Note: The data presented below are updated monthly as new Medicaid/CHIP enrollment data become available.

The Medicaid Enrollment and Unwinding Tracker presents the most recent data on monthly Medicaid/CHIP enrollment reported by the Centers for Medicare & Medicaid Services (CMS) as part of the Performance Indicator Project as well as archived data on renewal outcomes reported by states during the unwinding of the Medicaid continuous enrollment provision. The unwinding data were pulled from state websites, where available, and from CMS.

Medicaid/CHIP Enrollment Trends

Medicaid/CHIP enrollment trends generally use February 2020 as the baseline month because it was the month prior to the start of the COVID-19 pandemic and implementation of the continuous enrollment provision. During continuous enrollment, which was in place during the three years of the pandemic, states paused Medicaid disenrollments. As a result, when the continuous enrollment provision ended in March 2023, national Medicaid/CHIP enrollment had increased to a record high of 94 million enrollees. Beginning April 1, 2023, states could resume disenrolling people after conducting renewals to verify eligibility for the program, though some states delayed the start of their unwinding periods until May, June, or July 2023. Most states took 12 months to complete unwinding renewals and nearly all states completed renewals by August 2024.

The figures below show Medicaid and CHIP enrollment from February 2020 through the most current month of available data. Some figures also include enrollment for adults and children in Medicaid/CHIP. Key enrollment trends as of September 2025 include:

• There are 77.1 million people enrolled in Medicaid/CHIP nationally (Figure 1). This represents an 18% decline from total Medicaid/CHIP enrollment in March 2023, but is still 8% higher than Medicaid/CHIP enrollment in February 2020, prior to the pandemic (Figure 2 and Table 1).
• Several factors likely explain why national Medicaid/CHIP enrollment is higher than pre-pandemic enrollment. The pandemic may have encouraged some people who were previously eligible for Medicaid but not enrolled to newly enroll in the program. During the unwinding, many states took steps to improve their renewal processes, which reduced the number of people who were disenrolled despite remaining eligible. In addition, some states expanded eligibility for certain groups since the start of the pandemic, such as the Affordable Care Act’s (ACA) Medicaid expansion.
• Medicaid/CHIP enrollment is higher than pre-pandemic levels in all but fourteen states (AK, AR, CO, ID, IA, LA, MI, MT, NH, NM, SC, TN, TX, and WV). Enrollment changes from pre-pandemic baseline vary from a 16% decrease in Montana to a 54% increase in North Carolina (Figure 2). Many of the states with the largest increases in enrollment expanded eligibility since the start of the pandemic. For example, five states (NE, OK, MO, SD, and NC) implemented the Medicaid expansion between October 2020 and December 2023 and Maine increased the income limit for children to qualify for Medicaid.
• In the 49 states and DC with complete enrollment data by age, there are 36 million children (48%) and 39.3 million adults (52%) enrolled, a change from pre-pandemic (February 2020) enrollment patterns when children made up a slight majority (51%) of Medicaid/CHIP enrollees (Figure 1).
• Child enrollment in Medicaid/CHIP is below pre-pandemic enrollment in 19 states, while adult enrollment is below pre-pandemic levels in 12 states (Figure 2).
• There are 69.8 million people enrolled in Medicaid and 7.3 million people enrolled in CHIP (Figure 1). More states report Medicaid enrollment above their pre-pandemic baselines compared to the number reporting CHIP enrollment above the baseline (Figure 2).

Note: The data on unwinding renewal outcomes presented below were last updated on September 12, 2024; since most states have now completed the Medicaid unwinding, the information will not be updated again.

As of September 12, 2024 and with nearly complete unwinding data for most states: 

• Over 25 million people were disenrolled (31% of completed renewals) and over 56 million people had their coverage renewed (69% of completed renewals).  
• Disenrollment rates varied across states from 57% in Montana to 12% in North Carolina, driven by a variety of factors including differences in renewal policies and procedures as well as eligibility expansions in some states.  
• Among those who were disenrolled, nearly seven in ten (69%) were disenrolled for paperwork or procedural reasons while three in ten (31%) were determined ineligible.  
• Among those whose coverage was renewed during the unwinding, 61% were renewed on an ex parte, or automated, basis, meaning the individual did not have to take any action to maintain coverage. 

State Data on Renewal Outcomes

The data on unwinding-related renewal outcomes presented in this section rely primarily on monthly reports that states were required to submit to the Centers for Medicare & Medicaid Services (CMS) during the unwinding period. The data also reflect updates to the monthly reports that states submit three months after the original report submission to account for the resolution of pending cases and any other changes in renewal metrics. For 13 states, data were pulled from dashboards or reports published on state websites that provide more complete information, and for a few additional states, updated monthly reports were pulled from state websites because they were more timely than what is reported on the CMS website. 

To view archived data for specific states, click on the State Data – Archived tab.

 

  

Medicaid Disenrollments

• As of September 12, 2024, at least 25,198,000 Medicaid enrollees had been disenrolled during the unwinding of the continuous enrollment provision. Overall, 31% of people with a completed renewal were disenrolled in reporting states while 69%, or 56.4 million enrollees, had their coverage renewed.
• There is wide variation in disenrollment rates across reporting states, ranging from 57% in Montana to 12% in North Carolina. A variety of factors contribute to these differences, including differences in renewal policies and system capacity. Some states adopted policies that promote continued coverage among those who remain eligible and/or have automated eligibility systems that can more easily and accurately process renewals while other states have adopted fewer of these policies and have more manually-driven systems. In addition, North Carolina and South Dakota adopted Medicaid expansion and other states increased eligibility levels for certain populations (e.g., children, parents, etc.) during the unwinding, which may have lowered disenrollment rates in these states.

 

• Across all states with available data, 69% of all people disenrolled had their coverage terminated for procedural reasons. However, these rates vary based on how they are calculated (see note below). Procedural disenrollments are cases where people are disenrolled because they did not complete the renewal process and can occur when the state has outdated contact information or because the enrollee does not understand or otherwise does not complete renewal packets within a specific timeframe. High procedural disenrollment rates are concerning because many people who are disenrolled for these paperwork reasons may still be eligible for Medicaid coverage. 

(Note: The first tab in the figure below calculates procedural disenrollment rates using total disenrollments as the denominator. The second tab shows these rates using total completed renewals, which include people whose coverage was terminated as well as those whose coverage was renewed, as the denominator. And finally, the third tab calculates the rates as a share of all renewals due, which include completed renewals and pending cases.)

Medicaid Renewals

• Of the people whose coverage has been renewed as of September 12, 2024, 61% were renewed on an ex parte basis while 39% were renewed through a renewal form, though rates vary across states. Under federal rules, states are required to first try to complete administrative (or “ex parte”) renewals by verifying ongoing eligibility through available data sources, such as state wage databases, before sending a renewal form or requesting documentation from an enrollee. Ex parte renewal rates varied across states from 90% or more in Arizona, North Carolina, and Rhode Island to less than 20% in Pennsylvania and Texas. 

Federal Data on Renewal Outcomes

The data presented here are cumulative unwinding metrics published by CMS. These counts and percentages may differ from the above data, which present renewal metrics reported on state websites when state-reported data are more complete.  

Figure 1 below shows cumulative renewal data reported by CMS during states’ unwinding periods. Renewal data for the months after the end of states’ unwinding period are excluded. The data reflect updated unwinding data reported by states three months after the original monthly reports as they become available.   

For questions about this tracker, please contact KFFTracker@kff.org

Note: The state data presented below were last updated on September 12, 2024; since most states have now completed the Medicaid unwinding, the information will not be updated again. 

The data presented here provide state-level data on enrollment trends and renewal outcomes during the unwinding period. Figure 1 shows total Medicaid enrollment by month starting in January 2023 and, once disenrollments resumed in a state, the cumulative percent change in Medicaid enrollment relative to the month before Medicaid disenrollments started (this baseline month will differ across states). Figure 2 shows renewal metrics for each month of a state’s unwinding period (or cumulative data for the unwinding period for some states). 

For total national Medicaid enrollment, click on the Enrollment Data tab.

Resources on unwinding data

• An Examination of Medicaid Renewal Outcomes and Enrollment Changes at the End of the Unwinding
• How Did Medicaid Renewal Outcomes Change During the Unwinding?
• KFF Survey of Medicaid Unwinding
• Three Questions About Medicaid Unwinding: What We Know and What to Expect
• Halfway Through the Medicaid Unwinding: What Do the Data Show?
• Unwinding of Medicaid Continuous Enrollment: Key Themes from the Field
• Navigating the Unwinding of Medicaid Continuous Enrollment: A Look at Enrollees Experiences
• Six Months into the Medicaid Unwinding: What Do the Data Show and What Questions Remain?
• What Do Medicaid Unwinding Data by Race and Ethnicity Show?
• Understanding Medicaid Ex Parte Renewals During the Unwinding
• States Obtain Special Waivers to Help Unwinding Efforts
• Understanding Medicaid Procedural Disenrollment Rates
• Do State Decisions to Prioritize Renewals for Medicaid Enrollees Who are Likely Ineligible Affect Early Disenrollment Rates?
• What Do the Early Medicaid Unwinding Data Tell Us?
• How Many People Might Lose Medicaid When States Unwind Continuous Enrollment?

Resources on state policies and preparations for the unwinding

• A Look at Medicaid and CHIP Eligibility, Enrollment, and Renewal Policies During the Unwinding of Continuous Enrollment and Beyond
• State Policy Choices Are Likely to Affect the Extent of Medicaid Enrollment Declines During the Unwinding Period
• Medicaid and CHIP Eligibility, Enrollment, and Renewal Policies as States Prepare for the Unwinding of the Pandemic-Era Continuous Enrollment Provision
• The Unwinding of Medicaid Continuous Enrollment: Knowledge and Experiences of Enrollees
• Unwinding the Continuous Enrollment Provision: Perspectives from Current Medicaid Enrollees

Resources on pre-pandemic enrollment patterns and coverage transitions

• What Happens After People Lose Medicaid Coverage?
• Medicaid Enrollment Growth: Estimates by State and Eligibility Group Show Who may be at Risk as Continuous Enrollment Ends
• Unwinding the PHE: What We Can Learn From Pre-Pandemic Enrollment Patterns
• Medicaid Enrollment Churn and Implications for Continuous Coverage Policies
• Implications of Continuous Eligibility Policies for Children’s Medicaid Enrollment Churn
• Medicaid Enrollment Patterns During the Postpartum Year

KFF’s unwinding explainer

• 10 Things to Know About the Unwinding of the Medicaid Continuous Enrollment Provision

Long-standing workforce challenges in Medicaid home care (also known as home- and community-based services or HCBS) impact care for the over 5 million people who use these services. Shortages and high turnover rates among the direct care workforce reflect demanding work and low wages, particularly among home care workers (who are direct care workers that provide HCBS). This issue brief describes states’ ongoing efforts to respond to shortages of home care workers and how they pay these workers, finding that increased payment rates are a key component of states’ efforts to address workforce shortages.

Such shortages could increase as states will face tough choices about how to absorb Medicaid cuts stemming from the 2025 reconciliation law, which is estimated to reduce federal Medicaid spending by $911 billion over the next decade. When faced with fiscal pressures in the past, states have responded with restrictions on home care, and as a result of the reconciliation law, states may again face significant pressures to cut Medicaid payment rates, offer fewer covered benefits, or restrict eligibility. The Medicaid cuts could also affect access to health coverage among home care workers because over one-in-three workers in home care settings are enrolled in Medicaid. Reduced access to health coverage among the workforce could exacerbate other challenges.

Workforce challenges may also worsen in future years because of changes in immigration policy. Nearly one-in-three home care workers are immigrants, and the Trump Administration’s intensified immigration enforcement and restrictive policies are deepening anxiety and fear among immigrants of all statuses. KFF survey data finds that 13% of immigrants have avoided going to work since January 2025 because of concerns about drawing attention to someone’s immigration status, a number which rises to 40% among people who are likely to be undocumented immigrants. Fewer immigrants overall and potentially lower rates of employment among immigrants could reduce the size of the home care workforce. With more limited immigration, there will be fewer workers overall to care for an aging population.

Amidst this evolving landscape, this issue brief describes Medicaid payment rates for home care and other workforce supports that are in place in 2025, before the majority of the 2025 reconciliation law provisions start taking effect. This issue brief is one of several reporting the data from the 23^rd KFF survey of officials administering Medicaid home care programs in all 50 states and the District of Columbia (hereafter referred to as a state), which states completed between April and July 2025. The survey was sent to each state official responsible for overseeing home care benefits (including home health, personal care, and waiver services for specific populations such as people with physical disabilities). All states except Florida responded to the 2025 survey, but response rates for certain questions were lower. States generally completed the survey prior to enactment of the 2025 reconciliation law. Survey findings are reported by state and waiver target population, although states often offer multiple waivers for a given target population. Key takeaways include:

• All responding states reported taking actions to address workforce shortages, with most states raising payment rates (Figure 1).
• All states reported shortages of home care workers, most frequently among direct support professionals, nursing staff, personal care attendants, and case managers.
• Most (41) states reported permanent closures of home care providers within the last year.
• Among the 34 states that reported time-based payment rates for personal care providers, more than half pay less than $20 per hour.

How are States Addressing the Workforce Challenges in Home Care?

All responding states reported workforce shortages in 2025, with the most common shortages being among direct support professionals (48 states), followed by nursing staff (47 states) and personal care attendants (46 states) (Figure 2, Appendix Table 2). States were asked if they had shortages of each type of provider but were not provided with a definition of “shortage.” Most states also reported shortages in case managers (44 states), home health aides (41 states), certified nurse aides (39 states), community-based mental health providers (38 states), and occupational, physical, and speech therapy providers (30 states). In some cases, states may not have reported a shortage of a particular type of provider because that type of service is not offered through their home care program.

All states reported shortages for more than one type of provider, and 43 states reported shortages among five or more provider types. Such shortages may reflect low compensation coupled with demanding working conditions. In the spring of 2024, home care providers participating in KFF focus groups reported that their jobs had high physical demands and mental demands that were often “overwhelming.” The groups described their wages as low, particularly given the demands of their jobs; and how staffing shortages made their jobs harder because they may not know if they would be able to leave work at the end of their shift. In survey responses, states attributed shortages to low reimbursement rates, lack of qualified providers, and high turnover rates.

Within the last year, 41 states reported permanent closures of home care providers, which were most common among adult day health programs (28 states), followed by group homes (23 states), assisted living facilities, and the enrollee’s home (22 states each) (Figure 3, Appendix Table 3). States were asked if there were any permanent closures of providers that offer services for Medicaid enrollees based on the location in which the providers deliver care. For a setting such as an assisted living facility or group home, a closure could reflect either the closure of an assisted living facility or the closure of a home care agency that sent workers into facilities and group homes. States were not asked to provide a reason for the closures. Some states reported closures of supported employment providers (12 states), home health agencies (11 states), and community mental health providers (5 states). Most states reported closures among more than one type of provider: 35 states reported closures among two or more provider types, and 26 states reported closures among three or more provider types.

All responding states reported taking actions to address provider shortages, with 48 states increasing payment rates, 38 states developing or expanding worker education and training programs, and 24 states offering incentive payments to recruit or retain workers (Figure 1, Appendix Table 1). Less common initiatives included establishing or raising the state minimum wage (20 states), offering worker retention bonuses (20 states), and offering paid sick leave for workers (18 states). States also reported other types of initiatives to strengthen the workforce, including initiatives allowing people to receive paid care from family members. For example, Oregon created a new 1915(c) waiver that allows parents of minor children to be paid for providing attendant care to their child. States’ actions to address provider shortages in 2025 were similar to those in 2024.

All but 11 states use managed care to provide at least some home care, and in over half of the states with managed care, fee-for-service payment rates impact the payment rates that managed care plans pay home care providers. Out of the 39 states that use managed care to provide at least some home care, 20 states reported that the fee-for-service payment rates represent the minimum amount that plans must pay providers, 2 states, Michigan and Wisconsin, reported that the rate represents the maximum payment rate for managed care plans, 11 states reported that the fee-for-service rates do not affect payments by private plans, and 6 states responded that the answer was unknown or did not respond to the question.

How Much do States Pay for Medicaid Home Care?

KFF asked states to report their average hourly rate paid to two types of home care provider agencies (personal care agencies and home health agencies) and three types of specific home care providers (personal care providers, home health aides, and registered nurses), but many states were unable to report all rates (Appendix Table 4). The number of states that responded to the survey but did not provide hourly payment rates or reported that payment rates were unknown was 4 for personal care agencies and 32 for home health agencies. Many states also did not provide payment rates for specific provider types: For registered nurses and home health aides, more than half of states did not provide hourly payment rate information or reported that payment rates were unknown.

Starting July 2026, states are required to report detailed payment rates for personal care, home health, and other services, per the provisions of the Biden Administration final Access rule (see Box 1). In addition to reporting payment rates for certain home care services, starting in 2030, states must demonstrate that at least 80% of the payments went to compensation for providers, also described as “direct care workers.” Meeting that requirement will require states to know both agency and provider payment rates. Among the states that were able to report payment rates, only 15 could report payment rates for personal care agencies, home health agencies, personal care providers, and home health aides, all of which would be required under the rule. Those 15 states include states that reported a mix of hourly and non-hourly rates, which makes comparisons between provider and agency rates more complicated. These challenges highlight the difficulties states face as they implement the requirements in the new rule, which will take effect in July 2026 (Box 1).

States reported many reasons why it was difficult to report payment rates, including the following.

• Some states reported that services were bundled together in various ways and therefore, the payment rates were not distinguishable.
• Among states with managed care, some states responded that they did not know the payment rates for agencies because the services were paid for by managed care plans and they did not have access to those payment rates.
• Other states responded that they knew the payment rates for agencies but not what the agencies paid their home care workers. Multiple states reported that they do not “dictate” what agencies pay to providers or that individual providers negotiate their own payment rates with the agencies.

In addition to having difficulty reporting payment rates, many states reported different payment rates for personal care across different waivers, and the waiver payment rates often differ from the payment rates for personal care provided through the state plan. When states reported multiple payment rates for personal care, KFF used the median of those payment rates in the analysis.

The payment rates to home care providers show considerable variation and are somewhat higher than those reported by other organizations on account of differences in reporting and provider categorization (Figure 4). KFF’s survey estimates that median payment rates to providers are $19 per hour for personal care providers, $41 for home health aides, and $70 for registered nurses. It is difficult to compare those numbers to other sources of data for the following reasons.

• Other organizations group classes of providers together differently. PHI reports that in 2024, the median rate for home care workers was $17 per hour and $18 per hour for residential care aides. The Bureau of Labor Statistics reports $17 per hour for home health and personal care aides in 2024.
• Other organizations include payment rates for workers regardless of the source of payment whereas KFF rates only reflect the Medicaid rates. Medicaid often covers more intensive personal care services than other payers, which may contribute to the higher rates.

Payment rates to home health agencies are generally larger than those to personal care agencies, but there is considerable variation in both (Figure 4). Among states reporting hourly rates, the rates for home health agencies range from $25 to $159 whereas those for personal care agencies range from $14 to $44. Those states reported that the median hourly payment to home health agencies was $51 and $26 for personal care agencies. Between 2024 and 2025, the median payment rates for personal care agencies and most other provider types increased marginally.

Among states able to report any payment rate data, payments for personal care workers range from below $15 to over $30 per hour (Figure 5, Appendix Table 4). Rates for home health aides are somewhat higher than those of personal care workers, reflecting the additional training requirements for such workers. Among the states with payment rates for home health aides in the highest category, some states reported that the rates were per visit or per day (which is noted in Appendix Table 4). There were other states with particularly high payment rates that did not report providing rates per visit or per day, but the rates may still reflect a non-hourly payment basis.

States’ Use of Strategies to Increase the Number of Medicaid Home Care Workers in 2025

States’ Responses to Whether They Were Experiencing Workforce Shortages by Type of Worker in 2025

States Reporting Permanent Closures of Home Care Providers in 2025, by the Location in Which Services are Offered

States’ Hourly Payment Rates for Home Care Agencies and Workers in 2025

Many older adults and people with disabilities require assistance with self-care such as bathing, dressing, and eating. Help with such services is known as “long-term care” and may be provided in institutional settings such as nursing facilities or in people’s homes and the community, including assisted living facilities. Four-in-ten adults incorrectly believe that Medicare is the primary source of coverage for low-income people who need nursing or home care, but Medicaid is the primary payer—covering nearly two-thirds of all home care spending in the United States in 2023.

The 2025 reconciliation law is estimated to reduce federal Medicaid spending by $911 billion (roughly 14%) over a decade and may have broad implications for home care, including for the workforce, support for family caregivers, and states’ coverage of services. Over half of Medicaid spending finances care for people ages 65 and older and those with disabilities, the enrollees most likely to use home care and related services, and reductions of this magnitude will leave states with difficult choices to raise new revenues or reduce Medicaid spending. The reconciliation law also established a new type of 1915(c) home care waiver for people who do not need an institutional level of care. Take-up of the new waivers is expected to be low given the cuts to federal Medicaid spending and requirements for states to demonstrate that new waivers will not increase the average amount of time that people wait for existing waiver services. This issue brief provides an overview of what Medicaid home care (also known as “home- and community-based services” or HCBS) is, who is covered, and what services were available in 2025. Over 5 million people receive Medicaid covered home care services annually.

This brief is one of several describing data from the 23^rd KFF survey of officials administering Medicaid home care programs in all 50 states and the District of Columbia (hereafter referred to as a state), which states completed between April and July 2025. Other issue briefs from the survey describe the number of people on waiting lists for home care, how states manage home care spending, how home care programs support family caregivers, and payment rates for home care providers. The survey was sent to each state official responsible for overseeing home care benefits (including home health, personal care, and waiver services for specific populations such as people with physical disabilities). All states except Florida responded to the 2025 survey, but response rates for certain questions were lower. Where possible, KFF supplemented survey data with previously reported or publicly available data to provide information for the states that did not respond. Survey findings are reported by state and waiver target population, although states often offer multiple waivers for a given target population. States generally completed the survey prior to enactment of the reconciliation law. Key takeaways include:

• Nursing facility care is a required Medicaid benefit, but states can choose whether to provide most home care services. A key component of home care is personal care, which helps people who need assistance with self-care (such as bathing and dressing) and household activities (such as taking medications and preparing meals).
• Medicaid home care can be offered through either the Medicaid state plan or as part of a specialized waiver. All states offer Medicaid home care through waivers, most commonly 1915(c) waivers (47 states).
• Home care is also offered through 1115 waivers (15 states), personal care offered as a state plan benefit (33 states), or the Community First Choice option, which is also a state plan benefit (10 states, Figure 1).

• Most states provide Medicaid home care through waivers that offer benefits specifically targeted to people with intellectual or developmental disabilities (48) and people ages 65 and older or who have physical disabilities (46). For such waivers, most states offer multiple waivers for each population: Among states with intellectual or developmental disability waivers, only 16 offer one program, while 18 offer three or more; and among states with waivers serving people ages 65 and older or who have physical disabilities, 24 offer only one program and 10 offer three or more.
• Waivers’ coverage of different home care services, such as day services, supported employment, and home-based services, vary by the target populations they serve.

What programs do states use to provide Medicaid home care?

Unlike institutional long-term care, nearly all home care is optional for states to provide under Medicaid. States are required to offer cover home health—which consists of part-time nursing services; home health aide services; and medical supplies, equipment, and appliances suitable for use in the home—but all other home care services are provided at the discretion of the states. States use various federal legal “authorities,” also known as programs, to offer home care, which are generally categorized as being part of the Medicaid state plan or part of a waiver. If services are provided through a state plan, they must be offered to all eligible individuals. In contrast, services provided under waivers, such as 1115s or 1915(c)s, may be restricted to specific groups based on geographic region, income, or type of disability. Waivers may include a wider range of service types than can be provided under state plans, but states may limit the number of people receiving waiver services. When the number of people seeking services exceeds the number of waiver slots available, states may use waiting lists to manage participation in the waiver.

All states have at least one home care program and many states have multiple programs. Home care is most frequently offered through 1915(c) waivers (47 states) and the personal care state plan benefit (33 states), and less frequently offered through 1115 waivers (15 states) or the Community First Choice option (10 states, Figure 1). KFF estimates that 5.1 million people used Medicaid home care in 2023 compared with only 1.4 million people who used institutional long-term care.

All states offer people assistance with self-care and household activities under the personal care benefit, but they use different programs to do so. The primary home care benefit is personal care, which provides people with assistance with the activities of daily living (such as eating and dressing) and the instrumental activities of daily living (such as preparing meals and managing medication). States most commonly cover personal care through waivers (48 states), followed by the state plan (33 states).

How are people eligible for Medicaid home care?

Most people who are eligible for Medicaid home care qualify on the basis of having a disability or being ages 65 and older. Medicaid eligibility pathways in which eligibility is based on old age or disability are known as “non-MAGI” pathways because they do not use the Modified Adjusted Gross Income (MAGI) financial methodology that applies to children, pregnant individuals, parents, and other non-elderly adults with low incomes. In addition to considering income and age or disability status, non-MAGI eligibility pathways usually require people to demonstrate that they have limited savings and other financial resources (e.g., assets). Because nearly all non-MAGI pathways are optional, eligibility levels vary substantially across states.

Most states allow people with somewhat higher incomes to qualify for Medicaid home care, but income is capped at 300% of the supplemental security income limit ($2,901 per month in 2025) and assets are usually limited to $2,000 per person. Medicaid enrollees who use long-term care must also meet requirements related to their functional needs which are generally measured in terms of the ability to perform activities of daily living such as eating and bathing. Over half of people who use Medicaid home care are also enrolled in Medicare; such people are also known as dual-eligible individuals

In 2025, states operated over 300 different programs for Medicaid home care, many of which targeted a specific population. Most programs (259) were operated through 1915(c) waivers with 15 operated through 1115 waivers. The most common waiver programs target people with intellectual or developmental disabilities (48 states) and people who are ages 65 and older or have physical disabilities (46 states). States are likely to offer multiple waiver programs for the most common target populations, but states with less common waivers, such as those serving people with traumatic brain or spinal cord injuries or mental health conditions, typically only offer one program per target population.

Each year, some states’ waiver programs change, but in general, the trend has been towards offering more waivers. In 2025, only one state, Oregon, had new waivers and no states eliminated waivers. In Oregon, there is a new 1115 waiver for people who are ages 65 and older or have physical disabilities that provides in-home support services and support for family caregivers and a new 1915(c) waiver that allows parents of minor children with disabilities to be paid for providing attendant care to their child.

What services does Medicaid home care cover?

Besides personal care, Medicaid home care covers an array of services to help people with the activities of daily living and the instrumental activities of daily living. KFF asked states about what services they provide through Medicaid home care programs using the Centers for Medicare and Medicaid Services’ list of services, which are categorized in a comprehensive taxonomy. The taxonomy was developed to provide common language for describing home- and community-based services across waivers and state plans. Those services vary widely, including adult day care, supported employment, round-the-clock care, services to support unpaid family or friends who are caregivers, home-delivered meals, and non-medical transportation (Table 1).

All responding states (50) cover supported employment, day services, home-based services, and equipment, technology, and modifications in any home care program (Appendix Table 3). States often also offer other additional services for specific populations that are uniquely tailored to the needs of waiver recipients. Examples of such services reported in the 2025 survey include:

• Illness support, group counseling, and bereavement counseling in a waiver for children who are medically frail or technology dependent (Colorado);
• Discovery and career planning, additional residential supports, and community navigators in a waiver for people with intellectual or developmental disabilities (Hawaii);
• Dental services, permanent supportive housing, and prevocational/community career planning in a waiver for people with intellectual or developmental disabilities (Louisiana);
• Other speech, hearing, language, occupational, and physical therapies in a waiver for people who are ages 65 and older or have physical disabilities (Texas).

Among the categories defined by the Centers for Medicare & Medicaid Services, the least-frequently covered service was rent and food expenses for a live-in caregiver. For the most common services, there is little change in the number of states offering each type of service in a given year. (The numbers reported for most services are higher in 2025 but in many cases, that reflects a higher state response rate in 2025 than in 2024.)

States use waivers that target specific populations to offer tailored benefits, and covered services differ among different types of waivers (Figure 3, Appendix Table 4). Some services, such as equipment, technology and modifications, home-based services, and day services, are covered by most states and in most waiver programs. However, other services are much more targeted to specific populations. Comparing services among the most commonly-offered waivers (those serving people with intellectual or developmental disabilities and people who are ages 65 and older or have physical disabilities), shows some services are widely covered by one type of waiver but not the other. For example, 47 states cover supported employment for people with intellectual or developmental disabilities, but only 15 cover the service for people who are ages 65 and older or have physical disabilities, a population less likely to be working. Alternatively, home-delivered meals are covered by 41 states under waivers serving people who are ages 65 and older or have physical disabilities, but only under 10 states’ waivers serving people with intellectual or developmental disabilities. By enabling states to cover, at times, different services per target population, waivers allow states to customize services to the needs of the specific populations they serve.

Within waivers, states may change the benefit offerings from year to year, highlighting the flexibility that home care waivers offer to states in managing program benefits and spending. Focusing on the most common waivers and benefits, some notable changes between 2024 and 2025 include the following. (Due to variation in the number of states responding to KFF’s survey and changes in the number of waivers offered between 2024 and 2025, comparing the number of states or waivers offering each type of service could be misleading. However, looking at changes in covered services within a specific waiver can illuminate the flexibility available to states.)

• Oregon began offering coverage of equipment, technology, and modifications for waivers serving people who are ages 65 and older or have physical disabilities, and Idaho now covers case management services for waivers serving the same population.
• D.C. and South Dakota started offering coverage of non-medical transportation for waivers serving people with intellectual or developmental disabilities, but Illinois and Kentucky no longer cover this service for those waivers.
• Michigan, Nevada, and Washington began covering day services for waivers serving people with intellectual or developmental disabilities, and Idaho started offering this benefit for waivers serving people who are ages 65 and older or have physical disabilities.

How do states use managed care to provide home care?

All but 11 states use managed care to provide at least some home care (Figure 4). In managed care, states pay managed care plans a set fee—often called a capitation payment—for each person enrolled and the managed care plans are responsible for providing all services to enrollees. Use of managed care to provide home care has been growing over time, with states using managed care to make their Medicaid spending more predictable and to help coordinate the services enrollees use.

Managed care is more commonly used for home health benefits provided through the state plan or 1115 waivers than for 1915(c) waivers (Figure 5, Appendix Table 5). Among the 15 states with 1115 waivers, 10 use managed care plans to provide at least some home care; and over two-thirds of states use managed care plans to provide at least some home health through the state plan. Fewer than half of states use managed care plans to provide some personal care through the state plan. For 1915(c) waivers, over half of states (26) use managed care plans, 4 more states than in 2024, but managed care was much less common for waivers serving people with intellectual or developmental disabilities—of the 47 out of 51 responding states with such waivers, only 8 provided any of the benefits through managed care.

States Offering Medicaid Home Care Through Various Federal Programs

States Offer Medicaid Home Care for Several Target Populations

States Reporting Coverage of Each Medicaid Home Care Service Under Any Program

States’ Coverage of Medicaid Home Care Services Vary by Target Population

All States Provide Optional Medicaid Home Care, Many Using Managed Care

KFF estimates that 5.1 million Medicaid enrollees use home care, which provides medical and supportive services to help people with the activities of daily living (such as eating and bathing) and the instrumental activities of daily living (such as preparing meals and managing medications). Medicare generally does not cover home care (also known as home- and community-based services or HCBS), and Medicaid paid for two-thirds of home care spending in the United States in 2023.

In Medicaid home care, many people “self-direct” their services, giving them greater autonomy over the types of services provided and who they are provided by; and in some cases, allowing payments to family caregivers. Payments for caregiving can help mitigate the financial struggles family caregivers experience when they are forced to reduce their hours of work or quit their jobs on account of their caregiving duties. KFF focus groups of caregivers found that family caregivers often reported struggling to make ends meet and having to reduce the hours they are working other jobs due to the demands of caregiving. Self-directed services can also help address shortages of paid home care workers, which can be one of the factors placing additional strain on family caregivers. Beyond paying for their caregiving, Medicaid supports family caregivers with services such as training, support groups, and respite care (which is paid care that allows family caregivers to take a break from their normal responsibilities).   

The 2025 reconciliation law, passed on July 4, includes significant changes to the Medicaid program that are estimated to reduce federal Medicaid spending by $911 billion over the next decade. Given the substantial share of Medicaid spending that pays for home care, and the optional nature of most home care programs, cuts to home care programs could occur as states respond to the reductions in federal spending.

Such changes could affect Medicaid supports to family caregivers, all of which are optional for states to provide. A reduction in the availability of those supports could exacerbate challenges for people who need home care and are unable to find other sources of care due to workforce shortages, which may be amplified by the Trump Administration’s intensified immigration enforcement and restrictive policies, since nearly one-in-three home care workers are immigrants. For family caregivers, many may need to continue to provide care without payments and other Medicaid changes could affect access to health coverage. According to AARP’s 2025 Caregiving in the US report, there are over 8 million family caregivers for whom Medicaid is their source of health insurance (13% of 63 million total family caregivers).  

Amidst this background, this issue brief describes the availability of self-directed services and supports for family caregivers in Medicaid home care in 2025, before most provisions in the reconciliation law take effect. The data come from the 23^rd KFF survey of officials administering Medicaid home care programs in all 50 states and the District of Columbia (hereafter referred to as a state), which states completed between April and July 2025. The survey was sent to each state official responsible for overseeing home care benefits (including home health, personal care, and waiver services for specific populations such as people with physical disabilities). All states except Florida responded to the 2025 survey, but response rates for certain questions were lower. Survey findings are reported by state and waiver target population, although states often offer multiple waivers for a given target population. Key findings include:

• All reporting states except Alaska allow Medicaid enrollees to self-direct their home care in at least some circumstances, and among those states, all allow enrollees to select, train, and dismiss their caregivers.
• All responding states pay family caregivers under some circumstances and provide family caregivers with other types of support, including respite care (Figure 1, Appendix Table 1)
• Family supports are most widely available for caregivers of people with intellectual or developmental disabilities (I/DD).

How Many States Allow Medicaid Enrollees to Self-Direct Their Home Care?

Nearly all states allow Medicaid enrollees to self-direct their home care in some circumstances (Figure 2, Appendix Table 2). Self-direction came out of the “consumer-directed” movement for personal care services that started with demonstration programs in 19 states funded through grants from the Robert Wood Johnson Foundation. Today, states may give people the option to self-direct home care through a wide variety of optional home care programs. States most frequently allow self-direction in waivers that serve people with intellectual or developmental disabilities, followed by people who are ages 65 and older or have physical disabilities. Among the 50 states responding to KFF’s survey, Alaska is the only state that reported not permitting self-direction under any of the home care programs. 

Among states that authorize self-direction, all states allow enrollees to select, dismiss, and train workers (Figure 3). The ability to select, train, and dismiss workers is referred to as “employer authority” because it allows Medicaid enrollees (with the help of their designated representatives when appropriate) to decide who will be caring for them. All states with self-directed services programs provide employer authority to enrollees. Most states also allow enrollees to establish payment rates for their caregivers (41) and to determine how much Medicaid funding is spent among the various authorized services (39).

How Many States Pay Family Caregivers and Through Which Home Care Programs?

All responding states pay family caregivers through one or more Medicaid home care programs (Figure 1, Appendix Table 1). Family caregivers can generally be paid to provide personal care, which may be offered through several different types of Medicaid home care programs. Personal care may be provided through waivers such as the 1115 or 1915(c) programs, through the Medicaid state plan, or a combination of both. Waiver services tend to encompass a wider range of benefits than the state plan benefit, but waivers are usually restricted to specific groups of Medicaid enrollees based on geographic region, income, or type of disability; and are often only available to a limited number of people, resulting in waiting lists. 

All responding states allow payments to family and friends through one or more waiver programs, but fewer states allow payments to legally responsible relatives. Forty-four states allow payments to legally responsible relatives through waiver programs. Payments to legally responsible relatives are less common than those to other family and friends because of additional legal requirements that pertain to payments to legally responsible relatives (Box 1). Payments to family caregivers are less common through the state plan—allowed by 24 states for other family and friends and by 6 states for legally responsible relatives. States pay family caregivers through the state plan less frequently because fewer states offer personal care through the state plan and because the legal requirements governing state plan services are more restrictive than those governing waiver services. 

While all responding states allow payments to family caregivers, it is unknown what percentage of waiver participants are receiving paid care. KFF asked states, “What percentage of waiver recipients are receiving paid care from their legally responsible relatives/family members who are not legally responsible relatives?” Over two-thirds of states were unable to report the percentage of waiver recipients receiving paid care from either legally responsible relatives or other family members/friends. It is also unknown how often people with paid family caregivers also receive other paid care.

Payments for family caregivers are most common under waivers for people with intellectual or developmental disabilities (Figure 4, Appendix Table 3). Among the 47 states that responded to the survey and have waivers for people with intellectual or developmental disabilities, all 47 allow payments to family caregivers. There are fewer states with other types of waivers, and not all the other waivers allow payments to family caregivers. Among the 45 responding states with waivers for older adults and people with physical disabilities, 43 pay family caregivers, and among the 21 states with waivers for people with traumatic brain or spinal cord injuries, 19 do.

In most cases, family caregivers receive hourly wages like those of other employees, but 11 states have adopted programs known as structured family caregiving, in which family members are paid a per diem rate (Appendix Table 4). Structured family caregiving is a Medicaid benefit that supports unpaid caregivers of people who use Medicaid home care through waiver programs. In the structured program, Medicaid pays provider agencies a daily stipend for participants. The agency is responsible for directing a care coordinator or social worker and a nurse to oversee the family caregiver, answer health-related questions, and provide emotional support; conducting home visits about once per month; and passing a fixed percentage of the stipend (usually 50% – 65%) on to the family caregiver. Among the handful of payment rates reported in an overview of the program by the American Council on Aging, payments to family members are around $40 to $70 per day. States reported structured family caregiving programs in the following home care waivers:

• Older adults and people with disabilities in 9 states (Connecticut, Georgia, Indiana, Louisiana, North Carolina, North Dakota, Ohio, Rhode Island, and South Dakota),
• People with intellectual or developmental disabilities in 2 states (Indiana and New Hampshire), 
• Medically fragile children in North Carolina,
• People with traumatic brain and/or spinal cord injuries in Indiana and
• People with Alzheimer’s and related disorders in Missouri. 

Although KFF’s survey only includes home care waivers, according to the American Council on Aging, two states offered structured family caregiving as a standalone program: Massachusetts offers it as a state plan benefit through a program for adults in foster care, and Nevada has a standalone waiver to provide the benefit for caregivers of people with Alzheimer’s and related dementias.

What Other Types of Support Does Medicaid Home Care Provide for Family Caregivers?

All responding states provide support for family caregivers—who may be paid or unpaid—and most offer more than one type of support (Figure 5, Appendix Table 5). All responding states reported covering respite care, which provides short-term relief for caregivers, allowing them to rest, travel, attend appointments, or spend time with other family and friends. Other commonly covered benefits include caregiver training (37 states), and counseling or support groups (26 states).

Respite care may be provided anywhere from a few hours to several weeks at a time. Medicare only covers respite care for people who are receiving hospice care, which is only available for people who are terminally ill and electing to receive comfort care instead of curative care for their illness. That makes Medicaid’s respite care the primary source of coverage for caregivers of people with Medicare and Medicaid. Respite care is offered most frequently under waivers for people with intellectual or developmental disabilities (44 states) and older adults and people with disabilities (44 states).

Daily respite care is offered by the most states (43), followed by institutional respite care (40 states, Figure 6, Appendix Table 6). Daily respite care is available under waivers for people with intellectual or developmental disabilities in 34 states and available in 32 states within waivers for people who are ages 65 and older or have physical disabilities. Twenty-two states provide institutional respite care within waivers for people who are ages 65 and older or have physical disabilities and within waivers for people with intellectual or developmental disabilities. Weekly respite care is the least frequently offered (24 states total), and over half of states (32) report offering other types such as hourly, monthly, or annual.

States’ Policies to Allow Medicaid Home Care Payments to Spouses, Parents of Minor Children, and Other Legally Responsible Relatives for Caregiving

States’ Policies to Allow Individuals to Self-Direct Medicaid Home Care by Waiver/Program

States’ Policies to Allow Medicaid Home Care Payments to Spouses, Parents of Minor Children, and Other Legally Responsible Relatives as well as Family and Friends for Caregiving

States Offering the Structured Family Caregiver Program, Which Supports Unpaid Caregivers of Persons Who Are Using Medicaid Home Care, and Waivers the Program Is Offered Under

States’ Policies for Offering Different Types of Family Caregiving Supports

Types of Respite Care Offered by State and Home Care Program: Daily, Weekly, Institutional, and Other

American Indian and Alaska Native (AIAN) people experience substantial and enduring disparities in health, health care, and health coverage. While the federal government has a trust responsibility to meet the health care needs of AIAN people, the Indian Health Service (IHS), the primary federal agency charged with upholding the trust responsibility has historically been underfunded and unable to meet their health care needs. AIAN people face challenges accessing health care, including geographic isolation, economic challenges, and limited access to culturally appropriate care that reflect a long history of abuse and mistreatment by the federal government. Proposed cuts to Medicaid could widen health and health care disparities for AIAN people given that Medicaid is a major source of health coverage for AIAN people and funding for IHS and Tribal providers.

AIAN people are often excluded from data and analysis due to smaller population sizes, limiting the visibility and understanding of their health outcomes and the challenges they face in accessing health services and impeding efforts to address their health care needs and reduce disparities. Moreover, aggregate data for AIAN people may mask underlying disparities among Tribes and subgroups of the AIAN population. Data availability may become even more limited going forward, due to the Trump administration’s actions to reduce racial and ethnic data collection and reporting.

To help address gaps in data and information, this brief provides an overview of AIAN people’s health and health care, including by subgroup, where data allow, and differences are statistically significant. It is based on KFF analysis of data from multiple datasets, including the 2019-2023 American Community Survey, the 2023 Behavioral Risk Factor Surveillance System, and the Centers for Disease Control and Prevention (CDC) WONDER online database, as well as the 2023 KFF Survey on Racism, Discrimination, and Health. This report also incorporates analysis from Key Data on Health and Health Care by Race and Ethnicity, which examines 64 measures of health, health care, and social and economic factors that drive health outcomes, across six racial and ethnic groups, including AIAN people. The racial and ethnic group definitions for each table may vary depending on the source of the data. Some data are limited to specific age groups as specified in the notes. Key takeaways include:

AIAN people represent a diverse population, with many identifying with more than one race or ethnicity. As of 2023, approximately 7.2 million people in the U.S. identify as AIAN alone or in combination with another racial or ethnic group. The majority of AIAN individuals identify as AIAN and at least one other race, while about a quarter (1.7 million) identify as AIAN alone. This analysis identifies people based on self-identified race and ethnicity in federal survey data. However, AIAN is also a political and legal classification. This status recognizes over 570 AIAN Tribes as sovereign nations, establishing a government-to-government relationship that dictates the federal government’s trust responsibility, including the provision of health care to AIAN people in federally recognized Tribes.

AIAN individuals experience significant health disparities compared to their White counterparts. People identified as AIAN alone have shorter life expectancies (70.1 vs 78.4 years at birth), higher rates of chronic diseases such as diabetes and asthma, and higher rates of suicide deaths and substance use disorder. About a quarter (26%) of AIAN adults report having fair or poor health status compared to 17% of White adults. Additionally, AIAN people face higher risks during pregnancy, including higher rates of preterm births and infant mortality, as well as the highest rates of pregnancy related deaths across racial and ethnic groups.

Among those under age 65, people who identify as AIAN alone are three times more likely to be uninsured (21%) compared to White people (7%). This coverage gap contributes to challenges in accessing health care. About 22% of adults under age 65 who identify as AIAN alone report not having a personal health care provider, and 43% did not have a dental visit within the past year. Medicaid provides a key source of coverage for AIAN people, helping to mitigate their coverage gaps and serving as the largest third-party payer for the IHS. Medicaid covers roughly one in three (35%) people under age 65 who identify as AIAN alone compared with 15% of their White counterparts, and over half (52%) of AIAN children versus 23% of White children.

AIAN communities face racism and discrimination and substantial social and economic challenges that impact their health outcomes and reflect historical mistreatment and policies. Across measures of discrimination in daily life and health care settings, AIAN adults report the highest frequency of experiencing certain types of discrimination compared to other racial and ethnic groups, while White adults report the lowest frequency. They have a higher poverty rate compared to White people, with about 25% living below the poverty line, and are more likely to experience food insecurity compared to their White counterparts. They also have lower educational attainment levels. Additionally, AIAN people are less likely to own homes and more likely to live in crowded housing conditions compared to White people. These social and economic challenges reflect an array of historical policies implemented by the U.S. government that disadvantaged AIAN communities.

Aggregate data for AIAN people may mask underlying disparities among subgroups since there is a wide variation in experiences and key factors that influence health among AIAN people. Experiences and outcomes vary based on their racial and ethnic composition, where they live, and their Tribal affiliation or Tribal land residency. For example, among AIAN people, uninsured rates and limited English proficiency (LEP) are highest among those who identify as AIAN and Hispanic, creating additional barriers that may impact access to and quality of care. AIAN adults living on Tribal lands are more likely to report having a usual place of care and receiving a flu vaccine (92% and 50%, respectively) compared to AIAN adults living off Tribal lands (82% and 39%, respectively), which may reflect greater proximity to IHS services.

Most AIAN people identify with more than one race and ethnicity. The number of AIAN people who identify with more than one racial or ethnic group has grown over time, likely reflecting some demographic shifts as well as changes in the design of questions used to identify race and ethnicity. As of 2023, there are roughly 7.2 million people in the U.S. who identify as AIAN alone or in combination with another racial or ethnic group. The majority of AIAN people identify as AIAN and at least one other race, while about a quarter of AIAN people identify as AIAN alone (24% or 1.7 million) (Figure 1).

Overall, about nine in ten (89%) people who identify as AIAN alone indicate they are affiliated with a Tribe, while 11% do not identify a Tribal affiliation (Figure 2). There are over 570 federally recognized Tribes. Tribal enrollment has important implications for access to benefits, since members and descendants of members of federally recognized Tribes have broader access to certain federal programs, including the IHS (Box 2).

Among people who identify as AIAN alone or in combination, about three in ten (31%) reside in California, Texas, or Oklahoma (Figure 3). The AIAN population is largely concentrated in the Western U.S., at least in part due to forced displacement and relocation (Box 3). The majority of AIAN people (87%) live in metropolitan areas, some live in rural areas, and only 13% reside on reservations or land trusts.

Among people under age 65, people who identify as AIAN alone are three times more likely to be uninsured compared to White people (21% vs. 7%) (Figure 4). Among those who identify as AIAN alone, uninsured rates are higher for those who indicate that they are affiliated with a Tribe (23%) compared to those who do not indicate a Tribal affiliation (17%). This may, in part, reflect greater reliance on the IHS for health care among those affiliated with a Tribe. However, the IHS is not insurance, and people relying solely on the IHS may face gaps in care. Among people who identify as AIAN alone or in combination with another racial or ethnic group, uninsured rates are higher among those who identify as AIAN alone (21%) and AIAN and Hispanic (21%), than among those who identify as AIAN and White (11%) (Figure 5). Higher uninsured rates among AIAN people contribute to barriers to accessing and utilizing health care.

Medicaid is a major source of coverage for AIAN people, particularly AIAN children, it is one of the primary ways the federal government honors its federal trust responsibility. Among those under age 65, Medicaid covers over one in three (35%) of those who identify as AIAN alone and nearly one in four (23%) people who identify as AIAN alone or in combination with another race or ethnicity (Figure 5). Medicaid, in combination with the Children’s Health Insurance Program (CHIP), covers over half (51%) of children who identify as AIAN alone. Medicaid is also the largest third-party payer for the IHS, accounting for $1.3 billion out of the total almost $1.8 billion in third-party collections in fiscal year 2025. In contrast to IHS funds, Medicaid funds are not subject to annual appropriation limits and, since Medicaid claims are processed throughout the year, facilities receive Medicaid funding on an ongoing basis for covered services. As such, Medicaid revenues help facilities cover operational costs, including provider payments and infrastructure developments. Notably, during federal government shutdowns, some parts of the IHS that do not receive advance appropriations rely on third-party reimbursement, including Medicaid, to fund services.  

Uninsured rates among AIAN people vary by where they live. About one in four people under age 65 who identify as AIAN alone and live in the IHS regions of the Southern Plains (26%), Alaska (23%), and the Northern Plains (23%) are uninsured, which is higher compared to other IHS regions (Figure 5). The higher uninsured rate in the Southern Plains region reflects a relatively low rate of Medicaid coverage compared to the national rate (22% vs. 35%), which is largely driven by the fact that two (Texas and Kansas) out of three states in the region have not implemented the Affordable Care Act (ACA) Medicaid expansion to low-income adults. In contrast, the higher uninsured rate in Alaska and the Northern Plains largely reflects a lower rate of private coverage compared to the national rate (31% and 35% vs. 44%). Among people under age 65 who identify as AIAN alone, Medicaid coverage rates are lower in states that have not adopted the ACA Medicaid expansion to low-income adults compared to expansion states (31% vs. 37%). Research finds that while health coverage improved among AIAN people post-ACA, there are stark differences in coverage regionally. In the period following the ACA, AIAN people in the Southwest, West Coast, and Alaska regions experienced the greatest increases in Medicaid and other public health coverage.

AIAN adults are more likely to report not having a personal provider, not receiving dental care, and not being up to date on their flu vaccine compared to White adults, suggesting barriers to accessing care. About one in five (22%) adults who identify as AIAN alone under the age of 65 report not having a personal provider compared to 16% of White adults (Figure 6). AIAN adults are also more likely to have gone without a dental visit within the past year than White adults (43% vs. 32%) and to not be up to date on their flu vaccine (64% vs. 50%). However, they are not more likely than White adults to report going without a routine check-up in the past 12 months.

Among those who identify as AIAN alone or in combination, those living off Tribal lands generally report more limited health care access and use compared to those living on Tribal lands. AIAN adults who live on Tribal lands are more likely to report having a usual source of care compared to those who live off Tribal lands (92% vs. 82%). About half (50%) of AIAN adults living on Tribal lands report receiving a flu vaccine in the past 12 months compared to about four in ten (39%) AIAN people who live off Tribal lands. About one-third (34%) of AIAN people who live on Tribal lands report having at least one emergency room visit in the past 12 months compared to about a quarter (25%) of AIAN adults who live off Tribal lands. Among AIAN people who live on Tribal lands, 2% report delaying or not receiving mental health treatment due to cost, while 8% of those who live off Tribal lands report the same (Figure 7). The increased access and use of care among those living on Tribal lands may reflect increased access and proximity to IHS or Tribal Health facilities.

AIAN people have a shorter life expectancy at birth compared to White people (Figure 8). Since 2019, life expectancy has fallen for AIAN people, reflecting the impacts of the COVID-19 pandemic. The existing gap in life expectancy widened between people who identify as AIAN alone and White people from 7 years in 2019 (71.8 vs. 78.8 years) to 8.3 years in 2023 (70.1 years vs 78.4 years).

Adults who identify as AIAN alone report poorer health status compared to White adults. About a quarter (26%) of AIAN adults report having fair or poor health status compared to 17% of White people, and roughly one in five (22%) AIAN adults report having 14 or more mentally unhealthy days compared to 15% for White people (Figure 9).

Pregnancy-Related Outcomes and Infant Mortality

AIAN people fare worse than their White counterparts across multiple measures of birth risks and outcomes. People who identify as AIAN alone have higher shares of preterm births compared to their White counterparts (12% vs. 9%), low birthweight births (9% vs. 7%), and births for which they received late or no prenatal care (13% vs. 5%) (Figure 10). The birth rate among teens who identify as AIAN alone is more than two times higher than the rate for White teens (Figure 11). AIAN infants have a mortality risk that is twice as high as that of White infants (9.2 vs. 4.5 per 1,000 live births) (Figure 12).

Chronic Diseases

AIAN people have higher rates of certain conditions than their White counterparts. Adults who identify as AIAN alone are more likely to have asthma than White adults (15% vs. 10%) (Figure 13). AIAN adults also have higher rates of obesity than White adults. Among children, the prevalence of asthma was not significantly different between AIAN and White children, with 12% of AIAN children and 9% of White children reporting having asthma.

AIAN people have the highest rate of diabetes across racial and ethnic groups, with 18% of adults who identify as AIAN alone reporting being told by a doctor they have diabetes compared to 11% of White adults. Researchers suggest that higher diabetes prevalence among AIAN people may be linked to historical forced relocation, changes to traditional lifestyles, and reliance on government food assistance programs. AIAN people are about two times more likely to die from diabetes compared to White people (41.5 vs. 19.8 per 100,000) (Figure 14). In contrast, AIAN adults have similar rates of heart disease to White adults (8% vs. 7%) and lower heart disease mortality rates than White people (138.3 vs. 169.1 per 100,000). However, it is important to note that race misclassification on death certificates is particularly common for AIAN people and likely leads to underestimates of AIAN mortality rates, with research showing that at least 30% of individuals who identify as AIAN alone are misclassified on their death certificates.

Rates of diabetes and heart disease mortality vary by census region among people who identify as AIAN alone. Geographically, among AIAN people, rates of death due to diabetes range from 19.6 per 100,000 in the Northeast to 54.1 per 100,000 in the Midwest. Heart disease deaths range from 69.7 per 100,000 in the Northeast to 151.2 per 100,000 in the Western U.S. (Figure 15). Regional differences in mortality could in part reflect differences in health coverage and access in each region. However, a range of other factors may contribute to regional differences, including environmental, lifestyle, and socioeconomic factors.

AIAN people are more likely than White people to be diagnosed with HIV or AIDS, the most advanced stage of HIV infection. In 2022, the HIV diagnosis rate for people who identify as AIAN alone was about two times higher than the rate for White people (10.6 vs. 5.3 per 100,000). Similar patterns are observed in AIDS classification rates, the most advanced stage of HIV, reflecting barriers to treatment. People who identify as AIAN alone have higher AIDS classification rates than White people (4.1 vs. 2.3 per 100,000) (Figure 16).

Cancer

Differences in rates of cancer incidence are mixed between AIAN and White adults. People who identify as AIAN alone have lower rates of cancer incidence than White people overall, and across most leading types of cancer examined. However, AIAN people have higher incidence rates of colon and rectum cancer than White people (43.3 vs. 36.0 per 100,000) (Figure 17). Further, other data show that AIAN people have the highest rates of liver cancer incidence across racial and ethnic groups.

Cancer incidence rates among people who identify as AIAN alone vary across IHS regions. Rates of cancer incidence range from 304.4 per 100,000 in the Southwest to 635.3 per 100,000 in the Southern Plains (Figure 18). Rates of lung and bronchus, and prostate cancer are highest in the Northern Plains (105.9 and 128.8 per 100,000, respectively) and lowest in the Southwest (15.4 and 57.1 per 100,000, respectively). Alaska Native people have the highest colorectal cancer incidence and mortality rates in the world, which may in part be due to lower receipt of screening. This regional variation may reflect a variety of environmental, lifestyle, and socioeconomic factors.

Consistent with their lower incidence rates, AIAN people have lower rates of cancer mortality than White people for all cancers as well as across most leading cancer types (Figure 19). However, as of 2023, people who identify as AIAN alone and White people have similar rates of death due to colon and rectum cancer (13.1 and 13.0 per 100,000, respectively).

Suicide and Substance Use Disorder

AIAN people have the highest rates of deaths by suicide across all racial and ethnic groups. In 2023, people who identify as AIAN alone have higher rates of deaths by suicide than White people (23.8 vs. 17.6 per 100,000) (Figure 20). Additionally, AIAN adolescents have the highest rates of deaths by suicide across all racial and ethnic groups. Research finds that suicide is the second leading cause of death for high school-aged AIAN adolescents. Rates of deaths by suicide increased by 139% for AIAN adolescent females and 71% for AIAN adolescent males between 1999 and 2017, however, recent data show that these rates declined between 2021 and 2023. Studies have shown that the high rates of suicide are associated with AIAN youths’ high likelihood of having adverse childhood experiences combined with historical intergenerational trauma as a result of colonization and structural discrimination.

Deaths by suicide vary by region among people who identify as AIAN alone. AIAN people in the Western U.S. experience the highest rate of deaths by suicide (31.6 per 100,000), while AIAN people in the Northeast experience the lowest rate of deaths by suicide (9.6 per 100,000) (Figure 21). Deaths by suicide are higher among AIAN people than White people in all regions except the Southern U.S.

AIAN people report the highest prevalence of substance use disorder (SUD) in the past year compared with other racial and ethnic groups. AIAN people also experience the highest rates of drug overdose death, including the highest rates of opioid-related deaths in 2023. The high rates of opioid-related deaths likely reflect the low uptake of medication treatment services among AIAN people. Among those ages 12 years and older, over a quarter (27%) of people who identify as AIAN alone report experiencing substance use disorder in the past year, compared to 19% of White people (Figure 22). Similar shares of AIAN people (12%) and White people (14%) report experiencing alcohol use disorder.

AIAN people are about twice as likely to die from a drug overdose compared to White people (65 vs. 33.1 per 100,000) in 2023 (Figure 23). Alcohol-induced deaths are also higher among people who identify as AIAN alone in 2023 compared to White people. AIAN people have the highest rate of alcohol-induced deaths and the fastest growing rate of alcohol-induced deaths compared to other racial and ethnic groups, nearly doubling in the past 10 years. Increases in alcohol deaths among AIAN people follow worsening trends in other areas related to behavioral health, where AIAN people have both the highest and fastest-growing rates of suicide and overall drug overdose deaths.

Racism is an underlying driver of health disparities. Research has shown that exposure to racism and discrimination can lead to negative mental health outcomes and certain negative impacts on physical health, including depression, anxiety, and hypertension. Across measures of discrimination in daily life and health care settings, AIAN adults report the highest frequency of experiencing certain types of discrimination compared to other racial and ethnic groups, while White adults report the lowest frequency.

AIAN adults are more likely to report certain experiences with discrimination in daily life compared with their White counterparts. Based on KFF survey data from 2023, more than a quarter of AIAN adults (28%) say that they received poorer service than other people at restaurants or stores at least a few times in the past year, higher than the share of White adults who say the same (16%) (Figure 24). Similarly, about four in ten (42%) AIAN adults say that people have acted as if they think they are not smart at least a few times in the past year, higher than the one-quarter (26%) of White adults who say the same. Further, about one in five (19%) AIAN adults say people acted as if they were afraid of them at least a few times in the past year, compared to 9% of White adults. Cumulatively, at least half of AIAN (58%) adults say they have experienced one of these forms of discrimination at least a few times in the past year compared to about four in ten (38%) White adults (Figure 24).

AIAN adults report having less frequent positive and respectful interactions with health care providers than White adults. KFF survey data from 2023 also show that AIAN adults (18%) are about twice as likely as White adults (8%) to say their health care providers explained things in a way they could understand just some of the time, rarely, or never in the past three years. Similarly, about one in four AIAN adults (24%) say their health care providers understood and respected their cultural beliefs just some of the time, rarely, or never, compared with about one in ten White adults (12%). They also are more likely than their White counterparts to say their providers did not frequently involve them in decision-making about their care during their visits in the past three years (Figure 25).

There is wide variation in the share of AIAN people reporting LEP among racial and ethnic subgroups. Among people who identify as AIAN in combination with another race or ethnicity, LEP ranges from 30% of people who identify as AIAN and Hispanic to one percent or less of AIAN and Black, and AIAN and White people (Figure 26).  Having LEP can contribute to difficulty accessing health coverage and care and negatively impact quality of care and health outcomes.

AIAN people have lower educational attainment than their White counterparts, but there is significant variation among AIAN people by racial and ethnic subgroups. Among adults ages 25 and older, 16% of people who identify as AIAN alone have a bachelor’s degree or higher, compared to 39% of White people. The share with a bachelor’s degree or higher is similar among those who identify as AIAN and Hispanic (17%), but it rises to over a quarter among those who are AIAN and Black (26%), and AIAN and White (27%), and to over four in ten (42%) of those who identify as AIAN and Asian. Additionally, AIAN people living off Tribal lands are twice as likely to have a bachelor’s degree or higher compared to AIAN people who live on Tribal lands (18% vs. 9%) (Figure 27). Researchers have found that some of the educational attainment gap can be explained by a lack of culturally relevant coursework in traditional educational settings.

While most people who identify as AIAN alone are in a working family, they are less likely than White people to live in a family with at least one worker (85% vs. 95%). The share living in a working family also varies among AIAN people by racial and ethnic subgroup. More than eight in ten AIAN people who identify as AIAN alone (85%) or AIAN and Black (87%) are part of a working family, while more than nine in ten people who identify as AIAN and Hispanic (95%) and as AIAN and Asian (94%) live in a working family (Figure 28).

AIAN people are more likely than White people to live in a family with an income below poverty, although there is variation among racial and ethnic subgroups of AIAN people. Among AIAN people, poverty rates are lower among those who identify as AIAN and Asian (11%), and AIAN and White (14%), while they rise to about one in five among AIAN and Hispanic (18%) people and about a quarter among AIAN and Black (23%) people, and people who only identify as AIAN alone (25%) (Figure 29).

AIAN people are nearly twice as likely to experience food insecurity compared to their White counterparts. People who identify as AIAN alone (23%) are more likely to be in a household that experienced food insecurity compared to White people (12%) (Figure 30).  Food insecurity among AIAN people is closely linked to historical federal policies that removed and relocated AIAN people and disrupted their connection to traditional lands, foods, and cultural practices.

AIAN people are less likely to own a home than White people (62% vs. 77%). Lower rates of homeownership among AIAN people may reflect insufficient housing supply and a lack of access to affordable capital. Rates of home ownership vary among AIAN people by racial and ethnic subgroup. Nearly seven in ten AIAN and White (69%) people own a home, while about six in ten people who identify as AIAN alone (62%), and people who identify as AIAN and Asian (62%) own a home. The home ownership rate drops to about half or lower among people who identify as AIAN and Hispanic (52%) or AIAN and Black (43%) (Figure 31).

AIAN people are more likely to live in “crowded” housing compared to White people. About 16% of people who identify as AIAN alone and one in ten (12%) people who identify as AIAN alone or in combination with another race or ethnicity report living in crowded housing, compared to 3% of White people. “Crowded housing” is defined as housing with more than one occupant per room (not counting bathrooms, porches, balconies, hallways, or unfinished basements, etc.). Among AIAN people, the share of people living in crowded housing ranges from 5% for people who identify as AIAN and White to about one in five (22%) for people who identify as AIAN and Hispanic (Figure 32). Living in multigenerational households is more common among AIAN people, and family connection is important to health and well-being, which may contribute to higher shares reporting “crowded housing” arrangements and may reflect cultural preferences or choices rather than a housing challenge.

Emerging research also highlights a number of protective social factors that can support better health outcomes in AIAN communities. Strong family and community networks, access to culturally competent care, the prioritization of traditional food systems, and the preservation of language and cultural practices have all been shown to promote resilience and improve well-being. Strengthening these protective factors alongside efforts to address structural barriers can help reduce health disparities for AIAN people.