Introduction

One of the immediate impacts of the 2025 Federal Budget Reconciliation Law is a provision, Section 71113, that blocks certain reproductive health care providers (who also provide abortions) from receiving federal Medicaid reimbursement for one year. The law impacts three organizations: (1) Planned Parenthood; (2) Maine Family Planning, a network of clinics in Maine, (3) and Health Imperatives, a network of specialized reproductive health clinics based in Massachusetts. Shortly after President Trump signed the law, Planned Parenthood, Maine Family Planning (legally known as the Family Planning Association of Maine), and 22 states and the District of Columbia filed separate legal challenges to prevent the implementation of Section 71113. One of the key issues in the litigation is whether Congress acted rationally to reach its policy goal of reducing the number of abortions across the country or whether they unlawfully targeted Planned Parenthood. This brief provides an overview of these legal challenges and summarizes the key positions of the plaintiffs and the defendants, Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS). 

Background

The 2025 Federal Budget Reconciliation Law is not the first instance of federal policy targeting funding for abortion and abortion providers. Blocking coverage of abortion under Medicaid and limiting abortion access has been a priority for abortion opponents since soon afterRoe v. Wade granted individuals the right to an abortion. Since 1977, Congress has included the Hyde Amendment every year as a rider to the federal appropriations budget prohibiting federal funds for abortion except in situations where the pregnancy is the result of rape or incest, or the pregnant person’s life is at risk. Federal Medicaid dollars may only reimburse abortion providers in these very limited situations. Some states make their own funds available to pay for abortion in other circumstances for their Medicaid enrollees. Yet, despite this longstanding provision, abortion opponents at the state and federal level have advocated going further in restricting federal funding. They argue that by allowing providers that also offer abortion services to remain in the Medicaid program, federal funds that go to these providers for other services indirectly subsidize abortion services with federal Medicaid dollars. While federal policy blocks funding for abortions under most circumstances, federal law mandates the coverage of family planning services, including contraception. Unique among covered benefits, federal Medicaid law classifies family planning services and supplies as a “mandatory” benefit category that states must cover and established a 90% federal matching rate (FMAP) for the costs of services categorized as family planning, a higher proportion than for other services. States pay the remaining 10% of costs. Many abortion providers also offer family planning services to their patients. 

Over the years, anti-abortion policy makers and advocates have utilized many different strategies to block Planned Parenthood from participating in Medicaid. In 2017, Congress attempted to block Medicaid reimbursement to entities (including Planned Parenthood affiliates) that provide abortions outside of the Hyde Amendment exceptions as part of efforts to repeal and replace the Affordable Care Act. That year, the House of Representatives passed a Reconciliation bill that would have blocked federal Medicaid funds to Planned Parenthood; however, the bill failed in the Senate and did not become law. In addition to federal attempts to block Planned Parenthood from Medicaid reimbursement, in the past decade at least 14 states (AL, AR, AZ, FL, IA, ID, IN, KS, LA, MO, MS, OK, SC, TN, TX) have used state-level policies or sought federal permission to block the provider from participating in their state Medicaid programs. Though most of these provisions were blocked by court action, the Supreme Court’s June 2025 decision in a case challenging South Carolina’s exclusion of Planned Parenthood from their Medicaid program changed this precedent. In Medina v. Planned Parenthood South Atlantic the Court allowed states to exclude providers from their Medicaid programs if they provide abortions or other services the state does not condone. Since Medina, a few states (Indiana, Nebraska, Oklahoma) have taken new actions to exclude Planned Parenthood from their state Medicaid programs.

Who is Challenging Section 71113 of the 2025 Federal Budget Reconciliation Law?

Planned Parenthood, Maine Family Planning, and 22 states and the District of Columbia (CA, NY, CT, CO, DE, HI, IL ME, MD, MA, MI, MN, NV, NJ, NM, NC, OR, the Governor of PA, RI, VT, WA, WI and the District of Columbia) have filed separate legal challenges claiming that Section 71113 violates the United States Constitution. Health Imperatives has not filed a lawsuit challenging this provision, but Massachusetts is one of the states challenging the law. 

The plaintiffs in these lawsuits say that restricting Medicaid funding to entities under Section 71113 would harm affected organizations and lead to increased costs to states. Further, they say this provision would decrease access to millions of Medicaid enrollees who receive reproductive health care including contraception, sexually transmitted infection testing and treatment, pregnancy testing, cancer screening, and other preventive services from affected providers. Section 71113 blocks federal Medicaid funding from certain entities for one year starting the date the law was signed, July 4, 2025; however, the provision states that entities are only designated as a “prohibited entity” if they meet certain criteria on October 1, 2025. 

Status of Cases Challenging Section 71113

Section 71113 is currently in effect for all three entities, and they are blocked from receiving federal Medicaid reimbursement for services provided to patients; however, throughout the course of the ongoing litigation the enforceability of Section 71113 has varied. A district court initially granted a preliminary injunction for ten Planned Parenthood affiliates that do not individually meet the criteria of Section 71113 on July 21, 2025. On July 28, 2025, the district court extended the preliminary injunction to all Planned Parenthood affiliates. On September 11, 2025, the First Circuit Court of Appeals reversed the district court ruling by pausing the preliminary injunction, therefore blocking Planned Parenthood sites across the country from receiving federal Medicaid funds for any service they provide to Medicaid enrollees while the case is ongoing. On December 12, 2025, the First Circuit permanently blocked the district court’s preliminary injunction. The First Circuit held that Section 71113 does not impose punishment on Planned Parenthood and instead is a lawful exercise of Congress’ taxing and spending power. The district court is continuing to consider this case in accordance with the First Circuit’s ruling.

Maine Family Planning also requested a preliminary injunction to block the enforcement of Section 71113, but the district court denied their request, and Maine Family Planning appealed. However, on December 29, 2025, Maine Family Planning filed a motion to voluntarily dismiss their case.

On December 2, 2025, a district court granted a motion for a preliminary injunction blocking enforcement of Section 71113 for the 22 states and DC. However, the judge stayed her order for seven days, and HHS has appealed. The court held that text of Section 71113 does not provide clear notice to states of how a Medicaid provider is determined to be a “prohibited entity.” The court reasoned that Section 71113 does not sufficiently give states: (1) the criteria to determine whether an entity is “primarily engaged in family planning”; (2) guidance on calculating Medicaid expenditures (for the purpose of Section 71113’s $800,000 threshold) of entities in their state that are members of multistate organizations; and (3) how to identify “affiliates” when those organizations operate outside the state’s boarders. Further, the court asserted that the plaintiff states would be harmed by enforcement of Section 71113 including retroactive enforcement because the retroactive nature of the provision conflicts with states obligation to make payments on providers claim within 30 days of receipt.

 After initially blocking the law from being implemented, the First Circuit subsequently granted the Government’s request on December 30, 2025, allowing the provision to be enforced in the 22 Plaintiff States and DC. The First Circuit held that the asserted ambiguities in Section 71113, including the definition of “affiliate” are unlikely to support the granting of a preliminary injunction. Currently states may reimburse Planned Parenthood and other affected providers with non-federal dollars, but only a handful of states have indicated their willingness to provide this support.

On What Grounds are the Plaintiffs Suing the Federal Government?

The heart of the litigation is the constitutionality of Congress’ action of prohibiting payments to certain entities that provide services to Medicaid patients. 

While all plaintiffs concede that Congress has the power to dictate spending guidelines for Medicaid funds, the constitutionality of Congress’ actions in enacting Section 71113, and the resulting burden on states is at the heart of this litigation. The Spending Clause in the United States Constitution grants Congress the power to, “lay and collect taxes…and provide for the common defense and general welfare of the United States,”— but this power is not unlimited. All exercises of Congress’ Spending Clause authority are subject to constitutional limitations. These limitations include the requirement that Congress must give clear notice of what actions are required in exchange for federal funds. Further, Congress cannot attach discriminatory conditions to federal funds that would violate other constitutional rights. At issue in this litigation is whether Section 71113 provides clear notice of state’s enforcement obligations, and whether the provision violates Maine Family Planning and Planned Parenthood’s constitutional rights.

First Amendment Claims 

The First Amendment of the United States Constitution states that, “Congress shall make no law… abridging the freedom of speech…or the right of the people to assemble.” The First Amendment has been interpreted not only to guarantee freedom of speech, but also the right to associate with others. Planned Parenthood and the states contend that Section 71113 unconstitutionally burdens Planned Parenthood’s First Amendment right to freedom of association. The text of Section 71113 includes affiliates of an entity that meet the criteria of a prohibited entity. They argue that penalizing Planned Parenthood affiliates that do not independently meet the criteria of Section 71113 because they are associated with other Planned Parenthood affiliates that are prohibited entities, hinders the affiliates’ ability to freely associate.

Plaintiffs further allege that Section 71113 violates Planned Parenthood’s First Amendment rights because Section 71113 could be considered unconstitutional retaliation. The First Amendment prevents the government from restricting speech or retaliating against protected speech. Retaliation is an adverse action a plaintiff experiences where the motivating factor behind the action was the plaintiff’s protected speech. In their complaints, Plaintiffs, Planned Parenthood, and the states allege that the motivation for enacting Section 71113 is to stop Planned Parenthood’s advocacy for sexual and reproductive health care. The states and Planned Parenthood claim that due to the narrow criteria of abortion providers affected by Section 71113, the provision was specifically written to target Planned Parenthood and its affiliates.                                                                                                

Bill of Attainder Claims 

In addition to the First Amendment claims, Planned Parenthood Federation of America and the states contend that Section 71113 is a violation of the US Constitution because it is an unlawful “bill of attainder.” A bill of attainder is a law that imposes a penalty without trial and circumvents due process of law. In their complaint, plaintiffs draw on the legislative history of Section 71113, and statements made by lawmakers to support their claim that Section 71113 was enacted specifically to exclude Planned Parenthood from receiving federal Medicaid funds. Planned Parenthood and the states also cite a 2017 attempt by Congress to block Medicaid payments from entities that provide abortions outside of the Hyde Amendment exceptions. During the 2017 attempt, the enacted provision would have solely excluded Planned Parenthood. Planned Parenthood argues that the text of the 2017 and 2025 provisions that block payments to prohibited entities are similar, demonstrating Congress’ intent to specifically penalize Planned Parenthood.

Fifth Amendment Claims 

In all three cases, the plaintiffs allege some violation of the Fifth Amendment Equal Protection Principle. All Plaintiffs allege that Section 71113 violates the equal protection component of the Due Process Clause of the Fifth Amendment because it only applies to “prohibited entities.” The Fifth Amendment prevents arbitrary discrimination and generally requires that similarly situated entities are treated alike. If an entity believes they have been unfairly discriminated against by a government entity, they can file a claim alleging a violation of their Fifth Amendment rights. The courts will then analyze the government’s purpose for enacting the law, and whether the government has violated the entities’ guaranteed rights such as freedom of speech and equal protection under the law. Planned Parenthood maintains they are being treated differently than other abortion providers who provide abortions outside of the Hyde Amendment exceptions. They argue that there is not a legitimate government interest in drawing this distinction, and thus the provision violates the Fifth Amendment.

Planned Parenthood also asserts a separate Fifth Amendment claim, maintaining that Section 71113 is invalid because it is vague. The Fifth Amendment Due Process Clause states that a person cannot be deprived of their life, liberty, or property without due process of law. This has been interpreted to mean that statutes that lack specificity or definiteness can be invalidated because they do not give clear warning of a prohibited action (void for vagueness). Planned Parenthood alleges that Section 71113 does not define essential terms in the statutory text, thus making it void. Planned Parenthood maintains that the words “affiliates, subsidiaries, successors, and clinics,” in the statute are undefined leaving it unclear whether Section 71113 applies to Planned Parenthood affiliates who do not independently meet the provisions criteria. In a November 21, 2025, letter to State Medicaid Directors CMS provided guidance defining the statutory term “affiliate “as “a corporation that is related to another corporation by shareholdings or other means of control; a subsidiary, parent, or sibling corporation.” In the guidance CMS defines “control” as: “the direct or indirect power to govern the management and policies of a person or entity, whether through ownership of voting securities, by contract, or otherwise; the power or authority to manage, direct or oversee.” Planned Parenthood filed a response to this guidance in the district court contending that CMS’ definition of affiliate still leaves ambiguity on who is considered an “affiliate,” because of the overbroad terms used in the CMS guidance. Therefore, Planned Parenthood continues to allege that Section 71113 is “void for vagueness.”

The Trump Administration Contends Section 71113 is Constitutional 

The Trump administration maintains similar legal arguments in all the lawsuits challenging the constitutionality of Section 71113. The government contends that Section 71113 is a component of duly enacted legislation, and plaintiffs’ attempts to block implementation of this provision seek to override the intentions of Congress. The Trump administration also argues that Congress has broad discretion to tax and spend for the general welfare, which includes the ability to alter federal Medicaid expenditures. The government also states that the parameters for designating entities to be removed from Medicaid reimbursement are not arbitrary and serve a legitimate government purpose. Further, the government rejects plaintiffs’ argument that Section 71113 was enacted due to animus toward plaintiffs. Instead, the government offers the alternative explanation that Section 71113 was enacted to reduce the number of abortions performed in the United States, a legitimate government interest.

What are the Next Steps? 

Currently, Section 71113 in effect, and Planned Parenthood affiliates, Maine Family Planning, and Health Imperatives are blocked from receiving federal reimbursement for services provided to Medicaid patients. Litigation challenging Section 71113 has the potential to directly impact the over 2.1 million people who receive health care from these organizations. To continue to qualify for federal Medicaid funding it was reported that Planned Parenthood of Wisconsin responded by first stopping abortion care before the October 1, 2025, deadline and then when they resumed abortion care, they relinquished their Essential Community Provider status, to avoid meeting the criteria set forth in Section 71113. However, it is unclear whether this will be enough for them and other affiliates which do not meet the criteria of Section 71113 on their own to not land on HHS’s prohibited entity list based on CMS’ guidance released on November 21, 2025. If Section 71113 remains in effect, Planned Parenthood and Maine Family Planning may close clinics, reduce services, or be unable to serve Medicaid patients. While some states have announced plans to fill in gaps created by the loss of Medicaid funding, this is not likely enough to make up for lost federal funds. Planned Parenthood Mar Monte, Planned Parenthood North Central, Planned Parenthood Northern New England, Planned Parenthood of Greater New York, Planned Parenthood of Michigan, Planned Parenthood of Western Pennsylvania, and Planned Parenthood Greater Northwest, have already experienced clinic closures or service interruptions in the face of financial uncertainty, and Maine Family Planning has announced that they will no longer offer primary care services to Medicaid enrollees at three of their 18 sites. 

Even if the Plaintiffs ultimately prevail on their challenges to Section 71113, the Supreme Court’s decision in Medina v. Planned Parenthood South Atlantic, opens the door for states to block providers from their Medicaid program. Without a federal law preventing Planned Parenthood from being blocked from Medicaid, more states may choose to exclude Planned Parenthood from their state’s Medicaid program. Ultimately, the constitutionality of Section 71113 may be decided by the Supreme Court; however, because Section 71113 only prohibits funding from July 4, 2025, to July 3, 2026, the year may be up before there is a final decision. Some states, such as Colorado and California, have provided temporary financial support to Planned Parenthood and other affected providers to fill the gap from the loss in federal funding. Yet, many anticipate that this provision could be inserted into a similar reconciliation bill in future years. It is not clear whether states will be able to continue to provide this support if there is a future reconciliation bill blocking federal Medicaid payments to these providers, especially in the face of future fiscal challenges and competing programmatic demands. 

Summary

Stark racial disparities in maternal and infant health in the U.S. have persisted for decades despite continued advancements in medical care. Compared to other high-income countries, the U.S. remains the country with the highest rate of maternal deaths. The disproportionate impact of the COVID-19 pandemic on people of color brought increased attention to health disparities, including the longstanding inequities in maternal and infant health. Subsequently, the overturning of Roe v. Wade, growing barriers to abortion, cuts to staff and programs within the U.S Department of Health and Human Services (HHS), and the passage of the 2025 tax and budget law all have the potential to further widen existing disparities in maternal health.

This brief provides an overview of racial disparities for selected measures of maternal and infant health, discusses the factors that drive these disparities, and provides an overview of policy changes that may impact them. It is based on KFF analysis of publicly available data from CDC WONDER online database, the National Center for Health Statistics (NCHS) National Vital Statistics Reports, and the CDC Pregnancy Mortality Surveillance System.

While this brief focuses on racial and ethnic disparities in maternal and infant health, wide disparities also exist across other dimensions, including income, education, age, and other characteristics. For example, there is significant variation in some of these measures across states and disparities between rural and urban communities. Data and research often assume cisgender identities and may not systematically account for people who are transgender and non-binary. In some cases, the data cited in this brief use cisgender labels to align with how measures have been defined in underlying data sources. Key takeaways include:

Large racial disparities in maternal and infant health outcomes persist. Pregnancy-related mortality rates among Black women are over three times higher than the rate for White women (49.4 vs. 14.9 per 100,000). Black, American Indian or Alaska Native (AIAN), and Native Hawaiian or Pacific Islander (NHPI) women also have higher shares of preterm births, low birthweight births, or births for which they received late or no prenatal care compared to White women. Infants born to Black, AIAN, and NHPI people have markedly higher mortality rates than those born to White people.

Maternal and infant health disparities reflect broader underlying social and economic inequities that are rooted in racism and discrimination. Differences in health insurance coverage and access to care play a role in driving worse maternal and infant health outcomes for people of color. However, inequities in broader social and economic factors, including income, are primary drivers for maternal and infant health disparities. Moreover, the persistence of disparities in maternal health across income and education levels, points to the importance of addressing the roles of racism and discrimination as part of efforts to improve health and advance equity.

Recent actions by the Trump administration and Congress reflect a shift away from prioritizing maternal and infant health equity and may contribute to widening disparities. Several key programs that historically supported expanding access to care and services and efforts to address racial disparities, such as diversifying the health care workforce and enhancing data collection and reporting, now face funding cuts or elimination. Other recent federal program and budget cutbacks, including the reduction or elimination of diversity, equity, and inclusion (DEI) initiatives, may undermine efforts to improve disparities in maternal and infant health outcomes. Moreover, the 2025 tax and budget law is anticipated to lead to large coverage losses, particularly in Medicaid, which is a primary source of care for people of color. Coverage losses will likely contribute to access barriers, including for maternal care. Additionally, state variation in access to abortion in the wake of the overturning of Roe v. Wade may exacerbate existing racial disparities in maternal health.

Racial Disparities in Maternal and Infant Health

Pregnancy-Related Mortality Rates

In 2023, approximately 676 women died in the U.S. from causes related to or worsened by pregnancy. This is a decrease from 793 maternal deaths in 2022. Pregnancy-related deaths are deaths that occur within one year of pregnancy. The pregnancy-related mortality rate decreased among White and Hispanic women, will there were no significant changes for Asian or Black women. Approximately one in five (20%) deaths occur during pregnancy, nearly one quarter (23%) occur during labor or within the first week postpartum, and more than half (57%) occur one week to one year postpartum, underscoring the importance of access to health care beyond the period of pregnancy. Recent data show that more than eight out of ten (87%) pregnancy-related deaths are preventable.

As of 2023, Black people are more than three times as likely as White people to experience a pregnancy-related death (49.4 vs. 14.9 per 100,000 live births) in 2023 (Figure 1). The rate for Hispanic and Asian people is lower compared to that of White people (12.3 and 10.7 vs. 14.9 deaths per 100,000 live births). Data from 2023 were insufficient to identify mortality among AIAN and NHPI women. However, earlier data from 2021 show that AIAN and NHPI people (118.7 and 111.7 per 100,000, respectively) had the highest rates of pregnancy-related mortality across racial and ethnic groups.

Research shows that this disparity for Black women increases by age and persists across education and income levels. Data show higher pregnancy-related mortality rates among Black women who completed college education than among White women with the same educational attainment and White women with less than a high school diploma. Other research also shows that Black women are at significantly higher risk for severe maternal morbidity, including conditions such as preeclampsia, which is significantly more common than maternal death. Further, AIAN, Black, NHPI, Asian, and Hispanic women have higher rates of admission to the intensive care unit during delivery compared to White women, which is considered a marker for severe maternal morbidity.

Birth Risks and Outcomes

Black, AIAN, and NHPI women are more likely than White women to have certain birth risk factors that contribute to infant mortality and can have long-term consequences for the physical and cognitive health of children. Preterm birth (birth before 37 weeks gestation) and low birthweight (defined as a baby born less than 5.5 pounds) are some of the leading causes for infant mortality. Receiving pregnancy-related care late in a pregnancy (defined as starting in the third trimester) or not receiving any pregnancy-related care at all can also increase the risk of pregnancy complications. Black, AIAN, and NHPI women have higher shares of preterm births, low birthweight births, or births for which they received late or no prenatal care compared to White women (Figure 2). Notably, NHPI women are four times more likely than White women to begin receiving prenatal care in the third trimester or to receive no prenatal care at all (22.4% vs. 4.7%). Black women also are nearly twice as likely compared to White women to have a birth with late or no prenatal care compared to White women (10.4% vs. 4.7%).

While teen birth rates overall have declined over time, they are higher among Black, Hispanic, AIAN, and NHPI teens compared to their White counterparts (Figure 3). In contrast, the birth rate among Asian teens is lower than the rate for White teens. Many teen pregnancies are unplanned, and pregnant teens may be less likely to receive early and regular prenatal care. Teen pregnancy also is associated with increased risk of complications during pregnancy and delivery, including preterm birth. Teen pregnancy and childbirth can also have social and economic impacts on teen parents and their children, including disrupting educational completion for the parents and lower school achievement for the children. Research studies have found that increased use of contraception as well declines in teen sexual activity have helped lower the rate of teen births nationally.

Reflecting these increased risk factors, infants born to AIAN, Hispanic, Black, and NHPI women are at higher risk for mortality compared to those born to White women. Infant mortality is defined as the death of an infant within the first year of life, but most cases occur within the first month after birth. The primary causes of infant mortality are birth defects, preterm birth and low birthweight, sudden infant death syndrome, injuries, and maternal pregnancy complications. Infant mortality rates have declined over time, although the 2023 rate is unchanged from the 2022 rate (5.6 per 1,000 births, respectively). However, disparities in infant mortality have persisted and sometimes widened for over a century, particularly between Black and White infants. As of 2023, infants born to Black women are over twice as likely to die relative to those born to White women (10.9 vs. 4.5 per 1,000), and the mortality rate for infants born to AIAN and NHPI women (9.2 and 8.2 per 1,000) is nearly twice as high (Figure 4). The mortality rate for infants born to Hispanic mothers is similar to the rate for those born to White women (5.0 vs. 4.5 per 1,000), while infants born to Asian women have a lower mortality rate (3.4 per 1,000).

Data also show that fetal death or stillbirths—that is, pregnancy loss after 20-week gestation—are more common among NHPI, Black and AIAN women compared to White and Hispanic women. Moreover, causes of stillbirth vary by race and ethnicity, with higher rates of stillbirth attributed to diabetes and maternal complications among Black women compared to White women. 

Based on the most recently available federally published estimates from 2018, about one in five AIAN, Asian or Pacific Islander, and Black women reported symptoms of pregnancy-related depression compared to about one in ten White women (Figure 5). Hispanic women (12%) had similar rates of depression during and after childbirth compared to their White counterparts (11%). A recent study among women in Southern California suggests that the prevalence of PPD) has grown over the past decade , driven by increases among Black and Asian and Pacific Islander women. Women of color experience increased barriers to mental health care and resources, along with racism, trauma and cultural barriers. Research suggests that perinatal mental health conditions are a leading underlying cause of pregnancy-related deaths and that individuals with perinatal depression are also at increased risk of chronic health complications such as hypertension and diabetes. Infants of mothers with depression are more likely to be hospitalized and die within the first year of life. 

Factors Driving Disparities in Maternal and Infant Health

The factors driving disparities in maternal and infant health are complex and multifactorial. They include differences in health insurance coverage and access to care. However, broader social and economic factors and structural and systemic racism and discrimination also play a major role (Figure 7). In maternal and infant health specifically, the intersection of race, gender, poverty, and other social factors shapes individuals’ experiences and outcomes. Recently there has been broader recognition of the principles of reproductive justice, which emphasize the role that the social determinants of health and other factors play in reproductive health for communities of color. Notably, Hispanic women and infants fare similarly to their White counterparts on many measures of maternal and infant health despite experiencing increased access barriers and social and economic challenges typically associated with poorer health outcomes. Research suggests that this finding, sometimes referred to as the Hispanic or Latino health paradox, in part, stems from variation in outcomes among subgroups of Hispanic people by origin, nativity, and race, with better outcomes for some groups, particularly recent immigrants to the U.S. However, the findings still are not fully understood.

Disparities in maternal and infant health, in part, reflect increased barriers to care for people of color. Research shows that coverage before, during, and after pregnancy facilitates access to care that supports healthy pregnancies, as well as positive maternal and infant outcomes after childbirth. Overall, people of color are more likely to be uninsured and face other barriers to care. Medicaid helps to fill these coverage gaps during pregnancy and for children, covering more than two-thirds of births to women who are Black or AIAN. Given its significant role as a payor of maternity care for women of color, several health care professionals and state Medicaid programs have developed initiatives to improve maternal health and decrease maternal mortality and morbidity, such as broader inclusion of doulas as Medicaid providers. However, AIAN, Hispanic, and Black people are at increased risk of being uninsured prior to their pregnancy, which can affect access to care before pregnancy and timely entry to prenatal care. Beyond health coverage, people of color face other increased barriers to care, including limited access to providers and hospitals and lack of access to culturally and linguistically appropriate care.

Several areas of the country, particularly in the South, which is home to a large share of the Black population, have gaps in obstetrics providers. AIAN women also are more likely to live in communities with lower access to obstetric care. These challenges may be particularly pronounced in rural and medically underserved areas. For example, research suggests that the steep closures of hospitals and obstetric units over the past decade in rural areas has a disproportionate negative impact on Black infant health. Suggested approaches for stemming shortages include more training programs for perinatal nurses and midwives, raising Medicaid payment rates, and expansion of midwifery and birth centers services.

Research also highlights the role racism and discrimination play in driving racial disparities in maternal and infant health. Research has documented that social and economic factors, racism, and chronic stress contribute to poor maternal and infant health outcomes, including higher rates of pregnancy-related depression and preterm birth among Black women and higher rates of mortality among Black infants. In recent years, research and news reports have raised attention to the effects of provider discrimination during pregnancy and delivery. News reporting and maternal mortality case reviews have called attention to a number of maternal and infant deaths and near misses among women of color where providers did not or were slow to listen to patients. A recent report determined that discrimination, defined as treating someone differently based on the class, group, or category they belong to due to biases, stereotypes, and prejudices, contributed to 30% of pregnancy-related deaths in 2020. In one study, Black and Hispanic women reported the highest rates of mistreatment (such as shouting and scolding, ignoring or refusing requests for help during the course of their pregnancy). Even after controlling for insurance status, income, age, and severity of conditions, people of color are less likely to receive routine medical procedures and experience a lower quality of care. Another study found that Black women are more likely to receive a cesarian section compared to White women while controlling for health status, suggesting that differences in provider judgement and structural inequalities may be contributing to the disparity. A 2023 KFF survey found that about one in five (21%) Black women say they have been treated unfairly by a health care provider or staff because of their racial or ethnic background. A similar share (22%) of Black women who have been pregnant or gave birth in the past ten years say they were refused pain medication they thought they needed.

Current Policies Impacting Maternal and Infant Health Disparities

Since President Trump took office in January 2025, the Administration and Congress have made significant health policy changes. While in some cases pregnant and postpartum people have been specifically exempted or protected from changes, many changes may have significant impacts on maternal and infant health that could exacerbate existing disparities.

President Trump’s executive orders rolling back federal diversity efforts could exacerbate longstanding disparities in maternal health. As one of his first actions in office, President Trump signed executive orders revoking federal DEI related programs and actions in the federal government and among federal contractors and grantees. In implementing President Trump’s executive orders, the administration has taken significantly broader actions beyond eliminating DEI programs to include eliminating priorities, actions, information, data, and funding related to concepts of diversity or disparities among federal agencies as well as federal contractors and grantees. The broad nature of these actions risks reversing progress on health equity and may lead to widening disparities in maternal health.

Recent federal restructuring may reverse progress on maternal and infant health, particularly for communities already facing persistent disparities. On March 27, 2025, the Trump administration announced an Executive Order reorganizing HHS, which has disrupted key programs affecting maternal health. This impacts included laying off most staff in the CDC’s Division of Reproductive Health, halting community-based maternal health grants, erasing the prior White House Blueprint for Addressing the Maternal Health Crisis, and closing several federal offices that supported state and local efforts to address racial disparities in maternal care. The restructuring has also eliminated key initiatives, including the Pregnancy Risk Assessment Monitoring System (PRAMS), which for decades provided data to track maternal experiences and inform evidence-based policies, and the Safe to Sleep Campaign, a national effort to reduce sudden infant death syndrome (SIDS). These rollbacks come at a time when sleep-related infant deaths have risen nearly 12% between 2020 and 2022, with SIDS among Black infants increasing by 15% in 2020.

The 2025 tax and spending legislation makes large cutbacks in federal Medicaid spending that are expected to lead to large coverage losses, which will likely reduce access to care, including maternal care. According to the Congressional Budget Office (CBO), the law will reduce federal Medicaid spending over the next decade by an estimated $911 billion and increase the number of uninsured people by 10 million. Given the disproportionate role Medicaid plays in covering women of color, they are at increased risk for being affected by program cutbacks. In 2023, Medicaid covered 37% of AIAN 30% of Black and 26% of Hispanic reproductive age women, compared to 20% of reproductive age women overall. Moreover, among women of reproductive age enrolled in Medicaid, nearly four in ten are covered through the Medicaid expansion and could be at risk of losing coverage due to new work and eligibility requirements under the law. While the law provides exemptions from new work requirements for pregnant and postpartum women and for adults with children under age 14, many may still be at risk for losing coverage if they face challenges documenting information necessary to quality for the exemption. The requirements may also limit access to coverage before pregnancy, a particularly important time for addressing preventive care and managing chronic conditions, which are associated with healthier pregnancy outcomes.

The law also imposes a one-year ban on federal Medicaid payments to certain family planning providers, including all Planned Parenthood clinics, which could weaken resources and care that support maternal and infant health. This policy prohibits some family planning clinics that also offer abortion services from receiving any Medicaid payments for contraceptive and other preventive services. Because Medicaid covers 90% of the cost of family planning services, losing this funding would be a major financial blow. While Planned Parenthood clinics represent a small share of the reproductive health safety net overall, they serve many patients of color, provide a significant portion of contraceptive care and are often the only provider in rural or underserved areas. Excluding them from Medicaid could result in clinic closures, reduced services, and fewer reproductive care options for low-income women. 

In addition, President Trump’s policies and budget proposals are threatening to dismantle the Title X family planning program, disproportionately affecting communities already facing higher barriers to care. Title X, a federal program established in 1970, provides funding to clinics that offer contraceptive services, STI testing, and cancer screenings to low-income and uninsured patients. These clinics provide care to a diverse population, with nearly a quarter (23%) of the patient population identifying as Black, more than a third (36%) as Hispanic or Latino, and about a fifth (19%) reporting limited proficiency in English. In recent years, the program has faced mounting restrictions. During President Trump’s first term, his administration implemented rules that barred clinics from participating in Title X if they offered or referred for abortion services, resulting in roughly 1,000 clinics losing Title X funding. While the Biden administration later reversed these restrictions, the second Trump administration has resumed efforts to limit the program by withholding funds from some grantees and proposing to eliminate all funding for the program. If enacted, these policies would dismantle the program, leaving many rural and underserved communities with fewer resources for affordable reproductive health care.

State abortion bans and restrictions may exacerbate poor maternal and infant health outcomes and access to care. Since the Dobbs ruling in June 2022, about half of states have banned abortion or restricted it to early in pregnancy. People of color are disproportionately affected by these bans and restrictions as they are at higher risk for pregnancy-related mortality and morbidity, are more likely to obtain abortions, and more likely to face structural barriers that make it more difficult to travel out of state for an abortion. While the number of abortions has slightly increased nationally since the ruling, ongoing and impending legal challenges, state legislative efforts, and federal executive actions could further alter the reproductive care landscape and have impacts beyond abortion counts. A recent JAMA study, for instance, found that fertility rates have increased in states with complete or 6 week abortion bans, particularly among Black and Hispanic populations compared to White populations. A concurrent study showed infant mortality rates have also risen in these states and the increases were larger among Black infants. Abortion bans are exacerbating maternity workforce shortages, as some clinicians do not want to work in areas that criminalize their practice and restrict their ability to provide evidence-based care.

Summary

As routine and seasonal vaccination rates continue to decline among children, racial disparities in vaccination rates persist. Declining vaccination rates leave children at increased risk for preventable illnesses, while disparities leave some children at greater risk relative to others. Research shows that many childhood diseases require a high level of vaccination within the population to achieve community-wide protection. As vaccination rates decline, risk for disease outbreaks increases. For example, as of November 2025, there have been 44 measles outbreaks (3 or more related cases) in the U.S. during 2025, and the number of measles cases reported for 2025 is the highest level reported in decades, a consequence of declining measles vaccination rates in many areas.

This analysis examines recent childhood vaccination rates by race and ethnicity for children’s recommended vaccines overall and for the measles, mumps, rubella (MMR) and seasonal flu vaccines specifically, based on KFF analysis of data from the Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report (MMWR) and the CDC Flu Vaccination Coverage Report (see Methods). It also discusses potential factors contributing to the ongoing disparities in vaccination rates and recent declines in levels of vaccination coverage.

Overall, the data show that children’s vaccination rates, including receipt of recommended childhood vaccinations as well as for MMR and seasonal flu vaccine specifically, have declined in recent years largely due to decreases in vaccinations among White and Asian children. At the same time, and despite the declines among White and Asian children, Black and AIAN children remain least likely to have received recommended childhood vaccinations and the MMR vaccine specifically. In contrast, for the seasonal flu vaccine, White children along with Black and AIAN children are less likely to have received the vaccination compared to their Asian and Hispanic peers.

Ongoing racial disparities in vaccination rates likely reflect a combination of factors including differences in access to care as well as varying levels of trust in vaccines.For example, the 2025 KFF/Washington Post Survey of Parents shows lower levels of confidence in the safety of some vaccines among Black parents compared to White parents. The recent declines in vaccination rates may reflect spread of vaccine misinformation, growing public skepticism about the safety and effectiveness of vaccines, and increasingly partisan views on vaccination. The KFF/Washington Post Survey of Parents shows Republican parents are nearly three times as likely to report skipping vaccinations for their children compared to parents who are Democrats. Most recently, the Centers for Disease Control and Prevention (CDC) posted information to its website indicating that “studies have not ruled out the possibility that infant vaccines cause autism” despite longstanding scientific evidence disputing this connection. Going forward, these declines could be exacerbated by changes in federal vaccine policy.

Children’s Vaccination Rates by Race and Ethnicity

Largely driven by decreases among Asian and White children, rates of receipt of recommended childhood vaccinations for children ages 24 months or younger have declined. The U.S. Advisory Committee on Immunization Practices (ACIP) has established a recommended immunization schedule for children, which outlines the vaccines they should receive from birth through age two. Examination of vaccination rates by birth cohorts, which group children by the year they were born to allow for comparisons across groups and years, shows that vaccination coverage rates among Asian and White children up to age 24 months have declined, falling from 77% among Asian children in the 2017-2018 birth cohort to 70% in the 2020-2021 birth cohort and from 74% to 69% among White children across these cohorts (Figure 1). The rate for Hispanic children rose from 66% to 69% between the 2017-2018 and 2018-2019 cohorts but then declined again to 65% among the 2020–2021 birth cohort. Rates for Black children remained relatively stable over this period. Both Hispanic and Black children continue to have lower vaccination rates than Asian and White children, with only about two-thirds of each group receiving recommended childhood vaccinations. The rate for AIAN children has increased but is still lower than other groups at 59% among the 2020-2021 birth cohort. In addition to lower routine childhood vaccination rates among children ages 24 months and younger, the rate of school vaccine exemptions increased following the COVID-19 pandemic. Recent survey data suggest that parents who had a White child were less likely to agree that school and daycare vaccination requirements are important or necessary compared to parents of children of other racial and ethnic groups.

For the MMR vaccination specifically, Asian and White children have the highest rates of receiving at least one dose by age 24 months but their rates have been declining in recent years; rates for Black and AIAN children remain lower and below the Healthy People 2030 goal of 90.8% children receiving at least one MMR dose by their second birthday. Asian children have the highest MMR vaccination rate across racial and ethnic groups, although it fell from 95% among those born in 2017-2018 to 92% among those born in 2020-2021 (Figure 2). Similarly, the rate for White children fell from 93% to 90% across these birth cohorts. Rates for other groups remained largely stable across these cohorts, but rates for Black (89%) and AIAN (88%) children born in 2020-2021 remain lower and below the Healthy People 2030 vaccination goal.

Flu vaccination rates among children ages 6 months to 17 years have fallen to their lowest level in over a decade, with a steady decline among White children since the pandemic. Prior to the COVID-19 pandemic, flu vaccination rates had been increasing, with rates highest among Asian and Hispanic children and lower levels among White, Black, and AIAN children. Vaccination rates fell among all groups moving into the 2020-2021 season following the onset of the COVID-19 pandemic. The rate for AIAN children dropped by nearly 20 percentage points and there were larger declines in vaccination rates for Black, Asian, and Hispanic children compared to their White counterparts. Rates rebounded slightly after 2020-2021 season for most groups although they remain below pre-pandemic levels and continued to decline for White children. As of the 2023-2024 flu season, Asian children (70%) had the highest flu vaccination rate, followed by Hispanic children (61%). In contrast, just over half of AIAN (54%), Black (52%), and White (52%) children received the flu vaccine (Figure 3). Preliminary data for the 2024-2025 season that are available for selected groups also show that only about half of White (46%) Black (48%), and Hispanic (53%) children received the vaccine.

Factors Affecting Vaccination Rates

Racial differences in vaccination rates may reflect a variety of factors including differences in social and economic factors that impact access to care as well as differing levels of trust in vaccines. For example, Black, Hispanic, and AIAN people fare worse compared to their White and Asian counterparts on some measures of access to care and across social and economic factors that may impact access to and use of care, including education and income. In a July 2025 KFF Health Tracking Poll, Black and Hispanic adults were among the most concerned about the availability and insurance coverage of the COVID-19 vaccine. The long legacy of the medical system’s abuse and mistreatment of people of color may also contribute to distrust of vaccines. For example, KFF/Washington Post survey data from October 2025 show that just over half (55%) of Black parents say they are confident the flu vaccines are safe for children compared to about two-thirds of White parents (64%), and Black parents are at least 10 percentage points less likely than White parents to express confidence in the safety of the Polio and MMR vaccines.

A growing partisan divide in attitudes toward childhood vaccinations may be contributing to declining vaccination rates among White children. KFF polling data show that the share of parents who say they keep their child up to date with recommended childhood vaccines like the MMR has been declining over time. For example, KFF Tracking Poll data show that the share of parents who report skipping or delaying some vaccines for their children increased between 2023 and 2025, driven largely by Republican-leaning parents. KFF/Washington Post survey data from October 2025 show that Republican parents are nearly three times as likely to report skipping vaccinations other than flu or COVID for their children compared to parents who are Democrats (22% vs. 8%). Other data show that White voters make up the nearly eight in ten of Republicans and Republican leaders.

Changing attitudes towards vaccines may reflect the spread of vaccine misinformation. Some public health leaders have noted that vaccine hesitancy related to COVID-19 may have had spillover effects on routine child immunizations. More recently, HHS Secretary Robert F. Kennedy Jr. has amplified claims about vaccines that have been rejected by scientists and public health officials. Kennedy has suggested without evidence that the number of recommended childhood vaccines has led to a rise in chronic disease in the U.S. Kennedy has also repeated false claims that vaccines, including MMR, can cause autism and that the measles vaccine causes the illness it prevents. Most recently, the CDC posted information to its website indicating that “studies have not ruled out the possibility that infant vaccines cause autism” despite longstanding scientific evidence disputing this connection. KFF/Washington Post survey shows that many parents are uncertain whether false or misleading claims about vaccines and measles are true, and the share who say these false claims are true is higher among Republican parents, particularly those who identify as supporters of the Make America Great Again (MAGA) movement.

Shifts in federal policy on vaccines may contribute to continued declines in childhood vaccinations. Since his appointment as Secretary of Health and Human Services, Robert F. Kennedy Jr. has made several changes to U.S. vaccine policy, including replacing ACIP, removing COVID-19 vaccine recommendations for healthy children and pregnant women, and cancelling funding for mRNA vaccine research. Secretary Kennedy pledged to examine and revise the recommended vaccine schedule to reduce the number of vaccines given to children and perhaps remove vaccines from the recommended schedule altogether. President Trump has echoed many of Secretary Kennedy’s criticisms of the vaccine schedule, saying that children in the U.S. receive too many vaccines and that parents should disregard current federal recommended childhood vaccine schedule and instead space out shots. In response to changes in federal policies and statements from Trump Administration officials, many states have taken steps to maintain access to vaccines and de-link state vaccine policies from federal recommendations. In contrast, other states have expanded exemptions from school vaccine requirements. This variation in state policies may result in uneven levels of vaccine protection across the country, which could leave some areas at increased risk for disease outbreaks and weaken the nation’s overall community-level protection.

Summary

The Department of Homeland Security (DHS) released a proposed rule that would rescind 2022 Biden-era public charge determination regulations. In their place, DHS plans to provide interpretive and policy tools to guide public charge determinations and suggests it will “move away from a bright line primary dependence standard” and remove limitations on the types of public resources that are relevant for considering. As such, immigration officers would be given broad discretion to make determinations and could consider programs previously excluded from determinations, including Medicaid and the Children’s Health Insurance Program (CHIP), as well as potentially a much broader array of health and other support programs, other types of assistance, and family members’ use of programs. Under longstanding immigration policy, federal officials can deny entry to the U.S. or adjustment to lawful permanent resident (LPR) status (i.e., a “green card”) to someone they determine is likely at any time to become a public charge.

The proposed public charge changes along with other Trump administration policy changes will likely lead to decreased participation in public programs, including Medicaid and CHIP, among a broad group of immigrant families, including citizen children in those families. DHS indicates that the rule will deter immigration to the U.S. and reduce the number of immigrants relying on public programs. DHS further notes that the “elimination of certain definitions may lead to public confusion or misunderstanding of the proposed rule, which could result in decreased participation in public benefit programs by individuals who are not subject to the public charge ground of inadmissibility.” Research suggests that such “chilling effects” will likely lead to disenrollment and forgone enrollment among a broader group of individuals living in immigrant families than those subject to public charge determinations, including citizen children in these families. These fears may be further amplified by a recent notice from the Centers for Medicare and Medicaid Services (CMS) that it will begin sharing data it receives from states with Immigration and Customs Enforcement (ICE). Moreover, these changes come as immigrant families are already experiencing starkly increased fears due to President Trump’s immigration policies, leading them to limit their activities and participation in assistance programs and as recently passed legislation will make fewer lawfully present immigrants eligible for federally-funded health coverage programs.

If the proposed rule leads to disenrollment rates ranging from 10% to 30%, between 1.3 million to 4.0 million people could disenroll from Medicaid or CHIP, including nearly 600,000 to about 1.8 million citizen children. Additionally, assuming the same forgone enrollment rates, between about 200,000 to 500,000 uninsured people could forgo enrolling in Medicaid or CHIP despite being eligible, including over 50,000 to more than 150,000 citizen children. According to KFF analysis of American Community Survey (ACS) data, there are about 13.4 million Medicaid or CHIP enrollees living in a household with at least one noncitizen, including 5.9 million citizen children, who may be at risk for decreased enrollment. Additionally, nearly 1.8 million uninsured individuals are eligible for Medicaid and CHIP but are not enrolled and are living in a household with a noncitizen, including over 500,000 citizen children. These estimates differ from DHS estimates in the proposed rule (see Methods for more). Beyond Medicaid and CHIP, fear and confusion would likely have similar effects on participation in other programs, especially since DHS suggest it will give officers broad discretion to consider use of all sources of public resources in public charge determinations.

The proposed rule will likely lead to coverage losses and contribute to negative health outcomes, increases in uncompensated care, and broader negative spillover effects on communities and the workforce. Overall, the proposed rule would likely lead to reductions in health coverage, nutrition assistance, and other sources of support among immigrant families, including citizen children in those families. Nationally, one in four children live in a family with at least one immigrant parent. Reduced participation in health coverage and other assistance programs would negatively affect the health and financial stability of immigrant families and the growth and healthy development of their children. In addition, coverage losses would lead to lost revenues and increased uncompensated care for providers and have broader spillover effects within communities and on the workforce. DHS notes that the proposed rule may lead to worse health outcomes; increased use of emergency rooms; higher prevalence of communicable diseases; increases in uncompensated care; and increased poverty, housing instability, reduced productivity, and lower educational attainment. It also recognizes that it may result in reduced revenues for certain health, food, and housing providers. 

Background

Under longstanding immigration policy, federal officials can deny entry to the U.S. or adjustment to lawful permanent resident (LPR) status (i.e., a “green card”) to someone they determine is likely at any time to become a public charge. DHS regulations apply to public charge determinations for individuals seeking adjustment to LPR status within the U.S. Separately, media reports indicate new Department of State guidance directs visa officers to consider a wide range of health conditions when reviewing applications to enter the U.S. Under statute, officers must, at a minimum, consider age; health; family status; assets, resources, and financial status; and education and skills in making public charge determinations. Some groups, such as humanitarian immigrants, are exempt from public charge determinations under statute.

In 2022, the Biden administration published public charge regulations largely to address chilling effects of a 2019 Trump administration rule that led many immigrant families to avoid seeking health coverage and other services and assistance for which they were eligible. During his first term, President Trump implemented public charge rules that had newly considered the use of noncash assistance programs, including Medicaid, in public charge determinations. These changes led many immigrant families, including citizen children in these families, to forgo assistance and services for which they were eligible, including health coverage and care. In 2021, the Biden administration stopped applying the rule and reverted to prior 1999 field guidance. It subsequently published regulations in 2022 that largely codified the 1999 field guidance. The 2022 regulations defined a public charge as someone who is likely to become primarily dependent on the federal government as demonstrated by the use of cash assistance programs for income maintenance or government-funded institutionalized long-term care. The rule specifically excluded the consideration of noncash programs, including Medicaid (except for long-term institutionalization) and CHIP, from public charge determinations. It also prohibited the consideration of other family members’ use of programs. The 2022 regulations remain in effect until a new rule is finalized.

The proposed rule would rescind the 2022 public charge regulations (other than a provision related to bonds) and provide broad discretion to immigration officers in making public charge decisions, including considering factors and use of programs that had been excluded. DHS plans to provide interpretive and policy tools to guide public charge determinations if the proposed rule is finalized. In the preamble to the proposed rule, DHS notes that both the 2019 and 2022 rules were overly restrictive in providing narrow and finite lists of public benefits that could be considered as part of the public charge determinations and in not expressly providing officers with the authority to consider other factors beyond those specified in the rules. DHS suggests that eliminating the 2022 rule will allow for consideration of “receipt of any type of public benefits.” DHS proposes it will “move away from a bright line primary dependence standard” and remove limitations on the types of public resources that are relevant for consideration. As such, immigration officers would be given broad discretion to make determinations and could consider programs previously excluded from determinations, including Medicaid and CHIP, as well as potentially a much broader array of health and other support programs, other types of assistance, and family members’ use of programs.

Beyond the proposed changes to public charge, the Trump administration has implemented an array of immigration policy changes that have significantly increased fear among immigrant families, making them more reluctant to participate in activities or use services. The KFF/New York Times 2025 Survey of Immigrants shows that immigrant adults report rising fear and negative economic and health impacts amid this environment. More than one in five (22%) immigrant adults say they personally know someone arrested, detained, or deported for immigration-related reasons since January 2025, and 41% worry they or a family member could be detained or deported. Three in ten (30%) say they or a family member have limited their participation in activities outside the home since January due to concerns about drawing attention to someone’s immigration status, and 29% report skipping or postponing health care in the past 12 months, with 19% of this group (5% of all immigrant adults) citing immigration-related worries.

Past Evidence of “Chilling Effects”

Research indicates that the 2019 Trump administration public charge policy changes contributed to disenrollment from Medicaid and CHIP and other programs among immigrant families, including citizen children in these families. Analysis finds that between 2016 and 2019, the share of children receiving Medicaid, the Supplemental Nutrition Assistance Program (SNAP), and Temporary Assistance for Needy Families fell about twice as fast among U.S.-citizen children with noncitizen household members as it did among children with only citizens in their households. Specifically, the analysis found that participation in Medicaid and CHIP fell by 18% among low-income U.S. citizen children with a noncitizen in the household compared to 8% among their counterparts in citizen-only households. Other studies found larger drops in Medicaid coverage among children in mixed status or noncitizen families compared to those in citizen families between 2017 and 2019 as well as larger declines in SNAP enrollment among noncitizen children and citizen children living in mixed-status families compared to citizen children with U.S.-born parents. Survey data from 2019 found that more than one in seven adults (16%) in immigrant families reported avoiding a noncash government benefit program such as Medicaid or CHIP, SNAP, or housing subsidies for fear of risking future green card status, with the share rising to 26% among adults in low-income immigrant families.

Research also suggests that these fears persisted even after the Biden administration reversed the 2019 public charge policy changes in 2021. The KFF/LA Times Survey of Immigrants showed that, as of 2023, 8% of immigrant adults, rising to over a quarter (27%) of those who are likely undocumented, said they avoided applying for food, housing, or health care assistance in the past year because they didn’t want to draw attention to their or a family member’s immigration status. Other survey data found nearly one in four adults in mixed immigration status families and over one in seven adults in immigrant families with children avoided safety net programs because of concerns related to immigration status in 2023.

As of 2025, there was already an increase in the share of immigrants reporting disenrolling from or avoiding enrolling in assistance programs due to immigration-related fears under the Trump administration prior to the release of the proposed public charge rule. In the KFF/New York Times 2025 Survey of Immigrants, 11% of immigrant adults say they stopped participating in a government program that helps pay for food, housing, or health care since January 2025 because of immigration-related worries, ranging from 4% among those living in a citizen-only household to 18% of those living in a household with a noncitizen. Among those in a household with a noncitizen, the shares reporting stopping participation were 11% for those that do not have a likely undocumented immigrant in the household and 36% for those that include a likely undocumented immigrant (Figure 1). Further, about one in ten (12%) immigrant adults say they avoided applying for such a program in the past 12 months because they did not want to draw attention to their or a family member’s immigration status, ranging from 5% among those living in a citizen-only household to 19% among those living in a household with a noncitizen, including 11% for those that did not report having a likely undocumented immigrant in the household and 42% for those that include a likely undocumented immigrant.

Potential “Chilling Effects” on Medicaid and CHIP Enrollment

It is difficult to predict what actual disenrollment or forgone enrollment rates may be in response to the rule. Few lawfully present immigrants who are subject to public charge determinations are eligible for federally-funded programs, including Medicaid and CHIP. However, fear and confusion about the rule would likely lead to disenrollment and forgone enrollment among a much broader group of individuals living in immigrant families, including citizen children.

To estimate potential effects of the proposed changes to public charge determinations amid the current immigration policy environment on Medicaid and CHIP enrollment, this analysis applied disenrollment rates of 10%, 20%, and 30% to the total number of Medicaid and CHIP enrollees living in a household with at least one noncitizen. To estimate potential forgone enrollment, this analysis applies these same rates to the total number of uninsured individuals who are eligible for Medicaid and CHIP but not enrolled who are living in a household with a noncitizen. Given the uncertainty of disenrollment and forgone enrollment, the rates illustrate a range of potential impacts to account for potential underestimates and overestimates.

The midpoint disenrollment and foregone enrollment rate of 20% is based on experiences reported in the KFF/New York Times 2025 Survey of Immigrants. It reflects the share of immigrant adults living in a household with a noncitizen who say they stopped participating in a program that helps pay for food, health care, or housing in the past year due to fears of drawing attention to their or a family member’s immigration status. The share reporting avoiding applying for programs (i.e., forgone enrollment) was similar. The lower bound of 10% reflects the disenrollment and forgone enrollment rate DHS uses to estimate transfer payments in the proposed rule. The upper bound accounts for potential increased effects relative to the experiences reported in the survey due to subsequent policy changes, including the public charge proposal and CMS notice of plans to share Medicaid data with ICE, that were released after the survey was fielded, as well as continued public enforcement activity, which may deter participation.

According to KFF analysis of ACS data, there are about 13.4 million Medicaid or CHIP enrollees living in a household with at least one noncitizen, including 5.9 million citizen children, who may be at risk for decreased enrollment. If the proposed rule leads to disenrollment rates ranging from 10% to 30%, between 1.3 million to 4.0 million Medicaid and CHIP enrollees who are living in a household with at least one noncitizen would disenroll (Figure 2). This includes nearly 600,000 to about 1.8 million citizen children. Beyond potential disenrollment, the proposed rule may also deter new enrollment among the nearly 1.8 million uninsured individuals who are eligible for Medicaid and CHIP but not enrolled and are living in a household with a noncitizen, including over 500,000 citizen children. Assuming a forgone rate between 10% and 30%, between about 200,000 to over 500,000 uninsured individuals who are living in a household with at least one noncitizen could forgo enrollment in Medicaid despite being eligible. This includes over 50,000 to more than 150,000 citizen children.

These estimates differ from DHS estimates in the proposed rule. DHS estimated that 3.5 million Medicaid enrollees and approximately 600,000 CHIP enrollees lived in a household with at least one person who is not a citizen, for a combined total of 4.1 million Medicaid and CHIP enrollees. DHS expects about 400,000 Medicaid and about 60,000 CHIP enrollees to disenroll or forgo enrollment (see Methods for more information).

Methods

The findings presented in this brief are based on KFF’s analysis of the 2023 American Community Survey 1-year Public Use Microdata Sample. KFF classified individuals as not having citizenship, or noncitizens, by their self-reported status at the time of the survey interview. This excludes foreign-born individuals who obtained U.S. citizenship through naturalization.

The 2023 data show that approximately 13.4 million Medicaid/CHIP enrollees were noncitizens or living in a household with at least one noncitizen. Households were classified as having at least one noncitizen if any household member reported not having citizenship. In addition, KFF identified 1.8 million uninsured individuals who are eligible for Medicaid or CHIP but not enrolled and live in a household with a noncitizen. KFF applied its health care coverage eligibility model to identify individuals who are eligible for Medicaid/CHIP but are not enrolled. For more details on the model, see the following explanation. These numbers do not reflect anticipated reductions to Medicaid enrollment due to Medicaid spending reductions and eligibility changes, including increased restrictions for lawfully present immigrants, in the 2025 reconciliation law.

To estimate potential changes in coverage due to public charge policies, KFF considered disenrollment and forgone enrollment rates of 10%, 20%, and 30%. Results were disaggregated by age and citizenship, with children defined as individuals under age 18. The midpoint disenrollment and foregone enrollment rate of 20% is based on experiences reported in the KFF/New York Times 2025 Survey of Immigrants. It reflects the share of immigrant adults living in a household with a noncitizen who say they stopped participating in a program that helps pay for food, health care, or housing in the past year due to fears of drawing attention to their or a family member’s immigration status. The share reporting avoiding applying for programs (i.e., forgone enrollment) was similar. The lower bound of 10% reflects the primary disenrollment and forgone enrollment rate DHS uses to estimate transfer payments in the proposed rule. The upper bound accounts for potential increased effects relative to the experiences reported in the survey due to subsequent policy changes, including the public charge proposal and CMS notice of plans to share Medicaid data with ICE, that were released after the survey was fielded as well as ongoing public enforcement activity, which may further deter participation.

This method differs from the method applied by DHS in the proposed rule to estimate potential federal and state transfer costs due to disenrollment from Medicaid and CHIP and other programs. In the 2025 proposed public charge rule, DHS estimated that 3.5 million Medicaid enrollees and approximately 600,000 CHIP enrollees lived in a household with at least one person who is not a citizen, for a combined total of 4.1 million Medicaid and CHIP enrollees. DHS expects about 400,000 Medicaid and about 60,000 CHIP enrollees to disenroll or forgo enrollment. To reach this estimate:

• DHS used a six-year average from FY 2019 to FY 2024 to find the average annual number of Medicaid and CHIP enrollees, limiting Medicaid enrollment to adults. Each annual total was calculated by averaging monthly Medicaid or CHIP enrollment over the year.
• DHS then estimated the number of households with Medicaid or CHIP enrollees by dividing the average annual adult Medicaid (44 million) or CHIP (7 million) enrollment by the average U.S. household size (2.54) in 2023.
• DHS multiplied the share of the total U.S. population that is foreign born (6.61%) times the number of households with Medicaid or CHIP enrollees to calculate their estimate of enrollee households with at least one noncitizen.
• Lastly, DHS then multiplied these households by the average size of foreign-born households (3.12) to finally estimate the number of Medicaid or CHIP enrollees living in a household with at least one noncitizen. DHS applied a 10.3% disenrollment and forgone rate to the approximately 3.5 million Medicaid and 600,000 CHIP enrollees.

Note: Originally published on October 2, 2024, this resource is updated as needed, most recently on December 1, 2025, to reflect additional developments.

There have or will be several resource mobilization efforts for multilateral health organizations in 2024 and 2025. These include: the Pandemic Fund’s first pledging event; the World Health Organization’s (WHO) first investment round; Gavi, the Vaccine Alliance’s (Gavi) fourth replenishment; and the Global Fund to Fight AIDS, Tuberculosis and Malaria’s (Global Fund) eighth replenishment. The U.S. is the largest contributor to global health and has played an integral role in each of these four organizations, and while pledging events represent commitments rather than immediate transactions, as U.S. funding must be approved by Congress, these events will nevertheless signal future U.S. support to these entities and to global health more broadly. This KFF tracker provides up to date information on U.S. pledges thus far to these four multilateral health replenishments and U.S. government support to date for these entities.

For more than 50 years, a network of public programs and providers have assisted millions of reproductive age (18 to 49) women with low incomes in the U.S. to obtain sexual and reproductive health services. Over the past decade, the landscape of reproductive health care has changed dramatically as a result of shifts in federal and state policy as well as legal challenges and court rulings that have reshaped the state and federal laws that govern these programs. Recently, the 2025 Budget Reconciliation Law prohibits federal Medicaid payments for one year to some family planning providers that also offer abortion services, and the President’s most recent budget request proposes to eliminate funding for the federal Title X family planning program. This brief explains the major sources of public financing for family planning care, related policies, and their role financing services for low-income women.

Family Planning Services

Family planning encompasses a wide range of counseling, prevention, and treatment services that nearly all women use during their lifetimes. Contraceptives are the primary service, which most women use over the course of their lifetimes. Many options are available from clinicians including permanent methods, long-acting methods such as IUDs and Implants, as well as pills, injectables, patches, and rings. Over–the-counter methods include condoms and emergency contraception pills and more recently, Opill, a daily oral contraceptive pill. In addition to contraceptives, family planning includes sexual health services such as STI testing and treatment, gynecologic exams, and pregnancy testing (Figure 1).

Financing Family Planning Services for Low-Income People in the U.S.

Financing reproductive health care for people with low incomes comes primarily from a variety of public programs, including Medicaid, the federal Title X Family Planning Program, Section 330 of the Public Health Service Act (PHSA), and the Indian Health Service. Clinics and other providers may receive funds from a combination of these programs, which are described below.

Medicaid

Medicaid is a health coverage program for individuals with low incomes that covers more than 15 million reproductive age women nationally. Like private insurance, Medicaid pays clinicians and clinics for health services they provide to their patients. Jointly operated and funded by the federal and state governments, Medicaid provides health coverage to one in five women of reproductive age and more than four in ten (44%) who have low-incomes (Figure 2). The share of low-income reproductive-age women enrolled in Medicaid varies considerably by state, ranging from a high of 34% in Louisiana to a low of 10% in Utah. These differences are the result of a variety of factors, including demographic differences between states such as the share of women with low incomes, availability of employer-sponsored insurance, state choices about Medicaid eligibility, particularly whether the state has expanded Medicaid to all adults up to 138% FPL as permitted by the Affordable Care Act (ACA) and state-established income eligibility thresholds for parents in the non-expansion states. For these women, Medicaid provides comprehensive affordable coverage to help meet the full range of their health care needs, including family planning services.

Because it covers so many people, Medicaid is the largest source of public funds for family planning services. Federal law stipulates that family planning is a “mandatory” benefit that states must cover under Medicaid, but states have considerable discretion in specifying the services and supplies that are included in the program. Additionally, the ACA requires most private insurance plans and Medicaid expansion programs to cover the full cost of prescribed contraceptive methods for women. Most state Medicaid programs cover the full range of FDA approved contraceptives available to women, counseling and treatment for STIs and HIV, and screening for cervical cancer. Medicaid reimburses clinicians for delivering family planning care, just as it pays for other medical services. 

Abortion services are not considered to be family planning, and the Hyde Amendment prohibits any federal dollars, including Medicaid reimbursements, from being used to pay for abortion care except in cases of rape, incest or life endangerment of the woman. Other federal requirements that shape family planning policy under Medicaid include:

•  Federal Matching rate – The federal government pays 90% of all family planning services and supplies, which isconsiderably higher than the federal match that states receive for most other services for the traditional Medicaid population, which ranges from 50% to 78%, depending on the state. The federal government also picks up 90% of the costs for all services among the expansion population. 
• Ban on cost sharing – Federal law prohibits cost sharing for any family planning (and pregnancy-related) services.
• Freedom of choice – The federal Medicaid Act states that beneficiaries have “freedom of choice” to obtain family planning services from any qualified provider participating in the program, but recent policy decisions (discussed below) are changing this.
• Managed care –Nationally, nearly three in four (74%) reproductive age women with Medicaid are enrolled in managed care plans. While access to most services may be limited by managed care networks, federal law states that for family planning services, enrollees may seek care from any Medicaid provider even if the provider is outside of the plan’s network.
• Family planning specific programs – States may establish limited scope programs through Medicaid Section 1115 Research and Demonstration Waivers or through State Plan Amendments (SPAs) to provide coverage for family planning services only to individuals who do not qualify for full-scope Medicaid. Today, more than half of states have established such programs (Figure 3). 

Title X Program

The Title X National Family Planning Program, a federal block grant administered by the HHS Office of Population Affairs (OPA), is the only federal program specifically dedicated to supporting the delivery of family planning care. The program funds organizations in each state to distribute federal dollars to safety-net clinics to provide family planning services to low-income, uninsured, and underserved people. In 2023, approximately 4,000 clinics nationwide received Title X funding, including specialized family planning clinics such as Planned Parenthood centers, primary care providers such as federally qualified health centers (FQHCs), and health departments, school-based, faith-based, and other private nonprofits. In 2023, 60% of clients seen at Title X clinics had family incomes at or below the poverty level, almost half (46%) were covered by Medicaid or another public program, and more than a quarter (27%) were uninsured (Figure 4).

Signed into law by President Nixon in 1970, the Title X program’s funding has remained flat at $286.5 million for the past ten years. In addition to providing clinics with funds to cover the direct costs of family planning services and supplies such as contraceptives, Title X funds enable clinics to pay for patient and community education services about family planning and sexual health issues, as well as infrastructure expenses such as rent, utilities, information technology, and staff salaries. Clinics that receive Title X funds are also eligible to obtain discounted prescription contraceptives and devices through the federal 340B program. No other federal program makes funds available to support clinic infrastructure needs specifically for family planning. Clinics that receive Title X funds also receive Medicaid and private insurance reimbursements for specific clinical services they provide to enrollees with coverage. Title X grantees cannot charge patients with low incomes out of pocket for services they receive, and for people with annual family income above 250% FPL, charges should be on a sliding fee schedule based on ability to pay.

Title X regulations have historically stipulated that participating clinics must provide clients with a broad range of contraceptive methods as recommended by the national Quality Family Planning Guidelines (QFP), and ensure that the services are voluntary and confidential. This has been interpreted to mean that minors do not require parental involvement to obtain family planning services as a Title X funded site. The current QFP guidelines serve as standards for delivery of clinical sexual and reproductive health services and address a range of issues, including STIs, fertility, and gender-affirming care. Federal rules also require that participating clinics offer their patients non-directive pregnancy options counseling that includes abortion, adoption, and prenatal referral for those who seek those services. These requirements, however have changed with different presidential administrations shaping who can participate and what services can be offered.

Site of Care for Sexual and Reproductive Health for People with Lower Incomes

Most reproductive age women obtain reproductive care from a private doctors’ office; however many women with lower incomes get family planning services through the publicly funded health care safety-net, which is comprised of a variety of providers such as federally qualified health centers (FQHCs) and look-alike clinics, state and local health departments, the Indian Health Service, and specialized family planning clinics. Nationally, more than four in ten (43%) reproductive age women with Medicaid coverage had their last contraceptive visit at a safety-net clinic. This varies widely though, and in some states safety-net clinics play a larger role (Figure 5).

Federally Qualified Health Centers

Under Section 330 of the PHSA, the Health Resources and Services Administration (HRSA) administers federal grants to Federally Qualified Health Centers (FQHCs) whose main focus is providing primary and preventive care to populations that are underserved and predominantly low-income. FQHCs are required to provide “voluntary family planning” services along with a wide range of health care services, but they do not necessarily specialize in providing sexual and reproductive health care. Although it is not specifically defined in FQHC guidelines, voluntary family planning services can include contraceptives, screening and treatment of STIs, pre-pregnancy care and fertility counseling but the range of services that health centers offer can vary. FQHCs must have a sliding fee scale for patients with incomes below 200% FPL and offer services to all patients regardless of their ability to pay.

Specialized Family Planning Clinics

Specialized clinics such as Planned Parenthood centers focus on family planning and reproductive health care, typically offering the full range of contraceptives and other sexual and reproductive health services such as STI testing and treatment, cervical cancer screenings, and pregnancy testing. These clinics also employ clinicians and staff with expertise in family planning care. Planned Parenthood clinics comprise a relatively small portion of clinics that receive public financing for family planning services but have historically served a disproportionate share of safety-net patients (Figure 6).

Health Departments

State and local health departments offer public health services such as vaccines and chronic disease screenings to people who are low-income or uninsured. In many communities, they also offer family planning services, such as HPV vaccines and a limited range of contraceptive services. State and local health agencies may incorporate family planning counseling and services as part of other core public health functions, particularly maternal and child health programs.

Indian Health Services (IHS) Clinics

The Indian Health Service (IHS), an agency under the Department of Health and Human Services, provides a wide range of health services to approximately 2.8 million American Indian and Alaska Native (AIAN) individuals via a network of hospitals, clinics and health stations. Federal regulations require IHS to cover health promotion and disease prevention services, which include family planning services and STI services. However, the availability of contraceptive methods varies by clinic. Services at IHS and tribal clinics are provided with no cost-sharing and are generally only available to members or descendants of federally recognized Tribes who live on or near federal reservations.

Future of Public Financing for Sexual and Reproductive Health

Over the next few years, a confluence of policy changes at the federal level will challenge the network of publicly supported programs and clinics that provide access to free and low cost family planning services. The 2025 Budget Reconciliation law blocks Planned Parenthood clinics from receiving federal Medicaid payments for one year, cutting off a primary source of revenue from a major provider of sexual and reproductive health care for people with low incomes. Additionally, the President and other Republican leaders have proposed eliminating funding for the Title X program. Yet, the Congressional Budget Office estimates an increase of 10 million uninsured individuals over the next decade from the Budget Reconciliation law and the sunsetting of supplemental ACA premium tax credits at the end of 2025 could raise this number even further. With a steep rise in the number of uninsured people, clinics will likely face higher demand in the aftermath of sharp decreases in financing, greatly challenging an already fragile reproductive health safety net.