Key Points

• On May 8, 2025, the Trump administration invoked the “Kemp-Kasten amendment” in order to withhold FY 2025 funding for the United Nations Population Fund (UNFPA, the lead U.N. agency focused on global population and reproductive health); the same determination was made during President Trump’s first term. FY 2025 funding for UNFPA was expected to total $32.5 million in core support and potentially millions more for other project activities.
• While under current law any U.S. funding withheld from UNFPA is to be made available for other family planning, maternal health, and reproductive health activities, Congress rescinded (permanently canceled) FY 2025 funding appropriated for UNFPA as part of a broader foreign aid rescission package requested by the President. Although Congress again appropriated $32.5 million in core support for UNFPA for FY 2026, it is expected that President Trump will again withhold the funds from the organization.
• The Kemp-Kasten amendment is a provision of U.S. law, first enacted by Congress in 1985 and included in appropriations language annually, that states that no U.S. funds may be made available to “any organization or program which, as determined by the president of the United States, supports or participates in the management of a program of coercive abortion or involuntary sterilization.”
• Kemp-Kasten has often been used, as determined by presidents along party lines, to withhold U.S. funding to UNFPA. While framed broadly, Kemp-Kasten was originally intended to restrict funding to UNFPA specifically, after concerns arose about China’s population control policies and UNFPA’s work in China; to date, it has only been applied to UNFPA. Evaluations by the U.S. government and others have found no evidence that UNFPA directly engages in coercive abortion or involuntary sterilization in China, and more generally, UNFPA does not promote abortion as a method of family planning or fund abortion services.
• Kemp-Kasten has been used to withhold funding from UNFPA in 20 of the past 41 fiscal years.

What is the Kemp-Kasten Amendment?

The Kemp-Kasten amendment, first enacted in 1985, is a provision of U.S. law that states that no U.S. funds may be made available to “any organization or program which, as determined by the [p]resident of the United States, supports or participates in the management of a program of coercive abortion or involuntary sterilization.”¹ It was the congressional response to a Reagan administration decision in 1984 to temporarily withhold some funding from UNFPA and to begin conditioning its funding on assurances that the agency did not engage in or provide funding for abortion or coercive family planning. This policy change was made after concerns arose about whether UNFPA supported China’s coercive population policies.² It was announced by the Reagan administration at the 2nd International Conference on Population in 1984, in conjunction with the “Mexico City Policy.”³ The Mexico City Policy originally required foreign NGOs to certify that they would not “perform or actively promote abortion as a method of family planning” with non-U.S. funds as a condition of receiving U.S. family planning assistance; the Trump administration recently expanded this restriction to encompass more funding, more organizations, and more policy areas (see the KFF explainer on the policy).

What U.S. funding does Kemp-Kasten apply to?

Kemp-Kasten applies to all funds appropriated under the State and Foreign Operations appropriations act as well as any unobligated balances from prior appropriations. This includes all funding provided to the State Department and the now-dissolved USAID, which, in turn, includes the vast majority of U.S. global health funding.⁵

When has Kemp-Kasten been in effect?

The Kemp-Kasten amendment has been in effect for 41 years. First enacted in 1985,⁶ its language has been included in the State and Foreign Operations appropriations act every fiscal year since then. (Although the provision is present in current law, language similar to Kemp-Kasten was also included in President Trump’s presidential memorandum reinstating the Mexico City Policy on January 24, 2025.⁷) While Congress has kept the amendment in place annually, it remains up to the president to determine whether or not to invoke Kemp-Kasten as a reason to withhold funding from an organization (see below).⁸

Though Kemp-Kasten technically could apply to funding provided to any organization or program (including U.S. NGOs, non-U.S. NGOs, multilateral organizations, and foreign governments), the U.S. government has issued determinations about only one organization, UNFPA, thus far. The U.S. played a key role in the launch of UNFPA in 1969 and was, until 1985, the largest government donor to the agency.⁹ However, the U.S. has withheld funding from UNFPA due to presidential determinations that it violated Kemp-Kasten as often as it has provided funding since 1985 (in 20 of the past 41 fiscal years, to date), and in some years, funding was also withheld from UNFPA based on other provisions of the law, such as the dollar-for-dollar withholding requirement¹⁰ (see below). These determinations have been made along party lines with only one exception – the first year of President George W. Bush’s administration (see Figure 1 and Table 1).

How much funding does the U.S. provide to UNFPA?

In 2024, the U.S. was the largest donor to UNFPA, having provided 17% of all contributions. Total funding from the U.S. for UNFPA was $231.8 million – $30.5 million in core support and $201.3 million for other projects – in FY 2024 (see Box 2).¹¹ See Figure 1 and Table 1 for historical funding data.

How is a determination about Kemp-Kasten made?

By law, it is up to the president to determine whether any organization or program should be ineligible for funding due to a violation of the Kemp-Kasten amendment (in practice, this authority has generally been delegated to the State Department). In most recent years, legislative language has also specified that this determination must be: 1) made no later than six months after the date of enactment of the law that includes the provision and 2) accompanied by the evidence and criteria used to make the determination.¹³

Most recently, on January 24, 2025, at the beginning of his second term, President Trump directed the Secretary of State to begin the process of making a Kemp-Kasten determination by taking “all necessary steps,” and in May 2025, the United States again invoked Kemp-Kasten to withhold funding from UNFPA. These determinations are usually made after the annual appropriations process is completed. For example, in 2017, the Trump administration’s determination was made on March 30, 2017, at the six month mark after the passage of the FY 2017 continuing resolution appropriations bill and was accompanied by a two-page justification memorandum.¹⁴

Has there ever been evidence that UNFPA supports coercive abortion or involuntary sterilizations?

To date, there has been no evidence that UNFPA supports coercive abortion or involuntary sterilizations. Several evaluations by the U.S. government (including one by an assessment team sent to China by the State Department in 2002) as well as other groups, such as the British All-Party Parliamentary Group on Population, Development, and Reproductive Health (in 2002) and the Interfaith Delegation (in 2003), have found no evidence of direct engagement by UNFPA in such activities in China or elsewhere.¹⁵ In addition, UNFPA does not promote abortion as a method of family planning or fund abortion services.¹⁶ In years when a determination has been made that UNFPA violated Kemp-Kasten, the U.S. government has stated that the determination was based on its conclusion that UNFPA support to or partnering with the Chinese government for other population and reproductive health activities was sufficient grounds for invoking the amendment to withhold funding. In the March 30, 2017, determination by the Trump administration, for example, the justification memorandum stated that: “While there is no evidence that UNFPA directly engages in coercive abortions or involuntary sterilizations in China, the agency continues to partner with the NHFPC [China’s National Health and Family Planning Commission] on family planning, and thus can be found to support, or participate in the management of China’s coercive policies for purposes of the Kemp-Kasten amendment.”

What other legislative requirements apply to U.S. funding for UNFPA?

In addition to Kemp-Kasten, there are several other provisions of law that Congress has enacted in recent years to set conditions on U.S. funding for the agency.¹⁷ These provisions:

• require UNFPA to keep U.S. funding to the agency in a separate account, not to be commingled with other funds;
• prohibit UNFPA from funding abortion;
• prohibit UNFPA from using any U.S. funds for their programming in China;
• reduce the U.S. contribution to UNFPA by one dollar for every dollar that UNFPA spends on its programming in China (“dollar-for-dollar withholding”); and
• in some years, state that not more than half of funding designated for the U.S. contribution to UNFPA is to be released before a particular date, which varies by fiscal year (this provision is not currently in effect).

What happens to funding that is withheld from UNFPA?

For several years, including FY 2025 and FY 2026, Congress has required that funding withheld from UNFPA be reallocated to U.S. global family planning, maternal, and reproductive health activities. (However, despite this requirement, the withheld FY 2025 contribution to UNFPA will not be reallocated to those purposes since shortly after the Trump administration made its Kemp-Kasten determination that year, Congress rescinded, or permanently canceled, the funding as part of a larger foreign aid rescission package requested by the President.¹⁸) The enactment of this provision first affected reallocation of FY 2002 funds.¹⁹ It is now typically included in the State and Foreign Operations appropriations act each year.²⁰

1. U.S. Congress, FY 2017 Consolidated Appropriations Act (P.L. 115-31), May 5, 2017; KFF, The U.S. Government and International Family Planning & Reproductive Health: Statutory Requirements and Policies, fact sheet. ↩︎
2. Congressional Research Service (CRS), The U.N. Population Fund: Background and the U.S. Funding Debate, RL32703, July 2010; “Policy Statement of the United States of America at the United Nations International Conference on Population (Second Session), Mexico City, Mexico, August 6-14, 1984,” undated. ↩︎
3. “Policy Statement of the United States of America at the United Nations International Conference on Population (Second Session), Mexico City, Mexico, August 6-14, 1984,” undated; United Nations Division of Economic and Social Affairs/Population Division, “United Nations Conferences on Population,” webpage, undated, http://www.un.org/en/development/desa/population/events/conference/index.shtml. ↩︎
4. “Policy Statement of the United States of America at the United Nations International Conference on Population (Second Session), Mexico City, Mexico, August 6-14, 1984,” undated. ↩︎
5. KFF, The U.S. Congress and Global Health: A Primer; and KFF U.S. Global Health Budget Tracker, available at: https://www.kff.org/interactive/u-s-global-health-budget-tracker/. ↩︎
6. Via FY 1985 supplemental appropriations, per CRS, The U.N. Population Fund: Background and the U.S. Funding Debate, RL32703, July 2010. ↩︎
7. Specifically, in this memorandum, President Trump stated, “I further direct the Secretary of State to take all necessary actions, to the extent permitted by law, to ensure that U.S. taxpayer dollars do not fund organizations or programs that support or participate in the management of a program of coercive abortion or involuntary sterilization.” ↩︎
8. However, after UNFPA ended its program in China in 1997 but then began a new program there in 1999, this resulted in Congress withholding funding from UNFPA that year. ↩︎
9. CRS, The U.N. Population Fund: Background and the U.S. Funding Debate, RL32703, July 2010; PAI, Why the United States Should Maintain Funding for UNFPA, May 2015. ↩︎
10. In FY 1999, Congress prohibited UNFPA funding in response to the initiation of a new UNFPA program in China (this was unrelated to Kemp-Kasten), and in some other years when the U.S. made a contribution to UNFPA, UNFPA’s China program meant some UNFPA funding was withheld under the “dollar-for-dollar withholding” provision. ↩︎
11. KFF analysis of data from State Department, U.S. Contributions to International Organizations: Reports to Congress, available at: https://www.state.gov/u-s-contributions-to-international-organizationshttps://bidenwhitehouse.archives.gov/briefing-room/presidential-actions/2021/01/28/memorandum-on-protecting-womens-health-at-home-and-abroad/https://www.whitehouse.gov/briefing-room/presidential-actions/2021/01/28/memorandum-on-protecting-womens-health-at-home-and-abroad/. ↩︎
12. UNFPA, Annual Report 2013, 2014. ↩︎
13. Typically included in annual State and Foreign Operations appropriations since FY 2008, including in FY 2017 under the terms of the continuing resolution. CRS, The U.N. Population Fund: Background and the U.S. Funding Debate, RL32703, July 2010; KFF analysis of appropriations bills. ↩︎
14. State Department: Letter to Bob Corker, Chairman, Committee on Foreign Relations, from Joseph E Macmanus, Bureau of Legislative Affairs, State Department, dated April 3, 2017, and accompanying “Determination Regarding the ‘Kemp-Kasten Amendment,’” dated March 30, 2017, and “Memorandum of Justification for the Determination Regarding the “Kemp-Kasten Amendment,” undated. Available online (follows the article) at: https://www.buzzfeednews.com/article/jinamoore/the-us-wont-give-any-more-money-to-the-un-population-fund. ↩︎
15. CRS, The U.N. Population Fund: Background and the U.S. Funding Debate, RL32703, July 2010. ↩︎
16. UNFPA, “Frequently Asked Questions,” webpage, updated January 2025, http://www.unfpa.org/frequently-asked-questions#abortion. ↩︎
17. KFF, The U.S. Government and International Family Planning & Reproductive Health: Statutory Requirements and Policies, fact sheet. ↩︎
18. KFF analysis of Congressional Appropriations Bills. ↩︎
19. “Although such reallocation began in practice in FY 2002, it was first authorized by Congress in legislation beginning in FY 2004 with reference to FY 2002 and FY 2003 funds,” per KFF, The U.S. Government and International Family Planning & Reproductive Health: Statutory Requirements and Policies, fact sheet. ↩︎
20. The activities to which Congress directs reallocated funds varies by fiscal year; in FY 2003, for example, reallocated funding supported assistance to vulnerable children and victims of trafficking in persons. CRS, The U.N. Population Fund: Background and the U.S. Funding Debate, RL32703, July 2010. ↩︎

Employer-sponsored health insurance is the largest source of health coverage for people under 65, covering 165.6 million people in March 2025, but its reach is uneven. About four in five (80%) adult workers under age 65 work for an employer that offers health insurance to at least some employees—a share that falls to 60% for lower-paid workers. Additionally, some workers do not enroll even when coverage is offered: employer-sponsored health insurance covered only 22.5% of people under 65 with incomes below 200% of poverty—compared to 82.5% of people with incomes of at least 400% of poverty.

This analysis examines who among people under 65 have employer coverage and which workers are offered and eligible for coverage at their jobs, using the Annual Economic and Social (March) Supplements of the Current Population Survey.

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

For many years, KFF polling has found that the high cost of health care is a burden on U.S. families, and that health care costs factor into decisions about insurance coverage and care seeking. These costs also rank as the top financial worry for adults and their families. This data note summarizes recent KFF polling on the public’s experiences with health care costs. Main takeaways include:

• Just under half of U.S. adults say it is difficult to afford health care costs, and about three in ten say they or a family member in their household had problems paying for health care in the past 12 months. Hispanic adults, young adults, and the uninsured are particularly likely to report problems affording health care in the past year.
• The cost of health care can lead some to put off needed care. About one-third (36%) of adults say that in the past 12 months they have skipped or postponed getting health care they needed because of the cost. Notably three in four (75%) uninsured adults under age 65 say they went without needed care because of the cost.
• The cost of prescription drugs prevents some people from filling prescriptions. About four in ten (43%) U.S. adults say they have not taken their medication as prescribed in the past year due to costs. This includes three in ten who say they have taken an over-the-counter drug instead of getting a prescription filled (31%), a quarter (27%) who have not filled a prescription, and one in five (19%) who have cut pills in half or skipped doses of medicine because of the cost. Larger shares of lower-income, uninsured, women, Black, and Hispanic adults report taking these measures.
• Health care debt is a burden for a large share of Americans. In 2022, about four in ten adults (41%) reported having debt due to medical or dental bills including debts owed to credit cards, collections agencies, family and friends, banks, and other lenders to pay for their health care costs, with disproportionate shares of Black and Hispanic adults, women, parents, those with low incomes, and uninsured adults saying they have health care debt.
• Those who are covered by health insurance are not immune to the burden of health care costs. Almost four in ten insured adults under the age of 65 (38%) worry about affording their monthly health insurance premium and large shares of adults with employer-sponsored insurance (ESI) and those with Marketplace coverage rate their insurance as “fair” or “poor” when it comes to their monthly premium and to out-of-pocket costs to see a doctor.
• Notable shares of adults say they are worried about affording medical costs such as the cost of health care services (including the cost of health insurance and out-of-pocket costs for things like office visits and prescription drugs). About two-thirds of adults say they are either “very worried” (32%) or “somewhat worried” (34%) about being able to afford the cost of health care for themselves and their families. The cost of health care ranks at the top of the list when it comes to things that people worry about affording, followed by food, utilities, and other household expenses.

Difficulty Affording Medical Costs

Many U.S. adults have trouble affording health care costs. While lower income and uninsured adults are the most likely to report this, those with health insurance and those with higher incomes are not immune to the high cost of medical care. Just under half of U.S. adults say that it is very or somewhat difficult for them to afford their health care costs (44%). Uninsured adults under age 65 are much more likely to say affording health care costs is difficult (82%) compared to those with health insurance coverage (42%). Additionally, a slight majority of Hispanic adults (55%) and half of Black adults (49%) report difficulty affording health care costs compared to about four in ten White adults (39%). Adults in households with annual incomes under $40,000 are more likely than adults in households with higher incomes to say it is difficult to afford their health care costs. (Source: KFF Health Tracking Poll: May 2025)

When asked specifically about problems paying for health care in the past year, about three in ten (28%) adults say they or a family member in their household had problems paying for care, rising to four in ten among Hispanic adults (41%) and young adults ages 18 to 29 (40%). Among those under age 65, six in ten (59%) uninsured adults report problems paying for health care in the past year, about twice the share of insured adults who say the same (30%). (Source: KFF Health Tracking Poll: November 2025)

The cost of care can also lead some adults to skip or delay seeking services, with one-third (36%) of adults saying that they have skipped or postponed getting needed health care in the past 12 months because of the cost. Women are more likely than men to say they have skipped or postponed getting health care they needed because of the cost (38% vs. 32%). Adults ages 65 and older, most of whom are eligible for health care coverage through Medicare, are much less likely than younger age groups to say they have not gotten health care they needed because of cost.

Three-quarters of uninsured adults say they have skipped or postponed getting the health care they needed due to cost. Having health insurance, however, does not offer ironclad protection as about four in ten adults with insurance (37%) still report not getting health care they needed due to cost. (Source: KFF Health Tracking Poll: May 2025)

Skipping care due to costs can have notable health impacts. Nearly two in ten adults (18%) report that their health got worse because they skipped or delayed getting care. Among adults under age 65, those who are uninsured are twice as likely as those with health coverage to say that their health worsened due to skipped or postponed care (42% vs. 20%). About four times as many adults under age 65 (23%) say their health got worse after skipping or postponing care as adults ages 65 and older (6%), most of whom have Medicare coverage. (Source: KFF Health Tracking Poll: May 2025)

A 2022 KFF report found that people who already have debt due to medical or dental care are disproportionately likely to put off or skip medical care. Half (51%) of adults currently experiencing debt due to medical or dental bills say in the past year, cost has been a probititor to getting the medical test or treatment that was recommended by a doctor. (Source: KFF Health Care Debt Survey: Feb.-Mar. 2022)

Prescription Drug Costs

The high cost of prescription drugs also leads some people to cut back on their medications in various ways. About three in ten adults (31%) say in the past 12 months they have taken an over-the-counter drug instead of getting a prescription filled because of cost concerns, while about a quarter (27%) say they have not filled a prescription and about one in five (19%) say they have cut pills in half or skipped doses of medicine due to cost. Overall, four in ten (43%) adults report taking at least one of these measures in the past year, continuing an upward trend from a third (33%) in 2025 and about three in ten (31%) in July 2023.

Larger shares of adults in households with lower and middle incomes report resorting to these cost-saving prescription medication solutions compared to those with higher incomes. About half of adults in households with annual incomes under $40,000 (52%) or between $40,000 and $90,000 (47%) say they have not taken their medication as prescribed due to the cost in the last year, compared to three in ten adults in households with incomes of $90,000 or more. Uninsured adults under the age of 65 are more likely than their counterparts to also report not taking their medicine as prescribed due to costs (58% compared to 43% of insured adults under age 65). Additionally, half of women (49%) say they have taken any of these prescription medication measures compared to about a third (36%) of men. Over half (55%) of Black adults say the same, compared to half (47%) of Hispanic adults and four in ten White adults. (Source: KFF Health Tracking Poll: March 2026)

Health Insurance Cost Ratings

Health insurance provides some financial protection, but premiums and out-of-pocket costs can still present a financial burden for many individuals. Overall, most insured adults rate their health insurance as “excellent” or “good” when it comes to the amount they have to pay out-of-pocket for their prescriptions (61%), the amount they have to pay out-of-pocket to see a doctor (53%), and the amount they pay monthly for insurance (54%). However, at least three in ten rate their insurance as “fair” or “poor” on each of these metrics, and affordability ratings vary depending on the type of coverage people have.

Adults who have private insurance through employer-sponsored insurance or Marketplace coverage are more likely than those with Medicare or Medicaid to rate their insurance negatively when it comes to their monthly premium, the amount they have to pay out of pocket to see a doctor, and their prescription co-pays. About one in four adults with Medicare give negative ratings to the amount they have to pay each month for insurance and to their out-of-pocket prescription costs, while about one in five give their insurance a negative rating when it comes to their out-of-pocket costs to see a doctor.

Medicaid enrollees are less likely than those with other coverage types to give their insurance negative ratings on these affordability measures (Medicaid does not charge monthly premiums in most states, and copays for covered services, where applied, are required to be nominal). (Source: KFF Survey of Consumer Experiences with Health Insurance)

Health Care Debt

In June 2022, KFF released an analysis of the KFF Health Care Debt Survey, a companion report to the investigative journalism project on health care debt conducted by KFF Health News and NPR, Diagnosis Debt. This project found that health care debt is a wide-reaching problem in the United States and that 41% of U.S. adults currently have some type of debt due to medical or dental bills from their own or someone else’s care, including about a quarter of adults (24%) who say they have medical or dental bills that are past due or that they are unable to pay, and one in five (21%) who have bills they are paying off over time directly to a provider. One in six (17%) report debt owed to a bank, collection agency, or other lender from loans taken out to pay for medical or dental bills, while similar shares say they have health care debt from bills they put on a credit card and are paying off over time (17%). One in ten report debt owed to a family member or friend from money they borrowed to pay off medical or dental bills.

While four in ten U.S. adults have some type of health care debt, disproportionate shares of lower income adults, the uninsured, Black and Hispanic adults, women, and parents report current debt due to medical or dental bills.

Vulnerabilities and Worries About Health Care and Long-Term Care Costs

At the start of 2026, health care costs are at the top of the list of people’s financial worries, with two-thirds (66%) saying they are at least somewhat worried about affording the cost of health care, including the cost of health insurance and out-of-pocket costs for things like office visits and prescription drugs for themselves and their families. This is larger than the shares who say they worry about affording food and groceries (57%), utilities (57%), housing costs (52%), and gas or other transportation expenses (52%) for their families.

Notably, about nine in ten uninsured adults under age 65 say they are worried about affording the cost of health care (88%), but a large share of insured adults are also worried (68%). Health care costs are at the top of household cost worries across insurance types and partisans. (Source: KFF Health Tracking Poll: January 2026)

Many U.S. adults may be one unexpected medical bill from falling into debt. About half of U.S. adults say they would not be able to pay an unexpected medical bill that came to $500 out of pocket. This includes one in five (19%) who would not be able to pay it at all, 5% who would borrow the money from a bank, payday lender, friends or family to cover the cost, and one in five (21%) who would incur credit card debt in order to pay the bill. Women, those with lower household incomes, Black and Hispanic adults are more likely than their counterparts to say they would be unable to afford this type of bill. (Source: KFF Health Care Debt Survey: Feb.-Mar. 2022)

Among older adults, the costs of long-term care and support services are also a concern. Almost six in ten (57%) adults 65 and older say they are at least “somewhat anxious” about affording the cost of a nursing home or assisted living facility if they needed it, and half say they feel anxious about being able to afford support services such as paid nurses or aides. These concerns also loom large among those between the ages of 50 and 64, with more than seven in ten saying they feel anxious about affording residential care (73%) and care from paid nurses or aides (72%) if they were to need these services. See The Affordability of Long-Term Care and Support Services: Findings from a KFF Survey for a deeper dive into concerns about the affordability of nursing homes and support services.

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, with the option for states to implement requirements earlier. To implement Medicaid work requirements, states will need to make policy and operational decisions, develop new outreach and education strategies, implement system upgrades or changes, and hire and train staff, all within a relatively short timeframe. 

As states begin the process of implementing new Medicaid work requirements, they may draw on lessons from their recent experience with “Medicaid unwinding.” In April 2023, states began the process of unwinding the Medicaid continuous enrollment provision, a pandemic-era policy that generally stopped disenrollment in return for extra federal funds provided to states. During the unwinding, states conducted eligibility redeterminations for everyone on the program and disenrolled those who were no longer eligible or who did not complete the renewal process.

State experience with Medicaid unwinding illustrated the complexity of Medicaid eligibility processes and that outcomes reflect federal and state policy decisions, implementation and systems. KFF interviews with state officials, managed care plans, primary care associations, and advocacy organizations involved with the Medicaid unwinding in 2023, as well as interviews from the 23rd annual budget survey of Medicaid officials, provided lessons about outreach and engagement and renewal processes. This brief highlights lessons from unwinding that could help inform work requirement implementation. Key takeaways include:

• Successful outreach and communication generally utilize an array of strategies and partnerships to reach and educate enrollees about changes to the program. Managed care organizations (MCOs) can help identify enrollees and provide outreach.
• Streamlined renewal processes and increases to ex parte, or automated, renewals help to maintain enrollment for those eligible and reduce state burdens; however, implementing multiple policy changes in tight timeframes can result in significant challenges for systems and staff.
• While states can draw on their experiences from the Medicaid unwinding, they will face new challenges unique to implementing work requirements. These include the need to collect and incorporate new information when making eligibility determinations, conduct targeted rather than broad outreach, and implement complicated system changes and integrate new data, as well as the inability to replicate certain flexibilities that were available during unwinding.

What lessons from unwinding could inform implementation of work requirements?

Successful outreach and communication generally utilize an array of strategies to reach and educate enrollees about changes to the program. During unwinding, many states expanded the number of touchpoints before renewal and engaged in multi-modal communication strategies. These included broad efforts (e.g., traditional communication campaigns, paid advertising, press conferences, and toolkits for partner organizations), direct outreach to enrollees (e.g., mailers and text messaging), and targeted outreach to certain populations such as people with limited English proficiency. States also used new strategies to update contact information, such as using the National Change of Address database and accepting updated contact information from managed care organizations (MCOs), with reductions in returned mail. Groups reported that finding the correct balance of frequency of outreach and ensuring clear messaging is key to not overwhelm or confuse enrollees.

Partnerships can amplify outreach and provide feedback loops. During the Medicaid unwinding, most states worked with a wide range of groups to reach Medicaid enrollees, including managed care organizations (MCOs), providers (such as community health centers, other primary care providers, and pharmacies), community-based organizations, navigator/assister organizations, and faith-based groups to amplify state outreach efforts. State officials and groups working directly with affected enrollees found local marketing and word of mouth to be effective methods for reaching enrollees. Many states also held regular meetings to provide updates and review data with others involved in unwinding. Feedback loops with community partners helped identify early problems; conversely, limited state engagement and communication contributed to frustration and more reports of problems.

Managed care organizations (MCOs) can help identify enrollees and provide outreach. During unwinding, some MCOs were able to take on new roles with enrollees as a result of certain waivers and flexibilities (post-unwinding, states have the option to permanently adopt many renewal strategies). State officials and managed care representatives reported that MCOs providing direct outreach to enrollees and sharing updated contact information for enrollees with the state were both helpful. Other innovative approaches MCOs took included virtual renewal training events and coordination between MCOs and primary care providers so providers could work with individuals due for renewal.

Implementing multiple policy changes in tight timeframes can result in significant challenges for systems and staff. A number of states reported that their systems were old or difficult to use and not set up to produce real-time analytics. Respondents also cited staffing shortages as an ongoing challenge contributing to slower processing of renewals and backlogs. Several mentioned that their staff was not experienced enough to handle the large workload, mostly due to high turnover among eligibility workers. States mentioned taking steps to increase ex parte renewal rates to reduce the burden on eligibility staff and enrollees and providing additional staff training. Leading up to the implementation of Medicaid work requirements, states have reported workforce challenges, including the need to hire or reallocate staff in anticipation of increased workloads and the need for additional staff training.

Streamlined renewal processes and increases to ex parte, or automated, renewals help to maintain enrollment for those eligible and reduce state burdens. Heading into unwinding, two-thirds of states reported taking steps to improve the share of renewals processed on an ex parte basis, such as by improving system programming rules or expanding data sources. The ability to perform ex parte renewals varied by state system. Some were able to add data sources and prioritize automating eligibility processes more easily, which in turn reduced the burden on staff.

States reported both benefits and drawbacks to having Medicaid eligibility systems that are integrated with other benefit programs. Integrated eligibility systems allow people to apply for and renew coverage for multiple benefit programs at once. States with Medicaid eligibility systems that were integrated with the Children’s Health Insurance Program (CHIP) and social benefit programs like the Supplemental Nutrition Access Program (SNAP) and the Temporary Assistance for Needy Families (TANF) program reported that data sharing across programs helped improve ex parte renewal rates and simplify renewal processes. State officials also reported that it can be more challenging to make changes to integrated systems because of the need to reconcile complex eligibility rules across programs. Waivers allowing use of SNAP data to renew Medicaid were helpful during unwinding and using SNAP data may be helpful in assessing if individuals meet work or exemption criteria for new requirements. 

How will implementing work requirements differ from unwinding experiences?

New work requirements represent a major change to Medicaid eligibility policy and will require states to collect and incorporate new information when determining eligibility. While the volume of renewals posed challenging for states during unwinding, there was no change to enrollee eligibility policy. New work requirements will affect both existing enrollees and new applicants, and will require collecting new information to verify compliance or exemption status. For example, states will likely need to add new questions to Medicaid applications and renewal forms, as well as incorporate new data sources (see more below). States will also have to train staff on new eligibility policy and verification requirements. Instead of doing traditional point-in-time determinations, states will have to consider historical information and confirm that an individual was meeting requirements in one or more months prior to application. 

While states can draw on their experiences conducting outreach during the Medicaid unwinding, educating enrollees about work requirements may pose unique challenges. While unwinding affected the entire Medicaid population, work requirements affects only a subset of Medicaid adult expansion enrollees. Compared to the broad outreach conducted during unwinding, states will need to provide more targeted outreach to reduce confusion among Medicaid enrollees and applicants who are not affected by the new work requirements. For those who are affected, states will need to educate individuals on the new requirements, the list of exemptions, how to document compliance, and how to know that you need to submit information. States will likely want to work with a narrower subset of community partners than during unwinding that primarily work with or serve Medicaid expansion adults.

Some flexibilities made available during unwinding will not be helpful for verifying compliance with work requirements. CMS encouraged states to adopt a range of waivers and flexibilities to increase ex parte rates and streamline renewals during unwinding. States reported that streamlining renewals for those with zero and low income were among the most helpful waivers. However, these waivers will be less helpful going forward since determining compliance with work requirements may require income documentation and exemptions will not be based on income. Some states also received waivers that allowed MCOs to help their members complete renewals. The new federal reconciliation law prohibits MCOs from being able to determine beneficiary compliance, but states may be able to engage with MCOs to assist with identification and outreach to enrollees and assist members with completing renewals when implementing work requirements.

Implementing work requirements may require more complicated system changes than states experienced during unwinding, due to the need to integrate various data from agencies and external sources. While states will be able to build on system improvements made during unwinding, implementing work requirements will require more varied data to automate verification of exemptions and qualifying activities, such as meeting minimum education hours or participating in substance use disorder treatment. States may need to identify and establish linkages with new sources, such as gig work platforms, student databases, and claims data to increase the share of applicants and enrollees who can be automatically determined to meet the requirements. In addition, when implementing work requirements, states will have to simultaneously implement other forthcoming changes such as changes to eligibility renewal frequency for expansion adults and changes to retroactive eligibility. States also needed to complete work requirement changes for SNAP that went into effect at the end of 2025, which may have delayed the initiation of work on the Medicaid changes for states with integrated Medicaid and SNAP eligibility systems.

President Trump’s FY 2027 budget request, the second of his second term, was released on April 3, 2026, and proposes significantly reduced funding for some domestic HIV programs. A budget request lays out presidential administration priorities both in terms of policy issues and the level of funding requested (or proposed for elimination). Congress then considers the request but ultimately has “the power of the purse” and is responsible for appropriating funding for discretionary programs. Those appropriations can, and often do, differ from levels proposed by the administration. Indeed, while President Trump also called for reduced HIV funding in his budget request for FY 2026, Congress appropriated funding similar to prior year levels.

Beyond the traditional budget process, the Trump administration has taken several executive actions to terminate or limit already appropriated funding by delaying or cancelling funding, including for accounts and grants related to HIV. In some cases these actions have led to litigation, sometimes resulting in grants being reinstated. In addition, the administration has used the recission process, whereby the president asks Congress to rescind appropriated funds, which reduces funding if approved by Congress, though to date, recissions have not impacted domestic HIV accounts. These administrative actions have led to uncertainty regarding availability of federal dollars, including for HIV programs, grantees, and sub-grantees, even after funds are appropriated.

The FY 2027 request for domestic HIV, like the FY 2026 request, calls for the elimination or transformation of several core programs, while maintaining others. As with the FY 2026 request, proposals to bolster PrEP uptake that had become a feature of Biden Administration HIV requests, were not included. Funding for the Ending the HIV Epidemic Initiative, an effort born during the first Trump Administration, has been maintained. While detailed funding information is not available for all accounts, where levels are known, the FY 2027 budget request for domestic HIV programs represents a $1.6 billion (35%) decline compared to final FY 2026 funding levels.   

If these cuts are enacted, it could make addressing HIV more challenging at a time when other changes to the health policy landscape could negatively impact access to HIV care and prevention services.

A summary of the request for domestic HIV programs is below.

Overview

The request includes discretionary funding for key programs aimed at addressing the domestic HIV epidemic, including for the Ryan White HIV/AIDS and Health Center Programs, programs that the budget moves from the Health Resources and Services Administration (HRSA) to the proposed new agency, the Administration for Healthy America (AHA). Congress rejected the FY26 request’s proposal to create and fund AHA during the appropriations process. The FY27 request states that AHA will prioritize HIV/AIDS programs (among other areas), “aligning with the Administration’s priorities”. Other funding that has been provided to other departments/agencies for HIV activities is also moved to AHA. This includes funding for the Office of Infectious Disease and HIV/AIDS Policy (OIDP) for HIV and other infectious disease related activities, as well as all EHE funding previously allocated to Centers for Diseases Control and Prevention (CDC).

At the same time, the request eliminates a range of historical HIV programs including funding for domestic HIV prevention at the CDC, Part F of the Ryan White HIV/AIDS Program, and at least some parts of the Minority AIDS Initiative (MAI). Additionally, large cuts are proposed for the National Institute of Allergy and Infectious Diseases (NIAID) at the National Institutes of Health, which has been the largest source of HIV research funding in the world. The request also proposed cutting the Housing Opportunities for People with AIDS (HOPWA) program which is a program of Department of Housing and Urban Development.

Specific, known funding levels are as follows:

Centers for Disease Control and Prevention (CDC)- Domestic HIV Prevention

Funding for core HIV prevention programs at the CDC is eliminated in the budget request and only funding previously provided to the CDC for EHE activities ($220 million) is preserved but moved to AHA. Historically, CDC has accounted for almost all (91%) federal funding for domestic HIV prevention. This cut would represent a $794 million decrease (78%) over the FY26 level ($1 billion, including the EHE) for HIV funding, but a total elimination of funding for the division.

While CDC’s HIV prevention funds are eliminated in the proposal, some funding for infectious diseases has been retained and combined into one account. Previously, CDC funding for viral hepatitis, sexually transmitted infections, and tuberculosis prevention had separate funding lines. The request proposes to group those accounts into a single $300 million line. The $300 million funding level is $70 million below the sum of these individual accounts in FY 2026.

These changes at CDC were also proposed in the FY26 budget request but rejected by Congress.

Ryan White HIV/AIDS Program

The Ryan White HIV/AIDS Program, the nation’s safety-net for HIV care and treatment (now housed at HRSA, and would be moved to AHA), receives $2.5 billion in the FY 2026 request, a $74 million (3%) decrease over the FY 2026 enacted level. The request includes $165 million for EHE activities within Ryan White, the same as in FY 2026. The overall program decrease of $74 million is attributed to the elimination of funding for Part F of the program which has included the following components:

• AIDS Education and Training Centers (AETCs) whichprovide education and training for health care providers who treat people with HIV.
• Dental Programs: The “Dental Reimbursement Program” reimburses dental schools and providers for oral health services. The “Community-Based Dental Partnership Program” supports dental provider education and expands access to oral care for people with HIV. 
• Minority AIDS Initiative (MAI): Created in 1998 to address the impact of HIV on racial and ethnic minorities, MAI provides funding to strengthen organizational capacity and expand HIV services in minority communities. (See additional discussion of MAI below.)

Community Health Center HIV Funding

The FY 2027 budget request includes $157 million in HIV funding for the Health Center Program (now housed at HRSA and would be moved to AHA), all of which is for the EHE initiative; the same amount as the FY 2026 level. EHE funding in health centers “support efforts to reduce new HIV infections through outreach, routine and risk-based testing, and increased access to Pre-Exposure Prophylaxis for patient.”

Office of Infectious Disease and HIV/AIDS Policy (OIDP)

The FY27 budget provides $7.6 million in funding to the Office of Infectious Disease and HIV/AIDS Policy (OIDP) (now housed at the Office of the Assistant Secretary of Health, it would be moved to AHA). OIDP plays a coordinating role, including historically for EHE effort and national HIV, STI, and hepatitis strategies. Funding for OIDP is provided in the request to “drive progress [in] MAHA priorities by implementing innovative, evidence-based interventions to prevent, diagnose, and treat HIV/AIDS, STIs, viral hepatitis, nosocomial infections/hospital – acquired infections (HAIs), and antibiotic-resistant organisms.” It also supports OIDP to “coordinate national strategies, support data-driven program development, and engage communities most affected by these conditions.”

National Institutes of Health – Domestic HIV Research

Historically, the National Institutes of Health (NIH) has carried out almost all federally funded HIV research activities. The budget proposes significant cuts to NIH overall, including to the National Institute of Allergy and Infectious Disease (NIAID) which would be cut by $1.8 billion (27%), from approximately $6.5. billion to $4.8 billion. While the amount of funding for domestic HIV research at NIH is not yet known, in FY 2025, it was $3.3 billion (amount provided to KFF via data request). The Office of AIDS Research, which sits in the Office of the NIH Director and plays a coordinating role withing NIH is mentioned in the budget’s technical appendix, although a specific funding amount is not provided.

Indian Health Service (IHS)

In the FY27 budget, $5 million for IHS EHE activities to support ending HIV and hepatitis C in Indian Country is continued, the same as the FY26 final level. (Funding information provided to KFF via data request.)

The Minority AIDS Initiative (MAI)

As noted above, the MAI was created in 1998 to address the disparate impact of HIV on racial and ethnic minority communities and to build resources and organizational capacity within these communities. The status of the Minority AIDS Initiative is unclear. Funding that has been provided for MAI activities at the Substance Abuse and Mental Health Services Administration (SAMHSA) which the budget would move to AHA, aimed at “improving the health of people of color who have or are at risk for HIV” is eliminated in the proposal. In FY 2026 SAMHSA received $119 million for the MAI. Another $56 in MAI funding is eliminated from the Secretary’s Minority HIV/AIDS. In addition, as noted, Ryan White funding for Part F, which includes a funding line for MAI, is also eliminated in the proposal.

Housing Opportunities for Persons with AIDS (HOPWA)

The Department of Housing and Urban Development’s HOPWA Program is eliminated in the budget. In FY 2026, HOPWA was funded at $529 million. HOPWA, which was established in 1992, has provided housing assistance and supportive services to low-income people with HIV facing housing insecurity and is the only federal program centered on the housing needs of people with HIV. Its funding supports grants to localities, states, and community-based organizations.

The tables below compare federal funding levels for domestic HIV, where specified, in the FY 2027 request to the FY 2026 enacted levels. EHE funding is included in the overall table (Table 1) and in a dedicated table (Table 2).

Sources:

• HHS FY27 Budget in Brief: https://www.hhs.gov/sites/default/files/fy-2027-budget-in-brief.pdf
• HHS FY27 Budget Technical Appendix: https://www.whitehouse.gov/wp-content/uploads/2026/04/hhs_fy2027.pdf
• Indian Health Services Congressional Budget Justification: https://www.ihs.gov/sites/ofa/themes/responsive2017/display_objects/documents/IHS%20Draft%20CJ%20FY%202027.pdf
• Centers for Disease Control and Prevention Congression Budget Justification: https://www.cdc.gov/budget/documents/fy2027/fy-2027-cdc-cj.pdf
• Department of Housing and Urban Development Congressional Budget Justification:  https://www.hud.gov/sites/dfiles/CFO/documents/2027-Congressional-Justifications.pdf
• Administration for a Healthy America Budget Justification (includes accounts formerly at HRSA, SAMHSA, and OASH, among others): https://www.hhs.gov/sites/default/files/fy-2027-aha-cj.pdf  
• Departments of Labor, Health and Human Services, and Education, and Related Agencies Appropriations Act, 2026: https://www.congress.gov/bill/119th-congress/senate-bill/2587
• Transportation, Housing and Urban Development, and Related Agencies Appropriations Act, 2026: https://www.congress.gov/bill/119th-congress/house-bill/4552

The human papillomavirus (HPV) vaccine is the first and only vaccination that helps protect individuals from getting several cancers that are associated with different HPV strains. The vaccine holds the promise to safely prevent many kinds of cancers attributable to HPV that have long been responsible for the deaths of women and men. Since its introduction to the U.S. in 2006, the vaccine covers more strains of HPV, the dosage has dropped from three to two shots and the cost is fully covered by private insurance and public programs. The vaccine was originally recommended only for girls and young women, but was subsequently broadened to include boys, young men, and people of all genders. Uptake in the vaccine has risen over time, though there have been notable declines in vaccination rates since the COVID-19 pandemic. This factsheet discusses HPV and related cancers, use of the HPV vaccines for both females and males, and insurance coverage and access to the vaccine.

HPV and Cancer

HPV is the most common STI in the U.S. and is often acquired soon after initiating sexual activity. Approximately 42.5 million Americans are infected with HPV and there are at least 13 million new infections annually. There are more than 200 known strains of HPV, and while most cases of HPV infection usually resolve on their own, persistent infection with high-risk strains can cause cancer. HPV-related cancers have increased significantly in the past decade—between 2018 and 2022, over 49,000 people in the United States developed an HPV-related cancer compared to 30,000 in 1999. While HPV-related cervical and vaginal cancer rates have decreased since 1999, rates for oropharyngeal and anal HPV-related cancers have increased. 

Cervical Cancer

Over 90% of cervical cancer cases are HPV related, with two strains (16 and 18) responsible for approximately 66% of cervical cancer cases worldwide. In the U.S., it is estimated that 13,360 new cervical cancer cases were diagnosed in 2025. While cervical cancer is usually treatable, especially when detected early, approximately 4,320 deaths from cervical cancer occurred in 2025.

Despite widespread availability of cervical cancer screening, racial disparities in cervical cancer incidence and mortality rates persist in the U.S. For example, although Hispanic women have the second highest incidence rate of cervical cancer, cervical cancer mortality rates among this population are comparable to the national mortality rate. Black women, on the other hand, have the third highest incidence rate of cervical cancer, yet have the highest mortality rates of the disease (Figure 1). Another notable paradox is that Black and Hispanic women have the highest rates of recent Pap testing but higher rates of mortality attributable to cervical cancer. Lower rates in follow-up treatment after an abnormal screening result, differences in treatment options, diagnosis at later stages of disease progression, and negative experiences in the medical system may account for some of the disproportionate impact of cervical cancer.

Oropharyngeal and Anal Cancers

Approximately 22,585 cases of oropharyngeal (throat) cancer occur annually in the U.S, most of which (70%) are probably caused by HPV. Oropharyngeal cancers are the most common HPV-associated cancer among men and are more common among men than women (Figure 2). However, anyone who heavily uses both tobacco and alcohol is at much higher risk of developing these cancers. Research suggests that HPV vaccines can help protect against throat cancer since many are associated with HPV 16 and 18, two of the strains that the vaccine protects against. HPV is also responsible for the majority (91%) of the estimated 7,600 annual cases of anal cancer in the U.S. While cases of anal cancer are higher among women, men who have sex with men are at higher risk of developing anal cancer linked to HPV 16 and 18. Additional risk factors for anal cancer include a history of cervical cancer and having a suppressed immune system. Like oropharyngeal cancer, there has been an increase in the rate of anal cancers in the past 15 years.

HPV Vaccine Recommendations

Since 2016, Gardasil®9 has been the only HPV vaccine available in the U.S. The FDA approved first-generation Gardasil®—produced by Merck—in 2006, which prevented infection of four strains of HPV: 6, 11, 16, 18. In December 2014, Gardasil®9 was approved for use in individuals ages nine to 45 years old. This vaccine protects against the 9 strains of HPV associated with most cervical cancer, anal cancer, and throat cancer cases as well as most genital warts cases and some other HPV-associated ano-genital diseases. The vaccine was initially approved for cervical cancer prevention, but in 2020 the FDA broadened its approval to include the prevention of oropharyngeal cancer and other head and neck cancers. Current global research suggests Gardasil®9 protection is long-lasting: more than 10 years of follow-up data in both boys and girls indicate the vaccines are still effective and there is no evidence of waning protection, although it is still unknown if recipients will need a booster in the future. Other HPV vaccines show similar effectiveness. In Scotland, recipients of the bivalent HPV vaccine Cervarix®—which protects against HPV 16 and 18—who became fully vaccinated against HPV at age 12 or 13 have had no cases of cervical cancer since the vaccine program started in 2008. Additionally, new data from the American Society of Clinical Oncology shows that the vaccine reduced the risk of all HPV-associated cancers—including oropharyngeal, head, and neck cancers—by 50% in men. 

The federal Advisory Committee on Immunization Practices (ACIP) is responsible for issuing immunization recommendations for the U.S. population. ACIP is convened by the CDC and has historically been comprised of clinicians, scientists, public health experts, and other professionals with expertise in vaccine-related policies. In June 2024, during the Biden administration, the ACIP recommended that most adolescents receive a two-dose series of the HPV vaccine (Table 1). This recommendation was designed to promote immunization when the vaccine is most effective—before the initiation of sexual activity. Those already infected with HPV can also benefit from the vaccine because it can prevent infection against HPV strains they may not have contracted, but the vaccine does not treat existing HPV infections.

After the second Trump Administration took office, the Department of Health and Human Services (HHS) made changes in vaccine policy more broadly that also affected the HPV vaccine recommendations. In June 2025, Secretary of HHS, Robert F. Kennedy Jr., dismissed the entire membership of the ACIP and replaced them with new advisers, many of whom are known to be skeptical of vaccines. In December 2025, the newly reconstituted ACIP changed the recommendation from two doses to a single dose for adolescents. This recommendation, along with the other pediatric vaccine recommendation revisions made by the newly appointed committee, were blocked for the time being by a federal court in a legal challenge brought on by public health and health professional organizations led by the American Academy of Pediatrics. The ruling also blocked the changes that HHS made to the ACIP membership. As a result, the 2024 recommendations are currently in effect, for now.

While the FDA expanded its approval of the HPV vaccine to include adults ages 27 to 45, ACIP has not recommended routine catch-up vaccinations for all adults in this age group. ACIP recommends that adults ages 27 to 45 who have not been properly vaccinated and who may be at risk for new HPV infections consult with a medical professional about receiving the vaccine. 

Uptake

In 2024, over 60% of adolescents aged 13-17 in the U.S. were up-to-date with their HPV vaccinations (HPV UTD). On average, adolescents who were Asian, Black, or covered by Medicaid were more likely to be HPV UTD compared to adolescents who were White, privately insured, or uninsured. HPV vaccination rates among teen boys are slightly lower than for girls (61% vs. 64% HPV UTD in 2024), but they have been rising since 2016.

HPV vaccination rates vary by state, ranging from a low of 39% of adolescents being HPV UTD in Mississippi to a high of 80% in Massachusetts (Figure 3). Some states, such as Hawaii, Rhode Island, Virginia, and D.C., have laws that require HPV vaccination for school entry. In California, the Cancer Prevention Act requires schools to notify families of 6^th grade children about HPV vaccine recommendations and advise them to follow guidelines but does not require them to adhere to them for school entry. Vaccine exemptions due to religious or personal beliefs are permitted in most states.

Some people begin the vaccine series but do not complete it. In 2024, 79% of adolescent girls and 77% of boys received at least one dose of the HPV vaccine. Recent trends in vaccination coverage show that overall HPV vaccination initiation has stalled for the third consecutive year, and throughout the last decade, rates continue to remain lower among adolescents who live in predominately rural areas compared to those in urban areas. The findings indicate that children were more likely to be vaccinated when their parent/guardian received a vaccine recommendation for their child from a healthcare provider. In addition, while vaccine initiation among adolescents overall remained steady, initiation rates in recent years have slightly declined among adolescents who were uninsured or covered by Medicaid (Figure 4).

Vaccine hesitancy may also contribute to lower HPV vaccination coverage among these subgroups. Prior to the pandemic, parents’ top reasons for not vaccinating their children were perceptions of safety concerns and the belief that the vaccine was not needed. Since the pandemic began, some providers have observed an increase in vaccine hesitancy or refusal in parents of adolescents they attribute to difficulties cased by COVID-19 or mistrust in vaccines. HHS Secretary Kennedy also has a history of vaccine skepticism, and his views along with the vacillating recommendations for the HPV vaccine over the course of the second Trump administration will likely add to the hesitancy and confusion among parents and clinicians.

Vaccine Financing

There are multiple sources of private and public financing that assure that nearly all children and young adults in the U.S. have coverage for the HPV vaccine. Many of the financing entities base their coverage on ACIP recommendations.

The Affordable Care Act (ACA) requires public and private insurance plans to cover a range of recommended preventive services and ACIP recommended immunizations without consumer cost-sharing. Plans must cover the full charge for the HPV vaccine, as well as pap tests and HPV testing for women. 

Public Financing 

Vaccines for Children — Through the VFC program, the CDC purchases vaccines at a discounted rate and distributes them to participating healthcare providers. All children are eligible through age 18 if they are uninsured, underinsured, Medicaid-eligible, Medicaid-enrolled, or American Indian or Alaska Native.  

Medicaid — Medicaid covers ACIP-recommended vaccines for enrolled individuals under age 21 through the Early and Periodic Screening Diagnosis and Treatment program (EPSDT). Adults 21 and older who are insured through Medicaid are covered for approved adult ACIP-recommended vaccinations without cost-sharing.  

Public Health Service Act — Section 317 of the Public Health Service Act provides grants to states and local agencies to help extend the availability of vaccines to uninsured adults in the United States. These are often directed towards meeting the needs of priority populations, such as underinsured children and uninsured adults.  

Merck Vaccine Patient Assistance Program — Merck, the manufacturer of Gardasil®9 has established assistance programs to provide free HPV vaccines in the United States. To qualify, individuals must be aged 19 or older, uninsured, and low-income.  

Children’s Health Insurance Program (CHIP) — Children who qualify for CHIP are part of families whose incomes are too high to qualify for Medicaid but too low to afford private insurance. Each state has its own set of specific qualifications for CHIP. The program is managed by the states and is jointly funded by the states and the federal government. CHIP programs that are separate from the Medicaid Expansion must cover ACIP-recommended vaccines for beneficiaries since they are not eligible for coverage under the federal VFC.