Health care costs are a top concern for the public, and there is widespread interest among lawmakers in making health care more affordable. Attention has increasingly focused on hospitals, which represent nearly one third of total health care spending and accounted for 40% of spending growth from 2022 to 2024. Hospital spending reflects both the prices paid for services and the volume and intensity of care delivered, and trends in both factors have implications for affordability and spending growth. The prices paid by private insurers are higher than Medicare rates on average—e.g., nearly double traditional Medicare rates for hospital services when averaging across studies, according to a prior KFF review—and vary across regions and across hospitals and payers within regions. These high prices affect households through higher premiums and cost sharing obligations and reduced wages for those with employer-sponsored health coverage.

There has been some discussion at both the national and state level about policies that could rein in hospital prices. One set of policies aims to do so by promoting competition and reducing consolidation in provider markets. A substantial body of evidence shows that hospital market consolidation has contributed to higher prices, with unclear effects on the quality of services provided. Another set of policies would rein in prices more directly, such as by capping the prices that providers can charge. For example, Indiana recently enacted a law that will eventually cap private insurance prices for the state’s nonprofit hospitals, and Oregon has capped hospital prices at 200 percent of traditional Medicare rates for its state employee plan since 2019.

To inform policy discussions related to hospital prices and price regulation, this brief describes the growth of prices paid by private insurers for hospital care relative to increases in Medicare payment rates from April 2019 through April 2026, using data from the Bureau of Labor Statistics (BLS) Producer Price Index (PPI). The analysis begins in 2019 to fully capture changes in prices during the pandemic. See Methods for more detail.

Hospital Prices Have Risen Much Faster for Private Insurance Than Medicare Since 2019

Private insurance prices for hospital care rose 30% from April 2019 to April 2026 compared to a 21% increase in Medicare rates (Figure 1). Put differently, private insurance prices grew 47% more quickly than Medicare rates over this 7-year period. Private insurance prices grew at a similar pace as Medicare rates from April 2019 to April 2020, but grew more quickly than Medicare rates each year from April 2020 to April 2025, before increasing less quickly than Medicare rates from April 2025 to April 2026. These patterns are broadly consistent with prior research that finds faster price growth for private insurance than Medicare over time, with some variation across time periods. Private plans pay much higher rates than Medicare for hospital services according to prior research, and this analysis suggests that the gap has increased over time.

Private insurance prices for hospital care are the result of negotiations between hospitals and insurers. Increases in private prices over time can reflect changes in the cost of providing care and in the bargaining power of hospitals relative to insurers, among other factors. Hospital markets have become increasingly consolidated, with one or two health systems controlling at least 75% of the market for inpatient hospital care in the large majority of metropolitan areas (83%) in 2024, according to KFF analysis, contributing to higher prices. Large increases in labor and supply expenses during the pandemic have likely pushed providers to negotiate for higher prices (economy-wide inflation jumped in March and April 2021 before reaching a peak in June 2022). However, contracts between hospitals and insurers are only periodically renegotiated, and often last for multiple years, meaning there may be a lag before any effects of higher input costs are fully reflected in higher prices.

In contrast, traditional Medicare hospital prices are updated annually by the Centers for Medicare and Medicaid Services (CMS), primarily through the Inpatient and Outpatient Prospective Payment Systems (IPPS and OPPS). These changes are based on factors and methods described in law and regulation. Medicare IPPS and OPPS updates are based partially on estimates of increases in hospital services input costs, which are affected by overall inflation. There is some evidence that rates paid by Medicare Advantage plans for hospital services (incorporated with other private Medicare plans in the Medicare but not private insurance PPI) are generally close to rates paid by traditional Medicare. Increases in prices paid by Medicare Advantage insurers have likely been aligned with changes in traditional Medicare rates over time.

One factor that slowed Medicare growth is that the program underestimated inflation in recent periods when prospectively setting rates (e.g., inflation in 2022 was much higher than expected when hospital rates were set for that year), according to the hospital industry and others. Nonetheless, CMS has noted that its forecasts have tended to be close to actual inflation on average when looking over longer periods for the IPPS hospital market basket (see Methods for more detail).

Various other factors may have restrained Medicare price growth during the study period, such as the productivity adjustments enacted under the Affordable Care Act, which reduce the growth in traditional Medicare rates over time under the assumption that hospitals are becoming more efficient at delivering care. As another example, sequestration, which is an automatic reduction in Medicare payments required under budget rules, was temporarily suspended during the pandemic beginning in May 2020 but gradually reintroduced in April and July 2022, likely contributing to the increase and decrease in the Medicare PPI during those periods.

Methods

This brief used the Producer Price Index (PPI) to evaluate hospital prices and overall inflation over the seven year period from April 2019 to April 2026 (the most recent month available). The PPI measures prices from the perspective of producers of a good or service, such as hospitals. The PPI was used over other comparable measures like the Consumer Price Index (CPI) because it breaks out hospital price growth by payers, such as Medicare and private insurance. The PPI for private insurance excludes private Medicaid and Medicare plans. The PPI for Medicare includes both traditional Medicare and private Medicare plans, including Medicare Advantage, which accounted for 54% of the eligible Medicare population in 2025.

Hospital price growth overall (i.e., across all payers) as measured by the PPI grew much less quickly than hospital price growth as measured by the CPI during this period. Differences between the PPI and CPI reflect both conceptual and methodological differences. For example, the CPI—which measures prices from the perspective of consumers—excludes Medicare Part A, Medicaid, and certain other payers from its price measurements.

This analysis examines hospital PPI data classified by industry, in this case, the hospital industry. The PPI also produces series classified by a specific commodity, such as a product or service. This brief uses industry classifications because they provide an overall measure of hospital prices by payer, while the commodity classifications are separated into inpatient and outpatient price measures and only distinguish private insurers from other non-Medicare, non-Medicaid payers for the former.

Most of the increases in the Medicare hospital PPI occur in October and January over time. That likely reflects, at least in large part, the timing of when traditional Medicare updates inpatient and outpatient reimbursement for hospitals, respectively.

CMS noted in its FY2026 IPPS rule that its forecasts for the IPPS hospital market basket have tended to be close to actual inflation on average when looking over longer periods. This basket is used for both IPPS operating and OPPS payment updates (though it is unclear if CMS’s comment above was also including OPPS payments, which are updated on a different schedule). During the 2026 rulemaking process, CMS received comments, including from the hospital industry, recommending an increase in IPPS operating and OPPS payment rates to account for prior errors in forecasting, though CMS did not do so, citing various reasons. CMS does make certain adjustments for forecasting errors for IPPS capital payments (as it has proposed to do in FY2027), which account for a relatively small share of hospital payments.

The 2025 reconciliation law will—for the first time—require adults who are enrolled in Medicaid though the Affordable Care Act (ACA) expansion, along with those in partial expansion waiver programs in Georgia and Wisconsin, to meet work requirements or qualify for an exemption as a condition of eligibility starting in January 2027 in most states.

States may adopt an optional hardship exception to Medicaid work requirements for individuals living in counties with unemployment rates at or above 8%, or at least 1.5 times the national average unemployment rate. A recent KFF survey found that most states plan to adopt this exception, which will exempt both Medicaid applicants and enrollees in counties with unemployment rates that meet the specified thresholds. However, four states, Indiana, Iowa, Missouri, and Oklahoma, do not plan to adopt the exception.

An update to a previous KFF analysis of county unemployment rates, using 12-month average unemployment rates from February 2025 through January 2026, and county-level Medicaid expansion enrollment estimates that:

• 1.4 million expansion enrollees, or 7.5% of expansion enrollees, live in counties that meet the high unemployment threshold and may qualify for the hardship exception in the 27 states that plan to adopt the exception and in the 12 states that had not made a decision on adoption at the time of the KFF survey. 
• Among the states that are planning to adopt or may adopt the exception, 133 counties in 22 states meet the high unemployment thresholds, representing 7% of counties in expansion states and states with partial expansion waiver programs. No counties meet the thresholds in 16 states, and DC does not meet the thresholds. 
• Nine in ten expansion enrollees who are in counties that meet the high unemployment criteria and could be exempt from the work requirements live in five states—California, New York, Michigan, New Jersey, and Oregon.
• Among the states that do not plan to adopt the hardship exception, two counties in Iowa and Missouri meet the high unemployment thresholds, and approximately 3,300 expansion enrollees in those counties may have qualified for the high unemployment hardship exception if the states had decided to adopt the exception. In Indiana and Oklahoma, there are no counties that meet the thresholds.

Nebraska began enforcing work requirements on May 1, 2026, the first state to implement the new requirements. Although the state indicated it would adopt the high unemployment hardship exception, no counties in the state currently meet the thresholds. 

States are waiting for federal guidance on how to implement this hardship exception, including what data will be used to identify counties that meet the thresholds and what additional information states must submit. This analysis uses the most recent available county-level unemployment data from Bureau of Labor Statistics (BLS) and is consistent with the methods used to determine whether any counties qualify for the high unemployment exemption waiver from SNAP work requirements. However, the guidance, which CMS is expected to release in early June, may require a different method.

KFF’s interactive Medicaid work requirements tracker includes new county-level unemployment data by state, showing which counties meet the high unemployment thresholds and how many expansion enrollees in those counties may be exempt from work requirements.

The President’s Emergency Plan for AIDS Relief (PEPFAR) has been and continues to be subject to a range of Congressional reporting requirements. These include enduring (ongoing) requirements as well as time-bound requirements, through both PEPFAR’s authorizations as well as appropriations legislation in some years.

This document provides a list of reporting requirements identified in PEPFAR’s authorizing legislation over time as well as other key legislation. Table 1 includes current requirements and requests. Table 2 includes past requirements and requests that are no longer in effect. While this document lists most such requirements, it may not be exhaustive.¹

1. There are other requirements [such as those that are not specific to PEPFAR established under the Foreign Aid Transparency and Accountability Act (FATAA) of 2016, for example, which includes more general reporting requirements; and some in appropriations legislation, along with accompanying congressional reports and explanatory statements, over the more than 20 years of PEPFAR] that are not included in this analysis. ↩︎

The current administration is placing a new emphasis on potential fraud in Medicaid with its Comprehensive Regulations to Uncover Suspicious Healthcare (CRUSH) initiative. The Centers for Medicare and Medicaid Services (CMS’) started the new initiative in Medicaid focusing on Minnesota and three other states with Democratic governors (California, Maine, and New York) while the House Committee on Energy and Commerce sent requests for information to 11 states. CMS has historically partnered with states to identify and resolve issues of fraud, waste, and abuse, and denied the federal share of Medicaid spending when fraud has been identified by an audit, investigation, or reported by the state. However, CMS has recently announced a new approach to fraud that will rely more heavily on options to prevent spending federal funds in cases of potential fraud, which could have broad implications for states and enrollees. This issue brief explains the new approach. Key findings include:

• CMS’ historic practice has relied on disallowing federal Medicaid payments when fraud is identified (typically through an audit), a process that may take several years to implement.
• CMS’ new approach to potential fraud involves potentially pausing or withholding federal Medicaid payments when fraud is suspected (Figure 1). This approach differs from prior approaches because, if implemented, it could have more immediate consequences, place a much larger share of federal spending at risk (including spending that pays for services uninvolved in fraud), and proactively shift the burden of proof to states to obtain federal funds.
• While all approaches aim to limit future fraudulent payments using tools such as corrective action plans, the new approach to federal Medicaid spending when fraud is suspected creates uncertainty for state budgets and could have implications for Medicaid enrollees and providers who are not involved in fraud.

What is a disallowance?

The federal and state governments share responsibility for financing Medicaid, and states draw on federal funds to pay health care providers and health plans for providing health care to enrollees. The federal government makes quarterly grant awards to states to cover the federal share of Medicaid spending. Awards reflect states’ estimated expenditures for the upcoming quarter and adjustments from prior quarters’ expenses. Adjustments reflect various considerations such as:

• Instances where states’ estimated expenditures are higher or lower than actual expenditures
• Changes to accounting practices or federal matching rates
• Reductions in payment resulting from claims where fraud has been identified

Publicly-available data on Medicaid expenditures show the total amount of adjustments each year, reflecting the net impact of all various factors, and do not specifically identify adjustments due to disallowances and deferrals.

Historically, CMS has used disallowances to deny federal matching funds for state Medicaid expenditures that have already occurred and are later determined to be not allowable. There is limited information available about the frequency and scope of Medicaid disallowances, but an older report by the Government Accountability Office (GAO) suggests that they were not infrequent between 2014 and 2017. Upon receiving a disallowance notice, states may request that CMS reconsider the decision and provide additional information to CMS to demonstrate that the expenditures were allowable or accept the disallowance and resolve it directly with CMS. In all cases, once CMS has issued a disallowance, “the state has the burden of documenting the allowability” of the expenditures to overturn the disallowance. When states request a reconsideration, CMS has 60 days to decide, although this timeline may take longer if CMS requests additional information from the state.

States may appeal the disallowance decisions to a Departmental Appeals Board, but the state still has the burden of proof for documenting the allowability of expenditures and the process may take years to resolve. States are not required to request a reconsideration before appealing the disallowance. More information is publicly available for cases where states do appeal the decisions than for cases where they settle or request a reconsideration. In such cases, data about the decisions of the Department Appeals Board are available online through the Department’s website. Between 2020 and 2025, the Departmental Appeals Board has issued 12 Medicaid disallowance rulings (with 6 rulings being an appeal of a prior case). In all 6 new rulings, there were on average 15 years between the oldest year of disputed expenditures and the final ruling, highlighting how long it takes to resolve these cases (see Figure 2 for an example from Texas). All cases were decided in favor of CMS, but that may reflect the fact that CMS has historically used disallowances only in cases where fraud is well-established.

The amount of disputed disallowances where the Departmental Appeals Board issued a ruling between 2020 and 2025 ranged from less than $500,000 to almost $200 million, but these amounts reflect differences in the number of years and scope of services within the disallowed claims. Some of the largest disallowances to be upheld involve disproportionate share hospital (DSH) payments.

• The largest disallowance ruling between 2020 and 2025 was $195.7 million in a case involving Michigan’s DSH payments between 2001-2009. In that instance, CMS in 2018 determined that the state had made DSH payments to a small number of hospitals that were ineligible to receive them. The Departmental Appeals Board ruling was in 2024.
• The second largest disallowance ruling between 2020 and 2025 was for more than $97 million in a case where Florida made DSH payments between 2006-2013 in excess of the limits established for specific hospitals (CMS first issued this disallowance in 2016 and the Departmental Appeals Board ruling was in 2021).

What is a deferral?

With deferrals, CMS pauses payment for state Medicaid expenditures that have already ocurred and requires the state to provide additional information demonstrating that expenditures are “allowable.” Deferrals are usually initiated by the federal government and may be used to pause federal funding while the state and federal governments work out the details of a disallowance, and in cases where fraud, waste, or abuse has been identified and the state and federal governments are gauging the extent of the issue. In the past, deferrals were used as temporary measures that pause funding until CMS either reimburses the expenditures or issues a disallowance. Deferral notices must specify the reason for the deferral and include a request for all documents and materials that CMS believes are necessary to determine whether the expenses are allowable. After the notice is sent, the loss of federal funds occurs immediately.

After receiving a deferral notice from CMS, states have 60 days to provide all requested documents and materials unless they request an additional 60-day extension. CMS usually begins document review within 30 days but may request different formats or additional materials from the state. States have 15 days to submit additional materials and if they do not meet that deadline, CMS disallows the expenses. Once all documents are available, CMS has 90 days to review and determine whether expenditures are allowable. If CMS determines expenditures are not allowable, the disallowance process begins, offering the state the opportunity to request a reconsideration and appeal to the Departmental Appeals Board.

Deferrals are receiving new attention after the administration announced that it would temporarily defer $259 million in federal Medicaid payments to Minnesota for expenditures incurred in quarter 4 of in fiscal year (FY) 2025, an unprecedentedly large amount. In the announcement, CMS noted that it may continue to defer federal payments for either additional quarters in 2025 or future quarters in 2026, and that similar announcements for other states would likely be coming soon. As of March 25, 2026, 4 additional states have received formal letters from CMS requesting information about program integrity, and 11 states have received formal letters from the House Committee on Energy and Commerce (Figure 3).

What is a withhold?

In January 2026, CMS notified Minnesota that pending the outcome of a hearing, it would begin withholding $515 million in quarterly federal Medicaid payments moving forward, a process that has seldom been used in prior years. Withholding funds has been referred to as the “compliance process” because it is only permissible in cases where the state is failing to comply with Medicaid law. Prior use of withholding has been limited. When CMS has considered withholding as a compliance tool in the past, it announced withholdings that were at most between 1 and 10 percent of the federal share of Medicaid spending for specific services (in most cases, the administrative costs states incurred to implement their Medicaid programs). Prior CMS communication notifying states of possible withholdings appear to have been used when states incorrectly restricted eligibility or benefits, thus failing to comply with minimum requirements regarding access to coverage or eligibility. Minnesota’s case is different because of the scope of the proposed withholding and because the proposed withholding would be to address potential future fraud, rather than state policies that restrict Medicaid eligibility or benefits. The announced level of withholding would have represented nearly 20% of the federal share of Minnesota’s spending on an annual basis.

To withhold federal Medicaid funds, CMS must first provide states with the opportunity for an administrative hearing, and withholding generally ends when CMS is satisfied with states’ resolution of the issue. Withholdings may reflect issues with states’ Medicaid approved plans or with states’ implementation of the plans. Because CMS has authority to approve states’ plans, most issues arise regarding implementation of the plan and are resolved using a corrective action plan. Corrective action plans may also be used to address other types of issues in Medicaid (such as payment error rates or eligibility re-determinations). In general, the plans include a narrative of steps states are planning to take to address issues related to proper implementation of the Medicaid program. On January 13, 2026, Minnesota requested a hearing about the withholding and on January 30, 2026, Minnesota submitted a revised corrective action plan to CMS. On March 20, 2026, CMS accepted Minnesota's revised corrective action plan. Successful completion of the corrective actions outlined in the plan will resolve the threat of withholding.

What are the implications of new reliance on deferrals and withholds?

The new approach to federal Medicaid spending when fraud is suspected creates uncertainty for state budgets, particularly given the magnitude of federal funding at stake and the time it takes to resolve administrative disputes. Unlike the federal government, states must generally operate balanced budgets, which is one reason states are able to draw down matching funds to finance ongoing expenditures. If withholding is implemented, the loss of federal funds could make it difficult for states to maintain current programs while details of the cases are being sorted out. More extensive use of deferrals could have similar, but more immediate, destabilizing effects on states’ budgets because they reduce the amount of federal funds available to states for several months, and the state has no option to request reconsideration or appeal until a disallowance is issued. Increasing the use of deferrals so that it applies to entire categories of services where fraud is suspected but not established would also place a new administrative burden on states to demonstrate the allowability of expenditures. Other approaches to addressing suspected fraud, waste, and abuse remain available to CMS. The National Association of Medicaid Directors (NAMD) has suggested the following actions to help states to address fraud waste, and abuse in Medicaid:

• Help states identify federal materials about best practices such as recommendations and provider enrollment self-assessments;
• Create rapid methods to share information about provider disqualifications between Medicare, the Veterans' Health Administration, and Medicaid;
• Respond more quickly to fraud reports from state attorneys general and the Medicaid Fraud Control Units;
• Strengthen procedural pathways for states and CMS to work collaboratively on Corrective Action Plans to enhance adherence to provider requirements while maintaining access to Medicaid benefits;
• Conducting additional analysis of Medicaid data through the Center for Program Integrity;
• Strengthening federal data sources and their interoperability; and
• Providing technical assistance to state officials and staff.

New uncertainty about the availability of federal funding could have implications for Medicaid enrollees and providers who are not involved in fraud. If states have inadequate funding to maintain existing Medicaid services, they may face difficult decisions regarding how to limit Medicaid spending. In general, states can reduce Medicaid spending by decreasing payment rates for providers, covering fewer services, or enrolling fewer people. Such actions could affect enrollees and providers who are not using or providing services in which fraud is suspected. There will also be additional disruptions for providers who lawfully provide Medicaid services where fraud is suspected because of new administrative burdens associated with increased audits, delayed payments, and other administrative practices.

CMS’ new approach to addressing cases of suspected fraud may exacerbate administrative and financial challenges states face as they implement the 2025 reconciliation law. The 2025 reconciliation law made historic reductions in federal funding for Medicaid and created new administrative requirements for states, particularly those that must implement work requirements for enrollees eligible for Medicaid through the Affordable Care Act Medicaid expansion. As states work to implement those changes and adjust to changes in federal financing, the new approach to fraud creates additional administrative requirements and potential new reductions in federal funding. Combined, these changes may have more significant implications for states’ ability to maintain existing levels of Medicaid payment rates, coverage, and eligibility.

On May 22, the House passed a reconciliation bill, the One Big Beautiful Bill Act, which would partially pay to extend expiring tax cuts by cutting Medicaid. The Congressional Budget Office (CBO) estimates that the bill would reduce federal Medicaid spending by $793 billion over ten years and 10.3 million fewer people would be enrolled in Medicaid in 2034, including 1.3 million people with Medicare, otherwise known as “dual-eligible individuals”. The loss of Medicaid coverage for Medicare beneficiaries stems from delaying implementation of two rules that aimed to streamline the enrollment process and make it easier for people to maintain Medicaid coverage by reducing administrative barriers. Dual-eligible individuals would be disproportionately impacted by these provisions, comprising nearly 60% of the 2.3 million Medicaid enrollees who are estimated to lose coverage as a result of delaying these rules under the House reconciliation bill (Figure 1). Instead of placing a moratorium on implementation of the rules, the recently released Senate reconciliation language would prohibit nearly all of the provisions in the rules from ever being implemented.

Dual-eligible individuals have low incomes and modest savings. The 1.3 million people that would no longer have Medicaid if the eligibility and enrollment rules were not implemented would retain their primary health insurance coverage under Medicare, but lose Medicaid coverage of Medicare premiums, and in most cases, cost sharing, which are provided through Medicare Savings Programs (MSPs) administered by state Medicaid programs. Many would also lose coverage of Medicaid benefits that supplement their Medicare coverage, such as long-term care, dental services, and non-emergency medical transportation.

The loss of Medicaid coverage for Medicare beneficiaries stems from provisions in the House bill that would delay implementation of two Biden administration rules until 2035. The two rules that would be delayed under the House reconciliation bill were intended to make it easier for people to enroll in and maintain Medicaid coverage by minimizing administrative burden in the following ways.

• One rule aimed to reduce barriers to enrollment in the Medicare Savings Programs (MSPs), under which Medicaid pays Medicare premiums, and in most cases, cost sharing for low-income Medicare beneficiaries. Among other changes, the rule would automatically enroll Medicare beneficiaries with Supplemental Security Income (SSI) into the MSPs and would more closely align the MSP application to the application for Medicare’s Part D prescription drug Low-Income Subsidy (LIS).
• The second rule would more broadly streamline application, enrollment, and renewal processes in Medicaid. Among the changes most relevant for dual-eligible individuals are new requirements for states to assist applicants with procuring appropriate documentation to validate income and assets, a requirement to renew Medicaid coverage only once per year, and a prohibition on requiring in-person interviews as part of the application process

CBO estimates that delaying these two rules would reduce federal spending by $167 billion over 10 years, making this the second largest source of cuts to federal Medicaid spending in the bill. Illustrating why administrative burdens may make it hard for dual-eligible individuals to maintain Medicaid, prior KFF research finds that among people who newly become eligible for both Medicare and Medicaid, 28% lose Medicaid coverage within the first year despite living on fixed incomes.

Although states have already implemented some of the rules’ provisions (Table 1), if the rules are delayed, it is expected that further implementation will cease and states may resume some practices that were prohibited under the rules. For example, 38 states report sending pre-populated renewal forms to Medicaid enrollees who qualify because they are ages 65 and older or have a disability, a practice they may discontinue if the rules are delayed. Alternatively, it’s possible that some states will reinstate requirements for applicants to submit paper documentation or report for in-person interviews. In a few cases, states will be required to reinstate application requirements or be prohibited from using more streamlined application processes.

Losing Medicaid coverage would substantially increase out-of-pocket costs for low-income Medicare beneficiaries. Because Medicare beneficiaries who qualify for Medicaid typically have very low incomes and little to no savings, the loss of Medicaid payment for the costs of Medicare’s premiums and cost sharing could make their Medicare coverage unaffordable. For example, the first rule would automatically enroll low-income Medicare beneficiaries who receive Supplemental Security Income (SSI) into a MSP. Without the MSP, such people must pay 20% of the $967 SSI monthly benefits for the $185 Medicare Part B monthly premium in 2025. (In order to qualify for SSI, individuals must have low incomes, limited assets, and either be over age 64 or have a qualifying disability.) This same individual would have additional out-of-pocket costs if they went to the doctor or were admitted to the hospital. Those additional out-of-pocket costs could discourage low-income beneficiaries from using health care and is the reason for CBO’s estimate that delaying implementation of the rules would reduce Medicare spending by $11 billion over 10 years.

Additionally, some of the 1.3 million Medicare beneficiaries expected to lose Medicaid under the House reconciliation bill may also lose subsidies that help pay for prescription drug premiums and cost sharing. Medicare beneficiaries with Medicaid are automatically enrolled in the Medicare Part D Low-Income Subsidy (LIS), which provides assistance with Part D prescription drug premiums and cost sharing. Illustrating the connection between Medicaid enrollment and LIS coverage, between December 2024 and January 2025, the number of LIS recipients decreased by 1 million, following Medicaid disenrollments that stemmed from the unwinding of the Medicaid continuous enrollment provision. Before the decline, LIS enrollment had been slowly but steadily growing over time.

This factsheet was first published on March 20, 2024 and updated on May 14, 2026 to reflect policy updates and new data.

On June 24^th, 2022, the Supreme Court ruled on the Dobbs v. Jackson Women’s Health Organization, overturning Roe v. Wade. States can now set their own policies protecting or banning abortion without any federal standard protecting access to abortion. This has created a new focus on medication abortion as an option for expanding access to people facing barriers to abortion care.

Medication abortion, also known as medical abortion or abortion with pills, is a pregnancy termination protocol that involves taking two different drugs, Mifepristone and misoprostol, that can be safely used up to the first 70 days (10 weeks) of pregnancy according to the U.S. Food and Drug Administration (FDA).  The World Health Organization has authorized use up to 12 weeks of pregnancy. Since the FDA first approved the drug in 2000, its use in the United States has quickly grown. In 2023, 65% of clinician-provided abortions in the US were medication abortions. The medication abortion drug regimen approved by the FDA is available in many states across the nation, however, dispensing these pills for the purpose of terminating a pregnancy is now banned in some states. This factsheet provides an overview of medication abortion, how it is used and regulated, the role of the drug in self-managed abortions, and an analysis of the intersection of federal and state regulations pertaining to its provision and coverage.

What is a Medication Abortion?

There are two medication abortion regimens that have a long safety and efficacy record: mifepristone with misoprostol and misoprostol alone. Both involve taking oral medications to terminate a pregnancy.   

Mifepristone and Misoprostol Regimen

The most common medication abortion regimen in the United States involves the use of two different medications: mifepristone and misoprostol. Mifepristone, also known as the abortion pill, or RU-486 is sold under the brand name Mifeprex and through a generic manufactured by GenBioPro in the United States. Mifepristone works by blocking progesterone, a hormone essential to the development of a pregnancy, and thereby preventing an existing pregnancy from progressing. Misoprostol, taken 24–48 hours after mifepristone, works to empty the uterus by causing cramping and bleeding, similar to an early miscarriage. A follow-up visit can be scheduled a week or two later, to confirm that the pregnancy was terminated via ultrasound or blood test. The FDA has found that medication abortion is a safe and highly effective method of pregnancy termination. When taken, medication abortion successfully terminates the pregnancy 91.9% to 99.7% of the time, with a 0.4% risk of major complications, and an associated mortality rate of less than 0.001 percent (0.0005%). Between 2% to 4% of medication abortions may need a procedural intervention with this regimen.

The FDA first approved Mifeprex in 2000. In 2016, the FDA updated and approved a new evidence-based regimen and drug label. This regimen approves use of medical abortions for up to 70 days (10 weeks) of pregnancy (Table 1). Until 2019, mifepristone was only sold under the brand name Mifeprex, manufactured by Danco Laboratories. In 2019, the FDA approved GenBioPro, Inc.’s application for generic mifepristone. In 2021, the FDA announced they would not enforce the in-person dispensing requirement that had been in effect since the approval of mifepristone. With the new REMS in 2023, the in-person dispensing requirement was formally removed.

Misoprostol-Only Regimen

While the combined regimen of mifepristone and misoprostol for medication abortion is recommended, there is a second medication abortion protocol using misoprostol–only that is more commonly used internationally and currently not approved by the FDA. The regimen is also recommended for up to 70 days (10 weeks) of pregnancy. It involves taking 800 µg (4 pills) of misoprostol sublingually or vaginally every three hours for a total of 12 pills. Research has shown the misoprostol-only regimen to be a safe and highly effective method of pregnancy termination, however it may result in a higher incidence of side effects, particularly diarrhea, fever and chills. When taken, the misoprostol-only regimen successfully terminates the pregnancy approximately 80-100% of the time, with a complication rate of less than 1%. Some U.S. telehealth organizations have been providing the misoprostol-only regimen as an option for medication abortion for a number of years.  

Risk Evaluation and Mitigation Strategies (REMS)

In 2011, the FDA added a Risk Evaluation and Mitigation Strategy (REMS) to the dispensing requirements for mifepristone permitting only medical providers who had obtained certification from the manufacturer to prescribe and directly dispense the drug. This requirement has had the effect of limiting the number of clinicians able to prescribe medication abortions, but also necessitated an in-person visit to a health care setting and meant patients could not obtain the medication from a retail pharmacy or by mail.

On December 16, 2021, the FDA removed the in-person dispensing requirement for mifepristone and expanded the distribution to include certified pharmacies in addition to certified clinicians. This change removed the requirement to dispense the medication in person and expanded the opportunity for telehealth in states that have not banned abortion. Despite the change to the in-person requirement, prescribers are still required to be certified by the manufacturers. On January 3, 2023, the FDA approved a protocol for pharmacies, allowing those that have been certified by the manufacturers to dispense mifepristone directly to patients. In March 2024, two major pharmacy chains in the U.S. announced they had become certified to dispense mifepristone and would start dispensing the medication to patients in certain states later that month. Table 2 shows the change in REMS from 2011 to 2023.

State Regulations and Availability

State laws that ban or restrict abortion apply to medication abortion just as they apply to abortion procedures. There are currently large swaths of the country, mostly in the South and Midwest that ban abortion. Even though the federal FDA has approved mifepristone as safe and effective, following the Dobbs decision, the availability of medication abortion today depends on state laws. Even before the Dobbs decision, however, some states restricted access to medication abortion either by blocking the use of telehealth abortions by mandating in-person visits for abortions, imposing requirements for in-person dispensing, or limiting the kinds of clinicians who could dispense the pills (only permitting MDs to dispense). In many states these laws are now superseded by state laws that ban abortion.

There are other ways that state laws also affect use of and access to medication abortion. Some states require that patients be counseled about unsubstantiated claims about the ability to reverse an abortion after mifepristone is ingested. For example, Nebraska, a state that hasn’t banned abortion, requires patients to be counselled that medication abortion may be reversed if given a high dose of progesterone after taking mifepristone—despite a lack of scientific evidence to support this claim. Similarly, Utah requires counseling that mifepristone alone is not always effective in ending a pregnancy and that patients may still have a viable pregnancy after taking mifepristone despite its record of effectiveness. Prior to banning abortion, Arkansas, Idaho, Kentucky,  Oklahoma, South Dakota had similar requirements. Research demonstrates that APCs, such as nurse practitioners, physician assistants, or nurse-midwives, can provide medication abortion as safely as physicians can, but they are only permitted to do so in 24 states and DC out of the 37 states where abortion is not currently banned.

Telehealth

Telehealth can be used to expand access to health services in areas where the number of clinicians who provide abortion care is limited. Many patients, particularly those who live in rural communities, must travel long distances to obtain abortion services even in states where abortion is still permitted, which has raised interest in the potential of telehealth to expand access medication abortion. Because the updated FDA label now allows for telehealth, mifepristone has emerged as an option for patients who are either unable to travel to clinic or for other reasons wish to have an abortion in the privacy of their own home, if permitted by state law. A case brought forth by the State of Louisiana challenging the agency's 2023 decision to eliminate the in-person requirements is currently moving through the courts and could have major effects on the availability of medication abortion via telehealth.

As part of efforts to limit abortion access, some states have taken action to block the use of telehealth for abortion. Among the states that have not banned abortion, ten states have at least one restriction that requires at least one trip to the clinic, and effectively ban telehealth for medication abortion (Figure 1).

In the aftermath of the Dobbs decision, some states started passing "shield" laws. These laws aim to protect physicians from prosecution brought by the states where abortion is banned as long as the physician is located with the state with the shield law and the care they provide is legal in that same state, regardless of patient location. As of July 2025, eight states have shield laws in place that explicitly protect providers regardless of where the patient lives. States with abortion bans are testing the use of shield laws in the courts and lawsuits against telehealth providers in California and New York have been by Texas and Louisiana.

Cost

The national median self-pay price for medication in 2023 was $563, although medications provided by virtual telehealth clinics were much lower in price ($150). Although Danco Laboratories does not make the cost of Mifeprex public, providers report that Mifeprex pills alone cost them around $90 a pill. GenBioPro, the manufacturer of the generic mifepristone drug also does not report the cost of their pill but has stated that they want to drive down costs for those who choose medication abortion. Private insurance coverage of abortion services is variable and depends on the type of insurance plan, the policy holder’s state of residence, and employer coverage decisions. Federal Medicaid funding only pays for abortions when the pregnancy is a result of rape or incest or a threat to the pregnant person’s life. Twenty-one states have opted to use their own state funds to pay for abortions, including medication abortions, for Medicaid enrollees. For those who do not have abortion coverage, there are limited means of financial support, promoted on both Danco and GenBioPro’s website. The National Abortion Federation, as well as local abortion funds are sometimes able to cover some of the cost of an abortion (including travel) for a pregnant person. Outside of these funding sources or a sliding fee scale clinic, there are few options to help with abortion costs.

Use

Although the overall rate of abortion has declined over the past two decades, the use of medication abortion as a share of all abortions has greatly increased over the years. According to Danco Laboratories, by 2016, over 2.75 million women in the United States had used Mifeprex since its FDA approval in 2000. Data from the Centers for Disease Control and Prevention (CDC) show medication abortions have increased steadily over the past 15 years. A Guttmacher Institute report found that medication abortion accounted for 63% of all nonhospital abortions in 2023, although this is likely an undercount since it does not include self-managed abortions. In the first half of 2025, 27% of all abortions were provided via telehealth.

Self-Managed Abortion

Self-managed abortion, sometimes referenced as “self-induced” or “at-home” abortion, is when a person ends a pregnancy outside the medical care setting, typically by ordering abortion pills online. Patients may seek to manage their own abortion for many reasons, including state bans, clinic access barriers, cost, transportation, time limitations, and privacy. There are different medication protocols that can be used for a self-managed abortion. As detailed in this JAMA review, an individual can take the FDA-approved medication abortion regimen of mifepristone and misoprostol pills or misoprostol pills alone.

There are a number of companies that offer self-managed abortion services using different approaches. Some companies have a clinician that reviews a customer’s medical information and may have a telehealth visit. Other companies, such as AidAccess based outside the United States, will mail abortion medications to an individual without requiring a clinician visit. Plan C Pills operates a website that provides a list of online retailers in every state and includes information about clinician involvement, price, ship time, product quality, as well as information about how to take the drugs and resources for financing assistance. Prices differ between companies, but typically costs are lower than average charges for a clinic abortion as there is typically no involvement with a brick and mortar clinic.

Self-managed abortions have occurred around the world for years, particularly in areas where abortion access in the medical care system has been limited. Before the FDA removed the REMS requirement for in person dispensing of medication abortion, access to telemedicine abortion care (either through the medical system or self-managed) was extremely limited in the United States. Interest in self-managed abortion has grown in recent years in the United States, particularly since the Dobbs decision. For example, research has documented a sharp increase in requests for abortion pills to the company AidAccess since the Dobbs ruling, rising from an average of 82.6 requests daily before the ruling to 213.7 a day after it was issued, with the largest increases in states that have banned abortion.

None of the current state abortion bans or restrictions criminalize pregnant people for obtaining self-managed abortions, yet there have been many documented cases of people facing criminal charges for self-managing an abortion. Some states impose criminal penalties on clinicians or others who help an individual obtain abortion services. These policies can create a climate of fear related to self-managed abortion for both patients and clinicians, for instance if a patient were to present to a clinician for a complication or follow up care after a self-managed abortion. Some major medical and public health groups such as ACOG, AMA, and APHA oppose any criminalization of patients that seek self-managed abortion.

Conclusion

The use of medication abortion has grown significantly since its approval by the FDA in 2000. The FDA update of the REMS in 2023 has expanded the availability of medication abortion and broadened the use of telehealth dispensing. However, state abortion bans, specific bans on telehealth for medication abortion, and state-level requirements for in-person dispensation of mifepristone and for in-person counseling visits and ultrasounds that are not medically recommended will continue to restrict access in many states.