A new KFF analysis finds that a congressional proposal to significantly cut federal spending on the Affordable Care Act’s Medicaid expansion could reduce total Medicaid spending by up to nearly one-fifth, or $1.9 trillion, over a 10-year period, and end Medicaid coverage for as many as 20 million people.The impacts would be felt in both blue and red states and could effectively reverse and end the Medicaid expansion in most or all states that have adopted it.

The analysis shows state-by-state estimates for two scenarios if Congress eliminates the ACA provision under which the federal government picks up 90% of the cost of covering the Medicaid expansion population and instead reimburses states at their traditional match rate, which ranges from 50% to 77%. 

• The first scenario assumes that all states would maintain their Medicaid expansion by replacing lost federal dollars with increased state spending, meaning no enrollees would lose coverage.  That would result in a decrease in federal Medicaid spending of 10%, or $626 billion, across all states over a 10-year period, and a corresponding increase in collective state Medicaid spending of 17% (also $626 billion) over that time, according to the analysis.
• The second assumes that states would not make up the funding shortfall resulting from federal spending reductions and drop the ACA Medicaid expansion. This would result in a 25% decrease in federal Medicaid spending, or $1.7 trillion, and a 5% decrease in state Medicaid spending, or $186 billion, across all states over a 10-year period. All told, total Medicaid spending would decline by nearly one-fifth, or $1.9 trillion, and 20 million people would lose coverage.

Only the 40 states and Washington D.C. that have adopted the Medicaid expansion would see any spending or enrollment impacts under the current proposal being considered by congressional Republicans. But as the analysis shows, the impacts in those states – which include 21 states that voted for President Donald Trump and 19 states plus D.C. that voted for former Vice President Kamala Harris – would vary considerably by state.

For instance, if states drop the Medicaid expansion, enrollment declines will range from 49% in Oregon to 19% in Massachusetts, Minnesota, North Carolina and South Dakota. In raw numbers, at the extremes, 5 million people in California could lose Medicaid coverage, compared to 24,000 in North Dakota and South Dakota.

Twelve states currently have “trigger” laws in place that would automatically end expansion or require changes if the federal match rate were to drop below 90%, but other states would also likely drop the expansion in response to the loss of federal funding. 

If states seek to preserve their Medicaid expansion, the lost federal funding that they would have to replace (over the 10-year period) would range from $129.4 billion in California to $953.4 million in South Dakota.  Other states that would see notable federal funding declines/increases in state spending include New York ($71.7 billion), Illinois ($40.9 billion), Pennsylvania ($27 billion), and Ohio ($20.1 billion) to name a few. (See the full list in Appendix Table 1.)

Eliminating the Medicaid expansion match is one of several options under consideration by Republicans in Congress to reduce Medicaid spending to help pay for an extension of the 2017 tax cuts. Medicaid provides health coverage to low-income Americans and accounts for nearly $1 out of every $5 spent on health care in the U.S. 

There are several options under consideration in Congress to significantly reduce Medicaid spending to help pay for an extension of expiring tax cuts. Medicaid is the primary program providing comprehensive health and long-term care to one in five people living in the U.S. and accounts for nearly $1 out of every $5 spent on health care. Medicaid is administered by states within broad federal rules and jointly funded by states and the federal government, meaning restrictions in federal Medicaid spending could leave states with tough choices about how to offset reductions. This analysis examines the potential impacts on states and Medicaid enrollees of one prominent proposal, which would eliminate the 90% federal match rate for the Affordable Care Act (ACA) expansion, which currently covers over 20 million people. Key takeaways include:

• This analysis explores the impact of eliminating the ACA expansion match rate under two scenarios. The first assumes that states maintain Medicaid expansion coverage and pick up new expansion costs, resulting in a decrease of 10% (or $626 billion) in federal Medicaid spending and an increase of 17% (or $626 billion) in state Medicaid spending across all states over a 10-year period.
• The second scenario assumes that states drop the ACA Medicaid expansion in response to the elimination of the 90% federal match rate. This would result in a 25% (or $1.7 trillion) decrease in federal Medicaid spending and a 5% (or $186 billion) decrease in state Medicaid spending across all states over a 10-year period. This would also cut total Medicaid spending by nearly one-fifth (or $1.9 trillion), and nearly a quarter of all Medicaid enrollees (20 million people) would lose coverage.
• Only states that have adopted the Medicaid expansion would see any spending or enrollment impacts under this policy proposal, though changes vary by state.

What is the proposed policy change?

States that have implemented the ACA Medicaid expansion currently receive a 90% federal match rate or “FMAP” for adults covered through the expansion, meaning the federal government pays 90% of the costs for expansion enrollees. The ACA expanded Medicaid coverage to nearly all adults with incomes up to 138% of the Federal Poverty Level ($21,597 for an individual in 2025). However, a Supreme Court ruling effectively made the decision to implement the Medicaid expansion an option for states. Forty-one states (including DC) have since adopted Medicaid expansion, and Medicaid expansion enrollees represent nearly a quarter of Medicaid enrollment (as of March 2024) and one-fifth of total Medicaid spending (as of FY 2023). The FMAP for services used by people eligible through traditional Medicaid is determined by a formula set in statute. The formula is designed so that the federal government provides a match rate of at least 50% and provides a higher match rate for states with lower average per capita income. For FY 2026, the traditional FMAP will range from 50% to 77%.

This analysis estimates the impact of eliminating the enhanced FMAP for adults in the Medicaid expansion. The analysis assumes that, starting in FY 2026, expenditures for people eligible in the Medicaid expansion would be matched at each state’s traditional 2026 FMAP rate. Details regarding the design of this policy change have yet to be released, and the details of proposed legislation may differ from the assumptions made to complete this analysis. This is also only one of the various Medicaid policy changes that have been suggested and estimates would change if multiple policies were considered together.

What are the potential impacts on Medicaid spending and enrollment?

This analysis does not make assumptions about specific state behavioral responses and instead examines the impact of eliminating the ACA expansion match rate under two scenarios. These scenarios are designed to illustrate the range of potential policy change effects; in practice, each state may respond to the policy change differently. While some states may choose to continue ACA Medicaid expansion coverage with substantially reduced federal funding, many likely would not given the extra spending that would be required. The analysis also excludes secondary effects such as people who lose coverage through the Medicaid expansion enrolling in Medicaid under other eligibility pathways or enrolling in private health coverage. The estimates presented here are not directly comparable to the estimates of federal savings from the Congressional Budget Office (CBO) because CBO’s estimates account for assumptions about state behavioral responses and other secondary effects.

• Scenario 1: All expansion states pick up new expansion costs. Expansion enrollment and total spending would remain constant while costs shift from the federal government to the states.
• Scenario 2: All states drop the ACA Medicaid expansion, resulting in changes to enrollment as well as total, federal, and state spending.

Eliminating the enhanced FMAP for adults in the Medicaid expansion could reduce Medicaid spending by nearly one-fifth ($1.9 trillion) over a 10-year period and up to nearly a quarter of all Medicaid enrollees (20 million people) could lose coverage. Under scenario 1, federal Medicaid spending would decrease by $626 billion or 10% across all states over the 10-year period, with the federal government providing matching funds at the standard rate rather than 90%. If all states picked up those costs and retained the Medicaid expansion, that would mean an additional $626 billion in state spending or a 17% increase in state spending across all states over the 10-year period. Under scenario 2, all state and federal financial support for Medicaid expansion is withdrawn, resulting in a $1.7 trillion dollar or 25% cut to federal Medicaid spending and a $186 billion dollar or 5% cut to state Medicaid spending across all states, including non-expansion. Combined, Medicaid spending would decrease by 18% or $1.9 trillion over the 10-year period. The cuts are even larger when looking among expansion states alone, resulting in a 31% decline in federal spending, a 6% decline in state spending, and a 22% decline in total spending. Under this scenario, an estimated 20 million Medicaid enrollees eligible through expansion would lose coverage, decreasing total Medicaid enrollment by 24% (by year 10).

Only states that have adopted the Medicaid expansion would see any spending or enrollment impacts under this policy proposal, though changes vary by state (Figure 2 and Appendix Table 1). The 10 states, primarily in the South, that have not expanded Medicaid under the ACA would see no change. Enrollment under scenario 1 would not change from baseline projections with states picking up the extra cost, but enrollment declines under scenario 2 vary by state, ranging from a decrease in estimated total Medicaid enrollment by year 10 of 19% in Massachusetts, Minnesota, North Carolina, and South Dakota to 49% in Oregon. The number of enrollees that could lose coverage ranges from 5 million in California to 24 thousand in North Dakota and South Dakota. (This analysis includes all states that had expanded Medicaid as of February 2025. In practice, there could also be effects in states that expand Medicaid in the years after 2025. In its baseline projections of Medicaid enrollment and spending, CBO assumes some states will continue to expand Medicaid but does not specify which states those are.)

What are other implications to consider?

Twelve states currently have “trigger” laws in place that would automatically end expansion or require changes if the federal match rate were to drop, but coverage would be at risk in other states given the substantial loss of federal funding. Not all trigger laws would immediately end the Medicaid expansion, but enrollees in states with trigger laws are at greater risk of losing coverage. States are actively debating their Medicaid expansion trigger laws, with some states working to remove and others working to establish the automatic termination of Medicaid expansion coverage if federal support declines.

If states maintained their Medicaid expansion coverage in the wake of this policy change, they would need to find ways to offset the loss of federal funding. This could include increasing state tax revenues or decreasing spending on non-Medicaid services such as education, which is the largest source of expenditures from state funds. States could alternatively decrease Medicaid coverage for other groups, eliminate coverage of optional benefits such as prescription drugs and home care, or reduce provider payment rates. Given the size of the federal funding cut, states would face significant challenges in efforts to replace the loss of federal funds, which would be exacerbated if paired with other reductions in federal funding for Medicaid or in other areas such as education.

If states are unable to maintain Medicaid expansion coverage (or terminate expansion due to a trigger law), the number of uninsured would increase and could reverse gains in financial security, access to care, and health outcomes associated with Medicaid expansion. In all states, some of the people who lose expansion eligibility may qualify for Medicaid under a different eligibility pathway, for example based on a disability, but some of those people may only qualify for partial Medicaid benefits such as coverage of family planning services or breast and cervical cancer screening and prevention. Other enrollees with incomes between 100% and 138% of poverty could be eligible for coverage through the ACA marketplaces, but ACA coverage will soon become more costly for enrollees if the enhanced subsidies expire at the end of 2025.  Enrollees with incomes below poverty could fall into the coverage gap. Research shows that after losing Medicaid, many people become uninsured. Increasing numbers of uninsured people could lead to loss of revenues and increased uncompensated care costs for providers. A large body of prior research shows that Medicaid expansion has helped to reduce the uninsured rate and improve health care access, affordability, and financial security among the low-income population. More recent research shows improvements in health outcomes and continues to show positive effects for providers (particularly rural hospitals) and for sexual and reproductive health. Because of the widespread adoption of the Medicaid expansion across states, the financial and coverage impacts will fall on states that voted for President Trump and those that voted for former Vice President Harris.

Appendix

Methods

Data: To project Medicaid enrollment, spending, and spending per enrollee by state and eligibility group, this analysis uses the Medicaid CMS-64 new adult group expenditure data collected through MBES for FY 2023 (downloaded in December 2024), Medicaid new adult group enrollment data collected through MBES for June 2024 (downloaded in December 2024), the 2019-2021 T-MSIS Research Identifiable Demographic-Eligibility and Claims Files, and the June 2024 Congressional Budget Office (CBO) baseline.

Overview of Approach:

• Develop baseline projections of Medicaid enrollment, spending, and spending per enrollee by state and eligibility group from FY 2025 through FY 2034 (a 10-year period). This model estimates Medicaid enrollment and spending under the status quo with no policy changes.
• Estimate Medicaid enrollment, spending, and spending per enrollee by state and eligibility group over the same 10-year period after accounting for the effects of proposed policy changes.
• Calculate differences in Medicaid enrollment, spending (including federal, state, and total spending), and spending per enrollee in the policy change scenario relative to the baseline projections.
• The estimates do not predict states’ responses to federal policy changes, but we examine differences in Medicaid enrollment, spending, and spending per enrollee under different scenarios to reflect the range of outcomes depending on state responses.

Definitions and Limitations:

• At the time of publishing, CBO had released their January 2025 baseline. However, this analysis uses CBO’s June 2024 baseline because it was the most recent baseline with spending projections by Medicaid eligibility group.
• The estimates assume that all states experience the same growth rates for Medicaid enrollment and spending; and that total spending grows at the same rate as federal spending.
• FMAP calculations do not account for the other services that are matched at a higher rate, which include family planning, services received through an Indian Health Services facility, expenditures for Medicare beneficiaries enrolled in the “Qualifying Individuals” program, and health home services that are matched at a 90% rate. For this reason, the model may underestimate the federal share of spending in some states.
• Estimates of total spending include all spending that is matched as medical assistance but exclude states’ administrative costs which are matched at a separate rate. Federal payments for administrative costs are less than 4% of total federal spending, according to the CBO June 2024 baseline.
• The analysis does not account for secondary effects or people’s behavioral responses.
• The analysis does not include policy effects for states that had not expanded Medicaid under the ACA as of February 2025 but would have done so in the absence of the policy change.
• We implement the policy change scenarios in FY 2026 and assume they take effect immediately.

We provide more details about the baseline model below.

1. Estimate initial Medicaid spending and enrollment by eligibility group using the most recent years’ data available (FY 2023 for spending data and FY 2024 for enrollment data).

•  First, we pull the quarterly Medicaid CMS-64 new adult group expenditure data collected through MBES for FY 2023 and aggregate total spending by state for enrollees in the ACA expansion group and for all other Medicaid enrollees. Spending reflects an accrual basis of accounting.
• We exclude spending on DSH by calculating the share of spending on DSH from the FY 2023 CMS-64 Financial Management Report and reducing medical assistance among non-expansion enrollees by that share.
• Separately, we pull the Medicaid new adult group enrollment data collected through MBES for June 2024. This data includes enrollment by state and is broken into ACA expansion group enrollees and all other Medicaid enrollees. MBES enrollment includes individuals enrolled in limited benefit plans and only includes individuals whose coverage is funded through Medicaid (not CHIP).
• To obtain spending and enrollment estimates across the remaining eligibility groups (seniors, individuals with disabilities, children, and other adults), we apply the distribution of spending and enrollment across the groups and by state from T-MSIS to the FY 2023 spending data and June 2024 enrollment data. We use the average distribution from 2019 to 2021 to mitigate the impact of the continuous enrollment provision (data in states denoted as “unusable” for a given year by the DQ atlas were excluded from the averages).

2. Calculate initial spending per enrollee in FY 2024.

• We grow Medicaid spending in FY 2023 by CBO’s growth rates for federal benefit payments by eligibility group to get Medicaid spending in FY 2024. The June 2024 enrollment data is used as our FY 2024 enrollment.
• We divide Medicaid spending in FY 2024 by Medicaid enrollment in FY 2024 (for each state and eligibility group) to get Medicaid spending per enrollee in FY 2024.

3. Project total spending and spending per enrollee for fiscal years 2025 through 2034 using CBO growth rates and use those estimates to calculate future years’ enrollment.

• Starting with spending data for FY 2024, we apply the CBO growth rates to estimate Medicaid spending in FY 2025 through FY 2034.
• Starting with per enrollee spending in FY 2024, we apply the CBO growth rates for average federal spending on benefit payments per enrollee to estimate Medicaid spending in FY 2025 through FY 2034.
• We calculate enrollment growth in FY 2025 through FY 2034 by dividing estimated Medicaid spending by estimated spending per enrollee.

4. Split total Medicaid spending over the 10-year period into federal and state spending.

• We calculate federal and state spending by using a 90% match rate for the ACA expansion group and the traditional state FMAPs for the remaining eligibility groups. We use the FY 2025 FMAPs for FY 2025 and FY 2026 FMAPs for FY 2026 and beyond.

We provide more details about the policy change scenarios below.

1. Calculate spending and enrollment under scenario 1 (ACA expansion states pick up new expansion costs) by state.

• Assume expansion enrollment and total spending remain the same as the baseline model over the 10-year period.
• Split total Medicaid spending (from baseline) into federal and state spending.  We assume the policy change takes effect in FY 2026, so FY 2025 federal and state spending is the same as baseline.
• Starting in FY 2026, we apply the 2026 traditional state FMAPs to the expansion group spending instead of the 90% rate to split total spending into the federal and state share. For the expansion group, spending shifts from the federal to state governments. Spending for all other eligibility groups remains unchanged.

2. Calculate spending and enrollment under scenario 2 (all states drop the ACA Medicaid expansion) by state.

• Expansion enrollment is reduced to zero for FY 2026 – FY 2034, leading to zero total spending for expansion enrollees for FY 2026 – FY 2034.
• Spending and enrollment for all other eligibility groups remains unchanged.

3. Calculate differences in Medicaid enrollment and spending (including federal, state, and total spending) relative to the baseline projections.

Note: Originally published in Jan. 2017, this resource is updated as needed, most recently on Feb. 12, 2025, to reflect the latest developments. 

Key Points

• On January 24, 2025, President Trump reinstated the Mexico City Policy, marking the resumption of the expansion of the policy from his first term.
• First announced in 1984 by the Reagan administration, the policy has been rescinded and reinstated by subsequent administrations along party lines and has been in effect for 22 of the past 41 years.
• When in effect, the policy has 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. In 2017, President Trump reinstated the policy but also significantly expanded it to encompass the vast majority of U.S. bilateral global health assistance, and in 2025, he reinstated this expanded application of the policy.
• The expanded policy applies to all of global health, including PEPFAR, maternal and child health, malaria, nutrition, and other U.S. programs. When last in effect, it potentially encompassed $7.3 billion in FY 2020 alone, to the extent that such funding was ultimately provided to foreign NGOs, directly or indirectly (family planning assistance accounted for approximately $600 million of that total).
• The Trump administration’s recent reinstatement of the policy calls for the Secretary of State, in coordination with the Secretary of Health and Human Services, to implement a plan to extend the requirements of the policy to global health assistance provided by all departments or agencies.

What is the Mexico City Policy?

The Mexico City Policy is a U.S. government policy that – when in effect – has required foreign NGOs to certify that they will 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. global family planning assistance and, when in place under the Trump administration, most other U.S. global health assistance.

The policy was first announced by the Reagan administration at the 2nd International Conference on Population, which was held in Mexico City, Mexico, on August 6-14, 1984 (hence its name; see Box 1).¹   Under the first Trump administration, the policy was renamed “Protecting Life in Global Health Assistance” (PLGHA). Among opponents, it is also known as the “Global Gag Rule,” because among other activities, it prohibits foreign NGOs from using any funds (including non-U.S. funds) to provide information about abortion as a method of family planning and to lobby a foreign government to legalize abortion.

When first instituted in 1984, the Mexico City Policy marked an expansion of existing legislative restrictions that already prohibited U.S. funding for abortion internationally, with some exceptions (see below). Prior to the policy, foreign NGOs could use non-U.S. funds to engage in certain voluntary abortion-related activities as long as they maintained segregated accounts for any U.S. money received, but after the Mexico City Policy was in place, they were no longer permitted to do so if they wanted to receive U.S. family planning assistance.

The first Trump administration’s application of the policy to the vast majority of U.S. bilateral global health assistance, including funding for HIV under the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), maternal and child health, malaria, nutrition, and other programs, marked a significant expansion of its scope, potentially encompassing $7.3 billion in FY 2020 alone, to the extent that such funding was ultimately provided to foreign NGOs, directly or indirectly (family planning assistance accounted for approximately $600 million of that total).³  The Trump administration also moved to further tighten restrictions, reaching other areas of U.S. development assistance beyond global health and other non-U.S. funding streams. See “What is the definition of ‘financial support’?” below.⁴ 

Although President Biden rescinded the policy during his administration, President Trump’s reinstatement of the policy during his second term will once again require agencies involved in foreign assistance to apply the policy going forward. In addition, the Trump administration has also issued an executive order to re-evaluate foreign aid, including a 90-day review of all programs and pause on new obligations and disbursements as well as freeze of current program implementation; how the reinstated Mexico City Policy intersects with these other actions is not yet clear.

When has it been in effect?

The Mexico City Policy has been in effect for 22 of the past 41 years, primarily through executive action, and has been instated, rescinded, and reinstated by presidential administrations along party lines (see Table 1).

The policy was first instituted in 1984 (taking effect in 1985) by President Ronald Reagan and continued to be in effect through President George H.W. Bush’s administration. It was rescinded by President Bill Clinton in 1993 (although it was reinstated legislatively for one year during his second term;⁵  see below).⁶  The policy was reinstated by President George W. Bush in 2001,⁷  rescinded by President Barack Obama in 2009,⁸  and reinstated and expanded by President Trump in 2017.⁹  It was rescinded by President Biden at the beginning of his term in 2021,¹⁰  and again reinstated, in its expanded form, by President Trump at the beginning of his term in 2025.¹¹ 

The Mexico City Policy has, for the most part, been instituted or rescinded through executive branch action (typically via presidential memoranda¹² ). While Congress has the ability to institute the policy through legislation, this has happened only once in the past: a modified version of the policy was briefly applied by Congress during President Clinton’s last year in office as part of a broader arrangement to pay the U.S. debt to the United Nations.¹³  (At that time, President Clinton was able to partially waive the policy’s restrictions.¹⁴ ) Other attempts to institute the policy through legislation have not been enacted into law,¹⁵  nor have legislative attempts to overturn the policy.¹⁶  See Table 1.

Who does the policy apply to?

When in effect, the policy applies to foreign NGOs as a condition of receiving U.S. family planning support and, as expanded under President Trump, most other bilateral global health assistance, either directly (as the main – or prime – recipient of U.S. funding) or indirectly (as a recipient of U.S. funding through an agreement with the prime recipient; referred to as a sub-recipient). Specifically, a foreign NGO “recipient agrees that it will not, during the term of this award, perform or actively promote abortion as a method of family planning in foreign countries or provide financial support to any other foreign non-governmental organization that conducts such activities.”¹⁷ 

Foreign NGOs include:

• international NGOs that are based outside the U.S.,
• regional NGOs that are based outside the U.S., and
• local NGOs in assisted countries.¹⁸ 

U.S. NGOs have not been directly subject to the Mexico City Policy but, when in place, must also agree to ensure that they do not provide funding to any foreign NGO sub-recipients unless those sub-recipients have first certified adherence to the policy. Specifically, a U.S. NGO “recipient (A) agrees that it will not furnish health assistance under this award to any foreign non-governmental organization that performs or actively promotes abortion as a method of family planning in foreign countries; and (B) further agrees to require that such sub-recipients do not provide financial support to any other foreign non-governmental organization that conducts such activities.”¹⁹ 

Certain recipients of U.S. assistance have always been exempt from the policy, including foreign governments (national or sub-national) and public international organizations and other multilateral entities, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria and Gavi, the Vaccine Alliance.²⁰  However, as expanded by President Trump, this funding is subject to the policy if it flows through a foreign NGO that has accepted the policy;²¹  see “What is the definition of ‘financial support’?” below.

To what assistance does it apply?

“Assistance” includes “the provision of funds, commodities, equipment, or other in-kind global health assistance”.²²  In the past, foreign NGOs have been required to adhere to the Mexico City Policy – when in effect – as a condition of receiving support through certain U.S. international funding streams: family planning assistance through the U.S. Agency for International Development (USAID) and, beginning in 2003, family planning assistance²³  through the U.S. Department of State. In the 2003 memorandum announcing the policy’s expansion to include the Department of State, President Bush stated that the policy did not apply to funding for global HIV/AIDS programs and that multilateral organizations that are associations of governments are not included among “foreign NGOs.”²⁴  However, the first Trump administration greatly expanded – and the second Trump administration reinstated – the policy to apply to the vast majority of U.S. bilateral global health assistance furnished by all agencies and departments, including:²⁵ 

• family planning and reproductive health
• maternal and child health (including household-level water, sanitation, and hygiene (WASH))²⁶ 
• nutrition
• HIV under PEPFAR
• tuberculosis
• malaria under the President’s Malaria Initiative (PMI)
• neglected tropical diseases
• global health security
• certain types of research activities²⁷ 

The policy applies to the assistance described above that was appropriated directly to three agencies and departments: USAID; the Department of State, including the Office of the Global AIDS Coordinator, which oversees and coordinates U.S. global HIV funding under PEPFAR; and for the first time, the Department of Defense (DoD).²⁸  When such funding is transferred to another agency, including the Centers for Disease Control (CDC) and the National Institutes of Health (NIH), it remains subject to the policy, to the extent that such funding is ultimately provided to foreign NGOs, directly or indirectly.

The policy applies to two types of funding instruments: grants and cooperative agreements.²⁹  The first Trump administration had sought to apply the policy to contracts and issued a proposed rule to this effect, but it was not finalized;³⁰  it is not clear whether the second Trump administration will also seek to do so.

The policy does not apply to U.S. assistance for: water supply and sanitation activities, which is usually focused on infrastructure and systems;³¹  humanitarian assistance, including activities related to migration and refugee assistance activities as well as disaster and humanitarian relief activities; the American Schools and Hospitals Abroad (ASHA) program; and Food for Peace (FFP).³²  However, this funding is subject to the policy if it flows through a foreign NGO that has accepted the policy;³³  see “What is the definition of ‘financial support’?” below.

What activities does it prohibit?

The policy prohibits foreign NGOs that receive U.S. family planning assistance and, as expanded by President Trump, most other U.S. bilateral global health assistance from using funds from any source (including non-U.S. funds) to “perform or actively promote abortion as a method of family planning.” In addition to providing abortions with non-U.S. funds, restricted activities also include the following:

• providing advice and information about and offering referral for abortion – where legal – as part of the full range of family planning options,
• promoting changes in a country’s laws or policies related to abortion as a method of family planning (i.e., engaging in lobbying), and
• conducting public information campaigns about abortion as a method of family planning.

The prohibition of these activities is why the policy has been referred to by its critics as the “Global Gag Rule.”

Additionally, for the first time, the expanded policy during the first Trump administration prohibited foreign NGOs from providing any financial support with any source of funds (including non-U.S. funding) and for any purpose to other foreign NGOs that perform or actively promote abortion as a method of family planning;³⁴  see “What is the definition of ‘financial support’?” below.

When in effect, the policy, however, does not prohibit foreign NGOs from:

• providing advice and information about, performing, or offering referral for abortion in cases where the pregnancy has either posed a risk to the life of the mother or resulted from incest or rape;³⁵  and
• responding to a question about where a safe, legal abortion may be obtained when a woman who is already pregnant clearly states that she has already decided to have a legal abortion (passively providing information, versus actively providing medically-appropriate information).

In addition, the expanded policy during the Trump administrations does not apply to healthcare providers who have an affirmative duty required under local law to provide counseling about and referrals for abortion as a method of family planning.

Does it restrict direct U.S. funding for abortion overseas?

U.S. funding for abortion was already restricted and remains restricted under several provisions of the law.³⁶  Specifically, before the Mexico City Policy was first announced in 1984, U.S. law already prohibited the use of U.S. aid:

• to pay for the performance of abortion as a method of family planning or to motivate or coerce any person to practice abortion (the Helms Amendment, 1973, to the Foreign Assistance Act);
• for biomedical research related to methods of or the performance of abortion as a means of family planning (the Biden Amendment, 1981, to the Foreign Assistance Act); and
• to lobby for or against abortion³⁷  (the Siljander Amendment, first included in annual appropriations in 1981 and included each year thereafter).

Then, shortly after the policy was announced in 1984, the Kemp-Kasten Amendment was passed in 1985, prohibiting the use of U.S. aid to fund any organization or program, as determined by the president, that supports or participates in the management of a program of coercive abortion or involuntary sterilization (it is now included in annual appropriations).

Before the Mexico City Policy, U.S. aid recipients could use non-U.S. funds to engage in certain abortion-related activities but were required to maintain segregated accounts for U.S. assistance.³⁸  The Mexico City Policy reversed this practice: no longer were foreign NGOs allowed to use non-U.S. funds, maintained in segregated accounts, for voluntary abortion-related activities if they wished to continue to receive or be able to receive U.S. family planning funds.

Does the policy prohibit post-abortion care?

The Mexico City Policy does not restrict the provision of post-abortion care, which is a supported activity of U.S. family planning assistance. Whether or not the Mexico City Policy is in effect, recipients of U.S. family planning assistance are allowed to use U.S. and non-U.S. funding to support post-abortion care,³⁹  no matter the circumstances of the abortion (whether it was legal or illegal).

What has been the impact of the policy?

A KFF literature review of studies examining the policy, from 2001 to 2024, identified a range of impacts associated with the policy, including: increases in abortion rates and reductions in contraceptive prevalence (among other health outcomes); disruption and gaps in services; reduction in service integration; over-implementation and chilling effects; confusion about the policy; loss of civil society/NGO coordination and partnerships; and increased administrative burden. In addition, several studies sought to calculate or estimate the reach of the policy, as measured by amount of funding, countries, and/or NGOs affected (see Box 2).

KFF analyses have also found that during the first Trump administration, the expanded policy applied to a much greater amount of U.S. global health assistance, and greater number of foreign NGOs, across many program areas.⁴⁰  KFF found that more than half (37) of the 64 countries that received U.S. bilateral global health assistance in FY 2016 allow for legal abortion in at least one case not permitted by the policy and that had the expanded Mexico City Policy been in effect during the FY 2013 – FY 2015 period, at least 1,275 foreign NGOs would have been subject to the policy. In addition, at least 469 U.S. NGOs that received U.S. global health assistance during this period would have been required to ensure that their foreign NGO sub-recipients were in compliance. Additional foreign NGOs were likely impacted by the policy due to the revised interpretation of “financial support” announced in March 2019 and implemented beginning June 2019;⁴¹  see “What is the definition of ‘financial support’?” below.

During the first Trump administration, two official assessments by the U.S. Department of State were released (see below).⁴²  Additionally, a report released in March 2020 by the U.S. Government Accountability Office (GAO) provided new information on the number of projects (awards) and NGOs affected by the expanded policy during the first Trump administration. It found that from May 2017 through FY 2018:

• the policy had been applied to over 1,300 global health projects, with the vast majority of these through USAID and CDC, and
• NGOs declined to accept the policy in 54 instances, totaling $153 million in declined funding – specifically, seven prime awards amounting to $102 million and 47 sub-awards amounting to $51 million (more than two-thirds of sub-awards were intended for Africa) – across USAID and CDC; the Department of State and DoD did not identify any instances where NGOs declined to accept the policy conditions.

What did the U.S. government’s reviews of the expanded policy during the first Trump administration find?

During the first Trump administration, the U.S. government published two reviews of the expanded policy, with the first examining the initial six months of the policy released in February 2018 and the second examining the first 18 months of the policy released in August 2020.

First Review

In February 2018, the Department of State announced the findings of an initial six-month review of implementation of the policy through the end of FY 2017 (September 2017).⁴³  The report directed agencies to provide greater support for improving understanding of implementation among affected organizations and provided guidance to clarify terms included in standard provisions of grants and cooperative agreements. In the six-month review report, the Department of State report identified a number of “actions” for implementing agencies, such as a need for:

• more central and field-based training and implementation tools,
• a clearer explanation of termination of awards for NGOs found to be in violation of the policy, and
• a clarification of “financial support,” which was not defined in the standard provisions (see “What is the definition of ‘financial support’?” below).
• The six month review also identified the number of affected agreements with prime implementing partners and the number of those that have accepted the Mexico City Policy as part of their agreements through September 2017 (see Table 2).

Second Review

On August 17, 2020, the Department of State released its second review of the policy, updating its initial six-month review (as an action item in the six-month review report, the department stated it would “conduct a further review of implementation of the policy by December 15, 2018, when more extensive experience will enable a more thorough examination of the benefits and challenges”). The long-anticipated review, which examines the period from May 2017 through September 2018, found:

• the awards declined spanned a variety of program areas, including family planning and reproductive health (FP/RH), HIV and AIDS (HIV/AIDS), maternal and child health (MCH), tuberculosis (TB), and nutrition, in addition to cross-cutting awards;
• the awards declined spanned geographic areas but many were for activities in sub-Saharan Africa;
• agencies and departments made efforts to transition projects to another implementer in order to minimize disruption; but
• nevertheless, among USAID awards involving health service delivery where prime and sub-award recipients declined to accept the policy, gaps or disruptions in service delivery were sometimes reported.

The second review also identified the number of affected agreements with prime implementing partners and the number of those that have accepted the Mexico City Policy as part of their agreements through September 2018 (see Table 3).

Additionally, the review reported that 47 sub-awardees, all under USAID awards, declined to accept the policy. It is important to note that the review also stated that information on sub-awards is not systematically collected by departments and agencies and that DoD was not able to collect information on sub-awards.

What is the definition of “financial support”?

The first Trump administration also expanded (and the second Trump administration reinstates) the interpretation of “financial support” to apply to more funding and organizations, albeit indirectly. In February 2018, in the initial six-month review issued when then-Secretary of State Tillerson led the department, the Department of State report included an “action” statement to clarify the definition of “financial support” as used in the standard provisions for grants and cooperative agreements. At issue was whether it applied more narrowly to certain funding provided by foreign NGOs (i.e., funding other than U.S. global health funding) to other foreign NGOs specifically for the purpose of performing or actively promoting abortion as a method of family planning or if it applied more broadly to certain funding provided by foreign NGOs to other foreign NGOs for any purpose, if that foreign NGO happened to perform or actively promote abortion as a method of family planning. The State Department clarified that it was the more narrow interpretation.⁴⁴ 

However, on March 26, 2019, then-Secretary of State Pompeo reversed this interpretation, announcing further “refinements” to the policy to clarify that it applied to the broader definition of financial support.⁴⁵  Specifically, under the policy, U.S.-supported foreign NGOs agree to not provide any financial support (global health-related as well as other support), no matter the source of funds, to any other foreign NGO that performs or actively promotes abortion as a method of family planning. In June 2019, USAID provided additional information to reflect this broader interpretation of the standard provisions.⁴⁶ 

This marked the first time the policy had been applied this broadly, as it could then affect funding provided by other donors (such as other governments and foundations) and non-global health funding provided by the U.S. government for a wide range of purposes if this funding was first provided to foreign NGOs who had accepted the policy (as recipients of U.S. global health assistance) that then in turn provided that donor or U.S. non-global health funding for any purpose to foreign NGOs that perform or actively promote abortion as a method of family planning. For example, under the prior interpretation, a foreign NGO recipient of U.S. global health funding could not provide any non-U.S. funding to another foreign NGO to perform or actively promote abortion as a method of family planning but could provide funding for other activities, such as education, even if the foreign NGO carried out prohibited activities. Under the broader interpretation, a foreign NGO could not provide any non-U.S. funding for any activity to a foreign NGO that carried out prohibited activities. Similarly, while under the prior interpretation a foreign NGO recipient of U.S. global health funding could provide other U.S. funding (such as humanitarian assistance) to another foreign NGO for non-prohibited activities, even if the foreign NGO carried out prohibited activities, under the subsequent broader interpretation, it could not do so.

What has happened since President Trump reinstated the expanded policy during his second term?

Since President Trump reinstated his 2017 memorandum on the Mexico City Policy in January 2025 and also directed the Secretary of State and HHS Secretary to implement a plan to extend its requirements to global health assistance furnished at all agencies or departments, no additional specifics about what actions have been taken to implement the expanded policy have been announced. This is, in part, due to the recent executive actions affecting the operation of USAID and freezing foreign aid.

1. “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, https://www.jstor.org/stable/1973537?seq=1; 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. ↩︎
2. “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, https://www.jstor.org/stable/1973537?seq=1. ↩︎
3. KFF analysis of Trump Administration/Department of State: “Protecting Life in Global Health Assistance,” fact sheet, May 15, 2017, https://2017-2021.state.gov/protecting-life-in-global-health-assistance-2/index.html; “Background Statement: Announcement of ‘Protecting Life in Global Health Assistance,’” background opening statement, May 15, 2017; “Implementation of Protecting Life in Global Health Assistance (Formerly known as the ‘Mexico City Policy’),” PRM press guidance, May 15, 2017; “Background Briefing: Senior Administration Officials on Protecting Life in Global Health Assistance,” press release of special briefing by senior Department of State officials via teleconference, May 15, 2017, https://2017-2021.state.gov/background-briefing-senior-administration-officials-on-protecting-life-in-global-health-assistance/index.html; “Subject: Protecting Life in Global Health Assistance,” Federal Assistance Management Advisory Number 2017-01; “Protecting Life in Global Health Assistance (May 2019),” MCP-related portion of standard provisions for cooperative agreements and grants to U.S. NGOs (May 2020) and foreign NGOs (Aug. 2020)); and 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. ↩︎
4. USAID, “Protecting Life in Global Health Assistance Frequently Asked Questions and Answers,” Oct. 2019, https://www.usaid.gov/sites/default/files/documents/1864/FINAL_Protecting_Life_in_Global_Health_Assistance_FAQs_Oct_2019_USAID.pdf. ↩︎
5. The temporary, one-year legislative imposition of the policy occurred as part of a broader deal related to paying the U.S. debt to the United Nations. See FY 2000 Consolidated Appropriations Act, P.L. 106-113, https://www.congress.gov/bill/106th-congress/house-bill/3194/text; PAI, Global Gag Rule Timeline, July 12, 2011; and Richard Cincotta and Barbara Crane, “The Mexico City Policy and U.S. Family Planning Assistance,” Science, Oct. 19, 2001, Vol. 294: pp. 525-526, https://science.sciencemag.org/content/294/5542/525. ↩︎
6. Bill Clinton Administration, “Subject: AID Family Planning Grants/Mexico City Policy,” Memorandum for the Acting Administrator of the Agency for International Development, January 22, 1993, Clinton White House Archives, https://clintonwhitehouse6.archives.gov/1993/01/1993-01-22-aid-family-planning-grants-mexico-city-policy.html. ↩︎
7. George W. Bush Administration, “Subject: Restoration of the Mexico City Policy,” Memorandum for the Administrator of the United States Agency for International Development, January 22, 2001, Bush Administration White House Archives, https://georgewbush-whitehouse.archives.gov/news/releases/20010123-5.html; “Subject: Restoration of the Mexico City Policy,” Memorandum for the Administrator of the United States Agency for International Development, March 28, 2001, Federal Register, https://www.federalregister.gov/documents/2001/03/29/01-8011/restoration-of-the-mexico-city-policy; George W. Bush Administration, “Subject: Assistance for Voluntary Population Planning,” Memorandum for the Secretary of State, August 29, 2003, Bush Administration White House Archives, http://georgewbush-whitehouse.archives.gov/news/releases/2003/08/20030829-3.html. ↩︎
8. Barack Obama Administration, “Mexico City Policy and Assistance for Voluntary Population Planning,” Memorandum for the Secretary of State, the Administrator of the United States Agency for International Development, January 23, 2009, Obama White House Archives, https://obamawhitehouse.archives.gov/the-press-office/mexico-city-policy-and-assistance-voluntary-population-planning. ↩︎
9. Donald J. Trump Administration, “The Mexico City Policy,” Memorandum for the Secretary of State, the Secretary of Health and Human Services, the Administrator of the Agency for International Development, Jan. 23, 2017, Trump Administration  White House Archives, https://trumpwhitehouse.archives.gov/presidential-actions/presidential-memorandum-regarding-mexico-city-policy/. ↩︎
10. White House, “Memorandum on Protecting Women’s Health at Home and Abroad,” presidential actions, Jan. 28, 2021, https://www.whitehouse.gov/briefing-room/presidential-actions/2021/01/28/memorandum-on-protecting-womens-health-at-home-and-abroad/; White House, “FACT SHEET: President Biden to Sign Executive Orders Strengthening Americans’ Access to Quality, Affordable Health Care,” statements and releases, Jan. 28, 2021, https://www.whitehouse.gov/briefing-room/statements-releases/2021/01/28/fact-sheet-president-biden-to-sign-executive-orders-strengthening-americans-access-to-quality-affordable-health-care/. ↩︎
11. White House/Donald J. Trump Administration (second), “The Mexico City Policy,” Memorandum for the Secretary of State, Secretary of Defense, the Secretary of Health and Human Services, the Administrator of the Agency for International Development, Jan. 24, 2025, https://www.whitehouse.gov/presidential-actions/2025/01/memorandum-for-the-secretary-of-state-the-secretary-of-defense-the-secretary-of-health-and-human-services-the-administrator-of-the-united-states-for-international-development/; White House/Donald J. Trump Administration (second), “FACT SHEET: President Donald J. Trump Enforces Overwhelmingly Popular Demand to Stop Taxpayer Funding of Abortion,” fact sheets, Jan. 25, 2025, https://www.whitehouse.gov/fact-sheets/2025/01/fact-sheet-president-donald-j-trump-enforces-overwhelmingly-popular-demand-to-stop-taxpayer-funding-of-abortion/. ↩︎
12. Presidential memoranda “are often used to carry out routine executive decisions and determinations, or to direct agencies to perform duties consistent with the law or implement laws that are presidential priorities” and are not required to be published in the Federal Register (although those pertaining to the Mexico City Policy sometimes have been). These presidential instruments or directives “may have the force and effect of law only if the presidential action is based on power vested in the President by the U.S. Constitution or delegated to the President by Congress.” Memoranda have the same legal authority as executive orders, although the latter is always required to be published in the Federal Register. Quotes as stated in Congressional Research Service (CRS), Executive Orders: Issuance, Modification, and Revocation, April 16, 2014, RS20846, https://fas.org/sgp/crs/misc/RS20846.pdf. ↩︎
13. The legislative application of the policy – applying to FY 2000, which was from Oct. 1, 1999, until Sept. 30, 2000 – included language that prohibited USAID from providing family planning assistance to any foreign private, nongovernmental, or multilateral organizations until they certified that during the period for which the funding was made available 1) they would not perform abortions as a method of family planning in any foreign country and 2) they would not violate the laws of any foreign country regarding abortion and would not engage in lobbying any foreign country regarding abortion. FY 2000 Consolidated Appropriations Act, P.L. 106-113, https://www.congress.gov/bill/106th-congress/house-bill/3194/text; PAI, Global Gag Rule Timeline, July 12, 2011; and Richard Cincotta and Barbara Crane, “The Mexico City Policy and U.S. Family Planning Assistance,” Science, Oct. 19, 2001, Vol. 294: pp. 525-526, https://science.sciencemag.org/content/294/5542/525. ↩︎
14. The legislation included an option for the president to waive these restrictions; however, if he exercised the waiver option (for no more than $15 million in family planning assistance), then $12.5 million of this funding would be transferred to maternal and child health assistance. The president did exercise the waiver option. FY 2000 Consolidated Appropriations Act, P.L. 106-113, https://www.congress.gov/bill/106th-congress/house-bill/3194/text. ↩︎
15. CRS, Abortion and Family Planning-Related Provisions in U.S. Foreign Assistance Law and Policy, May 17, 2016, R41360, https://digital.library.unt.edu/ark:/67531/metadc855791/. ↩︎
16. CRS, Appropriations for FY2000: Foreign Operations, Export Financing, and Related Programs, updated August 4, 1999, RL30211, https://digital.library.unt.edu/ark:/67531/metadc814156/; CRS, International Family Planning: The “Mexico City” Policy, updated April 2, 2001, RL30830, https://digital.library.unt.edu/ark:/67531/metacrs1906/; CRS, Abortion and Family Planning-Related Provisions in U.S. Foreign Assistance Law and Policy, May 17, 2016, R41360, https://digital.library.unt.edu/ark:/67531/metadc855791/; PAI, Global Gag Rule Timeline, July 12, 2011. ↩︎
17. USAID: “Standard Provisions for U.S. Nongovernmental Organizations: A Mandatory Reference for ADS Chapter 303,” ADS Reference 303maa, partial revision May 18, 2020, https://www.usaid.gov/ads/policy/300/303maa; “Standard Provisions for Non-U.S. Nongovernmental Organizations: A Mandatory Reference for ADS Chapter 303,” ADS Reference 303mab, partial revision Aug. 18, 2020, https://www.usaid.gov/ads/policy/300/303mab; USAID, “Protecting Life in Global Health Assistance Frequently Asked Questions and Answers,” Oct. 2019, https://www.usaid.gov/sites/default/files/documents/1864/FINAL_Protecting_Life_in_Global_Health_Assistance_FAQs_Oct_2019_USAID.pdf. ↩︎
18. The USAID Standard Provisions state that “a foreign non-governmental organization is a for-profit or not-for-profit non-governmental organization that is not organized under the laws of the United States, any State of the United States, the District of Columbia, or the Commonwealth of Puerto Rico, or any other territory or possession of the United States.” USAID: “Standard Provisions for U.S. Nongovernmental Organizations: A Mandatory Reference for ADS Chapter 303,” ADS Reference 303maa, partial revision May 18, 2020, https://www.usaid.gov/ads/policy/300/303maa; “Standard Provisions for Non-U.S. Nongovernmental Organizations: A Mandatory Reference for ADS Chapter 303,” ADS Reference 303mab, partial revision Aug. 18, 2020, https://www.usaid.gov/ads/policy/300/303mab. ↩︎
19. USAID: “Standard Provisions for U.S. Nongovernmental Organizations: A Mandatory Reference for ADS Chapter 303,” ADS Reference 303maa, partial revision May 18, 2020, https://www.usaid.gov/ads/policy/300/303maa; “Standard Provisions for Non-U.S. Nongovernmental Organizations: A Mandatory Reference for ADS Chapter 303,” ADS Reference 303mab, partial revision Aug. 18, 2020, https://www.usaid.gov/ads/policy/300/303mab. ↩︎
20. Department of State: “Protecting Life in Global Health Assistance,” fact sheet, May 15, 2017, https://2017-2021.state.gov/protecting-life-in-global-health-assistance-2/index.html; “Background Statement: Announcement of ‘Protecting Life in Global Health Assistance,’” background opening statement, May 15, 2017; “Implementation of Protecting Life in Global Health Assistance (Formerly known as the ‘Mexico City Policy’),” PRM press guidance, May 15, 2017; “Background Briefing: Senior Administration Officials on Protecting Life in Global Health Assistance,” press release of special briefing by senior Department of State officials via teleconference, May 15, 2017, https://2017-2021.state.gov/background-briefing-senior-administration-officials-on-protecting-life-in-global-health-assistance/index.html; “Subject: Protecting Life in Global Health Assistance,” Federal Assistance Management Advisory Number 2017-01; “Protecting Life in Global Health Assistance (May 2019),” MCP-related portion of standard provisions for cooperative agreements and grants to U.S. NGOs (May 2020) and foreign NGOs (Aug. 2020). ↩︎
21. USAID, “Protecting Life in Global Health Assistance Frequently Asked Questions and Answers,” Oct. 2019, https://www.usaid.gov/sites/default/files/documents/1864/FINAL_Protecting_Life_in_Global_Health_Assistance_FAQs_Oct_2019_USAID.pdf. ↩︎
22. As stated in Department of State, “Implementation of Protecting Life in Global Health Assistance (Formerly known as the ‘Mexico City Policy’),” PRM press guidance, May 15, 2017. ↩︎
23. George W. Bush Administration, “Subject: Assistance for Voluntary Population Planning,” Memorandum for the Secretary of State, August 29, 2003, Bush Administration White House Archives, http://georgewbush-whitehouse.archives.gov/news/releases/2003/08/20030829-3.html. ↩︎
24. George W. Bush Administration, “Subject: Assistance for Voluntary Population Planning,” Memorandum for the Secretary of State, August 29, 2003, Bush Administration White House Archives, http://georgewbush-whitehouse.archives.gov/news/releases/2003/08/20030829-3.html. In other words, when President Bush extended the policy to include funding at the Department of State, he stated in the memorandum that the policy did not apply to foreign aid funding for global HIV/AIDS, malaria, and tuberculosis programs (including those under the U.S. President’s Emergency Plan for AIDS Relief or PEPFAR). He also stated that “foreign NGOs” do not include multilateral organizations that are associations of governments, such as the U.N. Population Fund (UNFPA) and the Global Fund to Fight AIDS, Tuberculosis and Malaria. For more information about PEPFAR, see the KFF fact sheet. ↩︎
25. Department of State: “Protecting Life in Global Health Assistance,” fact sheet, May 15, 2017, https://2017-2021.state.gov/protecting-life-in-global-health-assistance-2/index.html; “Background Statement: Announcement of ‘Protecting Life in Global Health Assistance,’” background opening statement, May 15, 2017; “Implementation of Protecting Life in Global Health Assistance (Formerly known as the ‘Mexico City Policy’),” PRM press guidance, May 15, 2017; “Background Briefing: Senior Administration Officials on Protecting Life in Global Health Assistance,” press release of special briefing by senior Department of State officials via teleconference, May 15, 2017, https://2017-2021.state.gov/background-briefing-senior-administration-officials-on-protecting-life-in-global-health-assistance/index.html; “Subject: Protecting Life in Global Health Assistance,” Federal Assistance Management Advisory Number 2017-01; “Protecting Life in Global Health Assistance (May 2017),” MCP-related portion of standard provisions for cooperative agreements and grants to NGOs, May 11, 2017; USAID: USAID: “Standard Provisions for U.S. Nongovernmental Organizations: A Mandatory Reference for ADS Chapter 303,” ADS Reference 303maa, partial revision May 18, 2020, https://www.usaid.gov/ads/policy/300/303maa; “Standard Provisions for Non-U.S. Nongovernmental Organizations: A Mandatory Reference for ADS Chapter 303,” ADS Reference 303mab, partial revision Aug. 18, 2020, https://www.usaid.gov/ads/policy/300/303mab; CDC, “Additional Requirement – 35: Protecting Life in Global Health Assistance,” webpage, https://www.cdc.gov/grants/additionalrequirements/ar-35.html; NIH, “Protecting Life in Global Health Assistance,” webpage, https://grants.nih.gov/policy/protecting-life-global-health-assistance.htm, ↩︎
26. The policy applies to certain safe water, sanitation, and hygiene activities at the household-level, particularly those related to behavior, which are described under the Health (HL) program element of the Updated Foreign Assistance Standardized Program Structure and Definitions (available at: https://www.state.gov/f/releases/other/255986.htm#HL6). However, HL.8: Water Supply and Sanitation is exempt from the policy; activities under this sub-element are usually focused on infrastructure and systems. ↩︎
27. “The policy covers implementation-science research, operational or programmatic research, surveys, needs assessments and related capacity-building conducted for the purpose of making improvements to global health assistance programs funded by the U.S. Government and implemented through a foreign NGO with a primary purpose or effect of benefiting a foreign country,” as stated in Department of State, “Implementation of Protecting Life in Global Health Assistance (Formerly known as the ‘Mexico City Policy’),” PRM press guidance, May 15, 2017. ↩︎
28. It also applies to global health assistance provided to foreign NGOs by other agencies and departments using funds transferred through the interagency process from USAID, the Department of State, and DoD. ↩︎
29. As of May 15, 2017, the policy applies to all new grants and cooperative agreements that provide global health assistance, as well as to all existing grants and cooperative agreements that provide global health assistance when such agreements are amended to add new funding. As of March 2, 2017, the same holds true for USAID grants and cooperative agreements that provide family planning assistance. Department of State: “Subject: Protecting Life in Global Health Assistance,” Federal Assistance Management Advisory Number 2017-01; “Protecting Life in Global Health Assistance (May 2017),” MCP-related portion of standard provisions for cooperative agreements and grants to NGOs, May 11, 2017; and USAID: “Standard Provisions for U.S. Nongovernmental Organizations: A Mandatory Reference for ADS Chapter 303,” ADS Reference 303maa, partial revision May 18, 2020, https://www.usaid.gov/ads/policy/300/303maa; “Standard Provisions for Non-U.S. Nongovernmental Organizations: A Mandatory Reference for ADS Chapter 303,” ADS Reference 303mab, partial revision Aug. 18, 2020, https://www.usaid.gov/ads/policy/300/303mab. ↩︎
30. The exception to this is “grants under contracts,” which were previously subject to the policy; they are essentially grants made to sub-awardees by recipients of contracts. ↩︎
31. The policy applies to certain safe water, sanitation, and hygiene activities at the household-level, particularly those related to behavior, which are described under the Health (HL) program element of the Updated Foreign Assistance Standardized Program Structure and Definitions (available at: https://www.state.gov/f/releases/other/255986.htm#HL6). However, HL.8: Water Supply and Sanitation is exempt from the policy; activities under this sub-element are usually focused on infrastructure and systems. ↩︎
32. Department of State: “Subject: Protecting Life in Global Health Assistance,” Federal Assistance Management Advisory Number 2017-01; “Protecting Life in Global Health Assistance,” fact sheet, May 15, 2017, https://2017-2021.state.gov/protecting-life-in-global-health-assistance-2/index.html; USAID: “Standard Provisions for U.S. Nongovernmental Organizations: A Mandatory Reference for ADS Chapter 303,” ADS Reference 303maa, partial revision May 18, 2020, https://www.usaid.gov/ads/policy/300/303maa; “Standard Provisions for Non-U.S. Nongovernmental Organizations: A Mandatory Reference for ADS Chapter 303,” ADS Reference 303mab, partial revision Aug. 18, 2020, https://www.usaid.gov/ads/policy/300/303mab. ↩︎
33. USAID, “Protecting Life in Global Health Assistance Frequently Asked Questions and Answers,” Oct. 2019, https://www.usaid.gov/sites/default/files/documents/1864/FINAL_Protecting_Life_in_Global_Health_Assistance_FAQs_Oct_2019_USAID.pdf. ↩︎
34. USAID, “Protecting Life in Global Health Assistance Frequently Asked Questions and Answers,” Oct. 2019, https://www.usaid.gov/sites/default/files/documents/1864/FINAL_Protecting_Life_in_Global_Health_Assistance_FAQs_Oct_2019_USAID.pdf. ↩︎
35. While the policy allows exceptions for foreign NGOs that perform abortions with non-U.S. funds in the cases of a pregnancy that threatens the life of the woman or was a result of rape or incest, long-standing USAID interpretation of the Helms Amendment to the Foreign Assistance Act has not permitted U.S. funding to support the performance of abortions in these exceptional cases. ↩︎
36. For information about other U.S. government requirements and policies related to family planning and reproductive health, see: KFF, The U.S. Government and International Family Planning & Reproductive Health: Statutory Requirements and Policies; KFF, Statutory Requirements & Policies Governing U.S. Global Family Planning and Reproductive Health Efforts, 2012; USAID, USAID’s Family Planning Guiding Principles and U.S. Legislative and Policy Requirements webpage, http://www.usaid.gov/what-we-do/global-health/family-planning/usaids-family-planning-guiding-principles-and-us-0l; CRS, Abortion and Family Planning-Related Provisions in U.S. Foreign Assistance Law and Policy, May 17, 2016, R41360, https://digital.library.unt.edu/ark:/67531/metadc855791/. ↩︎
37. When initially introduced, the amendment prohibited only lobbying for abortion, but in subsequent years Congress modified the language to include lobbying against abortion as well. ↩︎
38. CRS, International Family Planning: The “Mexico City” Policy, updated April 2, 2001, RL30830, https://digital.library.unt.edu/ark:/67531/metacrs1906/. ↩︎
39. Post-abortion care is the treatment of injuries or illnesses caused by legal or illegal abortions. ↩︎
40. 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. ↩︎
41. USAID, “Protecting Life in Global Health Assistance Frequently Asked Questions and Answers,” Oct. 2019, https://www.usaid.gov/sites/default/files/documents/1864/FINAL_Protecting_Life_in_Global_Health_Assistance_FAQs_Oct_2019_USAID.pdf. ↩︎
42. Department of State, “Protecting Life in Global Health Assistance Six-Month Review,” report, Feb. 6, 2018, https://2017-2021.state.gov/protecting-life-in-global-health-assistance-six-month-review/index.html. ↩︎
43. Department of State, “Protecting Life in Global Health Assistance Six-Month Review,” report, Feb. 6, 2018, https://2017-2021.state.gov/protecting-life-in-global-health-assistance-six-month-review/index.html. ↩︎
44. Department of State, “Protecting Life in Global Health Assistance Six-Month Review,” report, Feb. 6, 2018, https://2017-2021.state.gov/protecting-life-in-global-health-assistance-six-month-review/index.html. ↩︎
45. Department of State, “Remarks to the Press,” press release of remarks by Michael R. Pompeo, Secretary of State, March 26, 2019, https://2017-2021.state.gov/remarks-to-the-press-7/index.html; Trump Administration White House, “The Pro-Life Agenda: Secretary Pompeo’s Bold Leadership,” fact sheet, March 26, 2019, https://globalhealth.org/wp-content/uploads/2019/04/Mexico-City-Fact-SheetFinal.pdf. ↩︎
46. USAID, “Protecting Life in Global Health Assistance Frequently Asked Questions and Answers,” Oct. 2019, https://www.usaid.gov/sites/default/files/documents/1864/FINAL_Protecting_Life_in_Global_Health_Assistance_FAQs_Oct_2019_USAID.pdf. ↩︎

Note: This content was updated on July 1, 2025 to reflect new regulations eliminating ACA Marketplace eligibility for DACA recipients.

The Deferred Action for Childhood Arrivals (DACA) program was created to protect eligible young adults who were brought to the U.S. as children from deportation and to provide them with work authorization for temporary, renewable periods. As of September 30, 2024, there were roughly 538,000 active DACA recipients from close to 200 different countries of birth residing all over the U.S. While individuals with DACA status can be authorized to work, they had previously been ineligible for federal health coverage through Medicaid, the Children’s Health Insurance Program (CHIP), and the Affordable Care Act (ACA) health insurance Marketplaces. These restrictions result in higher uninsured rates among DACA recipients, contributing to barriers to accessing health care.

The Biden Administration published regulations to expand eligibility for ACA Marketplaces, including tax credits to help pay for premiums and cost-sharing, to DACA recipients as of November 1, 2024. However, as of January 2025, DACA recipients in 19 states are ineligible to enroll in ACA Marketplace coverage due to pending court challenges. On June 25, 2025, the Centers for Medicare and Medicaid Services (CMS) finalized a rule that will once again exclude DACA recipients from the definition of “lawfully present” immigrants for the purposes of health coverage, making them ineligible to purchase coverage through the ACA Marketplaces across the U.S. beginning 60 days after the final rule’s publication. The future of the DACA program as a whole also remains uncertain with a case challenging the legality of the program making its way to the Supreme Court in 2025.

This brief provides an overview of DACA and who DACA recipients are and provides data on health coverage, work status, and income among individuals who meet eligibility criteria for DACA since there are no administrative data on these measures available for DACA recipients. It also discusses potential impacts of ending the DACA program. It is based on analysis of data on DACA recipients from the United States Citizen and Immigration Services and analysis of individuals who are likely eligible for DACA using 2022 Current Population Survey Annual Social and Economic Supplement (CPS-ASEC) data (see methods for more details).

Overview of DACA

DACA was originally established via executive action in June 2012 to protect certain undocumented immigrants who were brought to the U.S. as children from removal proceedings and to receive authorization to work for renewable two-year periods. To be eligible, individuals must have arrived in the U.S. prior to turning 16 and before June 15, 2007; be under the age of 31 as of June 15, 2012 (i.e., under age 44 as of 2025); be currently enrolled in school, have completed high school or its equivalent or be a veteran; and have no lawful status as of June 15, 2012. The program has enabled over 900,000 immigrants to stay in the U.S., go to school, and contribute to the economy through employment.

The Biden Administration published a final rule in 2022 to codify DACA largely consistent with its existing eligibility requirements and scope, but its implementation remains limited subject to court rulings. Promulgation of this rule followed a rescission of the program by the Trump Administration in 2017, which was ruled unlawful by the Supreme Court in 2020. Subject to ongoing litigation and current court rulings, current DACA approvals and work authorizations remain in effect, and the Department of Homeland Security (DHS) will continue to process DACA renewal requests and related requests for employment authorization. It is also accepting initial DACA and employment authorization requests, however, it cannot process initial requests under the current court orders, so these requests remain on hold.

While DACA protects an individual from removal action for a certain period of time, it does not provide a pathway to U.S. citizenship, and people with DACA status previously were ineligible for any federally funded health coverage. Individuals with DACA status can be authorized to work, and studies have found that DACA eligibility helps improve physical and mental health, particularly among individuals with low incomes, and can improve the well-being of children of DACA recipients. However, individuals with DACA have limited options for health insurance coverage if they do not have access to employer-sponsored insurance since they previously were ineligible for federal health coverage programs, including Medicaid, the Children’s Health Insurance Program (CHIP), and the ACA health insurance Marketplaces.

The Biden administration expanded Marketplace coverage with subsidies to DACA recipients, but implementation of the expansion is blocked in 19 states due to pending litigation. On May 3, 2024, the Biden administration published regulations that updated the definition of lawfully present to include DACA recipients for purposes of eligibility to purchase coverage through the ACA Marketplaces and to receive tax credits to help pay for premiums and cost sharing effective November 1, 2024. The Biden administration estimated that this eligibility expansion could extend coverage to nearly 100,000 uninsured DACA recipients. However, as of January 2025, DACA recipients in 19 states are ineligible to enroll in ACA Marketplace coverage due to court decisions. Additionally, on June 25, 2025, the Centers for Medicare and Medicaid Services (CMS) finalized a rule that will once again exclude DACA recipients from the definition of “lawfully present” immigrants for the purposes of health coverage, making them ineligible to purchase coverage through the ACA Marketplaces beginning 60 days after the final rule’s publication in all states. Elimination of the coverage expansion could leave thousands of DACA recipients without an affordable coverage option.

Characteristics of DACA Recipients

As of September 30, 2024, there were roughly 538,000 active DACA recipients in the U.S. Over one in four (28%) active DACA recipients reside in California, with another 17% living in Texas, 5% in Illinois, 4% in New York, 4% in Florida, and the remaining 42% distributed in other states across the country (Figure 1). DACA recipients are young, with the majority under age 36 (Figure 2), and over half are female. Seven in ten DACA recipients are single, while nearly three in ten are married. The top countries of birth for active DACA recipients include Mexico (81%), El Salvador (4%), and Guatemala (3%).

Health, Work Status and Income among Individuals Likely Eligible for DACA

No administrative data are available on health, health coverage, work status, and income among DACA recipients. As such, using 2022 CPS-ASEC data we present data for undocumented immigrants likely eligible for DACA based on them meeting age, education, and length of residence requirements. (See methods for more details.)

Most individuals likely eligible for DACA are healthy and the large majority live in a family with at least one full-time worker (Figure 3). Among individuals who are likely eligible for DACA, nearly two-thirds (64%) report their health as excellent or very good, while an additional 28% report their health as good. In comparison, 71% of U.S.-born individuals ages 15-41 report being in excellent or very good health, with an additional 22% reporting being in good health. These findings reflect that younger individuals tend to be healthy. The large majority (84%) of individuals likely eligible for DACA live in a family with at least one full-time worker and over half (54%) of adults are working full-time themselves. Despite high rates of employment, 43% of individuals likely eligible for DACA have incomes below 200% of the federal poverty level (FPL) compared with 26% of U.S.-born individuals in the same age group (Figure 3). This income disparity likely reflects disproportionate employment in lower wage jobs among individuals likely eligible for DACA.

Uninsured Rates for Individuals Likely Eligible for DACA

Individuals likely eligible for DACA are much more likely than U.S.-born individuals in their age group to be uninsured (Figure 4). Overall, based on 2022 data, 47% of individuals likely eligible for DACA were uninsured, compared to 10% of U.S.-born individuals in their age group. These estimates are higher than other estimates of uninsured rates among DACA recipients based on survey data, likely reflecting differences in the group being analyzed and data source. Although most individuals who are likely eligible for DACA are in a family with a full-time worker, as noted above, they are more likely to be low-income, which likely reflects disproportionate employment in low-wage jobs that are less likely to offer employer-sponsored health insurance. Those without access to affordable coverage through an employer or who cannot afford coverage on the individual market are left with limited options since they previously were prohibited from enrolling in Medicaid, CHIP, and Marketplace coverage. With the Biden administration coverage expansion, DACA recipients are now eligible for Marketplace coverage in some states. Those who are uninsured are largely reliant on care through community health centers and public health services and can receive treatment for emergency conditions. California, which is home to the largest share of DACA recipients (28%), provides fully state-funded coverage to individuals regardless of immigration status for which DACA recipients can qualify.

Key Issues Looking Ahead

The number of young adults who may benefit from DACA is dwindling over time, and the future of the program remains uncertain. Given the requirements to have entered the U.S. prior to June 15, 2007, and to be under the age of 31 as of June 15, 2012, the number of people who could be eligible for DACA is decreasing over time. The American Dream and Promise (DREAM) Act of 2023 would provide a pathway to lawful permanent resident status and eventually citizenship for undocumented immigrants who were brought to the U.S. as children and who meet certain requirements. Different versions of this Act have been proposed in the U.S. Congress since 2001, but have never been passed, and there does not appear to be a current pathway to passage for such legislation. The future of the DACA program remains uncertain due to ongoing litigation. Since 2021, the DHS has been unable to process first-time DACA applications due to court challenges but has continued to process DACA renewal requests and related requests for employment authorization. In January 2025, a federal appeals court ruled against the legality of the DACA program in Texas, the state that filed the lawsuit. However, there is currently a stay on the ruling until there are further orders by the appeals court or the Supreme Court. As a result, there is no change to the status of the DACA program as of January 2025, with active DACA recipients nationwide continuing to be eligible to renew their status while the processing of first-time DACA applications by the DHS continues to be on hold.

President Trump attempted to end DACA during his first term but was blocked by the Supreme Court in 2020; how he will treat the program during his second term remains unclear. After the attempt to end DACA had failed in 2020, the Trump administration said that it would try again to eliminate DACA protections, suggesting it would be unlikely to appeal the decision if a court decides to eliminate the DACA program. While the second Trump administration has implemented a number of restrictive immigration policies, in an interview prior to his inauguration, President Trump indicated that he would work on addressing the status of “Dreamers” and indicated a willingness to work with Democrats on the issue, although the details of this proposed plan remain unclear.

Elimination of the DACA program would have implications for the health and well-being of DACA recipient families. There are over half a million DACA recipients, a majority of whom are working and many of whom have U.S.-born children, who could be at risk of deportation if the program is eliminated. Eliminating the DACA program could increase negative physical and mental health outcomes among recipients and their families due to increased likelihood of deportation, family separation, loss of employment, and increased barriers to health care. Research shows that DACA increases access to employer-sponsored health insurance, and expanded coverage is associated with reduced barriers to health care and increased access to culturally competent care. Research also finds that children of mothers that are eligible for DACA were more likely to participate in the Special Supplemental Nutrition Program for Women, Infant, and Children, compared to children of mothers who were ineligible. Uncertainty about DACA has been shown to increase negative mental health outcomes and worse self-reported health among DACA recipients, while program protections lead to improved mental health. A study found that children of mothers eligible for DACA experienced a significant decrease in anxiety disorder diagnoses compared to children whose mothers were ineligible.

Elimination of the DACA program could also have negative economic and workforce impacts. DACA has reduced unemployment rates and allowed DACA recipients to contribute to the workforce and their communities. Research also shows that DACA is associated with increased wages among U.S.-born workers with little to no decrease in their employment in labor markets with higher shares of DACA recipients, suggesting that DACA recipients act as complements instead of substitutes for U.S.-born workers in the labor market. Elimination of the DACA program would lead to loss of employment among DACA recipients since they would lose work authorization.

KFF’s January 2025 Prescription Drug Advertisements Poll looks at the public’s experiences with prescription drug advertisements. The poll measures the share of adults who report seeing such advertisements, as well as how these drug advertisements influence the care the public reports receiving from their doctor or health care provider.

On January 28, 2025, President Trump issued an Executive Order titled, “Protecting Children From Chemical And Surgical Mutilation.” Among other actions, the Order directs agencies and programs to work towards significantly limiting youth access to gender affirming care nationwide. It also includes misinformation about gender affirming care and young people who are transgender.

While the order does not immediately change policies or regulations that guide access to gender affirming care, it has already created significant confusion and some disruption of services, and there is now a legal challenge, as well as responses by several states. This Policy Watch reviews the key provisions of the Executive Order that aim to restrict youth access to gender affirming care and examines state and legal responses.

The Executive Order

Key provisions related to care restrictions include:

• Directs agency/department heads to take steps to prohibits those receiving certain federal research grants, including hospitals and medical schools, from proving gender affirming care to children: “The head of each executive department or agency (agency) that provides research or education grants to medical institutions…shall…take appropriate steps to ensure that institutions receiving Federal research or education grants end” end gender affirming care for children.
• Directs the Secretary of the Department of Health and Human Services (HHS) to take action to end gender affirming care for children “including [through] regulatory and sub-regulatory actions, which may involve the following laws, programs, issues, or documents:
  • Medicare or Medicaid conditions of participation or conditions for coverage;
  • clinical-abuse or inappropriate-use assessments relevant to State Medicaid programs;
  • mandatory drug use reviews
  • section 1557 of the Patient Protection and Affordable Care Act
  • quality, safety, and oversight memoranda
  • essential health benefits requirements; and
  • the Eleventh Revision of the International Classification of Diseases and other federally funded manuals, including the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.”

Taken together, and if implemented broadly, restrictions across these programs and policies could significantly limit access to gender affirming care for most young people nationwide, including for those with both private and public insurance, and even for some who are able to pay out-of-pocket. It would also likely lead to a reinterpretation of the major sex nondiscrimination protections in the Affordable Care Act (Section 1557) to remove explicit named protections on the basis of sexual orientation and gender identity in health programs receiving federal funding.

• Directs the Secretary of the Department of Defense “commence a rulemaking or sub-regulatory action” restrict access to gender affirming care for children in the TRICARE program. This restriction goes beyond those already enacted by Congress.
• Directs the Director of the Office of Personnel Management to limit access to care in coverage for federal employees’ families by requiring the inclusion of “provisions in the Federal Employee Health Benefits (FEHB) and Postal Service Health Benefits (PSHB) programs call letter for the 2026 Plan Year” that would require eligible carriers to exclude “coverage for pediatric transgender surgeries or hormone treatments…”

Additionally, the Executive Order promotes misinformation, including that large shares of youth are seeking gender affirming medical care, which is not the case, that regret rates among those who do seek care are high, when regret rates are very low, and erroneously conflating “female genital mutilation” and gender-affirming care.

Notably, the Executive Order defines children to include 18 year olds, which goes beyond how most states define minors.

State Responses

As of February 6, 2025, Attorneys General in seventeen (17) states have publicly responded to the Executive Order. Fifteen (15) have stated that they oppose the Executive Order in a coalition led by the Massachusetts Attorney General. The coalition press release states that the State Attorneys General “reaffirm their commitment to protecting access to gender-affirming care” and that the Executive Order “is wrong on the science and the law.” Additionally, the Oregon Attorney General issued a statement in support of youth access to gender affirming care and stated that they “are vigorously exploring all legal options to challenge any policies or actions that hinder access to the care Oregonians need and their rights to make their own medical decisions,”  but stopped short of directly opposing the Executive Order.

In addition to being part of the coalition letter, some Attorneys General have directed providers to continue proving gender affirming care, noting that failing to do so could be in violation of state nondiscrimination protections.

In contrast, the Attorney General in at least one state, Virginia, instructed at least two university Hospital systems to stop providing care in order to comply with the order and minimize “significant legal risk and substantial financial exposure.”

None of the 26 states with laws prohibiting or limiting youth access to gender affirming care have yet to officially respond to the Executive Order.

Legal Response

On February 4, 2025 the ACLU, Lambda Legal, and others, filed a lawsuit in federal court challenging the Executive Order. The complaint states that the Executive Order aimed at restricting gender affirming care (and another related to “gender ideology”) “were issued for the openly discriminatory purpose of preventing transgender people from expressing a gender identity different from their sex designated at birth” and are unlawful and unconstitutional. Specific counts named in the filing are that the orders:

• “unconstitutionally usurp congressional authority by withholding lawfully appropriated federal funds from medical institutions, providers, and researchers…”;
• conflict with protections imbedded in Section 1557 of the ACA (sex nondiscrimination protections in health programs in receipt of federal funds);
• violate federal disability protections;
• violate equal and due process (infringe upon parents’ fundamental rights) protections under the Fifth Amendment; and
• violate First Amendment freedom of speech protections.

In addition to asking the court to find the orders unconstitutional and unlawful, the plaintiffs seek injunctive relief, enjoining their implementation and enforcement.

On February 7, 2025 a second lawsuit was filed in federal court by three states (Washington, Minnesota and Oregon) and three physicians from the state of Washington, challenging the gender affirming care Executive Order, calling it “blatantly unconstitutional.”  Specific counts named in the filing are that the Order:

• violates protections under the Fifth Amendment
• “is an unconstitutional usurpation of the spending power of Congress, an unconstitutional effort to amend Congressional appropriations…, and a violation of the separation of powers”
• is a violation of the Tenth Amendment in its seizure of “the States’ historic police powers to regulate the practice of medicine

As with the plaintiffs in the first suit, the plaintiffs here ask the court to find certain sections of the Executive Order unconstitutional and seek injunctive relief, enjoining their implementation and enforcement. They also ask the court for an expedited hearing to determine whether the court should enter a preliminary injunction or the Temporary Restraining Order (in a separate case that stopped a pause on federal funding) should be extended.

On January 20, President Trump issued an Executive Order calling for a re-evaluation and realignment of U.S. foreign aid that put a 90-day pause on new obligations and disbursements and initiated a full review of all foreign aid programs. This was followed by a stop-work order for existing efforts (with limited exception) already funded and underway, freezing most service delivery in countries around the world. With reports of the effective dissolution of USAID, the international development agency created more than six decades ago, there is uncertainty about the future of the aid it provides if it is incorporated into the State Department as President Trump calls to “CLOSE IT DOWN!”.

To shed light on the role of USAID in global health, this brief provides an analysis of the share of global health assistance obligated or implemented by USAID and other agencies on behalf of countries (or, “bilateral”) in FY 2023, using data from foreignassistance.gov. This includes funding that agencies either: 1) obligated for global health activities (e.g., USAID manages and provides funding to an implementing partner, such as a non-governmental organization, to directly carryout health programs); or 2) received from other agencies to directly implement specific programs (e.g., State Department directs funding to USAID to implement HIV/AIDS programs in countries). This does not include funding appropriated by Congress to the Centers for Disease Control and Prevention (CDC) for global health efforts, as these totals are not part of the foreignassistance.gov database (in FY 2023 Congress appropriated approximately $693 million to CDC global health). As this analysis shows, the majority of U.S. bilateral global health assistance is obligated or implemented by USAID, including for PEPFAR. (For more information on federal funding flows for global health, see 10 Things to Know About U.S. Funding for Global Health).

In FY 2023, USAID obligated/implemented 73% of all U.S. global health bilateral assistance. Of the $8.5 billion for bilateral global health efforts, across all program areas, USAID obligated/implemented $6.2 billion (73%) (see Figure 1). The next largest share was at the Department of Health and Human Services (HHS) ($1.9 billion or 22%), primarily the Centers for Disease Control and Prevention (CDC). Two percent ($141 million) was at State and 3% ($280 million) at all other agencies combined.

For PEPFAR, the U.S. global HIV/AIDS program, USAID obligated/implemented 60% of bilateral assistance. Of the $4.2 billion for bilateral HIV programs in FY 2023, $2.5 billion (60%) was obligated/implemented by USAID, followed by $1.6 billion (37%) at HHS, and 2% ($79 million) at State (see Figure 2). Just 1% ($25 million) was at other agencies.

USAID’s role is even greater in some sectors, including 100% in some cases. For maternal and child health, TB efforts, and global health security, USAID obligated 100% of all bilateral support in FY 2023 (see Figure 3). It obligated 99% of family planning and reproductive health and 96% for malaria efforts. PEPFAR, as noted above, is 60%, and nutrition programs are 59%. As noted above, these totals do not include funding appropriated by Congress to the CDC for global health efforts, as these totals are not part of the foreignassistance.gov database.

There remains significant uncertainty surrounding the administration’s review of USAID and of U.S. foreign aid more generally, including which programs will be maintained, and how they will be carried out going forward. Given the current role of USAID in managing U.S. global health programs, through its thousands of staff around the world and its work with implementers on the ground, changing USAID, including by reducing or eliminating its capacity, would leave a gap that could affect service delivery and health outcomes, should it not be filled.

Options under consideration in Congress to reduce Medicaid spending by up to $2.3 trillion, nearly one-third over ten years, could have major implications for people with disabilities. Medicaid is the primary program providing comprehensive health and long-term care coverage to one in three with disabilities, including 2.3 million children, 8.8 million working-age adults, and 4.4 million adults ages 65 and older. Although some people with disabilities qualify for Medicaid because they receive Supplemental Security Income, most are eligible for Medicaid through other pathways, including the Affordable Care Act (ACA) expansion group.

Policy changes under consideration include imposing a per capita cap on federal Medicaid spending, reducing the federal government’s share of costs for the ACA expansion group, and imposing Medicaid work requirements, among other changes. Such policy changes would fundamentally alter how Medicaid financing works and federal spending reductions of this magnitude would put states at significant financial risk, forcing them to make tough choices about reducing the number of people covered, covering fewer benefits, or reducing payment rates for physicians, hospitals, nursing homes, and other providers. It is unknown how much Medicaid pays for people with disabilities because health care claims data do not include information about disabilities unless they are also a diagnosis code associated with the medical care being provided. However, Medicaid enrollees who are eligible because of disability or being over age 64 account for over half of Medicaid spending but less than a quarter of enrollees on account of their higher costs. That group includes most non-elderly adults with disabilities who qualify for Medicaid through regular eligibility pathways, such as the ACA expansion.

Because they have high levels of health care spending, people with disabilities may be particularly vulnerable if federal spending is capped. Loss of Medicaid coverage or benefits poses unique challenges for seniors and people with disabilities, many of whom live on fixed incomes, face barriers to employment and accessing private health coverage, have high health care needs and spending, and rely on Medicaid for coverage of long-term care and other services not available in other health coverage.

1. Medicaid is a major source of health coverage for people with disabilities.

More than 1 in 3 people with disabilities (15 million) have Medicaid (35%). In comparison, only 19% of people without disabilities have Medicaid (Figure 1). Disability is defined as having any of the following difficulties: hearing, vision, cognitive, ambulatory, self-care, or independent living. The difference in coverage rates stems from lower rates of employment and employer-based coverage among working age adults with disabilities. Among working age adults with disabilities, almost half of people with disabilities do not work at all and only one third work full time (defined as 35 or more hours per week). In comparison, over 64% of adults without a disability work full time and only 16% do not work at all. Lower rates of employment result in lower rates of employment-based coverage among working age adults with disabilities: Only 33% have insurance through an employer compared with 64% among working age adults without disabilities.

2. More than one in five Medicaid enrollees have a disability, many of whom are non-elderly adults.

Over 1 in 5 Medicaid enrollees have a disability, with the rate of disability among Medicaid enrollees rising steeply with age (Figure 2, Tab 1). Only 8% of children have a disability compared with 22% of adults ages 19 to 49 and 43% of adults ages 50 to 64. Over half of Medicaid enrollees ages 65 and older have a disability. Because disability incidence rises with age, Medicaid enrollees with disabilities tend to be older than those without (Figure 2, Tab 2). Among Medicaid enrollees with a disability, over 50% are ages 50 and older compared with less than 20% of Medicaid enrollees without disabilities.

3. Among Medicaid enrollees with disabilities, more than half have multiple difficulties.

Nearly 60% of Medicaid enrollees with disabilities have two or more difficulties and 16% have four or more difficulties (Figure 3, Tab 1). Among the over 15 million Medicaid enrollees with disabilities, 53% report difficulties with cognition, which is defined as difficulty concentrating, remembering, or making decisions; 48% report difficulties with ambulation (defined as difficulty with walking or climbing stairs); 44% report difficulties living independently (defined as difficulty doing errands alone such as visiting a doctor’s office or shopping); and 24% report difficulties with self-care (defined as difficult dressing or bathing). Fewer than 1 in 5 enrollees report difficulties with hearing or vision (Figure 3, Tab 2).

4. Two thirds of Medicaid enrollees with disabilities do not receive Supplemental Security Income (SSI).

Although federal statutes generally require states to enroll people who receive SSI in Medicaid, only one third of Medicaid enrollees with disabilities receive SSI income (Figure 5). That rate varies from a low of 18% in North Dakota to a high of 44% in Texas (Appendix Table 1). SSI is a disability program that provides monthly income to people who are unable to work on account of a disability and who have income and financial resources below federal limits. Receipt of SSI increases with age: Only 15% of children ages 15-19 receive SSI but close to 40% of adults ages 50 and older do. Medicaid enrollees ages 19-64 who do not receive SSI are eligible for Medicaid through other eligibility pathways, and many adults could be subject to Medicaid work and reporting requirement policies (Appendix Table 2). A smaller number of Medicaid enrollees with disabilities are eligible for Medicaid through pathways that relate to their disability or need for long-term care. Those pathways have more complex eligibility requirements than coverage for children and non-elderly adults. Most Medicaid enrollees with disabilities qualify for Medicaid under regular adult pathways, including the ACA expansion group.

5. Medicaid enrollees with disabilities are likely to comprise most of the people who use Medicaid long-term care.

Nearly half of Medicaid enrollees with a disability (47%) report having a difficult with self-care or independent living, disabilities that frequently require long-term care. Medicaid is the primary payer of long-term care because it is generally not covered by Medicare or private health insurance. KFF estimates that nearly 6 million people use Medicaid long-term care and spending for those people is much higher than spending for other enrollees, with the costs of enrollees who use institutional care nearing $50,000 each year. In comparison, average Medicaid spending for enrollees who do not use long-term care is under $5,000. Because of the higher spending, enrollees who use long-term care comprise 6% of Medicaid enrollment but 34% of Medicaid spending (Figure 5).

Appendix

Options under consideration in Congress to reduce Medicaid spending by nearly one-third in future years could have major implications for seniors and people with disabilities. Nearly 1 in 4 Medicaid enrollees are eligible for the program because they are ages 65 and older or have a disability, and they have higher per-enrollee costs than other enrollees. Within this group, there are multiple eligibility pathways, most of which are optional for states to cover, and all of which have more complex eligibility requirements than coverage for children and non-elderly adults. Proposals to limit federal spending on Medicaid may create incentives for states to drop or reduce their eligibility or coverage for seniors and people with disabilities in response to fewer federal revenues. Loss of Medicaid coverage poses unique challenges for seniors and people with disabilities, people who are likely to live on fixed incomes, have high health care spending, and rely on Medicaid for coverage of long-term care.

Considering the proposed reductions in Medicaid spending, this issue brief describes Medicaid eligibility pathways, enrollment, and spending among people eligible through the age and disability-related pathways (known as “non-MAGI” pathways because they do not determine eligibility based on Modified Adjusted Gross Income, as is the case for people covered under the Affordable Care Act Medicaid expansion and other groups). This analysis uses the most recent data available to KFF at the time of the analysis (Medicaid T-MSIS data, 2021, see Methods).

1.  Over half of Medicaid spending is on people eligible for Medicaid because of old age or disability.

Over half of Medicaid spending ($339 billion in 2021) pays for care for people eligible through the non-MAGI pathways (Figure 1). 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 non-MAGI enrollees (Appendix Table 1). In some states (Alaska, Nevada, Montana, Illinois and Indiana), only a third of spending went to these populations, and in five states (Alabama, Florida, Kansas, Mississippi, and North Dakota), care for seniors and people with disabilities accounted for at least two-thirds of spending (Figure 1). Differences in the percentage of spending across the states stem from differences in eligibility criteria for both MAGI and non-MAGI eligibility pathways, which also affects relative levels of enrollment in these pathways, as well as demographic variation across states.

2.  Most non-MAGI Medicaid enrollees are eligible through mandatory eligibility pathways that are tied to Medicare and Supplemental Security Income.

Federal statutes require states to enroll people who receive Supplemental Security Income (SSI) in Medicaid and to enroll eligible Medicare beneficiaries in the Medicare Savings Programs. SSI is a disability program that provides monthly income to people who are unable to work on account of a disability and who have income and financial resources below federal limits. The Medicare Savings Programs provide Medicaid coverage of Medicare premiums and in most cases, cost sharing to Medicare beneficiaries with limited financial resources. People who are eligible for the Medicare Savings Programs, but not full Medicaid, only receive Medicaid coverage for the costs of Medicare premiums and usually, cost sharing. Beyond these two “mandatory” eligibility pathways, there are optional Medicaid eligibility pathways that states may choose to offer for people who have disabilities or are ages 65 and older, including options to expand coverage beyond what is required under federal law to low-income seniors and people with disabilities and coverage for people who need long-term care.

Roughly two-thirds of Medicaid enrollees who qualify based on old age or disability are eligible for Medicaid through a mandatory pathway and those enrollees account for about two-thirds of Medicaid spending on non-MAGI enrollees (Figure 2). The remaining third of enrollees includes people coming in through optional income-related pathways (28% of all non-MAGI enrollees and 19% of spending) and those coming in on account of their need for long-term care (6% of enrollees, 16% of spending).

Most seniors and people with disabilities who are eligible for non-MAGI Medicaid must demonstrate limited financial resources and go through an application process that requires documentation of their income and savings (Table 1). States that offer eligibility based on long-term care have higher income eligibility criteria for those eligibility pathways, but nearly all still require applicants to demonstrate having limited savings ($2,000 for an individual, $3,000 for a couple). Some assets, including the home, are excluded from the calculation of financial resources, but states are required to recoup the certain Medicaid costs after enrollees die through a process known as estate recovery. States that offer eligibility for seniors and people with disabilities based on income, have income limits generally little more than the federal poverty level with similarly low thresholds for applicants’ savings; and most states have more complicated eligibility processes for non-MAGI pathways than they do for MAGI pathways.

3.  Enrollees eligible because they need long-term care have much higher spending per enrollee.

Among the four eligibility pathways specifically for people who use long-term care, per-enrollee spending is over $40,000 per year for three of the pathways (Figure 3). Per-enrollee spending for children with disabilities enrolled through Katie Beckett programs (which include Family Opportunity Act options too) is more similar to that of other eligibility pathways for seniors and people with disabilities (close to $20,000 per year) because many of those children also have private health insurance. In such cases, Katie Beckett coverage helps lower- and middle-income families cover the costs of long-term care for children, which are very difficult to save for. Although per-enrollee costs for people eligible through the long-term care pathways are high, they still represent a small share of total Medicaid spending because the number of people enrolled is so low.

4.  Per-enrollee spending varies across states, especially for enrollees who use long-term care.

For mandatory and income-related optional eligibility pathways, per-enrollee spending (including all services) varies from under $2,000 per enrollee to over $33,000 per enrollee for the Medicare Savings Programs and nearly $60,000 per enrollee for the SSI eligibility pathway (Figure 4). As large as that variation is, variation for the long-term care-related pathways is far greater: Variation in per-enrollee spending for people who use institutional care ranges from $24,000 to nearly $200,000 per year in Alaska. For people eligible through one of the two home care programs, per-enrollee spending ranges from about $3,000 to well over $100,000. in Washington, D.C. (Appendix Table 2).

The large variation in spending among the long-term care related pathways reflects states having considerable flexibility in determining who is eligible to receive optional benefits, what services to provide, and how much to pay providers. Long-term care is extremely expensive, with average nursing facility rates for all payers exceeding $100,000 per year, full-time home health aide costs nearing $70,000, and round-the-clock home health costs nearing $300,000 per year. Not all people use services for the full year, and Medicaid does not always cover 100% of the costs of people’s care or pay the same rate as private payers, contributing to the variation in spending. There is little information about how much states pay providers, but a KFF survey about payment rates for home care showed significant variation among states able to report. The Biden Administration finalized regulations that would require states to report payment rates for Medicaid, but Congress or the Trump administration may seek to undo that rule.

5.  Across all non-MAGI eligibility pathways, per-enrollee spending is higher in ACA expansion states.

Although some researchers have criticized the ACA eligibility pathway as diverting resources away from Medicaid enrollees with disabilities, the data show per-enrollee spending for seniors and people with disabilities is two times larger in expansion states ($20,345 versus $9,950, Figure 5). The largest difference in per-enrollee spending stems from people eligible through optional income-related pathways, where spending is $17,000 per enrollee per year in expansion states but less than $5,000 per year in non-expansion states. Even in mandatory pathways, expansion states spent more per enrollee: Expansion states spent $6,386 more per enrollee eligible through the Medicare Savings Program pathway, and $7,219 more per enrollee through the SSI pathway.

Appendix Tables