National opioid overdose deaths have declined since mid-2023 and provisional 2024 data suggest the decline is continuing. Despite recent improvements, opioids were still involved in over 79,000 deaths in 2023—well above pre-epidemic levels. The opioid epidemic’s impact remains widespread with nearly three in ten adults (29%) reporting in a 2023 KFF poll that they or a family member experienced an opioid addiction.

Medicaid provided coverage to nearly half (47%) of all nonelderly adults with opioid use disorder (OUD) in 2023, according to data from the National Survey on Drug Use and Health (NSDUH). State-level NSDUH data from 2021-2022 show even higher Medicaid coverage rates among adults with OUD in states that expanded Medicaid under the Affordable Care Act (ACA). In recent years, state Medicaid programs have also expanded access to OUD treatment and medications, which reduce the risk of overdose death.

The Trump administration’s opioid policies emphasize expanding access to medication treatment and naloxone. At the same time, the House and Senate are working on legislation to meet the requirements in the budget resolution, specifying cuts to Medicaid of up to $880 billion or more over 10 years. To meet the required federal budget cuts, a newly introduced House bill proposes a number of provisions that could affect Medicaid eligibility and coverage stability for adults with OUD including work requirements and increased eligibility determinations. Such changes would contribute to reductions in Medicaid enrollment and increases in the uninsured and would come at a tenuous moment for the opioid epidemic, as deaths have begun to decline, but future progress is not certain. Amid this evolving policy landscape, this brief analyzes Medicaid coverage and treatment of adults with OUD using data from NSDUH and Medicaid claims data.

Medicaid is the main source of coverage for adults with opioid use disorder and among those receiving treatment services.

Medicaid covers 47% of all nonelderly adults with OUD and is the primary coverage source among those receiving treatment services. Specifically, Medicaid covers over half (56%) of those receiving medication for opioid use disorder (MOUD) and roughly two-thirds (64%) of adults receiving outpatient treatment and peer support services (Figure 1). MOUD treatment, recommended by clinical guidelines, reduces risk of all-cause and overdose mortality.

Most adults with OUD in Medicaid are eligible through Medicaid expansion.

Overall, 61% of adult Medicaid enrollees diagnosed with OUD—about 900,000 adults—are eligible through Medicaid expansion (Figure 2), with state-level rates ranging from 33% in Arkansas to 95% in Illinois (Appendix Table 1). In expansion states, over two-thirds of Medicaid enrollees with OUD qualify through ACA expansion (Figure 2), facilitating access to medication treatment and other care. A number of provisions in the House bill would affect the expansion group, including work requirements and cost sharing requirements. Such changes could lead to coverage losses or disruptions, including for adults with OUD, potentially limiting or interrupting access to treatment. Research indicates that MOUD treatment cessation is linked to significantly increased mortality risk, with individuals experiencing a six-fold higher mortality risk in the four weeks immediately after discontinuing treatment.

Other federal actions may also affect opioid response efforts.

The restructuring of Health and Human Services (HHS) by the Trump administration folds the Substance Abuse and Mental Health Services Administration (SAMHSA) into a new agency, reduces staff, and may eliminate certain opioid-focused programs. Additionally, the reported dismissal of the entire staff administering the NSDUH—a key source of national data collecting data for over 50 years about trends in mental health and substance use disorders—-could limit access to key data used to monitor and respond to the opioid crisis. The President’s discretionary budget request for 2026–which has not been adopted to date–proposes just over $1 billion in cuts to SAMHSA programs, including cuts to programs funding clean syringe exchanges and safe supplies. The discretionary budget decisions will be part of the budget appropriations process.

Note: This fact sheet largely reflects activities prior to the second Trump administration, which has issued numerous executive actions that directly affect global health efforts, and has been updated to highlight key recent actions that may affect PMI and other U.S. global malaria efforts. See also the KFF fact sheet on the Trump administration’s foreign aid review and the status of PMI.

Key Facts

• About half of the world’s population is at risk of being infected with malaria. In 2023, there were an estimated 263 million cases of malaria and 597,000 deaths from malaria worldwide. Sub-Saharan Africa is the hardest hit region in the world.
• While gains have been made over the past two decades in increasing access to malaria prevention and treatment, many challenges (including drug and insecticide resistance and climate change impacts) continue to complicate malaria control efforts in hard-hit areas. Recently, in promising developments, the first malaria vaccine was recommended in 2021 by the World Health Organization (WHO) for widespread use in children, and its broader rollout began in 2023. Additionally, in late 2023, WHO recommended a second malaria vaccine. These vaccines are now being rolled-out across Africa in routine childhood immunization programs.
• The U.S. government (U.S.) has been involved in global malaria activities since the 1950s and, today, is the largest donor government to global malaria efforts.
• U.S. malaria efforts include activities primarily through the U.S. President’s Malaria Initiative (PMI) that is overseen by the U.S. Global Malaria Coordinator, as well as through other U.S. activities; collectively, the U.S. reaches approximately 30 countries.
• U.S. funding for malaria control efforts and research activities was approximately $1 billion in FY 2025, up from $873 million in FY 2016. Additionally, the U.S. is the largest donor to the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), which in turn is the largest overall funder of malaria efforts in the world.
• As the Trump administration reorganizes foreign assistance (and Congress considers whether to approve these changes), including dissolving the U.S. Agency for International Development (USAID) – the lead implementer of PMI, its impact on the future of U.S. global malaria efforts remains to be seen.

Global Situation¹ 

Malaria is one of the world’s most common and serious tropical diseases, with about half the world’s population at risk of being infected with malaria. Although preventable and treatable, malaria causes significant morbidity and mortality, with the greatest numbers of cases and deaths in resource-poor regions and among young children.² 

Strategies and efforts to address malaria have evolved over time, with global eradication efforts waning in the 1970s, resulting in rising rates.⁴  In the late 1990s, malaria began to receive renewed attention, particularly after the 1998 creation of the Roll Back Malaria Partnership (RBM), now referred to as the RBM Partnership to End Malaria.⁵  In 2000, all nations agreed to global malaria targets as part of Millennium Development Goal 6 (combat HIV/AIDS, malaria, and other diseases). Since then, expanded efforts by the U.S. government, other donor governments, multilateral institutions, and affected countries have helped to increase access to malaria prevention and treatment and reduce cases and deaths, and there has been, at times, discussion of the possibility of finally eradicating the disease.⁶ 

Today global malaria activities are focused on sustaining, improving, and expanding efforts to control the disease. Still, the rate of progress has stalled in some countries recently, and many challenges continue to complicate malaria control efforts in countries with ongoing malaria transmission, including poverty, poor sanitation, weak health systems, limited disease surveillance capabilities, natural disasters, armed conflict, migration, climate change, and the presence of counterfeit and/or sub-standard antimalarial drugs.⁷ 

Morbidity and Mortality⁸ 

• WHO estimates that there were approximately 263 million cases of malaria and 597,000 deaths, mostly among children under the age of five, in 2023. Overall, substantial scale-up of malaria interventions helped reduce the malaria case incidence and death rates over the past two decades, though case incident rates were slightly higher in 2023 than in 2022 due to increased rates in some countries.
• Multidrug-resistant malaria is a widespread and recurring problem, and while highly-effective artemisinin-based combination therapies (ACTs) have been introduced to treat drug-resistant strains, evidence suggests ACT resistance is occurring in parts of Asia and Africa.⁹  Resistance to insecticides has emerged as a problem in Africa, the Americas, Eastern Mediterranean, South-East Asia, and the Western Pacific.¹⁰ 
• Certain groups, particularly pregnant women and children, are more vulnerable. Making up 76% of all malaria deaths in the Africa region, children under five are especially at-risk of malaria infection, because they lack developed immune systems to protect against the disease. Other high-risk groups include people living with HIV/AIDS, travelers, refugees, displaced persons, and migrant workers entering endemic areas.

Interventions

Malaria control efforts involve a combination of prevention and treatment strategies and tools, such as:

• insecticide-treated bed nets (ITNs),¹¹ 
• indoor residual spraying (IRS) with insecticides,
• diagnosis and treatment with antimalarial drugs, particularly artemisinin-based combination therapies (ACTs),¹² 
• intermittent preventive treatment in pregnancy (IPTp, a drug treatment for pregnant women that prevents complications from malaria for a woman and her unborn child),
• perennial malaria chemoprevention (PMC, formerly called intermittent preventive treatment in infants (IPTi), a drug treatment aimed at reducing adverse effects of malaria in children belonging to age groups at high risk of severe malaria), and
• seasonal malaria chemoprevention (SMC, a treatment course administered at monthly intervals to children belonging to age groups at high risk of severe malaria during the high malaria transmission season).

More recently, in 2021, WHO recommended, and in 2022 prequalified, the first malaria vaccine (RTS,S/AS01 or RTS,S) and in 2023 recommended and prequalified a second malaria vaccine (R21/Matrix-M or R21), both of which have been shown to be safe and effective in preventing malaria in children during clinical trials.¹³  As of December 2024, 17 countries that represent approximately 70% of the global malaria burden offered these vaccines through routine childhood immunization programs, and more are planning to introduce or scale them up.¹⁴  Roll-out of these vaccines will depend on financing and country decisions about whether to adopt the vaccines as part of their national malaria control strategies, among other things.

Access to prevention and treatment services has grown over time, as ITN coverage has increased and the number of ACT treatments procured by the public and private sectors has expanded substantially.¹⁵ 

Global Goals

Since the late 1990s, new initiatives and financing mechanisms have helped increase attention to malaria and contributed to efforts to achieve global goals; these include the RBM Partnership to End Malaria, a global framework established in 1998 for coordinating malaria efforts among donor governments, major UN agencies, international organizations, and affected countries, among others; and the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), an independent, international financing institution established in 2001 that provides grants to countries to address TB, HIV, and malaria (see the KFF fact sheet on the U.S. and the Global Fund).¹⁶ 

These and other efforts work toward achieving major global malaria goals that have been set through:

• Sustainable Development Goals (SDGs). Adopted in 2015, the SDGs aim to end the malaria epidemic by 2030 under SDG Goal 3, which is to “ensure healthy lives and promote well-being for all at all ages.”¹⁷ 
• Global Technical Strategy for Malaria (GTS). Developed in close alignment with the RBM Partnership and adopted by the World Health Assembly in 2015, the GTS includes the goals of reducing malaria incidence and mortality rates by at least 90% by 2030, eliminating the disease in at least 35 new countries, and preventing the disease’s re-establishment in countries that are malaria free.

With these goals, the GTS sets out a vision for countries to accelerate progress towards malaria elimination, and globally, more countries are moving towards elimination. Since 2000, 26 countries (Algeria, Argentina, Armenia, Azerbaijan, Belize, Cabo Verde, China, Egypt, El Salvador, Georgia, Iran, Iraq, Kazakhstan, Kyrgyzstan, Malaysia, Maldives, Morocco, Oman, Paraguay, Sri Lanka, Syrian Arab Republic, Tajikistan, Turkey, Turkmenistan, United Arab Emirates, and Uzbekistan) have attained three consecutive years of zero indigenous malaria cases and are therefore recognized as having eliminated the disease.¹⁸  In 2023, of 83 malaria-endemic countries, 47 countries worldwide were reported to have been nearing elimination.¹⁹  Most recently, in March 2024, WHO along with Ministers of Health in Africa and other partners convened a Malaria Ministerial Conference and signed a declaration committing to accelerating action to end deaths from malaria.²⁰ 

The U.S. Government

Involved in global malaria activities since the 1950s, the U.S. government (U.S.) is the largest government donor to malaria efforts.²¹  It is also the largest donor to the Global Fund, which in turn is the largest overall funder of malaria efforts in the world.²² 

History

The U.S. government’s international response to malaria began in the 1950s through activities at the U.S. Centers for Disease Control and Prevention (CDC) and U.S. Agency for International Development (USAID); early efforts focused on technical assistance but also included some direct financial support for programs overseas.

Since the early 2000s, the U.S. has assigned a heightened priority to and provided greater funding for bilateral and multilateral malaria efforts. In 2003, the U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 (the legislation that created PEPFAR, the expanded U.S. government response to global AIDS) authorized five years of funding for bilateral malaria efforts and the Global Fund. In 2005, the U.S. launched the President’s Malaria Initiative (PMI), a five-year effort to address malaria in 15 hard-hit African countries, which has since been extended and expanded. In 2008, the Lantos-Hyde U.S. Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 (which reauthorized PEPFAR) authorized another five years of funding and codified the position of the U.S. Global Malaria Coordinator.²³  More recently, in 2021, the U.S. released its PMI strategy for 2021-2026, which outlines its goals as well as its approach to achieving them by 2026.²⁴  (See the KFF fact sheet on PEPFAR, the KFF fact sheet on the Global Fund, the KFF brief on PEPFAR reauthorization legislation, and the KFF dashboard monitoring progress toward global malaria targets in PMI countries.)

Organization and Goals

President’s Malaria Initiative (PMI)²⁵ 

Launched in 2005, the President’s Malaria Initiative (PMI) is an interagency initiative to address global malaria that was, until its recent dissolution, led by USAID and implemented in partnership with CDC. It is overseen by the U.S. Global Malaria Coordinator, who is appointed by the President and reports to the USAID Administrator, and an Interagency Advisory Group made up of representatives from USAID, CDC, the National Institutes of Health (NIH), the Department of Defense (DoD), the State Department, the Peace Corps, the National Security Council, and other U.S. government agencies.²⁶  USAID has served as the lead implementing agency for U.S. global malaria efforts, primarily through PMI, with other agencies also carrying out malaria activities. Collectively, prior to the second Trump administration, U.S. bilateral activities reached approximately 30 countries.²⁷  Now, as the Trump administration reorganizes foreign assistance (and Congress considers whether to approve these changes), having dissolved USAID, it is unclear whether it will integrate any remaining USAID global health activities, including PMI, into the State Department, and what the future holds for PMI. See the KFF fact sheet on the status of malaria efforts.

Goals

In 2021, the U.S. released the President’s Malaria Initiative Strategy 2021-2026; its goals include:

• reducing malaria mortality by one-third from 2015 levels in high-burden PMI-supported countries, ²⁸ 
• achieving a greater than 80% reduction from PMI’s original 2000 baseline levels,
• reducing malaria morbidity in PMI-supported countries with high and moderate malaria burden by 40% from 2015 levels,²⁹  and
• assisting at least ten PMI-supported countries to meet the WHO criteria for national or sub-national elimination and at least one country in the Greater Mekong subregion to reach national elimination.

The strategy also states that these efforts contribute to longer term goals, such as elimination of malaria in a growing number of countries, and aligns with global priorities.³⁰ 

Key Activities³¹ 

Prior to the current administration, PMI activities focused on expanding access to and the use of six key malaria control interventions: insecticide-treated bed nets (ITNs), indoor residual spraying (IRS) with insecticides, entomological monitoring, intermittent preventive treatment in pregnancy (IPTp),³²  diagnosis of malaria and treatment with artemisinin-based combination therapies (ACTs), and seasonal malaria chemoprevention (SMC).³³ 

They also included a range of malaria control activities, including technical assistance to affected countries, monitoring and evaluation, supply chain management, and commodity procurement (since the start of PMI, U.S. support for commodities, such as ITNs, insecticides, and antimalarial drugs, like ACTs, has increased significantly³⁴ ). Additionally, PMI supported activities in the following areas: behavior change communication, health systems strengthening, monitoring and evaluation, operational research, elimination, and community health.³⁵ 

USAID had also supported regional efforts in Latin America and the Caribbean, including providing technical assistance to support countries in tailoring their approaches for malaria control through its Amazon Malaria Initiative.³⁶  CDC provided technical assistance to these regional efforts and was also designated as the WHO Collaborating Center for Prevention and Control of Malaria,³⁷  though with the Trump administration’s announcement that the U.S. would withdraw from WHO, the future of this partnership remains an open question. It also remains to be seen how recent announcements of global health reductions at CDC could further affect malaria efforts.

Additionally, NIH and DoD have been involved in malaria research and development (R&D). NIH is the lead agency for U.S. malaria R&D efforts (including its International Centers of Excellence for Malaria Research program, which established a global network of malaria research centers in 2010 to support research activities in malaria-endemic countries).³⁸  DoD also supports extensive R&D efforts as well as worldwide malaria disease surveillance, and technical assistance and capacity building with local partners.³⁹   The future of U.S. support for these efforts is uncertain as the Trump administration reduces and eliminates foreign research grants.

Countries Reached

Prior to the current administration, PMI spanned 27 sub-Saharan African “focus countries” (gradually scaled up from three countries in FY 2006), as well as three countries in Southeast Asia under the PMI Greater Mekong Subregion regional initiative.⁴⁰  Focus countries were selected based on the following criteria:⁴¹ 

• high malaria burden,
• alignment of National Malaria Control Plan (NMCP) with WHO standards,
• country capacity to implement national control policies,
• willingness to partner with the US in fighting malaria, and
• involvement of other international donors (e.g., Global Fund; World Bank).

Both USAID and CDC stationed staff in each PMI focus country, though USAID staff are or have been recalled to the U.S. due to the Trump administration’s dissolution of USAID and reorganization of foreign assistance.

Beyond PMI, the Amazon Malaria Initiative spanned several countries in Latin America and the Caribbean, and other U.S. activities may reach more countries. For example, CDC and USAID have carried out activities in additional countries in sub-Saharan Africa, the Caribbean, and Asia.⁴² 

Multilateral Efforts

The U.S. partners with international institutions and supports global malaria funding mechanisms. Key partners include the World Health Organization (although the second Trump administration immediately announced the U.S. would withdraw as a member of and halt funding to WHO), the RBM Partnership, and the World Bank. Additionally, the U.S. government is the largest donor to the Global Fund, which has approved over $22 billion in funding for malaria programs worldwide and is the largest overall funder of global malaria efforts.⁴³ 

Funding⁴⁴ 

U.S. funding for malaria, which is specified by Congress in annual appropriations bills and includes support for PMI as well as other malaria control efforts and research activities, has increased over the past decade from $873 million in FY 2016 to approximately $1 billion in FY 2025; while funding increased over the period, it has been relatively flat in recent years (see figure for the latest information). Additional U.S. support for malaria activities is provided through its contribution to the Global Fund. (See the KFF fact sheet on the U.S. Global Health Budget: Malaria/PMI and the KFF budget tracker for more details on historical appropriations for U.S. global malaria efforts.)

Most U.S. bilateral funding for malaria has been provided through the Global Health Programs account at USAID with additional funding provided through NIH, CDC, and DoD. The majority of U.S. malaria funding has been directed to PMI focus countries, with additional funding directed to other bilateral and regional malaria efforts as well as malaria research activities.

1. WHO, World Malaria Report 2024, 2024. ↩︎
2. WHO, World Malaria Report 2024, 2024. WHO, “Malaria fact sheet,” webpage, Dec. 2024, https://www.who.int/en/news-room/fact-sheets/detail/malaria. ↩︎
3. CDC Malaria website, https://www.cdc.gov/malaria/hcp/clinical-features/ ↩︎
4. M. Tanner, D. de Savigny, “Malaria Eradication Back on the Table,” Bulletin of WHO, Vol. 86, No. 2, 2008. ↩︎
5. Launched by the World Health Organization, the United Nations Children’s Fund, the United Nations Development Programme, and the World Bank as “an effort to provide a coordinated global response to the disease.” RBM Partnership to End Malaria, “RBM Partnership to End Malaria Overview,” webpage, https://endmalaria.org/about-us/overview1. ↩︎
6. M. Tanner, D. de Savigny, “Malaria Eradication Back on the Table,” Bulletin of WHO, Vol. 86, No. 2, 2008; WHO, World Malaria Report 2024, 2024. ↩︎
7. WHO, World Malaria Report 2024, 2024; M. Tanner and D. de Savigny, “Malaria Eradication Back on the Table,” Bulletin of WHO, Vol. 86, No. 2, 2008; RBM, The Global Malaria Action Plan, 2008; K. Senior, “Climate Change and Infectious Disease: A Dangerous Liaison?”, The Lancet. Vol. 8, No. 2,  2008; CDC, “Preventing Malaria While Traveling,” webpage, https://www.cdc.gov/malaria/prevention/index.html. ↩︎
8. WHO, World Malaria Report 2024, 2024; WHO, “Malaria fact sheet,” webpage, Dec. 2024, https://www.who.int/en/news-room/fact-sheets/detail/malaria. ↩︎
9. WHO, World Malaria Report 2024, 2024; Global Plan for Artemisinin Resistance Containment (GPARC), 2011; Emergency Response to Artemisinin Resistance in the Greater Mekong Subregion: Regional Framework for Action 2013-2015, April 2013; Status report on artemisinin resistance and ACT efficacy, December 2019, accessed here: https://apo.who.int/publications/i/item/status-report-on-artemisinin-resistance-and-act-efficacy; “Malaria: Artemisinin partial resistance” webpage, https://www.who.int/news-room/questions-and-answers/item/artemisinin-resistance. WHO, Strategy to respond to antimalarial drug resistance in Africa, 2022. ↩︎
10. To address insecticide resistance, the WHO issued updated guidance in 2023 recommending the use of dual active ingredient ITNs. WHO, Press release: WHO publishes recommendations on two new types of insecticide-treated nets, March 2023. ↩︎
11. In 2023, WHO published recommendations on two new types of dual active ingredient insecticide-treated mosquito nets, designed to provide greater protection against malaria than previously recommended nets. WHO, World Malaria Report 2024, 2024. ↩︎
12. For a detailed description of WHO’s recommendations on the use of drugs to prevent malaria in high-risk groups, please see WHO’s Guidelines for Malaria. WHO, Guidelines for Malaria, March 2023. ↩︎
13. Vaccines that are added to WHO’s prequalification list are endorsed by WHO as having gone through comprehensive evaluation to determine that the vaccine is safe and effective. WHO, Press release: WHO recommends groundbreaking malaria vaccine for children at risk, October 2021. WHO, Press release: WHO recommends R21/Matrix-M vaccine for malaria prevention in updated advice on immunization, October 2023. WHO, Press release: WHO prequalifies a second malaria vaccine, a significant milestone in prevention of the disease, December 2023. ↩︎
14. WHO, Press release: Life-saving malaria vaccines reach children in 17 endemic countries in 2024, December 2024. ↩︎
15. WHO, Malaria Prevention Works: let’s close the gap, April 2017. WHO, World Malaria Report 2024, 2024. ↩︎
16. RBM Partnership to End Malaria website, https://endmalaria.org/; Global Fund website, https://www.theglobalfund.org/en/. ↩︎
17. UN, Transforming our world: the 2030 Agenda for Sustainable Development, 2015. ↩︎
18. WHO, World Malaria Report 2024, 2024. ↩︎
19. Countries that were malaria endemic in 2000 and reported fewer than 10,000 malaria cases are said to be “nearing elimination.” WHO, World Malaria Report 2024, 2024. ↩︎
20. WHO, Press release: African health ministers commit to end malaria deaths, March 2024. ↩︎
21. WHO, World Malaria Report 2024, 2024. ↩︎
22. KFF: Global Financing for Malaria: Trends & Future Status, 2014; Mapping the Donor Landscape in Global Health: Malaria, 2013; World Malaria Report 2024, 2024. KFF analysis of OECD DAC CRS database, February 2025. ↩︎
23. U.S. Congress, Public Law 108-25, May 27, 2003; U.S. Congress, Public Law 110-293, July 30, 2008. ↩︎
24. The PMI 2021-2026 strategy is an update to PMI’s 2015-2020 strategy. PMI, U.S. President’s Malaria Initiative Strategy 2021-2026, October 2021. ↩︎
25. PMI website, https://www.pmi.gov/; USAID, “The President’s Malaria Initiative,” fact sheet, May 2023; PMI, The President’s Malaria Initiative: Eighteenth Annual Report to Congress, 2024; PMI, FY 2017 Greater Mekong Subregion Malaria Operational Plan, 2017; CDC, “President’s Malaria Initiative,” webpage, https://www.cdc.gov/malaria/malaria_worldwide/cdc_activities/pmi.html. ↩︎
26. PMI. “Leadership” webpage, accessed: https://www.pmi.gov/about-us/#leadership. ↩︎
27. KFF analysis of data from the U.S. Foreign Assistance Dashboard website, www.foreignassistance.gov, accessed February 2025. PMI, Eighteenth Annual Report to Congress, 2024. CDC, “Malaria’s Global Malaria Activities” webpage, https://www.cdc.gov/malaria/malaria_worldwide/cdc_activities/index.html. ↩︎
28. The countries targeted by PMI that are considered high burden include Angola, Benin, Burkina Faso, Cameroon, Côte d’Ivoire, Democratic Republic of the Congo, Ghana, Guinea, Liberia, Mali, Mozambique, Niger, Nigeria, and Sierra Leone. PMI, President’s Malaria Initiative Strategy 2021-2026, 2021. ↩︎
29. The countries targeted by PMI that are considered moderate burden include Madagascar, Malawi, Tanzania, Uganda, and Zambia. PMI, President’s Malaria Initiative Strategy 2021-2026, 2021. ↩︎
30. PMI, President’s Malaria Initiative Strategy 2021-2026, 2021. ↩︎
31. PMI, “What We Do,” webpage, https://www.pmi.gov/what-we-do/. ↩︎
32. Another preventive treatment includes PMC in countries where that treatment is relevant. To date only Sierra Leone has prioritized PMC for PMI support in their NMCPs. PMI, President’s Malaria Initiative Technical FY 2024 Guidance. ↩︎
33.   SMC is only recommended for geographic regions where the malaria transmission season is four months or less. PMI, President’s Malaria Initiative Technical FY 2024 Guidance. ↩︎
34. PMI, “Malaria Operational Plans,” webpage, https://www.pmi.gov/resources/malaria-operational-plans-mops/. ↩︎
35. PMI, “What We Do,” webpage, https://www.pmi.gov/what-we-do/. ↩︎
36. USAID, “Malaria: Countries,” webpage, https://www.usaid.gov/global-health/health-areas/malaria/countries. CDC, “CDC’s Global Malaria Activities” webpage, https://www.cdc.gov/malaria/malaria_worldwide/cdc_activities/index.html. ↩︎
37. CDC, “CDC’s Malaria Program,” fact sheet, 2023. ↩︎
38. NIAID: “Malaria,” webpage, https://www.niaid.nih.gov/diseases-conditions/malaria; “International Centers of Excellence for Malaria Research (ICEMR),” webpage, https://www.niaid.nih.gov/research/excellence-malaria-research. ↩︎
39. KFF, The Department of Defense and Global Health: Infectious Disease Efforts, 2013. ↩︎
40. In September 2017, PMI announced the addition of five new focus countries, bringing the number of PMI programs to 24 in sub-Saharan Africa. PMI. Press release: PMI Launches and Expands in West and Central Africa, September 2017; In April 2023, PMI announced its intention to expand to three more sub-Saharan African countries, increasing the total number of partner countries reached to 30 (27 in Sub-Saharan Africa and 3 in the Greater Mekong Region); the three additional countries include Burundi, The Gambia, and Togo. PMI, U.S. President’s Malaria Initiative Announces Plans to Expand to New Partner Countries, April 2023; PMI, “Where We Work,” webpage, https://www.pmi.gov/where-we-work/. ↩︎
41. PMI, 2011 PMI Fifth Annual Report, April 2011. ↩︎
42. CDC, “CDC’s Global Malaria Activities,” webpage, https://www.cdc.gov/malaria/malaria_worldwide/cdc_activities/index.html. ↩︎
43. Global Fund, Global Fund Data Explorer: https://data.theglobalfund.org/; accessed October 2024. KFF analysis. ↩︎
44. KFF analysis of data from the Office of Management and Budget, Agency Congressional Budget Justifications, Congressional Appropriations Bills, and the U.S. Foreign Assistance Dashboard website, www.foreignassistance.gov. ↩︎

Note: This fact sheet largely reflects activities prior to the second Trump administration, which has issued numerous executive actions that directly affect global health efforts, and has been updated to highlight key recent actions that may affect PEPFAR. See also the KFF fact sheet on the Trump administration’s foreign aid review and the status of PEPFAR.

Key Facts

• Although the U.S. has been involved in efforts to address the global AIDS crisis since the mid-1980s, the creation of the President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003 marked a significant increase in funding and attention to the epidemic. Now, 20 years in, PEPFAR reports saving an estimated 26 million lives and is currently providing HIV prevention and treatment services to millions.
• PEPFAR is the largest commitment by any nation to address a single disease in the world, credited with not only saving millions of lives but also helping to change the trajectory of the global HIV epidemic.
• PEPFAR funding is comprised of U.S. bilateral funding and U.S. contributions to multilateral organizations addressing HIV, primarily the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund).¹ 
• To date, U.S. funding for PEPFAR has totaled over $120 billion, growing from $1.9 billion in FY 2004 to $6.5 billion in FY 2025; FY 2025 funding, which Congress provided through a continuing resolution, includes $4.8 billion provided for bilateral HIV efforts and $1.7 billion for multilateral efforts ($50 million for UNAIDS and $1.65 billion for the Global Fund).² 
• PEPFAR has been reauthorized by Congress four times, most recently in March 2024 for one year. Although that authorization expired on March 25, 2025, PEPFAR is a permanent part of U.S. law and, other than a set of eight time-bound provisions, continues as long as Congress appropriates funding for the program.
• More broadly, PEPFAR is – for the first time in its two-decade history – facing significant challenges that could impede its ability to fulfill its mission. The Trump administration has instituted a review of all foreign assistance, including for PEPFAR, as well as a funding freeze. These actions have already resulted in significant disruption and limitation of PEPFAR’s scope and services, and it is unknown whether the administration will recommend further changes to PEPFAR and how or if Congress will respond to these recommendations.

Global Situation

HIV, the virus that causes AIDS (“acquired immunodeficiency syndrome” or Advanced HIV Disease), has become one of the world’s most serious health and development challenges. Today, there are approximately 39.9 million people living with HIV, and tens of millions of people have died of AIDS-related causes since the beginning of the epidemic (see the KFF fact sheet on the global HIV epidemic).³ 

U.S. Government Efforts

Although the U.S. has been involved in efforts to address the global HIV/AIDS crisis since the mid-1980s,⁴  the creation of the President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003 marked a significant increase in funding and attention to the epidemic.⁵  PEPFAR, the U.S. government’s global effort to combat HIV and the largest global health program devoted to a single disease, is credited with saving millions of lives and helping to change the trajectory of the global HIV epidemic. It was announced in January 2003 during President George W. Bush’s State of the Union and authorized by Congress that same year through the Leadership Act (see Table 1). The Leadership Act governs PEPFAR’s HIV response, as well as U.S. participation in the Global Fund (an independent, international multilateral financing institution that provides grants to countries to address HIV, TB, and malaria) and bilateral assistance for TB and malaria programs.⁶  Congress has updated, extended, and made changes to the program through the Lantos-Hyde Act of 2008, the PEPFAR Stewardship Act of 2013, the PEPFAR Extension Act of 2018, and more recently, a short-term reauthorization of PEPFAR that extended certain timebound provisions through late March 2025, when they were allowed to lapse (see Table 1 and the KFF brief on PEPFAR reauthorization legislation over time). This short term reauthorization signaled a departure from the program’s long history of strong bipartisan support across multiple Congresses and administrations when, in an increasingly partisan environment, it was caught up in the broader U.S. political debate over abortion (see the KFF brief on PEPFAR’s short term reauthorization). This and other rapidly-evolving developments, including the Trump administration’s review of foreign assistance, has introduced significant uncertainty about PEPFAR’s future, including its reauthorization prospects, although PEPFAR is a permanent part of U.S. law and will continue as long as Congress continues to provide funding to it.

Organization

PEPFAR’s original authorization established new structures and authorities, consolidating all U.S. bilateral and multilateral activities and funding for global HIV/AIDS. Several U.S. agencies, host country governments, and other organizations are involved in implementation.⁷ 

PEPFAR is overseen by the U.S. Global AIDS Coordinator, who is appointed by the President, confirmed by the Senate, and reports directly to the Secretary of State, as established through PEPFAR’s authorizing legislation.⁸  The Coordinator holds the rank of Ambassador and leads the Office of the Global AIDS Coordinator (OGAC) at the Department of State.⁹  The Coordinator has primary responsibility for the oversight and coordination of all U.S. global HIV activities and funding across multiple U.S. implementing agencies and departments. In addition, the Coordinator serves as the U.S. Government’s board member to the Global Fund (the U.S. Government holds a permanent seat on the Global Fund’s Board). The Coordinator is dual-hatted as the U.S. Special Representative for Global Health Diplomacy and also leads the broader Bureau of Global Health Security and Diplomacy, which brings together PEPFAR with global health security and global health diplomacy functions.¹⁰  Currently, the President has not yet nominated a Coordinator and it is unclear when or whether someone will be nominated.

In addition to the Department of State, other implementing departments and agencies for HIV activities include: the U.S. Agency for International Development (USAID), PEPFAR’s largest government implementing agency (the Trump administration has moved to dissolve USAID, creating uncertainty about how PEPFAR’s implementation will be managed by the U.S. government going forward); the Department of Health and Human Services, primarily through the Centers for Disease Control and Prevention (CDC); the Departments of Labor, Commerce, and Defense (DoD); and the Peace Corps.¹¹  As the Trump administration continues its review of foreign assistance and pursues reorganization of global health programs, Congress has yet to weigh in and it is unclear what the future of PEPFAR will look like.

Key Activities and Results

PEPFAR reports saving an estimated 26 million lives and its activities have focused on expanding access to HIV prevention, treatment, and care interventions. These have included provision of antiretroviral treatment, pre-exposure prophylaxis, voluntary male circumcision, condoms, and other commodities related to HIV services (see Table 2).^12 ,13  In addition, PEPFAR has launched specific initiatives in key strategic areas. For example, in 2015, PEPFAR launched DREAMS, a public-private partnership that aims to reduce HIV infections in adolescent girls and young women.

The latest results reported by PEPFAR indicate that it has:

• supported testing services for 83.8 million people in FY 2024;
• prevented 7.8 million babies from being born with HIV, who would have otherwise been infected;
• provided care for more than 6.6 million orphans, vulnerable children (OVC), and their caregivers;
• supported training for nearly 342,000 new health care workers; and
• supported antiretroviral treatment for 20.6 million people.¹⁴ 

Additionally, it reports that PEPFAR reached 2.3 million adolescent girls and young women with HIV prevention services in FY 2024, and new diagnoses among this population have declined, with the higher rate of initiation of pre-exposure prophylaxis (PrEP) to prevent HIV infection in countries implementing the DREAMS initiative compared to areas without DREAMS programming.¹⁵  The Trump administration’s foreign aid review and funding freeze have limited PEPFAR’s activities to those defined in a limited waiver, significantly scaling back PEPFAR’s scope to what the waiver defines as “life-saving HIV services,” which include only certain activities: HIV treatment and care, prevention of mother-to-child transmission (PMTCT), pre-exposure prophylaxis (PrEP) for pregnant and breastfeeding women, and HIV testing.

Countries Reached

Historically, PEPFAR bilateral programs were carried out in more than 50 countries.¹⁶  Additional countries are reached through U.S. contributions to the Global Fund. PEPFAR currently requires 25 countries¹⁷  and the Asia, Western Hemisphere, and West Africa regional programs to develop “Country Operational Plans” (COPs) and “Regional Operational Plans” (ROPs), respectively, to document annual investments and anticipated results.¹⁸  OGAC reviews and the Global AIDS Coordinator approves COP/ROPs.

Funding¹⁹ 

Total PEPFAR funding²⁰  includes bilateral funding for HIV activities conducted by U.S. implementing agencies as well as U.S. contributions to the Global Fund and UNAIDS,²¹  as specified by Congress for PEPFAR in annual appropriations bills.²²  It represents the majority of U.S. global health funding (about 53% in recent years²³ ) and is the largest commitment by any nation to address a single disease in the world. To date, PEPFAR funding has totaled over $120 billion, with funding reaching $6.5 billion in FY 2025 (in FY 2025, PEFPAR funding was provided through a continuing resolution, which maintained the prior year amount; see figure).

PEPFAR’s creation marked a significant increase in the amount of funding provided by the U.S. for HIV. Trends in funding for bilateral programs and contributions to multilateral organizations are as follows (see the KFF fact sheet on the U.S. Global Health Budget: Global HIV Funding, Including PEPFAR and U.S. Global Health Budget: The Global Fund):

• Bilateral HIV Funding: The majority of PEPFAR funding (ranging from 70-77% each year over the past decade) is provided for bilateral programs through the State Department (most of which is then transferred to other agencies), USAID, CDC, and DoD. Bilateral funding rose rapidly from $822 million in FY 2003 (the year before PEPFAR) to a peak of $5.0 billion in FY 2010. Between FY 2010 and FY 2013, it declined by more than $750 million. While it has risen since then, bilateral funding in FY 2025 ($4.8 billion), which Congress provided through a continuing resolution, was still $233 million below its peak level, and funding has been mostly flat for the past several years.
• Multilateral Contributions: The U.S. also supports global HIV efforts through contributions to the Global Fund and UNAIDS. Support for the Global Fund, which accounts for most of the multilateral contributions, increased rapidly in its early years and fluctuated over time; it reached its highest level to date ($2.0 billion) in FY 2023. In FY 2025, funding for the Global Fund, which represented a carry-over from FY 2024 levels due to the continuing resolution, was $1.65 billion, $375 million less than the FY 2023 level, though this is due to a legislative requirement that limits the amount the U.S. can contribute to the Global Fund to not more than 33% of all contributions.²⁴  The U.S. contribution to UNAIDS was $45 million for most years over the past decade, but increased to $50 million in FY 2022, where it has remained.
• Emergency Funding: In FY 2021, an additional $3.8 billion in emergency supplemental funding was provided for bilateral HIV ($250 million) and the Global Fund ($3.5 billion) to address COVID-19.²⁵ 

Spending Directives²⁶ 

PEPFAR has included several spending directives, or earmarks, from Congress over the course of its history, many of which have changed over time:

1. The Leadership Act, PEPFAR’s original authorization, included the following spending directives: 55% of funds were to be spent on treatment; 15% on palliative care; 20% on prevention, of which at least 33% be spent on abstinence-until-marriage programs; and 10% on OVC. While these were included as “sense of Congress” recommendations, the treatment, OVC, and abstinence-until-marriage earmarks were made requirements as of FY 2006.
2. The Lantos-Hyde Act relaxed some of these directives for the FY 2009 – FY 2013 period: while still requiring that 10% of funds be spent on programs targeting OVC, it changed the treatment earmark from 55% to requiring that at least half of bilateral HIV assistance be spent on treatment and care. It removed the 33% abstinence-until-marriage directive and replaced it with a requirement of “balanced funding” for prevention to be accompanied by a report to Congress if less than half of prevention funds were spent on abstinence, delay of sexual debut, monogamy, fidelity, and partner reduction activities in any host country with a generalized (high prevalence) epidemic.
3. The PEPFAR Stewardship Act, The PEPFAR Extension Act, and recent short-term reauthorization have maintained the language in the Lantos-Hyde Act. With the expiration of the short-term reauthorization, eight timebound provisions have now lapsed.

PEPFAR & The Global Fund

The U.S. is the single largest donor to the Global Fund. Appropriations for the U.S. contribution to the Global Fund totaled approximately $31.5 billion from FY 2001 through FY 2025.²⁷  This includes, $3.5 billion in FY 2021 emergency funding that the U.S. government provided to the Global Fund to help the organization address the impacts of COVID-19 (in addition to the $250 million in emergency funds provided to bilateral HIV for COVID-19-related efforts).²⁸ 

The Global Fund provides another mechanism for U.S. support by funding programs developed by recipient countries, reaching a broader range of countries, and supporting TB, malaria, and health systems strengthening (HSS) programs in addition to (and beyond their linkage with) HIV.²⁹  To date, over 120 countries³⁰  have received Global Fund grants. Most Global Fund support (52%) has been committed to HIV and HIV/TB programs,³¹  followed by 29% to malaria, 15% to TB, and 4% to other health issues.³²  The original authorization of PEPFAR, and subsequent reauthorizations, included a limit on annual U.S. contributions to the Global Fund that prevented them from causing cumulative U.S. contributions to exceed 33% of the Global Fund’s total contributions (see the KFF fact sheet on the Global Fund). ^33 ,34 

1. KFF analysis of The Global Fund: https://data-service.theglobalfund.org/downloads. ↩︎
2. Totals represent funding specified by Congress in annual appropriations bills and/or identified by agencies for the Department of State, USAID, CDC, and DoD. In addition, international HIV research activities are supported by the NIH Office of AIDS Research (OAR) through its annual appropriated budget, but these amounts are not considered part of PEPFAR. See KFF’s “Breaking Down the U.S. Global Health Budget by Program Area” for additional information. ↩︎
3. UNAIDS. 2024 UNAIDS Global AIDS Update: The urgency of now – AIDS at the crossroads; July 2024. ↩︎
4. The U.S. first provided funding to address the global HIV epidemic in 1986. Then, in 1999, President Bill Clinton announced the Leadership and Investment in Fighting an Epidemic (LIFE) Initiative to address HIV in 14 African countries and in India. Later, in 2002, President George W. Bush announced the International Mother and Child HIV Prevention Initiative focused on 12 African and two Caribbean countries. ↩︎
5. PEPFAR. 2009 Annual Report to Congress; Jan. 2009. ↩︎
6. U.S. Congress. P.L. 108-25; May 27, 2003. ↩︎
7. KFF. The U.S. Government and Global Health, Sep. 2022. CRS. PEPFAR Reauthorization: Key Policy Debates and Changes to U.S. International HIV/AIDS, Tuberculosis, Malaria and Programs and Funding; Jan. 2009. ↩︎
8. U.S. Congress. Public Law No: 108-25; May 27, 2003. ↩︎
9. U.S. Department of State. “Leadership – Bureau of Global Health Security and Diplomacy” webpage, https://www.state.gov/leadership-bureau-of-global-health-security-and-diplomacy. ↩︎
10. Department of State. “ Leadership – Bureau of Global Health Security and Diplomacy,” webpage, https://www.state.gov/leadership-bureau-of-global-health-security-and-diplomacy/. ↩︎
11. PEPFAR. “About Us,” webpage, https://www.state.gov/about-us-pepfar/. ↩︎
12. Table 2 categorization is based on interventions laid out in the PEPFAR Financial Classification Reference Guide, used for program budgeting. See: PEPFAR Financial Classifications Reference Guide, June 2024. ↩︎
13. KFF. Funding for Key HIV Commodities in PEPFAR Countries; July 2021. ↩︎
14. PEPFAR. PEPFAR Latest Global Results; December 2024. ↩︎
15. The 15 African countries that are implementing DREAMS include Botswana, Cote d’Ivoire, Eswatini, Haiti, Kenya, Lesotho, Malawi, Mozambique, Namibia, Rwanda, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe. PEPFAR. DREAMS Country Fact Sheets; June 27, 2020; PEPFAR. PEPFAR Latest Global Results; December 2024. ↩︎
16. PEPFAR, “Where We Work” webpage, https://www.state.gov/where-we-work-pepfar/; PEPFAR 2023 Country Operational Plan Guidance for all PEPFAR Countries; and CDC’s “Where We Work” webpage, https://www.cdc.gov/global-hiv-tb/php/where-we-work/. ↩︎
17. The 25 countries that are required to complete a FY23 COP are Angola, Botswana, Burundi, Cameroon, Cote d’Ivoire, Democratic Republic of the Congo, Dominican Republic, Eswatini, Ethiopia, Haiti, Kenya, Lesotho, Malawi, Mozambique, Namibia, Nigeria, Rwanda, South Africa, South Sudan, Tanzania, Uganda, Ukraine, Vietnam, Zambia, and Zimbabwe.  PEPFAR. “Where We Work” webpage, https://www.state.gov/where-we-work-pepfar/. ↩︎
18. PEPFAR. 2023 Country and Regional Operational Plan Guidance and Technical Considerations; Feb. 2023. ↩︎
19. U.S. Congress. Public Law No: 112-25; Aug. 2, 2011. White House Office of Management and Budget (OMB). OMB Report to the Congress on the Joint Committee Sequestration for Fiscal Year 2013; March 1, 2013. KFF analysis of data from: Congressional appropriations bills and reports; Federal Agency Budget and Congressional Justification documents; ForeignAssistance.gov; KFF personal communication with the Office of Management and Budget. ↩︎
20. Overall PEPFAR funding technically includes support for bilateral HIV and TB activities, as well as contributions to multilateral organizations (specifically, the Global Fund and UNAIDS). This analysis only focuses on bilateral funding for HIV and contributions to multilateral organizations. ↩︎
21. UNAIDS is the Joint United Nations Programme on HIV/AIDS, the U.N. system’s coordinating body that serves to help galvanize worldwide attention to AIDS. ↩︎
22. Totals represent funding specified by Congress for PEPFAR in annual appropriations bills and/or identified by agencies for the Department of State, USAID, CDC, and DoD. In addition, international HIV research activities are supported by the NIH Office of AIDS Research (OAR) through its annual appropriated budget, but these amounts are not considered part of PEPFAR. See KFF’s “Breaking Down the U.S. Global Health Budget by Program Area” for additional information. ↩︎
23. Includes bilateral funding for HIV as well as U.S. contributions to UNAIDS and the Global Fund to Fight AIDS, Tuberculosis and Malaria through regular appropriations. ↩︎
24. U.S. Congress. Public Law No: 118-47; March 23, 2024. ↩︎
25. KFF analysis of data from the “American Rescue Plan Act of 2021” (P.L. 117-2). ↩︎
26. U.S. Congress. Public Law No: 108-25; May 27, 2003. U.S. Congress. Public Law No: 110-293; July 30, 2008. U.S. Congress. Public Law No: 113-56; Dec. 2, 2013. U.S. Congress. Public Law No: 115-305; Dec. 11, 2018. U.S. Congress. Public Law No: 118-47; March 23, 2024. ↩︎
27. Includes funding through regular appropriations and emergency supplemental funding. KFF analysis of data from: Congressional appropriations bills and reports; Federal Agency Budget and Congressional Justification documents; ForeignAssistance.gov; KFF personal communication with the Office of Management and Budget. ↩︎
28. KFF analysis of data from the “American Rescue Plan Act of 2021” (P.L. 117-2). ↩︎
29. Congress states that the Global Fund is the multilateral component of PEPFAR in the following: U.S. Congress. Public Law No: 110-293; July 30, 2008. U.S. Congress. Public Law No: 113-56; Dec. 2, 2013. ↩︎
30. Does not include countries that may have received funding through multi-country or regional programs. Additional countries may be reached through multi-country or regional programs. ↩︎
31. Of the 52% committed to HIV and HIV/TB programs, 39.4% was for HIV activities and 12.3% was for HIV/TB activities. ↩︎
32. In 2020, some donor governments provided COVID-specific emergency contributions to the Global Fund in addition to their contributions to core activities. For the purposes of this fact sheet, these COVID-specific amounts have been excluded as they cannot be attributed to a specific area, such as HIV, TB, or malaria. The Global Fund. Data Explorer; accessed July 2024: https://data.theglobalfund.org/. ↩︎
33. U.S. Congress. Public Law No: 108-25; May 27, 2003. U.S. Congress. Public Law No: 110-293; July 30, 2008. U.S. Congress. Public Law No: 113-56; Dec. 2, 2013. U.S. Congress. Public Law No: 118-47; March 23, 2024. KFF. PEPFAR Reauthorization: Side-by-Side of Legislation Over Time, brief. ↩︎
34. See the KFF. The U.S. & The Global Fund to Fight AIDS, TB and Malaria, fact sheet; and KFF. PEPFAR Reauthorization: Side-by-Side of Legislation Over Time, brief. ↩︎

The House and Senate are working on legislation to meet the requirements in the budget resolution, which targets cuts to Medicaid of up to $880 billion or more over 10 years. Although it is unclear what specific policies will be included in the final reconciliation bill, significant reductions in Medicaid spending would likely impact hospitals given that the program accounted for about one fifth (19%) of all spending on hospital care in 2023. Reductions in payments to hospitals, coupled with an increase in the number of uninsured Americans, resulting from Medicaid spending cuts or other policy changes would likely have implications for hospital finances, access to hospital services, the quality of patient care, and local economies (in that hospitals are the sixth largest employer in the country across industry subsectors).

The interactive map below shows the number of hospitals in each congressional district as reported in the American Hospital Association Annual Survey Database, updated through May 7, 2025. These counts include different types of hospitals, such as general, children’s, psychiatric, and long-term care hospitals. Federal hospitals, such as hospitals operated by the Department of Veterans Affairs, are excluded. (See Methods for additional information). Key takeaways include:

• There is at least one hospital in each of the 435 congressional districts, and as many as 69 hospitals in one district (KS01, which covers a large portion of the state).
• The large majority of congressional districts (94%) include at least five hospitals, most (61%) include at least ten hospitals, and about one in six (18%) include at least twenty hospitals.
• The average congressional district includes 14 hospitals.
• Republican congressional districts have 17 hospitals, on average, and Democratic districts have 10 hospitals, on average. Republican congressional districts may have more hospitals in part because they include some districts with large land areas, such as North Dakota, South Dakota, and Wyoming, each of which is one congressional district.

The Biden administration finalized several major Medicaid regulations with the intent of improving access to Medicaid services. Collectively, the rules span hundreds of pages of text, are extremely complex, and were set to be implemented over several years, with measurable increases in federal Medicaid spending. Overturning the rules would reduce regulation of managed care companies, nursing facilities, and other providers; increase barriers to enrolling in and renewing Medicaid coverage, and roll back enrollee protections, payment transparency, and requirements for improved access.

As Congress looks to meet the adopted budget resolution’s requirement of cutting federal Medicaid spending by up to $880 billion or more over ten years, overturning the Biden era rules could achieve some of those savings. Early leaked documents pointed to federal savings of $420 billion over ten years to roll back “major Biden Health rules,” although it is unclear which rules are included in the total and what the source is for the estimate. It is also unclear whether repealing all of the rules will be permissible under the Senate’s rules governing reconciliation legislation, which specify that provisions in reconciliation may not be “extraneous” to the federal budget.

To count as “savings” for the purposes of reconciliation, the federal budgetary effects of legislation changes must be estimated or “scored” by the Congressional Budget Office (CBO), raising the question of to what extent CBO will count repealing Biden era rules as savings for Medicaid. CBO has published its practices around how to incorporate administrative and judicial actions into cost estimates, explaining that after regulations are finalized, the effects of the rules are considered part of current law. The effects of repealing the regulations through legislation would, therefore, be included in a cost estimate, provided new regulations replacing the Biden rules aren’t proposed and assuming the courts don’t overturn any of the regulations (as new administrative or judicial action would change current law and may affect costs estimates). As of now, the only regulation for which savings are likely to be reduced because of administrative and judicial action is the requirement for nursing facilities to maintain minimum staffing levels (details below).

Major Medicaid health rules that could be repealed as part of reconciliation include the following:

• The Access rule addresses several dimensions of access: increasing provider rate transparency and accountability, standardizing data and monitoring, and increasing opportunities for Medicaid enrollees to provide feedback on state Medicaid policies through a new beneficiary advisory committee, with the goal of improving access to care.
• The rule requires states to compare fee-for-service (FFS) payment rates for primary care, obstetrical and gynecological care, and outpatient mental health and substance use disorder services to Medicare rates, and publish the analysis every two years, with the first analysis published by July 1, 2026.
• In addition, by July 1, 2026, states must publish all FFS rates on a publicly available and accessible website and make updates within one month of a payment rate change.
• The rule also included many provisions governing access to home care (also known as home- and community-based services or HCBS), which include ensuring that at least 80% of spending on certain services be spent on compensation for direct care workers and requiring states to report the number of people on waiting lists for care.
• The Managed Care rule addresses Medicaid managed care access, financing, and quality, including strengthening standards for timely access to care (e.g., through the establishment of national maximum wait time standards for certain “routine” appointments) and states’ monitoring and enforcement efforts. The rule requires states to submit annual payment analysis and establishes a ceiling on state directed payments to institutional providers like hospitals at “average commercial rates” or ACR. Other supplemental payments in fee-for-service use Medicare as the payment ceiling, which is generally substantially below what commercial insurers pay.
• The Long-Term Care Facility (LTC) Staffing rule establishes minimum staffing standards for nursing facilities, requires state Medicaid agencies to report the percent of Medicaid payments for institutional LTC that are spent on worker compensation, and provides funding for people to enter careers in nursing homes. It is unclear whether changes to the staffing rule would count as savings for reconciliation purposes because the US District Court for Northern Texas ruled to overturn the key staffing standards in early April. CBO generally does not account for district court rulings in its cost estimates but the Trump administration has signaled that it will not appeal the ruling, suggesting that in this case, the District Court decision may stand.
• Two rules streamline Medicaid enrollment and renewal processes for the Medicare Savings Program(MSP) and for Medicaid, CHIP and the Basic Health Program. The first rule helps eligible Medicare beneficiaries more easily access Medicaid coverage of Medicare premiums and cost sharing through the MSP while the second rule streamlines application and enrollment processes in Medicaid, aligns renewal policies for all Medicaid enrollees, including requiring states to renew eligibility only every 12 months for all Medicaid enrollees (a new requirement for people who qualify on the basis of age or disability pathways as 12-month renewals were already required for children and adults by the Affordable Care Act), facilitates transitions between Medicaid, CHIP, and subsidized Marketplace coverage, and eliminates certain barriers for children in CHIP. The rule also updates documentation and recordkeeping requirements to reduce payment errors based on insufficient documentation. Many provisions in the MSP rule have already taken effect and many states are already in compliance with other provisions ahead of scheduled implementation timelines. CBO estimates that repeal of these rules would reduce federal Medicaid spending by $170 billion over ten years and reduce Medicaid coverage by 2.3 million by 2034.

The recently passed budget resolution targets cuts to Medicaid of up to $880 billion or more over a decade to help pay for tax cuts. Major cuts to Medicaid may impact coverage for the almost 1 in 5 Medicare beneficiaries (11.9 million) who are also enrolled in Medicaid. For people covered under both programs (“dual-eligible individuals”), Medicare is the primary payer and covers medical acute and post-acute care, including skilled nursing facility services and home health care. Medicaid wraps around Medicare coverage by paying Medicare premiums and in most cases, cost sharing. Most dual-eligible individuals (8.5 million people in 2025) are “full-benefit” enrollees, which means they are eligible for Medicaid benefits that are not otherwise covered by Medicare, including long-term care, vision, and dental. The remaining 3.4 million dual-eligible individuals, “partial-benefit” enrollees, are eligible for Medicare premiums and often, cost sharing assistance, but not for full Medicaid benefits.

It is unclear what policies might be included in the reconciliation proposals, but significant reductions in Medicaid spending would have potential implications for Medicare beneficiaries who account for nearly 30% of Medicaid spending. The interactive maps below illustrate how many people are enrolled in Medicare and Medicaid in each congressional district, including the number of people receiving full Medicaid and partial Medicaid benefits. Key takeaways include:

• There are at least 7,300 dual-eligible individuals living in each of the 435 congressional districts, with enrollment as high as 81,300 in some districts.
• In each congressional district, there are at least: 4,100 full-benefit dual-eligible individuals and 100 partial-benefit dual-eligible individuals.
• The average number of dual-eligible individuals is 24,700 in Republican districts and 30,000 in Democratic districts.
• The share of dual-eligible individuals with full Medicaid benefits varies across congressional districts, ranging from 30% to 100%.
• The top 10 Republican districts with the highest number of dual-eligible individuals are: FL26 (58,800); KY05 (58,000); FL27 (56,300); NY11 (53,000); FL28 (51,100); WV01 (48,500); CA01 (46,300); NY21 (45,700); CA22 (41,500); and AR01 (40,900).
• The top 10 Democratic districts with the highest number of dual-eligible individuals are: NY13 (81,300); NY15 (73,700); NY08 (71,600); NY06 (64,800); ME02 (63,300); NY14 (57,800); NY09 (57,300); CA34 (56,500); MA01 (56,400); and NY10 (55,600).

Introduction

Intimate partner violence (IPV) is a persistent public health crisis that affects many women in the United States. IPV affects disproportionately affects women but also affects people of all genders. It has a wide range of negative effects on women’s physical and mental health, such as physical injuries, pregnancy complications, and substance use. IPV also has psychosocial impacts, affecting women’s safety, economic security and freedom, isolation, and ability to care for themselves and their children.

The 2024 KFF Women’s Health Survey provides data on women experiencing IPV in the past five years. This group includes women who said that in the past five years a current or former partner did at least one of the following: made them fear for their or their family’s safety, tried to control most or all of their daily activities, hurt them physically, forced them into sexual activity. However, this population does not include those who had experiences with IPV at earlier points in their lives or other forms of IPV and should not be used as an estimate of overall lifetime IPV prevalence Many women, particularly those who are older, may have experienced IPV prior to the last five years.

This analysis reports on a range of health topics affecting women who experienced IPV in the past five years, including their health care needs and use, barriers, and mental health. The impact on women who have been historically marginalized by society and health care systems, including those who are LGBTQ+, experience physical and mental disabilities, and those who are low-income is also examined. The survey was conducted from May 13 – June 18, 2024, online and by telephone among a nationally representative sample of 5,055 women ages 18 to 64.

Key Takeaways

• One in five (19%) women ages 18 to 64 say they have experienced intimate partner violence (IPV) in the last five years. Higher shares of women with lower incomes, LGBT+ women, and those who identify as disabled report recent IPV.
• Many women who have experienced IPV in the past five years contend with health challenges. Large shares characterize their physical (27%) and mental (46%) health as fair or poor. One in four say that a health condition keeps them from fully participating in work or other activities. Almost half of women who have experienced IPV in the past five years incurred a physical injury as a result.
• Over one in ten (14%) women who have experienced IPV in the past five years say that at some point they did not receive health care services they needed related to IPV. Privacy concerns, fear, and intimidation are leading reasons why people experiencing IPV do not obtain health care.
• There are differences in where women affected by IPV usually get health care. More than a third (35%) say their usual site of care is a clinic or health center. One in ten (9%) say it is the emergency room.
• IPV is a major concern during women’s reproductive years. Among women who experienced IPV in past five years, four in ten said they experienced violence during their most recent pregnancy or in the year before or after the pregnancy.
• Emergency contraception is an important back-up contraceptive for reproductive age women affected by IPV. One in five report using emergency contraception in the past year. One in ten also say they have obtained it since the Dobbs ruling in case they need it. These shares are approximately double the rates reported by women who have not experienced IPV in past five years.

Rates of IPV

One in five women ages 18 to 64 say they have experienced IPV in the past five years.

IPV presents in many forms, including physical, sexual, emotional, coercion, and online. The KFF Women’s Health Survey asked about a subset of IPV experiences that women have reported experiencing in the past five years. Approximately one in ten women say that in the past five years, a current or former partner has made them fear for their or their family’s safety (11%), tried to control most or all of their daily activities (11%), hurt them physically (9%), or forced them into sexual activity (9%) (Figure 1). In total, one in five (19%) women ages 18 to 64 said they have experienced at least one of these forms of IPV in the past five years.

Throughout this brief, this is the group referenced when discussing women who have experienced IPV.

Larger shares of women who are younger and have lower incomes consistently report experiencing IPV compared to those who are older and have higher incomes. Conversely, women who are Asian American or Pacific Islander report lower rates of IPV compared to women of other racial and ethnic groups. While women of all subpopulations experience IPV, rates are higher among some groups (Figure 2). More than one in four (27%) women who have lower incomes say they have experienced IPV in the past five years, about twice the share of those with higher incomes (14%). One in ten (9%) AAPI women report IPV in the past five years, which is lower than women of other racial/ethnic backgrounds.

One-third of women who are LGBT+ and one in four who identify as disabled report experiencing IPV in the past five years. Rates of all the IPV questions in the survey are higher among LGBT+ women compared to those who are not LGBT+ (Figure 2). Approximately one in five LGBT+ women said that in the past five years a current or former partner has made them fear for their or family’s safety (19%), tried to control most or all of their daily activities (20%), hurt them physically (18%), or forced them into sexual activity (18%). In total, twice as many LGBT+ women (32%) said they have experienced one of these forms of IPV in the past five years compared to non-LGBT+ women (16%). One in five women with a disability say they have feared for their or their family’s safety at the hands of a current or former partner (19%).  Overall, one in four (27%) women who identifies as disabled reports experiencing at least one form of IPV in the past five years.

On average, women who have experienced IPV in the past five years have lower incomes and lower rates of private health insurance.

More than half (54%) of women affected by IPV in the past five years have low incomes, compared to one-third of those who have not (Figure 3). Insurance profiles also differ between women affected by IPV and those who have not, with a lower rate of private insurance coverage and higher rate of Medicaid coverage among those who have experienced IPV in the past five years compared to those who have not.  Almost half (45%) of women who have experienced IPV in the past five years have young children, and half (54%) are not married. This is in part a reflection of the fact that many women experience IPV at young ages.

Women who have experienced IPV report higher rates of some health challenges, including disability and poorer health status. One in four women who have experienced IPV in the past five years rates their health as “fair” or “poor” (Figure 4). One in four (25%) also report having a chronic condition that keeps them from participating fully in work, school, or other activities. One in five (19%) say they identify as disabled. IPV may be a cause or contributor to these conditions or could exacerbate any of them.

Health Care Access and Barriers

Women who have experienced IPV in the past five years have heavier reliance on clinics and emergency rooms for their health care. Just under half (47%) of women who have experienced IPV in the past five years say they usually get health care in a private doctor’s office, whereas this is the site of care for the majority (62%) of those who have not experienced IPV recently (Figure 5). Three in ten (31%) women who have experienced IPV in the past five years say they usually obtain health care at a neighborhood clinic or health center, and one in ten (9%) usually get care at an emergency room. These differences in site of care may be driven by income, given that women who have experienced IPV are disproportionately lower-income.

Almost half of women who have experienced IPV in the past five years incurred a physical injury as a result. Some of the most common injuries reported by people who experience IPV include head trauma, gynecologic conditions, and fractures. Overall, 45% of women who experienced IPV in the past five years say that their IPV experience resulted in physical injury, which translates to about one in ten (9%) among all women ages 18 to 64 (Figure 6). Among women who experienced IPV in the past five years, majorities of those who identify as having a disability (61%) and have lower incomes (52%) report having physical injuries from IPV. The shares are similar across White, Black, and Hispanic women.

Over one in ten (14%) women who have experienced IPV in the past five years did not receive health care services they needed. Women who experience IPV may need a wide range of health care services related to the impact of IPV. However, 14% of women who recently experienced IPV were not able to get medical or mental health care services related to IPV (Figure 7). Three in ten women say they needed health care services and did obtain them, and more than half (56%) of women who experienced IPV in the past five years say they did not need health services related to their IPV experience.

Privacy concerns, fear, and intimidation are leading reasons why women experiencing IPV do not get care. People who experience IPV are typically dealing with multiple, complicated circumstances that can affect whether, when, and if they can disclose IPV and seek and obtain care. Among women who experienced IPV in the past five years and did not receive care that they needed, nearly six in ten (58%) say it is because they did not want anyone to find out (Figure 8). For some, fear of retribution from a partner is too high to seek care. Almost four in ten (37%) women who did not receive care say they feared the police or child protective services would get involved. Prior research finds that some women affected by IPV report that involvement of police authorities can backfire on them because they lose care of their children or are accused of crimes they did not commit. Health system barriers affect women experiencing IPV too. Almost four in ten (38%) say they could not afford to get care and one in ten (12%) say services were unavailable, which may be tied to their higher rates of uninsurance. Medical billing practices can make confidentiality challenging as violent partners may get a hold of billing statements and patient records.

IPV and Mental Health Care

Violence, control, and coercion have severe negative effects on an individual’s mental health and well-being.  IPV is associated with higher rates of depression, anxiety, and substance use.  Mental health care has been identified as one of the essential health services needed for women affected by IPV.

Women who have been affected by IPV in the past five years have poorer self-reported mental health status and emotional well-being than those who have not. Almost half (46%) of women who have experienced IPV in the past five years describe their mental health and emotional well-being as “fair” or “poor,” twice the share of those who have not (Figure 9). Conversely, 42% of women who have not been affected by IPV in the past five years describe their mental health as “excellent” or “very good,” over twice the share of women affected by IPV (18%). Just over one-third of each group rates their health as “good.”

Many women encounter barriers to mental health care, particularly those affected by IPV. Among women who have experienced IPV in the past five year who rate their health as fair or poor, two-thirds (66%) say that in the past year they did not obtain mental health care they thought they needed. This is also the case for half (50%) of women with fair or poor mental health who have not experienced IPV recently.

IPV and Reproductive Health

IPV often begins during women’s reproductive years, and research has documented associations between IPV and several sexual and reproductive health challenges, including higher risk for sexually transmitted infections, inconsistent use of contraception, and high rate of unplanned pregnancies.

Among reproductive age women who experienced IPV and were pregnant in the past five years, four in ten say they experienced violence around the time of pregnancy. Pregnancy can be a risky period for people experiencing IPV, as some people report that violence increases or intensifies during and after pregnancy. Experiences with IPV have been linked with greater risk for negative maternal and fetal health complications, including preterm birth, low birthweight, as well as maternal and fetal death in the most severe cases.  Among women of reproductive age (18 to 49 years old) who were pregnant and experienced IPV in the past five years, one in five say they experienced IPV in the year prior to their last pregnancy (21%), during their most recent pregnancy (22%), and in the year after (20%). Overall, four in ten women of reproductive age who have experienced IPV say they experienced IPV during one of these periods (Figure 10).

Among women who were pregnant in the past five years, a higher share of those who also experienced IPV (65%) said they needed mental health services during or within the first year after pregnancy, compared to those who were not affected by IPV (44%).

Eight in ten women of reproductive age who have experienced IPV in the past five years report using contraception in the past year. Preventing pregnancy is the leading reason for using contraception for this group, but one in five women who have experienced IPV in the past five years use it to prevent an STI.

The majority of reproductive age women who have experienced IPV, as well as those who have not, used contraception in the past year (Figure 11).  For most contraceptive methods, rates of use are similar between women who have experienced IPV in the past five years and those who have not. However, more women affected by IPV report using condoms (38%, 33% respectively) and withdrawal (32%, 21%) compared to those not affected by IPV, which is surprising given that these methods are controlled by men. One in four women affected by IPV report they have had a sterilization procedure, one in five use IUDs and one in five say they used EC. One notable difference is why women use contraception. One in five women who have experienced IPV in the past five years say they use it to prevent an STI, twice the share among women who have not experienced IPV in the past five years (9%).

Reproductive coercion, control by an intimate partner over reproductive health issues such as use of contraception or an abortion, is also a form of IPV. More than one in ten (13%) women who have experienced other forms of IPV in the past five years also report that a partner has tried to stop them from using contraception so they would become pregnant against their will (data not shown).

One in four reproductive age women who have experienced IPV in past five years says they or their partner made a change in contraception practices because of the overturning of Roe v. Wade. Since the 2022 Supreme Court ruling that overturned Roe v. Wade, many states have banned or severely restricted abortion access, which has prompted some people to make changes in their use of contraception. Overall, nearly twice as many women affected by IPV (26%) say they’ve made a change than those who have not recently experienced IPV (14%). In particular, 10% of reproductive age women who have experienced IPV in the past five year has obtained EC to have on hand in case they need it. Almost one in ten (8%) report starting contraception or switching to a more effective method (Figure 12).