The recently announced Ebola outbreak in the Democratic Republic of the Congo (DRC), which is quickly escalating in the region, emerges at a time when the larger fiscal and programmatic environment for global health efforts faces particular hurdles, and international cooperation has been significantly challenged. This is in large part due to policy decisions made by the Trump administration and presents the first real global outbreak test following those changes.

On May 15, news broke of a large, ongoing Ebola outbreak concentrated in northeastern DRC. Two days later, the Director-General of the World Health Organization (WHO) declared the outbreak to be a “public health emergency of international concern” (PHEIC) given its size and because Ebola cases were already reported across the border in Uganda, making the outbreak a regional threat. Despite only recently being detected and reported, this already appears to be one of the largest Ebola outbreaks to date, with almost 746 suspected cases and over 176 suspected deaths as of May 21^st. 

National and international health authorities have recent experience responding to Ebola outbreaks, such as in West Africa in 2014-2015 (the largest since the virus was discovered in 1976) and in DRC between 2018 and 2020. However, this outbreak presents particular challenges. These include:

• First, the species of Ebola virus circulating in the current outbreak is different from that which caused most prior major outbreaks, which means countermeasures such vaccines and treatments are not available, and even testing for this species can only be done at more specialized labs currently.
• Second, the outbreak is happening in a geographic area with ongoing insecurity, multiple concurrent humanitarian crises, high population mobility, and limited access to health services. These factors played a role in the delayed identification of the outbreak and pose difficulties for the response.
• Third, the international environment of health cooperation and financial support has changed significantly since the last big outbreak, driven in large part by the U.S. withdrawal from WHO and international cooperation more broadly as well as its reductions in foreign aid and health programming, but also by larger financial constraints due to aid cuts by other donors.

Even so, the public health effort has already started to ramp up, with DRC and Ugandan health authorities leading responses in their respective countries, supported by WHO, United Nations humanitarian agencies, the Africa CDC, and a network of other local, regional, and international non-governmental organizations.

For its part, the U.S. government has reported that it has already taken a number of steps in response to the outbreak, including:

• Providing some financial support to national Ebola responses in DRC and Uganda. Within two days of learning of the outbreak, the State Department announced it had mobilized $23 million in emergency funding to support DRC and Ugandan government health responses. The State Department also announced it would direct U.S. humanitarian funding to assist with the broader humanitarian response in these countries. By comparison, this initial funding amount is larger than the $8 million the U.S. provided through USAID in the weeks following the identification of the 2018 Ebola outbreak in Equateur province in DRC, though the 2026 outbreak is already much larger and affects a wider geographic area. It is unclear at this point how much funding will ultimately be necessary for the current Ebola response, with authorities still trying to understand the true scope of the outbreak and community needs. The State Department expects the U.S. will increase its financial support for the current outbreak response over time. Over the course of the series of DRC Ebola outbreaks from 2018-2020, which ultimately caused over 2,300 deaths, USAID contributed $324 million, and CDC $37 million, to country response efforts, with these funds drawn entirely from prior emergency Ebola appropriations provided by Congress during the 2014-2015 West Africa Ebola epidemic.
• Activating CDC emergency operations and mobilizing CDC staff and resources. CDC held a press conference within two days of the outbreak announcement, reporting that the agency has begun to assist DRC and Ugandan officials and connect with other partners via CDC offices in each country. CDC and State Department have begun supporting partner organizations in procuring and deploying needed supplies, such as personal protective equipment (PPE). CDC says it has a “long-standing” team of 30 staff in its DRC country office (primarily located in the capital, Kinshasa, which is hundreds of miles from the affected areas in northeastern DRC) and about 100 in Uganda, with more expected to be mobilized in the coming days, including experts from Atlanta who will travel to the affected countries. According to reports, CDC is taking the lead role for the U.S. government in the Ebola response in affected countries. For some context, during the response to Ebola outbreaks in DRC that began in 2018 and eventually grew to thousands of cases, CDC had 187 staff members complete 278 deployments through June 2019.  
• Committing to help stand up Ebola isolation and treatment units. In a May 19 announcement, the State Department says it will be financing the deployment of “up to 50” Ebola Treatment Units and “associated frontline costs” to assist further with the response. These units will provide emergency Ebola screening, triage, and isolation capacity in affected areas.  According to the State Department, the U.S. funding will be delivered via “pooled funding vehicles administered by the United Nations Office for the Coordination of Humanitarian Affairs (OCHA).”
• Deploying a Disaster Assistance Response Team (DART) to the region.  The State Department reports it will be deploying a DART to DRC, which is a mechanism meant to align and coordinate resources from various U.S. agencies under a single organizational structure. The State Department expects the DRC DART will allow CDC, State, and other U.S. agencies to be located together, fostering unified communications with host country governments and other partners.
• Investigating potential monoclonal antibody treatments. According to a spokesperson for the Department of Health and Human Services (HHS), the Biomedical Advanced Research and Development Authority (BARDA) is working with a biotechnology company to make available an experimental Ebola treatment based on monoclonal antibodies for potential use in high-risk individuals. It is unclear how much may be made available and under what circumstances the treatment may be used.  

Still, given all of the changes made by the U.S. to its foreign assistance and global health response, U.S. support is taking shape under very different circumstances and through different organizational mechanisms compared to past Ebola responses. For example:

• The absence of USAID. USAID supported Ebola prevention and detection activities in DRC, Uganda, and elsewhere for many years, employing dozens of staff members with outbreak surveillance and response expertise. However, much of that expertise and the underlying network of organizations was lost when USAID was dissolved and almost all its staff was fired last year. Historically, USAID was the lead agency representing the U.S. government during major Ebola response and was home to interagency DARTs. Now, the newly created State Department Bureau of Global Health Security and Diplomacy (GHSD) and State’s Bureau of Disaster and Humanitarian Response (DHR) are responsible for overseeing diplomatic and coordinating with CDC on technical aspects of an Ebola response for the first time, including through the newly announced DART, despite having fewer personnel than USAID had and limited prior experience overseeing an operational response. Ultimately, staffing for the U.S. response could be scaled up over time, as it was during prior outbreaks, such as during the 2014-2015 West Africa Ebola response, which ultimately consisted of a large U.S. government interagency presence that included the deployment of thousands of U.S. military personnel, hundreds of CDC and HHS staff, and representatives from other agencies.
• Ongoing effects of foreign assistance funding freeze and cuts. Alongside the dissolution of USAID, in early 2025 the Trump administration implemented a freeze on all foreign assistance funding for a period last year. As a consequence, partner organizations report that they had to fire staff and cease many disease prevention and detection activities, including Ebola-focused activities in Uganda and DRC. . Eventually, the State Department issued “waivers” to allow funding for existing “life-saving” assistance programs to continue, which included infectious disease outbreak detection and response programs. While certain activities resumed, the underlying system itself was affected.
• Withdrawal of U.S. membership in WHO. During past response to major Ebola outbreaks, WHO played important coordinating and financing roles, and is poised to serve a leading role in bringing international resources to bear in DRC and Uganda. WHO has already mobilized almost $4 million funding from its Contingency Fund for Emergencies (CFE), the mechanism created after the 2014-2015 West Africa Ebola outbreak to rapidly channel donor funding to support public health emergency response efforts. In the past, the U.S. had always been a major supporter of WHO’s responses and the CFE, including as one of the largest donors to the CFE, and to the multilateral Ebola response, during the 2018-2020 DRC Ebola outbreaks. However, given the U.S. withdrawal from WHO and more limited formal communications between U.S. government officials and WHO officials, the U.S. does has not indicated an interest in directly supporting a WHO-led response this time, a departure from past practices. With just $5.4 million in total donor contributions to the fund in 2026, CFE is already close to being exhausted, with other donors so far unable to fill the funding gaps left by the U.S. absence. While some formal communications between the U.S. and WHO have been limited, CDC has explicit permission to coordinate as necessary with international organizations involved in the response on the ground, including staff from WHO.
• Reduced funding for global health in new U.S. agreements with DRC and Uganda. As referenced above, the dissolution of USAID and the foreign assistance funding freeze last year created de facto cuts to global health assistance in the Ebola-affected countries, affecting country programs. U.S. pledges of assistance over the next few years do represent a cut in funding compared to previous years. The new U.S. approach to global health assistance relies on negotiating country-specific agreements (memoranda of understanding, or MOUs), and such agreements have already been reached with Uganda (signed December 2025) and DRC (signed February 2026). However, the amount of funding pledged by the U.S. for the next 5 years represents a 27% cut compared to that provided over the past five years (see Figure).  The MOUs also outline priorities for the US and the partner countries for global health assistance, with disease surveillance and response being a key aspect for both the DRC and Uganda agreements. For example, the MOU with Uganda states the U.S. wishes to “advance its bilateral relationship with the Government of Uganda and prevent the spread of emerging and existing infectious disease threats globally”, and outlines the funding amounts the U.S. intends to provide the country each year to advance these priorities. However, it is not exactly clear how this new mechanism will shape the programs and outcomes from U.S. global health funding in these priority areas going forward.

While these are still early days in a response that could last months (and facing an outbreak that appears to be escalating quickly), there are several key questions regarding the U.S. response going forward:

• If the needs on the ground increase significantly, will the Trump administration request additional emergency funding from Congress, as previous administrations have done? In addition to the United Nations OCHA funds the U.S. is tapping into, are there other, as of yet untapped existing resources that could be mobilized?
• If the outbreak worsens significantly, will the U.S. scale up its on the ground presence? Because the outbreak is occurring in an area with active conflict, direct deployment of CDC staff to affected areas in eastern DRC is unlikely, which is similar to the situation during the 2019 outbreaks of Ebola in DRC, where CDC provided support from afar but was not directly stationed in the field in affected areas. Could military personnel once again be called on to assist with the response, echoing the role they played in the 2014-2015 response?
• How far have U.S., WHO, and other disease response capacities been stretched now that officials are responding to two international emerging disease events in a short span – hantavirus and Ebola? And what might happen if yet another strain is placed on the already strained global response system?
• Will the Ebola outbreak and response affect other U.S. global health programs operating in the affected countries, and how might the U.S. government address any temporary interruptions or changes in services delivered through those programs?

Given its scale, the urgent messaging, and a rapid series of actions taken by national and international health authorities already, it appears that this Ebola outbreak will be a significant regional public health emergency ideally requiring a sustained, coordinated response. It also presents as the first real test of U.S. government commitment to supporting a major global outbreak response effort since the beginning of this administration, not unlike how hantavirus has been a test of sorts for U.S. domestic public health response to an emerging disease threat.

Key Facts

• Although the U.S. has been involved in efforts to address the global AIDS crisis since the mid-1980s, the creation of the President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003 marked a significant increase in funding and attention to the epidemic. Now, more than 20 years in, PEPFAR reports saving an estimated 26 million lives and is currently providing HIV prevention and treatment services to millions.
• PEPFAR has been the largest commitment by any nation to address a single disease in the world, credited with not only saving millions of lives but also helping to change the trajectory of the global HIV epidemic.
• PEPFAR funding is comprised of U.S. bilateral funding and U.S. contributions to multilateral organizations addressing HIV, primarily the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund).¹
• To date, U.S. funding appropriated by Congress for PEPFAR has totaled over $130 billion, growing from $1.9 billion in FY 2004 to $6 billion in FY 2026; in FY 2026, funding includes $4.7 billion provided for bilateral HIV efforts and $1.3 billion for multilateral efforts ($45 million for UNAIDS and $1.25 billion for the Global Fund).²
• PEPFAR has been reauthorized by Congress four times, most recently in March 2024 for one year. Although that authorization expired on March 25, 2025, PEPFAR is a permanent part of U.S. law and, other than a now-expired set of eight time-bound provisions, continues as long as Congress appropriates funding for the program.
• At the same time, changes made by the Trump administration starting in 2025 (including a reorganization of foreign assistance, reductions in funding, and cancellation of programs) have fundamentally altered the global health landscape generally and PEPFAR specifically. As part of its new America First Global Health Strategy, anchored in bilateral health agreements with countries, HIV services will be integrated into country health systems, and the U.S. will aim to reduce its funding over time.

Global Situation

HIV, the virus that causes AIDS (“acquired immunodeficiency syndrome” or Advanced HIV Disease), has become one of the world’s most serious health and development challenges. Today, there are approximately 40.8 million people living with HIV, and tens of millions of people have died of AIDS-related causes since the beginning of the epidemic (see the KFF fact sheet on the global HIV epidemic).³

U.S. Government Efforts

Although the U.S. had been involved in efforts to address the global HIV/AIDS crisis since the mid-1980s,⁴ the creation of the President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003 marked a significant increase in funding and attention to the epidemic.⁵ PEPFAR, the U.S. government’s global effort to combat HIV and the largest global health program devoted to a single disease, is credited with saving millions of lives and helping to change the trajectory of the global HIV epidemic. It was announced in January 2003 during President George W. Bush’s State of the Union and authorized by Congress that same year through the Leadership Act. The Leadership Act governs PEPFAR’s HIV response, as well as U.S. participation in the Global Fund (an independent, international multilateral financing institution that provides grants to countries to address HIV, TB, and malaria) and bilateral assistance for TB and malaria programs.⁶ Congress has updated, extended, and made changes to the program through the Lantos-Hyde Act of 2008, the PEPFAR Stewardship Act of 2013, the PEPFAR Extension Act of 2018, and more recently, a short-term reauthorization of PEPFAR in early 2024 that extended certain timebound provisions through late March 2025, which have since lapsed (see Table 1 and the KFF brief on PEPFAR reauthorization legislation over time). This short term reauthorization signaled a departure from the program’s long history of strong bipartisan support across multiple Congresses and administrations when, in an increasingly partisan environment, PEPFAR was caught up in the broader U.S. political debate over abortion (see the KFF brief on PEPFAR’s short term reauthorization). This and other developments, including the Trump administration’s review of foreign assistance and new America First Global Health Strategy, have fundamentally altered PEPFAR and introduced significant uncertainty about its future.

Organization

PEPFAR’s original authorization established new structures and authorities, consolidating all U.S. bilateral and multilateral activities and funding for global HIV/AIDS.⁷ Historically, PEPFAR has been overseen by the U.S. Global AIDS Coordinator, who is appointed by the President, confirmed by the Senate, and reports directly to the Secretary of State, as established through PEPFAR’s authorizing legislation.⁸ The Coordinator holds the rank of Ambassador and leads the Office of the Global AIDS Coordinator (OGAC) at the Department of State.⁹ The Coordinator has primary responsibility for the oversight and coordination of all U.S. global HIV activities and funding across U.S. implementing agencies and departments. In addition, the Coordinator serves as the U.S. Government’s board member to the Global Fund (the U.S. Government holds a permanent seat on the Global Fund’s Board). The Coordinator is dual-hatted as the U.S. Special Representative for Global Health Diplomacy and also leads the broader Bureau of Global Health Security and Diplomacy (GHSD), which brings together PEPFAR with global health security and global health diplomacy functions.¹⁰ Currently, the President has not yet nominated a Coordinator, and it is unclear when or whether someone will be nominated.

In addition to the Department of State, other implementing departments and agencies for HIV activities have included: the U.S. Agency for International Development (USAID), PEPFAR’s largest government implementing agency (the Trump administration dissolved USAID and integrated remaining USAID global health activities into GHSD); the Department of Health and Human Services, primarily through the Centers for Disease Control and Prevention (CDC), which has also gone through staff reductions and seen a diminished role under the Trump administration; the Departments of Labor, Commerce, and Defense (DoD); and the Peace Corps.¹¹ Currently, however, most PEPFAR activity is being managed out of the State Department as it transitions programs and services to country governments.

Key Activities and Results

PEPFAR reports having saved an estimated 26 million lives, focusing on expanding access to HIV prevention, treatment, and care interventions. This has included provision of antiretroviral treatment, pre-exposure prophylaxis, voluntary male circumcision, condoms, and other commodities related to HIV services, although some of these services have now been scaled back or discontinued by the administration.¹² In addition, PEPFAR launched specific initiatives in key strategic areas. For example, in 2015, PEPFAR launched DREAMS, a public-private partnership that aimed to reduce HIV infections in adolescent girls and young women; the DREAMS program has been discontinued.

In FY 2024, the last full year of data reported, PEPFAR indicated that it had supported testing services for 83.8 million people; prevented 7.8 million babies from being born with HIV, who would have otherwise been infected; provided care for more than 6.6 million orphans, vulnerable children (OVC), and their caregivers; supported training for nearly 342,000 new health care workers; and supported antiretroviral treatment for 20.6 million people.¹³ However, more recent data is mixed. For example, analysis of data from Quarter 4 of FY 2025 found that while the number of people on antiretroviral therapy was stable compared to Quarter 4 of FY 2024, the number newly enrolled on antiretroviral therapy, the number tested, and the number receiving PrEP, dropped significantly.¹⁴

Since the beginning of the second Trump administration, numerous actions have already had a significant impact on PEPFAR operations and programmatic outcomes), including the following:

• the administration’s foreign aid review and funding freeze, announced in 2025, which limited PEPFAR’s activities to those defined in a limited waiver, significantly scaling back PEPFAR’s scope to what the waiver defines as “life-saving HIV services,” which include only certain activities: HIV treatment and care, prevention of mother-to-child transmission (PMTCT), pre-exposure prophylaxis (PrEP) for pregnant and breastfeeding women, and HIV testing, but even after the initial period, not all of these services have been continued;
• the administration’s September 2025 announcement that PEPFAR would partner with the Global Fund to provide long-acting injectable PrEP, reaching up to 2 million people in high-burden HIV countries through 2028, and then more recently in April 2026, the announcement of an expanded commitment to reach an additional 1 million people, bringing the total to 3 million people; and
• the administration’s September 2025 release of its new America First Global Health Strategy, which provides a framework for global health efforts in countries receiving PEPFAR assistance through bilateral health agreements that aim to reduce U.S. funding over time. Under the agreements, the U.S. plans to provide 100% of current levels of PEPFAR funding for commodities and frontline healthcare workers in 2026 and reduced funding thereafter. More broadly, HIV services will be integrated into country health systems, as the U.S. reduces its funding and direct implementation role.

Countries Reached

Historically, PEPFAR bilateral programs were carried out in more than 50 countries.¹⁵ Additional countries are reached through U.S. contributions to the Global Fund. Prior to the second Trump administration, PEPFAR required 25 countries¹⁶ and the Asia, Western Hemisphere, and West Africa regional programs to develop “Country Operational Plans” (COPs) and “Regional Operational Plans” (ROPs), respectively, to document annual investments and anticipated results.¹⁷ OGAC reviewed and the Global AIDS Coordinator approved COP/ROPs. Currently, this process has been replaced by new bilateral global health agreements with partner countries, which are not specific to PEPFAR or HIV and which require partner countries to increasingly co-invest domestic government resources while the U.S. decreases its health assistance over time. (See the KFF tracker on bilateral global health agreements for more details.)

Funding¹⁸

Total PEPFAR funding¹⁹ includes bilateral funding to U.S. agencies for HIV activities as well as U.S. contributions to the Global Fund and UNAIDS,²⁰ as specified by Congress for PEPFAR in annual appropriations bills.²¹ It has represented the majority of U.S. global health funding (ranging from 53-55% in recent years²²) and is the largest commitment by any nation to address a single disease in the world. To date, funding appropriated for PEPFAR totals more than $130 billion, with funding reaching $6 billion in FY 2026 (see figure).

PEPFAR’s creation marked a significant increase in the amount of funding provided by the U.S. for HIV. Trends in funding for bilateral programs and contributions to multilateral organizations are as follows (see the KFF fact sheet on the U.S. Global Health Budget: Global HIV Funding, Including PEPFAR and U.S. Global Health Budget: The Global Fund):

• Bilateral HIV Funding: The majority of PEPFAR funding (ranging from 70-79% each year over the past decade) is provided for bilateral programs through the State Department (most of which had been transferred to other agencies – particularly USAID and CDC – but now is managed by the State Department). Bilateral funding rose rapidly from $822 million in FY 2003 (the year before PEPFAR) to a peak of $5.0 billion in FY 2010. Between FY 2010 and FY 2013, it declined by more than $750 million. While it has risen since then, funding leveled off for several years, and in FY 2026, appropriations totaled $4.7 billion ($316 million below its peak level).
• Multilateral Funding: The U.S. also supports global HIV efforts through contributions to the Global Fund and UNAIDS. Support for the Global Fund, which accounts for most of the multilateral contributions, increased rapidly in its early years and fluctuated over time; it reached its highest level to date ($2.0 billion) in FY 2023. In FY 2026, Congressionally-appropriated funding for the Global Fund was $1.25 billion, $400 million less than the FY 2025 level, though Congress noted that this funding is intended for the first installment of the $4.6 billion U.S. pledge to the Global Fund’s eighth funding replenishment period (2026-2028).²³ The U.S. contribution to UNAIDS has fluctuated between $45 and $50 million; it was $45 million in FY 2026.
• Emergency COVID-19 Funding: In FY 2021, an additional $3.8 billion in emergency supplemental funding was provided for bilateral HIV ($250 million) and the Global Fund ($3.5 billion) to address COVID-19.²⁴

Spending Directives²⁵

PEPFAR has included several spending directives, or earmarks, from Congress over the course of its history, many of which have changed over time:

1. The Leadership Act, PEPFAR’s original authorization, included the following spending directives: 55% of funds were to be spent on treatment; 15% on palliative care; 20% on prevention, of which at least 33% be spent on abstinence-until-marriage programs; and 10% on OVC. While these were included as “sense of Congress” recommendations, the treatment, OVC, and abstinence-until-marriage earmarks were made requirements as of FY 2006.
2. The Lantos-Hyde Act relaxed some of these directives for the FY 2009 – FY 2013 period: while still requiring that 10% of funds be spent on programs targeting OVC, it changed the treatment earmark from 55% to requiring that at least half of bilateral HIV assistance be spent on treatment and care. It removed the 33% abstinence-until-marriage directive and replaced it with a requirement of “balanced funding” for prevention to be accompanied by a report to Congress if less than half of prevention funds were spent on abstinence, delay of sexual debut, monogamy, fidelity, and partner reduction activities in any host country with a generalized (high prevalence) epidemic.
3. The PEPFAR Stewardship Act, The PEPFAR Extension Act, and recent short-term reauthorization have maintained the language in the Lantos-Hyde Act. With the expiration of the short-term reauthorization in 2025, eight timebound provisions have now lapsed, although PEPFAR is a permanent part of U.S. law.

PEPFAR & The Global Fund

The U.S. is the single largest donor to the Global Fund. Appropriations for the U.S. contribution to the Global Fund totaled almost $33 billion from FY 2001 through FY 2026 (including emergency funding for COVID-19).²⁶

The Global Fund provides another mechanism for U.S. support by funding programs developed by recipient countries, reaching a broader range of countries, and supporting TB, malaria, and health systems strengthening (HSS) programs in addition to (and beyond their linkage with) HIV.²⁷ To date, over 120 countries²⁸ have received Global Fund grants. Most Global Fund support (52%) has been signed and approved by the Board for HIV and HIV/TB programs,²⁹ followed by 29% to malaria, 15% to TB, and 5% to other health issues.³⁰ The original authorization of PEPFAR, and subsequent reauthorizations, included a limit on annual U.S. contributions to the Global Fund that prevented them from causing cumulative U.S. contributions to exceed 33% of the Global Fund’s total contributions (see the KFF fact sheet on the Global Fund). ³¹

Endnotes

1. KFF analysis of The Global Fund: https://data-service.theglobalfund.org/downloads. ↩︎
2. Totals represent funding specified by Congress in annual appropriations bills and/or identified by agencies for the Department of State, USAID, CDC, and DoD. In addition, international HIV research activities are supported by the NIH Office of AIDS Research (OAR) through its annual appropriated budget, but these amounts are not considered part of PEPFAR. See KFF's “Breaking Down the U.S. Global Health Budget by Program Area” for additional information. ↩︎
3. UNAIDS. 2025 UNAIDS Global AIDS Update: AIDS, Crisis and the Power to Transform; July 2025. ↩︎
4. The U.S. first provided funding to address the global HIV epidemic in 1986. Then, in 1999, President Bill Clinton announced the Leadership and Investment in Fighting an Epidemic (LIFE) Initiative to address HIV in 14 African countries and in India. Later, in 2002, President George W. Bush announced the International Mother and Child HIV Prevention Initiative focused on 12 African and two Caribbean countries. ↩︎
5. PEPFAR. 2009 Annual Report to Congress; Jan. 2009. ↩︎
6. U.S. Congress. P.L. 108-25; May 27, 2003. ↩︎
7. KFF. The U.S. Government and Global Health, Sep. 2022. CRS. PEPFAR Reauthorization: Key Policy Debates and Changes to U.S. International HIV/AIDS, Tuberculosis, Malaria and Programs and Funding; Jan. 2009. ↩︎
8. U.S. Congress. Public Law No: 108-25; May 27, 2003. ↩︎
9. U.S. Department of State. “Leadership – Bureau of Global Health Security and Diplomacy” webpage, https://www.state.gov/leadership-bureau-of-global-health-security-and-diplomacy. ↩︎
10. Department of State. “ Leadership – Bureau of Global Health Security and Diplomacy,” webpage, https://www.state.gov/leadership-bureau-of-global-health-security-and-diplomacy/. ↩︎
11. PEPFAR. “About Us,” webpage, https://www.state.gov/about-us-pepfar/. ↩︎
12. KFF. Funding for Key HIV Commodities in PEPFAR Countries; July 2021. ↩︎
13. PEPFAR. PEPFAR Latest Global Results; December 2024. ↩︎
14. KFF. What We Know from the Latest PEPFAR Data: Analysis of FY 2025 Quarter 4 Results; April 2026. ↩︎
15. PEPFAR, “Where We Work” webpage, https://www.state.gov/where-we-work-pepfar/; PEPFAR 2023 Country Operational Plan Guidance for all PEPFAR Countries; and CDC’s “Where We Work” webpage, https://www.cdc.gov/global-hiv-tb/php/where-we-work/. ↩︎
16. The 25 countries that were required to complete a FY23 COP are Angola, Botswana, Burundi, Cameroon, Cote d’Ivoire, Democratic Republic of the Congo, Dominican Republic, Eswatini, Ethiopia, Haiti, Kenya, Lesotho, Malawi, Mozambique, Namibia, Nigeria, Rwanda, South Africa, South Sudan, Tanzania, Uganda, Ukraine, Vietnam, Zambia, and Zimbabwe. PEPFAR. “Where We Work” webpage, https://www.state.gov/where-we-work-pepfar/. ↩︎
17. PEPFAR. 2023 Country and Regional Operational Plan Guidance and Technical Considerations; Feb. 2023. ↩︎
18. U.S. Congress. Public Law No: 112-25; Aug. 2, 2011. White House Office of Management and Budget (OMB). OMB Report to the Congress on the Joint Committee Sequestration for Fiscal Year 2013; March 1, 2013. KFF analysis of data from: Congressional appropriations bills and reports; Federal Agency Budget and Congressional Justification documents; ForeignAssistance.gov; KFF personal communication with the Office of Management and Budget. ↩︎
19. Overall PEPFAR funding technically includes support for bilateral HIV and TB activities, as well as contributions to multilateral organizations (specifically, the Global Fund and UNAIDS). This analysis only focuses on bilateral funding for HIV and contributions to multilateral organizations. ↩︎
20. UNAIDS is the Joint United Nations Programme on HIV/AIDS, the U.N. system’s coordinating body that serves to help galvanize worldwide attention to AIDS. ↩︎
21. Totals represent funding specified by Congress for PEPFAR in annual appropriations bills and/or identified by agencies for the Department of State, USAID, CDC, and DoD. In addition, international HIV research activities are supported by the NIH Office of AIDS Research (OAR) through its annual appropriated budget, but these amounts are not considered part of PEPFAR. See KFF's “Breaking Down the U.S. Global Health Budget by Program Area” for additional information. ↩︎
22. Includes bilateral funding for HIV as well as U.S. contributions to UNAIDS and the Global Fund to Fight AIDS, Tuberculosis and Malaria through regular appropriations. ↩︎
23. U.S. Congress. Public Law No: 119-75; February 2026. The explanatory statement accompanying the FY 2026 conference agreement notes that the U.S. contribution supports the $4.6 billion U.S. pledge to the eighth replenishment and that the $1.25 billion provided in the agreement is for the first installment of the replenishment. The explanatory statement also states that the “funds shall be contributed to the Global Fund on a quarterly basis to the fullest extent practicable” and that “sufficient unobligated balances [that] exist[ed] from prior Acts to fully fund the first installment of the eighth replenishment and to fulfill the United States pledge for the seventh replenishment” are to be provided in a “timely manner.” ↩︎
24. KFF analysis of data from the “American Rescue Plan Act of 2021” (P.L. 117-2). ↩︎
25. U.S. Congress. Public Law No: 108-25; May 27, 2003. U.S. Congress. Public Law No: 110-293; July 30, 2008. U.S. Congress. Public Law No: 113-56; Dec. 2, 2013. U.S. Congress. Public Law No: 115-305; Dec. 11, 2018. U.S. Congress. Public Law No: 118-47; March 23, 2024. ↩︎
26. Includes funding through regular appropriations and emergency supplemental funding. KFF analysis of data from: Congressional appropriations bills and reports; Federal Agency Budget and Congressional Justification documents; ForeignAssistance.gov; KFF personal communication with the Office of Management and Budget. KFF analysis of data from the “American Rescue Plan Act of 2021” (P.L. 117-2). ↩︎
27. Congress states that the Global Fund is the multilateral component of PEPFAR in the following: U.S. Congress. Public Law No: 110-293; July 30, 2008. U.S. Congress. Public Law No: 113-56; Dec. 2, 2013. ↩︎
28. Does not include countries that may have received funding through multi-country or regional programs. Additional countries may be reached through multi-country or regional programs. ↩︎
29. Of the 52% committed to HIV and HIV/TB programs, 38% was for HIV activities and 14% was for HIV/TB activities. ↩︎
30. Percentages may not sum due to rounding. In 2020, some donor governments provided COVID-specific emergency contributions to the Global Fund in addition to their contributions to core activities. For the purposes of this fact sheet, these COVID-specific amounts have been excluded as they cannot be attributed to a specific area, such as HIV, TB, or malaria. The Global Fund. Data Explorer; accessed January 2026: https://data.theglobalfund.org/. ↩︎
31. U.S. Congress. Public Law No: 108-25; May 27, 2003. U.S. Congress. Public Law No: 110-293; July 30, 2008. U.S. Congress. Public Law No: 113-56; Dec. 2, 2013. U.S. Congress. Public Law No: 118-47; March 23, 2024. KFF. PEPFAR Reauthorization: Side-by-Side of Legislation Over Time. ↩︎

Since early 2025, the Trump Administration has sought to limit youth access to gender-affirming care, taking a comprehensive approach to impose and enforce limitations. The administration has implemented or initiated dozens of actions with this aim, some of which have been challenged in court. In response to these actions, at least 40 health care institutions have walked back the provision of gender-affirming care over the last year and a half. This attrition has occurred in waves and in direct response to policy making – first following an executive order laying out the administration’s approach to limiting this care in January 2025, and then several times since in response to subpoenas (see below), proposed rulemaking, and a (now vacated) “declaration” from the Secretary of Health and Human Services, among other efforts. Over this period, when providers shut down services, they have generally said they were doing for reasons such “external pressures beyond our control,” “new federal orders targeting such procedures,” and “mounting pressure from the federal government”, not because they had concerns about safety, medical indication, or effectiveness. At times state Attorneys General have pushed providers to reopen or maintain services, stating that failing to do so would put them in potential violation of state non-discrimination laws and some have expressed frustration that pulling back on this care has at times preempted formal policy making. Pressure from the federal government to end care, oppositional pressure from states to provide care, and institutional barriers to providing best practice care, have left clinics and clinicians in a challenging position.

Notably, the most recent actions out of the administration have been concentrated in Texas, even though the state has banned youth access to gender-affirming medical care since 2023. The administration may have  selected Texas as a site to enforce and pursue investigations against providers in an effort to forum shop and force changes within a hospital in a state where the Attorney General has aligned policy priorities. This includes three main actions in just the last couple of weeks, widely seen as intensifying federal efforts to limit this care. The three actions are as follows:

• On April 30, 2026, the DOJ sought assistance from a federal district court in Texas  in enforcing a subpoena of Rhode Island Hospital (RIH). This request for enforcement stemmed from a July 2025 action where the department issued over 20 civil subpoenas (at least 7 of which have been quashed in court) to providers delivering gender-affirming care to young people, including to RIH. While the hospital does not operate in Texas, DOJ states its investigation of Federal Food, Drug, and Cosmetic Act (FDCA) claims is taking place in the Northern District of Texas in front of Judge Reed O’Connor  without providing a more detailed explanation for the relevance of the venue. The DOJ appears to be especially focused on off-label prescribing of hormonal/puberty blocking prescription medication, a common practice in medicine across medication classes and diagnoses. The FDA regulates drug approval, labeling and manufacturer promotion. However, the FDA does not regulate physicians’ prescribing decisions. This marked the first time the department asked a court to compel compliance with these administrative subpoenas. Within hours of the request for enforcement, and before hearing from RIH, the Texas court ordered RIH to comply within 14 days. RIH appealed to the 5^th Circuit Court of Appeals (covering Texas, Louisiana, and Mississippi) and sought a stay which was denied, though the appeal continues.
  
  In parallel, on May 4, 2026, the Rhode Island Child Advocate, the state official charged with protecting the legal rights of children in state care, asked a  federal district court in Rhode Island  to quash the same subpoena and on May 9^th the hospital asked to join as an intervenor (specifically noting it had not had an opportunity to respond to DOJ’s petition in Texas and that the clock to comply with the order was running), which the court granted. RIH filed its own motion to quash on May 11^th. On May 13, 2026, the court quashed the subpoena and enjoined DOJ from “seeking, receiving, using, retaining, or disseminating any patient-identifying information or protected health information produced by RIH in response to Administrative Subpoena.” The court also questioned the case’s nexus to Texas. DOJ stated it would comply and appeal to the 1st Circuit Court of Appeals (covering Maine, Massachusetts, Rhode Island, and Puerto Rico), which it filed on May 15th.
  
  On May 18^th the federal district court in Texas demanded that RIH produce the requested documents in just over 24 hours in camera (to be held by the court and not available to DOJ). In response, though they were not a party in the Texas matter, Rhode Island Child Advocate sought an emergency injunction with the 1^st Circuit on May 19^th , requesting the court order the hospital not to produce documentation (to the Texas district court). The 1^st Circuit denied the emergency request that night. At the same time, RIH told the Texas court it planned to comply with the document request and would anonymize and de-identify patient information (though on an extend timeline than that requested by the court). Watching what happens next will require monitoring both district (Texas and Rhode Island) and both appellate (5^th and 1^st) courts moving forward and teasing out parallel litigation.   
• On May 6, 2026, the U.S. Attorney’s office in the Northern District of Texas issued grand jury subpoenas to NYU Langone Hospital, and per NYU, other health care institutions. A grand jury summons suggests a criminal investigation, as does the direction to turn requested documents over to the FDA’s Office of Criminal Investigation. This is widely viewed as an escalation over the previous subpoena efforts that were administrative in nature. These subpoenas were issued by the Federal District Court in the Northern District of Texas  less than a week after DOJ efforts to enforce the out of state RIH administrative subpoena in Texas, in the same federal district court (discussed above).
  
  What is known is based on information released by NYU Langone, first by way of a public statement, and then in making the full subpoena public (and eventually adding it to an updated version of their statement. New York’s Shield Law requires any entity in the state that receives a request for legally protected health information to attempt to notify the individuals to whom that request pertains at least 30 days before complying with it, which may have influenced the hospital’s decision to go public.  The subpoena to NYU included a sweeping demand for document production for the 2020-2026 time period. The documents requested included, for example, personnel files of those associated with provision of or billing for gender-affirming care, billing records and documentation policies, communications and materials with pharmaceutical companies regarding gender-affirming care, the identities of and detailed medical information on patients seen for gender-affirming care, communications related to off-label use of hormones, communications with World Professional Association for Transgender Health (WPATH), among other types of information. The subpoena requests that the produced materials be sent to the FDA Office of Criminal Investigations in the Kansas field office which might suggest an investigation related to the FDCA. 
• On May 15, 2026, the DOJ announced a “resolution to end pediatric ‘gender-affirming care’ and create [a] detransition clinic” with Texas Children’s Hospital [TCH]. DOJ stated the settlement is part of its “ongoing national investigation into violations of federal law in connection with the provision of sex-rejecting procedures on minors” (their term for gender-affirming care). The release stated TCH “entered into agreements with the Department and the Texas Attorney General that include commitments” not to provide young people with gender-affirming medical care (which is already banned in Texas) and “pay over $10 million in damages and civil penalties” related to “false billing” allegations under the FDCA, the False Claims Act, and federal fraud and conspiracy laws. Additionally, TCH agreed to establish a clinic dedicated to providing detransition-related services, an unusual move that the state and DOJ say are “first-of-its-kind”.In relatively rare cases when someone seeks medical care in detransitioning, they would not need a specialized clinic to do so.Separately, the Texas AG, Ken Paxton, issued his own press release with similar content to the one issued by DOJ except that it additionally notes that as part of the settlement, multiple providers were terminated and had their privileges revoked.
  
  The DOJ wrote that “the claims resolved by the United States in the settlements are allegations only and there has been no determination of liability. Both entities have denied all allegations.” In a press statement that has since been removed from their website, TCH, wrote that throughout the process with the DOJ and Texas AG they have been “navigating an unconscionable campaign of mistruths and mischaracterizations related to gender affirming care.” The institution writes they have been compliant with all laws and is “settling to protect our resources from endless and costly litigation.” 

The administrative and grand jury subpoenas as well as the settlement DOJ entered into with TCH, especially relating to provider terminations and revocation of privileges, will likely add to the chilling effect already characterizing the provision of gender-affirming care. Additionally, the language used throughout the DOJ documents discussed here could foster misinformation related to gender-affirming medical care (such as referring to it as a “destructive and discredited practice”), which remains recommended for young people who need it.

While Texas has banned core gender-affirming medical services for young people since 2023, the Trump administration DOJ has chosen a federal district court in Texas to file its enforcement efforts, and with the help of the Texas Attorney General negotiated a settlement with a Texas hospital, potentially seeing it as a warning to other hospital systems. The Rhode Island federal district court judge who quashed the administrative subpoena offers one theory as to why the lone star state has been in the spotlight, in a generally sternly worded order, accusing DOJ of selecting Texas “in favor of a distant forum that DOJ deems friendly to its political positions.”

As of 2024, there were 24 million noncitizen immigrants, including lawfully present and undocumented immigrants, living in the U.S. Noncitizen immigrants, particularly those who are undocumented, face significant barriers to accessing health coverage and care and are significantly more likely than citizens to be uninsured. These higher uninsured rates reflect more limited access to private coverage and eligibility restrictions for federally funded coverage options. Undocumented immigrants are not eligible for federally funded coverage options and lawfully present immigrants face eligibility restrictions for coverage. Under the 2025 reconciliation law there will be increased eligibility restrictions for many lawfully present immigrants for Medicaid and the Children’s Health Insurance Program (CHIP), subsidized Affordable Care Act (ACA) Marketplace coverage, and Medicare coverage.

Some states have taken up options in Medicaid and CHIP to expand coverage for lawfully present immigrants and/or established fully state-funded programs to fill gaps in coverage for immigrants. However, some states have recently made reductions to these programs due to budget pressures. On the other hand, a few states are considering how they can use state-funded coverage to fill the gaps in coverage that will result from the reconciliation law eligibility restrictions. This brief provides an overview of state take-up of these options and fully state-funded health coverage programs for immigrants.

As of April 2026, 15 states, including DC, provide fully state-funded coverage for income-eligible children regardless of immigration status; seven states, including DC, provide fully state-funded coverage to some income-eligible adults regardless of status; and most states have taken up options in Medicaid and CHIP to expand coverage to lawfully present immigrant children and pregnant people. Six states, including DC, have recently scaled back their state-funded coverage for adults. Two states have plans to expand state-funded coverage to fill gaps in coverage that will be created by the 2025 reconciliation law eligibility restrictions, and several other states have pending legislation to fill gaps.

Looking ahead, states may face increased challenges maintaining state-funded coverage programs, while at the same time there may be growing need for coverage due to new restrictions in federally funded coverage for lawfully present immigrants under the reconciliation law. More limited access to federally funded coverage as well as reductions in state-funded coverage programs will likely lead to increases in uninsured rates for immigrant families contributing to greater challenges accessing care and potentially worse health outcomes over the long-term. These changes could also have negative implications for the U.S. economy and workforce, where immigrant families make significant contributions.

Health Coverage for Immigrants

Lawfully present immigrants may qualify for federally funded coverage but face eligibility restrictions. For example, many must meet a five-year waiting period before qualifying for Medicaid or CHIP even if they meet other eligibility criteria. Lawfully present immigrants can purchase coverage through the ACA Marketplaces and may receive tax credits for this coverage without a waiting period. Lawfully present immigrants have been eligible for Medicare if they have the required work quarters and meet the disability or age requirements. Under the 2025 reconciliation law, eligibility for Medicaid and CHIP, subsidized Marketplace, and Medicare coverage will be limited to immigrants who are lawful permanent residents (LPRs) or green card holders, certain Cuban and Haitian entrants, and people residing in the U.S. as citizens of the Freely Associated (COFA) nations of the Marshall Islands, Micronesia, and Palau. The law also eliminates ACA Marketplace coverage for lawfully present immigrants with incomes less than 100% FPL effective January 1, 2026. States may also continue to cover lawfully residing children and pregnant immigrants under a Medicaid or CHIP option. These changes will result in some groups of lawfully present immigrants losing access to federally funded coverage, including refugees and asylees.

Undocumented immigrants are ineligible to enroll in federally funded coverage, including Medicaid or CHIP, the ACA Marketplaces, or Medicare. Medicaid payments for emergency services reimburse hospitals for emergency care they are obligated to provide to individuals who meet other Medicaid eligibility requirements (such as income), but who do not have an eligible immigration status, including undocumented immigrants as well as some lawfully present immigrants. These payments help cover costs to hospitals for providing emergency care to immigrants who remain ineligible for Medicaid but are not coverage for individuals. Emergency spending accounted for less than one percent of total Medicaid spending between fiscal years 2017 and 2023. The 2025 reconciliation law reduces the federal Medicaid matching rate provided to states for Emergency Medicaid services provided to expansion adults who would otherwise be eligible for Medicaid except for their immigration status to the regular matching rate starting October 1, 2026.

State Take-up of Optional Coverage for Lawfully Present Immigrants

Most states have taken up options in Medicaid and CHIP to expand coverage for lawfully residing children and/or pregnant people. In general, lawfully present immigrants must have a “qualified” immigration status to be eligible for Medicaid or CHIP, and many, including most lawful permanent residents or “green card” holders, must wait five years after obtaining qualified status before they may enroll even if they meet other eligibility requirements. Some immigrants, such as those with Temporary Protected Status, are lawfully present but do not have a qualified status and are not eligible to enroll in Medicaid or CHIP regardless of their length of time in the country. As noted, under the 2025 reconciliation law, eligibility will be further restricted to lawfully present immigrants who are LPRs or green card holders, certain Cuban and Haitan entrants, and people residing in the U.S. under COFA starting October 1, 2026. States can provide coverage to lawfully residing children and pregnant people without a five-year wait under the Immigrant Children’s Health Improvement Act (ICHIA) option. As of April 2026, 38 states, including DC, have taken up this option for children and 32 states, including DC, have elected the option for pregnant people (Figure 1). States may continue to provide this coverage under the 2025 reconciliation law. North Carolina enacted a Medicaid funding bill in April 2026 that codified the 2025 reconciliation law’s immigrant eligibility changes by limiting eligibility to coverage that the state is federally required to provide, starting October 1, 2026. This would eliminate ICHIA coverage as it is optional for states to provide. However, the Governor has called for the state legislature to reinstate this coverage and some state legislators have indicated that the cut was unintentional.

A total of 25 states, including DC, have extended coverage through the CHIP From-Conception-to-End-of-Pregnancy (FCEP) option, which provides prenatal care and pregnancy related benefits to eligible low-income children beginning from conception to end of pregnancy regardless of their parent’s citizenship or immigration status (Figure 2). While other pregnancy-related coverage in Medicaid and CHIP requires 60 days of postpartum coverage, the CHIP FCEP option does not include this coverage. However, some states that took up this option provide postpartum coverage through a CHIP health services initiative or using state-only funding. Eleven of the states that have implemented the FCEP option (California, Colorado, Connecticut, Illinois, Maine, Massachusetts, Minnesota, New York, Oregon, Rhode Island, and Washington) have used state funding or CHIP health services initiatives to extend postpartum coverage to 12 months to align with the Medicaid extension established by the American Rescue Plan Act. Maryland extends coverage for four months postpartum, and Alabama, Texas, Virginia, and DC extend coverage for 60 days postpartum using CHIP health services initiatives.

Fully State-Funded Coverage

Beyond state take-up of options in Medicaid and CHIP for lawfully present immigrants, some states provide fully state-funded coverage to fill gaps in coverage for immigrants. States vary in the eligibility and scope of benefits offered through these coverage programs. These programs extend coverage to lawfully present immigrants who are in the five-year waiting period for Medicaid or CHIP or do not have “qualified status” and are ineligible for federally funded coverage as well as undocumented immigrants. These programs also extend coverage to Deferred Action for Childhood Arrivals (DACA) recipients who are not considered lawfully present for purposes of eligibility for federally funded health coverage programs. While the Biden administration had published regulations to extend Marketplace coverage to DACA recipients, new regulations by the Trump administration and the 2025 reconciliation law excluded them from coverage.

As of April 2026, 15 states, including DC, provide comprehensive state-funded coverage for children regardless of immigration status, with one state (Colorado) planning to scale back coverage due to budget pressures (Figure 3). These states include California, Colorado, Connecticut, Illinois, Maine, Massachusetts, Minnesota, New Jersey, New York, Oregon, Rhode Island, Utah, Vermont, Washington, and DC. Three of these states (Colorado, New Jersey, and Vermont) also provide state-funded coverage to income-eligible pregnant people regardless of immigration status, with Vermont extending this coverage for 12 months postpartum. Colorado plans to implement rollbacks to their state-funded coverage program for children and pregnant people, including capping enrollment and limiting certain benefits, starting January 2027 due to funding constraints.

As of April 2026, seven states, including DC, have also expanded fully state-funded coverage to at least some income-eligible adults regardless of immigration status (Figure 4). These states include California, Colorado, DC, Illinois, New York, Oregon, and Washington. In some cases, coverage is limited to certain age groups, and several states have closed new enrollment. Some additional states cover some income-eligible adults who are not otherwise eligible due to immigration status using state-only funds but limit coverage to specific groups, such as lawfully present immigrants who are in the five-year waiting period for Medicaid coverage, or provide more limited benefits.

Six states, including DC, have recently eliminated or reduced or plan to scale back state-funded coverage due to budget pressures.

• California previously extended state-funded coverage to all income-eligible adults regardless of immigration status but implemented coverage reductions for adults 19 and older who are not pregnant or former foster youth under age 26 due to funding constraints, including: closing enrollment starting January 2026, ending dental benefits starting July 2026, and charging $30 monthly premiums for adults ages 19-59 starting July 2027. The California governor’s 2026-27 budget also proposes applying Medicaid policy changes included in the 2025 reconciliation law (work requirements and more frequent six-month renewals) to adults enrolled in the state-funded coverage program.
• Colorado allows adults regardless of immigration status to obtain Marketplace coverage through OmniSalud using a section 1332 waiver. Colorado uses state funds to provide plans with $0 premiums through SilverEnhanced Savings. The state reduced the enrollment cap for the program from 12,000 in 2025 to 6,700 people due to funding constraints. As noted above, the state also plans to cap enrollment and limit benefits for children and pregnant people beginning in January 2027 due to funding constraints.
• DC provides health coverage to low-income adults 21 and older regardless of immigration status through its longstanding locally funded Healthcare Alliance program. However, DC closed enrollment to adults ages 26 and older and reduced income limits for adults 21 and older starting October 2025. DC plans to end coverage for all adults ages 21 and older by October 2027.
• Illinois extended state-funded coverage to low-income individuals ages 65 and older regardless of immigration status through its Health Benefits for Immigrant Seniors (HBIS) program in December 2020 but new enrollment has been paused since 2023. Illinois previously extended coverage to low-income immigrants ages 42 to 64 regardless of immigration status through the Health Benefits for Immigrant Adults (HBIA) program in 2022, but ended HBIA coverage on July 2025 due to funding constraints.
• Minnesota extended state-funded health coverage to income-eligible adults 18 and older regardless of immigration status in January 2025 but ended this coverage starting January 2026 due to funding constraints. 
• Washington uses state funds to provide Marketplace coverage with premium subsidies to individuals with incomes up to 250% FPL regardless of immigration status through Cascade Care using a section 1332 waiver, but funding is limited. In July 2024, Washington extended state-funded health coverage to individuals with incomes up to 138% FPL who are not eligible for either federal Medicaid or federal advance premium tax credits, but the state closed enrollment due to funding constraints and moves current and future enrollees to a fee-for-service program.

In addition to these states, Maryland also delayed plans to allow income-eligible individuals to purchase Marketplace coverage without subsidies regardless of immigration status to 2028 due to changes in the 2025 reconciliation law that will require additional administrative resources to implement.

Two states (New Mexico and New York) are planning to provide fully state-funded coverage to lawfully present immigrants that will lose Medicaid and ACA Marketplace coverage due to eligibility restrictions in the 2025 reconciliation law. New Mexico plans to use state funds to cover lawfully present immigrants losing Medicaid and ACA Marketplace Coverage in addition to DACA recipients. The New York governor’s 2026-27 budget proposes using state funds to cover lawfully present immigrants losing Medicaid coverage. The state will also use state funds to cover income-eligible lawfully present immigrants losing federally-subsidized health coverage through the Essential Plan. Under a longstanding court ruling, New York is required to provide state-funded coverage to lawfully present immigrants who would be eligible for Medicaid if not for their immigration status. Legislation introduced in New York and several other states, including California, Illinois, and Washington, would expand state-funded health coverage for immigrants to help fill gaps created by the reconciliation law; however, it is uncertain these bills will be enacted.

Impact of State Coverage Expansions on Health Care Access and Use

While coverage expansions for immigrants increase spending, research suggests that they reduce uninsured rates, increase health care use, and improve health outcomes. Data from the KFF/New York Times 2025 Survey of Immigrants show that immigrant adults who live in states that provide more expansive coverage, including the ACA Medicaid expansion for low-income adults overall and immigrant coverage expansions, are about half as likely to be uninsured compared with those living in states with less expansive policies (11% vs. 23%). Other research shows that coverage expansions for immigrant children increase access to health care and are associated with improved health outcomes. A study found that eliminating the five-year wait for Medicaid or CHIP was associated with a decline in uninsured rates among lawfully present foreign-born children in states without state-funded health care programs. California’s 2016 expansion to low-income children regardless of immigration status was associated with a 34% decline in uninsurance rates, and the state’s expansion to all adults was associated with an increase in health coverage among immigrant adults ages 50 and older. Similarly, a study found that children who reside in states that have expanded coverage to all children regardless of immigration status were less likely to be uninsured, to forgo medical or dental care, and to go without a preventive health visit than children residing in states that have not expanded coverage. Another study found that immigrant children residing in states with more expansive health coverage policies were more likely to have uninterrupted health coverage and a usual source of primary care than those residing in states with less expansive health coverage policies. Research has also found that expanding Medicaid coverage to pregnant people regardless of immigration status is associated with higher rates of prenatal care and improved birth outcomes, while more restrictive state coverage policies were associated with reduced postpartum care utilization.

Introduction

One in four children aged 18 and under living in the U.S. has at least one immigrant parent. Policies undertaken by the Trump administration and Congress aimed at restricting access to health coverage and care for immigrants as well as the significant increase in immigration enforcement activities could have significant implications for the health and well-being of these children, the vast majority of whom are citizens.

This brief provides key data on socioeconomic characteristics and health coverage among children (aged 18 and under) of immigrants based on KFF analysis of 2024 American Community Survey data. It also examines potential implications of recent policies and actions on the health and well-being of children in immigrant families drawing on KFF survey data from Fall 2025.

Children in Immigrant Families

One in four children aged 18 and under in the U.S. has an immigrant parent, and the vast majority of these children are U.S. citizens. As of 2024, close to 20 million, or one in four (26%), children in the U.S. had an immigrant parent (Figure 1). This includes about one in ten (12%) who are citizen children with a noncitizen parent, a similar share (11%) who are citizen children with a naturalized citizen parent, and 3% who are noncitizen children. The share of children with an immigrant parent varies significantly by state, ranging from about 3% in West Virginia to about 45% in California.

Most children of immigrants live in households with a full-time worker regardless of parental citizenship status; however, children with a noncitizen parent are more likely than children with citizen parents to live in lower income households. More than eight in ten citizen children live in a household with a full-time worker across parental citizenship statuses, and over three in four (77%) noncitizen children live in a household with a full-time worker (Figure 2). However, noncitizen children (34%) and citizen children with a noncitizen parent (26%) are more likely than those with U.S.-born parents (19%) and naturalized citizen parents (13%) to live in lower income households with annual incomes of less than $40,000. Lower household income among children of noncitizen immigrants reflects noncitizen immigrants’ disproportionate employment in lower-wage jobs in industries such as construction, agriculture, and service, which are less likely to provide employer-sponsored insurance.

Uninsured rates among children remain relatively low, but those with a noncitizen parent or who are noncitizens are more likely to be uninsured than those with citizen parents. As of 2024, the uninsured rate was 9% among citizen children with noncitizen parent(s) and 26% among the small share of children who are noncitizens compared to 5% of citizen children with citizen parents (Figure 3). Medicaid and the Children’s Health Insurance Program (CHIP) offer broad coverage to lower-income children. However, lawfully present immigrant children may face eligibility restrictions on coverage, including a five-year waiting period, and the small number of children who are undocumented are ineligible for Medicaid, CHIP, and other federally funded coverage options. Moreover, parents may be reluctant to enroll citizen or lawfully present children in coverage even if they are eligible due to immigration-related fears or have difficulty enrolling their children due to confusion about eligibility rules or language barriers. States have an option to expand Medicaid or CHIP coverage for lawfully residing children without a five-year waiting period, which was taken up by 38 states, including DC, as of April 2026. Additionally, as of April 2026, 15 states, including DC, provide comprehensive fully state-funded coverage for lower income children regardless of immigration status with one state (Colorado) planning to scale back coverage due to budget pressures (Figure 4).

Potential Implications of Recent Policies

Since taking office, the Trump administration has taken a range of actions focused on increasing immigration enforcement, restricting immigration, and limiting immigrants’ access to health care and other services. These actions include an Executive Order (EO) issued in January 2025 to end birthright citizenship, a right guaranteed under the 14^th amendment of the U.S. Constitution, for the children of some noncitizen parents, including those who may be undocumented as well as lawfully present individuals on non-immigrant visas (for example, certain work visas). Implementation of the EO is blocked as of April 2026 under court order, with the Supreme Court expected to rule on it in June or July 2026. Ending birthright citizenship for the children of some immigrants would have broad implications, including limiting their access to health coverage. Moreover, the 2025 reconciliation law will further restrict lawfully present immigrants’ access to health coverage, which is expected to increase the number of uninsured. The combination of growing immigration-related fears among immigrant families, increased restrictions on coverage for lawfully present immigrants, and growing financial pressures will likely negatively impact health and health care for children in immigrant families, including U.S. citizens, and could have longer-term impacts on the U.S. workforce.

Increased immigration-related worries will likely have long-term negative impacts on children’s physical and mental health. The American Academy of Pediatrics has identified fear of parental deportation and separation as a toxic stress, which can adversely affect a child’s development, leading to lifelong negative effects on physical, mental, and behavioral health. KFF survey data from Fall 2025 show that over one in four (27%) immigrant parents say their children have expressed worries about something bad happening to someone in their family due to immigration status, with this share rising to six in ten of likely undocumented parents. These worries have negative impacts on children’s health and well-being. About one in five (18%) immigrant parents say a child has experienced problems sleeping or eating (14%), changes in school performance or attendance (12%), or behavior problems (12%) due to worries about a family member’s immigration status (Figure 5). This share rises to nearly half among parents who are likely undocumented.

Children in immigrant families may face greater barriers to accessing health care due to increased restrictions on health coverage and immigration-related fears. The Trump administration and Congress have enacted a number of policy changes aimed at reducing access to health coverage and care for immigrants including but not limited to new restrictions on eligibility for health coverage for lawfully present immigrants under 2025 reconciliation law, proposed changes to public charge rules, sharing of noncitizen Medicaid enrollee data with immigration enforcement officials, as well as restrictions on access to community health centers and other social services. These changes are likely to result in coverage losses for immigrants, including among citizen children in immigrant families. Coverage losses among immigrant parents may lead to losses among their children as research shows that parental coverage impacts children’s access to health coverage and care. Moreover, growing immigration-related fears have made families more reluctant to access programs and services even if they are eligible. KFF survey data from Fall 2025 show that about one in ten (11%) immigrants say they stopped participating in government programs that help pay for food, housing, or health care since January 2025 due to immigration-related fears. Further, one in seven (14%) immigrant parents, rising to over four in ten (43%) of likely undocumented immigrant parents, say that their child missed, skipped, or delayed health care in the past 12 months due to immigration-related concerns (Figure 6).

Beyond impacts on the health and well-being of immigrant families, the current environment may negatively impact the U.S. workforce given the significant role immigrants and their adult children play, especially in health care. Adult children of immigrants have higher educational attainment and incomes than their parents as well as the adult children of U.S.-born parent(s) and play an outsized role in the U.S. health care workforce. Based on KFF analysis of 2024 federal survey data, adult children of immigrants ages 18 and older make up about 7%, or over 1.4 million, of the total health care workforce, including 11% of physicians, surgeons, and other practitioners. Moreover, immigrants and their adult children contribute billions of dollars in federal, state, and local taxes each year and help to create jobs for U.S.-born people. Research further shows that adult children of immigrants contribute more in taxes on average than their parents or the rest of the U.S.-born population and that their fiscal contributions exceed their costs associated with health care, education, and other social services. As such, restrictions in immigration could have long-term implications for the U.S. workforce and economy.