1115 waivers generally reflect priorities identified by states as well as changing priorities from one presidential administration to another. The Biden administration encouraged states to propose waivers that expand coverage, address health-related social needs (or “HRSN”), and assist individuals with reentry from incarceration. In contrast, the first Trump administration focused on work requirements and eligibility restrictions with a limited focus on enrollee social determinants of health; however, the administration approved a first-of-its kind waiver in North Carolina that allowed the state to provide limited housing and nutrition supports to targeted Medicaid enrollees. In addition, the Biden administration expanded waiver financing tools that had been limited under the first Trump administration.

While the future direction of demonstration waivers is uncertain, recent actions from the Trump administration could signal efforts to curtail waivers related to social determinants of health and to limit waiver financing tools and flexibility. Two major changes demonstrate this shift: (1)  rescinding Biden-era guidance on covering health-related social needs (HRSN) services, and (2) phasing out federal funding for “Designated State Health Programs” (DSHP) in waivers. This waiver watch examines these recent actions in the context of the recent history of Medicaid waivers aimed at addressing enrollee social determinants of health and DSHP.

Use of 1115 Waivers to Address Social Determinants of Health Under Biden and Trump Administrations

The first Trump administration generally had a limited focus on enrollee social determinants of health. Historically states have had limited ability to use Medicaid to help address social determinants of health. Social determinants of health (SDOH) are the conditions in which people are born, grow, live, work and age. SDOH include but are not limited to housing, food, education, employment, healthy behaviors, transportation, and personal safety. Despite a limited focus in general on SDOH, in 2018 the first Trump administration approved North Carolina’s “Healthy Opportunities Pilots,” allowing the state to cover certain non-medical services that target social needs, including housing, nutrition, transportation, and interpersonal relationship supports to specific and limited enrollees. The Pilots operated in three regions of the state and did not go as far as to provide coverage of rent/temporary housing or meal supports equivalent to three meals a day. The Trump administration later released guidance in 2021 highlighting existing federal authorities and opportunities for states to use Medicaid to address enrollee social determinants of health, including under Section 1115 authority.

The Biden administration moved to a more expansive 1115 “health-related social needs” framework and approved 18 waivers authorizing evidence-based housing and nutrition services for specific high-need populations under this framework. (Figure 1). Under the Biden administration, the Centers for Medicare and Medicaid Services (CMS) released a series of guidance documents (which were updated in 2024) on a new waiver opportunity to expand the tools available to states to address enrollee health-related social needs (or “HRSN”). The guidance included federal guardrails and requirements related to expenditure limits, service delivery requirements, and monitoring and evaluation requirements. The HRSN framework allowed for coverage of rent/temporary housing and utilities for up to six months and meal support up to three meals per day, departing from longstanding prohibitions on payment of “room and board” in Medicaid. CMS indicated broadening the availability of HRSN services was “expected to promote coverage and access to care, improve health outcomes, reduce health disparities, and create long-term, more cost-effective alternatives or supplements to traditional medical services.” CMS stressed new HRSN initiatives were not intended to replace other federal, state, and local social service programs but rather to complement and coordinate with these efforts. One of the final Biden administration HRSN approvals was an extension of North Carolina’s waiver under the new HRSN-framework. Reflecting findings from the evaluations of the initial waiver (discussed below in Box 1), the renewal expands the Healthy Opportunities program statewide, introduces new HRSN-framework services (e.g., short-term rental assistance, nutrition supports that were equivalent to three meals a day), and includes new DSHP funding authority.

Use of DSHP Under Biden and Trump Administrations

Spending on certain Designated State Health Programs (DSHP) have been used to draw down federal matching dollars, but support for this policy has varied across the Trump and Biden administrations. HHS has authorized states to access federal Medicaid matching funds for certain types of state-funded health programs in waivers pre-dating the first Trump administration. Generally, this policy may expand available resources by freeing up state funds to finance new Section 1115 waiver initiatives. These state health programs (called DSHPs) do not otherwise qualify for federal funding, must have existed prior to 1115 waiver implementation, and often provide safety-net health care services for low-income or uninsured individuals (such as addiction recovery treatment or support for individuals with intellectual and developmental disabilities). With DSHP authority, states can claim federal match (up to set limits) for state programs approved by CMS.

The first Trump administration announced in 2017 it would no longer accept state proposals for new or renewing 1115 demonstrations that rely on federal matching funds for DSHP. In the guidance, the administration noted oversight concerns and stated there was no “compelling case that federal DSHP funding is a prudent federal investment.” At the time, authority for DSHP in active / current demonstrations was not affected but they could not be extended or renewed. Prior to the Trump administration, DSHP was often used to help finance Delivery System Reform Incentive Payment (DSRIP) waivers, which provided states with significant federal funding to support hospitals and other providers in changing how they provide care to Medicaid beneficiaries. Along with phasing out DSHP funding, the first Trump administration reduced funding for DSRIP renewals and did not approve new DSRIP demonstrations.

The Biden administration rescinded the 2017 DSHP guidance and approved 1115 demonstrations in eight states (nine total demonstrations) that provide federal funding for DSHPs (Figure 1). CMS only approved DSHP expenditure authority in a subset of states with HRSN 1115 approval (in waivers including CalAIM, New York’s Medicaid Redesign, and MassHealth). CMS approved the use of “freed up” state funds for HRSN initiatives (in all states with DSHP expenditure authority) and approved limited other uses (e.g., reentry and workforce initiatives) that varied across state approvals. In waiver approvals, CMS notes that only new waiver initiatives that were determined to promote the objectives of the Medicaid program (such as by “improving access to high-quality covered services”) could be financed with freed up state funds; new DSHP-funded initiatives were expected to not supplant existing services or programs. DSHP authority was described as time-limited and states were expected to submit sustainability plans that describe the state’s strategy to fund and maintain these initiatives beyond the current demonstration approval period. With these DSHP approvals, the Biden administration also introduced new guardrails, including that federal funding for DSHPs could not exceed 1.5 percent of the state’s total Medicaid spending and that states must use non-federal funding sources for at least 15 percent of the state’s share of the cost of new waiver initiatives. Similar to its guidance for HRSN programs, as a condition of DSHP approval CMS required states to meet provider payment rate requirements for core Medicaid services.

Recent Actions Taken by the Trump Administration Related to Waivers

In recent months, the Trump administration rescinded HRSN guidance issued by the Biden administration and announced it would be phasing out DSHP funding authority. Neither action affects currently approved / existing waivers but both may limit new HRSN / SDOH state waiver requests or waiver extension requests. CMS indicates in its March 2025 letter that rescinding HRSN guidance does not nullify existing HRSN approvals but going forward they will consider HRSN / SDOH requests on a “case-by-case” basis. The Trump administration also announced in April 2025 that it does not intend to approve new or extend existing requests for federal matching funds for state expenditures for DSHP. The guidance also says it does not intend to renew a funding mechanism for state health programs specific to Tennessee’s waiver called “designated state investment programs” or DSIP, approved by the Trump administration in 2021 and renegotiated by the Biden administration in 2023. Similar to the 2017 letter, the 2025 letter notes that federal DSIP and DSHP funding have “appeared to serve primarily as a financing mechanism for states” rather than as an integral part of demonstrations. The CMS press release said that “DSHPs and DSIPs have grown from approximately $886 million in 2019 to nearly $2.7 billion in eligible expenditures in 2025, representing increasing costs to the federal government without a sustainable state contribution.” Phasing out DSHP authority may limit states’ ability to finance new 1115 initiatives.

Future waiver approvals and CMS guidance will provide additional insight into the waiver priorities and financing approach of the new Trump administration.  With regard to waiver financing, in addition to phasing out DSHP the first Trump administration made other changes to 1115 waiver budget neutrality policy in 2018 designed to limit the amount of federal funds that could be used for waiver spending. Limits included changing the amount of savings states can carry over between demonstrations and establishing new rules on spending trend rates used in budget neutrality calculations. The Biden administration made changes to Section 1115 budget neutrality policies that provided greater flexibility for states to design and implement 1115 demonstration programs, including HRSN initiatives (such as not requiring offsetting savings for HRSN services). More broadly, the first Trump administration’s Section 1115 waiver policy emphasized work requirements – which were challenged in court – and other eligibility restrictions and capped financing. Since the Trump administration has taken office, some states are again pursuing Medicaid work requirements through Medicaid demonstration waivers. Work requirements in Medicaid are also being considered as part of a broader federal legislative package of potential changes to Medicaid designed to significantly reduce federal Medicaid spending. The future of work requirement waivers may depend on the outcome of these legislative debates, as legislation may mandate work requirements.

This fact sheet provides a historical overview of U.S. funding for global health by program area over the past decade. Funding totals are based on amounts specified by Congress in annual appropriations bills, as well as some amounts that are determined at the agency level. See our Budget Tracker for more detail on historical funding and our Budget Summaries for the latest on ongoing appropriations discussions.

U.S. Global Health Budget: Overview

The U.S. Government is the largest donor to global health in the world and includes support for both disease (HIV, tuberculosis, malaria, and neglected tropical diseases) and population (maternal and child health, nutrition, and family planning and reproductive health) specific activities as well as global health security. Most U.S. funding for global health is provided bilaterally (approximately 80%). Of the multilateral share, the majority is provided to The Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund). The U.S. investment in global health grew significantly in the early 2000s, largely due to the creation of new initiatives including the President’s Emergency Plan for AIDS Relief (PEPFAR) and the President’s Malaria Initiative (PMI). However, over the last decade, U.S. funding for global health has remained relatively flat, with spikes in some years due to emergency supplemental funding for disease outbreaks, including Ebola, Zika, and COVID-19. In FY 2025, global health funding was provided through a continuing resolution (CR) which maintained the prior year (FY 2024) amount of $12.4 billion.

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U.S. Global Health Budget: Global HIV Funding, Including PEPFAR

The U.S. first provided funding to address the global HIV epidemic in 1986. U.S. efforts and funding increased slowly over time until the launch of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003, which initiated a period of significant increases and is the largest effort devoted to a single disease in the world. The majority of U.S. global HIV funding is for PEPFAR bilateral efforts (89%) with additional funding for UNAIDS and international HIV research activities. As part of its global HIV response, the U.S. also provides funding to the Global Fund (see below for details). PEPFAR funding is specified by Congress in annual appropriations bills and is largely provided to the Department of State, which is responsible, through the Bureau for Global Health Security and Diplomacy (GHSD), for coordinating all U.S. programs, activities, and funding for global HIV efforts. Other agencies that receive HIV funding under PEPFAR include the U.S. Agency for International Development (USAID), Centers for Disease Control and Prevention (CDC), and Department of Defense (DoD). In addition, the National Institutes of Health (NIH) supports international HIV research activities, (funding which is not counted as part of PEPFAR). Global HIV funding through regular appropriations¹  has historically accounted for the largest share of the U.S. global health budget (ranging from 42% to 50% between FY 2016 and FY 2025). In FY 2025, global HIV funding was provided through a continuing resolution, which maintained the prior year (FY 2024) amount and totaled $5.4 billion, of which $4.9 billion is for PEPFAR²  ($4.8 billion for bilateral HIV and $50 million for UNAIDS), and approximately $575 million is for international HIV research activities at NIH.

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U.S. Global Health Budget: Tuberculosis (TB)

Since 1998, when the U.S. Agency for International Development (USAID) began a global tuberculosis (TB) control program, U.S. involvement in global TB efforts has grown and it is now one of the largest donors to global TB control in the world. U.S. bilateral TB funding is provided through USAID and includes U.S. contributions to the TB Drug Facility (additional U.S. support for TB activities is provided through its contribution to the Global Fund to Fight AIDS, Tuberculosis and Malaria). U.S. funding for TB has grown over the past decade, with much of the increase occurring in more recent years. U.S. funding for TB rose from $240 million in FY 2016 to $406 million in FY 2025 and currently accounts for approximately 3% of the U.S. global health budget. FY 2025 funding was provided through a continuing resolution, which maintained the prior year (FY 2024) amount.

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U.S. Global Health Budget: Malaria/PMI

The U.S. government has been involved in global malaria activities since the 1950s and, today, is the second largest donor to global malaria efforts in the world (the largest is the Global Fund to Fight AIDS, Tuberculosis and Malaria). The U.S. response to malaria is driven by the President’s Malaria Initiative (PMI), an interagency initiative to address global malaria that was led by the U.S. Agency for International Development (USAID), and co-implemented together with the Centers for Disease Control and Prevention (CDC), with additional activities provided by the National Institutes of Health (NIH) and Department of Defense (DoD). In addition to its bilateral programs, the U.S. also supports malaria programs through its contribution to the Global Fund to Fight AIDS, Tuberculosis and Malaria. U.S. bilateral funding for malaria increased over the past decade from $873 million in FY 2016 to approximately $1 billion in FY 2025; while funding increased over the period, it has been relatively flat in recent years. In FY 2025, malaria accounted for 9% of the U.S. global health budget. FY 2025 funding was provided through a continuing resolution, which maintained the prior year (FY 2024) amount.

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U.S. Global Health Budget: The Global Fund to Fight AIDS, Tuberculosis and Malaria

The Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) is an independent, public-private, multilateral institution which finances HIV, TB, and malaria programs in low- and middle-income countries. The Global Fund receives contributions from public and private donors and in turn provides funding to countries based on country-defined proposals. The U.S. provided the Global Fund with its founding contribution in 2001 and has since been its largest single donor (U.S. contributions to the Global Fund are counted as part of PEPFAR). However, Congress places a number of restrictions on U.S. contributions, including a funding match requirement that limits the amount the U.S. can contribute. The U.S. contribution to the Global Fund through regular appropriations has fluctuated over the past decade but reached its highest level to date ($2.0 billion) in FY 2023. In FY 2025, funding for the Global Fund was $1.7 billion, flat compared to the FY 2024 level, as funding was carried over due to the continuing resolution, and $375 million less than the FY 2023 level, though Congress stated the decline was due to the funding match requirement that limits the amount the U.S. can contribute. In addition to regular appropriations, Congress provided $3.5 billion in emergency supplemental funding to the Global Fund to address the impacts of COVID-19 on HIV programs in FY 2021.

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U.S. Global Health Budget: Maternal & Child Health (MCH)

The U.S. has been involved in Maternal & Child Health (MCH) efforts since the 1960s (and is the largest donor government to MCH activities in the world). MCH funding, which includes funding for polio and U.S. contributions to Gavi, the Vaccine Alliance (GAVI) and the United Nations Children’s Fund (UNICEF), is provided through the U.S. Agency for International Development (USAID), Centers for Disease Control and Prevention (CDC), and the State Department. U.S. funding for MCH increased slightly from $1.14 billion in FY 2016 to $1.30 billion in FY 2025. This was primarily driven by increased funding to GAVI and polio during the period. In fact, when these are removed, bilateral MCH funding has remained relatively level for several years over the period. In FY 2025, MCH accounted for the third largest share of U.S. funding for global health (10%). FY 2025 funding was provided through a continuing resolution, which maintained the prior year (FY 2024) amount.

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U.S. Global Health Budget: Nutrition

The U.S. has a long history of supporting global efforts to improve nutrition and is the largest donor to nutrition efforts in the world. Historically, support for U.S. global nutrition activities was included as part of broader maternal and child health (MCH) funding; starting in 2010, Congress began to designate funding for nutrition activities, all of which is provided through the U.S. Agency for International Development (USAID).³  U.S. funding for nutrition increased from $144 million in FY 2016 to $165 million in FY 2025 and has accounted for approximately 1% of the total U.S. global health budget over the period. FY 2025 funding was provided through a continuing resolution, which maintained the prior year (FY 2024) amount.

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U.S. Global Health Budget: Family Planning & Reproductive Health (FP/RH)

The U.S. has been involved in Family Planning & Reproductive Health (FP/RH) efforts since the 1960s and is currently the largest donor to global FP/RH in the world. The majority of U.S. FP/RH funding is provided through the U.S. Agency for International Development (USAID) for bilateral activities, with additional funding provided through the State Department for the U.S. contribution to the United Nations Population Fund (UNFPA).⁴  U.S. funding for FP/RH rose steadily in its first two decades⁵  and more recently, has remained relatively flat at just about $600 million, accounting for approximately 5-6% of the U.S. global health budget each year from FY 2016-FY 2025. FY 2025 funding was provided through a continuing resolution, which maintained the prior year (FY 2024) amount.

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U.S. Global Health Budget: Global Health Security

Since the 1990s, there has been growing concern about new infectious diseases that threaten human health including, in more recent years, the emergence and spread of threats such as Ebola, Zika, H1N1 influenza, COVID-19, and antibiotic resistance. U.S. global health security efforts aim to reduce the threat of emerging infectious diseases by supporting preparedness, detection, and response capabilities worldwide. Funding designated by Congress for global health security through both emergency and regular appropriations has fluctuated over time, rising largely in response to outbreaks, including Ebola, Zika, and COVID-19.⁶  The share of global health funding that global health security represents has increased over time, rising from 4% in FY 2016 to 10% in FY 2025. In FY 2025, funding for global health security was $1.3 billion. FY 2025 funding was provided through a continuing resolution, which maintained the prior year (FY 2024) amount.

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U.S. Global Health Budget: Neglected Tropical Diseases (NTDs)

NTDs are a group of parasitic, bacterial, and viral infectious diseases that primarily affect the most impoverished and vulnerable populations in the world. The U.S. Congress first designated funding to address NTDs in 2006, through the U.S. Agency for International Development (USAID).⁷  Funding was flat at around $100 million for several years before rising to a peak of $115 million in FY 2023 and remained flat in FY 2024 and FY 2025. Funding for NTDs accounts for a relatively small share of the U.S. global health budget (1% in FY 2025). FY 2025 funding was provided through a continuing resolution, which maintained the prior year (FY 2024) amount.

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1. In addition to regular appropriations, Congress provided $250 million in emergency supplemental funding to address the impacts of COVID-19 on U.S. bilateral HIV programs in FY 2021. ↩︎
2. Total PEPFAR funding in FY 2025 is $6.5 billion ($4.8 billion for bilateral HIV, $50 million for UNAIDS, and $1.7 billion for the Global Fund). ↩︎
3. Totals do not include funding provided through Food for Peace (FFP) due to the unique nature of the program. ↩︎
4. Under current law, any U.S. funding withheld from UNFPA is to be made available to other family planning, maternal health, and reproductive health activities (see the KFF fact sheet on U.S. government international family planning and reproductive health statutory requirements and policies). ↩︎
5. PAI. Cents and Sensibility: U.S. International Family Planning Assistance from 1965 to the Present. Accessed September 2022 at https://pai.org/cents-and-sensibility. ↩︎
6. In FY15, Congress provided $5.4 billion in emergency funding to address the Ebola outbreak, of which $909.0 million was specifically designated for global health security. In FY16, Congress provided $1.1 billion in emergency funding to address the Zika outbreak, of which $145.5 million was specifically designated for global health security. In FY18, Congress provided $100 million in unspent Emergency Ebola funding for “programs to accelerate the capabilities of targeted countries to prevent, detect, and respond to infectious disease outbreaks.” In FY19, Congress provided $38 million in unspent Emergency Ebola funding for “programs to accelerate the capacities of targeted countries to prevent, detect, and respond to infectious disease outbreaks.” In FY20, Congress provided $1.235 billion in emergency COVID-19 funding to “prevent, prepare for, and respond to coronavirus” globally, and in FY21, Congress provided $9.4 billion in emergency COVID-19 funding “to prevent, prepare for, and respond to coronavirus, including for vaccine procurement and delivery.” While none of the FY20 funding was designated for global health security, all of the FY21 funding provided through CDC ($750 million) was designated by CDC as global health security. ↩︎
7. Additional NTD funding is used for NTD research at the Centers for Disease Control and Prevention (CDC) and National Institutes of Health (NIH), although this funding is not specified by Congress. ↩︎

As the Trump administration and Congress pursue broad cuts to federal health agencies and budgets, most of the public, including some Republicans, oppose deep budget and staffing cuts to federal health programs and agencies, a new KFF Health Tracking Poll finds.

Across a range of questions, large majorities of Democrats and independents oppose the Trump administration’s major cuts to federal health agencies and programs, while Republicans are more supportive. Those who identify with President Trump’s Make America Great Again movement are even more supportive of cuts to health agency’s staff and budget but still split on cuts to funding for Medicaid and a few other programs.

For example, most of the public (61%), including large shares of Democrats (89%) and independents (67%), oppose major health spending and staff cuts at federal health agencies. In contrast, MAGA supporters overwhelmingly support such cuts (78%), while Republicans and Republican-leaning independents who don’t align with MAGA are divided (48% support the cuts, 52% oppose).

Similarly, most (59%) of the public, including large majorities of Democrats (92%) and independents (65%), say the Trump administration and its Department of Government Efficiency (DOGE) have been “recklessly making broad cuts to programs and staff.”  

In contrast, the vast majority of MAGA supporters (87%), and a narrower majority of non-MAGA Republicans and Republican leaners (57%), say that the administration is “carefully making cuts to programs and staff to reduce fraud and waste.”

On Medicaid, a contentious issue as the Trump administration and Congressional Republicans weigh budget cuts to help finance tax cuts, three quarters (76%) of the public say they oppose major federal funding cuts.

A narrow majority of Republicans (55%), as well as larger majorities of Democrats (95%) and independents (79%), oppose major Medicaid cuts. MAGA supporters are closely divided on major funding cuts to Medicaid, with similar shares in favor (51%) and opposed (49%) to major cuts.

Large Majorities Oppose Specific Cuts to Federal Health Programs and Agencies

The poll also gauges the public’s views on federal funding cuts for other health programs. In each case, more than six in 10 oppose specific federal health cuts.  For example:

• About three quarters (74%) oppose major cuts to states for mental health and addiction prevention services. This includes a narrow majority of Republicans (58%), and large majorities of Democrats (89%) and independents (75%).
• Most (71%) oppose major cuts to funding to track infectious disease outbreaks. This includes half of Republicans (51%), and large majorities of Democrats (89%) and independents (74%).
• Seven in 10 (69%) oppose major cuts to research at universities and medical centers. This includes large majorities of Democrats (92%) and independents (69%). In contrast, most Republicans (56%) favor such cuts.
• Nearly two thirds (65%) oppose reduced federal funding to help people pay the premiums for health coverage purchased through the Affordable Care Act marketplaces. This includes large majorities of Democrats (88%) and independents (65%). In contrast, most Republicans, (61%) favor such cuts.

Most of the public also opposes major staffing cuts to key federal health agencies such as the Department of Veteran Affairs (74% oppose), Centers for Medicare & Medicaid Services (67%), the Centers for Disease Control and Prevention (63%), the Food and Drug Administration (63%), and the National Institutes of Health (62%).

Republicans and MAGA supporters narrowly oppose major staffing cuts for Veterans Affairs but favor them at each of the other agencies.

Partisans See Different Drivers of Fraud and Waste in Government Health Program

About half of the public say that fraud, waste, and abuse are a major problem in Medicaid (52%), Social Security (51%), and Medicare (50%), and a slightly larger majority say it is a major problem in private health insurance (57%).

Partisans choose different groups when asked who is most responsible for fraud, waste, and abuse in government health programs. About half of Democrats (49%) say private health insurers are most responsible, while Republicans most often name government workers (42%). Fewer across partisans blame people enrolled in the programs or hospitals, doctors and other health providers.

Designed and analyzed by public opinion researchers at KFF, this survey was conducted April 8-15, 2025, online and by telephone among a nationally representative sample of 1,380 U.S. adults in English and in Spanish. The margin of sampling error is plus or minus 3 percentage points for the full sample. For results based on other subgroups, the margin of sampling error may be higher.

Work requirements for Medicaid enrollees have once again resurfaced, now as part of a broader legislative package of potential changes for the Medicaid program aimed at reducing federal spending. Given that women make up over half of adult Medicaid enrollees and women’s well documented role taking on childcare and family responsibilities, Medicaid work requirements would heavily impact women in the program. Full details of the work requirements proposal are still unknown, but analysis of previous legislation from the Congressional Budget Office found that while national work requirements would lower federal spending, they would lead to a drop in Medicaid enrollment and an increase in the number of people who are uninsured but would not increase employment.

The first Trump Administration made a significant change to the Medicaid program by giving states the option to impose work requirements as a condition of Medicaid eligibility through Section 1115 waivers. While 13 states received approval for work requirement waivers, many were struck down in court and the Biden administration rescinded the remaining waivers. Today, only Georgia has a Medicaid work requirement in place for parents and childless adults with incomes below 100% of the federal poverty level (FPL) who are newly eligible through the state’s Pathways waiver. However, several states have submitted or are developing new 1115 waivers or considering legislation to condition Medicaid eligibility on meeting work and reporting requirements.

Medicaid, the nation’s health program for low-income people, provided health and long-term coverage to one in five adult women ages 19 to 64 in 2023. Imposing work requirements in Medicaid would heavily impact women on the program and could lead to Medicaid coverage losses not only for those who lose eligibility because they don’t work or meet an exemption but also among people who remain eligible for the program but lose coverage due to new administrative burdens or red tape. This data note documents differences by sex in the work status of adult Medicaid enrollees ages 19-64 who were not receiving Supplemental Security Income (SSI) and were not dually eligible for Medicare in 2023, and highlights differences by parent status.

What is the work status of women and men covered by Medicaid?

Over nine in ten women and men on Medicaid were working full or part-time for pay or were not working because of caregiving responsibilities, illness or disability, or school attendance in 2023 (Figure 1).¹  More than half of men (54%) and more than a third of women (36%) on Medicaid worked full-time during the year. A larger share of women (24%) compared to men (15%) worked part-time. Four in ten (40%) women and three in ten (31%) men enrolled in Medicaid did not work for pay in 2023, most for reasons that would likely exempt them from work requirements.

Among Medicaid adults who are not working, women are more likely to cite caregiving responsibilities while men are more likely to report an illness or disability as reasons for not working. One in five (19%) women enrolled in Medicaid did not work in 2023 because of caregiving responsibilities, compared to 4% of men (Figure 1). One in ten (9%) women said they did not work because of an illness or disability and 6% did not work because they were going to school. Similar shares of men and women report school as the reason they did not work. All the leading reasons women cite for not working would likely qualify for exemptions from state-level Medicaid work requirements. Depending on how work requirement policies are crafted, women who are exempt may have to submit paperwork to document the reasons for their exemption to remain eligible for Medicaid coverage.

Many Medicaid enrollees are working in service jobs with few benefits, such as health insurance and paid sick days. The top industries that employ women with Medicaid are the restaurant and food service industry, schools, and hospitals, while men tend to work in construction, the restaurant and food service industry, and landscaping services (Appendix Table 2).

What are the reasons that some adults work part-time?

Women were more likely than men to cite family obligations and child care issues as reasons for working part-time. Almost one in four (24%) women with Medicaid worked part-time in 2023 compared to one in seven (15%) men (Figure 2). Women were more likely than men to report they worked part-time because of family or personal obligations (27% vs. 12%) or child care problems (12%; data for men suppressed because it did not meet the minimum standards for statistical reliability). Four in ten men and three in ten women said they worked part time because of slack work/business conditions, they could only find part-time work or because their work week was less than 35 hours. Similar shares of women and men with Medicaid coverage worked part-time because of school or training responsibilities or because of health or medical limitations. Individuals who are working part-time are often ineligible for benefits even if they are offered by their employers, particularly health insurance coverage.

What is the work status of mothers and fathers with Medicaid coverage?

Parents with children under 18 – both mothers and fathers – with Medicaid were more likely to work for pay in 2023 than Medicaid adults without dependent children, but fathers were more likely to work than mothers. Just under half (48%) of women ages 19 to 64 with Medicaid have children under 18 as do one-third of men on the program. About two-thirds (64%) of women with children under 18 and 87% of men with children under 18 worked full or part-time compared to 56% of women and 59% of men without children under 18 (Figure 3). Fathers were more likely to work full-time compared to mothers (78% vs. 40%) in 2023. The leading reason cited by mothers for not working (28%) was they were taking care of children and family.

Among women and men without children, the leading reason for not working was an illness or disability (13% and 15%, respectively). One in ten women and men without children reported they were not working because they were going to school (10% and 9%, respectively). Notably, even among women without children, over one in ten (11%) said they were not working because of caregiving responsibilities, which could include caring for adult children or aging or ill parents (Figure 3). Caregiving responsibilities generally consume a lot of a person’s time and could make it difficult to meet paperwork requirements to file for exemptions from work requirements.

Appendix

1. This data note is based on KFF analysis of data from the Current Population Survey ASEC Supplement, which stratifies data by an individual’s sex as male or female. Throughout this brief we refer to “women” and “men” but recognize that not all people who are born as females identify as “women” and not all people who are born as male identify as “men.” ↩︎

President Trump has said he will not cut Medicare benefits. At the same time, key figures within the administration, policymakers, and some conservative groups have previously expressed support for boosting the role of Medicare Advantage within the Medicare program, which could include changing the Medicare enrollment process, making Medicare Advantage the default enrollment option rather than traditional Medicare. Under current law, people who sign up for Medicare Parts A and B are automatically enrolled in traditional Medicare, unless they affirmatively choose to enroll in a Medicare Advantage plan. In contrast, under a Medicare Advantage default enrollment approach, unless Medicare beneficiaries make an affirmative choice to enroll in either traditional Medicare or a specific Medicare Advantage plan, they would be automatically enrolled into a Medicare Advantage plan, with the option to switch plans or enroll in traditional Medicare.

This brief considers how default enrollment into Medicare Advantage might work, potential challenges with this approach, and implications for beneficiaries, insurers, providers, agents and brokers, and the federal budget.

How would default enrollment into Medicare Advantage differ from the current enrollment process?

In general, when eligible people first enroll in Medicare during their Initial Enrollment Period (IEP), they can sign up for Medicare Part A and Part B. Once enrolled, new Medicare beneficiaries have the option to get their benefits under traditional Medicare or a private Medicare Advantage plan. New Medicare beneficiaries are automatically covered under traditional Medicare unless they choose to enroll in a Medicare Advantage plan in their area. In 2025, beneficiaries have a choice of 34 Medicare Advantage plans with prescription drug coverage, on average.

In 2023, about 2.8 million beneficiaries newly enrolled in Medicare, with slightly more than half (54%) or 1.5 million people covered by traditional Medicare and slightly less than half (46%) or 1.3 million enrolling in Medicare Advantage (Figure 1). For those covered by traditional Medicare when they newly enrolled in Medicare, it is possible that they made a change to their coverage and switched to a Medicare Advantage plan after their initial enrollment period. Defaulting individuals into a Medicare Advantage plan would be a change in the way most new Medicare beneficiaries get their coverage.

In contrast to the current approach, some have proposed to enroll newly eligible beneficiaries in Medicare Advantage by default, rather than traditional Medicare. Proposals vary in the level of detail, but in general, this process would involve assigning individuals to a specific Medicare Advantage plan based on certain criteria, such as patient-provider relationships or plan attributes, as discussed below.

Default options have been used across a variety of fields, including in the areas of retirement savings, organ donations, and electricity pricing programs. In these instances, defaulting people into certain programs with the option to opt out have shown to have a powerful effect on people’s choices, often resulting in a large share of people accepting the default option. In an analysis of default enrollment into Medicare Part D plans for certain low-income beneficiaries (as discussed in more detail below), the authors found that only 16% of individuals opted out of the plan they were randomly defaulted into and actively selected a new plan. The evidence on the impact of default enrollment on individual choices is one of the reasons proponents have put forward this approach for Medicare Advantage.

There are a number of questions about proposals to default beneficiaries into Medicare Advantage plans, along with tradeoffs, such as:

• What criteria would be used to assign new Medicare beneficiaries to a specific Medicare Advantage plan offered in their area, and how would the assignment to a private plan affect the continuity of care between patients and their doctors (due to provider networks), the ability of beneficiaries to access drugs prescribed by their doctors (due to variations in plan formularies) or timely access to services (due to prior authorization requirements)?
• Would the new system take into account special considerations such as whether the new Medicare beneficiary has a disability, is covered under both Medicare and Medicaid, or has a condition that requires access to specific medical providers or health care facilities within proximity to their home?
• What information would be provided to beneficiaries who are default enrolled into a Medicare Advantage plan about other Medicare coverage options that are available to them, including other Medicare Advantage plans or traditional Medicare and stand-alone Part D prescription drug plans in their area? How much time would beneficiaries be given to make a change before being locked in until the next annual open enrollment period?
• Will beneficiaries who wish to switch out of the Medicare Advantage plan in which they were enrolled and switch to traditional Medicare be provided a special enrollment period for Medigap, without pre-existing condition exclusions, if they choose to switch beyond the current 12-month “trial period” for people switching from Medicare Advantage to traditional Medicare regardless of the duration of their enrollment in Medicare Advantage?
• How would this approach impact insurers that offer Medicare Advantage plans? Would insurers have the option to opt out of the default enrollment system and continue to enroll new Medicare beneficiaries? What would be the impact on insurance brokers?
• What would be the impact of default Medicare Advantage enrollment on Medicare spending? While some claim this approach could achieve savings, the increase in Medicare Advantage enrollment that results from default enrollment would likely increase Medicare spending (and Part B premiums paid by all beneficiaries), without a change in current payment methodology. The Medicare Payment Advisory Commission (MedPAC) has consistently found that Medicare pays more for people enrolled in Medicare Advantage than for similar beneficiaries in traditional Medicare.

How would the government assign individuals to Medicare Advantage plans?

One of the main policy considerations for proposals that would default beneficiaries into specific Medicare Advantage plans is how the government would make this assignment. This is particularly challenging because plans vary across an array of features, including premiums, cost sharing for services, provider networks, drug coverage, plan quality (star ratings), extra benefits, and the frequency with which they impose prior authorization requirements and issue denials.

There are a number of different approaches that could be considered to implement default enrollment into Medicare Advantage:

• Random assignment. The government could randomly assign new Medicare beneficiaries to one of the plans offered in their area. This would ensure more even distribution of enrollment across plans, without benefiting one plan (or insurer) over another. However, random assignment would not take into account any plan features that might matter to individual beneficiaries, such as premiums, cost sharing, the scope of extra benefits, existing relationships with providers, drugs taken by the individual, or quality ratings.
• CMS currently uses random assignment for certain beneficiaries with LIS, a process which is intended to ensure a generally even distribution of beneficiaries among benchmark (premium-free) plans and to minimize selection bias for plans. However, this process does not match an individual’s prescription drugs with the list of drugs covered by plans, as opposed to a more targeted approach (“intelligent assignment” or “person-centered” assignment, which has been proposed by some advocates and policymakers) tries to align beneficiary needs with plan features. The possibility for greater discordance between an individual’s medical care needs and circumstances would likely arise with a random approach to default enrollment in Medicare Advantage plans, which would encompass more domains than just prescription drugs, such as continuity of coverage with primary care providers.
• Preserve existing relationships with physicians, specialists and other health care providers. Some proposals would assign patients to plans based on their relationship with a primary care provider or a specific specialist. Being able to see preferred providers in-network is one of the plan elements that is a top priority for beneficiaries. However, this process might not be able to take into account relationships with all providers and may not account for relationships with providers that are most consequential to beneficiaries (e.g., for some beneficiaries it might be their primary care physician while for others it might be a certain specialty care physician). If there are also only one or two insurers offering plans in a certain area, any existing provider relationships may not be able to be prioritized at all if providers are not in plan networks. This process would also require a way to identify relationships with providers for individuals who are not yet covered by Medicare, which could prove challenging.
• Challenges with preserving existing provider relationships for beneficiaries automatically assigned to plans were evident as part of the Financial Alignment Initiative (FAI) for beneficiaries enrolled in both Medicare and Medicaid. As part of this demonstration, states were required to try to assign enrollees to plans based on the individual’s most frequently utilized providers and medical facilities to best meet the individual’s current needs and circumstances. To do this, states could use the most recent 12 months of Medicare and Medicaid claims data, though this data was not always available. Beneficiaries automatically assigned to plans were able to opt-out, however, and there were high-opt out rates among beneficiaries, due to a number of factors, including enrollees being satisfied with existing care and not seeing the benefit of being in one of the demonstration plans and resistance from providers who refused to participate in the plan’s network and encouraged their patients not to participate. In California, for example, after the first evaluation of the demonstration, only about 50 percent of beneficiaries in the demonstration plans were able to retain their primary care providers, and those beneficiaries who were not able to maintain existing relationships with providers were more dissatisfied with the new plans. Similar issues could arise for Medicare Advantage default enrollment if the assignment process is not able to adequately match beneficiaries with their current providers.

• Zero-dollar premiums (other than the Part B premium). Some proposals would assign beneficiaries to plans with a zero-dollar premium. Using this approach would prioritize a plan parameter that is often cited as a top reason for selecting a Medicare Advantage plan, making it very meaningful to potential enrollees. There are a small share of beneficiaries who do not have access to a plan with a zero-dollar premium – about 325,000 people in 2025 – and in those situations, assignment could be based on the lowest premium available in the area. However, nearly all beneficiaries (99%) have access to a Medicare Advantage plan with drug coverage with no additional monthly premium. Depending on the area, this plan parameter may not be enough to differentiate among plans.
• Star ratings. Some proposals would base assignment on plan quality, placing Medicare beneficiaries in plans with star ratings of 4 or higher. According to CMS, 40% of Medicare Advantage plans with prescription drug coverage earned a star rating of 4 of higher for their 2025 rating, with 62% of Medicare Advantage enrollees currently in plans that will have stars of 4 or higher in 2025. Similar to zero-dollar premium plans, depending on the area, using the quality rating measure alone may not be enough to differentiate among plans. Further, MedPAC has recommended replacing the quality-bonus program which assigns stars because it asserts that this system does not provide a reliable indicator of quality, and Medicare focus groups have shown that few beneficiaries consider quality ratings when choosing a plan, so this approach alone may not adequately match enrollees with plans that meet their preferences.
• Drug coverage. Individuals could be assigned to plans based on the drugs they take and whether those drugs are on the plan formulary. While coverage of prescription drugs is an important part of plan selection, implementing this kind of approach could prove challenging since it would require, at a minimum, identifying the list of prescription drugs used by people not yet covered by Medicare and could result in assigning people to plans that cover some but not all of their medications.Challenges in implementing this kind of approach have been apparent in the case of the LIS random assignment process, which has been used since the program’s beginning in 2006. Advocates and policymakers have called for using intelligent assignment or beneficiary-centered assignment instead of the current LIS random assignment process to minimize potential disruptions in access to specific medications for beneficiaries who become eligible for LIS. This approach would take into account enrollees’ current prescriptions and pharmacies. CMS previously considered modifying the current assignment process for LIS enrollees but did not implement any changes.

• Preserve existing relationships with insurers. Assignment could be based on maintaining a relationship with an insurer based on the plan an individual was enrolled in before enrolling in Medicare. Medicare focus groups have shown that some beneficiaries choose their Medicare Advantage plan based on prior relationships with insurers because they feel comfortable with them. Continuing a plan with the same insurer could potentially preserve some relationships with providers or may be more likely to cover the drugs beneficiaries already take, but commercial plans may have different networks than Medicare plans, and provider networks change from year to year, as do formularies. It might also be difficult to identify insurance coverage for individuals prior to their enrolling in Medicare and in some areas, it may not be an option to continue coverage from a specific insurer if they do not sponsor Medicare Advantage plans.
• Lowest cost plan. Assignment could also be based on the “lowest cost plan” offered in an area. If a goal of default enrollment into Medicare Advantage is to save money for the Medicare program, assigning beneficiaries to plans with the lowest “bid” to provide Medicare Part A and B services at the lowest cost in a specific area may be a way to achieve this. It could also encourage competition among insurers to provide care most efficiently. However, it might also mean enrollees assigned to the lowest-bid plan in an area end up with a less generous set of supplemental benefits, a more narrow network of providers, face higher cost-sharing requirements, or are subject to more utilization review requirements, than other available plans if a plan is trying to cut costs to be the lowest cost option.

What are the implications for beneficiaries, insurers, providers, and agents and brokers?

Beneficiaries. Proponents of default enrollment into Medicare Advantage observe that this approach would provide more individuals with access to benefits beyond those covered by traditional Medicare, such as dental, vision, and hearing benefits, lower cost sharing and an out-of-pocket limit. Beneficiaries would have access to all Medicare-covered and extra benefits, without needing a separate Part D plan or separate supplemental policy, such as Medigap, and Medicare Advantage plans have potential to provide better coordinated care than traditional Medicare.

At the same time, people who are newly eligible for Medicare may not be aware of the differences between traditional Medicare and Medicare Advantage and might accept default enrollment into a Medicare Advantage plan without understanding the potential implications. For example, while Medicare Advantage potentially offers coverage at lower costs with extra benefits not available in traditional Medicare, there are tradeoffs with Medicare Advantage plans, including more limited provider networks compared to traditional Medicare as well as the potential for denials or delays in care related to the use of prior authorization in Medicare Advantage. Default enrollment could also result in more enrollees experiencing cost-related problems than would be encountered by beneficiaries with traditional Medicare and other types of supplemental coverage, such as Medigap. Furthermore, only a small share of Medicare beneficiaries compare plans, meaning that once enrolled in a plan, beneficiaries are unlikely to review their coverage options, potentially leaving them in a plan that does not best meet their individual needs and preferences.

There are also tradeoffs and complications involved with the process of defaulting beneficiaries into Medicare Advantage plans, though the effects would vary on key policy decisions, such as the criteria used by the government to assign beneficiaries to specific Medicare Advantage plans, as discussed above. For example, if beneficiaries are assigned to a plan that does not have one or more of their doctors in network, the assignment could disrupt existing patient-provider relationships, which could be a particular concern for patients with serious medical conditions. Default enrollment algorithms may also not take into account beneficiaries’ health care needs and preferences, such as specific drugs on a formulary.

Insurers. Depending on how a default enrollment approach was structured, it would have implications for insurers, which could result in the realignment of the market in ways that would benefit some insurers but be negative for others. For example, if the assignment process gave priority to a previous insurer relationship, such as through a former employer, this could favor certain insurers who also offer private commercial insurance and disadvantage insurers who have a smaller presence in commercial insurance markets. A previous insurer relationship could also benefit insurers who have a strong presence in both Medicaid and Medicare, as millions of people on Medicaid ultimately become eligible for Medicare. If assignment was prioritized on certain metrics, such as preserving existing provider relationships, quality or premiums, this could favor established insurers who are more dominant in certain areas, rather than smaller insurers and newer entrants to the Medicare Advantage market. Conversely, a random assignment process could be more equitable in terms of allocating beneficiaries to all types of insurers. Some consideration would need to be given to the distribution of new beneficiaries if some insurers offered more plans than others, which would increase their share of new enrollees. Overall, most of these approaches would likely have adverse effects on insurers that have historically relied more heavily on brokers and marketing to attract new enrollees when they first sign up for Medicare.

Providers and Health Systems. Providers are likely to be impacted by a change in default enrollment for newly eligible Medicare beneficiaries. Recent news reports have indicated that some providers and health systems have dropped certain Medicare Advantage plans from their networks or are no longer taking Medicare Advantage altogether, due to what they claim are burdensome prior authorization requirements, slow payments from plans, and denied claims. Some health systems have also questioned whether they can afford to have Medicare Advantage plans in their networks based on reimbursement from these plans. For example, a recent study found that Medicare Advantage plans reimburse rural hospitals at just 90.6% of traditional Medicare rates on a cost basis. Further expansion of Medicare Advantage enrollment under a default enrollment approach could exacerbate tensions between providers and Medicare Advantage plans, which could disrupt access to care for both current and new Medicare Advantage enrollees.

Agents and Brokers. About one in three Medicare Advantage enrollees rely on insurance agents and brokers to help them select their Medicare Advantage coverage. Agents are paid a commission for signing up Medicare beneficiaries to plans and also receive compensation if enrollees renew their plan. Currently, for beneficiaries who do not select a Medicare Advantage plan and are default enrolled into traditional Medicare, agents do not play a role in their Medicare Parts A or B coverage, though they may help them select Part D prescription drug coverage and a Medigap supplemental policy. If instead new Medicare beneficiaries largely relied on a default enrollment system that auto-assigned them to a Medicare Advantage plan, rather than using an agent or broker to help them choose a plan, this change could disrupt business practices and revenues for insurance agents and brokers.

What are potential implications for the federal budget?

In 2025, MedPAC found that Medicare pays 20% more for enrollees in Medicare Advantage than it would cost to cover them in traditional Medicare, a total of $84 billion dollars in additional spending in 2025 alone. In the absence of any changes to Medicare Advantage payment policy to reduce expenditures, a default enrollment approach into Medicare Advantage would likely increase annual Medicare spending above currently projected levels. One study on default enrollment into Medicare Advantage estimates that federal outlays could increase by $189 billion to $269 billion over 10 years under different scenarios. This higher spending would affect taxpayers and beneficiaries themselves. Already, Medicare Advantage spending increases Part B premiums for all enrollees, including those not on Medicare Advantage, at a cost of $13 billion in 2025. Higher spending on benefits, including under Part B, would increase the amount of government contributions and beneficiary premiums required to cover this part of the program, so Part B premiums would likely further increase under this approach.

How could default enrollment into Medicare Advantage be adopted?

The Trump administration could take different approaches to implement a Medicare Advantage default enrollment system, including testing a model for default enrollment through the Center for Medicare and Medicaid Innovation (CMMI or Innovation Center), using Section 402 demonstration authority, or pursuing legislation through Congress.

CMMI. One approach would be testing a model through CMMI. As part of CMMI’s statutory requirements, the goal of a model must be reducing program spending while preserving or enhancing the quality of care or improving quality of care without increasing spending. Under CMMI rules, the Secretary has the authority to waive Medicare and other program requirements in order to develop and conduct these models, and this authority is not limited to reimbursement or payment related changes (in contrast to the Secretary’s waiver authority for Section 402 demonstrations, as discussed below). The testing, evaluation and expansion of CMMI models are also specifically exempted from the Paperwork Reduction Act, and specific features of models are not subject to administrative or judicial review. Implementing a model through CMMI would not require Congressional approval.

Some important questions that may arise when designing this model include (1) how to design a model that does not increase spending; (2) whether the model would require mandatory or voluntary participation; (3) whether it would be tested in certain regions or nationwide, and (4) whether it would apply broadly or to defined subgroups of the Medicare population, such as beneficiaries with both Medicare and Medicaid coverage (dual-eligible individuals).

Section 402. Another approach would be using Section 402 demonstration authority, which provides broad authority to the HHS Secretary to develop and implement demonstration projects to test new Medicare payment methodologies, and allows the Secretary to waive compliance with certain Medicare requirements only as long as they relate “to reimbursement or payment on the basis of reasonable cost, or (in the case of physicians) on the basis of reasonable charge.” While budget neutrality is not specified in statute or regulation, according to CMS’ Medicare Waiver Demonstration Application, “Medicare-waiver-only demonstrations must be budget neutral. Budget neutrality means that the expected costs under the demonstration cannot be more than the expected costs were the demonstration not to occur.” Although most demonstrations have generally conformed to the administrative practice of budget neutrality, there have been exceptions. Section 402 demonstrations also have typically been subject to certain types of review such as requirements under the Paperwork Reduction Act and administrative or judicial review. Similar to a CMMI model, a Section 402 demonstration does not have to be initiated or approved by Congress.

Legislation. Policymakers could also enact legislation to modify current law to make Medicare Advantage the default enrollment option, rather than traditional Medicare. While there is bipartisan support for Medicare Advantage, some policymakers have raised concerns recently about specific elements of the program, such as the Medicare Advantage payment system, as well as the use of prior authorization, leading to denials and delays in care. Traditional Medicare also continues to serve a larger share of beneficiaries in rural areas than Medicare Advantage. These issues might dampen support for legislative changes to the current Medicare enrollment process.

Beginning in 2014, the Centers for Medicare & Medicaid Services (CMS) has permitted Medicare Advantage insurers to offer Rewards and Incentives Programs to their enrollees to encourage participation in activities that focus on improving health, preventing illness or injury, or promoting the efficient use of health resources. Two common ways these programs work include offering gift cards, as long as they are not redeemable for cash, or “points” or “tokens” that can then be used to acquire tangible items, such as gift cards or fitness accessories.

Completing a health risk assessment (HRA) is one of the activities for which insurers may provide a reward or incentive. HRAs are used to collect information about enrollees’ characteristics and health status. They may be conducted in the home, at a physician’s office, or via telehealth, and HRAs are also required as a component of an Annual Wellness Visit. As part of their role in ensuring coordination of care, Medicare Advantage plans must make a “best-effort” attempt to conduct an initial health risk assessment of all new enrollees within 90 days of enrollment, as well as annually.

While HRAs may be used to develop a personalized care plan and help with care management, they are also a source of diagnoses codes used to calculate a person’s risk score, and the Medicare Payment Advisory Commission (MedPAC) has estimated that Medicare Advantage plans received $15 billion in 2023 as a result of diagnoses captured during HRAs. Further, MedPAC and the Office of the Inspector General (OIG) have both found that some diagnoses are only supported by HRAs, meaning enrollees received no related care. These findings raise concerns that either these diagnoses are inaccurate, or enrollees are not receiving follow-up services for conditions documented in these assessments, while at the same time, boosting payments to plans.

Insurers are required to enter into a contract with CMS to offer Medicare Advantage plans, and each contract may offer multiple Medicare Advantage plans. Many Medicare Advantage requirements and data, such as those pertaining to network adequacy and star ratings measures, are evaluated and reported at the contract rather than the plan level. Using data submitted by Medicare Advantage insurers to CMS, this analysis examines the share of Medicare Advantage enrollees in contracts (which usually include multiple plans) that offered rewards or incentives for completing HRAs in 2023, as well as differences across Medicare Advantage insurers. (See methods for more details.) Because these data are at the contract level, we do not have data about whether individual plans offered rewards or incentives, though a review of the largest reward and incentive programs suggest these programs are broadly available.

In 2023, the majority of Medicare Advantage enrollees were in contracts that offered a reward or incentive for completing an HRA.

More than six in ten (62%) or 18.2 million Medicare Advantage enrollees, were in contracts that offered a reward or incentive specifically for completing an HRA to at least some of its enrollees in 2023 (Figure 1). These contracts may also include a reward or incentive for an Annual Wellness Visit, which is mandated to include an HRA, or other activities, but specifically include a reward for completing an HRA.

One in five enrollees (20%), or nearly 6 million people, were in contracts that offered rewards and incentives for completing an Annual Wellness Visit, but do not specify rewards for HRAs more broadly. About one in ten (9% or 2.5 million) were in contracts that offered rewards and incentives for other activities with no mention of HRAs or Annual Wellness Visits. The remaining 9% of enrollees, or 2.7 million people, were in contracts that did not offer any Rewards and Incentives Programs.

Medicare Advantage insurers may offer a reward with a value intended to incentivize enrollee behavior but may not exceed the value of the health-related service. For example, a reward for completing a cancer screening cannot exceed the value of providing the screening itself. However, CMS has not identified explicit values for rewards, and it has not set a limit on how often rewards may be offered throughout the year. For 2023, rewards, typically in the form of gift cards, ranged from $10 to $100 for completing an HRA. Insurers are encouraged to offer enrollees a choice of gift cards to account for enrollees’ preferences and access to certain retailers, which may include, for example, IHOP, Chilis, Home Depot, Lowes, and CVS, among others.

The gift cards that Medicare Advantage enrollees receive for participating in certain health-related activities as described in this analysis are not the same as spending, debit, or “flex” cards that are offered by insurers to deliver extra benefits. These extra benefits include, but are not limited to, cards that help cover copays for dental, vision, and hearing benefits, and money toward over-the-counter products or food and produce.

The share of Medicare Advantage enrollees in contracts that offered a reward or incentive for completing an HRA varied by insurer.

Virtually all Medicare Advantage enrollees in Centene and CVS Health contracts (99%) and UnitedHealthcare contracts (98%) were offered a reward or incentive for completing an HRA. (Figure 2). Nearly two-thirds of enrollees in Blue Cross Blue Shield contracts (BCBS; 64%), and less than half of enrollees in Humana contracts (42%) were offered a reward or incentive for completing an HRA.

Due to data constraints, we are unable to determine which individual plans offered rewards within a contract and how many enrollees actually received a reward for completing an HRA. However, for those enrollees that do complete an HRA and receive a reward, there is the potential for insurers to receive a high return on investment for providing that reward. For example, in a recent report, OIG found that for each HRA completed in the home, Medicare Advantage insurers generated $1,869 on average in estimated risk-adjusted payments. For those HRAs conducted in a facility – typically as part of Annual Wellness Visit – insurers generated $365 on average in estimated risk-adjusted payments.

Rewards and Incentives Programs are often unique to each insurer and may also vary by contract. For example, UnitedHealthcare uses its HouseCalls program to perform HRAs in the home. It also offers rewards for completing other eligible-health related activities, such as receiving a flu shot or engaging in certain fitness activities such as biking, jogging, and swimming. Humana uses its Go365 program to encourage enrollees to participate in health and fitness activities, such as Annual Wellness Visits, preventive screenings, or being active 12 days a month. Once members have earned at least $10 in rewards, they can redeem them for gift cards in the Go365 Mall at retailers such as Barnes and Noble, Macy’s, PetSmart, and Chipotle, among others.

The current reporting requirements make it difficult to understand the full scope of Rewards and Incentives Programs.

The current reporting requirements make it impossible to determine how many unique enrollees receive rewards, the amount insurers spend on these rewards, and the specific activities enrollees complete to earn a reward. Medicare Advantage insurers are required to submit data on rewards and incentives at the contract level rather than that at the plan level to CMS, and CMS does not specify any quality assurance procedures to identify outliers or potentially erroneous entries, as it does for some other data sets, such as prior authorization determinations. Most data fields are free text, which results in a lack of uniformity in reporting. Frequently, information on multiple rewards is entered on the same line (for example, Annual Wellness Exam, cancer screenings, and HRAs), making it difficult to determine how many individual rewards were distributed, as well as the dollar amount allocated to each reward.

Due to this complexity, it is not possible to calculate the total amount spent by insurers on the Rewards and Incentives Programs generally, nor for specific activities such as HRAs. This information would be useful to better understand how insurers use their budgets to increase the completion of HRAs and what the potential return on that investment is in the form of higher payments from CMS due to increased coding, as well as the potential to improve the quality of enrollees’ care and identify conditions early and prevent them from becoming more costly in the future.

There are over 2.6 million people working on agricultural farms in the U.S. that play an important role in crop work and the nation’s food system. In addition to self-employed farmers and their unhired family members, these workers include 1 million hired workers, who are primarily noncitizen immigrants. The Trump administration’s restrictive immigration policies, including limits on entry at the border and increased interior enforcement efforts, may reduce the supply of immigrant workers available to fill these roles and increase fears among some immigrants about working. Reductions in the immigrant workforce to support agriculture could ultimately have negative impacts on the cost and availability of food. Moreover, increased fears among agricultural workers could compound health challenges and risks they already face.

Using data from the 2022 National Agricultural Workers Survey (NAWS), this analysis examines key characteristics of agricultural workers, including their citizenship status, health coverage, and access to health care. The analysis includes agricultural workers ages 14 years and older who are currently employed in crop and crop-related work (see Box 1 for more details). It does not include self-employed farm workers or their unpaid family members, agricultural workers with H-2A visas, or hired livestock workers. Key takeaways include the following:

• Most agricultural workers are Hispanic, noncitizen immigrants. Overall, over seven in ten (73%) agricultural workers are Hispanic, and about two-thirds (66%) are noncitizen immigrants. This includes 18% who report having an immigration status with work authorization, such as lawful permanent status or a “green card,” and nearly half (47%) who say they lack work authorization. Additionally, one in five (19%) agricultural workers report household income below poverty.
• Among agricultural workers, noncitizen immigrants are more likely than citizens to be Hispanic and to do field work. Nearly all (97%) noncitizen immigrant agricultural workers are Hispanic compared to three in ten (30%) of citizen agricultural workers. Noncitizen immigrant agricultural workers also are more likely to be employed in field work than their citizen counterparts, with about three in four of noncitizen immigrants with and without work authorization (78% and 74%, respectively) in a field work position compared to about half of citizens (52%). Field work involves all aspects of crop production and harvest, while work in nurseries, packing houses, or elsewhere typically takes place indoors. Agricultural workers engaged in field work may be at increased risk of climate-related adverse health effects given their routine exposure to heat stress.
• More than half (53%) of agricultural workers are uninsured, with this share rising to 77% of noncitizen immigrants without work authorization compared to 41% of noncitizen immigrants with work authorization and 26% of citizens. Additionally, one in four (25%) noncitizen immigrant agricultural workers report not being able to access needed care in the past 12 months compared to 15% of those who are citizens. Going without needed care may have negative health implications, as roughly half of agricultural workers report ever being told by a doctor or nurse that they have a chronic health condition.

Overview of U.S. Agricultural Workers

As of 2022, there were over 2.6 million people working on farms in the U.S, consisting of a mix of self-employed farm operators, their family members, and over 1 million hired workers. Hired workers include agricultural workers ages 14 years and older who are employed in crop and crop-related work at places like farms, orchards, groves, greenhouses, and nurseries that grow crops and plants, and are typically employed in larger farms rather than smaller or family-operated farms. These agricultural workers are concentrated in certain labor-intensive sectors, such as fruit, tree nuts, vegetable, and specialty horticultural crops that are challenging to be automated by technology. Corn, soybeans, and wheat are the leading crops produced in the U.S., with 80% of all crops going into the U.S. food system and the remainder exported to other countries.

Most agricultural workers are Hispanic, noncitizen immigrants. Overall, more than seven in ten agricultural workers say they are Hispanic (73%), a quarter report they are White (25%), and the remaining 3% report another race or ethnicity. Nearly two in three (66%) agricultural workers say they are noncitizen immigrants, including 18% who report having work authorization, including lawful permanent residents or “green card” holders, and 47% who do not report having work authorization (Figure 1). The remaining roughly third (34%) of agricultural workers are citizens. Most immigrant agricultural workers first arrived in the U.S. ten or more years ago, and they predominantly come from Mexico.

Agricultural workers who are noncitizen immigrants are more likely than those who are citizens to be Hispanic (97% vs. 30%) (Figure 2). Among agricultural workers who are noncitizen immigrants, 97% of those with and without work authorization say they are Hispanic, while among their citizen counterparts, over six in ten say they are White (64%), three in ten say they are Hispanic (30%), and the remaining 6% report another race or ethnicity.

Agricultural workers who are noncitizens also are more likely than those who are citizens to do field work (Figure 3). Overall, about two-thirds (67%) of agricultural workers do fieldwork while the remaining third (33%) work in nurseries or packing houses. Among noncitizen immigrant agricultural workers, 78% of those with work authorization and 74% of those without work authorization do field work, while among citizen agricultural workers, roughly half do either field work (52%) or work in nurseries or packing houses (48%). Field work involves all aspects of crop production and harvest, while work in nurseries and packing houses typically takes place indoors. Agricultural workers engaged in field work may be at increased risk of climate-related adverse health effects given their routine exposure to heat stress compared to other types of agricultural work that take place indoors more often.

Overall, agricultural workers have higher poverty rates than other workers. About one in five (19%) agricultural workers report household income below the federal poverty level (FPL) ($20,030 for a family of three as of 2022), higher than the share of all workers with income below poverty in 2022 (5%)¹ .

Health Coverage and Care for Agricultural Workers

About half (53%) of all agricultural workers report being uninsured, with higher uninsured rates among those who are noncitizen immigrants, particularly those without work authorization (Figure 4). Agricultural workers have a nearly five times higher uninsured rate than the rate for all nonelderly adults (10%) nationwide in 2022. Among agricultural workers, noncitizen immigrants without work authorization have the highest uninsured rate with over three in four (77%) lacking coverage, compared to about four in ten (41%) noncitizen immigrants with work authorization and 26% of citizens. These higher uninsured rates reflect a combination of limited access to employer-sponsored coverage among agricultural workers overall and Medicaid eligibility restrictions for noncitizen immigrants, including the exclusion of undocumented immigrants from federally-funded health coverage programs.

Overall, one in five (21%) agricultural workers report not being able to get health care when they needed it in the past 12 months (Figure 4). Among agricultural workers, noncitizen immigrants (25%) are more likely to report not being able to access care than those who are citizens (15%). Barriers to care likely include their higher uninsured rates, cost, and limited provider access in rural areas. Language access and immigration-related fears may pose additional barriers for those who are immigrants seeking health care. Going without needed care may have negative health implications for agricultural workers as about half (51%) report ever being told by a doctor or nurse that they have a chronic illness, including asthma, diabetes, hypertension, or other conditions. Among agricultural workers, citizens (60%) are more likely to report having a chronic condition than noncitizen immigrants without work authorization (42%). This difference may, in part, reflect more limited access to health care among noncitizen immigrants. Additionally, research shows that, overall, noncitizen immigrants, particularly those who are undocumented, generally are younger and healthier than their U.S.-born citizen counterparts.

1. Based on KFF analysis of 2022 Current Population Survey Annual Social and Economic Supplement (CPS-ASEC) ↩︎

The concurrent budget resolution that passed the House and Senate includes instructions for the House to reduce federal Medicaid spending by up to $880 billion or more over the next decade. The Senate is expected to seek at least $1.5 trillion in overall spending cuts, including substantial cuts to Medicaid. Medicaid is the primary program providing comprehensive health and long-term care to one in five people living in the U.S. and accounts for nearly $1 out of every $5 spent on health care. Medicaid is administered by states within broad federal rules and jointly funded by states and the federal government, meaning restrictions in federal Medicaid spending could leave states with tough choices about how to offset reductions through cuts to Medicaid, cuts to other programs, or tax increases.

While the detailed proposals under consideration by Congress to achieve federal Medicaid spending reductions have yet to be released, there are several options raised earlier in 2025, including eliminating the enhanced match rate for the Affordable Care Act (ACA) expansion population and implementing a per capita cap on the federal share of Medicaid spending, which were both examined in previous KFF analyses. This analysis examines the potential impacts on states and Medicaid enrollees of implementing a per capita cap on the federal share of Medicaid spending for the ACA Medicaid expansion population only, which is another proposal that has been discussed by members of Congress. Other proposals to reduce federal Medicaid spending may also be under consideration, including work requirements, a reduced federal matching rate, limits on provider taxes to finance the state share of Medicaid spending, and repeal of certain Medicaid regulations issued by the Biden administration. To achieve spending reduction targets, multiple proposals may be considered together. Future KFF analyses will examine these proposals as well.

Key takeaways

The estimated effects of a per capita cap depend highly on what assumptions are made about policy specifications, future growth in Medicaid spending, and states’ responses to federal cuts. This analysis is designed to illustrate the magnitude of the impact of a per capita cap on the ACA expansion population if all states responded by maintaining their ACA expansion coverage and spending and picking up the new expansion costs. However, in practice, states may respond to the policy change differently, and many may ultimately drop their Medicaid expansion coverage over time as the magnitude of the federal spending cuts grows.

• If states maintain their ACA expansion coverage and spending at current levels, a per capita cap on the expansion population tied to medical inflation would erode the effective enhanced federal match rate for the ACA expansion population over time. Assuming Medicaid spending grows as projected by the Congressional Budget Office, by FY 2034, the federal share of spending or the effective federal match rate for expansion enrollees would be 69%, a decrease of 21 percentage points from 90%, the current federal match rate for expansion enrollees.
• The effective enhanced federal match rate for the ACA expansion population would eventually fall below states’ traditional match rates, assuming there is no limit or floor on the federal contribution to the expansion population. The effective federal match rate in FY 2034 of 69% is lower than the traditional match rate in five states, though eventually the effective federal match rate for the expansion population would be lower than the traditional match rate (which is 50% or more) in all states as the federal contribution decreases over time.
• A per capita cap on the Medicaid expansion population could shift $246 billion in costs to states over the next ten years, with state spending increasing anywhere from 4% to 20% across expansion states.

As the effective FMAP for expansion enrollees declines, the pressure on states to eliminate ACA coverage would increase. Twelve states currently have “trigger” laws in place that would automatically end expansion or require changes if the federal match rate were to drop, but it is unclear how those trigger laws would treat a per capita cap that effectively lowers the federal match rate over time. If all states ultimately drop their Medicaid expansion coverage, up to 20 million Medicaid expansion enrollees could lose Medicaid coverage and the number of uninsured would increase.

What is the proposed policy change?

Like all other Medicaid spending, Medicaid spending on the ACA Medicaid expansion population is currently shared by states and the federal government without a cap; unlike most other spending, the federal government pays 90% of the costs of expansion enrollees. States that have implemented the ACA Medicaid expansion currently receive a 90% federal match rate or “FMAP” for adults covered through the expansion. The FMAP for services used by people eligible through traditional Medicaid is determined by a formula set in law designed to provide a higher federal match rate for states with lower per capita incomes and ranges from 50% to 77%. The ACA expanded Medicaid coverage to nearly all adults with incomes up to 138% of the Federal Poverty Level ($21,597 for an individual in 2025). However, a Supreme Court ruling effectively made the decision to implement the Medicaid expansion an option for states. Forty-one states (including DC) have since adopted Medicaid expansion, and Medicaid expansion enrollees represent nearly a quarter of Medicaid enrollment and one-fifth of total Medicaid spending.

This analysis estimates the impact of implementing a per capita cap on the federal share of Medicaid spending for the ACA expansion population. While specifics on the implementation of this policy would be included in a legislative proposal, details have yet to be released, and assumptions made here may differ from details included in any proposed legislation. To estimate a per capita (i.e., per enrollee) cap on the expansion group, this analysis first establishes FY 2025 per enrollee spending as the base year estimate; then, starting in FY 2027, the analysis limits federal spending growth for expansion adults to the consumer price index (CPI-U) plus 0.4 percentage points, which is KFF’s estimate of the difference between CPI-U and medical inflation (CPI-M) over the past 20 years (see Methods). Federal spending for all other eligibility groups remains as projected under current policy. There are a number of other Medicaid policy changes that have been suggested, and policy estimates would likely differ depending on the combination of policies and their interactive effects. The effects of a per capita cap on Medicaid spending and enrollment are also highly sensitive to policy design, inflation rates, and how states respond to the cuts; and estimates are highly sensitive to assumptions about those factors. We assume that Medicaid expansion spending per enrollee will grow at 5.9% per year on average over the 2027-2034 period, based on CBO projections. A cap based on CPI-U plus 0.4 percentage points is projected to grow by 2.6% per year on average over this period.

What is the potential impact on Medicaid spending?

This analysis does not make assumptions about specific state behavioral responses to a per capita cap on the ACA expansion population and instead examines the potential impact on Medicaid spending if all states maintained their ACA expansion coverage and spending at current levels in response to this policy change. This analysis assumes states would maintain expansion group per enrollee spending and eligibility at current levels, picking up new costs due to the federal cap on per enrollee spending. Enrollment and total spending would remain constant while costs would shift from the federal government to the states, and states would have to make offsetting cuts in other parts of Medicaid or in programs other than Medicaid or raise revenues. The analysis is designed to illustrate the magnitude of the impact of the policy change if states maintain their Medicaid expansion coverage and spending levels; however, in practice, state responses may vary. While some states may choose to continue ACA Medicaid expansion coverage with substantially reduced federal funding, many states may seek to restrain the growth in Medicaid expansion spending by reducing provider payment rates or eliminating the expansion altogether as the magnitude of the federal spending cuts compounds over time.

If states maintain ACA expansion coverage and spending at current levels, a per capita cap on the expansion population would erode the effective enhanced federal match rate for the expansion population over time (Figure 1). Per capita caps are typically designed to constrain federal Medicaid spending growth to a rate slower than is expected under current law, which is how they achieve federal savings. As time passes, the effects compound. If states maintain their ACA expansion coverage and spending, the federal share of Medicaid expansion spending would decrease while the state share of spending would increase to offset the loss of federal funds. By FY 2034, the final year in the analysis, the federal share of spending or the effective federal match rate for expansion enrollees would be 69%, a decrease of 21 percentage points from 90%, the current federal match rate for expansion enrollees.

Under these assumptions, the effective enhanced federal match rate for the expansion population would eventually fall below states’ traditional match rates. This analysis does not assume there is any kind of limit or floor on the federal contribution to the expansion population, meaning the federal share of spending on the expansion population would continue to decline over time. This would eventually result in the effective enhanced federal match rate for the expansion population falling below states’ traditional federal match rates. The effective federal match rate in FY 2034 of 69% is lower than the FY 2026 traditional match rate in five states: West Virginia (74%), New Mexico (72%), Kentucky (71%), District of Columbia (70%, which is set in statute), and Arkansas (69%). Another nine states have traditional match rates that are within 5 percentage points of 69%, including Louisiana (68%), Idaho (67%), Oklahoma (67%), Michigan (65%), Ohio (65%), Indiana (65%), North Carolina (65%), Missouri (64%), and Arizona (64%). The federal share of spending on the expansion population would continue to decline beyond FY 2034, resulting in more states where the effective federal match rate for the expansion population is lower than the traditional match rate over time.

If states maintain their Medicaid expansion spending and coverage, a per capita cap on the Medicaid expansion population could shift $246 billion in costs to states over the next ten years. Federal Medicaid spending could decrease by 4% or $246 billion over the 10-year period, and states would pay those costs, increasing the state share by 7% across all states. All expansion states would be impacted, but the increase in state spending would vary across states, ranging from 4% in Massachusetts and South Dakota to 20% in Louisiana. States with larger shares of expansion enrollment and spending would experience the largest shifts in spending from the federal government to the state.

What are other implications to consider?

As the effective FMAP for expansion enrollees declines, the pressure on states to eliminate ACA coverage would increase. As the effective ACA FMAP declines, states would face increasing difficulties raising the necessary state tax revenues or decreasing spending on non-Medicaid services such as education needed to offset federal cuts, resulting in increasing pressure to eliminate ACA expansion coverage.

Pressure to eliminate ACA expansion coverage might be greatest in the twelve states that currently have “trigger” laws in place that would automatically end expansion or require changes if the federal match rate were to drop. While not a direct change to the expansion FMAP, this change would reduce the federal contribution for expansion enrollees and could put people in states with trigger laws at greater risk of losing coverage. Amid the threat of changes to federal support for Medicaid expansion, some states are actively debating their Medicaid expansion trigger laws. Three states (South Dakota, Missouri, and Oklahoma) have passed constitutional amendments that require the state to cover the Medicaid expansion population, which means they could not easily drop their ACA expansion coverage and would have to find a way to offset the additional costs.

If all states ultimately drop their Medicaid expansion coverage, up to 20 million Medicaid expansion enrollees could lose Medicaid coverage and the number of uninsured would increase. Prior KFF analysis shows that if all states drop their Medicaid expansion coverage, federal Medicaid spending would decrease a quarter ($1.7 trillion) over a 10-year period and up to nearly a quarter of all Medicaid enrollees (20 million people) could lose Medicaid coverage. It’s unknown whether states would increase eligibility for other groups, such as parents and people with disabilities to offset some of the coverage losses associated with eliminating the expansion. While some people losing Medicaid would be eligible for ACA marketplace coverage (those with incomes 100-138% of the poverty level) and others may be able to obtain employer-sponsored health insurance, many expansion enrollees would become uninsured, with some enrollees with incomes below poverty falling into the coverage gap. A large body of prior research shows that Medicaid expansion has helped to reduce the uninsured rate and improve health care access, affordability, and financial security among the low-income population. More recent research shows improvements in health outcomes and continues to show positive effects for providers (particularly rural hospitals) and for sexual and reproductive health.

The effects of this policy change could be larger if paired with other Medicaid cuts, and there would be interactive effects across policies that affect the ACA expansion population, such as Medicaid work requirements. A number of House Republicans have expressed support for work requirements as a condition of eligibility for Medicaid. Work requirement proposals would likely apply to ACA Medicaid expansion enrollees as well as other adults. Prior estimates show that work requirements result in lower federal spending, an increase in the number of uninsured, and no increase in employment. Because work requirements and a per capita cap on expansion enrollees would target the same population, it is likely that these two policies would have substantial interactive effects resulting in spending and coverage implications for ACA expansion enrollees. In addition, if Congress does not extend enhanced ACA premium tax credits due to expire at the end of this year, ACA marketplace coverage would be less affordable for people who lose Medicaid expansion coverage but are eligible for ACA tax credits.

Appendix