, EBRI found that disproportionately White and Asian zip codes, as well as zip codes with a higher median household income, had a higher propensity to invest HSA funds in 2022.

How Have Standards for HSAs Changed in Recent Years?

The first Trump administration was a proponent of expanding access to HSAs. In 2019, an Executive Order and subsequent guidance expanded the list of services allowed to be covered pre-deductible by HSA-qualified HDHPs to include preventive services that help maintain health status for those with certain chronic conditions. This definition was further expanded in IRS guidance from 2024. Congress in COVID-relief legislation permitted telehealth services to be covered by HDHPs pre-deductible up until the end of last year. In the Inflation Reduction Act, Congress changed the HSA law to allow individuals to access certain insulin products pre-deductible.

How Would the House-Passed Budget Reconciliation Bill Expand HSAs?

If passed by the Senate and signed into law, key changes to HSAs would include:

Making gym memberships a qualified medical expense that individuals can pay for with their HSA. The reconciliation bill would allow HSA distributions to pay for certain sports and fitness expenses, such as gym memberships and participation/instruction in physical activities. Annual HSA distributions for these expenses would be capped at $500 for single taxpayers and $1,000 for joint or head of household filers. This is the costliest provision in the budget reconciliation bill: $10.5 billion from 2025 to 2034.

Allowing individuals to qualify for an HSA even if they are covered by a direct primary care arrangement or an on-site employee clinic. Direct primary care (DPC) is a different model of primary care delivery in which patients pay a periodic fee to a practice that covers unlimited primary care services (e.g., vaccines, lab work, office visits, consultive services) without cost-sharing. DPC does not usually cover specialized and other services and is therefore not generally considered comprehensive coverage. Some HDHP enrollees and others choose to add DPC to meet their primary care needs. The budget reconciliation bill stipulates that DPCs that meet specific requirements will not be treated as a health plan. In addition, the legislation would also treat dollars used to pay DPC fees as an HSA-specific qualified medical expense. This would allow HSA holders to add it on as a complement to their HDHP and use their HSA funds to pay DPC membership fees, with the caveat that these fees cannot exceed $150 monthly ($1,800 annually) in order to not be considered a health plan. This provision is projected to cost about $2.8 billion from 2025 to 2034.

On-site employee sponsored health clinics are health care facilities on an employer’s premises (or facilities used primarily for the same employer) that provide free or reduced cost services to employees. Current law makes an individual ineligible to use an HSA if they have access to an on-site employee clinic that provides significant health benefits (i.e., providing care for all medical needs for free or waiving copays and deductibles) in addition to disregarded coverage and preventive services. The budget reconciliation bill proposes to not treat on-site employee clinics offering qualified items and services as health plans for purposes of determining HSA eligibility if the services provided at the clinic meet certain parameters. This provision is projected to cost about $2.4 billion from 2025 to 2034.

Increasing the amount certain individuals can contribute to their HSAs in a year and allowing contributions that the law currently restricts. For example:

• The annual contribution limit to a health savings account for an individual would increase by $4,300 for individuals with self-only coverage and by $8,550 for family coverage, which doubles the 2025 basic limits on annual contributions. This increase would phase out at certain income levels ($75,000 to $100,000 of adjusted gross income; for joint filers with family coverage, $150,000 to $200,000 of adjusted gross income). This provision is projected to cost about $8.4 billion from 2025 to 2034.
• Individuals who are age 65 or older and enrolled only in Medicare Part A (not Part B) would be allowed to still make HSA contributions. This provision is projected to cost about $7.4 billion from 2025 to 2034. Other tax code changes would also apply to these individuals.

Treating Marketplace bronze plans and catastrophic plans as a high-deductible plan that can be paired with an HSA. To increase accessibility of HSAs in the individual market, bronze plans and catastrophic plans would be treated as HDHPs. Bronze plans have the highest cost-sharing and lowest premiums among metal-tier plans, while catastrophic plans have lower premiums than bronze plans and deductibles are equal to the ACA annual limit on out-of-pocket costs ($9,200 for individual coverage in 2025 and $10,150 in 2026). This provision is projected to cost about $3.6 billion from 2025 to 2034.

How Much Would the HSA-related Provisions of the House Budget Reconciliation Bill Cost the Federal Government?

If passed by the Senate and signed into law, HSA tax deductions would cost the federal government almost $14.8 billion in lost revenue in fiscal year (FY) 2025, and if eligibility and regulations governing the accounts remained the same, they would cost an estimated $180.9 billion from 2025 to 2034. The House-passed budget reconciliation bill contains ten reforms that broaden the range of HSA-eligible qualified medical expenses, loosen restrictions on individual contributions, and increase access to HSAs. According to the Congressional Budget Office’s estimated revenue effects for this bill, these expansions would increase the total projected cost of HSAs by approximately $44.3 billion over the next ten years (Figure 1).

Looking Forward

Efforts to expand HSAs would mean new large government expenditures, at a time when proposed tax cuts and significant changes to Medicaid and ACA programs will leave more people without coverage. Congress arguably created HSAs in 2003 to be paired with HDHPs as a tool to pay for current health care costs and to incentivize price shopping for anticipated health services. Today, expansions to HSAs appear to focus less on cost-conscious shopping, as federal rules have added more pre-deductible coverage of certain items and services and expand the items that can be treated as medical services, but only for consumers with health savings accounts. Proposals aimed at promoting “choice and control” would allow more individuals to use funds in an HSA to pay directly for certain services. Although some pre-deductible items and services are aimed at managing specific chronic illnesses, these provisions do not reach all consumers who could benefit from other types of specialized items and services, which often come at a high cost, to manage and treat their chronic condition.

As of 2023, there were 22.4 million individuals who are noncitizen immigrants residing in the U.S., accounting for about 7% of the country’s total population. Among noncitizen immigrants, about six in ten are lawfully present immigrants while the remaining four in ten are undocumented immigrants. Noncitizen immigrants, particularly those who are undocumented, face significant barriers to accessing health coverage and care and are significantly more likely than citizens to be uninsured. These higher uninsured rates reflect more limited access to private coverage and eligibility restrictions for federally funded coverage options. Some states have taken up options in Medicaid and the Children’s Health Insurance Program (CHIP) to expand coverage for lawfully present immigrants and/or established fully state-funded programs to fill gaps in coverage for immigrants. This brief provides an overview of state take-up of these options and state health coverage programs for immigrants regardless of status. It also examines how health coverage and care for immigrants vary by state coverage policies using data from the 2023 KFF/LA Times Survey of Immigrants.

In recent years, there was increased state action to expand coverage to immigrants, including immigrant adults, but more recently some states have begun scaling back coverage due to budget pressures. As of September 2025, 14 states plus D.C. provide fully state-funded coverage for income-eligible children regardless of immigration status, seven states plus D.C. provide fully state-funded coverage to some income-eligible adults regardless of status, and most states have taken up options in Medicaid and CHIP to expand coverage to lawfully present immigrant children and pregnant women. Data and research suggest that coverage expansions for immigrants are associated with lower uninsured rates and improved access to care. Congressional Republicans and President Trump passed the tax and budget law in July 2025. The new law includes significant cuts to the Medicaid program as well as eligibility restrictions for many lawfully present immigrants, including refugees and asylees, to access Medicaid and the Children’s Health Insurance Program (CHIP), subsidized Affordable Care Act (ACA) Marketplaces, and Medicare coverage, which may increase demand for state-funded coverage programs. However, at the same time, states are facing increasing budget pressures which may make it more challenging to maintain these coverage programs. More limited access to federally funded coverage as well as reductions in state-funded coverage programs will likely lead to increases in uninsured rates for immigrant families, contributing to greater challenges accessing care and potentially worse health outcomes over the long-term.

Health Coverage for Immigrants

Noncitizen immigrants have high uninsured rates because they have more limited access to private coverage due to working in jobs that are less likely to offer coverage and face eligibility restrictions for federally funded coverage options. Lawfully present immigrants may qualify for Medicaid and CHIP but are subject to eligibility restrictions that result in some, particularly recent immigrants, being ineligible to enroll even if they meet other eligibility criteria. For example, many must meet a five-year waiting period before qualifying for Medicaid or CHIP. Lawfully present immigrants can purchase coverage through the ACA Marketplaces and may receive tax credits for this coverage without a waiting period. Lawfully present immigrants have been eligible for Medicare if they have the required work quarters and meet the disability or age requirements. Under the new tax and budget law, some groups of lawfully present immigrants will lose access to federally funded coverage, including refugees and asylees. Eligibility for Medicaid and CHIP, subsidized Marketplace, and Medicare coverage will be limited to lawful permanent residents (LPRs) or green card holders, certain Cuban or Haitian entrants, and Compact of Free Association migrants. States may also maintain Medicaid or CHIP coverage for lawfully present pregnant people and children under an option to cover these groups.

Undocumented immigrants are ineligible to enroll in federally funded coverage, including Medicaid or CHIP, the ACA Marketplaces, or Medicare. Medicaid payments for emergency services reimburse hospitals for emergency care they are obligated to provide to individuals who meet other Medicaid eligibility requirements (such as income) but who do not have an eligible immigration status, including undocumented immigrants. These payments help cover costs to hospitals for providing emergency care to immigrants who remain ineligible for Medicaid but are not coverage for individuals. The new tax and budget law reduces the federal Medicaid matching rate provided to states for Emergency Medicaid services provided to expansion adults who would otherwise be eligible for Medicaid except for their immigration status to the regular matching rate. Emergency spending accounted for less than one percent of total Medicaid spending between fiscal years 2017 and 2023.

Medicaid and CHIP Options for Lawfully Present Immigrants

In general, lawfully present immigrants must have a “qualified” immigration status to be eligible for Medicaid or CHIP, and many, including most lawful permanent residents or “green card” holders, must wait five years after obtaining qualified status before they may enroll even if they meet other eligibility requirements. Some immigrants, such as those with Temporary Protected Status, are lawfully present but do not have a qualified status and are not eligible to enroll in Medicaid or CHIP regardless of their length of time in the country. As noted, under the tax and budget law, eligibility will be limited to LPRs or green card holders, certain Cuban and Haitan entrants, and Compact of Free Association (COFA) migrants as of October 1, 2026. For children and pregnant people, states can cover lawfully residing immigrants without a five-year wait, otherwise known as the Immigrant Children’s Health Improvement Act (ICHIA) option. As of April 2025, 37 states plus D.C. have taken up this option for children and 31 states plus D.C. have elected the option for pregnant people (Figure 1). Indiana plans to implement the option for children and pregnant people in 2025. States may maintain coverage through this option under the tax and budget law.

A total of 24 states plus D.C. have also extended coverage through the CHIP From-Conception-to-End-of-Pregnancy (FCEP) option, which provides prenatal care and pregnancy related benefits to targeted low-income children beginning from conception to end of pregnancy regardless of their parent’s citizenship or immigration status (Figure 2). While other pregnancy-related coverage in Medicaid and CHIP requires 60 days of postpartum coverage, the CHIP FCEP option does not include this coverage. However, some states that took up this option provide postpartum coverage through a CHIP health services initiative or using state-only funding. Twelve of the states that have implemented the FCEP option (California, Colorado, Connecticut, Illinois, Maine, Massachusetts, Minnesota, New York, Oregon, Rhode Island, Texas, and Washington) plus D.C. have used state funding or CHIP health services initiatives to extend postpartum coverage to 12 months to align with the Medicaid extension established by the American Rescue Plan Act. Maryland extends coverage for four months postpartum, and Alabama and Virigina extend coverage for 60 days postpartum using CHIP health services initiatives.

Fully State-Funded Coverage

Beyond state take-up of options in Medicaid and CHIP, some states provide fully state-funded coverage to fill gaps in coverage for immigrants. States vary in the eligibility and scope of benefits offered through these coverage programs. These programs extend coverage to lawfully present immigrants who are in the five-year waiting period for Medicaid or CHIP or do not have “qualified status” and are ineligible for federally funded coverage as well as undocumented immigrants. These programs also extended coverage to Deferred Action for Childhood Arrivals (DACA) recipients who are not considered lawfully present for purposes of eligibility for federally funded health coverage programs. While the Biden administration had published regulations to extend Marketplace coverage to DACA recipients, in June 2025, new regulations by the Trump administration excluded them from coverage, as did the new tax and budget law.

As of September 2025, 14 states plus D.C. provide comprehensive state-funded coverage for children regardless of immigration status (Figure 3). These states include California, Colorado, Connecticut, Illinois, Maine, Massachusetts, Minnesota, New Jersey, New York, Oregon, Rhode Island, Utah, Vermont, Washington, and D.C. Additionally, two of these states (New Jersey and Vermont) also provide state-funded coverage to income-eligible pregnant people regardless of immigration status, with Vermont extending this coverage for 12 months postpartum.

As of September 2025, seven states (California, Colorado, Illinois, Minnesota, New York, Oregon, Washington) plus D.C. have also expanded fully state-funded coverage to some income-eligible adults regardless of immigration status, but three states (California, Illinois, Minnesota) plus D.C. have begun or plan to scale back coverage due to budget pressures (Figure 4). Some additional states cover some income-eligible adults who are not otherwise eligible due to immigration status using state-only funds but limit coverage to specific groups, such as lawfully present immigrants who are in the five-year waiting period for Medicaid coverage, or provide more limited benefits.

• California extended state-funded health coverage to income-eligible young adults ages 19-25 in January 2020, adults ages 50 and older in May 2022 and adults ages 26 to 49 regardless of immigration status in January 2024, making all low-income immigrants in the state eligible for state-funded health coverage regardless of immigration status. California plans to pause enrollment for undocumented adults 19 and older who are not pregnant starting January 2026, end dental benefits for all undocumented adults who are not pregnant or up to one year post-partum starting July 2026, and charge $30 monthly premiums for adults ages 19-59 who are not pregnant starting July 2027.
• Colorado uses state funds to provide Marketplace coverage with premium subsidies to individuals with incomes at or below 300% of the federal poverty level (FPL) regardless of immigration status through OmniSalud using a section 1332 waiver. Colorado previously provided subsidized plans with $0 premiums through SilverEnhanced Savings, but the program is capped at 12,000 people and has paused enrollment for 2025 due to funding constraints.
• D.C. provides health coverage to low-income adults 21 and older regardless of immigration status through its longstanding locally funded Healthcare Alliance program. However, D.C. plans to pause enrollment of adults ages 26 and older and reduce income limits for adults 21 and older starting October 2025, and end coverage for all adults ages 21 and older by October 2027.
• Illinois extended state-funded coverage to low-income individuals ages 65 and older regardless of immigration status through its Health Benefits for Immigrant Seniors (HBIS) program in December 2020 but has paused enrollment due to funding constraints as of April 2025. Illinois previously extended coverage to low-income immigrants ages 42 to 64 regardless of immigration status through the Health Benefits for Immigrant Adults (HBIA) program in 2022 but ended HBIA coverage on July 2025 due to funding constraints.
• Minnesota extended state-funded health coverage to income-eligible adults regardless of immigration status in January 2025. However, Minnesota paused enrollment for undocumented adults ages 18 and older on June 2025 and plans to end coverage by January 2026. 
• New York extended state-funded coverage to individuals ages 65 and older regardless of immigration status beginning in 2023.
• Oregon extended state-funded health coverage to all income-eligible adults regardless of immigration status in July 2023.
• Washington uses state funds to provide Marketplace coverage with premium subsidies to individuals with incomes up to 250% FPL regardless of immigration status through Cascade Care using a section 1332 waiver, but subsidies are no longer available for 2025 due to funding constraints. In July 2024, Washington extended state-funded health coverage to individuals with incomes up to 138% FPL regardless of immigration status, but the program is capped at 13,000 people and has paused enrollment for 2025 due to funding constraints.

In addition to these states, Maryland plans to allow income-eligible individuals to purchase Marketplace coverage without subsidies regardless of immigration status starting November 2025 through a section 1332 waiver.

Impact of State Coverage Expansions on Health Care Access and Use

Data suggest that state coverage options for immigrants make a difference in their health coverage and health care access and use. The 2023 KFF/LA Times Survey of Immigrants shows that immigrants residing in states with more expansive coverage policies for immigrants have higher rates of health coverage, are less likely to postpone or go without care, and are more likely to receive care and to have a trusted health care provider compared to their counterparts living in states with less expansive coverage policies, as described below. (See Box 1).

Immigrant adults in states that provide more expansive coverage, including the ACA Medicaid expansion for low-income adults and at least some state-funded coverage for immigrants, are half as likely to be uninsured as those in states with less expansive coverage (11% vs. 22%). This difference is driven by higher rates of Medicaid and other public coverage (including state-funded coverage) in states with more expansive coverage compared to those with less expansive policies (23% vs. 9%) while rates of private and Medicare coverage are similar (Figure 5).

Reflecting higher rates of health coverage, immigrant adults in states with more expansive policies are somewhat less likely to say they skipped or postponed care due to cost. Immigrants in states with more expansive policies are half as likely to report delaying or going without medical care (4% vs. 10%) or dental care (7% vs. 14%) due to cost than those in less expansive states (Figure 6).

Differences in use of care among immigrants by state coverage policies are smaller, which may reflect use of safety-net resources available to uninsured immigrants such as community health centers and emergency rooms. Most (77%) immigrant adults in the U.S. report seeking health care in the past year. The shares reporting seeking health care are slightly lower in states with less expansive coverage (74%) compared to those in states with more expansive coverage (79%), although the majority still report seeking care. This pattern may reflect use of safety-net resources available to uninsured immigrants such as community health centers or emergency rooms. Immigrant adults are more likely than U.S.-born adults to say they rely on community health centers (CHCs) as their usual source of care, reflecting CHCs’ in providing free or low-cost care to low-income and uninsured populations and their ability to provide culturally and linguistically appropriate care. Immigrants in states with less expansive policies are somewhat more likely to say they use a CHC (33% vs. 28%) and somewhat less likely to say they use a private doctor’s office (39% vs. 44%) (Figure 7). Immigrant adults in states with less expansive policies are also less likely to report having a medical provider they trust to answer questions about their health than those in more expansive states (68% vs. 78%).

Other research suggests that state coverage expansions for immigrants can reduce uninsured rates, increase health care use, lower costs, and improve health outcomes. Noncitizen children are more likely to be uninsured and experience more delays in health care due to cost than their citizen siblings. Citizen children with a noncitizen parent are also more likely to be uninsured than citizen children with U.S-born parents. California’s 2016 expansion to cover low-income children regardless of immigration status was associated with a 34% decline in uninsurance rates. Similarly, a study found that children who reside in states that have expanded coverage to all children regardless of immigration status were less likely to be uninsured, to forgo medical or dental care, and to go without a preventive health visit than children residing in states that have not expanded coverage. Other research has found that expanding Medicaid coverage to pregnant people regardless of immigration status was associated with higher rates of prenatal care and improved outcomes including increases in average gestation length and birth weight among newborns, while more restrictive state coverage policies were associated with reduced postpartum care utilization. The cost of providing insurance to immigrant adults through Medicaid expansion was also found to be less than half the per person cost of doing so for U.S-born adults. Recent estimates also suggest that the state-funded expansion to all immigrants regardless of status in California could reduce poverty among noncitizen immigrants and their families.

Looking ahead, states may face increased challenges maintaining state-funded coverage programs, while at the same time there may be growing need for coverage due to new restrictions in federally funded coverage. The new tax and budget law includes significant cuts to the Medicaid program as well as eligibility restrictions for many lawfully present immigrants for Medicaid, CHIP, subsidized ACA, and Medicare coverage. At the same time, states are facing increasing budget pressures that may make it more challenging to cover these immigrants with state-only funding. More limited access to federally funded coverage as well as reductions in state-funded coverage programs will likely lead to increases in uninsured rates for immigrant families, contributing to greater challenges accessing care and potentially worse health outcomes over the long-term.

PEPFAR’s latest reauthorization expired on March 25, 2025, heightening the stress the program is now experiencing as the Trump administration reviews and rolls back foreign aid. It has also raised several questions about whether PEPFAR can continue in the absence of reauthorization. This policy watch provides an update on what this means for PEPFAR. As it notes, because PEPFAR operates largely under permanent authorities of U.S. law, the program continues as long as funds are appropriated by Congress (although certain time-bound requirements lapsed as of March 25, 2025). At the same time, the changes and reforms being instituted by the Trump administration are posing larger challenges for PEPFAR going forward.

What is “authorizing” legislation, and how does it differ from “appropriations” legislation?

There is an important distinction between “authorizing” and “appropriations” legislation. Authorizing (or reauthorizing) legislation, which is the purview of Congressional authorizing committees, establishes programs and policies, oversight and reporting requirements, and provides guidance to appropriators on funding amounts and conditions. It may include time-bound provisions or may provide no end date for programs to operate, which they can do as long as they are funded. Such legislation can be put forward as a standalone bill or attached to another legislative vehicle. Appropriations legislation, under the purview of Congressional appropriations committees, provides budget authority, allowing funding to be provided to an agency or program; absent an authorization (or reauthorization), an appropriations bill can have the effect of allowing the continued operation of an existing program by providing funding.

How was PEPFAR created?

PEPFAR was created in 2003 through authorizing legislation (The Leadership Act), which established the program, its structure – including creating a new position of U.S. Global AIDS Coordinator at the Department of State (with the rank of Ambassador) and participation in the Global Fund – and other program aspects without any end date or sunsetting of the program (with the exception of some provisions). This means that PEPFAR largely operates under permanent authorities of U.S. law that allow for the program to continue as long as Congress appropriates funding. The recent Continuing Resolution for FY 2025 included the same level of funding for PEPFAR as provided in FY 2024.

What is PEPFAR “reauthorization”?

Since PEPFAR was a new program when created in 2003 and because it included some time-limited provisions, Congress has passed reauthorizing legislation four times, some of which included modifications to adapt to new circumstances and others with only date changes (extensions) to allow expiring provisions to continue (see Table 1 and the KFF side-by-side of PEPFAR legislation over time.). Reauthorization has also served to demonstrate Congress’ support for the program. The first three reauthorizations of the program were each for five-year periods. The most recent was short-term, extending expiring provisions for only one year, largely due to partisan debate related to abortion. This is not the first time PEPFAR reauthorization has lapsed while Congress considered reauthorization. For example, in 2018, some provisions of the PEPFAR Stewardship Act lapsed at the end of FY 2018 (Sept. 30, 2018) until the PEPFAR Extension Act was enacted more than two months later on Dec. 11, 2018, and in 2023, some provisions of the PEPFAR Extension Act lapsed at the end of FY 2023 (Sept. 30, 2023) until the recent short-term extension was enacted nearly six months later on March 23, 2024.

Table 1

PEPFAR Legislation

What happened when PEPFAR’s latest reauthorization “expired”?

Under the recent short-term reauthorization of PEPFAR, there were eight time-bound requirements that “sunset” on March 25, 2025, when they were not extended by Congress. These included requirements related to Global Fund support, a funding directive for orphans and vulnerable children (OVC), and others (see Table 2). This means that these provisions are not currently required, although the administration can choose to follow them.

Table 2

PEPFAR Reauthorization’s Time-Bound Provisions

Does this mean that the PEPFAR program is not authorized anymore?

No. PEPFAR is a permanent part of U.S. law and will continue, provided funds are appropriated, which Congress has once again done for FY 2025, the current fiscal year.

Are there any other impacts of having a lapsed reauthorization?

If PEPFAR is not reauthorized this year or in the near future, as mentioned above, the program won’t end, but there are practical and symbolic implications for the program and the people it serves, including:

• The lack of reauthorization marks a significant departure from PEPFAR’s long-time bipartisan support, following its short-term reauthorization last year. PEPFAR had long enjoyed strong bipartisan support across multiple Congresses and administrations. Despite the fact that funding for PEPFAR could continue absent reauthorization, the program may be more vulnerable in future funding debates.
• Failure to reauthorize the program, alongside recent foreign aid developments, may further concern partner countries and the people served by PEPFAR. In light of uncertainty surrounding the future of the program under the Trump administration, the lack of reauthorization by Congress creates further uncertainty in the field. It could also weaken PEPFAR’s partnerships and diplomatic efforts, particularly regarding longer-term planning, financial sustainability, and country leadership of efforts.

What is next for PEPFAR reauthorization?

While it is unknown what Congress will choose to do regarding PEPFAR reauthorization, options include:

• Do nothing. This legally allows the program to continue, since Congress has appropriated funding for its operations in FY 2025.
• Extend the dates of the eight lapsed time-bound provisions, in a reauthorization bill or another legislative vehicle.
• Reauthorize the program with changes to address concerns raised by members of Congress and others related to abortion (which shaped congressional consideration over the past two years) and the need to better demonstrate sustainability and transition plans to scale-down the program over time (such as requiring progressive country co-financing or graduation requirements.

What is the outlook for PEPFAR more broadly?

More broadly, however, PEPFAR is, for the first time in its two-decade history, facing significant challenges that could impede its ability to fulfill its mission. Recent actions of the Trump administration, such as the foreign aid freeze, the proposed “realignment” of USAID’s functions into the State Department, and cancellation of many grant awards, have significantly affected PEPFAR services, operations, and health outcomes. This has included reduced spending on PEPFAR, below the funding levels appropriated by Congress, raising questions about whether the administration will spend all the funding that has been appropriated for this purpose. At the same time, a divided Congress is likely to mean heightened disagreements over funding levels more generally across the federal budget, particularly amid administration efforts to cut spending and dramatically reduce the U.S. government footprint in foreign aid, including for global health. The administration has already indicated that it may seek rescissions of prior year funding amounts, which could further affect PEPFAR activities and funding, should Congress agree to these. In addition, the President’s budget request for FY 2026 has included significant cuts to global health, although it specifies that PEPFAR funding “is preserved for any current beneficiaries.” Cuts to PEPFAR’s budget were proposed in the first Trump administration but were rejected by Congress. The current dynamic, however, is much less certain.

Most women use contraception at some point in their lives and for low-income women in particular, Medicaid provides access to family planning services which include contraceptives as well as many preventive and primary care services related to sexual and reproductive health. Congress is considering changes to Medicaid that would reduce federal spending on the program and lead to an estimated 7.6 million people losing Medicaid coverage and becoming uninsured. As the largest public payer for family planning services in the US, changes to Medicaid, including reductions in enrollment, benefits, or the type of providers that can participate in the program could have a large impact on access to contraception and other family planning care for low-income individuals. Amid debates to limit federal Medicaid support, this brief presents five facts to know about Medicaid’s role for family planning.

1. Medicaid plays an outsize role providing coverage for low-income women of reproductive age.

Medicaid, the nation’s health coverage program for poor and low-income people, provides access to health and long-term care services for millions of low-income women across the nation. Nationally, Medicaid covers one in five adult women of reproductive age (18 to 49 years old), and more than four in ten (44%) with low incomes (Figure 1). Medicaid coverage of adult reproductive age women with low incomes ranges across the country, from roughly one in five in Texas (22%) to six in ten (61%) in New York and New Mexico.

The ACA’s Medicaid expansion plays a major role in the program’s coverage of reproductive age women. Nearly four in ten (38%) adult women of reproductive age who are enrolled in Medicaid are covered through the expansion pathway. Ten states have not expanded Medicaid under the ACA.

2. All state Medicaid programs cover family planning benefits, which include contraception as well as a broad range of preventive health services.

The Medicaid program has a long history of covering family planning as part of a comprehensive set of preventive services, and the federal government pays a higher federal match rate of 90% for family planning services than it does for other health care services. Federal Medicaid law classifies family planning services and supplies as a “mandatory” benefit category that states must cover, but it does not formally define the specific services that must be included, giving states flexibility in how they design the coverage. States routinely cover prescription contraceptives and related services such as gynecologic exams and testing and treatment for sexually transmitted infections (Figure 2).

Research has found that the ACA’s Medicaid expansion is associated with an increased use of the most effective long-acting contraceptives as well as use of contraception after having a baby.

3. Medicaid coverage supports access to consistent contraceptive care which reduces unintended pregnancies and alleviates cost barriers for women with low incomes.

Federal law prohibits states from imposing out-of-pocket charges for family planning care in Medicaid, an important cost protection for women with low incomes. According to a national survey on contraceptive experiences, one in five (20%) reproductive age women who were uninsured reported that they had to stop using contraception in the past year because of the cost, compared to 5% of women covered by Medicaid.

Nationally, about half of reproductive age women with Medicaid coverage obtained family planning services in 2021, and in some states (Figure 3), it is higher (59% in Ohio and 60% in Louisiana). The family planning benefit most commonly accessed by women with Medicaid was oral contraceptives, which are also the most used reversible contraceptive among women in the general population. Medicaid also covers intrauterine devices, contraceptive implants, sterilization procedures, and injectable contraceptives along with follow up care.

4. Many Medicaid enrollees seek family planning services at specialized family planning clinics that also offer abortion services, such as Planned Parenthood.

Congress is considering a proposal to ban Planned Parenthood and other Medicaid essential community providers from participating in the Medicaid program. The federal Medicaid statute allows Medicaid enrollees to seek care from any provider that is qualified and willing to participate in the program, and for family planning services specifically, federal law allows enrollees to seek services outside of managed care provider networks if they desire. Some Medicaid providers, including many Planned Parenthood clinics, offer both family planning services and abortion care. Medicaid reimburses these clinics for the family planning services they provide but does not pay for abortion care because of the Hyde Amendment’s ban on the use of federal funds for abortions (except in the cases of rape, incest, or life endangerment). The current reconciliation bill under consideration in Congress (and passed by the House) would prohibit Planned Parenthood and some other family planning clinics that also provide abortion services from participating in the program and getting reimbursed for serving Medicaid patients. While the reconciliation bill seeks to reduce federal spending, the restriction on Medicaid payments to Planned Parenthood is a priority of Republican leaders and has been included in the reconciliation bill despite the fact that the Congressional Budget Office projects the provision would raise federal spending by $300 million.

Medicaid accounts for a major share of Planned Parenthood clinics’ financing. Excluding these clinics from Medicaid would likely result in many clinic closures and could lead to provider shortages in areas where they have a larger presence. Nationally, one in ten (11%) female Medicaid enrollees ages 15 to 49 who received family planning services went to a Planned Parenthood clinic in 2021, with larger shares in some states – as high as 29% in California (Figure 4). In some areas, there may not be other safety-net providers to absorb the patients Planned Parenthood currently serves. In other areas, existing clinics may not have the capacity to provide the same scope of care that family planning clinics, like Planned Parenthood, offer. KFF research has found that specialty reproductive health care clinics such as Planned Parenthood clinics offer a broader range of services to their patients compared to non-specialized clinics. In 2013, Texas replaced its Medicaid family planning program with a state-funded program that excluded Planned Parenthood as a participating provider. Following the change, there was a sizable drop in Medicaid claims for contraceptives and an increase in Medicaid-funded births.

5. More than half of states have established programs that use Medicaid coverage to pay for family planning services for people who are uninsured.

To help address gaps in coverage, several states extend Medicaid coverage for family planning services to people who do not qualify for full Medicaid benefits (usually because their incomes exceed the state income eligibility thresholds or they do not otherwise qualify for Medicaid). States can establish these family planning programs as a State Plan Amendment or through a Section 1115 waiver (Figure 5). States have the latitude to decide which services they cover in these limited scope family planning programs, though pharmacy coverage is restricted to family planning and related services. Nationally, 31 states provide family planning coverage to individuals who do not qualify for full Medicaid benefits. In 26 states, eligibility for the program is based solely on meeting certain income requirements, while eligibility in four states is limited to people who lose Medicaid for any reason (1 state) or lose Medicaid postpartum coverage (3 states). Most of the states (23) provide coverage to men as well as women.