Background on U.S. Global Tuberculosis (TB) Efforts

• The U.S. government has been involved in global TB activities for decades and began ramping up its efforts in the late 1990s when a global TB program was created at USAID.
• TB, an infectious disease caused by bacteria, causes more deaths than any other infectious agent worldwide, including 1.25 million people who died in 2023, and is among the 10 leading causes of death worldwide. TB is the leading cause of death among people with HIV.
• U.S. government efforts have contributed significantly to improving TB health outcomes, including contributing to a 29% decline in TB incidence and 47% decline in TB mortality in USAID TB priority countries since 2000.  
• The FY 2025 Continuing Resolution that passed in March included level funding for bilateral TB activities at USAID and CDC of $406 million (as well as level funding for the Global Fund to Fight AIDS, Tuberculosis and Malaria). The U.S. has been the top donor government to TB efforts, through its bilateral funding and contributions to the Global Fund. The administration’s FY 2026 budget request includes $178 million for TB, a decrease of $228 million (final appropriation levels are determined by Congress).
• USAID had served as the lead implementing agency for U.S. TB efforts, focusing on 24 priority countries – with activities in 50 (including at least 20 of the 30 high burden countries) – to support prevention, detection, and treatment of TB, including drug-resistant TB. The Centers for Disease Control and Prevention (CDC) also carries out global TB efforts and the State Department’s Bureau of Global Health Security and Diplomacy (GHSD), which oversees PEPFAR, leads U.S. efforts to address TB-HIV co-infection.

Current Status of U.S. Global TB Efforts

The following administration actions have had a significant impact on TB program operations:

• Funding freeze/stop-work order: The stop-work order initially froze all bilateral TB programming and services, halting existing work in the field. Because it halted payments, many implementers had to let go of thousands of staff and end some services.
• Limited waiver: Some TB activities were included in a limited waiver issued by the State Department on February 4 allowing “life-saving services” to continue, which are defined as “Essential screening, testing, and treatment for tuberculosis (TB) and drug resistant TB (DR-TB) including provision and monitoring of laboratory services, drug susceptibility testing, clinical visits, dispensing of essential medicines to avert near-term mortality and spread of infection.” HIV/TB activities were also allowed under PEPFAR’s limited waiver. Even with the waivers, services remain disrupted and implementers faced challenges in getting permission to resume programming and difficulties in getting paid.
• Dissolution of USAID: As the main government implementer of TB efforts, the dissolution of USAID and loss of most staff have significantly affected TB program implementation capacity and operations. In addition, announcements of reductions at CDC could further affect global TB efforts.
• Canceled awards: In early 2025 it was reported that the administration canceled 86% of all USAID awards. KFF analysis found that of the 770 global health awards identified, 162 included TB activities, 79% of which were terminated.

• Legal actions: In response to two lawsuits filed against the administration’s actions, a federal judge issued a preliminary injunction ordering the government to pay for work completed by February 13, 2025, although not all payments have been made and the court has not stopped the government from canceling awards. On August 13, the U.S. Court of Appeals for the D.C. Circuit overturned the district judge’s preliminary injunction, ruling that plaintiffs lacked legal standing to challenge the administration’s termination of funding. While a District Court subsequently found that the plaintiffs could seek relief through another legal avenue and granted a preliminary injunction ordering the government to obligate expiring funds, the Supreme Court ultimately ruled that the government could withhold these funds.
• Reorganization: The administration notified Congress on March 28, 2025 of its intent to permanently dissolve USAID and that any remaining USAID operations would be absorbed by the State Department with remaining global health activities to be integrated into its Bureau of Global Health Security and Diplomacy (GHSD) which oversees PEPFAR. On May 29, 2025, the State Department further notified Congress of its proposed reorganization plan and programs moved in July.
• New Global Health Strategy: In September 2025, the administration released the America First Global Health Strategy. Per the new strategy, the U.S. will:
  • Negotiate bilateral, multi-year agreements with countries receiving U.S. assistance, with implementation and monitoring plans in place by March 31, 2026. Agreements will include co-investment by countries and aim to transition the majority of countries to full self-reliance by the end of the agreement period;
  • Provide 100% of current levels of funding for TB commodities [TB diagnostics (including innovations in molecular diagnostics), TB treatments (including for drug-resistant TB) and TB preventive therapy] and frontline healthcare workers through FY 2026 and reduced funding thereafter;
  • Rapidly reduce funding for activities other than health commodities and frontline health personnel.

Impact on Global TB Services and Outcomes

• An internal USAID memo reported that the cessation of USAID’s TB control programs would increase global TB incidence by 28-32% and have a similar effect on new cases of multi-drug-resistant TB.
• According to WHO, the 30 highest TB-burden countries reported that U.S. funding withdrawals were affecting services, including the loss of thousands of health workers, and disruptions of the drug supply chain and laboratory services.
• A rapid assessment survey of 108 WHO country offices found that approximately 40% reported moderate or severe disruptions to TB services, including for medicines and health products, due to the U.S. foreign aid freeze and other shortages.
• Several modeling studies have found that cuts or termination in U.S. TB funding could result in significant numbers of additional TB cases and deaths in coming years.

What to Watch

• Reorganization: The dissolution of USAID and integration of any remaining USAID global health activities, including for TB, into GHSD raises several questions, including whether additional capacities will be provided to allow for the management and implementation of TB and these other health programs at the State Department.
• Funding/Budget Request: The administration’s FY 2026 budget request includes significant reductions in funding for global health, including a $228 million reduction for TB (final appropriation amounts will be determined by Congress). The administration also submitted its first rescission package to Congress in June, including proposed rescissions of more than $1 billion in FY 2025 funding for global health. Congress voted to amend the package, reducing that amount to $500 million and exempting some program areas, including TB, from the rescission.
• New Global Health Strategy: Over the next few months, it is expected that the administration will develop bilateral agreements with countries and plans to scale down funding, including for TB-related activities, the details of which will significantly shape the future of the global TB response.

Background on U.S. Global Health Programs

• Historically, U.S. global health programs have been overseen and managed by three main federal departments and agencies: the State Department, USAID (now dissolved), and CDC.
  • The State Department is home to the Bureau of Global Health Security and Diplomacy (GHSD), which leads and oversees PEPFAR (which receives direct appropriations from Congress) as well as global health security and, more recently, other global health programs.
  • USAID, an independent agency established by Congress, had housed and managed most other U.S. bilateral global health programs, including TB, malaria, maternal and child health, and nutrition, receiving direct appropriations from Congress for these efforts. Because the State Department had not historically served as an implementing agency, USAID also managed more than half of PEPFAR’s funding, through State department transfers and direct appropriations from Congress.
  • CDC has global programs for HIV, TB, polio, and global health security, which receive direct Congressional appropriations and also manages and implements PEPFAR funding transferred by State and USAID.
• To carry out global health programs, federal agencies fund other organizations, including non-profits, foreign governments, and international and multilateral health organizations, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) and Gavi, the Vaccine Alliance.
• U.S. funding for global health, across multiple federal agencies and for bilateral and multilateral programs, including global health research, totaled $12.4 billion in FY 2025.

Current Status of U.S. Global Health Programs

The following administration actions have or are likely to have a significant impact on the structure and operations of U.S global health programs:

• Funding freeze/stop-work order: The stop-work order, as part of the foreign aid review, initially froze all bilateral global health programming and services, halting existing work in the field (it was not applied to the Global Fund or Gavi). Because it halted payments, many implementers had to let go of thousands of staff and end some services.
• Limited waivers: Certain bilateral global health programs received waivers to allow “life-saving services” to continue, including a limited set of PEPFAR services and TB, malaria, maternal and child health, nutrition and infectious disease outbreak response services. Even with these waivers, services remain disrupted, and implementers faced challenges in getting permission to resume programming and difficulties in getting paid.
• Dissolution of USAID: Because USAID was the main implementing agency for global health efforts, its dissolution and loss of most of its staff have reduced program implementation capacity and operations. Announcements of reductions at CDC could further affect global health efforts.
• Cancelled awards: In early 2025 it was reported that the administration canceled 86% of USAID awards. KFF analysis found that of the 770 global health awards identified, 80% were listed as terminated, totaling $12.7 billion in unobligated funding.
• Other executive orders and actions: In addition to the foreign aid review, several other orders and actions have or will likely affect global health, including: a review of international organization participation, the reinstatement of the Mexico City Policy and withholding of UNFPA funding, and withdrawal from the World Health Organization.
• Reorganization: The administration moved to restructure and/or reduce global health efforts as follows:
  • On March 28, Secretary of State Rubio announced that the State Department and USAID had notified Congress of their intent to “restructure certain Department bureaus and offices that would implement programs and functions realigned from USAID” as follows:
    • Proposing legislation to abolish USAID as an independent agency.
    • Separating almost all USAID personnel from federal service within the current fiscal year.
    • Identifying USAID programs that “continue to advance the Administration’s foreign policy objectives,” including a subset of global health activities to be transferred to GHSD. These include programs that help reduce health disparities, deliver lifesaving vaccines, promote maternal and child health, and control malaria, TB, and other diseases.
  • On April 22, Secretary Rubio announced a reorganization of the State Department to “empower the Department from the ground up, from the bureaus to the embassies”, including removing redundant offices and non-statutory programs that are “misaligned with America’s core national interests.” On May 29, the State Department notified Congress with further details, including that GHSD would be reorganized to include three major divisions: Health Programs (with the Office of Health Programs and the Office of Program Transition and Supply Chain), Health Policy and Diplomacy (with the Office of Health Diplomacy and the Office of Program Planning and Evaluation), and Global Health Security (with the Office of Outbreak Detection and Response).
  • With the dissolution of USAID in July 2025, remaining U.S. global health programs were moved to the State Department.
• New Global Health Strategy: In September 2025, the administration released the America First Global Health Strategy, with 3 broad pillars – making America safer, stronger, and more prosperous – and focusing on HIV, TB, malaria, polio, and global health security. Per the new strategy, the U.S. will:
  • Negotiate bilateral, multi-year agreements with countries receiving U.S. assistance, with implementation and monitoring plans in place by March 31, 2026. Agreements will include co-investment by countries and aim to transition the majority of countries to full self-reliance by the end of the agreement period;
  • Provide 100% of current levels of funding for health commodities and frontline healthcare workers for HIV, TB, malaria, and polio through FY 2026 and reduced funding thereafter;
  • Rapidly reduce funding for activities other than health commodities and frontline health personnel;
  • Focus global health security activities on surveillance, data sharing and laboratory capacity, to enable early detection and rapid containment of outbreaks originating outside the U.S.

What to Watch

• Reorganization: While the reorganization of U.S. global health programs is well underway, there are still many questions about what programs will be maintained and how they will be managed, implemented and monitored, particularly given the significant reductions in federal staff as well as of health care workers more broadly who have been affected by U.S. cuts.  
• Leadership: Several leadership positions have yet to be announced, including the U.S. Global AIDS Coordinator (which requires Senate confirmation), the U.S. Malaria Coordinator, and others. Whether the administration will choose to nominate or appoint people to these positions is not yet known.

• Funding/President’s budget request: The administration’s FY 2026 budget request includes a $6.2 billion reduction in funding for global health through foreign assistance, reductions at HHS, and proposes to eliminate several funding lines (final appropriation amounts will be determined by Congress). The administration also submitted its first rescission package to Congress, including proposed rescissions of $400 million for PEPFAR and $500 million for other global health programs. Congress voted to amend the package, exempting PEPFAR funding as well as funding for maternal and child health, TB, malaria, and nutrition from the rescission, although $500 million in family planning and other programs was rescinded.
• New Global Health Strategy: Over the next few months, it is expected that the administration will develop bilateral agreements with countries regarding remaining global health programming including plans to scale down funding, the details of which will significantly shape the future of the global health response.

• Congressional oversight: As budget and reorganization proposals continue to circulate, members of Congress could choose to exert their own authority, including seeking further clarification and information about the potential impacts of proposed changes.

Background on PMI

• The U.S. government has been involved in global malaria activities since the 1950s. In 2005, the President’s Malaria Initiative (PMI) was launched to scale up efforts to address malaria in the hardest hit African countries.
• Malaria is a life-threatening disease spread to humans by mosquitoes. There are approximately 263 million malaria cases and 600,000 deaths each year; the majority of deaths are among children under age five.
• PMI is credited with helping to save 11.7 million lives and prevent 2.1 billion malaria cases since 2000. Indeed, since 2006, in countries where PMI works, global efforts have supported a 29% decrease in malaria case rates and a 48% decline in deaths. The introduction of two malaria vaccines in 2021 and 2023 has increased optimism in the potential to further strengthen global malaria control.
• U.S. malaria assistance bolsters national economies in countries and communities most heavily affected by the disease. A recent analysis found that every dollar of U.S. malaria assistance increased GDP in recipient countries nearly six-fold.
• The FY 2025 Continuing Resolution that passed in March included level funding for PMI and other malaria activities at USAID and CDC of $805 million (as well as level funding for the Global Fund to Fight AIDS, Tuberculosis and Malaria). The U.S. has been the top donor government to malaria efforts, through PMI and contributions to the Global Fund. The administration’s FY 2026 budget request includes $424 million for malaria, a decrease of $381 million (final appropriation levels are determined by Congress).
• Overseen by a U.S. Global Malaria Coordinator, a position created by Congress in 2008 to be appointed by the President and based at USAID (now dissolved), PMI had been an interagency initiative led by USAID in partnership with CDC, focused in 30 countries that account for 90% of the world’s malaria cases and deaths.

Current Status of PMI

The following administration actions have had a significant impact on PMI operations:

• Funding freeze/stop-work order: The stop-work order initially froze all PMI programming and services, halting existing PMI activities, including bed net provision, residual spraying and delivery of antimalarial medicines. Because the order halted payments, many implementers had to let go of thousands of staff and end some services.
• Limited waiver: Malaria programs received a limited waiver on February 4 allowing “life-saving services” to continue, including those that “must resume within 30 days to ensure malaria diagnosis and treatment, as well as prevention through distribution of nets and indoor residual spraying targeting highest burden areas…and lifesaving malaria medicines for pregnant women and children”. Even with the waiver, services remain disrupted and implementers faced challenges in getting permission to resume programming and difficulties in getting paid.
• Dissolution of USAID: USAID was the main government implementing agency for malaria efforts, obligating almost all bilateral malaria assistance in FY 2023 (96%). Without USAID and most of its staff, PMI’s implementation capacity has been affected. In addition, announcements of reductions at CDC could further affect global malaria efforts.
• Canceled awards: In early 2025 it was reported that the administration canceled 86% of all USAID awards. KFF analysis found that of the 770 global health awards identified, 157 included malaria activities, 80% of which were terminated.
• Legal actions: In response to two lawsuits filed against the administration’s actions, a federal judge issued a preliminary injunction ordering the government to pay for work completed by February 13, 2025, although not all payments have been made and the court has not stopped the government from canceling awards. On August 13, the U.S. Court of Appeals for the D.C. Circuit overturned the district judge’s preliminary injunction, ruling that plaintiffs lacked legal standing to challenge the administration’s termination of funding. While a District Court subsequently found that the plaintiffs could seek relief through another legal avenue and granted a preliminary injunction ordering the government to obligate expiring funds, the Supreme Court ultimately ruled that the government could withhold these funds.
• Reorganization: The administration notified Congress on March 28, 2025 of its intent to permanently dissolve USAID and move remaining USAID operations to the State Department, with remaining global health activities to be integrated into its Bureau of Global Health Security and Diplomacy (GHSD) which oversees PEPFAR. On May 29, 2025, the State Department further notified Congress of its proposed reorganization plan and programs moved in July.
• New Global Health Strategy: In September 2025, the administration released the America First Global Health Strategy. Per the new strategy, the U.S. will:
  • Negotiate bilateral, multi-year agreements with countries receiving U.S. assistance, with implementation and monitoring plans in place by March 31, 2026. Agreements will include co-investment by countries and aim to transition the majority of countries to full self-reliance by the end of the agreement period;
  • Provide 100% of current levels of funding for malaria control commodities ([insecticide-treated bednets, malaria diagnostic tests, anti-malarial medications and malaria vaccines) and frontline healthcare workers through FY 2026 and reduced funding thereafter;
  • Rapidly reduce funding for activities other than health commodities and frontline health personnel.

Impact on PMI Services and Outcomes

• An internal USAID memo estimated that an additional 12.5-17.9 million malaria cases and an additional 71,000-166,000 deaths could occur annually if PMI was halted permanently.
• A rapid assessment survey of 108 WHO country offices found that of the 64 malaria-endemic countries surveyed, more than half reported moderate or severe disruptions to malaria services, including for medicines and health products, due to the U.S. foreign aid freeze and other shortages.
• In early April 2025, almost 30% of planned insecticide treated net (ITN) distribution campaigns were off-track or at risk of being delayed due to funding shortages, and such risks continue today. Several countries also face stock-out risks for key commodities including for rapid diagnostic tests (RDTs) and artemisinin-based combination therapy (ACT). Reductions in funding also threaten investments in new and improved malaria prevention, diagnostic, and treatment interventions.
• Such disruptions pose significant risks, particularly during peak malaria seasons across Africa where seasonal malaria campaigns are needed to protect millions of people. In a court filing challenging the funding freeze, for example, a major U.S. implementer reported that it had already had to delay the start of anti-malarial campaigns in Africa.

What to Watch

• Leadership: A U.S. Malaria Coordinator has not yet been appointed, and it is unclear, given the dissolution of USAID, what the leadership structure will be going forward.
• Reorganization: The dissolution of USAID and integration of any remaining USAID global health activities, including for malaria, into GHSD raises several questions, including whether additional capacities will be provided to allow for the management and implementation of PMI at the State Department.
• Funding/Budget Request: The administration’s FY 2026 budget request includes significant reductions in funding for global health, including a $381 million reduction for malaria (final appropriation amounts will be determined by Congress). The administration also submitted its first rescission package to Congress in June, including proposed rescissions of more than $1 billion in funding for global health. Congress reduced that amount to $500 million and exempted some program areas, including malaria, from the rescission.
• New Global Health Strategy: Over the next few months, it is expected that the administration will develop bilateral agreements with countries and plans to scale down funding, including for malaria-related activities, the details of which will significantly shape the future of the global malaria response.

Background on U.S. Global Health Security Efforts

• The U.S. has supported global health security (GHS) and pandemic preparedness efforts for decades through funding and technical support provided to low- and middle-income countries (as well as support for multilateral efforts). This has included the development of formal GHS partnerships with other countries, starting with 17 in 2014 and rising to more than 50 in 2024, with programs focused in particular in countries at risk for emerging diseases.
• GHS efforts are designed to help countries and regions build capacities needed to prevent avoidable outbreaks, detect infectious disease threats early, and reduce the impacts of epidemics and pandemics through rapid and effective responses.
• Specific activities include: improving surveillance and laboratory systems, reducing the risks of animal to human disease exposures, training epidemiologists, and fostering better biosafety and biosecurity practices.
• Multiple U.S. agencies, coordinated by the National Security Council (NSC), have been involved in these efforts including USAID (now dissolved), CDC, the Department of Defense (DoD), the State Department, HHS, and USDA. The first U.S. GHS Strategy, providing overall guidance across the government, was released by the first Trump administration. The Biden administration released an updated Strategy in 2024.
• The FY 2025 Continuing Resolution passed in March included level funding of $993 million for GHS programs at USAID and CDC. At times, Congress has provided additional, time-limited emergency funding when outbreaks occur, such as for Ebola in 2014-2015, Zika in 2016, and COVID-19 starting in 2020. The administration’s FY 2026 budget request includes $493.2 million for GHS, a decrease of $500 million (final appropriation levels are determined by Congress).
• U.S. investments in GHS have led to measurable increases in capacity, including improvement in 9 of 15 technical areas between 2018 and 2023 in GHS partnership countries and reductions in average outbreak response times.

Current Status of U.S. Global Health Security Programs

The following administration actions have had a significant impact on U.S. GHS programs:

• Funding freeze/stop-work order: The stop-work order initially froze all USAID-based GHS programming and services. As a result, many GHS implementing partners let staff go and some USAID-supported GHS activities in progress were interrupted, such as funding for transport of samples and phone plans for contact tracers.
• Limited waiver: Some GHS activities were included in a limited waiver issued by the State Department on February 4 allowing “life-saving services” to continue, including: rapid emergency response to immediate infectious disease outbreaks, focused on pathogens with pandemic potential and those that pose a national security risk to U.S. citizens (e.g., mpox and H5N1), including detection, prevention, and containment and supply of medical countermeasures. Even with the waiver, services remain disrupted and implementers faced challenges in getting permission to resume programming and difficulties in getting paid.
• Dissolution of USAID: Earlier this year, USAID had about 50 staff supporting international outbreak response efforts, a number which dropped to six in the early weeks of the Trump administration (current levels are unknown). As a result, many GHS partners have lost points of contact and technical support, in addition to the loss of funding. Announcements of reductions at the CDC could further affect GHS capacity.
• DoD GHS programs may also be targeted for cuts, with potentially up to 75% of staff to be let go.
• Reorganization: The administration notified Congress on March 28, 2025 of its intent to permanently dissolve USAID and that any remaining USAID operations would be absorbed by the State Department with remaining global health activities (including GHS work) to be integrated into its Bureau of Global Health Security and Diplomacy (GHSD). On May 29, 2025, the State Department further notified Congress of its proposed reorganization plan, and programs transitioned in July.
• GHS Strategy: The administration has withdrawn the GHS strategy, stating that it would be replaced, although no timeline has been provided. This has raised questions about coordination across the government, particularly in the event of a major threat and given the reorganization and reduction of global health programs already underway.
• New Global Health Strategy: In September 2025, the administration released the America First Global Health Strategy. It includes “making America safer” as one of its pillars, marking the first outline of its plans for GHS going forward. Per the new strategy, the U.S. will aim to:
  • Enable detection of an outbreak with epidemic potential within seven days, through strengthened surveillance, data sharing and laboratory capacity, and will assign U.S. health staff to U.S. missions;
  • Contain outbreaks originating outside the U.S. rapidly at their source, prioritizing mobilization within 72 hours of detection, support to field epidemiological staff, essential commodities, and, if needed, travel restrictions.

Impact on GHS Services and Outcomes

• The combination of administration actions described above has reduced capacity and may challenge communication and coordination across U.S. agencies and with partners, contributing to slower responses to emerging health threats, greater impacts, and increased risk of importation of diseases into the U.S.
• Experts estimate that there is a 50% chance of another pandemic emerging in the next 25 years, with the risk greatest in the least prepared countries. 
• The health impacts of poorly controlled outbreaks can be severe. An internal USAID memo reported that the risk of losing USAID GHS programs alone could result in more than 28,000 new cases of dangerous infectious diseases, such as Ebola and Marburg, every year.
• Emerging diseases can result in major economic and social costs, even with small-scale outbreaks.
  • The SARS 2003 outbreak led to an estimated $30 billion in economic losses (over $3 million per case) from reduced commerce, travel and trade.
  • The 2014-2015 West Africa Ebola epidemic led to an estimated $53 billion in economic losses. A single Ebola patient in New York cost the city’s $4.3 million in response measures.
  • Measles outbreaks in the U.S., often initiated through importation from other countries, can lead to significant costs; a recent study from Washington state found that a 71-case measles outbreak led to societal costs of $3.4 million, or almost $50,000 per case.
• Pandemics have even more massive economic costs, as experienced with COVID-19, which cost the U.S. alone an estimated at $16 trillion – a number four times the lost economic output from the 2008 financial crisis.

What to Watch

• Reorganization: The dissolution of USAID and integration of remaining USAID global health activities, including GHS, into GHSD raises questions about how activities will be integrated with existing GHSD functions and whether new capacities will be needed. GHSD has historically focused on coordination and diplomatic roles rather than the in-country implementation roles that USAID and CDC led on.
• Funding/Budget Request: The administration’s FY 2026 budget request includes significant reductions in funding for global health, including a $500 million reduction for GHS (final appropriation amounts will be determined by Congress). The administration also submitted its first rescission package to Congress, including proposed rescissions of more than $1 billion in FY 2025 funding for global health. Congress voted to amend the package, reducing that amount to $500 million and exempting some program areas from the rescission, although global health security was not listed among those program areas.
• New Global Health Strategy: Over the next few months, it is expected that the administration will develop more specific plans for its GHS work at the State Department, including with countries, which will provide more details on the future of this work.

The uninsured rate, supplemental poverty rate, and food insecurity for children have all increased since the expiration of pandemic-era fiscal relief, and high household costs, including health care costs, are putting pressure on family budgets. After increasing during the pandemic, overall federal spending on children as a share of the economy (or GDP) has declined and is projected to continue to decline further over the next 10 years. At the same time, over the last decade, rates of chronic conditions among children, including obesity and mental health concerns, have increased. At the same time, children’s routine vaccination rates are declining, and many states are contending with measles outbreaks. Recent federal changes (Box 1), including the recently passed reconciliation law, administrative actions by the Centers for Medicare & Medicaid Services (CMS), and other broader Trump administration changes, could have further implications for children and their health and well-being. Nearly four in 10 children in the U.S. are covered by Medicaid, making the program (and changes to the program) particularly relevant to broader children’s health trends. This issue brief explores the latest data on Medicaid and children’s health and highlights five key issues to watch as federal changes are implemented (Figure 1).

Figure 1

1. Health Insurance Coverage

The uninsured rate for children has declined over time but has increased in the past two years. The uninsured rate for children has declined from 10.4% in 2008 to 6.0% in 2024 (Figure 2), largely due to policies at the state and federal level that expanded and streamlined Medicaid coverage, including the ACA Medicaid expansion. The children’s uninsured rate fell to an all-time low in 2016 (4.7%) before ticking up during the first Trump administration, when generally favorable economic conditions as well as Trump administration policy changes led to declines in Medicaid enrollment. The children’s uninsured rate declined again following the onset of the COVID-19 pandemic, but did increase slightly from 5.1% in 2022 to 5.3% in 2023 (a statistically significant increase of 0.2%), driven by a decline in Medicaid coverage as children lost coverage due to the unwinding of the Medicaid continuous enrollment provision, a pandemic-era policy. These trends continued in 2024, and recent federal changes could further reduce children’s Medicaid coverage and increase the number of children who are uninsured in the coming years.

2. Variation in Coverage Across States

The share of children covered by Medicaid varies substantially by state. Overall, Medicaid covers nearly 4 in 10 children in the U.S., but the share of children covered by Medicaid in each state varies, ranging from under 20% in Utah to over 60% in New Mexico (Figure 3). Seven states (Alabama, Kentucky, Oklahoma, Arkansas, Mississippi, Louisiana, and New Mexico) have over 45% of children enrolled in Medicaid. Medicaid also finances about 4 in 10 births nationally and over half of births in four states (Louisiana, Mississippi, New Mexico, Oklahoma). The program plays a particularly large role in rural areas, paying for nearly half of all births in rural communities and helping to shore up financing for hospitals in rural areas suffering from provider shortages. Research also shows that Medicaid enrollment in childhood can lead to better health outcomes throughout life, increase earnings in adulthood, and potentially reduce future federal spending. A number of states have expanded access to Medicaid and CHIP coverage for children since the pandemic began, but recent federal efforts could reverse this trend. The magnitude of Medicaid budget cuts stemming from the reconciliation law and the extent to which children may be impacted will vary across states, depending on state characteristics as well as how states implement and respond to various provisions.

3. Access to Care

Uninsured children are more likely to forgo needed care than children with health insurance coverage. Research has shown that health coverage provides children with access to needed care, and survey data show uninsured children are more likely than those with private insurance or Medicaid to report going without needed care due to cost and that they had not seen a doctor in the past year (Figure 4). Medicaid’s benefit package for children, Early and Periodic Screening, Diagnostic and Treatment (EPSDT), helps meet children’s health care needs and protects them from high out-of-pocket costs. Under EPSDT, states are required to cover primary care and screening services for children well as any services “necessary… to correct or ameliorate” a child’s physical or mental health condition. This is especially important for children with special health care needs as Medicaid provides more comprehensive coverage for children than the typical private insurance plan and increases access to needed services that improve the quality of daily life, including long-term care and home care.

Some children with Medicaid still face barriers to accessing care. Administrative data have shown that only half of Medicaid enrolled children receive a well-child visit or any kind of dental service within the year. These low rates indicate Medicaid children face barriers to accessing care, including a lack of available providers in their community. Children can also experience challenges accessing behavioral health care, with 57% of children reporting difficulties obtaining mental health care in 2023. Provider rate cuts in response to recent federal changes could reduce access to care, likely contributing to even lower rates of utilization among children and exacerbating access issues for services such as behavioral health care. Other broader Trump administration changes could also have implications for access, including recent changes to vaccine recommendations as well as MAHA commission proposals to enhance prior authorization requirements to prevent “the overuse of medications in school-age children—particularly for conditions such as ADHD”.

4. Access to Care in Schools

Medicaid coverage can facilitate access to care for children, including children with special education plans, in school. There are an estimated 7 million children, or 10% of all children in the U.S., who currently have special education plans. This includes children receiving special education services under a special education or early intervention plan (often an Individualized Education Plan (IEP) or Individualized Family Service Plan). Medicaid covers half of all children with special education plans, though the share varies by state ranging from 26% in New Jersey to 73% in Kentucky (Figure 5). Medicaid provides significant financing for the delivery of services in schools including reimbursement for medically necessary services that are part of a student’s special education plan, for eligible health services for students with Medicaid coverage more broadly, and for some administrative activities. Recent federal cuts are expected to squeeze school district budgets, potentially affecting school services and reducing access, including for students with special education plans.

As youth mental health concerns have grown, both the federal government and states have taken action to expand access to school-based mental health care. Schools receive support for providing mental health services in several ways, including support at the federal level through DOE and HHS, as well as through Medicaid, and nearly one in five students attending public schools in the U.S. utilize school-based mental health services. School-based mental health services can improve access to care and reduce access barriers for underserved populations, including children from low-income households and children of color. Recent cuts, including reductions in coverages as well as cuts to DOE and HHS staff, could dampen recent efforts to increase access to mental health care in schools.

5. Family Financial Security

Children with Medicaid experience higher rates of food insecurity than children overall. Survey data show that 19% of all children in the U.S. and 30% of children covered by Medicaid live in households that experience food insecurity, meaning they are unable to access adequate food due to lack of money or other resources (Figure 6). U.S. Department of Agriculture (USDA) data also show that food insecurity among children has increased in recent years. Food insecurity is associated with multiple chronic conditions, poorer self-reported health status, higher health care utilization, and lower rates of medication adherence. Overall, 19% of children, and 41% of children with Medicaid, receive SNAP benefits. Several studies indicate that individuals who receive SNAP benefits have better health and lower rates of food insecurity than similar people who are eligible but not receiving these benefits. While the MAHA commission highlights the importance of nutrition in recent recommendations, federal SNAP cuts in the reconciliation law could worsen access to food for children.

Medicaid covers 8 in 10 children living in poverty or over 9 million of the almost 12 million children who lived in poverty in 2023 (measured using the official poverty measure; the poverty threshold for a family with two adults and one child was $24,526 in 2023). New data show that from 2023 to 2024 the official poverty rate for children declined slightly and the supplemental poverty rate, which accounts for a wider set of resources, held steady; however, the supplemental poverty rate for children remains more than double what it was in 2021 due to the expiration of pandemic-era federal support. Inflation has cooled since 2022, but household costs remain high, contributing to additional financial hardship and increased food insecurity for families. Federal cuts in the reconciliation law and other recent federal changes could worsen affordability challenges and could lead to further increases in poverty and, ultimately, poorer health outcomes.

In anticipation of the Medicare annual open enrollment period, which runs from October 15 to December 7, the Centers for Medicare and Medicaid Services (CMS) recently released information about Medicare Advantage plans for the coming year. News articles following the release of plan information report that Medicare Advantage insurers are scaling back their offerings in response to changes in federal payments and because unexpected increases in the use of health services have led to rising costs and falling profits.

KFF’s analysis of plan offerings shows that Medicare beneficiaries will have the option of 32 Medicare Advantage prescription drug (MA-PD) plans in 2026, two fewer than the 34 options available in 2025 (excluding employer plans and special needs plans). The number of MA-PD options has grown steadily since 2010, peaking in 2024 when the average Medicare beneficiary had 36 options. Despite the decline in offerings over the last two years, the number of options available for 2026 will be higher than the number available in 2022 (31) and every year before (Figure 1).

Across all Medicare Advantage plans for individual enrollment, including those with and without prescription drug coverage, the average Medicare beneficiary has the option to choose among 39 plans in 2026, compared to 42 options in 2025. Similar to the trend for MA-PDs, the total number of Medicare Advantage plans available to the average beneficiary is higher than the average number of plans available in 2022 (38), and each year since 2010. While Medicare Advantage plans are required to cover all Medicare Part A and Part B benefits, plans decide whether to include Part D prescription drug coverage as part of the benefit package. Enrollees may pay a separate premium for Part D coverage, or plans can use the rebate portion of their payment from the federal government to cover these costs. Most Medicare Advantage enrollees are in plans that include prescription drug coverage.

The number of Medicare Advantage plans with prescription drug coverage available to the average beneficiary varies across states, as does the change in the number of plans compared to 2025 (Figure 2). In 35 states, DC and Puerto Rico, the average beneficiary has a choice of fewer plans on average in 2026 than in 2025. The states with the largest drop in the number of plans available were New Hampshire (13 fewer plans) and Minnesota (11 fewer plans). In Minnesota, UCare, the second largest Medicare Advantage insurer in the state, exited the market altogether, while UnitedHealthcare and Humana decreased their offerings, especially in more rural counties with lower enrollment. However, in 6 states (AL, HI, KS, MO, UT, and WV), the average beneficiary has access to more plans in 2026 than in 2025, on average. In the remaining 8 states, the number of plans available to the average beneficiary stayed the same. This includes Alaska, which had no plans available in 2026, as in 2025 (Alaska has historically had few or no Medicare Advantage plans available for general enrollment). Connecticut is not included in this calculation because of differences in how counties are reported across CMS enrollment and plan files.

While the average Medicare beneficiary will have more than 30 Medicare Advantage plans with prescription drug coverage to choose from, in certain states the number of options is substantially lower. Medicare beneficiaries will have fewer than 5 options, on average, in four states: Alaska (0), South Dakota (4), Wyoming (3), and Vermont (1). Within states, the number of plans also varies across counties (data not included). Historically, fewer Medicare Advantage plans have been offered in the most rural areas, and a larger share of Medicare beneficiaries in the most rural areas get Medicare coverage from traditional Medicare.   

The modest decrease in the average of Medicare Advantage plans means that some Medicare beneficiaries will find that their current coverage is no longer an option for next year. In most cases, these beneficiaries live in counties where they will continue to have dozens of other Medicare Advantage plan options available for 2026, as well as traditional Medicare. Some beneficiaries in plans that have exited the market will have the option to enroll in a plan offered by the same insurer, and in many cases, enrollees will be moved into a new plan offered by the same insurer automatically if the contract includes another plan of the same type (i.e., HMO or PPO) in the same county. Others will have to make an active choice about their Medicare coverage if they wish to enroll in another Medicare Advantage plan, or will be automatically covered by traditional Medicare.

Every year, Medicare Advantage plans change in ways that could be important to enrollees, including the scope and generosity of extra benefits, cost sharing for Medicare-covered benefits, rules for using covered services (such as referral requirements and prior authorization), drug formularies, and provider networks. Despite these changes, most Medicare beneficiaries report that they do not compare coverage options on an annual basis. Further, prior Medicare focus groups indicate that Medicare enrollees are often overwhelmed by the number of Medicare Advantage choices and have difficulty sorting through all plan options. With more than 30 Medicare Advantage plans with prescription drug coverage available in 2026, on average, understanding how plans differ, and why it may matter, may remain a challenge.

Much has been written about the Trump Administration’s early effort to suppress data collection, presentation, and research related to LGBTQ – and particularly transgender – people’s health. A day one executive order (and subsequent HHS guidance and an OPM memorandum) on “gender ideology” laid out the administration’s approach to sex and gender, defining sex as an immutable binary biological classification and removing recognition of gender identity. While they have each been challenged in court, together, these and other policies have underpinned the removal of a range of websites, cancellation of federal grants, and led to changes to federal survey instruments, including those related to health and well-being, actions that continue to be expanded upon.

Earlier this year, court orders required the restoration of certain webpages, datasets, and resources needed to provide medical care (and in a separate case, the government agreed to restoration of pages), yet data collection related to LGBTQ people remains limited and removal of information reportedly continues. ¹ In at least some cases where it was required to restore websites, the administration plainly states it is doing so only because of its legal obligation. By way of example, a Centers for Disease Control and Prevention (CDC) page on transgender people and HIV now includes a banner stating that it has been restored per court order and that “any information on this page promoting gender ideology,” including reference to transgender people “does not reflect biological reality and therefore the Administration and this Department rejects it.” Additionally, new reporting found that more pages relating to sexual health, LGBTQ people, and other topics have been removed from the CDC site, as recently as September. These actions stand to limit understanding of LGBTQ people’s experiences and challenge the ability of stakeholders to shape responsive policy.

Also in September, the CDC updated its “about” page to include a new set of agency priorities, with a section on “gender ideology and protecting children.”  This section references the HHS guidance and states that it is an agency “priority to recognize that a person’s sex as either male or female is unchangeable and determined by objective biology, and to ensure CDC programs accurately reflect science, including the biological reality of sex.” Removing acknowledgment of transgender people from agency materials has implications for public health messaging and services related to the population’s health needs, posing challenges for a community that has elevated health risks, including for some communicable diseases, like HIV. This could lead to gaps in individual, community, and scientific knowledge and, depending on what is removed, the ability to monitor, and ultimately, respond to outbreaks or health disparities. This priority shift could also negatively influence the LGBTQ community’s trust in the agency – which has historically been important when CDC has responded to certain events, like the mpox outbreak of 2022, necessitating community collaboration. Further, if CDC, aligns funding opportunities with this priority area, it could jeopardize CDC grants going to those working to engage gender diverse communities, thereby limiting service provision. Tailoring public health approaches to communities experiencing high unmet needs or not otherwise being reached is a basic public health approach and requires acknowledging their existence and approaching needs in culturally competent ways.

Additionally, recent CDC clinical guidelines, used to inform providers about the evidence and clinical recommendations related to public health interventions, omit mention of transgender people, seemingly reflecting administrative priorities. A new twice-yearly injectable pre-exposure-prophylaxis or PrEP (HIV prevention) drug, lenacapavir, was approved in June and holds significant promise in helping to bend the curve on the HIV epidemic by addressing adherence and clinical capacity issues. However, the clinical recommendations from the CDC do not reference transgender or non-binary people, who, because they experience HIV at disproportionate rates, were specifically included in “PURPOSE 2”, one of the clinical trials that led to the drug’s FDA approval. The PURPOSE 2 trial assessed lenacapavir’s efficacy in cisgender men, transgender men and women, and non-binary people. The trials found that lenacapavir was 96%-100% effective at preventing HIV transmission and the final drug label issued by the FDA specifies that “there were no clinically significant differences in the pharmacokinetics of lenacapavir based on…gender identity”, among other variables. This marks a departure from CDC’s 2021 PrEP guideline, released prior to approval of the new drug, which included a section on PrEP and transgender people. It also represents a departure from the approach taken by the World Health Organization (WHO) in their lenacapavir guidelines, which identified gender diverse people as a key population and discusses prescribing lenacapavir to those also taking gender affirming hormone therapy. While providers may look elsewhere for detailed information (such as to the WHO or the trial data), the exclusion could impact willingness to prescribe among those less experienced with PrEP or in working with transgender patients. In addition, given that an earlier PrEP drug (emtricitabine/tenofovir alafenamide), was not approved for people engaged in “receptive vaginal sex because the effectiveness in this population has not been evaluated,” providers may be especially cautious about reviewing sex and gender based indications for new PrEP drugs. Indeed, this earlier exclusion is a key reason that led to the more inclusive – of both cisgender women and gender diverse people – trial design and ultimate broad approval of lenacapavir. This follows the removal of detailed information on proving antiretrovirals to transgender people for HIV treatment from the HHS treatment guidelines, an action that took place sometime between March and April 2025.   

As with other changes, the exclusion of transgender people from treatment and prevention recommendations likely reflects and is consistent with the administration’s stance on sex and gender with the Executive Order directing agencies to “remove all statements, policies, regulations, forms, communications, or other internal and external messages that promote or otherwise inculcate gender ideology.”   

Looking across these actions, barriers to providing complete treatment and prevention information could impact individual health (HIV is a life-long chronic condition when treated, and a deadly one when untreated), as well as public health if ongoing HIV transmission continues. It also has implications for private and public budgets with the estimated lifetime cost of HIV treatment per person in the United States now over $1 million.

1. The Court in this case vacated the OPM Memo and the HHS Guidance, remanding them to the agencies. However, the remedy was limited to website and data restoration and “vacatur does not require the HHS defendants to undo every action taken pursuant to the OPM Memo or HHS Guidance” and the court “will not prevent the defendants from heading back to the drawing board and attempting to craft a lawful policy with similar objectives.” Other cases challenge the gender Executive Order itself. ↩︎

Introduction

On March 1, 2025, President Trump signed Executive Order (EO) 14224 designating English as the official language of the United States. This marks the first time in the country’s history that the U.S. has declared an official language at the federal level. Although the Order does not by itself trigger changes in services provided by agencies or organizations receiving federal funding, the policy represents a departure from previous administrations’ policies around language access for individuals with limited English proficiency (LEP). The federal government defines people with LEP as those who do not speak English as their primary language and who have a limited ability to read, write, speak, or understand English (also described as speaking English “less than very well”).

An accompanying official fact sheet released by the Trump administration outlines how EO 14224 will affect agencies and their services, including review of all services currently offered in languages other than English and phasing out of non-essential services. Prior guidance for agencies serving people with LEP has been suspended.

The Order will likely result in more limited availability of language access services for people with LEP.  Language and interpretation services are important for ensuring access to health coverage, care, and for improving health outcomes. Loss of services may further exacerbate disparities in health and health care, as people with LEP are disproportionately more likely to be Hispanic, Asian, immigrants, and to have lower incomes. Further, the new EO could also create challenges and confusion for health care and other service providers, who remain subject to other laws and regulations that still require provision of language access services.

This issue brief provides an overview of EO 14224 and its potential implications for multilingual resources, including data on the shares of individuals with LEP across different socioeconomic characteristics based on KFF analysis of 2023 American Community Survey (ACS) data.

Prior Language Access Policies

Prior laws and guidance have established requirements for language access and protection for people with LEP. Title VI of the Civil Rights Act of 1964 and Section 1557 of the Affordable Care Act (ACA) prohibit discrimination based on national origin, including discrimination based on the ability to speak English. Previously, the Department of Justice (DOJ) took the stance that Title VI of the Civil Rights Act prohibited discrimination against people with LEP, recognizing that a lack of language access represented discrimination based on national origin. In 2000, President Clinton issued EO 13166, which required all federal agencies to ensure meaningful access to services for people with LEP and established that failing to provide adequate services would be considered discrimination based on national origin. EO 14224, signed by President Trump, revokes EO 13166 and any policy guidance documents issued under it, and requires the Attorney General to provide updated guidance.

Section 1557 of the Affordable Care Act strengthened language access protections by prohibiting discrimination in health programs and other services that receive federal financial assistance. Section 1557 requires covered entities, including hospitals, clinics, insurers, and state Medicaid programs, to provide meaningful access for individuals with LEP. While Section 1557’s protections took effect when the ACA was enacted in 2010, much of its reach has been determined by implementation guidance issued across different presidential administrations. Under the Biden administration regulations issued in 2024, entities that operate health programs or activities and receive federal financial assistance must take reasonable steps to provide meaningful access to individuals with LEP who are eligible to be served or likely to be directly affected by the program or activity. The regulation specifies requirements regarding how the services must be provided, including that they be free of charge, accurate, and timely; outlines standards for interpretation and translation services; and identifies requirements for entities to provide notice of the availability of services. Section 1557 remains in effect despite the Executive Order, meaning that health care entities will continue to be required to provide language access services, even as federal agencies may scale back their language access resources.

Changes in Language Access Under the Trump Administration

EO 14224, issued by President Trump in March 2025, declares English as the official language of the U.S. and revokes prior orders requiring federal agencies to provide meaningful access to services for individuals with LEP. The Order also instructs the Attorney General to rescind all policy guidance stemming from EO 13166. As a result, in April 2025, the DOJ rescinded its 2022 LEP guidance, which directed agencies to assess and enhance their language access policies, and published a new memorandum providing implementation guidance related to the EO. The DOJ also removed LEP.gov, a website that provided resources to federal agencies and other entities receiving federal funding for developing language access plans.

Patients are still entitled to interpreter services under Title VI through qualified bilingual staff or interpreter services at no additional cost. Historically, providers have often aligned their services with the Department of Health and Human Services (HSS) outlined National Standards for Culturally Linguistically Appropriate Services (CLAS), a set of 15 voluntary guidelines designed to advance language access and cultural competence in healthcare. These standards include informing individuals of language assistance availability, ensuring the competence of individuals providing translation services, and providing written translation of key documents such as health consent and education documents. While the CLAS standards are not a binding federal regulation and therefore cannot be revoked by EO 14224, their adoption and implementation may decline as changes to federal language access policies reduce oversight, investment, and incentives for compliance.

The new memorandum recommends that federal agencies scale back the provision of language services, minimizing non-essential multilingual services, and recommends that agencies consider offering services exclusively in English. However, it does not require agency heads to amend, remove, or otherwise stop the production of documents, products, or other services prepared or offered in languages other than English. Despite these ongoing requirements, the new guidance signals that the DOJ will no longer treat a lack of multilingual services as discrimination, and that agencies are no longer required to implement wide-scale language access plans.

The EO and accompanying DOJ guidance apply only to federal government agencies and do not change existing language access requirements under laws like Title VI of the Civil Rights Act or Section 1557 of the ACA. Executive Orders cannot overturn existing statutes and regulations that go through formal revisions and public notice and comment processes. Title VI and Section 1557, which were issued by HHS, outline compliance measures that cannot unilaterally be changed by Executive Order. Entities that receive federal funding including state and local health departments, hospitals, insurance companies, clinics, and other health care providers remain legally obligated to provide meaningful language access under these laws. Under Section 1557 regulations, forms such as informed consent documents, intake forms, and discharge instructions are still required to be translated for individuals with LEP. Moreover, several states, including, New York, California, Hawaii, Maryland, and the District of Columbia, have state-level language access laws that remain in effect. However, the reduction in federal oversight, and granting agencies the ability to decide how and when to offer services in languages other than English, including at HHS and the DOJ, may create uncertainty about implementation and compliance practices, and reduce the availability of federal resources for providing language access services. Enforcement is also likely to shift since the DOJ has narrowed its interpretation of Title VI, indicating that it will no longer pursue enforcement based on disparate impact claims related to language access, instead, it will now focus on cases involving intentional discrimination. This change in enforcement could impact accountability measures and ultimately weaken protections for individuals with LEP.

Who is Likely to Be Affected by Reductions in Language Access Services?

Over 27 million people in the U.S. have LEP and may be affected by decreased access to language access services, with disproportionate impacts on Asian and Hispanic people, immigrants, and people with lower incomes. Data from the 2023 ACS show that 9% of the population ages 5 and older, or 27.3 million individuals, have LEP (defined as speaking a language other than English at home and speaking English less than very well). Asian (30%) and Hispanic people (29%), immigrants (47%), and those with incomes under $40,000 per year (13%) are disproportionately more likely to have LEP than the overall population (Figure 1). Decreased access to language assistance services comes at a time when immigrants are facing other barriers to accessing health care and other services, including increased immigration-related fears and more limited eligibility for health care coverage and other services.

Decreased access to language assistance services would have greater effects in some states, since there are wide variations in the shares of people with LEP across states (Figure 2). The share of people ages 5 and older with LEP ranges from less than 1% in West Virginia to 18% in California. New York (14%), New Jersey (14%), Texas (13%), and Florida (13%) also have relatively high shares of individuals with LEP, likely reflecting larger numbers of immigrants residing in those states.

Language access services have important implications for health and health care. People with LEP face challenges and barriers to accessing high-quality health care. Language barriers between providers and patients can reduce the quality of care and increase the risk of adverse outcomes or medical errors. Studies have found that a lack of language assistance often delays patients’ access to timely care, leading to poor chronic disease management and resulting in worse health outcomes. Despite existing language access requirements, KFF survey data find that around half (48%) of adults with LEP have encountered at least one language barrier in a health care setting within the past three years, such as difficulty filling out forms for a health care provider (34%), communicating with office staff at a doctor’s office or clinic (33%), understanding instructions given by a doctor or health care provider (30%), filling a prescription or understanding how to use it (27%), or scheduling a medical appointment (25%) (Figure 3). Among adults with LEP, one in five reported experiencing at least one of several negative experiences with a health care provider in the past three years, including a provider ignoring a direct request or question (11%), assuming something about them without asking (8%), suggesting they were personally to blame for a health problem (8%), or refusing to prescribe needed pain medication they thought they needed (8%).

Reductions in requirements for federal agencies to provide language access services may create new challenges for health care and other service providers. If federal agencies reduce language access guidance and requirements, providers will have fewer translated materials to rely on, such as consent documents and health education materials. This can also create inconsistencies in the quality and accuracy of materials across the health care landscape. Community health centers (CHCs) and other safety net providers may be disproportionately impacted by the reduced availability of federal language access resources as they are disproportionately likely to serve individuals with LEP and those with lower incomes. Federal cuts have already eliminated funding for community workers who help people who speak other languages navigate and sign up for health insurance coverage. Moreover, given differences between the new guidance and other laws that remain in place, providers may have questions or confusion about when translation services are required, compliance risks, and how comprehensive services must be.