On March 27^th, the Trump administration announced that the U.S. Department of Health and Human Services (HHS) would implement “a dramatic restructuring” in accordance with President Trump’s Executive Order, “Implementing the President’s ‘Department of Government Efficiency’ Workforce Optimization Initiative.” This included plans to reduce the Department’s workforce by 10,000 employees. As a result, thousands of federal HHS employees were given “reduction in force” announcements (or RIFs) or otherwise learned that their roles had been eliminated when they were denied access to their offices. Others were offered reassignments. In addition, several HHS offices and functions have reportedly been reduced or ended. These actions seem to be particularly focused on the federal government’s work on HIV and have the potential to negatively affect the nation’s HIV response. While there continues to be some uncertainty about the full extent of these actions, and there are some reports that certain personnel may be reinstated, here is what is known thus far about the implications of these actions on HIV efforts:

• Centers for Disease Control and Prevention (CDC): A near 20% cut to CDC staff and elimination of divisions and offices:
  • This includes cuts within the National Center for HIV, Viral Hepatitis, STD, and Tuberculosis Prevention (NCHHSTP), the division that handles most federal HIV prevention efforts, with several branches being effectively eliminated, and it’s director, Jonothan Mermin, reassigned. For HIV, these include the elimination of the following divisions:
    • Prevention Communication Branch
    • Division of Behavioral & Clinical Surveillance Branch
    • Capacity Development Branch
    • Quantitative Sciences Branch
    • HIV Research Branch
  • These divisions within the CDC have provided leadership, subject matter expertise, tools and campaigns for communication with the public (important for a providing evidence-based information on a communicable and often stigmatizing disease), generated and analyzed data, helped develop capacity among grantees, supported outbreak investigation, and conducted research across a range of areas to improve HIV prevention, care engagement, and response efforts.
  • Beyond these HIV specific divisions, cuts also occurred within branches or divisions related to public health concerns that have a disproportionate impact on people with HIV or relate to conditions that increase vulnerability to HIV, including those focused on addressing tuberculosis, viral hepatitis, and sexually transmitted diseases (STD). For example, the disease intervention and response branch within the STD division faced eliminations, an office whose role it is to identify STD case and outbreaks and mitigate spread through linkage to care and provision of technical assistance.
• HHS: Elimination of the Office of Infectious Disease Policy (OIDP) within the Office of the Secretary at HHS:
  • The OIDP office was eliminated and most staff were terminated or reassigned. This includes staff who supported coordination of the Ending the HIV Epidemic Initiative (EHE) which spans multiple HHS agencies and the Executive Director of the President’s Advisory Council on HIV/AIDS (PACHA), who was an employee within the office.
  • OIDP provides infectious disease leadership, expertise, and coordination across the federal government, with HIV being a special focus of the office. This includes coordinating multiple national strategies aimed at addressing infectious diseases including, the National HIV/AIDS Strategy (NHAS), Vaccines National Strategic Plan (Vaccine Plan), Viral Hepatitis National Strategic Plan (Viral Hepatitis Plan), and the STI National Strategic Plan (STI Plan), in addition to providing EHE leadership.
• National Institutes of Health (NIH): Key officials in NIH leadership were placed on administrative leave and some offices were eliminated:
  • Specific to HIV, Jeanne Marrazzo, the director of the National Institute of Allergy and Infectious Diseases (NIAID) was reportedly placed on administrative leave. The role was previously held by Anthony Fauci.
  • Additionally, there have been reports that the Workforce Operations, Communications, and Reporting Branch (WOCRB) at the Division of AIDS (DAIDS) within NAID has been eliminated. WOCRB’s role is to coordinate division-wide operational activities.
  • NIAID conducts and supports research related to infectious, immunologic, and allergic diseases, including HIV. Specifically related to HIV, NIAID has worked to “better understand HIV and how it causes disease, find new tools to prevent HIV infection, develop new and more effective treatments for HIV-infected people, and find a cure.” NAID’s HIV research has focused on HIV treatment, prevention, cure and vaccine.
• Beyond those offices dedicated to HIV, several others that have reportedly faced staff or complete elimination conduct activities relevant to addressing the needs of people with and at risk for HIV. These offices address communities disproportionately represented among people with HIV, including those focused on the needs of people of color, LGBTQ people, those with lower incomes, those with comorbidities, including mental health substance use problems, and those that address aging issues.
  • Examples of where such cuts/elimination have reportedly occurred include following offices/agencies: the Centers for Medicare & Medicaid Services (CMS)’s Office of Minority Health, the Substance Abuse and Mental Health Services Administration (SAMHSA) (including multiple offices such as the National Mental Health and Substance Use Policy Laboratory and the Office of Minority Health), and the Administration for Community Living (including the Center for Policy and Evaluation). In addition to NIAID at NIH described above, the National Institute on Drug Abuse with NIH was also reportedly The Office of Minority Health at HHS has also reportedly been told to prepare for elimination.

There are also plans for a new agency, the Administration for a Healthy America (AHA) to be created, consolidating activities from the Office of the Assistant Secretary for Health (OASH), the Health Resources Services Administration (HRSA) (home to the health center and Ryan White HIV/AIDS programs), SAMHSA, and others. AHA will consist of multiple divisions, including one on HIV/AIDS. It is not known whether AHA will seek to reinstitute some of the terminated positions or eliminate additional roles from within the agencies it consolidates.

Regardless of what happens with AHA, the elimination of directors, staff, and departments across HHS to date, represents a significant loss to HIV research, prevention efforts, leadership, expertise, and coordination of the HIV response across the federal government. In addition to cuts described above, it has also been reported that there may be cuts to CDC’s HIV prevention budget, that funding for NIAID’s HIV Prevention Trials Network and HIV Vaccine Trials Network (HVTN) has been suspended, and that some NIH grants focused on HIV have been rescinded. Taken together these actions could all hamper the nation’s ability to address HIV in the immediate term, jeopardize innovation, and lead to increased HIV incidence. In addition, expertise built by these officials and offices has been utilized in public health arenas outside of HIV, as was the case with the development of the COVID-19 vaccine which was built on HIV vaccine research. Given this, erosion of HIV expertise, research, and infrastructure could have ramifications for public health more broadly.

This slideshow explores trends in how costs affect access to health care in the U.S., including decisions to forgo or delay needed care and access to a usual source of care. Based on data from the 2023 National Health Interview Survey, more than 1 in 4 adults (28%) reported delaying or not getting health care due to cost.

The analysis also notes that Hispanic adults, non-elderly adults, adults in worse health (reported as fair or poor health status,) and uninsured adults are more likely to delay or forgo care due to cost. The slideshow also explores variations based on income and race.

The slideshow is available through the Peterson-KFF Health System Tracker, an online information hub dedicated to monitoring and assessing the performance of the U.S. health system.

Since 2001, KFF’s Program on Medicaid and the Uninsured has administered regular surveys of states about their home- and community-based services (HCBS) programs and their eligibility policies for people who are eligible for Medicaid on the basis of having a disability or being ages 65 and older (e.g., the “non-MAGI” eligibility pathways). Those reports are compiled here.

Use these links to navigate to the surveys and resources on this page.

Medicaid HCBS Surveys

Survey of Medicaid Eligibility Based on Disability or Age 65+ (non-MAGI eligibility)

Related Resources

Medicaid HCBS Surveys

The Medicaid HCBS survey is sent to officials administering Medicaid HCBS programs in all 50 states and the District of Columbia. The survey is sent to each state official responsible for overseeing the administration of HCBS programs (including home health, personal care, and waiver services). Before 2015, KFF and researchers at University of California San Francisco conducted the survey. Starting in 2016, KFF and Watts Health Policy Consulting have conducted the annual survey. Not all years’ surveys are available because the survey was not administered in some years and in other years, KFF replaced earlier reports with the most recent data.

Surveys are organized by the year in which they were administered, which may not match the date of publication or the year of data reported. Some reports include data from more than one year.

Report links for some prior years are no longer on our website, but may be requested via KFF’s Contact Us form.

2024 Survey

A Look at Waiting Lists for Medicaid Home- and Community-Based Services from 2016 to 2024 (October 2024)

How do Medicaid Home Care Programs Support Family Caregivers? (January 2025)

What is Medicaid Home Care (HCBS)? (February 2025)

Payment Rates for Medicaid Home Care: States’ Responses to Workforce Challenges (February 2025)

What Services Does Medicaid Cover in Assisted Living Facilities? (March 2025)

2023 Survey

Pandemic-Era Changes to Medicaid Home- and Community-Based Services (HCBS): A Closer Look at Family Caregiver Policies (September 2023)

Payment Rates for Medicaid Home- and Community-Based Services: States’ Responses to Workforce Challenges (October 2023)

A Look at Waiting Lists for Medicaid Home and Community-Based Services from 2016 to 2023 (November 2023)

How are States Implementing New Requirements for Medicaid Home- and Community-Based Services? (December 2023)

2022 Survey

Ongoing Impacts of the Pandemic on Medicaid Home & Community-Based Services (HCBS) Programs: Findings from a 50-State Survey (November 2022)

Ending the Public Health Emergency for Medicaid Home- and Community-Based Services (April 2023)

2021 Survey

Medicaid Home & Community-Based Services: People Served and Spending During COVID-19 (March 2022)

State Policy Choices About Medicaid Home and Community-Based Services Amid the Pandemic (March 2022)

2019 Survey

Medicaid Home and Community-Based Services Enrollment and Spending (February 2020)

Key State Policy Choices About Medicaid Home and Community-Based Services (February 2020)

Medicaid’s Money Follows the Person Program: State Progress and Uncertainty Pending Federal Funding Reauthorization (November 2019)

2014 Survey

Medicaid Home and Community-Based Services Programs: 2012 Data Update (November 2015)

2004 Survey

Medicaid 1915(c) Home and Community-Based Service Programs: Data Update (July 2005)

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Survey of Medicaid Eligibility Based on Disability or Age 65+ (non-MAGI eligibility)

Medicaid is an important source of health and long-term care coverage for people with disabilities and those who are ages 65 and older. The Medicaid pathways in which eligibility is based on old age or disability are known as “non-MAGI” pathways because they do not use the Modified Adjusted Gross Income (MAGI) financial methodology that applies to pathways for pregnant people, parents, and children with low incomes. In addition to considering old age/disability status and income, many non-MAGI pathways also have asset limits. Since 2015, this survey has been conducted by KFF and Watts Health Policy Consulting. Not all years’ surveys are available because the survey was not administered in some years and in other years, KFF replaced earlier reports with the most recent data.

Surveys are organized by the year in which they were administered, which may not match the date of publication or the year of data reported. Some reports include data from more than one year.

2025 Survey

Medicaid Eligibility Levels for Older Adults and People with Disabilities (Non-MAGI) in 2025 (April 2025)

2024 Survey

Medicaid Eligibility and Enrollment Policies for Seniors and People with Disabilities (Non-MAGI) During the Unwinding (June 2024)

What is Medicaid Estate Recovery? (September 2024)

What Are the Primary Medicaid Eligibility Pathways for Dual-Eligible Individuals? (October 2024)

2022 Survey

Medicaid Financial Eligibility in Pathways Based on Old Age or Disability in 2022: Findings from a 50-State Survey (July 2022)

Medicaid Public Health Emergency Unwinding Policies Affecting Seniors & People with Disabilities: Findings from a 50-State Survey (July 2022)

2018 Survey

Medicaid Financial Eligibility for Seniors and People with Disabilities: Findings from a 50-State Survey (June 2019)

Key State Policy Choices About Medical Frailty Determinations for Medicaid Expansion Adults (June 2019)

Implications of the Expiration of Medicaid Long-Term Care Spousal Impoverishment Rules for Community Integration (November 2019)

2015 Survey

Medicaid Financial Eligibility for Seniors and People with Disabilities in 2015 (March 2016)

2009 Survey

Medicaid Financial Eligibility: Primary Pathways for the Elderly and People with Disabilities (February 2010)

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Related Resources

KFF’s ongoing work related to LTSS and people with disabilities provides context and nuance to the data and information presented in the state surveys.

Long-Term Services and Supports

• 10 Things About Long-Term Services and Supports (July 2024)
• Who Uses Medicaid Long-Term Services and Supports (December 2023)
• How Many People Use Medicaid Long-Term Services and Supports and How Much Does Medicaid Spend on Those People? (August 2023)

Nursing Facilities

• A Closer Look at the Final Nursing Facility Rule and Which Facilities Might Meet New Staffing Requirements (May 2024)
• A Look at Nursing Facility Characteristics Between 2015 and 2023 (January 2024)

People with Disabilities

• 5 Key Facts about Medicaid Coverage for People with Disabilities  (February 2025)
• 5 Key Facts about Medicaid Eligibility for Seniors and People with Disabilities (February 2025)
• The Connection Between Social Security Disability Benefits and Health Coverage Through Medicaid and Medicare (September 2024)

• As Recommendations for Isolation End, How Common is Long COVID? (April 2024)
• Working Age Adults with Disabilities Living in the Community (January 2024)
• Supplemental Security Income for People with Disabilities: Implications for Medicaid (June 2021)

Medicaid Eligibility Rule, 2023-2024

• What Does the Medicaid Eligibility Rule Mean for Low-Income Medicare Beneficiaries and the Medicare Savings Programs (MSPs)? (November 2023)
• Potential Effects of the Proposed Medicaid Eligibility Rule for Newly Enrolled Medicare-Medicaid Enrollees(November 2022)
• 5 Things to Know: A Look at the Proposed Medicaid Eligibility & Enrollment Rule (September 2022)

Summary

Federal funding has long been a major source of support for public health efforts across the United States, estimated to account for more than half of state and local health department budgets. The Centers for Disease Control and Prevention (CDC), the primary public health agency of the federal government, provides much of this funding, helping to support public health systems and activities across the country. However, CDC and other federal health agencies are being targeted by the Trump administration for downsizing and budget cuts, reductions that could impact the amount of funding available for public health. To better understand how much CDC funding is provided to state and local jurisdictions, we analyzed FY 2023 funding obligation data (see Methods and Appendix 1). Among the key findings:

• In FY 2023, CDC obligated almost $15 billion to state and local jurisdictions. While most (62% or $9.2 billion) was from CDC’s regular budget, a significant share (38% or $5.7 billion) was from time-limited, supplemental funding for COVID-19 and public health infrastructure rebuilding.
• Of the $9.2 billion in regular budget obligations, half ($4.7 billion or 51%) was for the Vaccines for Children program, a mandatory program that provides vaccines at no cost for children who are uninsured or underinsured and other eligible children (4% was for additional mandatory programs). The remaining $4.1 billion (45%) was discretionary funding supporting a range of programs including HIV/AIDS, Viral Hepatitis, STI and TB Prevention, Chronic Disease Prevention and Health Promotion, Public Health Preparedness and Response, and Injury Prevention and Control.
• Both red and blue states benefit from CDC funding, with states that voted for President Trump in 2024 receiving the majority of funding (56%), compared to states that voted for Kamala Harris (44%); on a per capita basis, states voting for Harris received slightly more compared to those that voted for Trump ($46 vs $43 per capita).
• The top five state recipients also represent a mix of red and blue states (California, Texas, New York, Florida, and Georgia), as do the top five states by funding per capita (District of Columbia, Alaska, Maryland, Vermont, and Wyoming).
• By region, Southern states received the largest share of funding (43%) followed by the West (22%), Midwest (19%), and Northeast (17%); the South also ranked first in funding per capita.

Funding cuts, therefore, could have a significant impact on the amount of funding available to states and local jurisdictions for public health activities. Such cuts, coupled with the expected end in supplemental funding for COVID-19 and public health infrastructure support, could also represent a double whammy, affecting both red and blue states, and especially states in the South. While state and local governments could potentially fill some of the gap left by federal dollars, they may also be facing their own budget constraints and other cuts in federal funding, leaving the future of the nation’s public health infrastructure capacity uncertain.

Findings

• In FY 2023, CDC obligated $14.9 billion to state and local jurisdictions. This included $9.2 billion (62%) as part of its regular budget and $5.7 billion (38%) in supplemental funding (see Figure 1). These amounts were distributed to jurisdiction across a number of categories (see Figure 2).

• Of the $9.2 billion in regular budget obligations, $5.1 billion (56%) was mandatory funding, required by law, and $4.1 billion (44%) was discretionary and dependent on annual appropriations from Congress. The share of mandatory vs discretionary funding provided varied by state (see Appendix Table 2).
  • Most mandatory funding (92%) was for the Vaccines for Children program. The remainder was for Chronic Disease Prevention and Health Promotion, Cross-Cutting Activities and Program Support, and several other smaller mandatory programs.
  • Discretionary funding was spread across a wide range of public health areas, with the largest share (22%) directed to HIV/AIDS, Viral Hepatitis, STI and TB Prevention efforts. Chronic Disease Prevention and Health Promotion received the next largest share (17%), followed by Public Health Preparedness and Response (16%), and Injury Prevention and Control (15%). A variety of other programs comprised the remainder (see Figure 3).
• Of the $5.7 billion in supplemental funding, most ($4.9 billion or 87%) was from the Public Health and Social Services Emergency Fund (PHSSEF), transferred to CDC by HHS to support COVID-19 response activities as well as public health infrastructure and workforce. The remainder was for Cross-Cutting Activities and Program Support, which included COVID response activities and hurricane supplemental funding.

• There was significant variation in the amount of CDC funding provided to the 50 states and Washington D.C., ranging from $45.9 million to $1.4 billion; when standardized by population size, funding ranged from $35 to $314 per capita (see Figure 4 and Appendix Table 3).
  • Funding was concentrated in a subset of states, with the top 10 state recipients accounting for 51% of all funding, and the top five states accounting for a third (34%). The top five state recipients were California, Texas, New York, Florida, and Georgia. Per capita, the top five state recipients were the District of Columbia, Alaska, Maryland, Vermont, and Wyoming (see Figure 5).
  • If supplemental funding is removed, CDC’s funding by state ranged from $25.7 million to $906 million, or $21 to $235 per capita; the top five state recipients, representing over a third (36%) of non-supplemental funding, remain the same (California, Texas, New York, Florida, and Georgia), with some variation in the rank by per capita funding (District of Columbia, Alaska, Vermont, Rhode Island, and Wyoming).

• By region, the South received the largest share of funding overall (43%) followed by the West (22%), Midwest (19%), and Northeast (17%). In per capita terms, the South remained the top funded region followed by the Northeast, West, and Midwest. With supplemental funding removed, the funding distribution is largely the same as is the per capita rank by region (see Figure 6).
• States that voted for President Trump in the 2024 election received the majority of CDC funding, although there was a more even distribution when standardized by population size. The 31 states that voted for President Trump received 56% of overall CDC funding, compared to 44% for the 20 states that voted for Kamala Harris. On a per capita basis, states voting for Harris received slightly more ($46 per capita) compared to those voting for Trump ($43 per capita). With supplemental funding removed, the distribution of funding remains almost the same (57% for Trump states and 43% for Harris states) while funding per capita was almost even ($27 per capita for Trump states vs $28 per capita for Harris states) (see Figure 7).

Appendix 1: What Does the CDC Budget Include?

CDC’s budget is comprised of three major categories:

• A discretionary budget determined and appropriated annually by Congress;
• A mandatory budget determined by a specific set of congressionally-mandated program authorizations, such as the Vaccines for Children program;
• In some years, supplemental funding is also provided to CDC outside of the regular annual appropriations process, typically to help with response to disease outbreaks or other health emergencies. Starting in 2020, CDC funding has included supplemental funds supporting COVID-19 response.

In FY 2023, the CDC discretionary budget was $8.28 billion, while mandatory budget totaled $6.97 billion. The exact amount of supplemental funding in CDC’s FY2023 budget is not clear. Since 2020, Congress provided CDC with additional funding via five different COVID-19 relief laws, with much of these supplemental appropriations made available to be spent over several years. In addition, other supplemental funds have been provided to CDC via transfers from other agencies. Further, in later legislation Congress rescinded some of the previously appropriated COVID-19 relief funding for CDC. CDC does not publicly report how much supplemental funding it has available in its budget, so developing a full picture of CDC’s available funding is a challenge.

However, CDC does report the amount of funds that it directs to state and local entities, which amounted to $14.9 billion in FY2023. CDC reports this funding by category and sub-category (program areas and activities) In addition, KFF designated these by funding type (discretionary, mandatory, and supplemental), as determined by appropriation bill language; Appendix Table 1 shows these categories and corresponding funding types.

Appendix 2: Additional Charts

Key Takeaways

• Most females who used their private insurance to pay for their abortion had out-of-pocket costs for their services, including 62% of those who accessed medication abortion, 68% of those who obtained a D&C procedure, and 76% of those who received a D&E procedure.
• Median private insurance reimbursement rates for abortion and ancillary services ranged from $562 for medication abortion to $1,046 for D&C, and $4,872 for D&E procedures.
• For those with coverage through employer sponsored insurance plans, median out-of-pocket costs were less than $100 for medication abortion and D&C procedures but rose to over $200 for D&E procedures, typically done later in pregnancy. However, a quarter of females with private insurance paid more than $100 for medication abortion and D&C procedures, and close to $1,000 for D&E procedures.
• Out-of-pocket costs were substantially higher for D&C and D&E procedures provided in ambulatory/outpatient hospital settings than office-based settings.
• In the five states that had policies eliminating cost-sharing for abortion services in place in 2023, the share of women with cost-sharing for an abortion decreased substantially from 82% in 2022 to 60% in 2023, while it was unchanged in states that permit cost-sharing for abortion (80% in 2022 and 79% in 2023).

In recent years, insurance coverage of abortion has been the focus of state lawmakers in their efforts to either restrict or expand access to abortion services. Since the passage of the ACA in 2010, many of the states that now have moved to ban or restrict abortion have banned state regulated plans sold through their state exchanges from covering abortion.  However, since 2022 when Roe v Wade as overturned, many states that support abortion rights enacted laws requiring coverage, typically free of cost-sharing, to support access to services (Figure 1).

Even before these state actions, many women did not use their insurance to pay for abortions, even when it was covered, because of the highly confidential and stigmatized nature of abortion care.  As a result, most people with private insurance end up paying the full costs of abortion that can range from $563 for medication abortion to upwards of $895 for second-trimester abortion. The result has been that those full costs have been borne by women even when they are insured, and insurance has not had to pay for a service that is often covered.

In their efforts to shore up and protect access to abortion and reproductive rights after the Dobbs decision, a handful of states have enacted policies, requiring first dollar coverage for abortion services for people enrolled in state regulated plans. The intent of these policies is to reduce financial barriers to abortion by making the services more affordable.  To get a better understanding of how much private plans are reimbursing health care providers for abortion and related services (see Medicaid reimbursement analysis) and document the out-of-pocket spending that people incur when they use their insurance, we conducted an analysis of the 2023 Merative Marketscan claims database, a large national sample of healthcare claims for people enrolled in employer sponsored insurance plans in both the state-regulated and self-insured markets.

Costs for Ancillary Abortion Services

For medication abortion, there are typically two different approaches to billing for services provided: (1) billing the medications plus any ancillary services; or (2) billing the medications plus the global medication abortion code (S0199), a bundled code that includes all associated services and supplies. For abortion procedures (such as D&Cs and D&Es), most providers bill for the procedure plus any associated services and supplies (Table 1). However, some states have implemented a bundled reimbursement that includes the procedure and associated services and supplies.

For non-bundled scenarios, other services commonly billed as part of the abortion service include ultrasounds, pain medication/sedation, Rh testing and/or treatment, the office visit, cervical dilator, specimen handling, and the surgical tray (Figure 2).

Ultrasound: Ultrasounds were commonly billed with a D&C procedure (71%) and D&E procedure (69%); 44% of medication abortions also include a separate ultrasound claim. This is likely an undercount of ultrasound provision because ultrasounds could be bundled into the abortion codes, especially for the global medication abortion code. Ultrasound is not a medical requirement for first-trimester abortion care but is required by some state laws. Medication abortion without ultrasonography has been shown to be as effective and safe as medication abortion with ultrasonography.

Pain Medication and/or Sedation: A claim for pain medication and/or sedation was billed with many D&E procedures (73%) and over half of D&C procedures (57%). Other medications may be provided that are bundled as part of the procedure and not separately billed.

Rh testing and/or treatment: One third of D&C procedures (33%) and over half of D&E procedures (53%) included a claim for Rh testing and/or treatment (53%). Only 12% of medication abortions included a claim for Rh testing and/or treatment.  have shown that induced first-trimester abortion is not a risk factor for Rh sensitization, indicating that Rh testing and treatment are unnecessary before 12 weeks’ gestation.

Office Visit: Comprehensive office visits are often considered part of the abortion procedure and may not be separately reimbursable. However, half of D&E procedures (50%), four in ten (43%) D&C procedures, and nearly half 48%) of medication abortions included a separate office visit claim within 5 days of the abortion.

Surgical Tray, Specimen Handling, and Cervical Dilator: Other services that providers bill for with an abortion include the surgical tray used during the surgical procedure, specimen handling, and a cervical dilator. These may appear less commonly in claims because they may be bundled with the procedure code for the abortion. Cervical dilators are sometimes inserted a day or two before a procedure.

Total Costs of Abortion Care

The median total costs of abortion services and all ancillary services billed for on the day of the abortion including the insurance payment plus any out-of-pocket expenses paid by the consumer including coinsurance, deductible, and copay were $562 for medication abortion, $1,046 for D&C, and $4,872 for D&E procedures, which usually occur later in pregnancy (Figure 3). Higher costs may also be associated with abortions taking place in emergency situations. We found 3% of abortions included an evaluation management code for an emergency room visit or an ambulance ride on the day of the abortion or within the five days prior to the abortion.

Most incurred out-of-pocket costs for their abortion services including 62% of those obtaining a medication abortion, 68% of those obtaining a D&C procedure, and 76% of those obtaining a D&E procedure (Figure 4). This can include copays, coinsurance, or deductible amounts. Among those with some out-of-pocket costs, 62% had a copay, 29% paid something towards their deductible, and 40% had some coinsurance payment.

Among those with out-of-pocket costs, half with a medication abortion or D&C procedure paid less than $70. However, a quarter paid more than $121 for a medication abortion and more than $194 for a D&C. Median out-of-pocket amounts on the day of a D&E procedure were $235, but those in the upper quartile paid close to $1,000 out-of-pocket (Figure 5).

The site of abortion services can have a substantial impact on the amount of out-of-pocket costs incurred by the patient. While out-of-pocket costs for medication abortion are similar in office-based and ambulatory/outpatient hospital settings, procedural abortions in ambulatory/outpatient hospital settings result in higher out-of-pocket costs for patients compared to those in office-based settings. The differences are largest for D&E procedures where the median out-of-pocket costs for a D&E procedure in an office-based setting is $90 compared to $616 in an ambulatory/outpatient hospital setting. Those in the upper quartile paid around $200 and more out-of-pocket for an office-based D&E procedure, while those in an ambulatory/outpatient hospital setting paid more than $1500 out-of-pocket (Figure 6). Higher out-of-pocket costs in ambulatory/outpatient hospital settings compared to office-based setting is not unique to abortion services.

Of the nine states that have passed policies eliminating cost-sharing for abortion in state-regulated plans, five were in effect in 2023, which is the most recent year of the Merative Marketscan Claims data: OR, CA, MA, MD, and NY. On average, in these five states, the share of women with cost-sharing for an abortion decreased substantially from 82% in 2022 to 60% in 2023 (Figure 7). In states that permit cost-sharing for abortions in their state-regulated plans, there was essentially no change in the share of women with cost-sharing for abortions from 2022 (80%) to 2023 (79%).

The reduction in the share of women with cost-sharing for abortion seems to be largely driven by a large reduction in California, which is also the state with the largest number of abortions in the Merative Marketscan Claims. However, Maryland, New York, and Oregon also saw reductions in the share of women with cost-sharing for abortion from 2022 to 2023. The Merative Marketscan Claims data include both state-regulated and self-funded plans that are generally not subject to state requirements for insured plans and it is not possible to determine which plans in the claims data are state-regulated or self-funded. Therefore, the reduction in cost-sharing in states that have eliminated cost-sharing for abortions could represent women enrolled in state-regulated plans or it could demonstrate a spillover effect into self-funded plans following state requirements or both.

On the Horizon

Policies that eliminate cost-sharing for abortion services could encourage individuals to use their insurance to pay for their abortion service rather than pay directly for the services. For many this will be a substantial reduction in out-of-pocket costs, potentially making abortion services more accessible and affordable for those with coverage.  Women with low incomes are disproportionately affected as they are less likely to be able to afford the out-of-pocket costs for an abortion without relying on assistance or forgoing the service.

While eliminating out-of-pocket costs for abortion care could increase plan premiums, the University of California found these increases if implemented in the state would be less than 0.01% of premium costs, a minor increase. Plans pay significantly more for pregnancy care and labor and delivery than abortion services. Abortion care also tends to be more isolated episodes without requiring substantial ongoing care and therefore has lower impact on premiums.

It should be noted that even if out-of-pocket costs for abortion services are eliminated, the many costs outside of the actual service, such as travel, lodging, unpaid time off, can still place a financial burden on individuals seeking abortion services, particularly for those living in states where abortion is banned or restricted and must travel for their care.

Methods

The 2023 Merative Marketscan claims database was used to examine the amounts paid by insurance for abortion and related services, the share of females ages 18 to 49 who had out-of-pocket charges for their abortion, and the amount of out-of-pocket costs paid for the abortion and associated services on the day of the abortion and within five days prior to the abortion. Out-of-pocket costs were calculated by summing the coinsurance, copay, and deductible costs among those with any out-of-pocket costs (i.e. greater than $0). Claims representing 7,685 unique abortions: 4,137 medication abortion claims, 1,916 dilation and curettage (D&C) claims, and 1,531 dilation and evacuation (D&E) claims were identified (Table 1). All spending on the day of the abortion, as well as other associated services provided within the 5 days prior to the abortion, including ultrasounds, office visits, pain medication/sedation, Rh testing and/or treatment, cervical dilator, specimen handling, and the surgical tray were also included in the analysis since many state laws mandating coverage, include the abortion itself as well as abortion-related medical services.

Key Takeaways

• Misoprostol and mifepristone, the two drugs used as part of the FDA approved medication abortion regimen, also have a wide range of clinical applications and are used to manage the reproductive health of millions of women across the nation that include but are not limited to abortion.
• Louisiana has enacted and implemented a law reclassifying mifepristone and misoprostol as Schedule IV controlled substances. Similar legislation has been introduced in Texas, Missouri, and Kentucky.
• Among a sample of claims weighted to represent people with employer sponsored insurance, over half of reproductive age women with an outpatient claim for misoprostol unrelated to abortion did not have a pregnancy related diagnosis and 28% were prescribed the medication to manage a miscarriage.
• About half of outpatient claims for misoprostol in Texas and Missouri Medicaid, and a third in Kentucky and Louisiana were used to manage miscarriages. About one in five were used for other pregnancy-related reasons, such as induction of labor or to manage pregnancy-related hemorrhages in Texas, Missouri, and Louisiana Medicaid.
• States seeking to reclassify mifepristone and misoprostol as controlled substances to limit access to medication abortion may impede access to medications that impact the health and safety of women who rely on these medications to manage a wide range of conditions.

On October 1, 2024, Louisiana enacted a new law that reclassifies two drugs commonly used for medication abortion, mifepristone and misoprostol, as Schedule IV controlled substances. Soon after, lawmakers in Texas, Missouri, and Kentucky proposed similar legislation to designate these medications as controlled substances. Typically, only drugs with the potential for dependency or abuse are classified as controlled substances, with their scheduling (I-V) determined by their level of abuse risk. Examples of Schedule IV drugs include Ambien and Xanax. In addition to abortion care, mifepristone and misoprostol are used to treat several medical conditions. As controlled substances in Louisiana, they require special storage, ordering, and documentation procedures, which could result in delays in access to emergency and routine outpatient care. The other impact of these kinds of laws is to cause clinicians and pharmacists to be hesitant to prescribe or dispense these medications for non-abortion related care as to avoid becoming a formal part of the state record tracked through the Louisiana Prescription Monitoring Program (PMP).

Using data from both a convenience sample of claims weighted to be representative of people with employer sponsored health insurance and Medicaid claims from Texas, Missouri, Kentucky, and Louisiana, this analysis finds that these medications are often provided for many reasons other than abortion. Laws that limit access to these drugs could particularly affect women who rely on these medications to manage miscarriages, get IUDs, manage ulcers or autoimmune conditions as well as the clinicians that serve them.

Indications for Use of Misoprostol and Mifepristone

Both misoprostol and mifepristone are classified as essential medicines by the World Health Organization (WHO). Misoprostol is frequently used in obstetrics and gynecology for procedures like the medical management of miscarriage, induction of labor, cervical ripening before surgical procedures, and the treatment of postpartum hemorrhage. It is a prostaglandin that causes cervical softening and dilation, as well as uterine contractions. It is also indicated for reducing the risk of nonsteroidal anti-inflammatory drug (NSAIDs like aspirin and ibuprofen) induced gastric ulcers in patients at high risk of complications. Either alone or in combination with mifepristone, misoprostol can be used to terminate an intrauterine pregnancy in early stages.

Mifepristone, the other drug included in the abortion medication regimen approved by the Food and Drug Administration (FDA), works by blocking the hormone progesterone. And while most patients who receive medications for miscarriage management are given misoprostol alone, the combination of mifepristone and misoprostol has been shown to be more effective in miscarriage management and is the recommended protocol by The American College of Obstetricians and Gynecologists (ACOG). In addition, mifepristone is also indicated for controlling hyperglycemia in adults with Cushing syndrome.

Use of Misoprostol and Mifepristone

The analysis examines the outpatient diagnoses of reproductive aged females, ages 15-49, who had a non-abortion related misoprostol or mifepristone prescription or outpatient claim using the 2023 Merative MarketScan Encounter Database and 2021 Medicaid claims. These medications are often used for inpatient pregnancy-related procedures, such as miscarriage management, labor and delivery, as well as emergency situations such as hemorrhage. However, a limitation of this analysis was that it was not able to identify misoprostol or mifepristone use in an inpatient setting due to the bundling of drug claims along with other inpatient procedures for reimbursement purposes. The findings in this analysis thus include only the provision of the medications in an outpatient setting. Additionally, the claims used in this analysis only include medications for which there were claims that were submitted to the benefit plan and do not include services for which a claim was not filed. As this most directly impacts circumstances when mifepristone and misoprostol were used for medication abortions that were paid for out-of-pocket without using insurance and could result in an underestimate of the share of individuals using these drugs for the purposes of terminating a pregnancy, this analysis focuses only on medications provided via prescription or outpatient claim for non-abortion related care.

Among those with a non-abortion related mifepristone or misoprostol claim, the following outpatient diagnoses were flagged if they were within 90 days of the mifepristone or misoprostol claim because these drugs can be provided a month or two prior to a procedure:

• miscarriage
• other pregnancy-related conditions (including hemorrhage, induction of labor, delivery)
• non-pregnancy related cervical ripening (IUD insertions, polyps, noninflammatory disorders of cervix uteri)
• other non-pregnancy-related conditions for which misoprostol or mifepristone are used (including rheumatoid arthritis, fibroids, gastric ulcers, dermatitis, low back pain, osteoarthritis, and Cushing syndrome)

Because some patients had diagnoses in more than one of these categories, a hierarchy was applied to classify health plan enrollees into one category: miscarriage, other pregnancy-related, non-pregnancy-related cervical ripening, and other non-pregnancy-related conditions. Individuals with a mifepristone or misoprostol claim that did not have a diagnosis from one of these categories within 90 days of their claim or individuals that only had prescription claims for mifepristone or misoprostol without outpatient claims within 90 days were classified as “unexplained.”

Misoprostol Use

Among the reproductive aged women enrolled in employer-sponsored plans who had a non-abortion related outpatient misoprostol claim, 65% had no indication of pregnancy within 90 days of their misoprostol claim date (Figure 1). Diagnoses for conditions where misoprostol would be indicated for non-pregnancy-related cervical ripening, such as for an IUD insertion, made up the largest share of those with a non-abortion related outpatient or prescription misoprostol claim (42%). Another 14% had a diagnosis for another non-pregnancy related reason for which misoprostol can be used, such as gastric ulcers, rheumatoid arthritis, fibroids, or other conditions related to abnormal bleedings. More than one in four (28%) had a miscarriage diagnosis within 90 days and 7% had an outpatient diagnosis for another pregnancy-related condition, such as maternal hemorrhage or labor induction. The remaining 9% of women with an outpatient misoprostol claim did not have a diagnosis related to one of these conditions within 90 days and were categorized as unexplained.

Similarly, about three in ten Medicaid beneficiaries in Kentucky and Louisiana had a miscarriage diagnosis within 90 days of their misoprostol claim. In contrast, among Texas and Missouri Medicaid beneficiaries, around half of misoprostol claims had a miscarriage diagnosis within 90 days of the claim, likely because misoprostol is commonly used to expedite the expulsion of nonviable pregnancy tissue in miscarriage management (Figure 2). About one in five beneficiaries in Texas, Missouri, and Louisiana had another pregnancy-related diagnosis within 90 days, which could have included hemorrhage or labor induction.

About a third of beneficiaries in Texas and Missouri did not have a pregnancy diagnosis within 90 days of their misoprostol claim, while over half of beneficiaries in Kentucky and Louisiana did not. Around one in ten beneficiaries in Texas, Missouri, and Louisiana had a claim for non-pregnancy-related cervical ripening typically indicated for an IUD insertion or stricture or stenosis of the cervix for which misoprostol may be used to facilitate IUD insertion. However, over a quarter of beneficiaries in Kentucky had a claim for non-pregnancy-related cervical ripening within 90 days of their misoprostol claim. One in five beneficiaries in Kentucky had other non-pregnancy-related diagnoses for which misoprostol is used, such as gastric ulcers, fibroids, and abnormal bleeding, while this share was smaller in Texas, Missouri, and Louisiana, but still around 10%.

Mifepristone Use

In contrast to misoprostol, the vast majority of women with non-abortion related outpatient claims for mifepristone (94%) had a miscarriage diagnosis within 90 days of their mifepristone claim (Figure 3). The remaining 6% had a diagnosis for another condition, such as Cushing syndrome.

Implications for Access

Misoprostol and mifepristone have clinical applications that are used to manage the reproductive health of millions of women across the nation. Despite their use as effective medications for terminating pregnancies, they are also frequently prescribed to manage many other conditions outside of abortion. Laws that seek to restrict access to these drugs will also impact healthcare for reproductive aged women who rely on them to treat a range of non-abortion related conditions, especially in states where abortion is already banned. Because controlled substances require specific prescribing and dispensing protocols and documentation outside of clinical records, health care providers, and pharmacies may choose not to stock or dispense them to avoid the risk of penalties or criminalization. Healthcare providers must also be licensed with the Drug Enforcement Administration (DEA) in order to prescribe controlled substances which could cause a further chilling effect in their use, despite the robust evidence of their effectiveness and safety. This could affect women who are prescribed misoprostol for procedures such as IUD insertion or uterine polyp removal, but it also jeopardizes effective and potentially life-saving miscarriage management for the up to one-in-five pregnancies that are estimated to result in early pregnancy loss.

Beyond outpatient care, these barriers could also result in treatment delays in emergency situations such as hemorrhage during labor and delivery, which accounts for 14% of pregnancy-related deaths in the United States. Under the new Louisiana law, hospitals must now securely lock away mifepristone and misoprostol or use a passcode-protected dispensing system. Some resource-limited hospitals, such as rural or community hospitals, may also lack the capacity to stock controlled substances, making these medications unavailable to patients at those facilities. States like Louisiana, Texas, Kentucky and Missouri that seek to reclassify mifepristone and misoprostol as Schedule IV controlled substances may not only limit access to medication abortion, but they may also have consequences that impact the health and safety of many who need these medications for reasons other than terminating a pregnancy.

Methods

The analysis is based on prescription drug and outpatient medical claims from the 2023 Merative MarketScan Commercial Claims and Encounters Database, which contains claims information provided by employer-sponsored plans, and 2021 Transformed Medicaid Statistical Information System Analytic File (TAF) data from Texas, Missouri, Kentucky, and Louisiana. There were 6,106,254 total women of reproductive age in the 2023 Merative MarketScan Commercial Claims and Encounter Database representing a weighted population of 47,235,846 women of reproductive age. The 2021 Transformed Medicaid Statistical Information System Analytic File included women of reproductive age from Texas (n = 1,625,479), Missouri (n = 337,305), Kentucky (n = 501,500), and Louisiana (n = 551,103).

Reproductive aged women, ages 15-49, were included if they had a non-abortion related misoprostol or mifepristone prescription or outpatient claim. National Drug Codes (NDC) were used to identify misoprostol and mifepristone in prescription claims, while Healthcare Common Procedure Coding System (HCPCS) codes S0190 and S0191 were used to identify outpatient provision. International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes and Current Procedural Terminology (CPT)/HCPCS procedure codes were used to classify conditions from outpatient claims within 90 days of a misoprostol or mifepristone claim date. We chose 90 days because misoprostol can often be prescribed a month or two before a procedure, especially prior to LARC insertions. Women with a misoprostol or mifepristone claim who had multiple diagnoses within this period were categorized according to a mutually exclusive hierarchy as follows: miscarriage, other pregnancy-related conditions, cervical ripening, other non-pregnancy-related conditions. If no diagnosis from one of these categories was found within 90 days of the drug claim, they were included in the unexplained category. A small group of women (1%) with a misoprostol prescription claim who did not have an outpatient claim within 90 days were also included in the unexplained category. To make MarketScan data representative of enrollment in employer-sponsored insurance health plans nationally, weights were applied to match counts in the Current Population Survey for enrollees and their dependents employed by firms of a thousand or more workers by sex, age and state.

Appendix

Introduction

Immigrants and their children form a growing share of the U.S. population and, as of 2023, there were over 47 million immigrants residing in the country, accounting for 14% of the total population. Regardless of their countries of birth, about three in four (77%) immigrant adults say they moved to the U.S. for a better future for their children. Research shows that children of immigrants attain higher educational outcomes than the children of U.S.-born parent(s), play an outsized role in the U.S. health care workforce, and contribute more in taxes on average than the rest of the U.S.-born population. Actions being undertaken by the federal government to restrict immigration, including attempts to end birthright citizenship, rescission of protections from immigration enforcement in schools, and plans to carry out mass deportation, could negatively impact children living in immigrant families and have longer-term ramifications for the U.S. workforce and economy. Some states have also proposed actions to verify student immigration status in schools, which could further exacerbate fears and challenges among children in immigrant families.

Recent reports indicate that immigrant families are scared to send their children to school and that there have been declines in school attendance among children in immigrant families since President Trump took office. Declines in school participation and performance may not only negatively influence children’s educational outcomes and health but may also have impacts on school funding. This brief presents research on the impacts of immigration enforcement on children, including school attendance and performance; provides data on the share and number of school-aged children by state who live in immigrant families based on KFF analysis of the 2023 American Community Survey (ACS); and discusses potential implications of declines in school enrollment and/or attendance among these children on school funding. Key takeaways include:

• Increased immigration enforcement can increase absenteeism and negatively impact academic outcomes and student health. Research shows that increased immigration enforcement in schools is associated with chronic absenteeism, drops in school enrollment, exacerbation of racial and/or ethnic disparities in student outcomes, and negative physical and mental health outcomes among children in immigrant families, who are predominantly U.S.-born. Negative impacts on education may also have consequences for children’s long-term health. Adults with higher educational attainment tend to have longer life spans and be healthier than their counterparts with lower educational attainment. High educational attainment also is associated with better jobs that are more likely to provide employer-sponsored health coverage and higher incomes which, in turn, improve access to health care and resources to support health.
• Nationwide, about one in six (17%) or 9 million, school-aged children (5 to 17 years old) live in a household with at least one noncitizen adult, who could be impacted by immigration enforcement fears. This share increases to one in three (32%) school-aged children in California and about one in four in Texas (25%), New Jersey (24%), and Nevada (23%).
• Increases in absenteeism or decreased enrollment arising from enhanced immigration enforcement activity could lead to decreases in school funding. Public schools in the U.S. are primarily funded through a combination of state and local funding. Each state has its own formula for funding school districts, but they all are directly or indirectly based on the number of students served by a school district as determined through student attendance or enrollment. Schools in states that use attendance-based models to determine student counts for school funding may be particularly affected by increases in absenteeism or decreases in enrollment due to immigration-related fears. These states include California and Texas, which are home to the largest shares of school-aged children living in immigrant families. While the overall decrease in funding may be relatively small, school districts that serve large shares of students from immigrant families may be more heavily impacted by funding cuts.
• Schools may also face increased challenges addressing fears among children in immigrant families to prevent declines school performance and negative impacts on health. Some teachers and schools are working to mitigate negative impacts of increased immigration-related fears among families by preparing safety plans, establishing policies for dealing with ICE encounters, and providing families information about their legal rights.

Background

President Trump has increased immigration enforcement efforts, which have impacts across immigrant families, including the millions of U.S. citizen children living in them. These efforts include a slew of immigration policy changes focused on restricting both lawful and unlawful immigration into the U.S., increasing interior enforcement to support mass deportation, attempts to end birthright citizenship for the children of noncitizen immigrants, and rescinding protections against enforcement action in previously protected areas such as schools and health care facilities. KFF analysis shows that one in four, or 19 million, children in the U.S. have an immigrant parent, and the vast majority of these children are U.S. citizens. About one in ten (12%) children in the U.S. are citizen children with a noncitizen parent. Other analysis estimates that about 4.4 million U.S.-born children live with an undocumented immigrant parent.

Research shows that enhanced immigration enforcement actions have a wide array of impacts on children, including on school attendance and performance and mental and physical health. Specifically, research shows that increased immigration enforcement can lead to chronic absenteeism, drops in school enrollment (including among U.S.-born students), as well as increases in students’ moving out of school districts with high enforcement. Further, increased immigration enforcement is associated with “declines in academic achievement”, an exacerbation of racial and ethnic gaps in educational outcomes, feelings of lack of safety in schools, and negative mental and physical health outcomes among children of immigrants. Negative impacts on education may also have consequences for children’s long-term health. Adults with higher educational attainment tend to have longer life spans and be healthier than their counterparts with lower educational attainment. High educational attainment also is associated with better jobs that are more likely to provide employer-sponsored health coverage and higher incomes which, in turn, improve access to health care and resources to support health.

Recent reports indicate that immigrant families are scared to send their children to school and that there have been declines in school attendance among children in immigrant families since President Trump took office. Schools, which were historically considered to be “safe” spaces, are now within the purview of immigration enforcement following the Trump administration rescinding protections against enforcement action there. Recent reports suggest declines in school attendance due to immigration-related fears. In the Boston-area, reports suggest that over 1,000 students did not show up to school following news of Immigration and Customs Enforcement (ICE) activity nearby, similar to Fresno, where attendance dropped by around 1,000 per day following President Trump’s inauguration. In Chicago, one educator serving immigrant families noted a nearly 50% drop in school attendance in the days immediately following President Trump’s inauguration. In some cases, there have been reports of school officials sharing information with parents about potential ICE encounters on school property which later turned out to be false. In response to growing fears among immigrant families, a number of teachers and schools are working to prepare safety plans, establishing policies for dealing with ICE encounters, and providing families information about their legal rights.

Fears and attendance declines among children in immigrant families may be exacerbated by other state-level actions. For example, Tennessee is in the process of advancing a bill “that would require public K-12 and charter schools to verify student immigration status and… bar children who cannot prove they lawfully reside in the United States unless they pay tuition.” Oklahoma also has proposed a rule that would require parents or legal guardians to provide proof of citizenship and/or immigration status for children enrolled in the state’s public schools. While Oklahoma’s proposed rule does not explicitly bar enrollment for students who may be undocumented, it is likely to cause fear among immigrant families about their immigration status being recorded and may lead to drops in student enrollment due to chilling effects. Similar bills have also been proposed by lawmakers in Texas, Indiana, and New Jersey, but it is unclear if there is a clear pathway to passage for such legislation.

Findings

This analysis uses 2023 ACS data to identify school-aged children living in a household with a noncitizen adult who could be impacted by immigration-related fears overall and by state. Additionally, it provides an overview of state school funding models based on data from the Education Commission of the States to give insight into where schools may be at particular risk for decreased funding due to declines in school attendance or enrollment.

Nationwide, about one in six (17%), or 9 million, school-aged children (5 to 17 years) live in a household with at least one noncitizen adult, who could be impacted by immigration enforcement fears. This share rises to nearly one in three (32%) or 2 million school-aged children in California and about one in four school-aged children in Texas (25%), New Jersey (24%) and Nevada (23%) (Figure 1 and Appendix Table 1). By region, the West has the highest share (24%) of school-aged children in a household with at least one noncitizen adult, followed by about one in six school-aged children in the Northeast (17%) and the South (16%); and about one in ten school-aged children in the Midwest (9%). As noted, five states (Indiana, New Jersey, Oklahoma, Tennessee, and Texas) have introduced bills to verify student immigration status. Over 2 million school-aged children in these states live with at least one noncitizen adult in the household, including about one in four school-aged children in Texas (25%) and New Jersey (24%), and about one in ten in Oklahoma (11%), Tennessee (10%), and Indiana (9%).

All state school funding models are directly or indirectly tied to the number of students served by a school district. Most (35) states plus DC fund schools on a per student basis (Figure 2). In these states “districts receive a base amount of funding per student.” Nine states use a resource-based funding model, in which districts receive funds based on the resources they anticipate needing (such as teachers and supplies) depending on how many and what types of students the school districts serve. Four states use hybrid models that combine aspects of student- and resource-based funding, and two states use a guaranteed tax base model that allows districts to determine per student spending on a state-guaranteed tax base.

States employ a variety of methods to determine a district level student count for their funding models, including attendance averages, single or multiple student counts, or enrollment averages. To determine the student count that goes into funding models, six states use the average daily attendance in school districts over a year, also known as an attendance average; 20 states plus DC use student enrollment or attendance from a single day or multiple days, also known as single or multiple counts; and 24 states use the average daily enrollment in school districts over a year (or over a 20-day period in the fall in Alaska), also known as enrollment average (Figure 3). Districts in states that base student counts on attendance are more likely to have their school funding negatively impacted by short-term absenteeism among children in immigrant families due to increased immigration enforcement. These states include California and Texas, which are home to the largest shares of school-aged children in households with a noncitizen adult. Districts in states that base student counts on enrollment could also be impacted if, over the longer-term, immigrant families disenroll their children from school or move out of school districts due to immigration-related fears. While the overall decrease in funding may be relatively small, school districts that serve large shares of students from immigrant families may be more heavily impacted by funding cuts.

Appendix

Introduction

President Trump has made a slew of immigration policy changes focused on restricting entry at the border and increasing interior enforcement efforts to support mass deportation. While these actions are focused on undocumented immigrants, they likely will have ripple effects across immigrants of all statuses and millions more people living in immigrant families.

Mass deportations could negatively impact the U.S. economy and workforce, given the role immigrants play, particularly in certain industries. Deportation of immigrants may exacerbate health care workforce shortages as immigrants and their adult children play outsized roles in the health care workforce. To increase understanding of how shifting immigration policies may affect the direct care workforce providing long-term care services, this data note uses the 2023 American Community Survey (ACS) to provide an overview of the role that immigrants play in the direct care workforce for long-term care (LTC) services (see Methods). Key takeaways include:

• Immigrants make up 28% of the overall direct care workforce for LTC services. As of 2023, there were over 820,000 immigrants working as direct care workers providing long-term care in the U.S. (including over 500,000 naturalized citizens and over 300,000 noncitizen immigrants).
• Immigrants play a particularly large role in the home care workforce, making up one in three workers (32%) in home care settings. They also make up 21% of workers in nursing facilities and 24% of workers in residential care settings.
• Immigrants have made up an increasing share of the direct care LTC workforce over time. The share of direct care workers providing LTC services who are immigrants increased from 24% in 2018 to 28% in 2023.

Together the data show that immigrants comprise a large and growing role of the direct care workforce providing LTC services, particularly in home care settings. Restrictions on immigration and mass deportations could lead to reductions in immigrants available to fill these roles, which would exacerbate workforce shortages, making it harder for people to find caregivers for themselves and their loved ones.

Background

Direct care workers play a pivotal role in providing long-term care services in both home care and institutional care settings. Direct care workers provide a broad range of paid and unpaid medical and personal care services that assist with activities of daily living (such as eating, bathing, and dressing) and instrumental activities of daily living (such as preparing meals, managing medication, and housekeeping). More than 6 million people use paid LTC delivered in home care settings and more than 2 million people use LTC delivered in institutional settings, according to CBO estimates. This workforce performs demanding, high-stress work for low wages and often no benefits.

Prior research shows that immigrants help fill workforce shortages in the direct care LTC workforce and contribute to improvements in care. There is historic demand for long-term care services, with particularly high demand for workers who can help people age at home. One study found that communities that have increased immigration have a greater share of adults that are able to age in place. Other research finds that the home care workforce is declining relative to the number of adults needing these services. Analysis of the Secure Communities immigration enforcement program found that the program reduced direct care staff hours, suggesting that stringent immigrant enforcement exacerbates health care worker and direct care worker shortages in the U.S. Research also finds that immigration increases the local supply of workers in nursing fields, with the largest effect on the number of nurse aides. Similarly, increased immigration significantly raises the staffing levels of nursing homes in the U.S., particularly in full time positions.

Immigrants also provide culturally competent care to an increasingly diverse population of older adults. In particular, some older adults may feel more comfortable with direct care workers who share or understand their language, race, ethnicity, or other cultural characteristics. A KFF focus group of family caregivers noted that a challenge to finding paid care was a language barrier. One caregiver described the difficulty of finding culturally competent care because her father only spoke Spanish.

Key Findings

Using 2023 ACS data, this analysis identifies immigrants as a share of the direct care workforce providing LTC, how this share varies by setting, and how this share changes over time. The direct care workforce includes aides (home health aides, personal care aides, and nursing assistants) and nurses (licensed practical nurses and registered nurses). We define the direct care workforce as all individuals 18 and older who earned at least $1,000 during the year and indicated that their job was in both the long-term care industry and their occupation fell under the category of either aide or nurse (see Methods for more details). The ACS does not include unpaid LTC caregivers, such as relatives and friends, who provide the majority of home-based long-term care in the U.S.

Immigrants make up 28% of the overall direct care workforce providing LTC services, higher than the share of all adult workers in the U.S. who are immigrants (17%) (Figure 1). This includes 17% who are naturalized citizens and 11% who are noncitizen immigrants. Immigrants make up a higher share of aides (30%) than nurses (20%). The large majority of immigrants in nursing roles are naturalized citizens. Most immigrants working as aides also are naturalized citizens, although there is a more mixed distribution of naturalized citizens and noncitizen immigrants. Aides provide hands-on assistance to older adults and people with disabilities and include home health aides, personal care aides, and nursing assistants.

Immigrants play a particularly large role in the home care workforce, making up one in three workers (32%) in home care settings (Figure 2). Immigrants make up 21% of workers in nursing facilities and 24% of workers in residential care settings. The share of workers that are immigrants is highest in home care settings when compared to other settings because aides (who are more likely to be immigrants when compared to other direct care workers) make up the majority of workers in home care settings. Reflecting this pattern, noncitizen immigrants make up a larger share of immigrants working in home care settings compared to nursing facilities and residential care settings.

Immigrants make up a growing share of the direct care workforce, increasing from 24% of direct care workers in 2018 to 28% in 2023 (Figure 3). This growth reflects increases in the share of workers who are naturalized citizens; the share who are noncitizen immigrants remained relatively stable during this time period. Immigrants’ role in the direct care workforce grew in both home care and residential care facilities. The share of the total direct care workforce who are immigrants increased from 28% to 32% in home care and from 19% to 24% in residential care facilities between 2018 and 2023 (data not shown). The share of the direct care workforce who are immigrants has remained relatively stable over time in nursing facilities (data not shown).

It was recently reported that a list was sent to Congress of awards to be terminated at USAID, an agency already effectively shuttered as part of the administration’s foreign aid review and funding freeze. The list generally confirms what has been in administration court filings and other announcements – that most awards at the agency are slated to be terminated. Specifically, it indicates that of more than 6,200 awards, 5,341 or 86% will be terminated, representing $27.7 billion in unobligated funds. Of this, $7.4 billion in unobligated funds falls directly under USAID’s global health bureau and billions more are for global health activities funded through other bureaus or at the individual country mission level. While the situation does appear to be fluid, with Congress having yet to weigh in and with litigation ongoing, the list does raise several questions:

• Despite a waiver continuing “life-saving humanitarian assistance,” including core life-saving medicine and medical services, several such projects are on the USAID terminated list. Shortly after the foreign aid review and funding freeze were initiated, putting a stop to most bilateral foreign assistance activities, Secretary of State Rubio issued an emergency waiver stating that “Implementers of existing life-saving humanitarian assistance programs should continue or resume work if they have stopped.” This was followed by specific waivers for some PEPFAR services and a subset of other health services. Despite these waivers, however, several projects that seem to meet the definition of life-saving as indicated in the waiver language and are interventions that have been shown to reduce morbidity and mortality, are on the terminated list. These include, for example, efforts to strengthen and deliver malaria diagnosis and treatment services as part of the President’s Malaria Initiative (PMI) in Cambodia, Ethiopia, and The Gambia and TB projects focused on diagnosis and treatment in Nigeria and South Africa. Also on the terminated list is a contract for Gavi, the vaccine alliance, an international public-private partnership that provides routine vaccines to more than half of the world’s children helping to avert almost 19 million childhood deaths.
• Several awards on the terminated list are already spent in full. According to the list, there are several awards for which all funding has already been obligated and, per USASPENDING, the government’s funding database, fully spent. In global health, for example, these include funding for COVAX, the COVID-19 vaccine mechanism that was housed at Gavi (all funding was already disbursed in 2021), an award for CEPI, the Coalition for Epidemic Preparedness Innovations, and an award for the Pandemic Fund (housed at the World Bank). These may be on the list because their awards are technically still open.
• Other awards on the terminated list appear to be for broader contract arrangements, listing outstanding obligations for funding that has yet to be appropriated by Congress. This appears to be the case for Gavi, for example, which is listed as having $1.7 billion in unspent obligations through 2030. However, of this, only $300 million has been appropriated by Congress (for FY 2025) and the remaining amount appears to be a projection of future funding. This also seems to be the case for polio and immunization funding at the World Health Organization (WHO), for which $781 million is listed as unobligated but is likely an estimate of future appropriations.
• The list confirms other reports and administration statements about what is not being supported, including several projects related to HIV prevention and interventions for key populations, family planning projects, and support for WHO. This includes, for example, a project in Zambia focused on voluntary medical male circumcision to reduce the risk of HIV, one in Malawi focused on preventing new HIV infections among men and women including adolescent boys and young men, and one in Namibia focused HIV prevention and treatment among key populations; family planning projects in Ghana, Kenya, and Zimbabwe; and projects that sought to integrate family planning with maternal health and others services in several countries. Support for WHO is also on the terminated list.
• There are many awards on the terminated list that worked to strengthen host country government, civil society, and private sector capacity to deliver services. While these awards are not directly life-saving, they are designed to support country ownership and sustainability, to help reduce the reliance on the U.S. government, such as an HIV project in Uganda and a malaria project in Uganda. As such, canceling these projects could set back such efforts.
• Finally, it is unclear if this list is final, or just the most recent one circulating. There have been at least three other lists circulating thus far with different sets of terminated awards. Given that this list is reported to have just gone to Congress, it is possible some negotiation may still be underway. In particular, while the administration typically has the authority to choose which specific implementing organizations it will work with, in global health, Congress provides agencies with specific funding instructions including amounts for different program areas (e.g., HIV, TB, malaria, maternal health and others) and for certain international institutions (e.g., The Global Fund to Fight AIDS, Tuberculosis and Malaria, Gavi). As such, Congress may evaluate the list of terminations against these directives. Indeed, the FY 2025 funding bill that was just signed into law requires the administration to report to Congress within 45 days regarding its spending plans for foreign assistance.