Key Points

• On January 24, 2025, President Trump directed the Secretary of State to “take all necessary actions to ensure 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.” This provision of law, known as the Kemp-Kasten amendment, was first enacted by Congress in 1985 and has been included in appropriations language annually.
• Kemp-Kasten has often been used, as determined by presidents along party lines, to withhold U.S. funding to the United Nations Population Fund (UNFPA, the lead U.N. agency focused on global population and reproductive health).
• The U.S. government provided $194.4 million in FY 2023 for UNFPA – $30.6 million in core support and $163.8 million more for other project activities – making it the largest government contributor in that year.
• 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 19 of the past 40 fiscal years. Under current law, any U.S. funding withheld from UNFPA is to be made available to other family planning, maternal health, and reproductive health activities.

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 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 include all U.S. global health assistance (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 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 40 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 19 of the past 40 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 2023, the U.S. was the largest government donor to UNFPA, having contributed 11% of all contributions (funding amounts for 2024 are not yet available). Total funding from the U.S. in FY 2023 for UNFPA was $194.4 million – $30.6 million in core support as well as $163.8 million in non-core support (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 Kemp-Kasten determination by taking “all necessary steps.” 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 not been 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 2017, FY 2018, FY 2019, and FY 2020, Congress has required that funding withheld from UNFPA be reallocated to USAID’s family planning, maternal, and reproductive health activities.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://modern.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: Congressional Appropriations Bills, Press Releases, and Conference Reports; Federal Agency Budget and Congressional Justification documents and Operating Plans; ForeignAssistance.gov; Office of Management and Budget, personal communication; UNFPA, personal communication; Biden Administration, “Memorandum on Protecting Women’s Health at Home and Abroad,” presidential actions, Jan. 28, 2021, Biden White House Archives, https://bidenwhitehouse.archives.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. ↩︎

Options under consideration in Congress to significantly reduce Medicaid spending could have major implications for adults who live with mental illness. Nationwide, an estimated 52 million nonelderly adults live with mental illness, and Medicaid covers nearly one in three (29%) of them, or about 15 million adults. Changes to Medicaid under consideration include imposing a per capita cap on federal spending, reducing the federal government’s share of costs for the ACA expansion group, and imposing work requirements. Such policy changes would fundamentally alter how Medicaid financing works and large federal spending reductions would force states to make tough choices on whether to raise new revenue, restrict the number of people covered, cover fewer benefits, or cut payment rates for physicians, hospitals, and other providers. For people with mental illness, losing Medicaid coverage would reduce access to mental health treatment and other health care, which could have negative implications for their mental and physical health.

1. More than one in three adult Medicaid enrollees have a mental illness.

More than one in three nonelderly adults enrolled in Medicaid have a mental illness (35%), including 10% with a serious mental illness. These rates are higher than the rates among adults with private insurance or no coverage (Figure 1). Serious mental illness generally involves more severe symptoms and may include other neurological factors, both of which can complicate treatment and impact daily functioning. Data in Figure 1 come from the National Survey on Drug Use and Health (NSDUH), which categorizes respondents as having a probable mild, moderate, or serious mental illness through a combination of mental health scales and indicators of functional impairment. Generally, adults with severe symptoms and with greater impairments in daily functioning would meet the threshold for serious mental illness, while “any mental illness” includes adults who meet criteria for mild, moderate or serious mental illness (see methods). Among Medicaid adults, any mental illness is most prevalent among White adults, rural or small metro residents, those aged 26-34, and females (Appendix Table 1). Rates of any mental illness among adult Medicaid enrollees vary widely by state, from 22% in New Jersey to 51% in Iowa. Similarly, the percentage of adult Medicaid enrollees with a serious mental illness ranges from 4% in Mississippi to 22% in Wyoming and Missouri (Appendix Table 2).

2. Mental health treatment rates for Medicaid-enrolled adults are higher or similar to those with private insurance.

Nonelderly adults in Medicaid receive mental health treatment at rates that are higher or similar to those with private insurance, and much more often than those who are uninsured. In 2023, 59% of adult Medicaid enrollees with any mental illness received treatment – somewhat above the rate for privately insured adults (55%) and far higher than for those who are uninsured (37%). Across all coverage types, treatment rates increased with the illness severity, with adults diagnosed with serious mental illness reporting the highest rates of treatment. Although adults with mild mental illness covered by Medicaid or private insurance report similar treatment rates, Medicaid-enrolled adults with moderate and serious mental illnesses report higher treatment rates than those with private coverage. In every category, adults with either Medicaid or private insurance receive treatment at much higher rates than those who lack health coverage. These data indicate only that care was accessed, not the adequacy or quality of that care. In an effort to increase access to care, many state Medicaid programs have expanded covered services and adopted policies to address workforce shortages.

3. Adults enrolled in Medicaid experience a range of mental health diagnoses.

Anxiety and depressive disorders are the most frequently diagnosed mental illnesses among nonelderly Medicaid-enrolled adults (over 5 million diagnoses for anxiety alone). Serious mental illnesses – such as bipolar disorder and schizophrenia or other psychotic disorders – were diagnosed in over 2.3 million adult Medicaid enrollees (Figure 3). Many people experience overlapping mental health conditions (e.g., a person with depression may also have anxiety). Estimates of the number of people with specific types of mental illnesses come from Medicaid administrative data (i.e. claims data) which only capture diagnoses for people with a mental illness diagnosis recorded in their medical claims. This is not a measure of overall prevalence of mental illness because not everyone is screened, and diagnoses are not always recorded. Prevalence rates estimated through surveys are generally higher than the prevalence rates observed in claims data.

4. Medicaid enrollees with mental illness have higher rates of chronic conditions.

Medicaid enrollees diagnosed with mental illness have higher rates of chronic conditions and substance use disorder compared to those without a mental health diagnosis. Approximately two-thirds of adult enrollees with any mental illness have at least one other chronic condition – twice the rate of those without a diagnosed mental illness (Figure 4). Enrollees with serious mental illness have the highest rates of chronic conditions with 76% having at least one chronic condition. Chronic conditions are those that last at least a year and require ongoing medical care or limit daily activities, such as heart disease, diabetes, cancer, and mental illnesses. The most common chronic condition among Medicaid enrollees with mental illness is substance use disorder. These often overlap with mental illness, potentially due to shared risk factors. One in four enrollees diagnosed with any mental illness also have a diagnosed substance use disorder, and about 40% of those diagnosed with SMI do, compared to 5% of enrollees without a mental health diagnosis (Figure 4).

5. Average annual spending for enrollees with a mental illness is twice that of those without.

Average annual Medicaid spending per nonelderly adult enrollee is twice as high for those with any mental health diagnosis—about $14,000 per year—compared to roughly $7,000 for those without a mental health diagnosis. Spending is highest among adults diagnosed with a serious mental illness, at approximately $21,000 per enrollee per year—three times higher than the annual spending for those without a mental illness (Figure 5). Medicaid spending for adults with any mental illness accounts for one-third of the total Medicaid spending for non-elderly adults enrolled only in Medicaid. Higher rates of other chronic diseases among adults with mental illness may contribute to higher spending (Figure 3).

Appendix Tables

PEPFAR, the U.S. global HIV/AIDS program, is – for the first time in its two-decade history – facing significant challenges that could impede its ability to fulfill its mission. One of President Trump’s first actions was to issue an executive order to re-evaluate and realign foreign aid, requiring a 90-day pause in foreign aid funding while a review was undertaken, as well as dismissal of thousands of USAID staff and contractors, and other changes, effectively halting most programs, including for PEPFAR, around the world. Despite PEPFAR receiving a limited waiver to continue some services and the courts stepping in to provide temporary relief, services are still disrupted. In addition, PEPFAR’s current short-term authorization expires on March 25, 2025, about a month before the 90-day aid review is scheduled to be completed, and Congress is increasingly looking for program reforms and ultimately scale down.

The current situation, coupled with uncertainty about future changes, poses potential risks to health outcomes for a program that has been shown to have saved millions of lives and helped to build health infrastructure in sub-Saharan Africa; already, analyses have estimated that the foreign aid freeze and ensuing service disruptions have led to increases in HIV-related deaths and new HIV infections. This policy brief provides an overview of these recent events and ongoing challenges facing the program.

Background

Despite almost two decades of strong, bipartisan support and demonstrated success and impact, PEPFAR began facing growing headwinds in recent years. This was due to several external shifts, including pressures on the global economy; an increasingly crowded global health and development space; and shrinking resources to address the global HIV epidemic, with a concomitant and growing reliance on the United States, the largest donor to HIV.

Within the U.S., members of Congress were increasingly asking questions about PEPFAR’s “end game,” pressing the program for its plans for the future to scale down and transition services, programming and, ultimately, financing to countries. In addition, some members began raising concerns that PEPFAR was supporting abortion activities, which is prohibited under federal law and policy. Together, these issues rendered PEPFAR unable to secure a five-year reauthorization for the first time in its history. Instead, Congress reauthorized the program for just one year (from March 23, 2024, to March 25, 2025), pushing further decision until after the 2024 election. In the meantime, ongoing concerns about abortion prompted Senator Risch to put a $1 billion hold on the program in September 2024.

What to Watch

Against this backdrop, several recent developments have made PEPFAR’s future particularly precarious; many of these intersect with one another, adding uncertainty and complexity to an already shifting landscape. These include:

• Increasing Abortion Concerns. In January, just before President Trump assumed office, PEPFAR notified Congress that some funds had, in violation of the Helms amendment, mistakenly been used to support a limited number of abortions in Mozambique, where abortion is legal in certain circumstances. According to one report, this was discovered by U.S. officials in late October 2024 when routine compliance measures found that some PEPFAR-funded nurses had not received required training on the prohibition on paying for the performance of abortion in U.S.-funded services, with four found to have performed abortions. In a statement issued on January 17, PEPFAR enumerated the steps it took to halt and remediate the violation and to prevent future violations, including immediately suspending funding and obtaining reimbursement from the Government of Mozambique for the amount (reported to be $4,100 spent on the nurse’s salaries) and putting in place new, additional measures, such as “requiring an annual signed attestation by PEPFAR-funded clinical service providers to ensure compliance with U.S. funding restrictions.” While this was the first time there had been evidence of any PEPFAR violation of the prohibition on abortion, it raised significant additional concerns among members of Congress who called for further investigation. This has led to increased scrutiny of the program and is likely to figure significantly in any discussion of reauthorization and PEPFAR’s future more broadly.
• President Trump’s Foreign Aid Funding Freeze and PEPFAR’s Limited Waiver. Beginning on the first day of his second term, President Trump issued several executive actions that affected and continue to affect PEPFAR’s operations, most notably a January 20 Executive Order reevaluating foreign aid. The order called for a 90-day freeze on U.S. foreign aid, including PEPFAR funding, to allow for a review of foreign assistance programs for alignment with Trump administration policy. While the order focused on pausing funding for new obligations and disbursements, on January 24, Secretary of State Rubio issued a stop-work order on all existing operations (those already underway), with limited exception. This, coupled with actions affecting USAID, PEPFAR’s main U.S. government implementing agency (see below), effectively halted service delivery.Although PEPFAR was able to secure a limited waiver on February 1 to allow some services to continue, communication about the waiver has been slow or unclear and the payment system remained unavailable. In addition, the waiver was limited to care and treatment only, as well as PMTCT and PrEP for pregnant and breastfeeding women; no other prevention services, including PrEP for those at risk of HIV infection or already on PrEP, were allowed. Even where the waiver might have been communicated to implementers, the capacity to deliver services has already been negatively affected with thousands of aid workers having already lost their jobs.In a set of lawsuits brought by organizational recipients of U.S. foreign aid, the court issued a temporary restraining order on February 13, requiring the administration to end the foreign aid freeze. Still, the case continues to move through the legal process and the government has since indicated that, despite the requirement to resume funding, it acted within its authority to cancel most grants and contracts. It is also unknown how much of the damage already done to service capacity can be repaired, should funding resume. Finally, the administration’s foreign aid review is ongoing, and expected to conclude by April 19 with recommendations for programmatic changes and potential cuts. How PEPFAR fares in this process is unclear but could have significant implications for its future. It is also unknown how any recommendations about changes to PEPFAR under the foreign aid review will be met by Congress and/or figure into Congress’ own deliberations about reauthorization.

• The Potential Dismantling of USAID. PEPFAR is overseen by the State Department but implemented primarily by other U.S. government agencies – particularly USAID and CDC. In FY 2023, 60% of PEPFAR’s bilateral HIV assistance was obligated and implemented by USAID. Shortly after the foreign aid pause was announced, however, President Trump and others in the administration announced their intention to dissolve USAID and implemented a series of actions that affected its operations and capacity including: taking down its website and payment and data systems, letting go of hundreds of staff and plans to put thousands more on leave (although a federal judge has temporarily enjoined the administration from doing so), closing the USAID building, and appointing the Secretary of State as the Acting Administrator of USAID. As mentioned above, this has already significantly affected PEPFAR’s operations even with a limited waiver issued, including widespread reports that there are no USAID personnel to communicate about the waiver, answer questions about waiver implementation, or facilitate payment. More long-term, it remains unclear what will happen with the agency including the recommendations that will be made by the State Department and whether Congress will accept proposed changes. Given the current reliance of PEPFAR on USAID as one of its main implementing agencies, any change stands to impact programming.
• The Reinstatement of the Expanded Mexico City Policy. As was expected, President Trump reinstated the Mexico City Policy, marking the resumption of the expansion of the policy from his first term that, for the first time, included PEPFAR. The Trump administration’s 2017 expanded policy required foreign non-governmental organizations (NGOs) to certify that they would not “perform or actively promote abortion as a method of family planning” using funds from any source (including non-U.S. funds) as a condition of receiving U.S. government global family planning funding and most other bilateral U.S. global health assistance (prior to this time, only family planning assistance had been subject to the policy). An analysis of the impact of Trump’s expanded policy found significant decreases in services offered by PEPFAR implementing organizations, including reductions in HIV testing and counseling among other services. The newly reinstated policy calls for the Secretary of State, in coordination with the Secretary of Health and Human Services, to develop a plan to implement the policy, and it is possible that the plan will reach even further than during Trump’s first presidency, as some have called for.
• PEPFAR’s Reauthorization Uncertainty. As mentioned earlier, PEPFAR’s current authorization expires March 25, which means that eight time-bound provisions would lapse if Congress does not act to extend them. However, the PEPFAR program overall would continue, so long as funding is appropriated. Still, how concerns raised by some members of Congress about abortion and increasing pressure on PEPFAR to demonstrate more concrete plans about its future, will figure into reauthorization have yet to be seen. It is possible that the new measures announced by PEPFAR to assure compliance with U.S. law, the reinstatement of the Mexico City Policy, and, presumably, a new PEPFAR coordinator appointed by President Trump, will alleviate abortion concerns. At the same time, the current upheaval in PEPFAR services and disruptions around the world may accelerate Congress’ interest in playing a more active role in charting its future, as will its interest in seeing more active sustainability reforms – for example, Congress could assess whether to include new provisions in PEPFAR authorizing language, such as country co-financing or graduation requirements.
• Future Funding. Finally, while PEPFAR’s funding has been relatively flat for several years, it now enters a much more uncertain funding environment. Last year, during budget negotiations, both the House and Senate’s final FY 2025 appropriation bills for State, Foreign Operations, and Related Programs (which funds most of PEPFAR) included level funding for program. Still, Congress could not agree on an overall budget for FY 2025 and the entire government is operating under a continuing resolution through March 28, 2025, requiring Congress to either agree on a FY 2025 budget or adopt another continuing resolution (or the government shuts down), and reports already indicate that Republicans will be looking for deep cuts in the budget. This changes the overall funding calculus for PEPFAR potentially for FY 2025 but also beyond. Contributing to this is the likelihood that President Trump’s first budget request for FY 2026, which will be released soon, will call for funding cuts to global health, including PEPFAR, as it did during his first term – at that time, Congress balked at those cuts but it is much less certain how they will respond now, given current fiscal and political pressures.

Confusion persists about immigrants’ eligibility for federal programs, with about half or more of U.S. adults and immigrants adults saying they are unsure or incorrectly believe that most immigrants to the U.S. are eligible to enroll in federal health insurance programs, including Medicaid, as soon as they arrive to the U.S. Eligibility for Medicaid and the Children’s Health Insurance Program (CHIP) is limited to citizens and certain lawfully present immigrants. Many citizens and lawfully present immigrants live in families with mixed immigration status, which may include undocumented immigrants. For example, 19 million or one in four children in the U.S. has an immigrant parent, including one in ten (12%) or 9 million who are citizen children with a noncitizen parent. Although most immigrant families have a full-time worker in the household, they tend to have lower incomes. As such, Medicaid and CHIP help keep uninsured rates for children in these families low and provide an affordable coverage option to eligible lawfully present immigrants. Despite having lower incomes, among those under age 65,  immigrants are less likely than U.S.-born citizens to have Medicaid or CHIP coverage (19% vs. 23%) and eligible noncitizen immigrants account for just 6% of Medicaid and CHIP enrollees.

The Congress is considering options to reduce federal Medicaid spending in order to offset the cost of tax cuts, including reinstating changes made to public charge immigration rules that were made under the first Trump administration and reducing federal funding for states that use state-only funds to expand coverage for immigrants. Proposals also suggest restricting eligibility for federal health programs to lawfully present immigrants, although this restriction is already in place. At the same time, the Trump administration has implemented an array of restrictive immigration policies that will likely increase fears among immigrant families about lawfully present immigrants and citizens accessing health coverage for which they are eligible. These changes may lead to disenrollment and coverage losses among lawfully present immigrants and citizens in immigrant families, which could have negative short and long-term effects on their health and reduce their productivity. The savings achieved from such changes are likely to be modest given that noncitizens account for a small share of Medicaid and CHIP enrollees. This brief provides five key facts on Medicaid and immigrants as context for understanding the potential impacts of the changes under consideration.

1. Undocumented immigrants are not eligible for Medicaid or CHIP, and only some lawfully present immigrants qualify subject to eligibility restrictions.

Undocumented immigrants are not eligible to enroll in federally funded coverage including Medicaid, CHIP, or Medicare or to purchase coverage through the ACA Marketplaces. Emergency Medicaid spending reimburses hospitals for emergency care they are obligated to provide to individuals who meet other Medicaid eligibility requirements (such as income) but who do not have an eligible immigration status, including undocumented immigrants and lawfully present immigrants who remain ineligible for Medicaid or CHIP.

Lawfully present immigrants may qualify for Medicaid or CHIP but are subject to eligibility restrictions. In general, in addition to meeting other eligibility requirements, lawfully present immigrants must have a “qualified” immigration status to be eligible for Medicaid or CHIP (Table 1), and many, including most lawful permanent residents or “green card” holders, must wait five years after obtaining qualified status before they may enroll. They may enroll in Marketplace coverage and receive subsidies during this five-year waiting period. Some immigrants with qualified status, such as refugees and asylees, as well as citizens of Compact of Free Association (COFA) nations, do not have to wait five years before enrolling. Some immigrants, such as those with temporary protected status, are lawfully present but do not have a qualified status and are not eligible to enroll regardless of their length of time in the country. Individuals with Deferred Action for Childhood Arrivals (DACA) status are not eligible for Medicaid or CHIP, and implementation of a Marketplace coverage expansion for them remains subject to ongoing litigation. States must verify citizenship and immigration status with the Social Security Administration and Department of Homeland Security to determine eligibility for coverage.

2. Despite having lower household incomes, immigrants under age 65 are less likely to be covered by Medicaid than their U.S.-born citizen counterparts.

In 2023, 19% of immigrants under age 65 were covered by Medicaid compared to 23% of U.S.-born citizens (Figure 1). Eligible noncitizen immigrants represent a small share of people covered by Medicaid, comprising just 6% of individuals under age 65 with Medicaid. Immigrants are also not more likely than U.S.-born citizens to receive assistance with food or housing. Data from the 2023 KFF/LA Times Survey of Immigrants show that, overall, about a quarter (28%) of both immigrant adults and U.S.-born citizen adults say they received assistance with food, housing, or health care in the past 12 months.

Many families face barriers to enrolling eligible lawfully present immigrants and citizen children in assistance programs due to fear, confusion about eligibility policies, difficulty navigating the enrollment process, and language access challenges. Restrictive immigration policies, including increases in enforcement actions, being implemented by the Trump administration will likely increase fears of enrolling in coverage and accessing health care. Even prior to the Trump administration, in 2023, nearly one in ten (8%) immigrants said they avoided applying for food, housing, or health care assistance in the past year because they didn’t want to draw attention to their immigration status or the status of someone in their family.

3. Emergency Medicaid spending makes up less than 1% of total Medicaid spending.

Emergency Medicaid spending represented less than 1% of overall Medicaid spending between fiscal years 2017 and 2023. Spending on Emergency Medicaid was $3.8 billion in FY 2023 and was 0.4% of total Medicaid spending that year (Figure 2). Emergency Medicaid spending reimburses hospitals for emergency care they are obligated to provide to individuals who meet other Medicaid eligibility requirements (such as income) but who do not have an eligible immigration status. These include lawfully present immigrants who are subject to a five-year waiting period for Medicaid or who remain ineligible for Medicaid and undocumented immigrants. Emergency services include those requiring immediate attention to prevent death, serious harm or disability, although states have some discretion to determine reimbursable services. Much of Emergency Medicaid spending goes toward labor and delivery costs. Without Emergency Medicaid, the costs of care would be shifted to hospitals that are required to treat individuals in emergency situations or fully to states.

4. States have expanded Medicaid coverage for lawfully present immigrant children and pregnant people, and some have fully state-funded coverage for immigrants.

For children and pregnant people, states can eliminate the five-year waiting period for Medicaid and CHIP coverage. As of January 2025, 37 states plus D.C. have taken up this option for children, and 31 states plus D.C. have elected the option for pregnant individuals (Figure 3). Additionally, 23 states plus D.C. provide prenatal care and pregnancy-related benefits to low-income children beginning from conception to end-of-pregnancy regardless of their parent’s citizenship or immigration status under the CHIP From-Conception-to-End-of-Pregnancy option. Some states have fully state-funded health coverage programs for immigrants regardless of status, particularly children. Research suggests that state coverage expansions for immigrants lead to increases in coverage and improvements in health care access and use.

5. Immigrants use less health care and have lower health care costs than people born in the U.S.

Research shows that immigrants use less health care and have lower health care costs than U.S.-born citizens. Lower use of health care among immigrants likely reflects a combination of them being younger and healthier than their U.S.-born counterparts as well as them facing increased barriers to care, including language access challenges, confusion, and immigration-related fears. Prior KFF analysis found that Trump-era policies amplified these fears and contributed to greater reluctance to access care. Reflecting their lower use of health care, immigrants have lower health care expenditures than their U.S.-born counterparts. Consistent with other research, KFF analysis of 2021 medical expenditure data shows that, on average, annual per capita health care expenditures for immigrants are about two-thirds those of U.S.-born citizens ($4,875 vs. $7,277), with no significant difference in the average amount paid by Medicaid for immigrants ($854) and U.S.-born people ($830). Given the Medicaid eligibility restrictions for immigrants, it is likely that a greater share of Medicaid spending for immigrants goes toward pregnancy-related care and emergency care, which tend to be costly. In contrast, U.S.-born enrollees include a high share of children, who typically utilize lower cost care.

Immigrants contribute to the economy through their role in the workforce and tax payments, with research showing that they help subsidize health care for U.S.- born people and stabilize Medicare and Social Security. Immigrants support the nation’s workforce by filling unmet labor market needs, and research suggests that they do not take jobs away from U.S.-born people. They play a disproportionate role filling jobs in essential industries such as construction and agriculture. In addition, immigrants as well as the adult children of immigrants play outsized roles in the health care workforce as physicians, surgeons, nurses, and long-term care workers (Figure 4). They also play a particularly large role as direct care workers in home and community-based settings. As health care workforce shortages are projected to continue and the U.S. 65 and older population grows, immigrants could help mitigate these shortages. Analysis also shows that undocumented immigrants contribute billions in federal, state, and local taxes each year, and research shows that they pay more into the health care system through taxes and health insurance premiums than they utilize, helping to subsidize health care for U.S.-born citizens.

Work requirements in Medicaid have resurfaced as part of a broader legislative package of potential changes to Medicaid designed to significantly reduce federal Medicaid spending. Reductions could help offset the costs of extending expiring tax cuts. A draft bill introduced in the U.S. House of Representatives in February 2025 includes a minimum work requirement for certain adults enrolled in Medicaid as a condition of coverage. The idea of promoting “work” is popular, particularly among Republicans who view Medicaid as a form of welfare. As debate heats up about Medicaid work requirements, data show most Medicaid adults are working or face barriers to work. Many Medicaid adults who are working low-wage jobs are employed by small firms and in industries that have low employer-sponsored insurance offer rates.

If Congress does not include work requirements in federal legislation, some states will pursue Medicaid work requirements through Medicaid demonstration waivers. The first Trump administration encouraged and approved “Section 1115” demonstration waivers that conditioned Medicaid coverage on meeting work and reporting requirements, approving 13 state work requirement waivers. Only Arkansas implemented such requirements with consequences for noncompliance, which resulted in over 18,000 people losing coverage. These approvals were either rescinded by the Biden administration or withdrawn by states, and Georgia is the only state with a Medicaid work requirement waiver in place (following litigation over the Biden administration’s attempt to stop it). While work requirement waivers were the subject of litigation during the Trump and Biden administrations, the Supreme Court never ruled on the issue leaving it open for future administrations. This issue brief highlights five key facts about Medicaid work requirements, including what research shows about the impact of work requirements.

1. Most Medicaid adults under age 65 are working already, without a “work requirement.”

Among adults under age 65 with Medicaid who do not receive benefits from the Social Security disability programs, Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI), and who are not also covered by Medicare, 92% were working full or part-time (64%), or not working due to caregiving responsibilities (12%), illness or disability (10%), or school attendance (7%) (Figure 1). The remaining 8% of Medicaid adults reported that they are retired, unable to find work, or were not working for another reason. Those in better health, with more education, and without disabilities are more likely to be working. Many Medicaid adults who work are employed by small firms or in industries (e.g., agriculture, service) with historically low employer-sponsored health insurance rates; even if eligible for job-based insurance, some low-wage workers may not take up the offer because it is not affordable to them.

2. CBO estimates of national work requirements show lower federal spending and an increase in the number of uninsured, but no increase in employment.

In April 2023, the U.S. House of Representatives passed a debt ceiling bill (HR 2811, the Limit, Save, Grow Act of 2023) that included a requirement for states to implement work requirements for certain Medicaid enrollees. While this bill never became law, the Congressional Budget Office (CBO) estimated (under this proposal) each year an average of 15 million enrollees would be subject to the requirements and 1.5 million would lose eligibility for federal funding, resulting in federal savings of $109 billion over a ten-year period (2023 – 2033). CBO analysis also showed the policy would increase the number of people without health insurance (by 600,000) but would not increase employment. CBO cited evidence of the effects of Medicaid work and reporting requirements implemented in Arkansas, the only state where a work requirement was established with disenrollment for noncompliance.

A 2022 CBO report notes high rates of employment among SNAP and Medicaid recipients leave little room to increase employment rates further. When people (who are not working) have conditions that make it difficult to find and keep employment (e.g., disabilities, caregiving responsibilities etc.), CBO indicates work requirements are less likely to lead to employment and more likely to reduce income/benefits. Targeted work supports (e.g., childcare, transportation, job training) can boost employment for some; however, CBO notes Medicaid and SNAP do not provide such supports.

3. In Arkansas, implementing Medicaid work requirements resulted in more than 18,000 people losing coverage.

Arkansas implemented Medicaid work and reporting requirements with consequences for noncompliance before a federal court deemed the work requirement unlawful. The requirements were in effect from June 2018 through March 2019. More than 18,000 people lost coverage, or about 25% of the population subject to the requirement, primarily due to failure to regularly report work status or document eligibility for an exemption. Researchers found work and reporting requirements in Arkansas were associated with losses in Medicaid coverage, an increase in the percentage of adults who were uninsured, and no significant change in employment—as nearly everyone targeted by the policy met the requirements already or qualified for an exemption. More recent research looking at two-year impacts of Arkansas’s work and reporting requirements found disenrollment was also associated with poorer medication adherence, delays in care, and medical debt.

Georgia has not expanded Medicaid under the ACA but expanded eligibility (under its “Pathways” waiver) to 100% of the federal poverty level (FPL) for parents and childless adults, with initial and continued enrollment conditioned on meeting work requirements. The current waiver does not include any exemptions (e.g., for caregiving). The waiver was implemented in July 2023 and as of January 2025, the state had only enrolled about 6,500 adults, considerably short of the state’s own estimates (25,000 adults in the first year and 64,000 over 5 years). In August 2024, Georgia’s governor announced a $10.7 million ad campaign aimed at boosting Pathways low enrollment. The Pathways waiver expires in September 2025. The state is seeking changes in its waiver renewal application including allowing parents / caretakers of children up to age 6 (in households at or below 100% FPL) to receive Medicaid without work requirements and eliminating the requirement to monthly report work activities (in exchange for annual reporting).

4. Evidence shows Medicaid work and reporting requirements are confusing to enrollees and complex and costly for states to implement.

In Arkansas, lack of awareness and confusion about the requirements were common. Despite robust outreach efforts, many enrollees were not successfully contacted. Lack of computer literacy and internet access were also barriers, as individuals were required to report on their work or exemption status monthly using an online portal. Providers reported the most vulnerable enrollees (e.g., people with disabilities, people experiencing homelessness) were the most likely to face barriers in complying with the requirements. (While proponents of Medicaid work requirements often describe these policies as applying to “able-bodied” adults, people with disabilities may be subject to the requirements—as many people with disabilities do not meet criteria to receive Supplemental Security Income (SSI) and therefore qualify for Medicaid based on income (vs. disability status).) Although Arkansas’s program included safeguards intended to protect coverage for people with disabilities and others who should not have been subject to the requirements from losing coverage, few people used these safeguard measures relative to the number who lost coverage.

For states, implementing work requirements involves complex systems changes (e.g., developing or adapting eligibility and enrollment systems), enrollee outreach and education, and staff training. GAO examined selected states’ estimates of the administrative costs to implement work requirements and found costs varied from under $10 million to over $270 million. States estimated that federal funds would cover most of these costs, largely due to higher matching rates of 75% and 90% percent of applicable IT costs. GAO found CMS did not consider administrative costs when approving Medicaid work requirement demonstrations. According to data obtained by KFF Health News, Georgia’s “Pathways” program cost the state and federal government more than $40 million (through June 2024), with nearly 80% of costs spent on program administration and consulting fees (vs. paying for health care).

5. Research shows access to affordable health insurance and care promotes individuals’ ability to obtain and maintain employment.

Research shows that being in poor health is associated with increased risk of job loss, while access to affordable health insurance has a positive effect on the ability to obtain and maintain employment. Many of the jobs held by people with low incomes involve walking, standing, lifting and carrying objects, repetitive motions, and other physical labor. Most Medicaid adults work in industries with low offer rates for employer-sponsored insurance, such as the agriculture and service industries. As a result, working does not replace the need for affordable coverage, including Medicaid coverage. Having access to regular preventive health care to manage chronic conditions, access medications, and address health issues before they worsen can help support work. In addition, an unmet need for mental health or addiction treatment results in greater difficulty with obtaining and maintaining employment, and Medicaid is an important source of coverage for mental health and addiction treatment services, such as opioid addiction.

Medicaid is the primary program providing comprehensive coverage of health and long-term care to 83 million low-income people in the United States. Medicaid accounts for one-fifth of health care spending, more than half of spending for long-term care, and a large share of state budgets. Medicaid is jointly financed by states and the federal government but administered by states within broad federal rules. Because states have a degree of flexibility to determine what populations and services to cover, how to deliver care, and how much to reimburse providers, there is significant variation across states in program spending and the share of state residents covered by the program.

At the start of 2025, many issues are at play that will affect Medicaid coverage, financing, and access to care. While Medicaid was not discussed much on the campaign trail, Congress may consider big changes as part of tax and spending debates and the Trump administration may make changes to Medicaid through executive actions. Amid the potential changes, this brief highlights ten key things to know about Medicaid.

1. Nationally, one in five people have Medicaid, but this varies across the states.

The percentage of people who report having Medicaid is 21% nationally, but ranges from 11% in Utah to 34% in New Mexico (Figure 1). The percentage tends to be higher in the 41 states that expanded Medicaid under the Affordable Care Act (ACA), which includes 21 states that voted for Trump and 20 that voted for Harris. Rates of Medicaid coverage are also higher in states with lower average incomes and lower rates of health insurance offered through employers.

2. Medicaid is a key source of coverage for certain populations.

While Medicaid covers 1 in 5 people living in the United States, Medicaid is a key source of coverage for certain populations. In 2023, Medicaid covered nearly 4 in 10 children, over 8 in 10 children in poverty, 1 in 6 adults, and almost half of adults in poverty. Relative to White children and adults, Medicaid covers a higher share of Black, Hispanic, and American Indian or Alaska Native (AIAN) children and adults. Medicaid covers more than 1 in 4 adults ages 19-64 with disabilities, who are defined as having one or more difficulty related to hearing, vision, cognition, ambulation, self-care, or independent living (Figure 2).

Medicaid provides coverage for several special populations.  For example, Medicaid covers 41% of all births in the United States, nearly half of children with special health care needs, 5 in 8 nursing home residents, 29% of non-elderly adults with any mental illness, and 40% of non-elderly adults with HIV. Medicaid pays Medicare premiums and often provides wraparound coverage for services not covered by Medicare (like most long-term care) for nearly 1 in 5 Medicare beneficiaries (13 million).  Medicaid is a key source of coverage for individuals experiencing homelessness and those transitioning out of carceral settings, particularly in states that have adopted the Medicaid expansion.

3. Medicaid is jointly financed by the federal government and states.

States are guaranteed federal matching dollars without a cap for qualified services provided to eligible enrollees. The match rate for most Medicaid enrollees is determined by a formula in the law that provides a match of at least 50% and provides a higher federal match rate for states with lower per capita income (Figure 2). States may receive a higher match rate for certain services and populations. The ACA expansion group is financed with a 90% federal match rate, so states pay 10%; however, the American Rescue Plan Act included an additional temporary fiscal incentive to states that newly adopt the Medicaid expansion. In FY 2023, Medicaid spending totaled $880 billion of which 69% was federal spending. Total Medicaid spending typically accelerates during economic downturns because people may lose income and enroll in the program. To help states manage increased costs, the federal government has temporarily increased the federal share of Medicaid. Most recently, states received an increase in the match rate between 2020 and 2024 to help manage increased enrollment and costs due to the pandemic related continuous enrollment provision.

4. Medicaid accounts for one fifth of all health care spending, and over half of spending on long-term care.

Medicaid provides a major source of funding for the U.S. health care system, covering 19% of all health care spending and 19% of hospital spending (Figure 4). In addition to covering the services required by federal Medicaid law, all states elect to cover optional benefits including prescription drugs and home care. Home care, also known as home- and community-based services or HCBS, is long-term care provided in non-institutional settings including homes, day care centers, and assisted living facilities. Other long-term care is provided in institutions such as nursing facilities. Medicaid is the primary payer for long-term care in the United States, covering 61% of total spending. Beyond long-term care, Medicaid provides other benefits not usually covered by health insurance including non-emergency medical transportation, which helps enrollees get to appointments, and comprehensive benefits for children, known as Early Periodic Screening Diagnosis and Treatment (EPSDT) services.

5. People who qualify for Medicaid based on age or disability account for more than half of spending.

Overall, seniors and individuals with disabilities account for 23% of enrollment but 51% of spending whereas children account for 34% of enrollment, but 14% of spending (Figure 5). The disproportionate spending on certain eligibility groups stems from variation in spending per enrollee across the eligibility groups. Spending per enrollee was highest for enrollees ages 65 and older ($18,923) and eligible because of disability ($18,437). Seniors and people with disabilities often have higher health care costs than other enrollees due to more complex health care needs, higher rates of chronic conditions and being more likely to utilize long-term care. There is significant state variation in the percentage of Medicaid spending that pays for enrollees eligible because of a disability or being age 65 and older: In some states (Alaska, Nevada, Montana, Illinois, and Indiana), only a third of spending went to those populations, and in five states (Alabama, Florida, Kansas, Mississippi, and North Dakota), care for people eligible because of disabilities or being over age 64 accounted for at least two-thirds of spending.

6. Flexibility to administer Medicaid results in variation in per enrollee costs across states.

Across the states, spending per full-benefit enrollee ranged from a low of $3,713 in Alabama to $10,229 in the District of Columbia in 2020 (Figure 6). Variation in spending across the states reflects considerable flexibility for states to design and administer their own programs – including what benefits are covered and how much providers are paid — and variation in the health and population characteristics of state residents as well as overall health care costs. Although all states are required to provide some Medicaid benefits, many others are optional, including prescription drugs (covered by all states), vision services, dental care and most home care. In recent years, states have expanded coverage of behavioral health services and benefits to help enrollees address social determinants of health (SDOH) like nutrition or housing.

7. Three-quarters of all Medicaid enrollees receive care through comprehensive, risk-based MCOs.

Overall, 75% of all Medicaid enrollees receive care through comprehensive, risk-based managed care organizations (MCOs) (Figure 7). Payments to MCOs accounted for more than half (52%) of Medicaid spending in FY 2023. As of July 2024, 42 states (including DC) contract with comprehensive MCOs. Medicaid MCOs provide comprehensive acute care (i.e., most physician and hospital services) and in some cases long-term care to Medicaid enrollees and are paid a set per member per month payment for these services. Medicaid MCOs represent a mix of private for-profit, private non-profit, and government plans. Five for-profit parent firms (Centene, Elevance (formerly Anthem), UnitedHealth Group, Molina, and CVS) account for 50% of all Medicaid MCO enrollment. States have increased their reliance on MCOs with the aim of improving access to certain services, enhancing care coordination and management, and making future costs more predictable. While the shift to MCOs has increased budget predictability for states, the evidence about the impact of managed care on access to care, costs, and outcomes is both limited and mixed.

8. Medicaid coverage facilitates access to care, improves health outcomes, and provides financial protection from medical debt.

A large body of research shows that Medicaid beneficiaries have substantially better access to care than people who are uninsured (who are also primarily low-income) and are less likely to postpone or go without needed care due to cost, as federal rules generally limit out of pocket Medicaid costs. Key measures of access to care among Medicaid enrollees are generally comparable to rates for people with private insurance (Figure 8). Gaps in access to certain providers (e.g., psychiatrists and dentists) is an ongoing challenge in Medicaid that may reflect system-wide problems, but may be exacerbated by provider shortages in low-income communities, Medicaid’s lower physician payment rates, and lower Medicaid physician participation compared with private insurance.

Longstanding research shows that Medicaid eligibility during childhood is associated with positive effects on health (including reduced avoidable hospitalizations and mortality) and impacts beyond health, such as improved long-run educational attainment. Early and updated research findings show that state Medicaid expansions to low-income adults are associated with increased access to care, increased economic security, improved self-reported health status, and other outcomes including increased early-stage cancer diagnosis rates, lower mortality rates for certain conditions (e.g., cancer, cardiovascular disease, liver disease), decreased maternal mortality, improved treatment management for conditions (e.g., diabetes, HIV), and improved outcomes related to substance use disorders. Research conducted by NBER (National Bureau of Economic Research) suggests that the ACA Medicaid expansion had impacts beyond health care use, including on consumer financial outcomes – reducing unpaid bills and medical debt sent to collections.

9. Section 1115 demonstration waivers reflect changing priorities across presidential administrations.

Section 1115 demonstration waivers offer states an avenue to test new approaches in Medicaid that differ from what is required by federal statute, if [in the HHS Secretary’s view] the approach is likely to “promote the objectives of the Medicaid program.” Waivers generally reflect priorities identified by states as well as changing priorities from one presidential administration to another (Figure 9). Waivers have been used to expand coverage or benefits, change policies for existing Medicaid populations (e.g., testing premiums or other eligibility requirements), modify delivery systems, restructure financing or authorize new payments (e.g., supplemental payments or incentive-based payments), as well as make other program changes. Waivers vary in size and scope. States can obtain “comprehensive” Section 1115 waivers that make broad program changes or narrow waivers focused on a specific population. Nearly all states have at least one active Section 1115 waiver and some states have multiple 1115 waivers.

10. The majority of the public holds favorable views of Medicaid.

In the most recent KFF tracking poll, more than three-fourths (77%) of Americans held favorable views of Medicaid, including six in ten Republicans (63%), and at least eight in ten independents (81%) and Democrats (87%) (Figure 10). Medicaid is also viewed favorably by a majority of voters who say they voted for President Trump in the 2024 election (62%). Nearly half of the public (46%) say the federal government doesn’t spend enough on the Medicaid program, with another third (33%) saying it spends “about the right amount,” and around one in five (19%) saying it spends “too much.” With possible changes to government health programs, seven in ten (72%) say they are worried about the level of benefits that will be available to people covered by Medicaid in the future

Americans’ life expectancy is significantly lower than the average for people in other large, wealthy countries.

This analysis compares 2021 data about deaths in the U.S. and 11 other large, wealthy countries by age and cause to understand the primary drivers of the longevity gap between the U.S. and the comparable countries. It finds that the primary reasons for the gap in 2021 were chronic disease, COVID-19 and substance use disorders.

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