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

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 These approvals were either rescinded by the Biden administration or withdrawn by states, and Georgia is the only state with a Medicaid work requirement waiver in place (following litigation over the Biden administration’s attempt to stop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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Summary

Health coverage plays a major role in enabling people to access health care and protecting families from high medical costs. There have been longstanding racial and ethnic disparities in health coverage that contribute to disparities in health. This brief examines trends in health coverage by race and ethnicity from 2010 through 2023 and discusses the implications for health disparities. All noted differences between groups and years described in the text are statistically significant at the p<0.05 level. It is based on KFF analysis of American Community Survey (ACS) data for people under age 65. Key takeaways include:

There were gains in coverage across most racial and ethnic groups between 2019 and 2023 after several years of rising uninsured rates during the first Trump administration. The coverage gains between 2019 and 2023 were largely driven by increases in Medicaid coverage, reflecting policies to stabilize and expand access to affordable coverage that were implemented during the COVID-19 pandemic. These policies included enhanced subsidies to purchase Marketplace coverage and a requirement that states keep Medicaid enrollees continuously enrolled during the public health emergency (PHE), which led to record high Medicaid enrollment. While Medicaid enrollment fell as the pandemic era protections were unwound, it has remained higher than in 2019. These coverage gains helped narrow differences in uninsured rates for Hispanic, Black, and American Indian or Alaska Native (AIAN) people compared with White people, but the gains may be at risk due to potential Medicaid cuts and the expiration of the enhanced Marketplace subsidies.

Despite these coverage gains, disparities in coverage persisted as of 2023. AIAN and Hispanic people under age 65 had the highest uninsured rates at 18.7% and 17.9%, respectively. Uninsured rates for Native Hawaiian or Pacific Islander (NHPI) (12.8%) and Black people (9.7%) under age 65 also were higher than the rate for their White counterparts (6.5%). Coverage disparities have persisted over time, and in some cases widened despite recent gains and earlier large gains in coverage under the Affordable Care Act (ACA). For example, between 2010 and 2023, the uninsured rate for AIAN people grew from 2.4 to 2.9 times higher than the uninsured rate for White people, the Hispanic uninsured rate grew from 2.5 to 2.7 times higher than the rate for White people, and Black people remained 1.5 times more likely to be uninsured than White people.

Uninsured rates in states that have not expanded Medicaid are higher than rates in expansion states across most racial and ethnic groups as of 2023. Further, the differences in coverage rates between Hispanic, Black and NHPI people compared with White people are larger in non-expansion states compared with expansion states. However, the relative risk of being uninsured for Black and Hispanic people compared to White people is similar in expansion and non-expansion states.

Going forward, racial and ethnic disparities in coverage could widen due to potential Medicaid cuts, expiration of the enhanced subsidies for Marketplace coverage, and immigration policy changes. The incoming Trump administration and Republican controlled Congress are signaling plans to make significant changes to Medicaid and the ACA. House Republicans appear to be considering large cuts to Medicaid, which could help offset the cost of extending expiring tax cuts but would shift a substantial amount of Medicaid spending from the federal government to states, and likely lead states to make reductions in eligibility and/or benefits. Further, if Congress does not take action to extend the enhanced ACA Marketplace subsidies, which are set to expire in 2025, premiums will rise, likely leading to an increase in the number of uninsured people. Additionally, the Trump administration’s changes to immigration policy, including increased enforcement, the rescission of protections from enforcement activity in sensitive locations including health care facilities, and potential changes to public charge policy, will likely lead to reduced enrollment in health coverage of lawfully present immigrants and citizen children in immigrant families. Medicaid and Marketplace coverage losses would likely lead to widening racial disparities in coverage given that disproportionately large shares of Hispanic, Black, AIAN, and NHPI people are covered through these sources, which, in turn, would likely contribute to widening disparities in health.

Trends in Uninsured Rates by Race and Ethnicity, 2010-2023

Prior to the enactment of the ACA in 2010, Hispanic, Black, Asian, AIAN, and NHPI people under age 65 were more likely to be uninsured compared to their White counterparts, with Hispanic and AIAN people at the highest risk of lacking coverage (Figure 1). Their higher uninsured rates reflected more limited access to affordable health coverage options. Although the majority of individuals have at least one full-time worker in the family across racial and ethnic groups, there are ongoing racial disparities in employment and income that result in some groups having more limited access to coverage offered by an employer or having greater difficulty affording private coverage when it is available. While Medicaid helped fill some of these gaps in private coverage, prior to the ACA, Medicaid eligibility for parents in most states was limited to those with very low incomes (often below 50% of the poverty level), and adults without dependent children—regardless of how poor—were ineligible under federal rules.

Between 2010 and 2016, there were large gains in coverage across racial and ethnic groups under the ACA, but racial and ethnic disparities in coverage persisted. The ACA created new coverage options for low- and moderate-income individuals. These included provisions to extend dependent coverage in the private market up to age 26 and prevent insurers from denying people coverage or charging them more due to health status that went into place. Further, beginning in 2014, the ACA expanded Medicaid coverage to nearly all adults with incomes at or below 138% of poverty in states that adopted the expansion and made tax credits available to people with incomes up to 400% of poverty to purchase coverage through a health insurance Marketplace. Following the ACA’s enactment in 2010 through 2016, coverage increased across all racial and ethnic groups, with the largest increases occurring after implementation of the Medicaid and Marketplace coverage expansions in 2014. Hispanic people under age 65 had the largest percentage point increase in coverage, and their uninsured rate falling from 32.6% to 19.1%. Black, Asian, and AIAN people also had larger percentage point increases in coverage compared to White people over that period. Despite these larger gains, Hispanic, Black, AIAN, and NHPI people under age 65 remained more likely than their White counterparts to be uninsured as of 2016.

Beginning in 2017, coverage gains began reversing, and the number of uninsured increased for three consecutive years. The uninsured rate for the total population under age 65 increased from 10.0% in 2016 to 10.9% in 2019. Among this age group, Hispanic people had the largest statistically significant increase in their uninsured rate over this period (from 19.1% to 20.0%). There were also small but statistically significant increases in the uninsured rates among White and Black people under age 65, which rose from 7.1% to 7.8% and 10.7% to 11.4%, respectively, between 2016 and 2019. Rates for AIAN, NHPI, and Asian people under age 65 did not have a significant change. These coverage losses likely reflected policy changes made by the first Trump administration after taking office in 2017. These changes included decreased funds for outreach and enrollment assistance, guidance encouraging states to seek waivers to add new eligibility requirements for Medicaid coverage as well as to increase the frequency of eligibility verifications, and changes to public charge immigration policy that made some immigrant families more reluctant to participate in Medicaid and the Children’s Health Insurance Program (CHIP) (which were later reversed by the Biden administration).

After increasing for several years prior to the pandemic, uninsured rates declined between 2019 and 2023. The number of people under age 65 with insurance increased by 3.6 million between 2019 and 2023 as the uninsured rate dropped from 10.9% to 9.6%. (Because of disruptions in data collection during the first year of the pandemic, the Census Bureau did not release 1-year ACS estimates in 2020.) AIAN people had the largest percentage point increase in coverage, with their uninsured rate falling from 21.7% in 2019 to 18.7% in 2023. There were also smaller but statistically significant declines in uninsured rates among Hispanic (from 20.0% to 17.9%), Black (from 11.4% to 9.7%), Asian (from 7.2% to 5.8%), and White people (from 7.8% to 6.5%) during this period. These coverage gains were primarily driven by increases in Medicaid coverage, which offset declines in employer-sponsored coverage over the period. NHPI people did not have statistically significant changes in coverage over this period.

The coverage gains observed between 2019 and 2023 largely reflect policies adopted during the pandemic to stabilize coverage in Medicaid and enhance subsidies to purchase Marketplace coverage. Coverage gains reflected provisions in the Families First Coronavirus Response Act (FFCRA), enacted at the start of the pandemic that prohibited states from disenrolling people from Medicaid during the Public Health Emergency in exchange for enhanced federal funding. While Medicaid enrollment fell as the pandemic era protections were unwound, it has remained higher than in 2019. In addition, gains reflected enhanced ACA Marketplace subsidies made available by the American Rescue Plan Act (ARPA) and renewed in the Inflation Reduction Act of 2022 (IRA), boosted outreach and enrollment efforts, and low Marketplace attrition. Further, in 2019, the Biden administration reversed changes the Trump administration previously made to public charge immigration policies that had increased reluctance among some immigrant families to enroll in public programs, including health coverage.

Coverage disparities have persisted, and in some cases widened, over time even with recent gains and the large earlier gains in coverage under the ACA. For example, in 2010, the uninsured rate for AIAN people was 2.4 times higher than the uninsured rate for White people; however, in 2023, the uninsured rate for AIAN people had increased to 2.9 times higher than the rate for White people. Similarly, the Hispanic uninsured rate grew from 2.5 to 2.8 times higher than the rate for White people from 2010 to 2023, while Black people remained 1.5 times more likely to be uninsured than White people.

Coverage by Race and Ethnicity as of 2023

While there were minimal changes in overall uninsured rates between 2022 and 2023, Hispanic, Black, AIAN, and NHPI people under the age of 65 years old remained more likely than their White counterparts to be uninsured (Figure 2). AIAN and Hispanic people had the highest uninsured rates at 18.7% and 17.9%, respectively, as of 2023. Uninsured rates for NHPI (12.8%) and Black people (9.7%) also were higher than the rate for their White counterparts (6.5%). These differences in uninsured rates are driven by lower rates of private coverage among these groups. Medicaid coverage helps to narrow these differences but does not fully offset them.

Medicaid and CHIP coverage help fill gaps in private coverage and reduce coverage disparities for children, but some disparities in children’s coverage remain (Figure 2). Medicaid and CHIP cover larger shares of children than adults, reflecting more expansive eligibility levels for children. This coverage helps fill gaps in private coverage, with over half of Hispanic, Black, AIAN, and NHPI children covered by Medicaid and CHIP. However, there remain some disparities in children’s coverage. For example, AIAN children are about three times as likely as their White counterparts to lack coverage (12.7% vs. 4.0%). Moreover, Hispanic children are more than twice as likely as White children to be uninsured (8.5% vs. 4.0%).

Among people under the age of 65, uninsured rates in states that have not expanded Medicaid are higher than rates in expansion states across most racial and ethnic groups as of 2023 (Figure 3). The differences in coverage rates between Black and Hispanic people compared with White people are larger in non-expansion states compared with expansion states. However, the relative risk of being uninsured for Black, Hispanic, and Asian people compared with White people is similar in expansion and non-expansion states. For example, Hispanic people under the age of 65 years old are roughly 2.6 times as likely as their White counterparts to lack coverage in both expansion and non-expansion states. Uninsured rates for AIAN people are similar in expansion and non-expansion states. Overall, the differences in coverage by expansion status are primarily driven by differences in coverage rates among adults ages 18-64. However, White, Hispanic, Black, Asian, and NHPI children in non-expansion states also are more likely to be uninsured than those in expansion states. For example, 13.5% of Hispanic children in non-expansion states are uninsured compared to 6.1% of Hispanic children in expansion states.

Eligibility for Coverage among the Uninsured as of 2023

There are opportunities to increase coverage by enrolling eligible people in Medicaid or Marketplace coverage, but eligibility varies across racial and ethnic groups, and many remain ineligible for assistance. Overall, six in ten people who were uninsured in 2023 were eligible for financial assistance either through Medicaid or through subsidized Marketplace coverage, while the remaining four in ten were not eligible because they fell in the Medicaid coverage gap in states that have not expanded Medicaid, they were deemed to have access to an affordable Marketplace plan or offer of employer coverage, or they were ineligible due to their immigration status. However, the share of the remaining uninsured eligible for assistance varied by race and ethnicity. For example, uninsured Black people under age 65 were more likely than their White counterparts to fall in the coverage gap in states that have not expanded Medicaid, and uninsured Hispanic and Asian people under age 65 were less likely than White people to be eligible for coverage options, in part, reflecting higher shares of noncitizens who face immigrant eligibility restrictions among these groups (Figure 4).

Uninsured Black people under age 65 are more likely than their White counterparts to fall in the Medicaid “coverage gap” because a greater share live in states that have not implemented the Medicaid expansion. As of November 2024, 10 states have not adopted the ACA provision to expand Medicaid to adults with incomes through 138% of poverty. Most of these states are in the South, where a higher share of the Black population resides (Figure 5). In these states, 1.4 million uninsured people with incomes under poverty fall into the “coverage gap” and do not qualify for either Medicaid or premium subsidies in the ACA Marketplace.

Uninsured Asian, Black, Hispanic, and NHPI people under age 65 are less likely than their White counterparts to be eligible for coverage because they include larger shares of noncitizens who are subject to eligibility restrictions for Medicaid and Marketplace coverage (Figure 6). Lawfully present immigrants face eligibility restrictions for Medicaid coverage, with many having to wait five years after obtaining lawful status before they are eligible to enroll in Medicaid. Undocumented immigrants are not eligible to enroll in Medicaid and are prohibited from purchasing coverage through the Marketplaces.

Looking Ahead

Policies implemented amid the COVID-19 pandemic helped stabilize coverage and contributed to gains in coverage during this period. The coverage gains experienced during the COVID-19 pandemic were largely driven by an increase in Medicaid coverage, which offset declines in employer-sponsored coverage. As noted, temporary continuous enrollment provisions stabilized Medicaid coverage during the PHE, contributing to increases in enrollment. Additionally, the temporary enhanced subsidies for Marketplace coverage provided under ARPA, which were extended through 2025 under the IRA, also contributed to coverage gains. However, even with these gains, disparities in coverage remained.

Since the Medicaid continuous enrollment provision ended in March 2023, millions of people have been disenrolled. While there is limited data available on disenrollments by race and ethnicity, research suggests that Black and Hispanic people were two times more likely than White people to lose Medicaid due to being unable to complete the renewal process during the unwinding period. Many people who were disenrolled from Medicaid could find low-cost coverage on the ACA Marketplaces, including, in some cases, coverage with a zero (or near-zero) monthly premium requirement. However, others became uninsured. In focus groups, adults who were disenrolled from Medicaid reported losing coverage for a variety of reasons, including because they were no longer eligible; however, some believed they were still eligible and did not know why they were disenrolled. Many reported facing communication problems with their Medicaid agencies, and some who were disenrolled indicated that they faced gaps in coverage before reenrolling in Medicaid or became uninsured, which contributed to high out-of-pocket costs and difficulties accessing care that negatively impacted their health.

Going forward, racial and ethnic disparities in coverage could widen due to potential Medicaid cuts, expiration of the enhanced subsidies for Marketplace coverage, and immigration policy changes. The incoming Trump administration and Republican controlled Congress are signaling plans to make significant changes to Medicaid and the ACA. House Republicans appear to be considering large cuts to Medicaid, which could help offset the cost of extending expiring tax cuts but would shift a substantial amount of Medicaid spending from the federal government to states, and likely lead states to make reductions in eligibility and/or benefits. Further, if Congress does not take action to extend the enhanced ACA Marketplace subsidies, which are set to expire in 2025, premiums will rise, likely leading to an increase in the number of uninsured people. Additionally, the Trump administration’s changes to immigration policy, including increased enforcement, the rescission of protections from enforcement activity in sensitive locations including health care facilities, and potential changes to public charge policy, will likely lead to reduced enrollment in health coverage of lawfully present immigrants and citizen children in immigrant families. Medicaid and Marketplace coverage losses would likely lead to widening racial disparities in coverage given that disproportionately large shares of Hispanic, Black, AIAN, and NHPI people are covered through these sources, which, in turn, would likely contribute to widening disparities in health.

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.