On March 23, 2010, President Obama signed the Affordable Care Act (ACA) into law, marking a significant overhaul of the U.S. health care system. Prior to the ACA, high rates of uninsurance were prevalent due to unaffordability and exclusions based on preexisting conditions. Additionally, some insured people faced extremely high out-of-pocket (OOP) costs and coverage limits. The ACA aimed to address these issues, though it did not eliminate all of them.

The ACA affects virtually all aspects of the health system, including insurers, providers, state governments, employers, taxpayers, and consumers. The law built on the existing health insurance system, making changes to Medicare, Medicaid, and employer-sponsored coverage. A fundamental change was the introduction of regulated health insurance exchange markets, or Marketplaces, which offer financial assistance for ACA-compliant coverage to those without traditional insurance sources. This chapter has a special focus on these Marketplaces that are integral to the ACA’s framework.

A key goal of the ACA was to expand health insurance coverage. It did so by expanding Medicaid to people with incomes up to 138% of the federal poverty level (the poverty level in the continental U.S. is $15,650 for a single individual in 2025); creating new health insurance exchange markets through which individuals can purchase coverage and receive financial help to afford premiums and cost sharing, in addition to separate exchange markets through which small businesses can purchase coverage; and requiring employers that do not offer affordable coverage to pay penalties, with exceptions for small employers. In the years leading up to the passage of the ACA, about 14-16% of people in the United States were uninsured (across all ages). By 2023, the uninsured rate had fallen to a record low of 7.7%. Most of the gains in insurance coverage have come from the ACA’s expansion of Medicaid, followed by the creation of the exchange markets.

For people with private health insurance, the ACA also includes several consumer protections and market rules (discussed in more detail in the chapter on regulation of private insurance). For example, the ACA prohibits health plans from denying people coverage, charging them higher premiums, as well as rescinding or imposing exclusions to coverage due to preexisting health conditions. The ACA also prohibits annual and lifetime limits on the dollar amount of coverage and restricts the amount of out-of-pocket costs individuals and families may incur each year for in-network care. Additionally, the law requires most health plans to cover preventive health services with no out-of-pocket costs. Health insurers must also issue rebates to enrollees and businesses each year if they fail to meet Medical Loss Ratio standards. Moreover, people with private coverage can keep their young adult children on their health plan up to age 26.

The ACA imposes additional new regulations on private health plans sold to individuals and small businesses. These rules significantly limit the ways in which health plans can charge higher premiums. ACA-compliant health plans sold on the individual and small group markets can only vary premiums based on location, family size, tobacco use, and age (with older adults being charged no more than three times younger adults). This means that people with preexisting conditions cannot be charged higher premiums, nor can insurers charge higher rates based on gender or other factors. The ACA requires individual and small group insurers planning to increase premiums significantly to justify those rate increases publicly and also included grants for states to improve their rate review programs. The ACA also created risk programs in the individual and small group markets to mitigate adverse selection and to reduce health insurers’ incentives to avoid attracting sicker enrollees.

While Medicaid expansion is one of the most impactful provisions of the ACA, the law changed Medicaid in other ways too. For example, people gaining coverage through the Medicaid expansion are guaranteed a benchmark benefit package that covers essential health benefits. Furthermore, the ACA required state Medicaid programs to cover preventive services without cost sharing. The law also increased Medicaid payments to primary care providers, provided new options for states to cover in-home and community-based care, increased Medicaid drug rebates, and extended those rebates to Medicaid managed care plans.

The ACA also made a number of changes to Medicare. Notably, the ACA phased out the Medicare Part D prescription drug benefit coverage gap (colloquially known as the “donut hole”) and provides preventive benefits for Medicare enrollees without cost sharing. The ACA also includes several changes aimed at reducing the growth in Medicare spending. For example, the ACA includes reductions in the growth of Medicare payments to hospitals and other providers, and to Medicare Advantage plans. The law also created an Innovation Center within the Centers for Medicare and Medicaid Services (CMS) tasked with developing and testing new health care payment and delivery models and established the Medicare Shared Savings Program, a permanent accountable care organization (ACO) program in traditional Medicare that offers financial incentives to providers for meeting or exceeding savings targets and quality goals.

Finally, the ACA includes many other provisions that do not relate directly to health coverage. For example, the ACA authorizes the Food and Drug Administration to approve generic versions of biologic drugs. There are also provisions that aim to reduce waste and fraud, expand the health care workforce, increase data collection and reporting on health disparities, and improve public health preparedness.

When passed, the ACA was designed to be budget neutral, with health insurance subsidies and expansions of public programs financed through a variety of taxes and fees on individuals, employers, insurers, and certain businesses in the health sector, as well as savings from the Medicare program. As discussed in more detail below, some of these taxes or fees have since been repealed or reduced to zero dollars, including the individual mandate penalty, the medical device tax, and the so-called “Cadillac Tax,” which would have imposed an excise tax on high-cost employer health plans. Additionally, at times, a tax on health insurance carriers has been temporarily put on hold.

Health Insurance Marketplaces (also known as exchanges) are organizations set up to create more organized and competitive markets for individuals and families buying their own health insurance. The Marketplaces offer a choice of different health plans, certify plans that participate, and provide information and in-person assistance to help consumers understand their options and apply for coverage. Premium and cost-sharing subsidies based on income are available through the Marketplace to make coverage more affordable for individuals and families. People with very low incomes can also find out if they are eligible for coverage through Medicaid and CHIP while shopping on the Marketplace.

Some small businesses can buy coverage for their employees through separate exchanges called Small Business Health Options Program (SHOP) Marketplace plans, but this chapter focuses primarily on the Marketplaces for individuals and families.

There is a health insurance Marketplace in every state for individuals and families and for small businesses. Some enrollment websites are operated by the state government or quasi-governmental bodies at the state level and have a special state name (such as Covered California or The Maryland Health Benefit Exchange). In 28 states where the federal government runs the enrollment website, it is called HealthCare.gov. As of early 2025, three state-based Marketplaces (Arkansas, Illinois, and Oregon) use the federal platform.

The Marketplaces exist alongside other coverage that is also sold to individuals or small businesses. The Marketplaces for individuals and families are part of what is called the “individual insurance market,” which also includes ACA-compliant and non-compliant insurance sold off the Marketplace (also called off-exchange coverage). Similarly, the “small group insurance market” includes the SHOP Marketplace plans as well as other ACA-compliant and non-compliant coverage sold to small businesses.

While many Americans are allowed to purchase unsubsidized coverage on the ACA Marketplaces, these markets primarily exist to fill a gap in coverage options for people who cannot get insurance through work or public programs. Some people who sign up for Marketplace coverage are unemployed or between jobs, while others are students, self-employed or work at businesses that do not offer coverage (e.g., very small companies) or offer coverage that is deemed unaffordable.

To receive the premium tax credit for coverage starting in 2025, a Marketplace enrollee must meet the following criteria:

• Have a household income at least equal to the Federal Poverty Level (FPL), which for the 2025 benefit year will be determined based on 2024 poverty guidelines.
• Not have access to affordable coverage through an employer (including a family member’s employer).
• Not be eligible for coverage through Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP).
• Have U.S. citizenship or proof of legal residency (lawfully present immigrants whose household income is below 100 percent FPL can also be eligible for tax subsidies through the Marketplace if they meet all other eligibility requirements, though this exception is set to end starting in 2026).
• If married, must file taxes jointly.

Employer coverage: If a person’s employer offers health coverage but that coverage is deemed unaffordable or of insufficient value, the employee and/or their family may be able to receive subsidies to buy Marketplace coverage. Employer coverage is considered affordable if the required premium contribution is no more than 9.02 percent of household income in 2025. The Marketplace will look at both the required employee contribution for self-only and (if applicable) for family coverage. If the required employee contribution for self-only coverage is affordable, but the required employee contribution for family coverage is more than 9.02 percent of household income, the dependents can purchase subsidized exchange coverage while the employee stays on employer coverage.

The employer’s coverage must also meet a minimum value standard that requires the plan to provide substantial coverage for physician services and for inpatient hospital care with an actuarial value of at least 60 percent (meaning the plan pays for an average of at least 60 percent of all enrollees’ combined health spending, similar to a bronze plan). The plan must also have an annual OOP limit on cost sharing of no more than $9,200 for self-only coverage and $18,400 for family coverage in 2025.

People offered employer-sponsored coverage that fails to meet either the affordability threshold or minimum value requirements can qualify for Marketplace subsidies if they meet the other criteria listed above.

Eligibility for Medicaid: In states that have expanded Medicaid under the ACA, adults with income up to 138 percent FPL are generally eligible for Medicaid and, therefore, are ineligible for Marketplace subsidies. In the states that have not adopted the Medicaid expansion, adults with income as low as 100 percent of FPL can qualify for Marketplace subsidies, but those with lower incomes are not eligible for tax credits and generally not eligible for Medicaid unless they meet other state eligibility criteria.

Starting in 2026, federal policy changes will restrict premium tax credit eligibility for legal immigrants who are ineligible for Medicaid due to their alien status. An exception to the rule restricting tax credit eligibility for adults with income below the FPL was previously made for certain lawfully present immigrants. Other federal rules restrict Medicaid eligibility for lawfully present immigrants, other than pregnant women, refugees, and asylees, until they have resided in the U.S. for at least five years. Prior to the implementation of this policy change, immigrants who would otherwise have been eligible for Medicaid but had not yet completed their five-year waiting period instead qualified for tax credits through the Marketplace. If an individual in this circumstance has an income below 100 percent of FPL, for the purposes of tax credit eligibility, their income would have been treated as though it was equal to the FPL. Immigrants who are not lawfully present are ineligible to enroll in health insurance through the Marketplace, receive tax credits through the Marketplace, or enroll in non-emergency Medicaid and CHIP. In November 2024, the Biden administration published new rules that deemed Deferred Action for Childhood Arrivals (DACA) recipients as lawfully present, making them eligible for subsidized ACA Marketplace coverage. However, finalized Marketplace Integrity and Affordability rules undo this change.

The ACA requires all qualified health benefits plans to cover essential health benefits, including those offered through the Marketplaces and those offered in the individual and small group markets off-exchange. Grandfathered individual and employer-sponsored plans (which existed before the ACA was passed) and non-compliant plans (which include short-term plans) do not have to cover essential health benefits.

The law specifies that the essential health benefits package must include at least 10 categories of items and services: ambulatory patient services; emergency services; hospitalization; pregnancy, maternity, and newborn care; mental health and substance use disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care. It also requires that the scope of benefits be equal to that of a “typical employer plan.”

These categories are broad and subject to interpretation. For example, there could be limits on the number of physical therapy services an enrollee receives in a year. For more specific guidance on how to interpret these requirements, the federal government allows states to select a “benchmark” health plan (often one that was already offered to small businesses) as a standard.

Essential health benefits are a minimum standard. Plans can offer additional health benefits, like vision, dental, and medical management programs (for example, for weight loss). The ACA prohibits abortion coverage from being required as part of the essential health benefits package. The premium subsidy does not cover non-essential health benefits, meaning that people enrolling in a plan with non-essential benefits may have to pay a portion of the premium for these additional benefits.

Although plans must cover essential health benefits, they are allowed to apply cost sharing (deductibles, copayments, and coinsurance). This means enrollees may still face some out-of-pocket costs when receiving these services. However, preventive health services are required to be covered without cost sharing. Examples of preventive health services include vaccinations, cancer screenings, and birth control.

There are two types of financial assistance available to Marketplace enrollees. The first type, called the premium tax credit (or premium subsidy), reduces enrollees’ monthly payments for insurance coverage. The second type of financial assistance, the cost-sharing reduction (CSR), reduces enrollees’ deductibles and other out-of-pocket costs when they go to the doctor or have a hospital stay. To receive either type of financial assistance, qualifying individuals and families must enroll in a plan offered through a health insurance Marketplace. In addition to the federal subsidies discussed here, some states that operate their own exchange markets offer additional state-funded subsidies that further lower premium payments and/or deductibles or other forms of cost sharing.

Premium Subsidies

Premium tax credits can be applied to Marketplace plans in any of four “metal” levels of coverage: bronze, silver, gold, and platinum. Bronze plans tend to have the lowest premiums but have the highest deductibles and other cost sharing, leaving the enrollee to pay more out-of-pocket when they receive covered health care services, while platinum plans have the highest premiums but very low out-of-pocket costs. There are also catastrophic plans, usually only available to younger enrollees, but the subsidy cannot be used to purchase one of these plans.

The premium tax credit works by limiting the amount an individual must contribute toward the premium for the “benchmark” plan – or the second-lowest cost silver plan available to the individual in their Marketplace. This “required individual contribution” is set on a sliding income scale. In 2025, for individuals with income up to 150 percent FPL, the required contribution is zero, while at an income of 400 percent FPL or above, the required contribution is 8.5 percent of household income. 

These contribution amounts were set by the American Rescue Plan Act (ARPA) in 2021 and temporarily extended by the Inflation Reduction Act (IRA) through the end of 2025. Prior to the ARPA, the required contribution percentages ranged from about two percent of household income for people with income at the FPL to nearly 10 percent for people with income from 300 to 400 percent of FPL. Before the ARPA was passed, people with incomes above 400 percent of FPL were not eligible for premium tax credits. If Congress does not act to extend the IRA enhanced premium tax credits before the end of 2025, they will expire, and the original ACA premium caps will return.

The amount of tax credit is calculated by subtracting the individual’s required contribution from the actual cost of the “benchmark” plan. So, for example, if the benchmark plan costs $6,000 annually, the required contribution for someone with an income of 150 percent FPL is zero, resulting in a premium tax credit of $6,000. If that same person’s income equals 250 percent FPL (or $37,650 in 2025), the individual contribution is four percent of $37,650, or $1,506, resulting in a premium tax credit of $4,494.

The premium tax credit can then be applied toward any other plan sold through the Marketplace (except catastrophic coverage). The amount of the tax credit remains the same, so a person who chooses to purchase a plan that is more expensive than the benchmark plan will have to pay the difference in cost. If a person chooses a less expensive plan, such as the lowest-cost silver plan or a bronze plan, the tax credit will cover a greater share of that plan’s premium and possibly even the entire cost of the premium. When the tax credit exceeds the cost of a plan, it lowers the premium to zero and any remaining tax credit amount is unused.

As mentioned above, the premium tax credit will not apply for certain components of a Marketplace plan premium. First, the tax credit cannot be applied to the portion of a person’s premium attributable to covered benefits that are not essential health benefits (EHB). For example, a plan may offer adult dental benefits, which are currently not included in the definition of EHB. In that case, the person would have to pay the portion of the premium attributable to adult dental benefits without financial assistance. In addition, the ACA requires that premium tax credits may not be applied to the portion of premium attributable to “non-Hyde” abortion benefits. Marketplace plans that cover abortion are required to charge a separate minimum $1 monthly premium to cover the cost of this benefit; this means a consumer who is otherwise eligible for a fully subsidized, zero-premium policy would still need to pay $1 per month for a policy that covers abortion benefits. Finally, if the person smokes cigarettes and is charged a higher premium for smoking, the premium tax credit is not applied to the portion of the premium that is the tobacco surcharge.

Cost-Sharing Reductions

The second form of financial assistance available to Marketplace enrollees is a cost-sharing reduction. Cost-sharing reductions lower enrollees’ out-of-pocket cost due to deductibles, copayments, and coinsurance when they use covered health care services. People who are eligible to receive a premium tax credit and have household incomes from 100 to 250 percent of FPL are eligible for cost-sharing reductions.

Unlike the premium tax credit (which can be applied toward any metal level of coverage), cost-sharing reductions (CSR) are only offered through silver plans. For eligible individuals, cost-sharing reductions are applied to a silver plan, essentially making deductibles and other cost sharing under that plan more similar to that under a gold or platinum plan. Individuals with income between 100 and 250 percent FPL can continue to apply their premium tax credit to any metal level plan, but they can only receive the cost-sharing subsidies if they pick a silver-level plan.

Cost-sharing reductions are determined on a sliding scale based on income. The most generous cost-sharing reductions are available for people with income between 100 and 150 percent FPL. For these enrollees, silver plans that otherwise typically have higher cost sharing are modified to be more similar to a platinum plan by substantially reducing the silver plan deductibles, copays, and other cost sharing. For example, in 2025, the average annual deductible under a silver plan with no cost-sharing reduction is nearly $5,000, while the average annual deductible under a platinum plan is $0. Silver plans with the most generous level of cost-sharing reductions are sometimes called CSR 94 silver plans; these plans have 94 percent actuarial value (which represents the average share of health spending paid by the health plan) compared to 70 percent actuarial value for a silver plan with no cost-sharing reductions.

Somewhat less generous cost-sharing reductions are available for people with income greater than 150 and up to 200 percent FPL. These reduce cost sharing under silver plans to 87 percent actuarial value (CSR 87 plans). In 2025, the average annual deductible under a CSR 87 silver plan was about $700.

For people with income greater than 200 and up to 250 percent FPL, cost-sharing reductions are available to modestly reduce deductibles and copays to 73 percent actuarial value (sometimes called CSR 73 plans). In 2025, the average annual deductible under a CSR 73 silver plan was about $3,600.

Insurers have flexibility in how they set deductibles and copays to achieve the actuarial value under Marketplace plans, including CSR plans, so actual deductibles may vary from these averages. The ACA also requires maximum annual out-of-pocket spending limits on cost sharing under Marketplace plans, with reduced limits for CSR plans. In 2025, the maximum OOP limit is $9,200 for an individual and $18,400 for a family for all QHPs. Lower maximum OOP limits are permitted under cost-sharing reduction plans.

Cost-sharing reductions work differently for Native American and Alaska Native members of federally recognized tribes. For these individuals, cost-sharing reductions are available at higher incomes and can be applied to metal levels other than silver plans.

Since it was first signed into law, the ACA has undergone many changes through regulation, legislation, and legal challenges. Some provisions never got off the ground, and others were repealed, while more recent changes have expanded and enhanced other provisions. This section summarizes some of the most significant changes to the law.

Medicaid Expansion: The ACA originally expanded Medicaid to all non-Medicare eligible individuals under age 65 with incomes up to 138% of the FPL. A Supreme Court ruling on the constitutionality of the ACA upheld the Medicaid expansion, but limited the ability of HHS to enforce it, thereby making the decision to expand Medicaid effectively optional for states. As of the beginning of 2025, 40 states and the District of Columbia had expanded Medicaid. Additionally, while not taking up Medicaid expansion under the ACA, Wisconsin did increase Medicaid eligibility to 100% of the FPL, which is where ACA Marketplace subsidy eligibility begins. In the remaining states that have not expanded Medicaid, an estimated 1.4 million people fall into the so-called Medicaid coverage gap, meaning their incomes are too high to qualify for Medicaid but too low to qualify for ACA Marketplace subsidies. The federal government covers 90% of the cost of Medicaid expansion.

Individual Mandate: The ACA also originally included an “individual mandate” or requirement for most people to maintain health insurance. In health insurance systems designed to protect people with pre-existing conditions and guarantee availability of coverage regardless of health status, countervailing measures are also needed to ensure people do not wait until they are sick to sign up for coverage, as doing so would drive up premiums. The ACA included a variety of these countervailing measures, with both “carrots” (e.g., premium tax credits and cost-sharing reductions) and “sticks” (e.g., the individual mandate penalty and limited enrollment opportunities) to encourage healthy as well as sick people to enroll in health insurance coverage.

American citizens and U.S. residents without qualifying health coverage had to pay a tax penalty of the greater of $695 per year up to a maximum of three times that amount ($2,085) per family or 2.5% of household income. The penalty was set to increase annually by the cost-of-living adjustment. Exemptions were granted for financial hardship, religious objections, American Indians, those without coverage for less than three months, undocumented immigrants, incarcerated individuals, those for whom the lowest cost plan option exceeds 8% of an individual’s income, and those with incomes below the tax filing threshold.

Despite the popularity of the ACA’s protections for people with pre-existing conditions, the individual mandate was politically controversial and consistently viewed negatively by a substantial share of the public. In early 2017, under President Trump, the Internal Revenue Service (IRS) stopped enforcing the individual mandate penalty. After several attempts to repeal and replace the ACA stalled out in the summer of 2017, Congress reduced the individual mandate penalty to $0, effective in 2019, as part of tax reform legislation passed in December 2017.

Cost-Sharing Reduction Payments: The ACA originally included two types of payments to insurers participating in the ACA Marketplace. First, insurers received advanced payments of the premium tax credit to subsidize monthly premiums for people buying their own coverage on the Marketplace. Second, insurers were required to reduce cost sharing (i.e., deductibles, copayments, and/or coinsurance) for low-income enrollees and the federal government was required to reimburse insurers for these cost-sharing reductions (CSRs). However, the funds for the payment of cost-sharing reductions were never appropriated. The Trump administration ended federal CSR payments to insurers weeks before ACA Marketplace Open Enrollment for 2018 coverage began. In response to this, most states allowed insurers to compensate for the lack of government payments by raising premiums. At the time, the Congressional Budget Office (CBO) estimated termination of CSR payments to insurers would increase the federal deficit by $194 billion over 10 years, because of these higher premiums and corresponding increased premium tax credit subsidies. Although the CSR payments have ceased, cost-sharing reduction plans continue to be available to low-income Marketplace enrollees.

Enhanced and Expanded ACA Marketplace Premium Tax Credits: Another controversial aspect of the ACA was the so-called “subsidy cliff,” where people with incomes over 400% of the FPL were ineligible for financial assistance on the Marketplace and, therefore, would have to pay a large share of their household income for unsubsidized health coverage. As a result, many middle-income people were being priced out of ACA coverage. The March 2021 COVID-19 relief legislation, the American Rescue Plan Act (ARPA), extended eligibility for ACA health insurance subsidies to people with incomes over 400% of FPL buying their health coverage on the Marketplace. The ARPA also increased the amount of financial assistance for people with lower incomes who were already eligible under the ACA, making many low-income people newly eligible for free or nearly free coverage. Both provisions were temporary, lasting for two years, but the Inflation Reduction Act extends those subsidies through the end of 2025.

Family Glitch: Financial assistance to buy health insurance on the Affordable Care Act (ACA) Marketplaces is primarily available for people who cannot get coverage through a public program or their employer. Some exceptions are made, however, including for people whose employer coverage offer is deemed unaffordable or of insufficient value. For example, people can qualify for ACA Marketplace subsidies if their employer requires them to spend more than about 8-9% (indexed each year) of their household income on the company’s health plan premium. For many years, this affordability threshold was based on the cost of the employee’s self-only coverage, not the premium required to cover any dependents. In other words, an employee whose contribution for self-only coverage was less than the threshold was deemed to have an affordable offer, which means that the employee and their family members were ineligible for financial assistance on the Marketplace, even if the cost of adding dependents to the employer-sponsored plan would far exceed the approximately 8-9% of the family’s income. This definition of “affordable” employer coverage has come to be known as the “family glitch,” which affected an estimated 5.1 million people. Under a Biden administration federal regulation, the worker’s required premium contributions for self-only coverage and for family coverage will be compared to the affordability threshold of approximately 8-9% of household income. If the cost of self-only coverage is affordable, but the cost for family coverage is not, the worker will stay on employer coverage while their family members can apply for subsidized exchange coverage.

Public Opinion: Americans’ views of the Affordable Care Act have evolved over time. From the time the ACA passed, to when the Marketplaces first opened in 2014, and through the months leading up to President Trump’s election in 2016, public opinion of the ACA was strongly divided and often leaned more negative than positive. Many individual provisions of the ACA, such as protections for people with preexisting conditions, were popular, but the individual mandate was particularly unpopular.

News coverage during the ACA Marketplaces’ early years often centered on the rocky rollout, from the early Healthcare.gov website glitches to skyrocketing premiums in subsequent years. Coverage in later years focused on how unprofitable insurers exited the market, leaving people in some counties at risk of having no Marketplace insurer—and thus, no Marketplace through which to access health insurance subsidies.

In 2017, during his first term, President Trump and Republicans in Congress attempted to repeal or fundamentally alter the ACA. As proposals to replace the ACA became more concrete, though, public support for the ACA, particularly among Democrats and Independents, began to grow. Ultimately, the only key aspect of the law that was removed was the penalty for not purchasing health insurance—now lowered to $0 as part of the 2017 tax reform package. Following repeal efforts and the removal of the individual mandate penalty, as well as a stabilization of the ACA Marketplaces, public support for the law has continued to grow and is now solidly more positive than negative. Although this support remains divided by party lines, several Republican-led states have adopted the ACA’s Medicaid expansion through popular votes.

Following repeal efforts and the removal of the individual mandate penalty, as well as a stabilization of the ACA Marketplaces, public support for the law has continued to grow and is now solidly more positive than negative. Although this support remains divided by party lines, several Republican-led states have adopted the ACA’s Medicaid expansion through popular votes.

After volatile initial years, the ACA Marketplaces have become more stable—a pattern which can be seen across a variety of measures, including enrollment, premiums and insurer participation.  

Enrollment

ACA Marketplace enrollment has more than tripled since its launch in 2014. The number of people who enrolled and effectuated their Marketplace coverage in early 2024 reached 20.8 million, surpassing prior record-setting years in 2021, 2022, and 2023. The recent enrollment growth was likely primarily driven by the enhanced tax credits in the American Rescue Plan Act and the Inflation Reduction Act, as well as the Biden administration’s decision to direct more resources toward marketing, outreach, and enrollment assistance, reversing substantial reductions in funding by the Trump administration.

The ARPA’s subsidies didn’t simply bring people from off-Marketplace plans to the Marketplace; they also helped increase overall individual market enrollment. Enrollment grew to 25.2 million in early 2025, which is an increase of about 81% from early 2020.

With passage of enhanced tax credits in the American Rescue Plan Act (ARPA), combined with boosted outreach and an extended enrollment period, 2021 marked the first year since 2015 when individual market enrollment increased relative to the year prior. Individual market enrollment grew about 5% from 13.9 million in the first quarter of 2020 to 14.7 million in the first quarter of 2021.

In the early years of the rollout of the ACA Marketplaces, on-exchange enrollment was comparable to off-exchange enrollment, meaning that the Marketplaces represented about half of overall individual market enrollment. Some off-exchange enrollment was represented by people in ACA-compliant coverage (similar to that offered on-exchange, but without subsidies), while other individual market enrollees were signed up for non-compliant coverage, like “grandmothered” or short-term plans.

Non-compliant short-term plans often do not include certain benefits or coverage for pre-existing conditions and can impose a dollar limit on insurance coverage. For example, many short-term plans do not cover maternity care, prescription drugs, or mental health or substance use treatment, and most impose a dollar limit on covered services or drugs. In 2024, the Biden administration finalized a rule that reverses the Trump administration’s expansion of short-term plans.

Premiums

ACA Marketplace premiums have risen substantially over time. When insurers entered the ACA Marketplaces in 2014, most were operating with virtually no experience participating in an individual market like this (e.g., with subsidies, preexisting condition protections, and an individual mandate). Insurers also had to submit premiums almost a year in advance for review and approval by state regulators. Even 2015 premiums were submitted in early 2014, meaning insurers did not have much experience in the market on which to base their premium and claim projections. Eventually, though, it became clear that they were underpriced and unprofitable, so in 2016, many insurers began to raise premiums. By 2017, the temporary reinsurance and risk corridors programs had phased out, leading to another market correction. In 2018, with the discontinuation of cost-sharing reduction payments, insurers raised premiums yet again, though most insurers concentrated these premium increases on silver plans (a practice known as “silver loading”). More recently, though, as the markets have stabilized and as the pandemic led to a temporary reduction in health care utilization, premiums have at times fallen or at least grown at a slower pace. Heading into 2025, ACA Marketplace benchmark premiums rose by about 4% on average, driven primarily by inflation and increased utilization of specialty drugs.

Deductibles and other cost sharing

Generally, deductibles have also risen since the ACA Marketplaces were first launched in 2014. Bronze plans, which typically have the highest deductibles among ACA Marketplace plans, have an average deductible of $7,186 in 2025, compared to $5,113 in 2014. However, as discussed above, many ACA Marketplace enrollees are low income and therefore qualify for cost-sharing reductions if they purchase a silver plan. For the most generous cost-sharing reduction plans, which are available to people with incomes just above the FPL, the average deductible is $87 in 2025, compared to $183 in 2014.  

Insurer participation

Insurer participation in 2025 is more robust than in recent years, surpassing record high levels of participation set in 2023 and 2024.

Insurer participation on the ACA Marketplaces fell dramatically in 2017 with the exit of UnitedHealthcare from most states. In 2018, with President Trump’s announcement that cost-sharing reduction payments would cease and the corresponding attempts to repeal the ACA in Congress, many more insurers exited or scaled back their participation. Though all counties in the country continued to have at least one ACA Marketplace insurer, there had initially been concern that there could have been counties left without any insurer, thus leaving residents in those counties without access to ACA subsidies.

However, in subsequent years, with premium increases and changes in strategies, it became apparent that the ACA Marketplaces could be quite profitable and many insurers entered or expanded their footprints.

The ACA has faced both support and opposition over time, and its fate has been subject to numerous political and legal debates, including efforts to repeal and replace the law and to overturn it in whole or in part in several court cases. Future changes in presidential administrations and shifts in the composition of Congress will likely continue to impact the implementation and stability of the ACA.

Key issues to watch include:

Federal Policy Changes: Federal policy changes finalized and passed in the summer of 2025 will change how the ACA Marketplaces will operate in the coming years. Combined, the finalized Marketplace Integrity and Affordability final rule as well as the budget reconciliation legislation will make several changes to consumer protections, ACA Marketplace coverage and premium tax credit eligibility, as well as verification processes. Implementation dates of specific policies vary, but some are set to begin in August of 2025. Changes include effectively ending auto-renewals, removing repayment limits on the premium tax credit, and implementing new eligibility verification procedures.  The CBO estimates that an additional  10 million people would become uninsured due to the impact of the budget reconciliation legislation, with about 2 million becoming uninsured due to changes to the ACA Marketplaces.

Enhanced Premium Tax Credits: Currently, the enhanced premium tax credits in the ACA Marketplaces are set to expire at the end of 2025. If these tax credits are allowed to expire, people purchasing subsidized coverage will face significant increases in their monthly premium payments and some may become priced out of the market. Some action has been taken ahead of a potential expiration. In preparation for the possibility of enhanced tax credits expiring, some states are working on ways to fund state subsidies that keep the cost of ACA Marketplace coverage affordable. The CBO previously projected that an additional 4.2 million people would become uninsured by 2034 if the enhanced premium tax credits expire.

State Actions: In recent years, some states have moved off the federal platform (Healthcare.gov) to implement their own enrollment websites. Additionally, more states have expanded Medicaid. Some states have sought 1332 waivers under the ACA to implement reinsurance programs, expand coverage to undocumented residents (though federal policy changes discussed above will undo these efforts), and create public options.

Consumer Protections: The ACA includes various consumer protections that continue to evolve through the regulatory process. For example, proposed and finalized rulemaking has focused on improving network adequacy, simplifying the shopping process, and reexamining essential health benefits. Planned federal policy changes will undo some of the consumer protection processes currently in place. In response to claims of mass fraudulent enrollment, the finalized Marketplace Integrity and Affordability Rule was issued in June 2025. In it, CMS issued rules permitting coverage denials for outstanding premium payments from prior coverage and eliminated the automatic 60-day extension to resolve income discrepancies.

Funding Cuts: In February 2025, CMS announced that it would be reducing funding for its navigator program down from $100 million to $10 million starting next year. This is equal tothe amount awarded to navigators in 2018-2020 during President Trump’s first administration.

Health Costs and Affordability: Though the ACA has made insurance coverage more accessible and affordable for millions of people, health costs in the United States continue to be high and many people with insurance nonetheless face cost-related barriers to care.

• KFF Subsidy Calculator
• How Much More Would People Pay in Premiums if the ACA’s Enhanced Subsidies Expired?
• Explaining Health Care Reform: Questions About Health Insurance Subsidies
• Implementation Dates for 2025 Budget Reconciliation Law
• Health Provisions in the 2025 Federal Budget Reconciliation Law
• Health Reform FAQs
• Inflation Reduction Act Subsidies  
• Ten Things to Watch for 2025 ACA Open Enrollment
• State Health Facts – ACA state data
• Enrollment Growth in the ACA Marketplaces
• Deductibles in ACA Marketplaces

Ortaliza, J., McGough, M., & Cox, C., The Affordable Care Act 101. In Altman, Drew (Editor), Health Policy 101, (KFF, October 2025) https://www.kff.org/health-policy-101-the-affordable-care-act/ (date accessed).

Health coverage in the United States is marked by a blend of private and public insurance options that leaves about 8% of the population uninsured. This coverage system has evolved over the years, most recently with the implementation of the Affordable Care Act (ACA), which aimed to reduce the uninsured rate by expanding Medicaid, creating health insurance Marketplaces for individuals, and providing subsidies to make the coverage more affordable. Many factors, including economic conditions, federal and state policy changes, and significant health crises, such as the COVID-19 pandemic, influence the uninsured rate. The ACA and policy changes designed to protect coverage during the pandemic led to increased health coverage overall; however, passage of the 2025 Federal Budget Reconciliation Bill (referred to as the One Big Beautiful Bill Act) along with other policy changes are expected to increase significantly the number of people who are uninsured over the next ten years.

Health coverage in the U.S. is a complex patchwork of private and public insurance coverage options. In 2023, most residents had private insurance coverage, with nearly half covered by an employer-based plan. About 1 in 5 U.S. residents received coverage through the Medicaid program, the federal and state-financed comprehensive health coverage program for low-income people. Another roughly 15% of the population had health coverage from the federal Medicare program, which covers seniors and people under age 65 with long-term disabilities. About 6% of the population had private non-group insurance either purchased through the ACA Marketplace or off-market, and just over 1% of the population was covered through the military’s TRICARE or VA health care programs. The uninsured rate for the total population was 7.9% for the year (Figure 1). (In some cases, people have multiple forms of coverage. For example, about 12 million people are enrolled in both Medicare and Medicaid and are classified in these figures as covered by Medicaid.)

In 2023, there were 25.3 million uninsured residents ages 0-64, and the uninsured rate among the population ages 0-64 was 9.5%, the lowest rate in U.S. history (Figure 2). The analysis of the uninsured population focuses on coverage among people ages 0-64 since Medicare offers near-universal coverage for seniors—just 457,000, or less than 1%, of people over age 65 were uninsured.

Prior to the implementation of the ACA, gaps in the public insurance system and lack of access to affordable private coverage left over 40 million people without health insurance. The ACA expanded Medicaid coverage to nearly all adults with incomes up to 138% of the federal poverty level (FPL) (the poverty level in the continental U.S. is $15,650 for a single individual in 2025) and created new health insurance Marketplaces through which individuals can purchase coverage with financial help to afford premiums and cost-sharing. Following the passage of the ACA in 2010 and the rollout of the coverage provisions, the number of uninsured people ages 0-64 dropped to 27 million in 2016. The ACA envisioned that all states would adopt the Medicaid expansion; however, a Supreme Court ruling in 2012 made expansion optional for states. As of early 2025, 40 states and Washington, D.C. had adopted the ACA’s Medicaid expansion (Figure 3).

The declines in uninsured rates following implementation of the ACA coverage expansions were largest among poor and near-poor individuals, particularly adults. People of color, who had higher uninsured rates than White people prior to 2014, had larger coverage gains from 2013 to 2016 than White people, although the coverage disparities were not eliminated.

Before implementation of the ACA, expansions of Medicaid coverage and the enactment of the Children’s Health Insurance Program (CHIP) helped to lower the uninsured rate for children. Changes in the 1980s and early 1990s expanded Medicaid eligibility levels for children and pregnant people, and the establishment of CHIP in 1997 provided coverage for children with incomes above Medicaid thresholds. When states implemented CHIP, extensive outreach efforts along with the adoption of streamlined processes facilitated enrollment of children in Medicaid and CHIP and reduced the number of uninsured children.

After declining through 2016, the number of uninsured people and the uninsured rate began increasing in 2017 and continued to grow through 2019. Generally favorable economic conditions as well as policy changes during the Trump Administration, such as reduced funding for outreach and enrollment assistance, encouraging periodic Medicaid eligibility checks, changes to immigration policy related to public charge rules, and approval of some demonstration waivers to restrict enrollment led to a decline in Medicaid enrollment, which likely contributed to the increase in uninsured people.  

With the arrival of the COVID-19 pandemic, policies adopted to protect coverage drove a decline in the uninsured population from 2019 to 2023. The Families First Coronavirus Response Act required states to keep people continuously enrolled in Medicaid in exchange for enhanced federal funding. Medicaid continuous enrollment ended in March 2023, and most states completed renewals for individuals who enrolled during continuous enrollment by December 2024. In addition, the American Rescue Plan Act (ARPA) provided temporary enhanced ACA Marketplace subsidies to make Marketplace coverage more affordable, and these subsidies were renewed for another three years in the Inflation Reduction Act of 2022. These enhanced subsidies will expire at the end of December 2025 unless Congress acts to extend them.

Most people who are uninsured are adults under age 65, are in working low-income families, are people of color, and, reflecting geographic variation in income, immigration status, and the availability of public coverage, live in the South or West. In 2023, over 8 in 10 people ages 0-64 who were uninsured were adults and 16% were children.

Nearly three-quarters (73.7%) of the uninsured population ages 0-64 had at least one full-time worker in their family and an additional 11.2% had a part-time worker in their family (Figure 4). More than 8 in 10 (80.9%) people ages 0-64 who were uninsured were in families with incomes below 400% FPL in 2023 and nearly half (46.7%) had incomes below 200% FPL. People of color comprised 62.9% of the uninsured population ages 0-64 in 2023 despite making up about 46% of residents ages 0-64. Most uninsured individuals (74.2%) were U.S. citizens, while 25.8% were noncitizens in 2023. Nearly three-quarters lived in the South and West.

Adults ages 19 to 64 are more likely to be uninsured than children. The uninsured rate among children (5.3%) was less than half the rate among adults ages 19-64 (11.1%) in 2023, largely due to the broader availability of Medicaid and CHIP coverage for children than for adults. Among adults ages 19-64, men had higher uninsured rates than women in 2023 (12.6% vs. 9.5%).

Reflecting persistent disparities in coverage, people of color are generally more likely to be uninsured than White people. In 2023, American Indian and Alaskan Native (AIAN) and Hispanic people ages 0-64 had the highest uninsured rates at 18.7% and 17.9%, respectively, which were nearly three times higher than the uninsured rate for White people (6.5%). Uninsured rates for Native Hawaiian or Pacific Islander (NHPI) (12.8%) and Black people (9.7%) ages 0-64 were also higher than the rate for their White counterparts (Figure 5). These differences in uninsured rates are driven by lower rates of private coverage among these groups. Medicaid coverage helps to narrow these differences but does not fully offset them.

Noncitizens are more likely than citizens to be uninsured. Nearly one-third of noncitizen immigrants were uninsured in 2023 while the uninsured rate for U.S.-born citizens was 7.5% and 8.9% for naturalized citizens. One in 4 children has an immigrant parent, including over 1 in 10 (12%) who are citizen children with at least one noncitizen parent.

Uninsured rates vary by state and by region and were generally higher in states that had not taken up the ACA Medicaid expansion in 2023 (Figure 6). Economic conditions, availability of employer-sponsored coverage, and demographics are other factors contributing to variation in uninsured rates across states.

The fragmented U.S. health coverage system leads to gaps in coverage. While employer-based insurance is the prevalent source of coverage for the population ages 0-64, not all workers are offered coverage by their employer or, if offered, can afford their share of the premiums. Medicaid covers many low-income individuals, especially children, but eligibility for adults remains limited in most states that have not adopted the ACA Medicaid expansion. While subsidies for Marketplace coverage are available for many low and moderate-income people, few people can afford to purchase private coverage without financial assistance.

The cost of health coverage and care poses a challenge for the country broadly and is a significant barrier to coverage for people who are uninsured. In 2023, 63.2% of uninsured adults ages 18-64 said they were uninsured because coverage is not affordable, making it the most common reason cited for being uninsured (Figure 7). Other reasons included not being eligible for coverage (27.0%), not needing or wanting coverage (26.6%), and signing up being too difficult (23.9%).

Not all workers have access to coverage through their jobs. In 2023, 64.7% of uninsured workers worked for an employer that did not offer them health benefits. Among uninsured workers who are offered coverage by their employers, cost is often a barrier to taking up the offer. Low-income families with employer-based coverage spend a significantly higher share of their income toward premiums and out-of-pocket medical expenses compared to those with income above 200% FPL.

A decade after the implementation of the ACA coverage options, 10 states have not adopted the Medicaid expansion, leaving 1.4 million uninsured people without an affordable coverage option. A coverage gap exists in states that have not adopted the expansion for poor adults who earn too much to qualify for Medicaid coverage but not enough to be eligible for subsidies in the Marketplace.

Lawfully-present immigrants generally must meet a five-year waiting period after receiving qualified immigration status before they can qualify for Medicaid. States have the option to cover eligible children and pregnant people without a waiting period, and as of January 2025, 38 states have elected the option for children, and 32 states have taken up the option for lawfully-present pregnant individuals. Under current law, lawfully-present immigrants are eligible for Marketplace tax credits, including those who are not eligible for Medicaid because they have not met the five-year waiting period. Undocumented immigrants are ineligible for federally-funded coverage, including Medicaid and Marketplace coverage, although some states provide fully state-funded health coverage to these individuals.

Health care provisions in the 2025 reconciliation package narrow eligibility for federally-subsidized health coverage, including Medicaid and CHIP, Medicare, and Marketplace subsidies, to a limited group of lawfully-present immigrants. These changes take effect on January 1, 2027 and are expected to increase the number of lawfully residing immigrants without health coverage.

Though financial assistance is available to many of the remaining uninsured under the ACA, not everyone who is uninsured is eligible for free or subsidized coverage. Nearly 6 in 10 (14.5 million) uninsured individuals in 2023 were eligible for financial assistance through Medicaid or subsidized Marketplace coverage (Figure 8). However, over 4 in 10 uninsured (10.9 million) were outside the reach of the ACA because their state did not expand Medicaid, their immigration status made them ineligible, or they were deemed to have access to an affordable Marketplace plan or offer of employer coverage (Figure 8).

Lacking health insurance in the United States can impact a person’s access to health care, their financial situation, and their health status. It can also broadly impact a community’s public health (illustrated by the COVID-19 pandemic) and the economy through lower productivity.

Adults who are uninsured are almost five times more likely than adults with insurance to report not having a usual source of care, which is often a key entry point for accessing health care whether for preventive services or for treating existing conditions. Consequently, in 2023, nearly half (46.6%) of uninsured adults ages 18-64 reported not seeing a doctor or health care professional in the past 12 months compared to 15.6% with private insurance and 14.2% with public coverage (Figure 9). Uninsured individuals are also more likely to face cost barriers to accessing needed care. In 2023, uninsured adults were nearly three times more likely to report not getting medical care due to cost compared to publicly insured adults and four times more likely than privately insured adults (22.6% vs 7.7% and 5.1%, respectively).

The lack of access to health care and a delay in seeking care due to costs mean uninsured people are more likely to be hospitalized for avoidable health problems and to experience declines in their overall health. Research also shows that when they are hospitalized, uninsured people receive fewer diagnostic and therapeutic services and have higher mortality rates than those with insurance.

Uninsured individuals often face unaffordable medical bills when they do seek care, which can lead to medical debt and other forms of financial instability. Nearly half of uninsured adults reported difficulty paying for health care, compared to 21% of insured adults and over 8 in 10 (84%) uninsured adults said they worried that health care costs would put them in debt or increase their existing debt, compared to 71% of adults with insurance (Figure 10). Uninsured adults are also more likely to face negative consequences due to health care debt, such as using up savings, having difficulty paying other living expenses, or borrowing money.

Driven by pandemic-era policies to promote health coverage, the number of people without insurance and the uninsured rate dropped to historic lows in recent years. Although millions of people lost Medicaid coverage during the unwinding of continuous enrollment, Medicaid enrollment remains higher than in February 2020, before the start of the pandemic. Enhanced Marketplace subsidies adopted during the pandemic led to record Marketplace signups, with enrollment topping 25 million in 2025. States have also taken action to reduce the number of people who are uninsured. In 2023, two states, North Carolina and South Dakota, newly adopted the Medicaid expansion, and several states have expanded state-funded coverage for certain individuals regardless of immigration status.

However, actions by Congress and the Trump Administration threaten to reverse these recent coverage gains. Congress passed the 2025 Federal Budget Reconciliation package on July 3, 2025, which makes significant changes to Medicaid and ACA Marketplaces, and President Trump signed the reconciliation package into law on July 4, 2025.  The Congressional Budget Office (CBO) estimates that the law will increase the number of people without health insurance by 10 million. The expiration of the enhanced premium tax credits for Marketplace enrollees, which will happen at the end of 2025 unless Congress takes action to extend them, will further increase the number of people without health insurance. CBO projects that over 14 million more people will be uninsured in 2034 due to the combined effects of the reconciliation package and the expiration of the enhanced Marketplace subsidies. In addition to these potential coverage losses, the Trump administration’s increased immigration enforcement activities are likely to have a broad chilling effect that could cause immigrants to decide to disenroll or not enroll themselves or their children, most of whom are U.S. citizens, in health coverage programs even if they are eligible due to immigration-related fears.

Enactment of the ACA helped close some gaps in our fragmented health coverage system and led to a significant decline in the number of people who were uninsured. Recent efforts built on that success to further shrink the share of people without insurance. Yet, despite this success and the ACA’s continued favorability—the public has a favorable view of the ACA by a 2 to 1 margin—policymakers enacted cuts to federal support for Medicaid and ACA coverage to fund other budget priorities. The impact on health coverage and people’s ability to access needed health care services will be significant.

• Key Facts about the Uninsured Population 
• How Many Uninsured Are in the Coverage Gap and How Many Could be Eligible if All States Adopted the Medicaid Expansion?
• A Closer Look at the Remaining Uninsured Population Eligible for Medicaid and CHIP
• Health Coverage by Race and Ethnicity, 2010-2023
• Key Facts on Health Coverage of Immigrants
• How Does Cost Affect Access to Health Care?
• State-Funded Health Coverage for Immigrants
• How Will the One Big Beautiful Bill Act Affect the ACA, Medicaid, and the Uninsured Rate?

Tolbert, Jennifer, Bell, Clea, Cervantes, Sammy & Singh, Rakesh, The Uninsured Population and Health Coverage. In Altman, Drew (Editor), Health Policy 101, (KFF, October 2025) https://www.kff.org/health-policy-101-the-uninsured-population-and-health-coverage/ (date accessed).

Health policy and politics are inextricably linked. Policy is about what the government can do to shift the financing, delivery, and quality of health care, so who controls the government has the power to shape those policies.

Elections, therefore, always have consequences for the direction of health policy – who is the president and in control of the executive branch, which party has the majority in the House and the Senate with the ability to steer legislation, and who has control in state houses. When political power in Washington is divided, legislating on health care often comes to a standstill, though the president still has significant discretion over health policy through administrative actions. And, stalemates at the federal level often spur greater action by states.

Health care issues often, but not always, play a dominant role in political campaigns. Health care is a personal issue, so it often resonates with voters. The affordability of health care, in particular, is typically a top concern for voters, along with other pocketbook issues, and, at over 17% of the economy, health care has many industry stakeholders who seek influence through lobbying and campaign contributions. At the same time, individual policy issues are rarely decisive in elections.

Health “reform” – a somewhat squishy term generally understood to mean proposals that significantly transform the financing, coverage, and delivery of health care – has a long history of playing a major role in elections.

Harry Truman campaigned on universal health insurance in 1948, but his plan went nowhere in the face of opposition from the American Medical Association and other groups. While falling short of universal coverage, the creation of Medicare and Medicaid in 1965 under Lyndon Johnson dramatically reduced the number of uninsured people. President Johnson signed the Medicare and Medicaid legislation at the Truman Library in Missouri, with Truman himself looking on.

Later, Bill Clinton campaigned on health reform in 1992, and proposed the sweeping Health Security Act in the first year of his presidency. That plan went down to defeat in Congress amidst opposition from nearly all segments of the health care industry, and the controversy over it has been cited by many as a factor in Democrats losing control of both the House and the Senate in the 1994 midterm elections.

For many years after the defeat of the Clinton health plan, Democrats were hesitant to push major health reforms. Then, in the 2008 campaign, Barack Obama campaigned once again on health reform, and proposed a plan that eventually became the Affordable Care Act (ACA). The ACA ultimately passed Congress in 2010 with only Democratic votes, after many twists and turns in the legislative process. The major provisions of the ACA were not slated to take effect until 2014, and opposition quickly galvanized against the requirement to have insurance or pay a tax penalty (the “individual mandate”) and in response to criticism that the legislation contained so-called “death panels” (which it did not). Republicans took control of the House and gained a substantial number of seats in the Senate during the 2010 midterm elections, fueled partly by opposition to the ACA.

The ACA took full effect in 2014, with millions gaining coverage, but more people viewed the law unfavorably than favorably, and repeal became a Republican rallying cry in the 2016 campaign. After the election of Donald Trump, a high-profile effort to repeal the law was ultimately defeated following a public backlash. The ACA repeal debate was a good example of the trade-offs inherent in all health policies. Republicans sought to reduce federal spending and regulation, but the result would have been fewer people covered and weakened protections for people with pre-existing conditions. KFF polling showed that the ACA repeal effort led to increased public support for the law, which persists today.

While President Trump failed in his first term to repeal the ACA, his administration repealed the individual mandate penalty, reduced federal funding for consumer assistance (navigators) by 84% and outreach by 90%, and expanded short-term insurance plans that can exclude coverage of preexisting conditions.

In a strange policy twist, the Trump administration ended payments to ACA insurers to compensate them for a requirement to provide reduced cost sharing for low-income patients. But, insurers responded by increasing premiums, which in turn increased federal premium subsidies and federal spending, likely strengthening the ACA.

Between President Trump’s presidential terms, the Biden administration restored outreach funding and signed legislation increasing the premium tax credits that help ACA Marketplace enrollees pay their premiums, leading to record enrollment and historically low uninsured rates.

The increased premium tax credits are set to expire at the end of 2025 unless Congress and President Trump take action. If these tax credits do expire, people purchasing subsidized coverage will face significant increases in their monthly premium payments and some may become priced out of the market.

President Trump’s second term has already brought federal policy changes that will significantly alter ACA Marketplace operations, consumer protections, and premium tax credit eligibility. Key changes in the 2025 budget reconciliation law, such as ending auto-renewals, removing repayment limits for tax credits when income rises, and tightening eligibility verification, are projected by the Congressional Budget Office (CBO) to result in 2 million people becoming uninsured.

Since its establishment in 1965, Medicaid has evolved as states took up the optional joint federal-state program to the point that in the 1980s all 50 states were participating. Due to the nature of its federal and state management, there has been a give-and-take over the flexibility of and spending for the program, but it has generally expanded in its coverage of key population groups.

With the passage of the ACA, Medicaid experienced its largest federal policy coverage expansion with the addition of what was ultimately a state option to cover adults with incomes up to 138% of the federal poverty level in exchange for enhanced federal funding for the coverage. Much like the take-up of the original Medicaid program, states have gradually adopted the expansion so that only 10 states, mainly concentrated in the South, remain holdouts. However, recent federal actions may alter the expansion landscape.

Until 2025, the most serious attempt by federal policymakers to make cuts to the Medicaid program was during the 2017 failed attempt to repeal the ACA. Medicaid changes in the legislation included a rollback of enhanced federal matching funds for the Medicaid expansion and a per-enrollee cap of federal funds for most Medicaid enrollees. The 2025 budget reconciliation law includes the largest enacted cuts in Medicaid’s history, instituting Medicaid work requirements, tightening eligibility checks and reducing or capping types of provider funding. The CBO estimates that 7.5 million people will become uninsured due to the Medicaid provisions of the law. However, several of the Medicaid provisions will not be implemented until after the 2026 midterm elections.

One persistent feature of health care as an election issue is that it is fundamentally an economic issue for the country and for individuals. If you are uninsured, you not only experience access issues, but also the high cost of health care treatment. If you have health insurance, you worry about annual premium changes, deductibles, and cost-sharing related to health care services and prescription drugs whose prices continue to rise.

President Trump has often spotlighted the high price of prescription drugs, criticizing both the pharmaceutical industry and pharmacy benefit managers. Although he kept the issue of drug prices on the political agenda as president, in the end, his first administration accomplished little to restrain them. 

President Biden signed the Inflation Reduction Act, which requires the federal government to negotiate the prices of certain drugs in Medicare, which was previously banned. How aggressively the prescription drug negotiation program proceeds during the second Trump administration is an open question. While President Trump has issued an executive order calling for a “most favored nation” policy for drug pricing, with prices in the U.S. matching the currently lower prices in other countries, it remains unclear how drug companies will respond to the call and whether there will be any enforcement mechanism.

A feature of the second Trump administration has been the push to remake the executive branch of the federal government to reflect his priorities at a scale that hasn’t occurred in the recent past. Secretary of Health and Human Services (HHS), Robert F. Kennedy, Jr., announced a plan to restructure the department in March 2025 that would reduce the workforce substantially, create the new agency Administration for a Healthy America, reorganize and consolidate divisions and relocate offices.

HHS Secretary Kennedy is also leading the Make America Healthy Again (MAHA) Commission and making substantial changes to the vaccine approval process by remaking the roster for the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices and having CDC change recommendations for who should receive the COVID-19 vaccine.

These changes to the federal health care infrastructure could impact the accessibility of vaccines and other preventive services, as well as undermine the confidence the public has in the government, particularly its scientific agencies.

Ultimately, irrespective of the issues that get debated during the campaign, the outcome of federal elections – who controls the White House and Congress – has significant implications for the future direction of health care.

However, even with changes in party control of the federal government, generally incremental movement to the left or the right is the norm. Sweeping changes in health policy, such as the creation of Medicare and Medicaid or passage of the ACA, are rare in the U.S. political system and are usually preceded by one-party control of Congress and the presidency. More fundamental changes in health care financing and coverage, such as Medicare for All, face long odds. This is the case even though most of the public favors Medicare for All, though attitudes shift significantly after hearing messages about its potential impacts.

It has historically been politically difficult to take benefits away from people once they have them. That, and the fact that seniors are a strong voting bloc, has been why Social Security and Medicare have been considered political “third rails.” While Medicare and Social Security were largely untouched in the Republican tax and spending law passed in 2025, the law made substantial cuts to the ACA and Medicaid, and millions more people are projected to become uninsured in what will be the biggest rollback in federal support for health coverage ever. Looking toward the 2026 midterm election and beyond, changes to both the ACA and Medicaid, as well as fundamental changes to the health care infrastructure and public health policies of the federal government, may emerge as major campaign issues.

• Explaining the Muddle on ACA Tax Credits
• KFF Health Tracking Poll: ACA Enhanced Subsidies
• Make American Health Care Affordable Again
• We’ve Never Seen Health Care Cuts This Big
• Health Provisions in the 2025 Federal Budget Reconciliation Law
• ACIP, CDC, and Insurance Coverage of Vaccines in the United States

Levitt, L. & Singh, R., The Politics of Health Care and the 2024 Election. In Altman, Drew (Editor), Health Policy 101, (KFF, October 2025) https://www.kff.org/elections/health-policy-101-the-politics-of-health-care-and-elections/ (date accessed).

While there is currently no standard, agreed-upon definition of global health, the National Academy of Medicine (formerly Institute of Medicine) defines global health as having “the goal of improving health for all people in all nations by promoting wellness and eliminating avoidable diseases, disabilities, and deaths.” A key dimension of global health is an emphasis on addressing inequities in health status between rich and poor countries and also for those who are most marginalized within countries, as well as a recognition that the health of people around the world is highly interconnected, with domestic and foreign health inextricably linked. 

The U.S. government has long been the largest donor to and implementer of global health programs in the world. These efforts have aimed to help improve the health of people in low- and middle-income countries while also contributing to broader U.S. global development goals, foreign policy priorities, and national security concerns, including helping safeguard the health of Americans. These efforts began decades ago and saw major expansion in the early part of the current century with the creation of the President’s Emergency Plan for AIDS Relief (PEPFAR) and other programs. Since the beginning of the second Trump administration, however, the U.S. global health response has undergone significant change, disruption, and retraction, and the global health landscape has been altered in fundamental ways. This has included, as part of a major review of U.S. foreign aid, the dissolution of the U.S. Agency for International Development (USAID), the main implementing agency for U.S. global health programs, the elimination of numerous programs and projects, and the transition of remaining programs to the State Department.  As part of its review, the administration is seeking to assess whether U.S. foreign aid programs are aligned with U.S. national interests.

Historically, the U.S. role in global health is multifaceted and includes a broad range of activities. Its primary roles are as a supporter of bilateral (i.e., country-to-country) efforts, directly funding implementation of global health efforts in partner countries, and as a donor to multilateral health institutions (i.e., international organizations that pool support from multiple countries for one or more areas of global health). The U.S. also engages in global health diplomacy through its relationships with other governments, multilateral institutions, non-governmental organizations, and the private sector. Specifically, the U.S. government:

• acts as a donor by providing financial and other health-related development assistance (e.g., commodities, like contraceptives or bed nets for protection from disease-carrying mosquitoes) to low- and middle-income countries;
• operates programs and delivers health services;
• provides technical assistance and other capacity-building support;
• participates in major international health organizations and coordinates health efforts with other stakeholders through global health diplomacy;
• conducts research;
• supports international responses to disasters and other emergencies; and
• partners with governments, non-governmental groups, and the private sector (Figure 1).

U.S. global health activities have targeted a variety of issues and used different intervention approaches such as:

• Health services and systems strengthening: improving basic and essential health services, systems, and infrastructure;
• Disease detection and response: supporting surveillance, prevention, and treatment of diseases, including both infectious (e.g., HIV, TB, malaria) and non-communicable diseases (e.g., cardiovascular disease, cancer);
• Population and maternal/child health: promoting maternal health; reproductive health and family planning; child nutrition, immunization, and other child survival interventions;
• Nutrition, water, and environmental health: providing non-emergency food aid and supporting dietary supplementation and food security; clean/safe water and sanitation; mitigation of environmental hazards; and
• Research and development: investigating and developing new technologies, interventions, and strategies, including vaccines, medicines, and diagnostics.

While the U.S. government’s involvement in global health currently faces an uncertain future – with a more limited scope, the dissolution of USAID, and cancelation of numerous U.S.-supported global health projects, as the Trump administration seeks to reorganize foreign aid more broadly –  the U.S. has historically supported global health through a wide array of bilateral and multilateral global health programs in countries around the world including:

HIV/PEPFAR

While the U.S. first provided funding to address the emerging global HIV epidemic in 1986, U.S. funding and attention for these efforts has grown significantly in the last two decades, particularly following President George W. Bush’s 2003 announcement of the President’s Emergency Plan for AIDS Relief (PEPFAR), the coordinated U.S. government response to global HIV. Now the largest commitment by any nation devoted to a single disease, the launch of PEPFAR led to substantially increased U.S. support for HIV prevention, treatment, and care efforts, as well as U.S. contributions to multilateral entities, including the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), the Joint United Nations Programme on HIV/AIDS (UNAIDS), and the International AIDS Vaccine Initiative (IAVI).  PEPFAR, which is housed in the Department of State, has been credited with saving 26 million lives and contributing to broader health, educational, and economic gains.  Currently, PEPFAR faces significant change. While U.S. policymakers had been increasingly looking at when and how to transition PEPFAR services and financing to country governments, the current Trump administration has sought to narrow PEPFAR’s scope and significantly accelerate this timeline. See the “Status of PEPFAR” fact sheet for more information.

Tuberculosis (TB)

Since the 1998 launch of USAID’s global TB control program, the U.S. response to global TB has expanded, particularly after 2003 when PEPFAR highlighted the U.S. government’s commitment to addressing TB. Prior to the current Trump administration, these efforts focused on diagnosis, treatment, and control of TB (including multi-drug-resistant and extensively drug-resistant TB, or MDR/XDR TB) as well as on research. The U.S. was also a donor to the Global Drug Facility of the Stop TB Partnership.  With the dissolution of USAID, remaining TB programming has been moved to the State Department and its scope has been reduced. See the “Status of U.S. Global Tuberculosis Efforts” fact sheet for more information.

Malaria/PMI

Engaged in malaria work since the 1950s, the U.S. supported expanded malaria efforts in low- and middle-income countries through the President’s Malaria Initiative (PMI), launched in 2005 and housed at and managed by USAID, as well as through research and other activities. PMI programs centered on expanding coverage of six key high-impact interventions to control or eliminate malaria, which included: diagnosis of malaria and treatment with artemisinin-based combination therapies (ACTs), entomological monitoring, intermittent preventive treatment in pregnancy (IPTp), indoor residual spraying (IRS) with insecticides, insecticide-treated mosquito nets (ITNs), and seasonal malaria chemoprevention (SMC). The U.S. has also supported the RBM Partnership to End Malaria.  Under the current administration, remaining PMI programming has been moved into the State Department. See the “Status of the President’s Malaria Initiative (PMI)” fact sheet for more information.

Maternal and Child Health (MCH)

Involved in efforts to improve MCH since the 1960s,  U.S. global MCH activities, which had been housed at and managed by USAID, aimed to bring to scale a range of high-impact interventions that mitigate maternal, newborn, and under-five deaths; prevent and address the indirect causes of such deaths (such as HIV, TB, and malaria); strengthen integration of maternal health services with family planning; improve equity of access to and use of services by vulnerable populations; and strengthen health systems. The U.S. has also been a donor to global organizations and initiatives addressing MCH, such as Gavi, the Vaccine Alliance, the United Nations Children’s Fund (UNICEF), and the Global Polio Eradication Initiative (GPEI).Under the current administration, remaining MCH programming has been moved into the State Department. See the “Status of U.S. Global Maternal and Child Health Efforts” fact sheet for more information.

Nutrition

For more than 40 years, the U.S. had been involved in nutrition efforts in low- and middle-income countries that aimed to prevent undernutrition through support for effective interventions, such as nutrition education, nutrition during pregnancy, exclusive breastfeeding, and micronutrient supplementation. Housed at and managed by USAID, U.S. global nutrition efforts were coordinated with the U.S. Feed the Future Initiative (FtF, launched in 2009), which aimed to address global hunger and food security. Currently, remaining nutrition programming has been moved to the State Department. See the “Status of U.S. Global Maternal and Child Health Efforts” fact sheet for more information.

Family Planning and Reproductive Health (FP/RH)

Engaged since the 1960s in international research on family planning and population issues as well as other FP/RH efforts (including the purchase and distribution of contraceptives in developing countries),  U.S. global FP/RH activities were designed to decrease the risk of unintended pregnancies and maternal and child mortality through effective interventions, including contraception, counseling, and post-abortion care. The U.S. also provided funding to global organizations addressing FP/RH, such as the United Nations Population Fund (UNFPA), though in some years, funding for UNFPA was withheld. The current administration has moved to end U.S. bilateral and multilateral support for family planning efforts. See the “Status of U.S. Family Planning and Reproductive Health Efforts” fact sheet for more information

Neglected Tropical Diseases (NTDs)

Having historically worked on addressing NTDs through research and surveillance, attention to and funding for U.S. global NTD efforts increased markedly in 2006 with the launch of the USAID NTD Program and the subsequent announcement of expanded efforts across the U.S. government in 2008. These efforts had focused on five NTDs (soil-transmitted helminths,  lymphatic filariasis or elephantiasis, onchocerciasis or river blindness, schistosomiasis or snail fever, and trachoma) that are responsible for the overwhelming majority of the NTD burden but can be controlled and even eliminated with low-cost and effective interventions, such as an integrated control approach targeting multiple NTDs simultaneously through mass drug administration (MDA). The future of NTD efforts is uncertain amid the current Trump administration’s foreign aid freeze and dissolution of USAID.

Global Health Security (GHS)

While the U.S. has supported global health security work for more than two decades, its involvement has expanded over time, with attention to these efforts growing significantly due to the COVID-19 pandemic. These efforts aimed to reduce the threat of emerging and re-emerging diseases by supporting preparedness, detection, and response capabilities worldwide. The U.S. had also played a key role in the development and 2014 launch of the “Global Health Security Agenda (GHSA).” Through this international partnership that now involves more than 70 countries and international organizations, the U.S. worked to help countries make measurable improvements in their GHS capabilities. The U.S. had also been a donor to the new Pandemic Fund, which seeks to provide sustained financing to help countries build their capacity to prevent, prepare for, and respond to epidemics and pandemics.  While the first U.S. global health security strategy had been developed by the first Trump administration, the current Trump administration has withdrawn this strategy, eliminated several global health security positions and some offices, and withdrawn from U.S. engagement in key international efforts. See the “Status of Global Health Security/Pandemic Preparedness” fact sheet for more information.

In FY 2025, U.S. funding appropriated by Congress for global health totaled $12.4 billion. While this funding has been appropriated to federal agencies, the current administration has withheld much of it from programming and sought to formally rescind (cancel) more than $1 billion in funding for global health, including some PEPFAR funding (Congress voted to amend the rescission package, reducing that amount to $500 million, and exempting PEPFAR and some other global health programs from cuts).  As such, funding amounts presented here for the current fiscal year may not reflect actual obligations or outlays of U.S. support. There is ongoing litigation federal court regarding these actions.

As Figure 2shows, U.S. appropriations for global health have grown significantly since the early 2000s, in large part due to funding for initiatives such as PEPFAR and PMI, but with spikes in some years due to emergency or supplemental funding for disease outbreaks such as Ebola, Zika, and COVID-19. Funding reached its highest level to date in FY 2021, largely due to the U.S. global response to the COVID-19 pandemic.

Although a large majority of the American public overestimates the share of the federal budget that is spent on foreign aid (with nearly half believing that the share is greater than 20%), U.S. foreign aid actually accounts for 1% or less of the federal budget, with U.S. funding for global health—which is part of the foreign affairs budget—accounting for an even smaller share.

U.S. Global Health Funding by Program Area

Looking across funding for the major global health program areas since FY 2006, most U.S. global health funding over time has been directed to HIV programs, accounting for approximately 50% of U.S. global health funding in most years (Figure 3). The Global Fund accounted for the next largest share over the period, followed by MCH and malaria. More recently, the U.S. has emphasized global health security more, with funding for these efforts increasing considerably during the COVID-19 pandemic and afterward. Consistent with this trend, most funding was provided to HIV efforts ($5.4 billion or 44%), followed by the Global Fund ($1.7 billion or 13%) and maternal and child health and global health security (both $1.3 billion or 10%) in FY 2025 (Figure 4).

Bilateral vs. Multilateral Aid

Most U.S. global health funding is provided bilaterally – that is, funding provided by the U.S. directly to or on behalf of a recipient country or region. In FY 2025, about 80% of the U.S. global health budget was provided through bilateral programs. The remainder (about 20%) is provided multilaterally through U.S. contributions to international institutions and organizations (see “What Multilateral Health Organizations Are Supported by the U.S.?”).

Historically, the U.S. government’s engagement in global health has been carried out and overseen by multiple executive branch departments and agencies and the legislative branch, including several congressional committees (Figure 5). The current administration has made significant changes to this infrastructure. See the “Proposed Reorganization of U.S. Global Health Programs” fact sheet for more information.

Executive Branch

In general, U.S. global health engagement has developed within two main structures of the Executive Branch of government: the foreign assistance structure, which is predominantly global development-oriented and has close links to foreign policy; and the public health structure, which has its roots in disease prevention, control, and surveillance efforts.

Most funding for and oversight of U.S. global health resides within the foreign assistance structure, including:

• Department of State (State): Established in 1789, the Department of State is the Cabinet-level foreign affairs agency of the United States. It advances U.S. objectives and interests worldwide through its primary role in developing and implementing the President’s foreign policy. Prior to the current Trump administration, it also provided policy direction to USAID, the lead federal agency for development assistance. The Trump administration has dissolved USAID and moved remaining global health activities into the Department of State. The Department of State’s Bureau for Global Health Security and Diplomacy (GHSD) coordinates the Department’s work on global health security, including HIV, and houses PEPFAR.
• U.S. Agency for International Development (USAID): Established in 1961, USAID was an independent U.S. federal government agency that received overall foreign policy guidance from the Secretary of State. Its role was to support long-term and broad-based economic growth in countries and advance U.S. foreign policy objectives by supporting activities through each of its programmatic functional bureaus (e.g., Bureau for Global Health) and regional bureaus. Most USAID global health programs had been coordinated through the Bureau for Global Health, including HIV and other infectious diseases, MCH, nutrition, FP/RH, NTDs, and global health security. USAID has now been dissolved by the current administration.  
• Millennium Challenge Corporation (MCC): Established in 2004, MCC administers the Millennium Challenge Account (MCA), a U.S. government initiative providing development assistance to eligible countries to promote economic growth and reduce poverty in low- and middle-income countries. Although MCC supports several health-related programs, health is not the main focus or purpose of its work; its design is intended to link MCC contributions for development assistance (to reduce poverty through support for economic growth) to greater responsibility by low- and middle-income countries for successfully attaining certain governance and development benchmarks. The current Trump administration had sought to close down the agency but ultimately did not do so.

Agencies within the public health structure operate global health programs directly or in conjunction with foreign assistance agencies. They are represented most prominently by several agencies within the Department of Health and Human Services (HHS), including:

• Office of Global Affairs (OGA): OGA’s primary function is global health diplomacy – particularly coordinating and maintaining engagement across HHS and the U.S. government with foreign governments and ministries of health, multilateral organizations, civil society groups, and the private sector – exchanging best practices and sharing technical knowledge to advance U.S. global health priorities and research.
• Centers for Disease Control and Prevention (CDC): With a long history of working on international health issues, prior to the current Trump administration, CDC focused on disease control and prevention and health promotion through operations, development assistance, basic and field research, technical assistance, training/exchanges, and capacity building. The current administration has eliminated many of the staff working on these issues and sought to eliminate the CDC’s global health center.
• National Institutes of Health (NIH): One of the world’s leading research entities on global health, NIH conducts biomedical and behavioral science research on diseases and disorders to enhance diagnosis, prevention, and treatment and provides technical assistance and training. Prior to the current Trump administration, all 27 of the agency’s institutes and centers engaged in global health activities, but these activities are already being curtailed or eliminated.
• Food & Drug Administration (FDA): The FDA screens pharmaceutical and biological products for safety and efficacy and helps oversee the safety of the U.S. food supply.
• Health Resources and Services Administration (HRSA): HRSA builds human and organizational capacity and promotes health systems strengthening to deliver care in PEPFAR countries.

In addition to the foreign assistance and public health service agencies, other departments and agencies involved in global health have included the Department of Defense (DoD), the Department of Agriculture (USDA), the Peace Corps, the Environmental Protection Agency (EPA), the Department of Homeland Security (DHS), the Department of Labor (DoL), the Department of Commerce (Commerce), the Office of the U.S. Trade Representative (USTR), and the National Security Council (NSC). The NSC, which sits within the White House, plays a significant role across the U.S. government, as it is responsible for coordinating and reviewing the U.S. strategy and activities related to global health security, including its international response. However, the administration has eliminated many of the staff working on these issues, and is no longer operating the White House Office of Pandemic Preparedness and Response (OPPR), which had been responsible for domestic policy coordination related to health security.

Legislative Branch

The U.S. Congress introduces, considers, and passes global health-related legislation; oversees global health efforts, specifying how funds for these programs are to be (and not to be) spent; authorizes and appropriates funding; and confirms presidential appointees to key U.S. global health positions. Major committees of the House of Representatives (House) and Senate with jurisdiction over global health efforts include: the House Committee on Foreign Affairs, Senate Committee on Foreign Relations, House Committee on Energy and Commerce, Senate Committee on Health, Education, Labor, and Pensions, and the Senate and House Appropriations Committees.

The U.S. global health response has been defined by numerous governing statutes, authorities, and policy decisions. For instance, the legislation that created PEPFAR in 2003 and its subsequent reauthorizations in 2008, 2013, 2018, and 2024 are key statutes of U.S. global health policy, as they govern its bilateral HIV response, bilateral assistance for TB and malaria, and participation in the Global Fund. Other statutory requirements that shape the implementation and scope of U.S. global health activities are those governing U.S. global FP/RH efforts, such as those directing how U.S. funds may not be spent. For instance, the Helms Amendment (1973) prohibits the use of foreign assistance to pay for the performance of abortion as a method of family planning or to motivate or coerce any person to practice abortion. The Kemp-Kasten Amendment (1985) prohibits funding any organization or program, as determined by the President, that supports or participates in the management of a program of coercive abortion or involuntary sterilization (it has been invoked at times to restrict funding to UNFPA).

While Congress has authority over many aspects of global health, the current administration has taken several actions without its direct consent (such as eliminating USAID and withholding Congressionally-directed appropriations), and has questioned the extent of Congressional authority in these areas. It is unclear if Congress will act on these issues and some of these questions are being litigated in federal court.

Prior to the current Trump administration, the U.S. provided bilateral support for U.S. global health programs in almost 80 countries, with additional countries reached through U.S. regional global health programs and U.S. contributions to multilateral organizations. Multiple factors determined where the U.S. channeled its global health support. While more U.S. support was generally directed to countries facing a higher burden of disease, it was also influenced by factors such as the presence of willing and able partner governments, a history of positive relations and goodwill with host countries, strategic and national security priorities, and funding and personnel availability. The majority of countries receiving U.S. bilateral support for global health (“partner countries”) were located in sub-Saharan Africa (35 countries), followed by the Western Hemisphere (14 countries), East Asia and Oceania (11 countries), South and Central Asia (9 countries), Europe and Eurasia (4 countries), and Middle East and North Africa (4 countries) (Figure 5). Most U.S. bilateral support for global health programs was provided in sub-Saharan Africa (84%) (Figure 6). Furthermore, the top 10 country recipients of U.S. global health funding, representing 59% of U.S. bilateral support for global health, were all in this region (Figure 7).

The U.S. typically operated more than one health program (HIV, TB, malaria, etc.) in each partner country. While in most countries, the U.S. operated programs in four or fewer global health areas, this number was generally higher in countries in sub-Saharan Africa (five or more).

In addition to its bilateral programs, the U.S. has a long history of engagement with multilateral health organizations and international institutions, beginning with its role in the development of the first such organizations, including the Pan-American Health Organization (PAHO) in the early 1900s and the World Health Organization (WHO) a few decades later. This involvement continued with, for example, the Global Fund (which the U.S. helped to launch in 2001), Gavi (launched in 2000), the GHSA (which the U.S. played a key role in developing and launching in 2014), and the Pandemic Fund (launched in 2022). Prior to the current Trump administration – which is carrying out a review of its engagement in international organization to determine the future of U.S. multilateral participation and support – U.S. support for multilateral global health efforts has taken various forms, including:

• Funding. The U.S. has often been the largest or one of the largest donors to multilateral health efforts, funding core (generally used to support essential functions and operations) and voluntary (used for specific projects or initiatives the U.S. seeks to support) contributions. About a fifth (19%) of U.S. global health funding supported U.S. contributions to multilateral health organizations (Figure 8). However, some global health support to multilateral organizations has already been reduced or eliminated by the current Trump administration, such as funding and engagement in the World Health Organization, UNFPA, and the Pandemic Fund.
• Governance. The U.S. has been active in the governance structures that oversee multilateral global health organizations and initiatives, including holding permanent or rotating seats on many of their boards.
• Technical assistance. The U.S. has offered technical assistance in support of grants to partner countries, providing additional staff capacity to international organizations (by detailing U.S. government employees to these organizations for periods of time).
• Standard setting. The U.S. has engaged in standard-setting, weighing in on global plans, treaties, and agreements to respond to a range of health issues as they are developed and considered for approval by the larger body.

The U.S. has engaged with a number of multilateral global health organizations, including health-focused specialty agencies of the United Nations (U.N.) and international financing mechanisms for global health. Key among these are eight to which Congress specifically directs funding (though the U.S. also reaches other multilateral health institutions without direct Congressional appropriations but rather through general support), of which the U.S. has been the top contributor to five (the Global Fund, PAHO, UNAIDS, UNICEF, and WHO):

U.N. Agencies

• World Health Organization (WHO): WHO, created in 1948, is the directing and coordinating authority for health within the U.N. system. WHO provides international leadership on global health matters, shaping the health research agenda, setting norms and standards, providing technical support to countries, and monitoring and assessing health trends. The U.S. has been involved in WHO since its creation, providing financial and technical support as well as participating in its governance structure. However, President Trump announced on the first day of his second term that the U.S. would withdraw as a member of WHO and halt funding to the organization.
• Pan American Health Organization (PAHO): PAHO is the oldest international health agency, founded originally as the International Sanitary Bureau in 1902. The U.S. joined PAHO as a member state in 1925. PAHO, the specialized international health agency for the Americas, “works with countries throughout the region to improve and protect people’s health” and serves as the WHO Regional Office for the Americas and as the health organization of the inter-American System.
• Joint United Nations Programme on HIV/AIDS (UNAIDS): UNAIDS, created in 1996 as the successor organization to the WHO Global Programme on AIDS (GPA), is the leading global organization for addressing HIV/AIDS. Coordinating efforts across the U.N. system, it is made up of 11 U.N. co-sponsors and guided by a Programme Coordinating Board (PCB), which is a subset of its co-sponsors and government representatives. The U.S. currently serves on the PCB.
• United Nations Children’s Fund (UNICEF): UNICEF, created in 1946, aims to improve the lives of children, particularly the most disadvantaged children and adolescents, and is one of the largest purchasers of vaccines worldwide. The U.S. was a founding member that same year.
• United Nations Population Fund (UNFPA): UNFPA, created in 1969, is the largest purchaser and distributor of contraceptives worldwide. While the U.S. helped to found UNFPA and was a leading supporter for many years, its support has fluctuated significantly and sometimes been withheld entirely over the years, due to ongoing U.S. political debates about abortion. The Trump administration has announced that it is withholding funding from UNFPA.

Non-U.N. Financing Mechanisms

• Gavi, the Vaccine Alliance (Gavi): Gavi, created in 2000, is a public-private partnership that aims to increase access to immunization in poor countries. The U.S. has been involved in Gavi since its creation through contributions, participation in Gavi’s governance, and technical assistance. The U.S. is the second largest donor to Gavi’s core programs and the top donor to Gavi’s COVAX Advance Market Commitment (COVAX AMC), a financial mechanism within COVAX that supports low- and middle-income countries through procurement and distribution of COVID-19 vaccines.
• Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund): The Global Fund, created in 2001, is an independent multilateral financing entity that supports HIV, TB, and malaria programs in low- and middle-income countries. The U.S. was involved in creating the Global Fund and maintains a permanent seat on its Board. U.S. contributions and those of other donors are pooled and then provided by the Global Fund to country-driven projects based on technical merit and need.
• TB Global Drug Facility: The Global Drug Facility, created in 2001, is a financing mechanism of the Stop TB Partnership; it provides grants to countries for TB drugs.

U.S. support for multilateral institutions overall has fluctuated over time, reflecting, in part, changing U.S. leadership views on the relative value of bilateralism versus multilateralism. As a result, U.S. engagement in and contributions to specific multilateral health organizations and institutions may change over time. For example, the U.S. under the first Trump administration did not participate in the partnership to create  COVAX (an international partnership led by the Coalition for Epidemic Preparedness Innovations [CEPI], Gavi, and WHO) to facilitate greater global access to the COVID-19 vaccine, although Congress did provide $4 billion in emergency funding to Gavi in support of COVID-19 vaccine access. Under the Biden administration, the U.S. joined the COVAX partnership.

Multilateral initiatives complement U.S. bilateral global health efforts, helping make progress toward U.S. goals in various program areas. In some cases, U.S. multilateral global health support allows the U.S. to reach a larger number of countries; it also may help to leverage additional funding and provide opportunities for improved coordination and technical consultations. Additionally, U.S. policies related to funding can greatly influence other financial support for multilaterals. For instance, since U.S. law has required that the U.S. contribution to the Global Fund cannot exceed 33% of total contributions from all donors, the U.S. contribution has leveraged other donor contributions; in effect, this requirement encouraged increased support from other donors and prevented the U.S. from becoming the predominant donor to the Global Fund.

The U.S. has been the largest donor to global health, providing over 40% of all international health assistance among major donor governments (Figure 9).

In addition, the U.S. has historically devoted more of its foreign assistance to health than any other donor government, contributing over a quarter of its foreign assistance to global health in 2023 (Figure 10). The U.S. has also been the largest government donor to several specific global health areas, including HIV and family planning. Currently, however, the Trump administration is withholding global health funds in several areas and actual spending levels are still unknown.

While the U.S. has been engaged in international health activities for over a century and has historically been the largest funder and implementer of global health programs worldwide, it is currently undergoing a fundamental shift, with a significantly reduced footprint and role.  Given the prominence of the U.S. in global health, these actions have and will influence the larger global health ecosystem and the health of those in low and middle income countries. Among the key issues to watch are:

• The future direction of U.S. leadership in and degree of commitment to global health as the Trump administration reorganizes foreign assistance more broadly and seeks to permanently alter the U.S. role.
• The status of U.S. funding for global health, particularly given the interplay between Congress and the administration on whether and how that funding gets spent and ongoing litigation in this area.
• The ability of global health implementers to continue to deliver services to those who need them, given their loss of funding and future uncertainty.
• The future role of multilateral institutions in global health, as the U.S. bilateral role is reduced, but also its support for multilateral health efforts remains unclear.
• Whether other donors (governments, foundations, the private sector) will help to fill some of the gaps left by the U.S.
• Whether the nations that have been recipients of U.S. global health support will increase their own financing and delivery of health services to their populations.

• Overview of President Trump’s Executive Actions on Global Health
• KFF Resources on the Trump Administration’s Foreign Aid Review and Global Health Aid Cuts
• KFF Global Health Fact Sheets including The U.S. Government and Global Health and Breaking Down the U.S. Global Health Budget by Program Area
• U.S. Global Health Budget Tracker
• KFF Global Health Budget Summaries
• The Outlook for PEPFAR in 2025 and Beyond
• PEPFAR Policy Resource Hub
• KFF Dashboard: Progress Toward Global HIV Targets in PEPFAR Countries
• KFF Dashboard: Progress Toward Global Malaria Targets in PMI Countries
• The U.S. Congress and Global Health: A Primer
• U.S. Global Health Legislation Tracker
• Key Global Health Positions and Officials in the U.S. Government

Oum, S., Moss, K., & Kates, J., The U.S. Government and Global Health. In Altman, Drew (Editor), Health Policy 101, (KFF, October 2025) https://www.kff.org/health-policy-101-the-u-s-government-and-global-health/ (date accessed).