For coverage of Medicare benefits, people face a choice between traditional Medicare and private Medicare Advantage plans. While there are many distinguishing features between these coverage types, one key benefit of Medicare Advantage is an annual cap on out-of-pocket costs for medical benefits, which traditional Medicare does not include. In 2026, the out-of-pocket limit for Medicare Advantage plans may not exceed $9,250 for in-network services and $13,900 for a combination of in-network and out-of-network services, but plans can have lower out-of-pocket limits than the maximum.

Policymakers have long considered whether to add a similar out-of-pocket cap in traditional Medicare. In 1988, Congress enacted a Medicare out-of-pocket cap, but the law was repealed one year later principally due to concerns about the financing mechanism. The Medicare Payment Advisory Commission (MedPAC) has recommended changes in traditional Medicare to give beneficiaries better protection against high out-of-pocket spending, including an out-of-pocket cap as part of a broader redesign that also includes combining Part A and Part B deductibles and simplifying cost sharing. Traditional Medicare remains the only major form of health insurance that does not include a cap on out-of-pocket spending, though most beneficiaries in traditional Medicare have additional financial protection through supplemental coverage, including Medicaid, employer- or union-sponsored retiree coverage, or a Medigap policy (which may require additional premiums).

This brief analyzes out-of-pocket limits in Medicare Advantage plans in 2026, variation by plan type, the distribution of enrollees facing different out-of-pocket limits, and trends over time. Of note, this analysis does not show the share of enrollees that reach their plan’s out-of-pocket limit in any year because spending data are not available. The analysis includes Medicare Advantage plans generally available for individual enrollment, reflecting coverage for 21.3 million Medicare beneficiaries in 2026, excluding special needs plans and employer-and union-sponsored group plans (See Methods for details).

Takeaways

• In 2026, the average enrollment-weighted out-of-pocket limit for Medicare Advantage enrollees is $5,421 for in-network services and $9,825 for in-network and out-of-network services combined. The average out-of-pocket limit for in-network services is higher for preferred provider organizations (PPOs) ($6,592) than health maintenance organizations (HMOs) ($4,636).
• Just over one in ten Medicare Advantage enrollees (13% or 2.8 million people) are in plans with limits of $3,000 or less for in-network services in 2026, more than two-thirds (68%) are in plans with limits above $3,000 and up to $7,000, and about one in five (19%) are in plans with limits above $7,000.
• About one in 10 (9%; 1.8 million) Medicare Advantage enrollees are in plans with the maximum out-of-pocket limit for in-network services ($9,250). Among the 8.6 million enrollees in PPOs, roughly one in five (22%; 1.8 million) are in plans with the maximum out-of-pocket limit for in-and out-of-network services combined ($13,900).

• The average out-of-pocket limit for in-network services decreased by nearly $600 from 2017 to 2023 ($5,253 to $4,685), before increasing by about $700 from 2023 to 2026 ($4,685 to $5,421).

In 2026, the Average Enrollment-Weighted Out-of-Pocket Limit for Medicare Advantage Enrollees Is Lower for HMOs Than PPOs

The average out-of-pocket limit faced by Medicare Advantage enrollees in 2026 is $5,421 for in-network services and $9,825 for in-network and out-of-network services combined (Figure 1). These averages are lower than the maximum allowable out-of-pocket limits ($9,250 and $13,900, respectively).

Differences in out-of-pocket limits may reflect how Medicare Advantage plans choose to allocate rebate dollars, which are extra payments they receive from the federal government beyond the cost of providing Part A and Part B services. Plans may use rebates to reduce beneficiary cost sharing, including lowering out-of-pocket limits, but they can also use these funds for other purposes, such as offering supplemental benefits not covered by traditional Medicare, offering a rebate against the Part B premium, or lowering Part D premiums.

Out-of-pocket limits for in-network services vary by plan type. HMOs, which have 12.8 million Medicare Advantage enrollees in 2026, generally offer no coverage of services from out-of-network providers, but offer a lower out-of-pocket limit for in-network services than PPOs. PPOs, which have 8.6 million enrollees in 2026, cover services delivered by in-network and out-of-network providers, but require higher cost sharing for out-of-network providers. While PPO enrollees have broader access to out-of-network providers than HMO enrollees, they also face a higher out-of-pocket limit, even for in-network services. Specifically, the average enrollment-weighted out-of-pocket limit for in-network services is $6,592 for PPOs and $4,636 for HMOs.

The distribution of enrollment between HMOs and PPOs, as well as the average out-of-pocket caps for in-network services by type of plan, vary across states (Appendix Table 1). Due in part to PPOs (which have higher average in-network out-of-pocket limits than HMOs) comprising a larger share of enrollment in rural areas, the average out-of-pocket cap is about $800 higher for Medicare Advantage enrollees in rural areas than in urban areas ($6,078 vs $5,291).

In 2026, Roughly One in Ten Medicare Advantage Enrollees Are in Plans With Limits of $3,000 or Less for In-Network Services and About One in Five Are in Plans With Limits Above $7,000

Among all Medicare Advantage enrollees in individual plans, just over one in ten (13%, 2.8 million) are in plans with out-of-pocket limits of $3,000 or less for in-network services (Figure 2). Nearly all of these enrollees (99%) are in an HMO. More than two-thirds (68%, 14.4 million) of Medicare Advantage enrollees are in plans with out-of-pocket limits above $3,000 and up to $7,000. About one in five (19%, 4.1 million) are in plans with limits above $7,000, including 1.8 million enrollees who are in a plan with the maximum in-network out-of-pocket limit of $9,250. PPOs enrollees account for the majority of these enrollees at the maximum cap (66%).

Among the 8.6 million Medicare Advantage enrollees in PPOs, about one in ten (9%) have a combined limit for in-network and out-of-network services at or below $6,000. More than two-thirds (66%; 5.7 million) of enrollees are in plans with a combined limit for in-network and out-of-network services between $6,000 and $12,000. One quarter (25%; 2.1 million) are in plans with an out-of-pocket limit for in-and out-of-network services combined above $12,000, including 1.8 million enrollees in plans with the maximum out-of-pocket limit for in-and out-of-network services combined ($13,900) (Figure 2).

Average Out-of-Pocket Limits for In-Network Services Generally Declined Between 2017 and 2023 but Have Increased Since Then

The average limit for in-network services decreased by nearly $600 from 2017 ($5,253) to 2023 ($4,685), before increasing by about $700 from 2023 to 2026 ($5,421) (Figure 3, Appendix Table 2). The average limit for in-network and out-of-network services combined has fluctuated over time but increased overall by about $750 between 2017 ($9,073) and 2026 ($9,825).

The maximum allowable out-of-pocket cap has generally increased over time, consistent with projected beneficiary out-of-pocket spending in traditional Medicare, which CMS uses to calculate maximum out-of-pocket limits in Medicare Advantage. However, the maximum cap decreased by $100 between 2025 and 2026. The average out-of-pocket limit faced by enrollees each year has always been lower than the maximum allowable limit. This gap has generally widened over time, but shrank somewhat between 2025 and 2026.

Appendix Tables

Health care costs and affordability recently topped the public’s list of economic anxieties in the U.S., according to KFF polling. Even people with insurance say they struggle to afford health care costs, including people with Medicare. While Medicare provides health insurance coverage to 70 million people age 65 or older and younger adults with long-term disabilities, having Medicare coverage does not insulate beneficiaries from health-related affordability challenges, such as not getting needed medical care due to costs or incurring medical debt. In a 2026 KFF Health Tracking Poll, half (49%) of all Medicare beneficiaries ages 65 and older say they expect their health care costs to become less affordable in the next year.

This brief presents key facts and analysis about affordability of health care costs among people with Medicare, including younger adults with long-term disabilities, drawing on data from various sources (see methods for additional information).

Many Medicare Beneficiaries Have Low Incomes and Modest Savings, Which Can Make It Hard To Afford Medical and Long-Term Care Services

• One in four Medicare beneficiaries (16.5 million people) had income below $24,600 per person in 2024, or about 160% of the federal poverty level that year (Figure 1). These estimates take into account income from Social Security, pensions, retirement account (IRA) withdrawals, and other sources. At the upper end of the income spectrum, the top 5% of Medicare beneficiaries (3.3 million people) had incomes above $169,700 per person. Many beneficiaries also have relatively low levels of savings, with one in four Medicare beneficiaries having savings below $18,950 per person in 2024. Financial resources are even lower among some subgroups of beneficiaries, including Black and Hispanic beneficiaries. For example, one in four Black beneficiaries had income below $20,150 per person in 2024, while one in four Hispanic beneficiaries had income below $14,150 per person.

• About 6 million people ages 65 and older (10%) were living in poverty in 2024 under the official poverty measure, meaning they had income of $15,050 or less that year (if single), while 17.3 million (28%) had incomes below 200% of poverty. Poverty rates among older adults are higher under an alternative measure (the supplemental poverty measure, or SPM) that accounts for certain expenses that are higher among older people, including out-of-pocket medical expenses, with 15% of older adults living in poverty in 2024 under the SPM.
• In 2025, nearly a quarter (23%) of all Medicare beneficiaries who received Social Security benefits relied on Social Security income for 90% or more of their total per capita income, while about one-third (32%) relied on Social Security for at least 75% of their income (Figure 2). In 2025, the average per capita Social Security income was $20,168 among those who depended on Social Security for at least 90% of their income and $20,670 among those who depended on Social Security for at least 75% of their income.

Medicare Premiums and Other Health Expenses Consume a Sizeable Portion of Income and Household Budgets for People With Medicare

• Out-of-pocket health care spending for Medicare premiums and out-of-pocket costs for health care services accounted for 36% of Medicare beneficiaries’ average Social Security income per person in 2023 (Figure 3). In 2023, Medicare beneficiaries spent an average of $6,459 out of pocket on health care costs and had average Social Security income of $17,718 (though most older adults have other sources of income beyond Social Security that can be used to pay their out-of-pocket health care costs). Out-of-pocket spending includes premiums for Medicare supplemental coverage (Medigap) for those who enroll in traditional Medicare and buy private supplemental insurance.

• Health care spending accounted for 14% of Medicare beneficiaries’ total household spending in 2024. Medicare households spent a larger share of their total household spending on health care than non-Medicare households in 2024 (6%) (Figure 4).

• More than 7 million Medicare beneficiaries enrolled in Medicare Part B in 2024 spent more than 10% of their annual per capita income on Part B premiums alone. The standard Part B premium is paid by beneficiaries in both traditional Medicare and Medicare Advantage and has roughly doubled in the last decade, from an annual amount of $1,259 in 2015 to $2,435 in 2026.

The Choice Between Traditional Medicare and Medicare Advantage Has Cost Implications for Beneficiaries

• Out-of-pocket spending for Medicare-covered hospital and physician services is not capped in traditional Medicare, while Medicare Advantage plans are required by law to provide an out-of-pocket limit for these services. In 2025, the average out-of-pocket limit for Medicare Advantage enrollees was $5,320 for in-network services and $9,547 for in-network and out-of-network services combined. The maximum allowed limits were $9,350 for in-network services and $14,000 for in-network and out-of-network services combined in 2025, and increased to $9,250 and $13,900, respectively, in 2026. (Figure 5). This cap protects Medicare Advantage enrollees from unlimited health care costs for Medicare-covered services, but cost-sharing requirements can lead to high out-of-pocket expenses before reaching a plan’s annual limit. People enrolled in Medicare Advantage plans typically pay no additional premium.

• Medicare Advantage plans can reduce cost sharing, offer benefits not covered under traditional Medicare (such as dental and vision services), and lower Part B and Part D premiums, using extra payments they receive from the federal government beyond the cost of providing Part A and Part B services. In 2026, these extra payments (known as rebates) amounted to about $2,660 per person on average in 2026. For Medicare-covered services under Part A and Part B, Medicare Advantage plans can charge different amounts than what someone in traditional Medicare would pay, though they often reduce cost sharing for Medicare-covered benefits, and they are prohibited from charging more for certain services, such as Skilled Nursing Facility (SNF) stays. Plans are required to provide coverage that is at least as generous overall as traditional Medicare, even though what enrollees pay out of pocket can vary depending on the type of plan, the type and quantity of services they use, and whether they see a provider that participates in the plan’s network.

• Medigap limits traditional Medicare beneficiaries’ exposure to out-of-pocket medical costs, and the most popular Medigap policies cover virtually all cost sharing for Medicare-covered services. However, Medigap underwriting rules make these policies difficult, if not impossible, for beneficiaries with pre-existing conditions to obtain outside of limited enrollment opportunities. For beneficiaries with modest incomes, the monthly Medigap premium ($217 per month, on average, in 2023) could be unaffordable (Figure 6).

• More than 3 million Medicare beneficiaries in traditional Medicare have no additional coverage that helps with Medicare cost-sharing requirements, such as Medigap, employer coverage, or Medicaid. This leaves them at risk of facing high out-of-pocket costs if they need a lot of medical services, or high-cost services, because there is no limit on out-of-pocket spending for Parts A and B in traditional Medicare.

Paying for Health Care, Including for Services Not Covered by Medicare, Can Be a Financial Burden

• Medicare beneficiaries can face high out-of-pocket costs for dental, hearing, and vision care services, which are not covered under traditional Medicare (Figure 7). In 2023, traditional Medicare beneficiaries spent $1,107 on dental services and $564 on hearing services, on average (Figure 7). While most Medicare Advantage plans cover dental, hearing, and vision benefits, Medicare Advantage enrollees also face out-of-pocket costs for these services, spending an average of $571 on dental services and $212 on hearing services.

• About one in five (22%) Medicare-age adults reported having some type of debt as a result of medical or dental bills in 2022 (Figure 8). Among older adults with medical debt, about 4 in 10 say they cut back on other household spending and used up or all or most of their savings as a result of their health care debt.

• Long-term services and supports, which are not covered by Medicare, are unaffordable for all but the highest-income Medicare beneficiaries. In 2025, the median annual costs of common long-term services and supports in the U.S were $80,080 for full-time non-medical caregiver services (including home health aide and homemaker services for people who need help with instrumental activities of daily living such as preparing meals and doing laundry), $129,575 for a private room in a nursing home, and $305,760 for round-the-clock home health aide services (Figure 9). These costs greatly surpass median income ($43,200) and savings ($110,100) among people with Medicare. Long-term care services are generally not covered by Medicare, regardless of whether a beneficiary is enrolled in traditional Medicare or Medicare Advantage.

Medicaid Helps Make Medicare Affordable for About 12 Million Low-Income Medicare Beneficiaries

• In 2025, about 12 million people with Medicare also had Medicaid coverage (“dual-eligible individuals”).
  • More than seven in ten (72%) dual-eligible individuals, or 8.5 million people, are eligible for the full range of Medicaid benefits not otherwise covered by Medicare, including long-term services and supports, vision and dental services, and non-emergency medical transportation (also known as wraparound services) (Figure 10).These “full-benefit” dual-eligible individuals also usually receive additional help through the Medicare Savings Programs (MSPs), which cover Medicare premiums, and in most cases, cost sharing for people with limited income and assets.
  • The remaining 3.4 million dual-eligible individuals (“partial-benefit” individuals) do not receive coverage of the full range of Medicaid benefits, but do receive payments to cover Medicare premiums, and, in most cases, cost sharing through the Medicare Savings Programs. Under federal guidelines, Medicare beneficiaries with income up to 135% of the federal poverty line and assets below specified levels ($9,950 for an individual and $14,910 for a couple in 2026) qualify for financial assistance from their state Medicaid program through a Medicare Savings Program. States can choose to cover Medicare beneficiaries with income or assets above the federal limits, and in 2026, 18 states do so. Without financial support from Medicaid, the Part B premium alone would consume 15% of income for a dual-eligible individual with monthly income of $1,350, not including other out-of-pocket costs.

Medicare Part D Offers Protection Against High Out-of-Pocket Prescription Drug Costs, but Prescription Drug Costs Remain a Concern for Older Adults

• Virtually all Medicare beneficiaries (96%) use prescription drugs and most are enrolled in Medicare Part D drug plans for prescription drug coverage. On average, Medicare Part D enrollees who did not receive low-income subsidies spent an average of $872 on prescription drugs in 2023, and people in fair or poor health spent roughly twice as much, on average ($1,671) (Figure 11). The Part D low-income subsidy (LIS) provides substantial financial support to income below 150% of poverty (under $23,940 for an individual in 2026) and limited assets (under $18,090 for an individual). Part D enrollees with LIS had average out of pocket drug costs of $156 in 2023, roughly one fifth the amount paid by those without these low-income subsidies.

• Under changes made by the Inflation Reduction Act, Part D enrollees have a cap on out-of-pocket drug spending equal to $2,100 in 2026. Prior to this change, enrollees could have faced several thousand dollars in out-of-pocket costs for expensive medications each year. The Inflation Reduction Act also includes other changes that make prescription drugs more affordable for people with Medicare, including a $35 monthly cap on insulin, expanded eligibility for full benefits under the Part D Low-Income Subsidy, and $0 cost sharing for adult vaccines under Medicare Part D. Additionally, the law requires the federal government to negotiate lower drug prices for some high-cost drugs covered under Medicare through the Medicare Drug Price Negotiation Program.
• Even with a cap on overall out-of-pocket costs, prescription drug costs are a concern for Medicare beneficiaries, with half (50%) of Medicare beneficiaries age 65 and older worried about being able to afford prescription drugs for themselves or their family in 2026, according to a March 2026 KFF health tracking poll.

The Growth in Medicare Spending Will Lead to Higher Medicare Premiums, Deductibles, and Copayments Over Time

• People with Medicare will face higher premiums and other out-of-pocket costs for Medicare benefits over time since Medicare premiums and deductibles are directly tied to increases in spending on Medicare-covered services. Higher Medicare spending is driven in part by rising prices, higher utilization, and growth in spending on Medicare Advantage. Between 2026 and 2034, the Medicare Part B premium and deductible are projected to increase by roughly 70%—from $2,435 to $4,170 for the Part B premium (annualized) and from $283 to $486 for the Part B deductible, while the Part A deductible is projected to grow by about 30% (from $1,736 to $2,212) (Figure 12).

• Rising Medicare premiums and cost sharing will consume a growing portion of Medicare beneficiaries’ financial resources. On average, premiums and cost sharing for Medicare Part B and Part D accounted for 25% of the average Social Security benefit in 2025, and this share is projected to increase to 33% in 2040. Including other premium and cost-sharing amounts would increase these shares even further, though as noted earlier most older adults can tap other sources of income beyond Social Security to pay for health care expenses.

The 2025 reconciliation law requires states to condition Medicaid eligibility for adults in the Affordable Care Act (ACA) Medicaid expansion group and enrollees in partial expansion waiver programs (Georgia and Wisconsin) on meeting work requirements starting January 1, 2027 or sooner at state option. The law specifies mandatory exemptions, including individuals who are “medically frail.” To ease the burden on individuals, the law directs states to use available information “where possible” to verify compliance with Medicaid work activities or exemption status, without requiring additional documentation from individuals. Given the abbreviated implementation timeline, states are moving forward with key decisions over how to implement the medical frailty exemption even as they wait for formal guidance from the Centers for Medicaid and Medicare Services (CMS), which is required to issue an interim final rule by June 1, 2026. This brief describes early state plans to operationalize the medical frailty exemption and identifies key issues that they are facing and may be answered in the forthcoming guidance.

What is the Medical Frailty Exemption?

The reconciliation law requires states to exempt from work requirements an individual who is “medically frail or otherwise has special medical needs.” The law specifies this includes individuals who are blind or disabled; have a physical, intellectual, or developmental disability that limits their ability to perform one or more activities of daily living (ADL); have a substance use disorder or a “disabling” mental disorder; and those with “serious or complex” medical conditions. This definition closely aligns with an existing federal medical frailty definition that CMS uses for states choosing to set “alternative benefit plans” that differ from the traditional Medicaid benefit package. In that context, CMS used the definition as a minimum standard for medical frailty but allows states flexibility to define medical frailty beyond the statutory and regulatory definitions. To identify individuals who are medically frail, CMS noted in the 2013 final rule that it expected states to use Medicaid claims data and encouraged them to use self-attestation and health screeners for applicants and new enrollees where the state does not have information on their current health status or historic encounter data.

How do States Plan to Operationalize the Medical Frailty Exemption?

Most states have not yet finalized a medical frailty definition, likely reflecting ongoing uncertainty over how much flexibility states will have as they await June CMS guidance. In a recent KFF survey (fielded January-March 2026), about half of states (22) subject to work requirements report having a current state medical frailty definition, though it is unclear whether these definitions align with the medical frailty provisions in the reconciliation law (Figure 1). Most of these definitions were not developed with work requirements in mind and may need to be updated to reflect the new federal requirements. Thirty-three states indicated they had not yet determined what definition they plan to use at the time the survey was fielded. If states are given flexibility by CMS to define who is medically frail and exempt from work requirements, six states would prefer to use a state definition (either an existing definition or a new definition,) while four states would use a federal definition.

States plan to use a variety of methods to verify medical frailty status, including using data to automate the process where possible. Most states reported plans to use Medicaid claims data (32) to verify medical frailty exemption status, while Georgia indicated it would not use claims data, and the remaining ten states had not yet made a decision at the time of the survey. New applicants and recent enrollees may not have claims data on file, requiring states to use other forms of verification.  All 32 states reporting plans to use claims data also reported plans to use other sources, such as data from other programs (e.g., enrollment in a behavioral health managed care plan or HCBS program), managed care utilization or claims data, and/or managed care case management data. Twenty-nine states said they will seek confirmation from a treating provider. Many states are developing health assessment screeners to collect information to identify medical exemptions, and 11 states said they will use the health screeners to verify medically frail status. Most states (30) also reported wanting to allow applicants and enrollees to self-attest to their medically frail status if verification data are not available and self-attestation is permitted by CMS. However, some states reported they do not plan to accept self-attestation (AR, HI, IN, MT) or have since passed legislation barring the use of self-attestation (NC and UT).

Nebraska, which became the first state to implement new work requirements on May 1, 2026, has released resources outlining how it will process medically frail exemptions, as well as an index of diagnosis and procedure codes. Examples of conditions covered in the thousands of codes include types of cancer, HIV, diabetes, heart disease, and certain types of mental health conditions and substance use disorders, among others. For existing enrollees, Nebraska is reviewing medical claims data prior to renewal and will auto-exempt an individual if indicated based on diagnosis/procedure codes. If Nebraska cannot determine medical frailty through claims data or other data sources, existing enrollees will need to submit a self-declaration form. Not all individuals will be able to be auto-exempted due to limitations of claims data such as:

• A lack of data on file for new applicants and recent enrollees;
• A lack of data on file due to providers not consistently coding or not using the codes identified by the state;
• Selected diagnoses and procedures potentially not being comprehensive of all individuals with target conditions or not capturing functional limitations;
• A lack of claims within the look-back period despite an individual having an exempted chronic condition or disability; and
• Delays between clinical care and claims presenting.

The state also intends to use the self-declaration form to identify medically frail exemption status for new applicants. The self-declaration form requires individuals to provide a description of their health condition, the contact information of their treating provider, and a note if services were provided while enrolled in Medicaid. No additional documentation is required at this time (e.g., a note from a provider or other proof of a condition). Nebraska indicates that it plans to move from self-declaration to more automated verification methods consistent with federal guidance over time, and plans to continue to review and update the index of ICD-10, CPT, and HCPCS codes as federal direction is clarified.

Early insights from other states highlight the variety of ways states are planning to use multiple sources of information to identify medical frailty. For example:

• California plans to automatically exempt individuals who are eligible for certain programs (e.g., home care—also known as home- and community-based services or HCBS) and has been exploring more timely data sources such as managed care plan care management systems in conjunction with evaluating which diagnostic codes could be used to establish medical frailty.
• Pennsylvania has outlined a plan to first check health care claims, followed by information from electronic health records exchanged through regional health information organizations, managed care organization (MCO) health assessments and case management information, and finally information provided by the applicant. Pennsylvania explains its approach is designed with data limitations in mind, and aims to reduce paperwork burden and streamline the process for beneficiaries.
• South Dakota has shared early plans to use clinical code lists and a medically frail health screener. Indicating lingering uncertainty on CMS’s stance regarding self-attestation, the state notes it may have to use physician attestation at renewal if screeners cannot be repeated and claims data is still not available.
• Several states also have reported that they would be interested in adding new categories such as homelessness to the medical frailty category but understand from communications with CMS that states may not have flexibility to do so.

How Will the CMS Guidance Address Key Issues and Potential Implications?

Although states are moving forward with operationalizing the medical frailty exemption, the interim final rule that CMS is required to release by June 1, 2026, is expected to address key issues related to defining and verifying medical frailty. Because of the time required to make system changes, states have been moving forward with implementing work requirements based on informal communication and guidance CMS has shared. Any significant changes to that informal guidance could require states to change course and could have implications for states’ readiness to implement work requirements as well as the costs associated with implementation. Key issues that may be addressed in the guidance, and that states report waiting on, include:

Defining Medical Frailty

• Defining medical frailty. CMS may provide a federal definition of medical frailty in the guidance. The law suggests the need for a Secretary-provided definition in its list of exemptions by including anyone “who is medically frail or otherwise has special medical needs (as defined by the Secretary).” It is not clear if CMS will rely on the existing definition or develop a new definition that more directly relates to work requirements. The statute includes people who are both medically frail and those with “serious or complex medical conditions,” which includes people with significant medical needs that may or may not limit their ability to engage in qualifying activities. For these individuals maintaining access to health coverage protects against serious health consequences if treatment is interrupted and may enable them to work.
• State flexibility to define medical frailty. Whatever federal definition CMS establishes, another important consideration is whether the definition serves as a minimum standard that states can use or expand on or whether CMS will require states to use the federal definition with little or no flexibility to interpret how it will be applied. For example, CMS may specify a set of diagnoses codes for states to use in their claims data analysis, but the effect of that list will depend greatly on whether states are allowed to add additional codes to CMS’ list. This may be particularly relevant in states that use state-specific diagnosis or treatment codes in their Medicaid billing systems. 
• Identifying people with functional limitations and mental health conditions. As noted, the law required people “with a physical, intellectual or developmental disability that significantly impairs their ability to perform 1 or more activities of daily living” be exempted. Guidance may provide additional insight into how states are expected to capture functional limitations in medical frailty definitions, as it may prove more difficult to identify these individuals using claims data. While there is a diagnostic code that could help to capture this, it is generally underutilized, with one barrier being a lack of financial incentive. More comprehensively identifying enrollees with these functional disabilities may require technical assistance for states and providers (i.e. in terms of utilizing different codes). Guidance may also provide clarity on identifying individuals with mental health conditions who may also be difficult to identify using claims data, as well as provide clarity on the exact diagnoses that would qualify.

Verifying Medical Frailty

• Data sources for verifying medical frailty. States will likely be expected to use claims data to automate identification of medically frail individuals. The guidance may provide information on other data sources states can use or would be expected to use, such as electronic health records, MCO health assessments and case management information, and pharmacy data. States may also be required to use SNAP data and other program data, such as HCBS enrollment or enrollment in a behavioral health managed care program, to identify medically frail individuals. Accessing some of these data sources may raise privacy concerns that the guidance may or may not address.
• Data look-back. The guidance may also specify the length of time states are permitted to look back to identify individuals with qualifying conditions when using data or verification from providers, including whether there are different look-back periods permitted at application versus renewal. The length of the look-back period will affect how many individuals are captured under the medically frail exemption (longer look-back periods are likely to pick up more people who may qualify as medically frail).
• Exemption re-verification. The legislation does not currently clarify how frequently medical frailty exemptions may last before states are expected to re-verify individuals’ exemption status. States may need to reverify exemption status at every renewal, or states may be able to create an internal flag and/or permanently exempt some people if their health condition or disability status is unlikely to change.
• Self-attestation. It is unclear if states will be permitted to accept self-attestation or if they will be prohibited from using it (altogether or in certain circumstances). Some state officials have noted the limitations of existing data sources, particularly claims data, for identifying new applicants who are medically frail as well as enrollees at their first renewal. Self-attestation could be subject to CMS audits, and guidance may outline under what circumstances states are expected to use self-attestation (e.g., only initial application, at renewal). If self-attestation is permitted, questions remain whether attestation alone will suffice or whether enrollees will be required to also provide supplemental information (e.g. provider sign-off, clinical or pharmacy records, etc.).
• Health screeners. States may look to use health screeners at application and renewal, especially in the absence of self-attestation. States may have flexibility to create their own health screeners, or there may be a federal template.
• Confirmation from providers. When using provider verification, the guidance may specify any requirements, including what information must be collected and whether providers will be required to assess whether an individual’s condition limits their ability to work. Relying on provider confirmation could increase administrative burden (on the clinical workforce, individuals, and states), particularly for providers that treat large shares of Medicaid patients, and, depending on the information requested, could raise ethical concerns among providers.
• Exemption hierarchy. When individuals qualify under multiple exemptions or when they would qualify for a medical frailty exemption but also are engaged in qualifying work activities, states will need to develop standards for how to operationalize which status is prioritized (e.g., checking exemption status and work status in a specified order, choosing to use whichever is longer lasting), especially if certain conditions will have longer exemption periods. The guidance may establish a hierarchy for states to follow or may give states the ability to set their own hierarchies.

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

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

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

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

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

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

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

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

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

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

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

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

Key Facts

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

Global Situation

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

U.S. Government Efforts

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

Organization

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

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

Key Activities and Results

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

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

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

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

Countries Reached

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

Funding¹⁸

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

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

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

Spending Directives²⁵

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

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

PEPFAR & The Global Fund

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

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

Endnotes

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