As one of his first actions in office, President Trump signed executive orders revoking federal diversity, equity, inclusion, and accessibility (DEIA) related programs and actions in the federal government and among federal contractors and grantees. DEI initiatives are intended to create more diverse and inclusive work environments, to address discriminatory policies or practices, as well as to counter the impacts of historical actions that led to unequal opportunities for certain groups. In implementing President Trump’s executive orders, the administration has taken significantly broader actions beyond eliminating DEI programs to include eliminating priorities, actions, information, data, and funding related to concepts of diversity or disparities among federal agencies as well as federal contractors and grantees. Some of these actions have been paused due to ongoing litigation, and it remains to be seen what actions may proceed under final court rulings. Given the broad nature of these actions, they will not only likely lead to a less inclusive and diverse workforce, including in health care, but will also likely lead to widening disparities in health and health care, reversing prior efforts to address disparities and advance equity.

This brief explains the potential impacts of the elimination of diversity and disparities-related initiatives under the Trump administration on racial health disparities. While this brief focuses on racial and ethnic disparities, these actions have implications for health equity across other dimensions, including gender and sexual orientation. The terms DEI and DEIA are similar and often used interchangeably. The “A” in DEIA refers to accessibility for people with disabilities. The remainder of this brief uses DEI as it is more commonly known and used, but with the recognition that accessibility is also a key part of health equity

Federal Actions to Eliminate Disparities Initiatives

On the first day of his second term, President Trump signed Executive Order 14148 which revoked 78 executive orders and memoranda issued by the Biden administration, many related to DEI. This included President Biden’s Executive Order 13985, which required federal agencies to conduct equity assessments and collect data to track and address trends and barriers that underserved communities face in accessing federal positions and programs. The reversal also eliminated DEI frameworks that prioritized equity-driven decision-making and resource allocation in agencies such as the Department of Health and Human Services (HHS) and the Centers for Disease Control and Prevention (CDC).

President Trump also issued Executive Order 14151 and directives that mandate federal agencies to terminate all DEI related offices and positions; equity action plans, actions, initiatives or programs; equity-related grants or contracts; and DEI performance requirements for employees, contractors, or grantees. In addition, he issued Executive Order 14168 to “recognize two sexes, male and female;” specify that sex shall refer to a biological classification of male or female; direct federal agencies and employees to only use “sex” and not “gender;” remove all references to “gender ideology” or identity; and ensure that grant funds do not promote “gender ideology.” Further, he signed Executive Order 14173, which revoked the 1965 Equal Employment Opportunity rule that protected against discrimination in employment among federal contractors; the order also added new requirements for federal contractors and grantees to certify that they do not operate DEI programs that violate anti-discrimination laws and for federal agencies to identify entities, including publicly traded corporations, large nonprofit corporations or associations, and foundations, to target with civil investigations to deter DEI programs. Other actions include Executive Order 14224, which named English as the official language of the U.S. and rescinded an executive order and guidance that reaffirmed the federal government’s commitment to make services accessible to people with limited English proficiency, as well as guidance directing schools and other entities that receive federal funds from the Department of Education to stop using “racial preferences.” This guidance broadens the landmark 2023 U.S. Supreme Court ruling that effectively ended the use of race-conscious admissions policies in higher education, overturning decades of precedent supporting affirmative action.

To carry out the executive orders, the Office of Personnel Management (OPM) directed agencies and departments to take down all outward facing media that “inculcate or promote” “gender ideology,” as well as to remove all public facing DEI related websites and content. This resulted in the temporary shutdown of websites and removal of key health datasets. While some web pages and datasets began returning in several days, they included a warning message that they were being modified to comply with President Trump’s executive orders and some materials, such as codebooks and questionnaires, did not immediately return. The administration also directed departments and agencies to pause grants provided to federal contractors to identify and review programs and activities for consistency with the President’s policies. Reports also indicate that the administration has flagged over 100 words that federal agencies should limit or avoid to comply with the President’s policies, including disparities, diversity, equity, and race. The CDC reportedly ordered the withdrawal of papers pending publication to ensure language compliance. Similarly, reports suggest that the National Science Foundation froze payments to grantees and began screening grant proposals for terms related to gender, equity, and inclusion and that the National Institutes of Health began terminating research grants to comply with the new restrictions.

Multiple lawsuits have been filed challenging the executive orders and actions, which have halted some of these actions, but it remains to be seen what actions will be allowed under final court rulings. For example, a preliminary nationwide injunction blocked enforcement of significant provisions of the executive orders, including the termination of federal contracts and funding. Other litigation has ordered the return of public health web pages and datasets. Some of this information has been restored, such as the FDA’s draft guidance on diversity in clinical trials, but with an explanatory note that any information on the page promoting “gender ideology” is “extremely inaccurate” and that “Administration and this Department reject” the content:

Implications for Health and Health Equity

In the wake of the COVID-19 pandemic and racial reckoning following the murders of George Floyd and others, the federal government as well as many states and private entities increased efforts focused on addressing health disparities, including recognizing the role of historical and ongoing racism in driving disparities. This increased focus led to the development of programs and initiatives focused on mitigating disparities, including efforts to address disparities in maternal and infant health, cancer, and chronic disease, as well as other efforts, such as increasing diversity in clinical trials for development of new drugs and devices. Research efforts also increased to understand disparities, the factors driving them, and effective interventions to mitigate them. Implementation of President Trump’s executive orders eliminates much of this work, which will likely lead to widening disparities in health.

Elimination of focused efforts to address health disparities will potentially further exacerbate disparities, contributing to worsening overall health and unnecessary health care costs. To comply with the President’s executive orders, federal agencies have eliminated health equity plans, strategies, and guidance focused on mitigating disparities. For example, the administration ordered the Centers for Medicare and Medicaid Services to disband its Health Equity Advisory Committee, which was charged with addressing systemic barriers to access that included structural racism, and Federal Drug Administration draft guidance on diversity in clinical trials (although it was restored pursuant to a court order). Focused plans and initiatives to mitigate health disparities seek to address the underlying inequities that drive disparities and meet the needs and preferences of diverse populations. These efforts are important for equity and for improving the nation’s overall health and economic prosperity. Racial and ethnic health disparities result in higher rates of illness and death across a wide range of health conditions. Research also shows that disparities are costly, resulting in excess medical care costs and lost productivity, as well as economic losses due to premature deaths. In the absence of focused efforts, disparities will likely widen because the underlying inequities that contribute to them persist, leading to worse overall health and unnecessary health care costs.

Loss of information, data, and research will inhibit the ability to identify disparities and understand the factors driving them. In implementing the executive orders, agencies removed health information, such as HIV-related content, and reports on current disease threats, like bird flu, as well as federal data, including data from the Centers for Disease Control and Prevention and the U.S. Census. While some of the datasets were returned, they were marked with a warning message suggesting there could be future changes, leaving uncertainty about what data will be available over the long-term. Additionally, as noted, federal agencies are now screening and halting research related to disparities, equity, and inclusion, which will likely lead to reductions in funding to support research on disparities. Data are a cornerstone for efforts to address health disparities and advance health equity. Data are essential for identifying where disparities exist, directing efforts and resources to address disparities as they are identified, measuring progress toward achieving greater equity, and establishing accountability for achieving progress. Without adequate data and research disparities may remain unseen and unaddressed.

Elimination of DEI efforts among the federal workforce and contractors as well as in education will likely lead to a less diverse health care workforce, which would contribute to widening disparities in health care experiences and outcomes. People of color have historically been underrepresented in the health care workforce relative to their share of the population. Research shows that increasing the racial and ethnic diversity and cultural competency of health professionals is associated with improved access to care, greater patient choice and satisfaction, and other benefits. KFF 2023 survey data show Black, Hispanic, and Asian adults who have more health care visits with providers who share their racial and ethnic background report more frequent positive and respectful interactions. Other research suggests that patient and provider racial concordance contributes lower emergency department use, increased visits for preventative care, and greater treatment adherence. One study found that greater representation of Black primary care physicians led to increased life expectancy and lower mortality among Black people. The recent actions to eliminate diversity efforts among federal agencies and contractors as well as in education will likely reverse progress diversifying the health care workforce. For example, research suggests that the 2023 Supreme Court ruling banning affirmative action resulted in a decline in Black, Hispanic and American Indian and Alaska Native medical school students. Moreover, it remains unclear whether hospitals and providers are considered federal contractors subject to the executive orders to eliminate DEI-related activities, but there are concerns about the potential impact to hospital hiring, training, and programming.

Elimination of diversity efforts will lead to a less diverse and inclusive workforce among federal agencies and contractors with fewer protections against discrimination. The new executive orders undo longstanding policies that grew out of antidiscrimination laws focused on increasing employment opportunities for historically underrepresented groups in the federal government and among federal contractors. It reverses efforts by President Biden to strengthen the federal government’s ability to “recruit, hire, develop, promote our nation’s talent and remove barriers to equal opportunity.” Reports suggest that DEI initiatives can support talent acquisition and performance. Prior analysis from the Office of Personnel Management, which has since been removed from the web, found that the federal government achieved significant declines in the gender pay gap for women over time and has a much smaller gap compared to the national gap. Without diversity efforts, certain groups may face increased barriers to employment and advancement, which has impacts for health care access and health.

Federal actions to eliminate diversity and disparities-related efforts are having ripple effects in the private sector, schools, and states. As part of federal actions to eliminate DEI efforts, the federal government issued a statement that they will “investigate, eliminate, and penalize illegal DEI and DEIA preferences” at private companies and universities that receive federal funds. Reports show a wide range of private companies ending or reframing DEI related initiatives in the last several months as well as reversal of DEI efforts in universities and schools. Some states also are reversing or prohibiting DEI-related work, including efforts that began prior to President Trump taking office. In 2024, state legislatures introduced over 30 bills aimed at restricting DEI initiatives in public colleges and universities. Some states also have imposed limits on teaching concepts related to systemic racism, historical inequities, and unconscious bias.

The recently passed House budget resolution targets cuts to Medicaid of up to $880 billion or more over a decade to help pay for tax cuts. Major cuts to Medicaid may impact coverage for the almost 1 in 5 Medicare beneficiaries (12.2 million) who are also enrolled in Medicaid. For people covered under both programs (“dual-eligible individuals”), Medicare is the primary payer and covers medical acute and post-acute care, including skilled nursing facility services and home health care. Medicaid wraps around Medicare coverage by paying Medicare premiums and in most cases, cost sharing. Most dual-eligible individuals (8.9 million people in 2024) are “full-benefit” enrollees, which means they are eligible for Medicaid benefits that are not otherwise covered by Medicare, including long-term care, vision, and dental. The remaining 3.3 million dual-eligible individuals, “partial-benefit” enrollees, are eligible for Medicare premiums and often, cost sharing assistance, but not for full Medicaid benefits.

It is unclear what policies might be designed to achieve $880 billion in savings, but there are possible implications for Medicare beneficiaries, who account for nearly 30% of Medicaid spending. Effects would vary across states as coverage and benefits do.

1. Medicaid helps make Medicare more affordable for more than 12 million people with Medicare by covering the cost of premiums.

Nearly 1 in 5 (18%), or 12.2 million Medicare beneficiaries also have Medicaid coverage (Figure 1). Most Medicare beneficiaries with Medicaid have low incomes and modest savings, and Medicaid coverage makes the Medicare program more affordable by paying premiums, and in most cases, cost sharing. Medicare Part B premiums are $185 per month in 2025 and without Medicaid, these premiums alone would consume close to 15% of income for people in poverty. Most Medicare beneficiaries with Medicaid also get help from Medicaid to pay their Part A and B deductibles, coinsurance, and copayments through the Medicare Savings Programs, which provide coverage of Medicare premiums and often, cost sharing, to Medicare beneficiaries with limited financial resources. Many dual-eligible individuals receive additional Medicaid-covered wraparound services, such as long-term care, vision, and dental services. Just over half (55%) of Medicare beneficiaries who are under age 65 (who are eligible for Medicare on the basis of a permanent disability) are also covered by Medicaid. Most people with both Medicare and Medicaid receive benefits from separate Medicare and Medicaid coverage arrangements. In 2021, just 5% of people with Medicare and Medicaid were in a program that covered Medicare and Medicaid benefits under a single plan or program with integrated financing.

2. The share of Medicare beneficiaries who are also covered by Medicaid varies across states, ranging from 9% to 34%.

Across the 50 states and the District of Columbia, the share of Medicare beneficiaries who are also covered by Medicaid ranges from 9% in New Hampshire to 34% in D.C (Figure 2). The variation stems from differences in eligibility criteria for Medicaid, as well as the income and asset levels of Medicare beneficiaries living in different states. The primary Medicaid eligibility pathways for people with Medicare are through Supplemental Security Income and Medicare Savings Programs, both of which are mandatory. In addition, there are several optional pathways that states can choose to use to expand coverage, making eligibility complex and different across states. In general, in states where more people meet Medicaid eligibility criteria—which may reflect either lower incomes among Medicare beneficiaries or higher income eligibility criteria, a higher share of Medicare beneficiaries are also covered by Medicaid.

3. Medicare beneficiaries with coverage under Medicaid are in poorer health and have greater health needs than Medicare beneficiaries without Medicaid.

Four in ten (41%) people with both Medicare and Medicaid report their health as fair or poor, compared with 15% of Medicare beneficiaries without Medicaid coverage (Figure 3). More than a third (34%) of those with both Medicare and Medicaid have five or more chronic conditions, such as diabetes, hypertension, and heart disease, compared with 23% of Medicare beneficiaries without Medicaid coverage. Additionally, more than four in 10 (44%) have at least one mental health condition, such as depression and schizophrenia, compared with 24% of Medicare beneficiaries without Medicaid coverage.

A larger share of people with both Medicare and Medicaid experience functional or cognitive impairments than Medicare beneficiaries without Medicaid coverage. More than a third (34%) report difficulties performing two or more activities of daily living—such as eating, bathing, and toileting—compared to 11% of Medicare beneficiaries without Medicaid coverage. Additionally, a higher share of people with both Medicare and Medicaid coverage have cognitive impairments (36% versus 12%) and Alzheimer’s or other dementia (8% versus 3%) than beneficiaries without Medicaid coverage.

4. People with both Medicare and Medicaid account for a disproportionately high share of spending in both programs.

People with both Medicare and Medicaid comprise 16% of the traditional Medicare population and 31% of traditional Medicare spending in 2021 (Figure 4). Similarly, people with both Medicare and Medicaid comprise 14% of all Medicaid enrollment and 29% of federal and state Medicaid spending. The higher spending relative to enrollment is consistent with the greater health and functional needs of people with both Medicare and Medicaid. (People enrolled in private Medicare Advantage plans are not included in this analysis because Medicare comparable spending data are not available.)

5. Nearly 5 million Medicare beneficiaries receive Medicaid wraparound services, including long-term care.

Almost 5 million Medicare beneficiaries with Medicaid used at least one of four Medicaid wraparound services in 2021, including long-term care, vision services, dental services, and non-emergency medical transportation (Figure 5). Medicaid wraparound services are Medicaid benefits available to most Medicare beneficiaries with Medicaid that are not covered under Medicare Part A or Part B. (The services may be covered as a supplemental benefit for people enrolled in a Medicare Advantage plan.) All states are required to provide some wraparound benefits including nursing facility care (part of institutional long-term care), home health (part of home care), and non-emergency medical transportation. Other services are optional for states to provide including dental services, vision services, and all other home care, which includes personal care, support for family caregivers, and services for people in assisted living facilities.

Medicaid covered vision services for 1.9 million Medicare beneficiaries, dental services for 1.4 million beneficiaries, and non-emergency medical transportation for 1.0 million Medicare beneficiaries. In addition, Medicaid covered long-term care services for 2.8 million Medicare beneficiaries (some of whom used both home care and institutional long-term care). Most of the people using long term-care (2.2 million) receive services in home and community settings. The costs of long-term care often exceed the median income and would quickly exhaust the median savings of Medicare beneficiaries, making Medicaid the primary payer of long-term care in the U.S., covering 61% of total spending.

Since the Columbine school shooting in 1999, there have been over 420 school shootings across the United States. More than 160 of these shootings occurred after the onset of the COVID-19 pandemic, indicating a significant increase. While 2024 marked the beginning of a decline in the number of mass shootings per year since the onset of the pandemic, this trend did not apply to school shootings, the number of which remains consistently high to date. Although school shootings continue to account for a small portion of total firearm violence, they can have a widespread impact that goes beyond physical harm. According to the Washington Post, at least 390,000 students were exposed to a school shooting (exposure is defined as students attending a school at which a shooting occurred during the current school year) since the 1999 Columbine shooting.

This brief analyzes the rate of student exposure to school shootings over time. While these exposures often occur at the community level, this brief quantifies exposures at the state and national level in order to draw comparisons. Individual state policies may play a role in their exposure rates. A KFF analysis found that states with more restrictive firearm laws generally have lower youth firearm morality than states with fewer firearm laws. The rate of exposure to school shootings depends on factors including school enrollment size and state population size. Therefore, even a single school shooting incident in a state can impact many youths beyond those that are physically injured and may significantly increase exposure rates. Key findings include:

• The U.S. average yearly rate of student exposure to a school shooting has increased threefold over time (from 19 per 100,000 students in 1999-2004 to 51 in 2020-2024).
• From 2020 to 2024, the rate of school shooting exposure per 100,000 students was highest in Delaware (359), DC (356), Utah (166), Arkansas (130), and Nevada (127).
• Children exposed to gun violence may experience serious adverse effects, including anxiety, PTSD, suicide risk, and substance use issues. Some safety measures at schools, such as active shooter drills, may also negatively affect student mental health.

How has exposure to school shootings changed over time among U.S. students?

Since 1999, the rate of U.S. students exposed to a school shooting has nearly tripled, with most of the increase occurring during the pandemic years (2020-2024) (Figure 1). KFF analysis of the Washington Post’s school shooting database found that the average yearly rate of student exposure to school shootings grew from 19 per 100,000 in 1999-2004 to 51 in 2020-2024.

Delaware, the District of Columbia, Utah, Nevada, and Arkansas had the highest rates of students exposed to school shootings since the pandemic. These states have experienced student exposure rates that are at least double the U.S. average yearly rate of exposure (51 per 100,000 students) from 2020-2024. The rate per 100,000 students was highest in Delaware (359), DC (356), Utah (166), Arkansas (130), and Nevada (127) (Figure 2). Note that student exposure rates can vary greatly at the state level due to factors such as school student enrollment size and state population. For example, Delaware and DC had low student populations (under 200,000) from 2020 to 2024, making their exposure rates more volatile than in higher-population states, and a small number of shootings could produce a high rate. For more information, see Methods.

While student exposure to school shootings spiked during the pandemic, several states, including Washington state and Maryland, have had exposure rates higher than the U.S. average for the past several decades (Figure 3). Since 1999, Washington’s exposure rates have remained at or above national average exposure rates – including the state’s lowest average yearly rate in 2010-2014 (25 per 100,000 students) to the state’s highest average yearly rate in 2020-2024 (62). Similarly, Colorado, Maryland, North Carolina, and Nevada have often endured school shooting exposure rates that are higher than the national average rate. Some states have consistently experienced increases in exposure rates over time, including Florida (from a yearly average of 13 per 100,000 students in 1999-2004 to 52 in 2020-2024) and Georgia (from a yearly average rate of 12 in 1999-2004 to 76 in 2020-2024).

In contrast, Maine, Vermont, West Virginia, and Wyoming have had no student exposure to school shootings since 1999. However, there may have been incidences of gunfire on school grounds in these states that did not meet the Washington Post’s criteria for school shootings.

How do exposures to school shootings and efforts to mitigate them affect student mental health and well-being?

Although school shootings account for a small portion of gun violence, they are linked to negative mental health consequences for students and communities at large. Youth antidepressant use and suicide risk can increase in communities with exposures to school shootings. More broadly, exposure to gun violence is linked to post-traumatic stress disorder and anxiety, in addition to other mental health concerns among youth. Gun violence may also lead to challenges with school performance, including increased absenteeism and difficulty concentrating. Additionally, a survey prior to the pandemic found that the majority of teenagers and their parents felt at least somewhat worried that a school shooting may occur at their school. Although research is limited on how mass shootings affect individuals not directly exposed to them, current literature suggests that information and knowledge of mass shootings may be linked to increased levels of fear and anxiety.

Measures intended to combat school violence – such as the placement of school officers and the use of metal detectors – may also negatively affect the well-being of students and their sense of safety. Fifty-four percent of public schools reported having a sworn law enforcement officer (SLEO) such as a police officer or school resource officer on campus during the 2023-2024 school year. While many public schools report feeling that SLEOs have a positive impact on the school community, evidence that they reduce gun violence or school shootings is lacking. Further, among school shootings that involved a SLEO, several involved the officer shooting an unarmed student or staff member. Although nearly all (92%) public schools with SLEOs report that these officers carry a firearm, just over half of these schools have a written policy for firearm handling expectations among SLEOs. Further, the placement of these officers on school campuses may negatively impact students of color specifically, as they are more likely to face disciplinary action than their White counterparts. Separately, 8% of public schools report having metal detectors at school gates for all or most students and 14% of public schools perform random metal detector checks on students. While these detectors are used as a security measure, there are not enough data to demonstrate that they decrease the risk of violent behavior on school grounds. Additionally, the presence of metal detectors may damage students’ sense of safety at school.

Other safety measures include written action plans and drills in the event of an active shooter, with the latter being linked to psychological harm among participants. While 98% of public schools had a written procedure to handle an active shooter during the 2023-2024 school year, only 27% of these schools reported feeling “very prepared” for an active shooter situation. Additionally, many public schools drill students on emergency lockdown and evacuation procedures for school shootings with varying degrees of intensity, with some being psychologically harmful to participants. A longitudinal study on children exposed to school shootings in Texas demonstrated that even when school shootings do not result in deaths, the impacts of gun violence at schools – such as chronic absenteeism and economic consequences – can follow children into early adulthood. Similarly, when schools properly execute a plan prepared in advance, physical and mental harm is not completely preventable. For example, in the recent shooting at a Madison, Wisconsin school, officials praised the well-executed response by authorities, but injury and death occurred regardless.

Appendix

On March 15, 2025, the President signed a full-year “continuing resolution” (CR) that continues funding the federal government through the rest of the fiscal year. It maintains U.S. global health funding at the prior year (FY 2024) level ($10.8 billion).[i] The Full-Year Continuing Appropriations and Extensions Act, 2025, which was passed by the House on March 11, 2025 and the Senate on March 14, 2025, references relevant sections of the Further Consolidated Appropriations Act, 2024 – as well as the associated explanatory report, specifying funding levels for global health programs at the Department of State (State), U.S. Agency for International Development (USAID), Centers for Disease Control and Prevention (CDC), and National Institutes of Health (NIH). The CR also includes language (Section 1113) instructing departments and agencies to report back to Congress within 45 days on spending, expenditure, or operating plans at the program, project, or activity level for FY 2025, and specifically for foreign assistance programs funded under State and Foreign Operations (SFOPs), which includes State and USAID, at the country, regional, and central program level, and for any international organization. See other budget summaries for details on historical annual appropriations for global health programs.

[i] The $10.8 billion in global health funding is based on those amounts specified in appropriations bills. In past years, additional funding for global health has also been determined at the agency level.

Medicaid is the primary program providing comprehensive coverage of health and long-term care to 83 million low-income people in the United States and accounts for one-fifth of health care spending. Medicaid is jointly financed by states and the federal government but administered by states within federal rules. The recently passed House budget resolution targets cuts to Medicaid of up to $880 billion or more over a decade. While several options appear to be under consideration to significantly reduce Medicaid spending, President Trump publicly said recently about Medicaid, “We are not going to touch it. Now, we are going to look for fraud.” Speaker Johnson has said, “Medicaid is hugely problematic because it has a lot of fraud, waste, and abuse.” Although fraud, waste, and abuse can be related concepts (and all fall under a broader “program integrity” umbrella), they are also distinct in important ways (Box 1). These terms apply to other government health care programs, private health insurance, and other government programs more broadly.¹  On March 11, 2025, the White House released a statement saying most federal spending lost to fraud is from entitlement programs such as Medicaid and Medicare, citing “improper payment” estimates, without clarifying (as GAO does) that “improper payments” are not a measure of fraud or abuse and most improper payments are the result of missing documentation or missing administrative steps, and are not necessarily payments made for ineligible enrollees, providers, or services.

Speaker Johnson has referenced $50 billion in annual fraudulent payments (a figure that may reflect improper payments rather than fraud). In debates about broader Medicaid spending reductions, Republicans may try to recast policy changes such as adding work requirements to Medicaid and restricting the use of provider taxes as addressing fraud, waste, and abuse. Despite talk about eliminating fraud, the President’s recent order to remove Inspectors General (IGs), who are responsible for providing independent oversight of federal programs, from at least 17 government agencies—including HHS—appears to run counter to the stated focus on fraud, waste, and abuse. Recent KFF polling shows, while the public thinks that reducing fraud and waste in government health programs could lead to reductions in overall federal spending, many (60% of Republicans, 55% of Democrats, and 51% of independents) also think reducing fraud and waste in government programs could result in a reduction of benefits. Overall, most Americans (77%) hold favorable views of Medicaid, including six in ten Republicans (63%), and at least eight in ten independents (81%) and Democrats (87%).

This brief explains what is known about improper payments and fraud and abuse in Medicaid and describes ongoing state and federal actions to address program integrity.

1. Both the federal government and states are responsible for ensuring program integrity.

Program integrity refers to the proper management and functioning of the Medicaid program to ensure it is providing quality and efficient care while using funds–taxpayer dollars–appropriately with minimal waste. Medicaid is a very complex program that involves millions of beneficiaries, hundreds of thousands of providers, and significant federal and state expenditures. Program integrity efforts work to prevent and detect waste, fraud, and abuse, to increase program transparency and accountability, and to recover improperly used funds. Program integrity activities help ensure that eligibility decisions are made correctly; prospective and enrolled providers meet federal and state participation requirements; services provided to enrollees are medically necessary and appropriate; and provider payments are made in the correct amount and for appropriate services. Program integrity also includes routine oversight to ensure compliance with state and federal law.

State Medicaid agencies administer Medicaid on a day-to-day basis and have the primary responsibility for program integrity. Program integrity includes specific, dedicated activities, as well as activities that are built into program functions (e.g., beneficiary and provider enrollment, service delivery, payment). Federal laws and regulations include requirements for states to reduce fraud, waste, and abuse. Each state must have a Medicaid Fraud Control Unit (MFCU) to investigate fraud and prosecute or refer to prosecution individuals or entities defrauding Medicaid. Other state agencies and fiscal officers may be involved, including state auditors. Comprehensive managed care is the primary Medicaid delivery system (accounting for 75% of beneficiaries and over 50% of total Medicaid spending) which creates different risks, as the state is delegating provider contracting, utilization management, and claims processing to a managed care organization (MCO). States with managed care programs have additional program integrity responsibilities.

The federal government’s responsibility is to provide “effective support and assistance to states to combat provider fraud and abuse.” CMS supports states through funding, training, and defining in regulation how states must comply with Medicaid program integrity requirements. Three federal agencies – the HHS Office of Inspector General (OIG), U.S. Department of Justice (DOJ), and Government Accountability Office (GAO) – are also involved in this work, each with different roles and responsibilities. Federal agencies regularly report on Medicaid program integrity performance, including:

• The CMS Improper Payments Fact Sheet, which summarizes and explains annual statistics on HHS improper payment measurements
• The HHS Agency Financial Report, which includes Medicaid payment integrity statistics
• The Payment Error Rate (PERM) Findings and Reports, Supplemental Improper Payment Data Reports²  include state specific data
• The HHS-OIG Healthcare Fraud and Abuse Control (HCFAC) report and the Medicaid Fraud Control Units (MFCU) report, which summarize program integrity oversight and enforcement activities
• GAO’s High-Risk Series identifies government operations with vulnerabilities to fraud, waste, abuse

2. There is no comprehensive or reliable measure of fraud in Medicaid.

Fraud is not unique to Medicaid. Fraud occurs in Medicaid, Medicare, and private health insurance. Most monetary loss from fraud is by providers. Fraud includes obtaining a thing of value through willful misrepresentation. Measuring fraud is difficult, in part, because it can only be determined with certainty after the fact and if it is identified. There are no reliable measures of fraud against Medicaid. DOJ and HHS-OIG operate a Health Care Fraud and Abuse Control (HCFAC) program, designed to coordinate federal, state, and local health care fraud and abuse law enforcement activities. A HCFAC report is published annually, describing health care fraud enforcement actions. Recent analysis of the FY 2023 HCFAC report found no beneficiary fraud in the listing. Providers convicted (of different kinds of fraud against Medicaid and Medicare) included ambulance service providers, durable medical equipment suppliers, diagnostic labs, nursing homes, pain clinics, pharmacies, physical therapists, physicians, and substance use treatment providers. Examples of successful criminal and civil investigations highlighted in the report include:

• Sentencing of an EMT supervisor for an ambulance company who wrote and signed hundreds of false ambulance run sheets that were used to send fraudulent bills to the Texas Medicaid program;
• Sentencing of a pharmacy owner in a scheme to bill Kentucky Medicaid (and other health benefit programs) for drug prescriptions that were never filled; and
• Sentencing of a Michigan physician for his role in a health care fraud scheme that exploited patients suffering from addiction by administering unnecessary back injections and illegally distributing millions of medically unnecessary opioids.

In FY 2023, total HCFAC recoveries reached $3.4 billion (across Medicaid and Medicare). The reported return on investment for the HCFAC program (2021-2023) was $2.80 for every $1 spent. HHS-OIG also publishes an annual summary of the cases brought by state Medicaid Fraud Control Units (MFCUs). The report identifies criminal convictions and civil settlements and judgments by provider type. In FY 2024, MFCUs reported 1,151 convictions and $1.4 billion in recoveries (or $3.46 for every $1 spent).

3. Improper payments are not a measure of fraud.

The Improper Payments Information Act (IPIA) of 2002 (replaced by the Payment Integrity Information Act (PIIA) of 2019) requires the heads of federal agencies to annually review programs they administer and identify those that may be susceptible to significant improper payments, to estimate the amount of improper payments, to submit those estimates to Congress, and to submit a report on actions the agency is taking to reduce the improper payments. The Office of Management and Budget (OMB) has identified Medicaid and CHIP as programs at risk for significant improper payments. As a result, CMS developed the Payment Error Rate Measurement (PERM) program to comply with the IPIA / PIIA and related guidance issued by OMB.

The PERM program measures improper payments in Medicaid and produces a national improper payment rate, which is not a fraud rate. Improper payments, which are often cited when discussing program integrity, are payments that do not meet CMS program requirements. PERM is based on reviews of fee-for-service (FFS), managed care, and eligibility components of a state’s Medicaid program in the year under review. The error rate is not a “fraud rate” (or a waste or abuse rate) but a measurement of payments made that did not meet statutory, regulatory, or administrative requirements or are made in an incorrect amount (including overpayments and underpayments). While fraud and abuse may be one cause of improper payments, not all improper payments represent fraud or abuse. PERM is not designed to detect or measure fraud. States are audited on a rolling three-year basis, meaning each PERM cycle measurement includes one-third of states. Annually, the most recent three cycles are combined to produce a national improper payment rate (weighted by state size). (CMS also produces improper payment rates for CHIP, Medicare, and advanced premium tax credits (APTCs) for the federally facilitated exchange.) As with variation in all aspects of Medicaid operations, PERM rates vary across states ranging from under 1% in Alabama, South Dakota, and Washington to over 20% in South Carolina and Wyoming.

In 2024, Medicaid paid an estimated 94.9% of total outlays properly, representing $579.73 billion in proper federal payments (Figure 1). The overall Medicaid improper payment rate was 5.1% (or $31.10 billion in federal payments). However, 79.1% of the improper Medicaid payments were the result of insufficient documentation or missing administrative steps (Figure 1). These payments were not necessarily for ineligible enrollees, providers, or services (i.e., since they may have been payable if the missing information had been on the claim and/or the state had complied with requirements). Examples include state failure to document beneficiary eligibility or to appropriately screen enrolled providers, or medical records not submitted or missing required documentation to support the medical necessity of a claim. Other improper payments include payments for beneficiaries who were ineligible or were eligible but received a service that was not covered (15.6%), for providers not enrolled in the program (2.0%), and other monetary losses (3.3%) (Figure 1). States are often required to develop and implement corrective action plans for errors and deficiencies.

The 2024 improper payment rate was the lowest rate since the COVID-19 pandemic began due, in part, to flexibilities granted during the public health emergency (e.g., suspended eligibility renewal determinations and reduced requirements for provider enrollment and revalidations) and to improved state compliance with program rules. Prior to the pandemic, the improper payment rate increased following the reintegration of the PERM eligibility component in 2019, which was suspended from 2015 – 2018 to provide states with time to adjust to eligibility process changes in the Affordable Care Act.³  (In its place, CMS required states to implement pilots to assess the accuracy of their eligibility determinations.) While the national improper payment rate increased notably in 2019, 2020, and 2021 (to 21.7%), more than three quarters of improper payments (in each year) were due to insufficient documentation or missing administrative steps (data not shown). In 2024, CMS finalized rules related to eligibility and enrollment that included guidance for states on eligibility documentation procedures to reduce “paperwork” errors that lead to the majority of eligibility-related improper payments. Specifically, the rule requires records to be kept in electronic format for the entire period the case is active and for at least three years after and identifies the information that must be included in all case records; however, Congress may repeal these rules.

4. HHS and CMS identify key areas of program integrity focus, informed in part by recommendations made by other federal agencies.

HHS works with all states to develop strategies to address the root causes of improper payments. States are responsible for implementing, overseeing, and assessing the impact of these strategies and actions. Efforts include systems and process improvements (e.g., adding new claims processing checks, upgrading claims processing systems, and enhancing procedures for provider and beneficiary enrollment).

Every five years, HHS and CMS must issue a comprehensive Medicaid program integrity plan that outlines the agency’s strategy for working with states on program integrity. Historically, program integrity efforts focused on the recovery of misspent funds, but more recent initiatives move beyond “pay and chase” models to focus more heavily on prevention and early detection of fraud and abuse and other improper payments. The FY 2024-2028 CMS plan highlights key areas of focus including Medicaid managed care oversight, eligibility determination processes, systems improvements, data analytics and data sharing, and federal training and technical assistance. To help target oversight activities, CMS will continue to use a risk-based approach to focus efforts on high-risk states, providers, managed care plans, and program areas to maximize return on investment. CMS identified Medicaid managed care, non-emergency medical transport (NEMT), dental benefits, nursing facilities, and home- and community- based services as areas where there may be high-risk program integrity vulnerabilities.

Independent agencies like MACPAC and GAO regularly make recommendations to reduce fraud, waste, and abuse in Medicaid. In 2024, GAO indicated CMS had taken steps to address improper Medicaid payments (consistent with their recommendations) including improving managed care oversight (e.g., increasing audits), assessing fraud risks (including documenting vulnerabilities and identifying mitigation strategies), and improving state compliance with provider screening and enrollment requirements. GAO notes, however, actions on recommendations that remain unimplemented could further enhance program integrity—including additional CMS oversight/action to improve state compliance with provider enrollment and screening requirements, ensure timely state eligibility determinations, and improve collaboration with state auditors. Additionally, GAO made recommendations to CMS about other areas where program oversight and transparency could be improved including managed care, demonstration waivers, and other financing. MACPAC recommendations include simplifying and streamlining program integrity regulatory requirements, improving state-federal coordination, and identifying the most effective program integrity activities.

5. “Fraud, waste, and abuse” are at the forefront of current debates as a basis for making changes in Medicaid and more broadly.

Medicaid is a very complex program that involves millions of beneficiaries, hundreds of thousands of providers, 51 state agencies (including DC), different delivery systems, complicated eligibility rules, and significant federal and state expenditures—all of which together create vulnerabilities and opportunities for error. Since the enactment of Medicaid in 1965, the statute has evolved to promote program integrity. The focus of program integrity efforts has also evolved at CMS in response to changing legislation, policy developments, and priorities. Each administration may approach program integrity differently, with different goals and a willingness to accept different tradeoffs. Republicans in Congress and the Trump Administration state they are not aiming to cut Social Security, Medicare, or Medicaid benefits but aiming to root out fraud, waste and abuse—often citing improper payment estimates as evidence of extensive fraud in Medicaid and Medicare, despite GAO stating improper payments are not designed to identify fraud and are not a measure of fraud or abuse. While policy makers and the public support efforts to root out fraud and make government more efficient, there is little support for broad reductions in federal spending on Medicaid that could affect coverage, benefits, or access to care.

What is known about fraud in Medicaid is that it’s not unique to Medicaid (fraud also occurs in Medicare and private health insurance) and is mostly committed by providers. There are checks on fraud, waste, and abuse at both the federal and the state levels, as described in the sections above. GAO and MACPAC recommendations to reduce fraud and abuse may involve additional investments in oversight and transparency but not reductions in federal funding. As the budget debate continues, there may be efforts to recast certain Medicaid policy changes such as adding work requirements to Medicaid and restricting the use of provider taxes as addressing fraud, waste, and abuse. There are proponents and opponents of such policies, and these policies may come with tradeoffs (e.g., decreasing federal funding while shifting costs to the states and reducing coverage), but they are not about rooting out fraud in Medicaid.

1. GAO has issued separate overviews that apply government-wide of fraud and improper payments,  waste, and abuse. ↩︎
2. A subset of states are audited each year; CMS publishes an improper payment rate for the states measured in each cycle – most recently available in 2024 (p. 52), 2023 (p. 52), and 2022 (p. 53). ↩︎
3. CMS continued to report the 2014 improper payment rate for eligibility errors as part of its overall PERM improper payment rate calculation. ↩︎

Note: This piece was updated on March 14th to reflect the latest data from MedPAC.

The privatization of Medicare has been taking place without much public debate – a trend that has implications for the 68 million people covered by Medicare, health care providers, Medicare spending, and taxpayers. Since 2010, the share of Medicare beneficiaries receiving their Medicare benefits from private Medicare Advantage insurers has more than doubled (Figure 1). The Congressional Budget Office (CBO) projects nearly two-thirds of all Medicare beneficiaries will be in private plans by 2033, though data released in the early part of 2025 show enrollment growth in 2025 has been somewhat lower than CBO projected. The Trump administration has the opportunity to weigh in on the pace of growth in private Medicare Advantage enrollment and the future of traditional Medicare, which remains the source of coverage for close to half of the Medicare population.

Questions about Medicare Advantage are likely to come up at the forthcoming confirmation hearing of Dr. Mehmet Oz, President Trump’s nominee to head up the Centers for Medicare & Medicaid Services (CMS). In the past, Dr. Oz has promoted Medicare Advantage in co-authored papers, interviews and on his television show. His support for Medicare Advantage aligns with general preferences among Republicans to maximize the role of the private sector, including Medicare Advantage, over government-run public programs, such as traditional Medicare.

The growth in Medicare Advantage is due to a number of factors, but none may be greater than the appeal of potentially lower costs and extra benefits like dental coverage and debit cards, offered by Medicare Advantage plans and aggressively marketed by brokers and insurers. Insurers are required to offer extra benefits when they estimate that their costs for Medicare-covered (Part A and Part B) benefits will be lower than the maximum amount the government is willing to pay in an area. They are able to offer additional extra benefits, in part, due to a payment system that, on average, sets maximum payments well above the costs of similar people in traditional Medicare and adjusts payments for health status in a way that overestimates costs for Medicare Advantage enrollees.

According to MedPAC, an independent, non-partisan agency that advises Congress about Medicare payment, the federal government pays insurers 20% more for Medicare Advantage enrollees than it pays for similar people in traditional Medicare, at a cost of $84 billion in 2025. To put the $84 billion in context, that’s more than Medicare paid physicians under the physician fee schedule to treat traditional Medicare patients in 2024. The higher Medicare spending for Medicare Advantage enrollees results in $13 billion in higher Medicare Part B premiums paid by Medicare beneficiaries, including those who are not in Medicare Advantage.

To promote efficiencies and trim federal spending, the administration could, for example, make technical adjustments to the payment system through the annual rate notice that could have the effect of lowering payments to plans. To achieve further savings, the administration could work with Congress to adopt savings proposals, including those that have recently been advanced by the Paragon Health Institute. These include ending the quality bonus program that increases Medicare spending by nearly $12 billion a year or capping Medicare Advantage benchmarks at 100 percent of local traditional Medicare costs except in areas with low Medicare Advantage penetration. Such changes would achieve Medicare savings but could also make it less profitable for insurers and potentially slow growth or even reduce private plan enrollment.

Alternatively, the Trump administration could adopt policies to accelerate the pace of privatization, such as boosting payments to plans through the annual rate notice and adopting other policies to encourage more private plan enrollment. The administration could, for example, make it easier for insurers and brokers to market Medicare Advantage plans to attract new enrollees, by unwinding the requirement that all television ads be approved before they can be aired or easing the requirement that brokers provide certain information to beneficiaries before they can enroll them in a plan.

The administration could also advance policies to make Medicare Advantage the default enrollment option for new beneficiaries – an approach that would likely accelerate the pace of privatization, and potentially increase spending, all other things equal.

The transformation of Medicare into a marketplace of private plans raises a number of questions that are not being debated. Should the payment system for Medicare Advantage plans be modified, and if so, how and to what end? What should be the role of traditional Medicare nationwide and in rural areas, where fewer beneficiaries are enrolled in Medicare Advantage? Should traditional Medicare be strengthened, with additional benefits and an out-of-pocket cap, so beneficiaries have a meaningful choice when comparing Medicare coverage options? What more should be done to help beneficiaries understand the tradeoffs between traditional Medicare and Medicare Advantage including the potential for extra benefits and lower costs in Medicare Advantage versus challenges that may arise due to limited provider networks and prior authorization requirements?

It’s not yet clear whether the administration will promote policies that fast track the privatization of Medicare in a way that may increase federal spending, or focus more on achieving efficiencies and savings within Medicare Advantage. How this plays out will have implications for beneficiaries, health care providers and insurers, and is worthy of serious debate.

As bird flu continues to circulate among animals in the U.S. with some human cases, about six in 10 (58%) people overall have at least “a fair amount” of trust in the Centers for Disease Control and Prevention (CDC) to provide reliable information about bird flu, though only 21% have a “great deal of trust,” the latest KFF Tracking Poll on Health Information and Trust finds.As the White House withdraws the nomination of Dr. David Weldon to lead the CDC, Republican trust in the agency is low, with about six in 10 (58%) Republicans saying they have little to no trust in the CDC to provide reliable information on bird flu. Most Democrats (72%) and independents (61%) have at least a fair amount of trust in the CDC to provide reliable information on bird flu.

The poll also finds that many people are unaware or unsure about current public health recommendations for preventing the spread of bird flu. For instance, about 4 in 10 adults (39%) are aware that public health officials recommend avoiding raw or unpasteurized milk as a precaution against bird flu, while most either are unsure (50%) or incorrectly say that officials do not recommend avoiding raw milk (11%).

A larger share of Democrats (47%) compared with independents (38%) and Republicans (34%) are aware that public health officials recommend avoiding raw milk. At least half of independents (52%) and Republicans (55%) say they are not sure if this is recommended. However, few across partisans say avoiding unpasteurized milk is not recommended.Amid concerns about egg prices and inflation more broadly, the poll finds nearly nine in 10 adults (86%) are concerned that bird flu will increase the cost of food. Fewer, but still around half (51%), are concerned that bird flu will be the next pandemic in the U.S. or will negatively affect their family’s health (50%). Democrats are almost twice as likely as Republicans to worry that bird flu will be the next pandemic (68% and 36%, respectively) or that it will negatively affect their family’s health (64% and 36%, respectively).

The poll is part of KFF’s Health Information and Trust Initiative, which is aimed at tracking health misinformation in the U.S, analyzing its impact on the American people, and mobilizing media to address the problem.Designed and analyzed by public opinion researchers at KFF, this survey was conducted Feb. 18-25, 2025, online and by telephone among a nationally representative sample of 1,322 U.S. adults in English and in Spanish. The margin of sampling error is plus or minus 3 percentage points for the full sample. For results based on other subgroups, the margin of sampling error may be higher.