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.

Over the past decade, cost-sharing (the out-of-pocket portion of household health spending) has grown faster than both workers’ wages and general inflation for those with employer coverage. In recent years, that growth has reached a rate more similar to inflation. Since 2003, average out-of-pocket costs have increased by 37%. In 2023, a majority (66%) of people with employer coverage spent more than $100 on out-of-pocket costs.

This chart collection examines trends in employee spending on deductibles, copayments, and coinsurance from 2012 to 2023, using a sample of health benefit claims for individuals under 65 from the Merative™ MarketScan® Commercial Database.

The full analysis and other data on health costs are available on the Peterson-KFF Health System Tracker, an online information hub dedicated to monitoring and assessing the performance of the U.S. health system.

Health communicators face the persistent challenge of balancing correcting misinformation with the risk of amplifying claims that audiences might not have noticed otherwise. As KFF’s President and CEO, Drew Altman noted in a previous column, reporters and communicators “likely [have] no choice when [politicians] spread false information but to cover it and correct the lies in the process, but there are choices to be made about how it’s done.” This tension was recently illustrated when President Donald Trump briefly shared, and later deleted, an AI-generated video on Truth Social that falsely alleged “medbeds,” a fake technology featured in a long-standing conspiracy theory, could cure all diseases and reverse aging. Although the video was deleted and widely debunked by mainstream media, like ABC, CNN, MSNBC, and Forbes, coverage and discussion briefly amplified the claim, exposing new audiences and sustaining its circulation. In this example, most of the coverage and online posts criticized or shared background on the claim, but coverage and attention intended to correct or criticize misinformation to an audience that was previously unaware of it can extend the claim’s reach and persistence.

Amplifying Misinformation Can Increase its Reach and Persistence

Several mechanisms contribute to amplification risks when reporting on or criticizing a claim:

• Engagement-driven dissemination: Content that provokes a reaction, whether agreement or criticism, generates engagement like clicks, comments, likes, and shares. Social media algorithms are designed to detect this potential for attention and amplify it further. This allows posts that criticize or mock false claims to travel just as far, or farther, than posts promoting them. A similar pattern occurs in  news media, as coverage that elicits reactions like fear, disgust, and surprise is more likely to be shared across networks.
• Repetition and familiarity: Repeated exposure to a false claim, whether through multiple news stories or recurring social media posts, increases the perception of plausibility (the “illusory truth effect”). Some studies have even shown that neither fact-checking nor media literacy interventions can fully mitigate the effects of exposure to repeated misinformation.
• Extended lifespan: Any reporting, corrective or not, keeps a claim in public view longer than if it were ignored, allowing it to resurface and influence perceptions over time.

Exposure to Misinformation Can Erode Trust

Misinformation spreads more easily during periods of uncertainty and low institutional trust. In these contexts, even when a specific claim is debunked, narratives like medbeds can persist because they reinforce doubts about official institutions and align with their ideology. These dynamics occur in a landscape of fractured trust. KFF’s Tracking Poll on Health Information and Trust finds that many Republicans report more trust in health information from President Trump than from the CDC, FDA, or their local health department. In this environment, even unsubstantiated claims can have indirect effects. Exposure to these claims and corrections can erode trust in health authorities and government by reinforcing skepticism, even without belief in the specific conspiracy. So, people may reject the literal claim that medbeds exist but accept the broader idea that powerful institutions hide cures or they may have difficulty believing true information in the future.

Proactive and Strategic Communication

While reporting on misinformation too early can have unintended effects, leaving it unchecked can also leave information voids. Reporting on misinformation requires balancing transparency with amplification risks. Focusing on verified facts, limiting repetition of false claims, and avoiding sensationalizing or mocking narratives can reduce unintended spread. Research and practice offer additional strategies:

• Build Audience Resilience through Proactive Prebunking: Prebunking exposes audiences to fact-based information and explains how misinformation spreads before false claims appear. It strengthens resistance, fills knowledge gaps, emphasizes accurate facts without repeating false claims, and highlights manipulative tactics. Prebunking is especially useful for low- or medium-risk narratives and can complement later debunking if a claim gains traction.
• Debunk Strategically: If there is reason to believe that misinformation has reached the large swaths of Americans who are unsure about health information, or “the muddled middle”, debunking may be necessary. The Public Health Communication Collaborative suggests beginning with a clear fact, providing context on the misinformation and tactics used, and ending with a reinforcing fact. This helps audiences retain accurate information while limiting amplification of the false claim.
• Build Trust to Make Corrections Stick: Misinformation persists partly because of underlying distrust. Strengthening community relationships, amplifying trusted messengers, and communicating consistently reduces the appeal of conspiracies more effectively than corrections alone.

Misinformation is not just about what is said, but how it spreads. By anticipating false narratives, using prebunking and debunking strategically, reporting responsibly, and prioritizing trust-building, communicators can limit the reach of false claims while supporting informed, resilient audiences.

Introduction

What used to be rare extreme weather events have increased in both intensity and frequency due to climate change. August 29, 2025 marked the 20^th anniversary of Hurricane Katrina’s landfall in the Gulf Coast region of the U.S. Hurricane Katrina was one of the deadliest storms to hit the continental U.S., resulting in the deaths of nearly 2,000 people and the displacement of over one million. Since Katrina, major hurricanes such as Rita, Sandy, Harvey, Maria, and Helene, have resulted in massive loss of life and billions of dollars of damage. In January 2025, Los Angeles County experienced one of the deadliest wildfires in California’s history, killing over 30 people and injuring many more. In early May 2025, tornadoes in Kentucky, Missouri, and Virginia killed at least 25 people. In early July 2025, communities in Texas, New Mexico, and North Carolina experienced deadly flash floods, with over 100 people dying in the Texas floods. This brief provides an overview of who is impacted by health risks of natural disasters and recent federal and state actions related to disaster preparedness and response.

Reflecting underlying structural inequities, low-income communities, people of color, and other historically underserved groups are at increased risk of being affected by a natural disaster. In addition to the immediate hazards created by extreme weather events, their impacts can extend to miles away and years into the future. Natural disasters also have significant economic impacts. It is estimated that if left unaddressed, climate change related natural disasters could cost the U.S. economy approximately $14.5 trillion over the next fifty years.

While prior administrations have taken steps to bolster the nation’s efforts to prepare for and respond to natural disasters, the Trump administration has recently taken actions that may reverse some of these efforts. Weakened federal protections may deepen existing disparities, leaving communities that already face disproportionate climate risks with fewer safeguards against natural disasters. The elimination of key offices, programs, and data tools may also make it more difficult to assess and mitigate the health risks associated with natural disasters. As climate change-related disasters worsen, the federal government’s shrinking of emergency and disaster preparedness support to state and local governments may leave millions of people vulnerable and unable to recover from natural disasters. As of October 2025, more than two dozen local jurisdictions sued the federal government over the withholding of more than $350 million in emergency and disaster funds unless they complied with immigration enforcement efforts and federal policies against diversity, equity, and inclusion conditions. The lawsuit follows a recent decision by a federal judge blocking the Trump administration’s efforts to freeze federal emergency preparedness funds for states that opposed the administration’s mass deportation efforts. Some states have taken actions to prepare for and respond to natural disasters, however variation in state-level actions may leave some areas and communities at increased risk.

Who is at Increased Risk for Negative Health Impacts Due to Natural Disasters?

Many of the same factors that contribute to health inequities leave some communities at higher risk of being affected by a natural disaster. Low income communities and communities of color are often on the front lines of natural disasters and climate change. Due to historical residential segregation, including redlining, people of color are more likely to live in neighborhoods that have worse infrastructure, increasing their risk of harm and limiting their ability to prepare or safely shelter-in-place. Rural communities face challenges responding to natural disasters, ranging from physical isolation, high poverty rates, to limited access to health care as well as limited financial capacity. Barriers such as language access and immigration-related fears may prevent immigrants from receiving timely warnings or recovery assistance and financial challenges make it harder for low income families to evacuate, with surveys showing that costs often run into the thousands of dollars. Further, there are gaps in federal disaster management and response efforts. Recovery efforts are not always distributed equitably, with research finding wealthier and White communities more likely to benefit than communities of color. For example, during the 2025 L.A. County wildfires, fewer fire trucks were deployed to west Altadena, a historically Black neighborhood that experienced the greatest loss of life.

Natural disasters have immediate negative impacts on health and can limit access to health care and basic necessities. In addition to immediate loss of life and injury, damage to infrastructure caused by storms can also compromise emergency response efforts, limit access to basic needs, and disrupt access to health care and needed medications. These disruptions can be particularly severe for people who rely on continuous medical treatments or who live in communities with limited health care capacity. For example, immediately after Hurricane Maria, residents in Puerto Rico reported difficulties in accessing basic needs, including health care, water, food, gas and money. Those with chronic conditions such as asthma, diabetes and kidney disease had trouble managing their conditions due to power outages that impacted dialysis centers and their ability to refrigerate their medicines. A KFF Health News investigation found that at least 170 hospitals in the U.S. are at risk of severe flooding, potentially jeopardizing access to care and endangering the lives of hospital workers and people reliant on hospital care during flooding disasters. The cumulative effects of these challenges can widen existing health disparities, leaving some groups at greater risk of adverse outcomes during and after natural disasters.

Impacts of natural disasters can extend beyond the immediately affected area to people miles away. For example, in 2023, smoke from wildfires in Canada caused air pollution that affected more than 60 million people in the U.S. During that time, U.S. emergency room visits for asthma increased by nearly 20%. Research also shows that wildfire smoke accounts for significant amounts of particulate matter, worsening air pollution and creating persistent and chronic health risks. Communities of color are particularly susceptible to the adverse impacts of wildfires and wildfire smoke exposure due to their higher rates of underlying conditions including higher rates of asthma among American Indian and Alaska Native and Black people compared to White people.

Natural disasters can also affect communities years after their immediate impacts. For example, research shows that years after hurricanes have occurred, excess mortality persists, with Black people experiencing higher cumulative excess deaths than their White counterparts. One year after Hurricane Katrina, about one third (32%) of New Orleans residents reported that their lives remained “very disrupted” or “somewhat disrupted” by the storm, with this share rising to about six in ten (59%) of African American residents in Orleans Parish compared to about three in ten (29%) of White residents. Ten years after the storm, KFF survey data also showed that New Orleans residents who lived in the area during Katrina still reported lingering stress and problems with their mental health due to the hurricane.

What Are Recent Federal Actions Related to Natural Disasters and Health?

Prior administrations took steps to strengthen the nation’s capacity to prepare for and respond to natural disasters. These efforts focused on building federal infrastructure, improving coordination, and investing in hazard mitigation. For example, after Hurricane Katrina, President George W. Bush signed the Post-Katrina Emergency Management Reform Act of 2006 to overhaul the Federal Emergency Management Agency (FEMA), which included creating regional offices and stronger protections for people with disabilities and those with limited English proficiency. Later, the Obama administration expanded flexibility for states and Tribes in using recovery funds and allowed Tribes to make disaster declarations independently. The Preparing the United States for the Impacts of Climate Change Executive Order directed federal agencies to integrate climate preparedness into operations and planning. During its first term, the Trump administration established a national fund for pre-disaster mitigation, giving states more reliable access to resources for strengthening infrastructure. Together, these actions enhanced the federal framework for disaster preparedness, improved coordination, and increased protections for disproportionately affected populations.

The Biden administration took additional steps to prepare for, respond to, and address the impacts of climate change, natural disasters, and emergency and rescue services on health. The passage of the Infrastructure Investment and Jobs Act in 2021 and the Inflation Reduction Act in 2022 dedicated significant funds to disaster mitigation and resilience, including increasing the resilience of infrastructure and investing in more resilient energy grids to reduce power outages during extreme weather events. The National Climate Resilience Framework launched a whole-of-government climate resilience strategy, which directed agencies to integrate climate risk into planning and strengthening building standards to withstand disasters. Through the Building Resilience Infrastructure and Communities (BRIC) program and the Hazard Mitigation Assistance (HMA) Grant, FEMA awarded billions of dollars for pre-disaster mitigation and resiliency projects, with an emphasis on projects in underserved communities. By mid-2024, more than 20 federal agencies released climate adaptation plans that aligned with the National Climate Resilience Framework, which emphasized environmental justice and Tribal engagement.

On the first day of its second term, the Trump administration began implementing policies and regulations that cut funding and reversed efforts to mitigate the impacts of natural disasters and extreme weather events on health. In March 2025, the administration announced the cancelation of grants worth $1.7 billion aimed at preparing communities for extreme weather events as well as improving their air and water quality. In April 2025, FEMA suspended the BRIC and HMA programs, both of which funded flood control, wildfire mitigation, and infrastructure resilience projects. FEMA also reduced staff and training capacity by 20%, limiting the agency’s ability to coordinate disaster response and recovery. In addition to significant workforce cuts, the National Oceanic and Atmospheric Administration (NOAA) faces significant budget cuts that are expected to hinder severe weather forecasting and early warning systems that are key for preparing for natural disasters and extreme weather events. NOAA is one of the few reliable sources that people can access when determining how and when to respond to a natural disaster; cuts to its programs may contribute to increases in loss of life. Further, the Trump administration stopped updating the Billion-Dollar Weather and Climate Disasters database, which documented the economic cost of natural disasters. The loss of this source of data will leave researchers, policymakers, and other actors with less reliable information to determine the impacts of natural disasters and plan for future events.

Beyond the changes at FEMA, the administration has pursued broader policy shifts that affect disaster preparedness and health. The administration has made major cutbacks to the Environmental Protection Agency’s (EPA) climate and resilience programs, including reduced enforcement of clean air and water standards that help protect communities during and after extreme weather events. In July 2025, the EPA finalized its proposal to rescind the 2009 Endangerment Finding under the Clean Air Act, which found that greenhouse gas emissions endangered public health and welfare and implemented greenhouse gas emissions standards for vehicles and other sectors. If this finding is eliminated, the EPA could no longer limit emissions from cars or power plants. The administration also eliminated the U.S. Global Change Research Program and fired the scientists who worked on the National Climate Assessment, a report that outlined the dangers of climate change and global warming, which the government used to help prepare for extreme weather events. The administration also eliminated or restructured federal environmental justice and diversity, equity, and inclusion initiatives, scaling back efforts designed to identify and address disproportionate environmental burdens on low income communities and communities of color. Areas like the Southeast U.S. are particularly vulnerable to the impacts of these changes as they are often affected by severe tropical storms and have high concentrations of low income communities and communities of color who due to underlying factors are less able to prepare for and recover from natural disasters. These actions reduce the agency’s ability to monitor risks, provide data to communities, and enforce protections in areas most likely to experience climate-related harm.

The Trump administration has also taken actions that block or weaken state level climate measures, including responses to natural disasters. Through the Executive Order, “Protecting American Energy From State Overreach,” the federal government directed the Department of Justice to challenge state and local climate resilience policies, including building codes and emission standards that support disaster preparedness. By targeting these measures, the order weakens safeguards that protect buildings against natural disasters and cuts emission standards that lower the production of greenhouse gas emissions that cause extreme weather events and mitigate toxin exposures during natural disasters. Further, the Trump administration’s efforts to limit the role of the federal government in state disaster response and management efforts will have significant effects for states that do not have the fiscal capacity or resources to adequately prepare for and recover from natural disasters. In 2019, of the 31 states that received federal disaster response and recovery resources, only five states would have had enough disaster-specific relief funds to cover the costs of disasters in 2019 without the support of the federal government.

What are Recent State Actions Related to Natural Disasters and Health?

Reflecting the increase in frequency and intensity of extreme weather and other natural disasters and the resultant economic losses associated with these events, several states have passed recent legislation focused on disaster preparedness and recovery. Most state policies emphasize centralized planning, identifying at-risk communities, developing mitigation strategies, and building infrastructure and community resilience. For example, New Jersey and South Carolina enacted bills that require all land-use agreements to include resiliency clauses or climate change-related hazard vulnerability assessments that take into account the impacts of natural disasters on local communities and built infrastructure. In Colorado, SB222-206 established the Office of Climate Preparedness to coordinate disaster recovery and develop a statewide climate roadmap, integrating climate adaptation, mitigation, and resilience strategies to support long-term environmental and community health efforts. The bill also created the Disaster Resilience Rebuilding Program to provide financial support for rebuilding homes, businesses, and infrastructure after disasters, as well as encouraging sustainable rebuilding projects that promote high-efficiency and sustainable reconstruction efforts.

Some states have integrated actions into their disaster response policies to help identify and reach historically marginalized populations who are often left behind during disaster preparedness and recovery efforts due to social and economic inequities. For example, Washington’s Greenhouse Gas Emissions-Cap and Invest Program encourages the use of an environmental justice assessment to ensure that funds and programs provide benefits to and reduce disparities faced by overburdened communities−“communities that have historically borne the disproportionate impacts of environmental burdens and now bear the disproportionate negative impacts of climate change.” As part of HB 1237, Colorado directed funds to study how to improve language access in their warning systems by hiring multilingual staff and translating materials into languages other than English. They are also developing best practices for engaging with communities in other languages. Hawaii established a recovery fund for Native Hawaiian people who are at the frontline of climate change and experiencing loss from natural disasters. While Hawaii has dedicated funds to support Native Hawaiian people, the Lahaina fire from 2023 highlighted the hurdles survivors faced in accessing and utilizing recovery funds. Challenges in accessing funds, inability to pay rent and mortgages, and difficulty rebuilding have forced many Native Hawaiian survivors to move out of West Maui. For survivors who stayed, substantial increases in housing costs and recent changes to FEMA may jeopardize their ability to stay on their ancestral land long-term. Research shows that two years after the fire, survivors continue to report worsened mental and physical health and about four in ten (41%) adults still live in temporary housing.

Introduction

Immigrants form a growing share of the U.S. population and workforce, and as of 2024, there were over 50 million immigrants residing in the country. President Trump’s agenda has focused on restricting immigration and enhancing immigration enforcement, which research shows has negative impacts on the mental and physical health of immigrant families, including the millions of U.S. citizen children living in them, as well as broader economic effects on communities. The Trump administration and Congress also have made policy changes that further restrict access to health coverage and care for immigrant families.

This issue brief provides an overview of Trump administration and Congressional actions that are likely to impact immigrants’ access to health coverage and care, including new restrictions on eligibility for health coverage and services as well as changes in immigration enforcement and other policies. Together, these changes will likely increase uninsured rates and reduce access to care among immigrants and their children. Over the long-term, these changes may also lead to worse health outcomes and have negative impacts on the U.S. economy and workforce, given the major role immigrants play, particularly in certain industries, including health care, agriculture, and construction.

Reductions in Access to Health Coverage

The 2025 tax and budget law includes significant cuts to the Medicaid program as well as eligibility restrictions that make many lawfully present immigrants (LPIs) ineligible for Medicaid and the Children’s Health Insurance Program (CHIP), subsidized coverage through the Affordable Care Act (ACA) Marketplaces, and Medicare coverage. Under the new law (H.R.1), eligibility for Medicaid and CHIP, subsidized Marketplace coverage, and Medicare will be limited to lawful permanent residents (LPRs or “green card” holders), Cuban or Haitian entrants, and citizens of Compact of Free Association (COFA) residing in the U.S (Table 1). States can also maintain Medicaid and CHIP coverage for lawfully residing pregnant people or children covered through a state option as well as through the “From-Conception to End of Pregnancy” option, which provides coverage to low-income children regardless of their parent’s immigration status. This change will make many groups of lawfully present immigrants ineligible for coverage, including refugees, asylees, people with Temporary Protected Status (TPS), as well as individuals on work visas, among others. The law also eliminates eligibility for subsidized ACA Marketplace coverage for all lawfully present immigrants with incomes below 100% of the federal poverty level (FPL) who do not qualify for Medicaid coverage due to immigration status. The Congressional Budget Office (CBO) estimates that these coverage restrictions will result in 1.4 million LPIs becoming uninsured with $131 billion in reduced federal spending and $4.8 billion in increased federal revenues by 2034. There is no effect on coverage of undocumented immigrants, who are already ineligible for all federally funded health coverage. Some states use their own money to provide health coverage to undocumented immigrants.

The new eligibility restrictions for lawfully present immigrants have staggered implementation dates. The eligibility restrictions for Medicare became effective July 4, 2025 (the date that the 2025 tax and budget law was enacted), and current beneficiaries subject to the new restrictions will be disenrolled from coverage no later than 18 months from enactment of the legislation (January 4, 2027). Eligibility for subsidized ACA Marketplace coverage for lawfully present immigrants with incomes below 100% FPL ends January 1, 2026, while the other restrictions for subsidized ACA Marketplace coverage take effect as of January 1, 2027. The eligibility restrictions for Medicaid and CHIP go into effect October 1, 2026 (Table 2).

Beyond changes in the law, enhanced premium tax credits are set to expire at the end of 2025, which will make coverage unaffordable for many immigrants and likely lead to coverage losses. Without renewal of the enhanced tax credits, average premiums could rise by over 75%, and in some states, they may even double. As a result, total Marketplace enrollment is projected to fall from 22.8 million in 2025 to 18.9 million in 2026 and 15.4 million by 2030. Without enhanced subsidies, many immigrants who remain eligible could lose access to affordable coverage, particularly in states that have not expanded Medicaid to adults. 

Some states also have reduced or eliminated state-funded coverage designed to fill gaps in federally funded coverage for immigrants. Three states (California, Illinois, and Minnesota) plus D.C. have recently proposed or enacted budgets to end or limit new enrollment of adults in state-funded health coverage programs for immigrants regardless of immigration status as part of broader efforts to reduce state budget deficits.

Regulations published by the Trump Administration in June 2025 eliminated ACA Marketplace eligibility for Deferred Action for Childhood Arrivals (DACA) recipients on August 25, 2025. Under earlier policy, individuals with DACA status were not considered lawfully present for purposes of health coverage eligibility and remained ineligible for Medicaid, CHIP, and ACA Marketplace coverage despite having a deferred action status, which otherwise qualified for Marketplace coverage. These eligibility restrictions left DACA recipients ineligible for federally funded health coverage programs. The Biden administration published regulations that made DACA recipients newly eligible to purchase ACA Marketplace coverage with premium tax credits and cost sharing reductions beginning November 1, 2024. Following legal challenges, implementation of the Biden administration regulations was limited to 31 states and D.C. New regulations published by the Trump administration once again made DACA recipients in all states and D.C. ineligible for ACA Marketplace coverage. Most states will terminate coverage for enrolled DACA recipients on September 30, 2025.

The Trump administration published new guidance regarding verification of citizenship and immigration status of Medicaid enrollees, which could contribute to disenrollment due to challenges providing documentation. According to the Centers for Medicare and Medicaid Services (CMS), states will be required to separately verify the citizenship or immigration status of individuals whose status cannot be confirmed through federal databases such as the Systematic Alien Verification for Entitlements (SAVE) system based on monthly enrollment reports. Under already existing policies, in addition to meeting other eligibility requirements, lawfully present immigrants must have a “qualified non-citizen” status to be eligible for Medicaid or CHIP, and many, including most lawful permanent residents or “green card” holders, must wait five years after obtaining qualified status before they may enroll. States already are required to verify citizenship and immigration status with the Social Security Administration (SSA) and the Department of Homeland Security (DHS) SAVE system to determine eligibility for Medicaid coverage at the initial application and provide Medicaid benefits to applicants during a “reasonable opportunity period” of 90 days while their immigration status is being verified, if they otherwise meet all eligibility criteria. Although some implementation details of the new verification process announced by CMS remain unclear, it is possible that states will need to re-verify the eligibility of enrollees identified in reports and applicants may need to provide paperwork as proof of their eligible immigration status for manual verification, which could increase administrative burdens on both states and applicants or enrollees and potentially lead to coverage losses due to administrative challenges. 

Restricted Access to Health and Other Services

The Trump administration issued a policy change that expands the list of health and other service programs that certain immigrants are prohibited from accessing. On July 14, 2025, the U.S. Department of Health and Human Services (HHS) issued a notice of a policy change to update the definition of “federal public benefits” as outlined in the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) to add an additional 13 programs to the 31 programs considered “federal public benefits” that are restricted to individuals with a “qualified” immigration status. The notice further indicates that the updated list of federal benefits is not exhaustive, and additional programs may be added in the future. Among the 13 new programs added to the list are Head Start, the Health Center Program, and the Title X family planning program, among others (Box 1). This change bars many groups of lawfully present immigrants as well as undocumented immigrants from accessing several health care, educational, and other social services and will likely have negative impacts on the health and well-being of immigrant families. It also may create new challenges and complexities for service providers. This policy change was expected to take effect immediately upon publication of the notice in the federal register on July 14, 2025, although it provided for a 30-day comment period. However, the HHS had to delay implementation until September 11, 2025, following court orders. Further, on September 10, 2025, a District Court issued an injunction on the administration’s new policy, blocking the implementation of the policy as it relates to the Health Center Program and Head Start in 20 states and D.C.

Enhanced Immigration Enforcement

President Trump also has increased immigration enforcement activity to support mass deportation and detention, which research shows negatively impacts the health and well-being of immigrant families. The administration has shifted enforcement actions from focusing on criminals and recent border crossers to prioritizing all of the estimated 14 million undocumented immigrants for deportation, even though many have some form of temporary deportation protections. As a result, there have been increased worries about detention and deportation among immigrants, including among naturalized citizens, and immigrant families with undocumented immigrants report that immigration-related fears have worsened their mental health and well-being. KFF survey data from March 2025 find that about a third (32%) of immigrants overall say they have experienced negative health repercussions due to worries about their own or a family member’s immigration status (Figure 1). Immigrants also reported they avoided seeking health care due to concerns about costs and fears, were fearful of accessing public programs, and were confused whether these programs can negatively impact immigration status.

In January 2025, the Trump administration rescinded longstanding protections that prohibited immigration enforcement action in certain areas including health care facilities, schools, and places of worship. Based on a memorandum originally issued by the Director of U.S. Immigration and Customs Enforcement (ICE) in 2011, immigration enforcement actions were prohibited from occurring in “sensitive locations” such as health care facilities, schools, and places of worship, with limited exceptions. In 2021, the Biden administration issued an updated memorandum further strengthening and expanding these protections by including disaster relief areas and other sites of essential services on the list of “sensitive locations”. Following the recission of these longstanding protections by the Trump administration, there have been reports of ICE agents showing up at hospitals. Some health care facilities have invested resources into training staff on how to comply with the new policy. Health care providers also have expressed concerns about the new policy deterring individuals in immigrant families from seeking health care. In KFF focus groups conducted with likely undocumented Hispanic immigrants, several participants talked about avoiding seeking health care due to concerns about potential enforcement risks.

Immigration-related worries may be exacerbated by the Trump administration’s actions to share Medicaid enrollee information with enforcement officials. In June 2025, there were reports of the Trump administration sharing the personal and health data of noncitizen Medicaid enrollees with the DHS for purposes of immigration enforcement despite concerns related to the violations of federal and state data privacy protections. A federal court in California issued a preliminary injunction in August 2025 that temporarily blocks the Trump administration from sharing enrollee data for the purposes of immigration enforcement in 20 states that filed a lawsuit against the administration. Breaches or sharing of Medicaid enrollees’ information for purposes other than the provision of health coverage and care pose risks for individuals and may jeopardize confidence in the security of data held by agencies. They may also exacerbate immigration-related fears, potentially leading to immigrants and their children foregoing enrollment in health coverage or seeking health care. 

Reducing Federal Language Access Resources

On March 1, 2025, President Trump signed Executive Order 14224 designating English as the official language of the United States with subsequent guidance suggesting the elimination or phasing out of some language access services. The Trump administration’s actions represent a departure from previous administrations’ policies around language access, and it is the first time in the country’s history that the U.S. has declared an official language at the federal level. Based on an accompanying fact sheet released by the administration, all services currently offered in other languages will be reviewed, and non-necessary services will be phased out. However, the Executive Order also states that federal agencies or other agencies that receive federal funding, such as hospitals and doctors’ offices, are not required to stop existing language services due to existing laws and regulations which supersede this guidance. Data from the 2023 KFF Survey of Immigrants find that about half (47%) of immigrant adults report having limited English proficiency (LEP) and that immigrant adults with LEP are more likely than their English proficient counterparts to report barriers to accessing health care and to have worse self-reported health. Reduced availability of language access resources could exacerbate the challenges immigrants with LEP already face and negatively impact their health and health care.

ACA premium tax credits, which make health insurance Marketplace plans more affordable, were first enhanced as part of the American Rescue Plan Act in 2021 and then extended by Congress through 2025. The enhanced credits have improved insurance coverage affordability for millions of people, including those with HIV. However, they are currently set to expire at the end of the year, unless Congress acts to extend them. Their extension became a major political  issue playing a role in the government shutdown.  In addition, because of the political uncertainty surrounding their extension, health insurers have proposed premium increases beyond what would otherwise be the case. The loss of the enhanced tax credits, coupled with increased premiums for some, could jeopardize coverage or health care affordability for millions. People with HIV may be particularly vulnerable, given that they are more likely to have Marketplace plans than the public overall and many also rely on the federally-funded Ryan White HIV/AIDS Program, which could be further stretched if Marketplace plans become more expensive. Moreover, loss of coverage and increased costs could lead to disruptions in care for people with HIV which could have serious implications for individual and public health. Being engaged in HIV care, including being on antiretroviral therapy, promotes optimal health outcomes including viral suppression, which in turn prevents transmission of HIV to others. This issue brief provides an overview of these potential impacts. 

People with HIV and Marketplace Coverage

A larger share of people with HIV receive coverage through the Marketplaces than the general population. As with Marketplace enrollees overall, the costs they face could rise significantly if the tax credits are not extended (detail on how the enhanced tax credits are calculated and differ from the original ACA tax credit here). For example:

• Scenario 1: A 45-year-old enrolled in a Marketplace plan in Miami-Dade County, FL with an annual income of $38,000 (243% of the federal poverty level (FPL)), demographics similar to the HIV epidemic overall, would pay an estimated $1,699 more per year for coverage for the second lowest cost silver plan, with the monthly premium going from $117 to $259. (Additional scenarios can be run using this KFF interactive tool.)

Separately, those with incomes over 400% of the FPL (estimated at $62,600 in 2026 for a single-individual household) would face a double hit when it comes to cost increases without an extension. First, people with incomes in this range were provided with a new tax credit, limiting premium costs to 8.5% of income, which they would lose entirely without an extension. Second, without any cap on costs, they would be fully exposed to increased premiums proposed for 2026. (This differs from those in the 100%-400% FPL income group who would still receive some federal assistance, albeit at a lower level than with the enhanced credits.)

• Scenario 2: A 45-year-old enrolled in a Marketplace plan in Miami-Dade County, FL with an annual income of $65,000 (415% of the federal poverty level (FPL)), would pay an estimated $2,027 more per year for coverage for the second lowest cost silver plan, with the monthly premium going from $460 to $629. (Additional scenarios can be run using this KFF interactive tool.) Costs would go from being caped at 8.5% of their income to consuming 11.6%

Certain state enrollees are already facing especially large hikes. Looking at the 5 states with the greatest HIV prevalence the, median and range requested premium increases for the 2026 plan year are as follows:

• CA: 14% (7%-20%)
• FL: 26% (19%-41%)
• GA: 20% (9%-43%)
• NY: 13% (10%-37%)
• TX: 19% (3%-42%)

There are multiple potential impacts of increased premium costs for individuals with HIV paying for their own coverage. While some people may retain coverage, and be able to manage the increased costs, others could:

• Retain coverage and struggle with the increased costs.
• Choose a plan with less expensive premiums, but potentially higher out-of-pocket costs for items like HIV medications, labs, and provider visits.
• Drop coverage altogether and not seek alternative access to care or coverage.
• Drop coverage and seek support from the Ryan White Program.

AIDS Drug Assistance (ADAPs) Programs

Notably, HIV programs would also be impacted if enhanced tax credits are not extended, with the policy lapse costing them potentially tens of millions of dollars. This is especially the case for AIDS Drug Assistance Programs (ADAPs), which are part of the Ryan White HIV/AIDS Program, a federal safety net program for those with low-to-moderate incomes, reaching over half of people with HIV in the U.S. ADAPs provide HIV medications to people with HIV either directly or by purchasing insurance coverage with prescription drug benefits on their behalf and/or assisting with cost-sharing of insurance coverage. Each state/territory runs its own ADAP and programs differ in their operation and services provided. ADAPs face limited budgets and federal allocations have been fairly flat over time, making the program vulnerable to changes in the size of the population needing services as well as the cost of those services. ADAPs hit with rising premiums or increased enrollment, could be faced with modifying their programs in ways that could impede access.

Most ADAPs purchase private insurance premiums for clients (at least 42 states and DC in 2023¹). In total, in 2023 at least 76,365 clients were assisted with insurance assistance that included help paying for premiums across insurance markets. Among all ADAP clients, over 40,000²  were enrolled in Marketplace plans in 2023 and most received insurance support from the program. ADAPs that enroll eligible clients in Marketplace plans receive the benefit of the tax credits (currently available to those 100% of the poverty level and above) and have processes in place to work with clients on tax credit reconciliation at the end of the year. Larger shares of ADAP clients receiving premium support ³ have incomes above 100% FPL (the income level at which tax credit eligibility begins) compared to those enrolled in full-pay drug support only.

Increased costs resulting from expiring enhanced tax credits and higher premiums, would not impact ADAPs evenly across the country. Levels of enrollment, differences in typical family income and age of clients, and type of plan enrollment would impact how these changes affect ADAP budgets, among other factors. ADAPs with smaller client enrollment or less robust insurance purchasing programs would be more sheltered and those with larger client enrollment and robust insurance assistance programs would likely to be harder hit. It is possible that ADAPs in non-Medicaid expansion states could being especially impacted. In expansion states, many clients with incomes 100-138% of the FPL would be enrolled in the Medicaid program whereas in non-expansion states, those clients would be more likely to be enrolled in ADAP insurance assistance through the ACA marketplace. For example, the share of ADAP clients enrolled in Marketplace plans (regardless of whether ADAP is assisting with costs) is much higher for Florida (31%) and Georgia (25%), high prevalence non-expansion states, than in California (15%) or Illinois (11%), high prevalence expansion states.

Additionally, as noted above, issuers are planning large premium increases for the coming year. ADAPs with clients enrolled in Marketplace plans would still have some protections from these price hikes through premium tax credits. Even if the enhanced credits expire, clients 100%-400% FPL would still have the original tax credits provided through the ACA. However, clients enrolled in off Marketplace ACA compliant plans (about 9,600 clients in 2023) and clients with incomes over 400% FPL (7% of ADAP clients with premium support or multiple types of ADAP support in 2022) would not have any buffer against these rising costs. Further, ADAPs might also face higher costs if those who had been purchasing coverage independently, find increases in premiums unaffordable and turn to the program for assistance.

Even relatively small cost increases in ADAP budgets can challenge their ability to maintain their current levels of services and some have raised questions about how they would respond to this and other future policy changes. ADAPs could respond in a number of ways, some of which could amount to limiting access to program services or generosity and/or seeking alternative resources to supplement federal funds:

• Cost-containment strategies could include changing the eligibility for the program – for example reducing the income eligibility level – or further limiting plans in which clients can enroll. Another possible action is making ADAP formularies for clients receiving direct drug assistance less generous or introducing more utilization management techniques like prior authorization or step-therapy. ADAPs could also introduce or reduce caps on their programs (or on drug utilization) and could also create waiting lists. Waiting lists have been used in the past when program budgets have been strained but were last cleared through infusion of supplemental federal funds in 2012.
• ADAPs faced with increased costs could try and supplement ADAP earmark funding (funding dedicated to ADAPs by Congress) with funding from other sources such as the state’s non-ADAP Ryan White fundings (Part B), funding from local county/city Ryan White Grantees (Part A), other state/local funding, maximizing generation of program income, and seeking deeper rebates from pharmaceutical companies, among other actions. However, if funding is shifted from Part B or other state or local funding (entities with already constrained budgets) to ADAPs, this could mean a reduction of other public health services.

Beyond ADAPs, grantees of other “Parts” of the Ryan White Program are also permitted to use funding to support client enrollment in health insurance, including in Marketplace plans. While this occurs less commonly among other grantees than it does with ADAPs, any other grantees currently using funding this way, would also be impacted by the above cost-increases resulting from expiration of enhanced tax credits and increases premiums for 2026.

Potential Impact of Policy Changes on HIV Care

As described above, if these changes occur, they are likely to have an impact on both individuals with HIV and the programs people with HIV rely on. Individuals could lose coverage and/or face higher costs, and might turn to Ryan White for assistance. To address funding shortfalls due to these changes, ADAPs could work to inject new funding into their programs but could also constrain existing eligibility and benefits or restrict enrollment.

Increased premiums or certain changes to ADAPs could lead to enrollees being less engaged with or fall out of HIV care and treatment. Higher out-of-pocket costs are a known deterrent to care engagement. KFF has found that over-quarter (27%) of people with HIV who are out-of-care say that at least one barrier to care has been problems with money or insurance and of those who recently missed an antiretroviral dose, nearly 10% say problems were as a barrier. Since HIV care and treatment engagement improves individual health and because viral suppression prevents transmission of HIV to others, monitoring access to services and safety net program capacity moving ahead will be important, as will assessing the potential public health impact, if people with HIV lose access to care and treatment.

Finally, while the potential expiration of tax credits is a looming  major change on the health policy horizon, there are other significant changes coming that could impact care, coverage, and programs for people with HIV. The recent budget reconciliation bill (HR1) makes a range of changes to the health system that will reduce coverage, some impacting the private market but the biggest, reshaping state Medicaid programs, the primary payer for HIV care in the U.S. These changes too could put downward pressure on ADAPs which are already operating on budgets that have remained mostly flat for decades.

Methods and Limitations

Methods: The estimated average income was generated based on income and age date from the Health Resources and Services Administration (HRSA). Ryan White HIV/AIDS Program AIDS Drug Assistance Program (ADAP) Annual Data Report 2022. Published September 2024 (Updated May 2025). The data is based on 2022 ADAP client enrollment. Age and income data was examined for ADAP clients with premium support and those getting multiple ADAP services (likely including premium support). Age and income data in the HRSA report is presented in ranges with the number of clients in each category. The range midpoints were identified within each category. For age, the estimated average age was calculated based on a weighted average of age midpoints, excluding those over 65, a group likely enrolled in Medicare. The average age used in this analysis was 47. For each income category incomes were calculated based off the range midpoints using the 2025 FPL guidelines from HHS. For the mid-point of each category for incomes above 100% FPL (those currently tax credit eligible), the increased cost of expired tax credits was assessed using the KFF calculator and then weighted based on the number of clients within the category (the weighted average estimated increases for each range are below). This analysis used the “US average”, and was based on a single person family size, representing a national average of second-lowest cost silver page weighted by plan selections. Across all income categories we estimated an average subsidy loss of $1,364. (See Table 1.)

Limitations: There are several limitations with this estimate: While those over 65 were excluded from the average age estimates, it was not possible to exclude the incomes of those over 65 from the income calculations. It is possible Marketplace enrollees have different demographics from these estimates which include clients receiving any ADAP insurance premium (e.g. some clients receiving ADAP assistance for employer insurance). It is estimated that about 40,000 ADAP clients are enrolled in Marketplace plans (the data above is for about 60,000 clients). In particular, it is possible that these income estimates are high given that those with employer coverage are likely to have higher incomes than those with Marketplace coverage. The estimates also inlcude those receiving “multiple ADAP services” which is thought to inlcude those with premium assistance but could theoretically inlcude others. Averages could also obscure actual changes in costs.  Location of enrollment should not impact costs for most of those under 400% FPL because of the structure of the tax credits. However, the US average used for the location may be imprecise for the 7% of enrollees assisted with premiums over 400% whose costs would vary by location. As noted above, actual costs will vary by client demographics (i.e. age, income, family size and location for those over 400% FPL who would lose the entirety of their tax credit) as well as client plan metal level enrollment. Additional scenarios can be run using the KFF calculator.

1. Data from Alabama, Montana, and West Virginia were not available. ↩︎
2. The number of ADAP clients in Marketplace plans in unknown in full or in part in several states, including New York and Texas, states with high HIV prevalence and ADAP enrollment, so this is likely an undercount. ↩︎
3. This is not specific to QHP enrollees includes any client getting premium support (e.g. it includes those getting assistance for employer plans or other coverage). ↩︎