President Trump has made a slew of immigration policy changes focused on restricting entry at the border and increasing interior enforcement efforts to support mass deportation. These include rescinding protections against enforcement action in previously protected areas such as health care facilities and schools. While many of these actions focus on the estimated 11 million undocumented immigrants in the U.S., they will have ripple effects among the much larger number of people in immigrant families, including millions of U.S.-born citizen children. During the first Trump administration, restrictive immigration policies and increased enforcement activity led to increased fears among immigrant families across immigration statuses that had negative effects on health and well-being, employment, and daily life. They also could lead to family separations as well as mass detentions, which can have negative mental and physical health impacts on immigrants across statuses and their children. Mass deportations also could negatively impact the U.S. economy and workforce, given the role immigrants play, particularly in certain industries, including health care.

The extent to which President Trump will be able to carry out his plans without additional legislative action and in the face of potential court challenges remains uncertain. However, these plans are already affecting immigrants’ daily lives and increasing fears, with Immigrations and Customs Enforcement (ICE) agents carrying out raids across communities, and reports of nearly 1,000 people arrested in one recent day. This brief discusses the potential implications of increased enforcement actions under the Trump administration for the health and well-being of families and potential broader impacts for communities, the workforce, and the economy, including health care.

What actions is President Trump taking to increase interior enforcement and who may be affected?

Upon taking office, President Trump issued a series of executive orders focused on restricting immigration and increasing interior enforcement activity. These include orders limiting birthright citizenship, declaring a national emergency at the Southern border and restricting access at the border, expanding enforcement policies, suspending the refugee admissions program, and rescinding numerous Biden-era policies, including a policy that protected against enforcement in “sensitive areas,” including schools and health care facilities. Many of the changes outlined in the orders may require legislative or regulatory action to implement, and many are likely to be challenged in court. For example, a federal judge has already blocked the order to end birthright citizenship through a temporary restraining order. However, these changes are already increasing fears and uncertainty among families and communities. Other changes may put other groups with lawful status at risk of losing protections, including Deferred Action for Childhood Arrivals (DACA) recipients and people with Temporary Protected Status (TPS) designations from some countries. The administration recently revoked TPS for Venezuelans living in the U.S., which will make them at risk for deportation in coming months and eliminate their work authorizations.

While enforcement actions are focused on undocumented immigrants, they will have ripple effects across millions more people living in immigrant families, including U.S.-born citizen children. As of 2023, there were 47.1 million immigrants residing in the U.S., including 22.4 million noncitizen immigrants, of whom an estimated 11 million are undocumented. Additional immigrants that currently have lawful statuses may be at risk for enforcement actions under new policies if they lose protections, including nearly 1.2 million immigrants who either have or are eligible for TPS, the over 530,000 active DACA recipients, and individuals in the U.S. with pending asylum cases. Millions of additional individuals living in immigrant families also are likely to be impacted. Many undocumented immigrants live in families with mixed immigration statuses that may include people with lawful status and U.S. citizens. As of 2023, 19 million, or one in four, children in the U.S. had an immigrant parent, including one in ten (12%) who are citizen children with a noncitizen parent. An estimated 4.4 million U.S.-born children live with an undocumented immigrant parent.

What are the likely impacts of enhanced enforcement activity on the health and well-being of immigrant families?

Prior KFF focus groups with immigrant families during the first Trump administration found that restrictive immigration policies, including increases in detention and deportation, led to increased fears among immigrant families across immigration statuses that had negative effects on health and well-being. Immigrant families, including those with lawful status, reported experiencing resounding levels of fear and uncertainty. Some also reported changes in daily life such as increased difficulty finding employment, leading to increased financial strains on families. Some parents, particularly those who are undocumented or who have an undocumented family member, said they would only leave the house when necessary, such as for work; limit driving; or no longer participate in recreational activities, leading to children spending many hours inside. Parents and pediatricians reported a broad array of impacts of increased fears among children, including behavioral changes, such as problems sleeping and eating; psychosomatic symptoms, such as headaches and stomachaches; and mental health issues, such as depression and anxiety. Parents and pediatricians also felt that fears negatively affected children’s behavior and performance in school. Pediatricians expressed significant concerns about the long-term health consequences of these fears for children, including the damaging effects of toxic stress on physical and mental health over the lifespan, negative effects on children’s growth and development, and compounding social and environmental challenges that negatively impact health.

Increased fears under the first Trump Administration also led to growing reluctance among some families, including lawfully present immigrants and citizen children, about participating in programs and seeking services for which they are eligible, including health coverage and care. In KFF focus groups with immigrant families during the first Trump administration, parents noted that they highly prioritize their children’s health and generally viewed hospitals and doctors’ offices as safe spaces. However, there were some reports of changes in health care use, including decreased use of some care, and decreased participation in Medicaid and CHIP and other programs due to increased immigration-related fears. Despite efforts by the Biden administration to reduce these fears, data from the KFF/LA Times Survey of Immigrants showed that, as of 2023, nearly seven in ten (69%) likely undocumented immigrants, a third (33%) of lawfully present immigrants, and over one in ten (12%) naturalized citizen immigrants said they ever worried that they or a family member could be detained or deported. Moreover, about a quarter (27%) of likely undocumented immigrants and nearly one in ten (8%) lawfully present immigrants say they avoided applying for food, housing, or health care assistance in the past year due to immigration-related fears (Figure 1). Fears about accessing health care services may be enhanced under the second Trump administration, given the recission of a policy dating back to 2011, that protected against enforcement activity in sensitive areas, including health care facilities. Health care providers will face new challenges helping families feel safe accessing health care, protecting patient information, and establishing protocols to respond to potential encounters with ICE agents. Additionally, Florida and Texas have implemented policies that require hospitals to request immigration status from patients, which may further enhance fears about accessing care.

KFF interviews with individuals who had a family member detained or deported during the first Trump administration reported broad negative impacts on health and well-being. Respondents reported that detention and deportation of family members often occurred suddenly and unexpectedly, leaving families in shock and unprepared. One of the most immediate and significant effects on families was the loss of income, which left them struggling to pay their bills, including rent, food, and utilities. They further reported disruptions to children’s daily lives, and, in some cases, older children assuming new responsibilities and changing plans, such as no longer attending college, to support the family. Families also reported direct health impacts, including symptoms of depression and worsening chronic conditions. Some families reported losing health coverage and increased barriers to accessing coverage or care due to fears and increased financial challenges.

Other research shows that immigration enforcement raids and family separations can lead to worsened physical and mental health of both parents and children of deported parents. Exposing children to traumatic events and prolonged or toxic stress such as raids and separation from a parent disrupts a child’s healthy development and can result in short- and long-term negative effects on physical, mental, and behavioral health. Research has found that living near areas subject to immigration enforcement raids increased the risk of negative mental health among children of immigrants and worse birth outcomes among both Hispanic immigrant mothers as well as U.S.-born Hispanic mothers as compared to non-Hispanic White mothers. Education outcomes also worsened among Hispanic children in areas impacted by raids compared to White children. One potential consequence of raids and detentions and deportations is the separation of parents from their children. Studies have found that children and caregivers impacted by family separations experience worse mental health, including anxiety, depression, and posttraumatic stress disorder. Family separations can also lead to financial challenges for mixed-status households due to loss of income.

Prior experience suggests that immigrants held in detention facilities may not receive sufficient health care and face unsafe conditions. As the Trump administration escalates enforcement actions, the number of people held in detention facilities will grow likely beyond current capacity. Research showed that detainees, including children, experience poor conditions and inadequate care in detention facilities. An analysis found that most of the deaths of immigrants in detention occurred among “relatively young and healthy men” and were associated with ICE violating their own medical standards. Detention and solitary confinement can also worsen the mental health of immigrants. Studies show high levels of psychiatric distress, including depression and post-traumatic stress, among detained immigrants and their children, even after short detention periods. Research on immigrant detention centers have also found gaps in care for pregnant Hispanic migrants and that LGBT detainees experience higher rates of harassment than non-LGBT detainees.

What are the potential impacts of enhanced enforcement activity on the nation’s economy and workforce?

Mass deportations could also negatively impact the U.S. workforce, given the role immigrants play, particularly in certain industries, including health care. Most immigrants say they came to the U.S. for better work and educational opportunities. Immigrants and their U.S.-born children fill unmet labor market needs and have been the primary drivers of workforce growth, accounting for 83% of the growth in the U.S. labor force between 2010 and 2018. Research shows that immigration does not displace nor lead to more unemployment among U.S. born workers as they often do not compete for the same jobs. Immigrants and their adult children play outsized roles in certain occupations, including agriculture, construction, and health care (Figure 1). As the U.S. 65 and older population grows, deportation of immigrants may exacerbate the health care workforce shortage. Immigrants and their adult children make up a larger share of physicians, surgeons, and other health care practitioners than they do of the population and play a particularly large role as direct care workers in home and community-based settings.

Mass deportations may also reduce the billions of dollars immigrants, including undocumented immigrants, pay in federal, state, and local taxes, which help subsidize health care for U.S.-born citizens. It is estimated that more than a third of their tax dollars are payroll taxes that fund programs they cannot access, including Social Security, Medicare, and the federal share of unemployment insurance. Children of immigrants also contribute more in taxes on average than their parents or the rest of the U.S.-born population. The Congressional Budget Office (CBO) estimates that the recent immigration surge will reduce the federal deficit over the next decade. Research further finds that immigrants pay more into the health care system through taxes and health insurance premiums than they utilize, helping to subsidize health care for U.S.-born citizens. Earlier research found that without the contributions undocumented immigrants make to the Medicare Trust Fund, it would reach insolvency earlier, and that undocumented immigrants result in a net positive effect on the financial status of Social Security.

Expanding capacity to carry out mass deportations would likely be a significant cost to taxpayers and may require additional allocations by Congress. New estimates suggest that Trump’s plan to deport millions of undocumented immigrants could cost hundreds of billions of dollars. Trump’s selected border czar reported an estimated cost of $86 billion. Increases in enforcement activity would likely strain limited resources at ICE and the current system of detention centers, which is already at capacity. Expanding detention capacity to support large-scale deportations would require large investments in infrastructure, including setting up new detention facilities, expanding immigration court capacity, increasing the use of private contractors, and paying for more flights used for deportations.

This resource provides visualizations on the U.S. global health budget and will be updated as needed. Click through the table of contents to jump to different figures.

Table of Contents

1. U.S. Global Health Funding as a Share of the Federal Budget
2. U.S. is the Largest Donor of International Health Assistance
3. Top 10 Donor Governments to International Health Assistance as a Share of Total Assistance
4. U.S. Funding for Global Health, Trends Over Time
5. U.S. Funding for Global Health, Request vs. Enacted Levels
6. U.S. Global Health Funding (in millions), By Program Area
   1. U.S. Global Health Funding (in millions), By Program Area, FY 2024
   2. U.S. Global Health Funding (in millions), By Program Area, FY 2025 Request
7. U.S. Global Health Funding Percent Change by Program Area, Request Compared to Enacted
8. U.S. Funding for Global Health (in millions), Bilateral and Multilateral Share

1. U.S. Global Health Funding as a Share of the Federal Budget

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2. U.S. is the Largest Donor of International Health Assistance

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3. Top 10 Donor Governments to International Health Assistance as a Share of Total Assistance

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4. U.S. Funding for Global Health, Trends Over Time

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5. U.S. Funding for Global Health, Request vs. Enacted Levels

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6. U.S. Global Health Funding (in millions), By Program Area

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7. U.S. Global Health Funding Percent Change by Program Area, Request Compared to Enacted

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8. U.S. Funding for Global Health, Bilateral and Multilateral Share

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Centene, CVS Health, Elevance, Molina, and UnitedHealth are the five largest publicly traded companies (also referred to as “parent” firms) operating Medicaid MCOs, accounting for half of Medicaid MCO enrollment nationally. During the unwinding of the pandemic-era Medicaid continuous enrollment provision, millions of people were disenrolled and states and plans have faced considerable rate setting uncertainty. Firms report current capitation rates do not align with higher member risk and utilization patterns, and many states have sought federal approval to adjust rates to address these shifts. As we look ahead, shifts in state fiscal conditions and talks in Congress about cutting federal Medicaid spending could result in the reductions in Medicaid funding with implications for coverage as well as plans and providers. While plans confront continued uncertainty looking ahead, plan attention and scrutiny has intensified in the aftermath of the killing of UnitedHealthcare’s CEO, Brian Thompson. Within this broad context, this brief examines enrollment and financial data through the end of September 2024 from quarterly company earnings reports and calls, financial filings, and other company materials as well as from national administrative data. Key findings include:

• Medicaid enrollment. As of September 2024, combined Medicaid enrollment across the five firms was 6.2 million (or 20%) higher than enrollment at the start of the pandemic. However, Medicaid enrollment across the firms declined by more than 7 million since March 2023 (just before the “unwinding” began). Medicaid membership as a share of total medical membership has declined for all five firms.
• Medicaid revenue and MLRs. While the three firms that reported Medicaid-specific revenues (Centene, Molina, and UnitedHealth) reported growth in Medicaid revenue in the first nine months of 2024 compared to the same period in 2023, the two firms that reported Medicaid medical loss ratios (MLRs) (percentage of premium revenue spent on medical care costs) reported higher Medicaid MLRs in 2024 (Q1-Q3) compared to 2023 (Q1-Q3), implying a potential decrease in profitability.
• Member acuity and utilization trends. During Q3 2024 earnings calls, firms reported higher member acuity (i.e., average risk profile) due to unwinding redeterminations as well as increased utilization trends in 2024. Higher acuity could be related to a number of factors including that during the unwinding people with higher health care needs were less likely to be disenrolled. Firms say that the Medicaid rate updates they have received (from states) fall short of covering current acuity and cost trends. This could put upward pressure on Medicaid spending at a time when Congress may consider cuts in federal Medicaid contributions.

Medicaid enrollment in the five largest publicly traded companies operating Medicaid MCOs

Five for-profit, publicly traded companies – Centene, Elevance (formerly Anthem), UnitedHealth Group, Molina, and CVS Health – account for 50% of Medicaid MCO enrollment nationally (Figure 1). All five are ranked in the Fortune 500. Each company operates Medicaid MCOs in 14 or more states (Figure 2).

All five firms also operate in the commercial and Medicare markets (Figure 3); however, the distribution of membership across markets varies across firms. Two firms – Molina and Centene – have historically focused predominantly on the Medicaid market. Medicaid members accounted for nearly 90% of Molina’s overall medical membership and about 60% of Centene’s medical membership as of September 2024 (Figure 3). Since March 2023 (just before unwinding began), Medicaid membership as a share of total medical membership has declined for all five firms, ranging from a decline of about 1 percentage point for UnitedHealth to 8 percentage points for Centene. The unwinding may have contributed to membership distribution shifts.

Despite a combined 7.3 million decline in enrollment during the unwinding, Medicaid enrollment across the five firms remains higher by 6.2 million (or 20%) compared to enrollment at the start of the pandemic (Figure 4). In comparison, national data show total Medicaid/CHIP enrollment in September 2024 was 11% higher than Medicaid/CHIP enrollment in February 2020, prior to the pandemic. These changes in “net” enrollment reflect the people who are dropped from Medicaid as well as those who newly enroll, and those who re-enroll within a short timeframe following disenrollment, also known as “churn.” Changes in parent firm enrollment also reflect activity including firm acquisitions or sales and new or lost Medicaid contracts.

While some firms report growth in Medicaid revenue through the end of September 2024, other measures of financial performance (gross margins and medical loss ratios) show a potential decrease in profitability (Figure 5). Even accounting for enrollment declines due to the unwinding, the three firms that report Medicaid-specific financial information through Q3 (UnitedHealth, Molina, and Centene) reported growth in Medicaid revenue in the first nine months of 2024 compared to the same period in 2023. For the first nine months of 2024, medical margins (the amount by which premium revenue exceeds medical costs) earned by the Medicaid segment declined by 27% for Centene and 2% for Molina when compared to the same period in 2023, and Medicaid simple medical loss ratios (medical costs as a share of premium revenue) increased for Centene from 89.9% to 92.3% and for Molina from 88.5% to 90.3%, implying a potential decrease in profitability.

Impact of unwinding for the five largest publicly traded companies operating Medicaid MCOs

During Q3 2024 earnings calls, firms reported current capitation rates do not align with increased Medicaid medical cost trends. Capitation provides upfront fixed payments to plans for expected utilization of covered services, administrative costs, and profit (see Box 1). Plan capitation rates, usually for a 12-month rating period, are set using baseline utilization and cost data from prior periods (which can lag one to two years, to allow claims to complete) trended forward to determine per member per month payment amounts. States may also use different mechanisms to adjust plan risk (e.g., to ensure payments are not too high or too low), including risk-sharing arrangements (see Box 1). During Q3 2024 earnings calls, firms reported higher member acuity (i.e., average risk profile) due to unwinding redeterminations as well as increased utilization trends in 2024. Specifically, firms pointed to increased utilization of behavioral health care, pharmaceuticals (including GLP-1s), and long-term services and supports (LTSS).

A recent analysis conducted by Wakely, a consulting firm with actuarial expertise, highlights many states have recently implemented program changes to improve access to care (e.g., increasing provider rates, implementing limitations to prior authorization, etc.), which can affect utilization trends and put upward pressure on per person costs. Wakely notes that these program changes may be adding complexity to an “already challenging year for capitation rate setting.”

Parent firms expect the misalignment between rates and emerging acuity and cost/utilization trends is temporary but may extend through 2025. In a 2024 KFF survey of Medicaid directors, about two-thirds of responding MCO states reported seeking CMS approval for a capitation rate amendment to address shifts in the average risk profile (or “acuity”) of MCO members in FY 2024 and/or FY 2025. During earnings calls, firms say that the rate updates they have received fall short of covering current acuity and cost trends. Parent firms also report continuing discussions with states on adjustments to 2024 rates and on the development of 2025 rates (which often renew on January 1 or July 1). Centene and Elevance reported sharing current experience / trend data with states to inform these discussions.

Starting on day one of his second term, President Trump began to issue several executive orders and other actions that affect global health. One was “Reevaluating and Realigning United States Foreign Aid” which calls for a 90-day pause in new foreign assistance obligations and disbursements pending review of all foreign aid programs. A notice sent to all diplomatic and consular officials on January 24 implementing the order went further, requiring stop-work orders to be issued for all existing foreign assistance awards, effectively halting implementation of U.S. global health efforts, including PEPFAR, in low and middle-income countries around the world. While PEPFAR was issued a limited waiver a week later, allowing it to restart some services, the situation remains fluid and fast-moving, intersects with several other executive orders and an apparent effort to dissolve USAID (the U.S. international development agency which implements most U.S. global health programs) as an independent agency. In addition, no waivers for other global health programs have been announced. This policy watch provides an overview of what has happened to date, as of February 3, 2025.

What does the Executive Order (EO) pausing foreign aid do? The order, issued on January 20, 2025, was one of the first to be issued by the President. It states that “It is the policy of United States that no further United States foreign assistance shall be disbursed in a manner that is not fully aligned with the foreign policy of the President of the United States” and calls for two main actions:

• A 90-day pause in U.S. foreign development assistance (new obligations and disbursements) to assess programmatic efficiencies and consistency with U.S. foreign policy.
• A review of U.S. foreign assistance programs under guidelines provided by the Secretary of State, in consultation with the Director of the Office of Management and Budget (OMB).

Determinations are to be made within 90 days about whether to continue, modify, or cease programs based on the review, with the concurrence of the Secretary of State. New obligations and disbursements may resume prior to the end of the 90-day period if a review and a determination are made to do so. The EO also allows the Secretary of State to waive the pause for specific programs but does not provide criteria for waivers.

Why was the executive order issued? The rationale for the order appears to be based on both economic efficiency and ideological grounds. According to its preamble, the U.S. “foreign aid industry and bureaucracy are not aligned with American interests and in many cases antithetical to American values. They serve to destabilize world peace by promoting ideas in foreign countries that are directly inverse to harmonious and stable relations internal to and among countries.” A media note issued by the State Department states that the EO is “rooting out waste” and “blocking woke programs.” It also states that “Every dollar we spend, every program we fund, and every policy we pursue must make America safer, stronger, and more prosperous”, a statement made Secretary Rubio during his confirmation hearing and one that underpins the current department’s mission and priorities in Trump’s second term. These ideas also echo several that were included in Project 2025’s Mandate for Leadership, a set of recommendations for the next Republican president released in 2023 by a coalition of conservative organizations. For example, Project 2025 called for freezing foreign aid pending a review by political appointees (p. 174), refocusing “attention away from the special interests and social experiments that are used in some quarters to capture U.S. foreign policy” (p. 196), realigning U.S. foreign assistance “with American national interests and the principles of good governance” and undoing “the gross misuse of foreign aid by the current Administration to promote a radical ideology that is politically divisive at home and harms our global standing” (p. 279).

What is the “stop-work”order and is that different than the pause of new funds? While the EO calls for a pause on new foreign assistance obligations and disbursements (funds that have already been appropriated by Congress usually for specific programs or activities but have not yet gone to programs), a notice sent to all diplomatic and consular officials on January 24 went further. It requires all grant and contract officers to immediately issue stop-work orders for all existing foreign assistance awards (not just new obligations and disbursements) until a review is conducted. This means that work already underway with funding provided to organizations must be immediately stopped, such as clinics providing services, health care workers being funded, and other activities. The notice indicates that waivers had been granted for foreign military financing for Israel and Egypt and emergency food assistance (as well as some salaries and administrative costs).

Have any waivers been granted? While the EO notice indicates that waivers for foreign military financing for Israel and Egypt and emergency food assistance have been granted, it does not provide any further detail or indicate what the process is for requesting a waiver. Separately, on January 28, Secretary Rubio announced that he had issued an additional emergency humanitarian waiver, which allows implementers of “existing life-saving humanitarian assistance programs” to continue or resume work. The waiver is temporary and does not apply to new contracts (unless a separate waiver is granted). Life-saving humanitarian assistance is defined as “core life-saving medicine, medical services, food, shelter, and subsistence assistance, as well as supplies and reasonable administrative costs as necessary to deliver such assistance.”

While additional waivers could be requested through the Director of Foreign Assistance at the Department of State, several activities are not eligible for waivers at all, including those that involve: abortions (which are not paid for using U.S. government funds anyway), family planning, conferences, administrative costs other than those covered by the humanitarian assistance waiver, gender or DEI ideology programs, transgender surgeries, or other non-life saving assistance. Some of these services are also the subject of other executive orders and actions issued by the President include (including “Ending Radical And Wasteful Government DEI Programs And Preferencing” and “Defending Women from Gender Ideology Extremism And Restoring Biological Truth to The Federal Government”).

Despite the emergency humanitarian waiver specifying life-saving medicine and medical services, it was still unclear what programs it actually applied to and whether it included services provided by PEPFAR, the President’s Malaria Initiative, and other health programs, since under the State Department’s framework for foreign aid, health programs and humanitarian assistance efforts are categorized separately. As a result, the PEPFAR program applied for a specific waiver, which was granted on February 1, for certain activities. No other waivers have been announced for any other U.S. global health program, such as for the President’s Malaria Initiative (PMI), TB, maternal and child health, and nutrition activities.

What does PEPFAR’s limited waiver allow for? PEPFAR’s limited waiver, granted on February 1, allows for some PEPFAR services to resume during the 90-day period (unless other guidance is issued). Specifically, the waiver was granted to “implement urgent life-saving HIV treatment services in alignment with the Secretary of State’s January 28 memo “Emergency Humanitarian Waiver to Foreign Assistance Pause.” Life-saving HIV treatment is defined by the waiver as follows:

• Life-saving HIV care and treatment services (including antiretroviral treatment), inclusive of HIV testing and counseling, prevention and treatment of opportunistic infections including TB, laboratory services, and procurement and supply chain for commodities/medicines. This includes health care workers providing these services.
• Prevention of mother-to-child transmission services, inclusive of commodities/test kits, medicines and PrEP for pregnant and breastfeeding women.

Activities covered by the waiver may be resumed, including new disbursements and limited obligations (only where pre-planned obligations already existed for the activities or where they otherwise could not be restarted without new obligations). No other activities can be resumed. The waiver indicates that the PEPFAR program will create an interagency team to provide ongoing guidance to programs. 

What are the implications of stopping U.S. global health programs? The stop-work orders on existing awards and pause on new obligations and disbursements have, for the time being, halted current U.S. global health (and other foreign assistance) programs, other than activities permitted under PEPFAR’s limited waiver. This is because health care workers have been told to stop work, clinics are having to close, and commodities and other supplies cannot be provided to clients, affecting access for millions of individuals around the world, many of whom are women and children. Some of the interventions at risk of interruption and discontinuation are:

• PEPFAR/HIV: services not included in the limited waiver such as cervical cancer screening, PrEP (other than for pregnant women), and services for orphans and vulnerable children.
• PMI/Malaria: bed-nets, indoor residual spraying, seasonal malaria chemoprevention, intermittent preventive treatment in pregnancy.
• Tuberculosis: diagnosis of TB and drug-resistant TB, provision of life-saving medicines.
• Polio: identification of polio cases, vaccination of children.
• Maternal and child health: emergency obstetric care, prenatal and antenatal care, essential newborn care, skilled birth attendants.
• Family planning: contraception, birth spacing counseling, prevention and repair of obstetric fistula, linkage to maternal health services.
• Nutrition: nutrition education, nutrition during pregnancy, exclusive breastfeeding, and micronutrient supplementation.
• Outbreak investigations: halting investigations of and responses to current outbreaks of Ebola, Marburg, and mpox.

Beyond these direct impacts on access to services for people, hundreds of health care and aid workers have lost their jobs and it is expected that many more will as well, and there are widespread reports of confusion as criteria are not often specified, changes are rapid, and high level health officials at the agency which has historically overseen implementation of many of these programs, have been placed on leave.

What happens next? The implications of the pause in global health efforts will likely increase over the 90-day period, as additional programs and activities — those without waivers — are forced to shut down and lay off staff, and more people are unable to get services. The review of foreign aid programs is also underway. Depending on the results of the review, some programs may be recommended for continuation, modification, or may be discontinued. For those that are allowed to continue, it is not clear whether they will still have the capacity (staff, clinic infrastructure, systems) to be able to do so. There is also some confusion regarding the legal status of the foreign aid EO, given that a separate administrative action requiring all federal agencies to temporarily pause all new obligations and disbursements of all Federal financial assistance to ensure compliance with EOs has been successfully challenged in court and temporary restraining orders are in effect, preventing any pause. There are also reports that a lawsuit may be brought specifically challenging the foreign aid EO. Finally, Congress could step in. Congress has oversight of foreign aid programs and, in some cases, Congressional notification is required for program changes. Still, only Democratic Senators have publicly weighed in on the foreign aid freeze and other changes underway thus far (https://www.foreign.senate.gov/press/dem/release/ranking-members-shaheen-schatz-meeks-frankel-we-cannot-afford-to-take-a-timeout-from-usaid-programs and https://www.coons.senate.gov/news/press-releases/senator-coons-decries-president-trumps-freeze-on-almost-all-foreign-assistance-in-speech-on-senate-floor) and it is unclear if additional oversight efforts will be made.

Enhanced Affordable Care Act (ACA) subsidies were first made available as part of the American Rescue Plan Act in 2021 and were extended through the end of 2025 by the Inflation Reduction Act. The enhanced subsidies build on the ACA’s original tax credits by increasing the amount of premium assistance lower-income enrollees receive, and by making middle- and higher-income enrollees (with incomes over four times poverty) newly eligible for financial assistance to buy health insurance. These enhanced subsidies will expire at the end of this year unless Congress further extends them and President Trump signs it into law. In 2024, 56% of ACA Marketplace enrollees live Congressional Districts represented by Republicans and 76% of enrollees are in states won by President Trump in the 2024 election.

If the enhanced subsidies expire, monthly premium payments for the vast majority of Marketplace enrollees will increase sharply starting January 1, 2026. Among subsidized enrollees living in states that use Healthcare.gov (where data are available), premium payments would have been an average of 93% higher in 2024 without the enhanced tax credits. If these enhanced subsidies expire, the Congressional Budget Office (CBO) projects that there will be an average of 3.8 million more uninsured people each year. Unsubsidized premiums will also likely rise as healthier enrollees drop their coverage. While some state-based Marketplaces offer additional premium financial assistance for certain enrollees, the amount of and availability of these state subsidies would not be enough to fully replace the federal enhanced subsidies.

The interactive map below illustrates how much premium payments would rise without the enhanced subsidies, net of tax credits, at the congressional district level. The tool presents average net premium increases (for states that use Healthcare.gov, where data are available) and two hypothetical scenarios (in all states): one of an older couple who would lose subsidy eligibility due to their income exceeding four times poverty and another for a single individual with a $31,000 income (206% of poverty). A KFF calculator allows users to evaluate zip-code specific changes in premium payments with and without enhanced subsidies for other income and family scenarios.

Because enhanced tax credits decrease premium payments across the board for people receiving a tax credit, all subsidized Marketplace enrollees will experience increases in their monthly premium payments if the enhanced subsidies expire. However, how much each enrollee’s premium payment increases will vary widely and will depend on their family size, location, and income.

Average Increases in Premium Payments Among Subsidized ACA Enrollees

In some congressional districts, there is both a large share of the population enrolled in ACA Marketplace coverage and an expectation of very high average increases in premium payments without the enhanced tax credits. Among states that use Healthcare.gov (where average enhanced tax credit data are available), there are 39 congressional districts where at least 10% of the population is enrolled in the ACA Marketplaces and where 2024 average premium payments would have been double or more had it not been for the enhanced subsidies (Table 1). While these 39 districts are politically split (19 are represented by Democrats and 20 are represented by Republicans), these districts are mostly concentrated in a few red states. Twenty of these 39 districts are in Texas, 7 are in Florida, and 3 are in Georgia. These states are among those that have seen ACA Marketplace enrollment grow the most since the enhanced subsidies went into effect. Since 2020, ACA Marketplace enrollment has more than doubled in Florida and more than tripled in Texas and Georgia.

Increases in Premium Payments for An Older Couple on the “Subsidy Cliff”

The expiration of the enhanced premium tax credits would mean that people with incomes over four times the poverty level are no longer eligible for financial assistance. Prior to the availability of enhanced subsidies, ACA Marketplace premium assistance eligibility capped at 400% of poverty (which is $60,240 for a single person or $81,760 for a couple in 2025). If enhanced subsidies expire, Marketplace enrollees making just above 400% of poverty will encounter the “subsidy cliff” and would face the full price of a Marketplace plan. If the enhanced subsidies expire, a 60-year-old couple making $82,000 (401% of poverty) would see their premium payment for the benchmark silver plan, on average, at least double in the vast majority of congressional districts. The benchmark silver premium for a 60-year-old couple at this income would triple or more, on average, in 328 congressional districts.

Premium Increases for Lower-Income Enrollees

A 40-year-old Marketplace enrollee in the contiguous U.S. making $31,000 (206% of poverty) would see monthly premium payments in 2025 rise by $95 (a 165% increase) from $58 to $153. (Alaska and Hawaii have different poverty guidelines). Nationally, there are 75 congressional districts where at least 10% of the population is enrolled in the Marketplace. For a 40-year-old making $31,000, premium payments would at least double on average in all 75 districts. 62 of these districts are in Florida, Georgia and Texas. 38 of these 62 districts are represented by Republicans while 24 are represented by Democrats.

Under the enhanced phase out caps, Marketplace enrollees with incomes up to 150% of poverty currently pay zero (or near zero) dollars for a benchmark silver plan. Should the enhanced subsidies expire, enrollees in this income group will be on the hook for some of the cost of their premiums if they want to keep a silver plan. Before the enhanced subsidies went into effect, Marketplace enrollees at this income group paid about 2-4% of their income for a benchmark plan. A sizeable portion of the Marketplace population benefits from zero dollar premiums, with 42% of HealthCare.gov enrollees in 2024 paying nothing for Marketplace coverage (up from 14% of HealthCare.gov enrollees in 2021).

On Friday January 31, 2025, several federal government datasets went offline. The datasets taken down included some widely used, large-scale national health surveys, indices, and data dashboards that inform research, policy making, and media coverage about health care and public health. For example, several Centers for Disease Control and Prevention (CDC) surveys and datasets were offline Friday and Saturday, with messages simply saying the page “was not found.” The homepage of the United States Census displayed an error message, but data.census.gov – where many datasets can be downloaded – was functioning.

By Sunday February 2, 2025, some of the landing pages started to come back online – now with a warning message: “CDC’s website is being modified to comply with President Trump’s Executive Orders,” suggesting there could be future changes. In some cases, survey data files are back online and appear to be intact, but the survey documentation (questionnaires and codebooks), which researchers use to analyze the data files, remained offline. Some related reports also remained offline. It is not yet clear whether all the datasets and their documentation that went offline will come back or remain online, and if they do, what changes, if any, will be made. It also remains to be seen what changes may be made to future data collection efforts.

The removal or modification of these data sources appears to be in response to executive orders issued by President Trump on his first day in office outlining the administration’s perspectives and approach to sex and gender and on racial equity and diversity equity and inclusion (DEI), as well as a pause on foreign assistance. An Office of Personnel Management (OPM) memorandum on the first EO directed departments and agencies to “take down all outward facing media (websites, social media accounts, etc.) that inculcate or promote gender ideology” and “withdraw any final or pending documents, directives, orders, regulations, materials, forms, communications, statements, and plans that inculcate or promote gender ideology.” Another OPM memorandum similarly directed departments and agencies to “Take down all outward facing media (websites, social media accounts, etc.) of DEIA offices”. None of these executive orders nor the OPM memos specifically mention datasets or survey data.

Federal surveys play a key role in the health surveillance system, which helps direct initiatives to address some of the most pressing health conditions and problems facing the country. For example, one of the affected datasets is CDC’s Behavioral Risk Factor Surveillance System (BRFSS), which is one of the most widely used national health surveys and has been ongoing for about 40 years. Datafiles for all years were temporarily offline and as of this writing have been reposted, but without questionnaires or codebooks. BRFSS is described on one federal website as a source of state-level “information about health risk behaviors, preventive health practices, and health care access primarily related to chronic disease and injury.” The survey has been used for decades to inform policymakers, the media, and the public on a wide range of health topics, such as obesity rates, access to breast cancer screenings, vaccination rates, and the share of people with pre-existing conditions. With sampling in every state, BRFSS data are particularly helpful for understanding health issues in low-population states and rural areas.

In reviewing KFF’s archives of the BRFSS core questionnaire, it did not include detailed questions about sexual orientation or gender identity. However, in recent years, BRFSS offered an optional module on sexual orientation and gender identity, which was implemented in most states. This supplemental data has been used by KFF to show that adults who identify as transgender are more likely than cisgender adults to be uninsured, experience depression, and report being in poor health. At the time of this writing, the BRFSS data file is back online and appears to be intact, including the question about gender identity, though the survey documentation is not online.

Another of the datasets taken offline was CDC’s Youth Risk Behavior Survey (YRBS), which, since 1990, has tracked high school students’ behaviors that can influence health and social outcomes, like smoking, drug and alcohol use, and dietary and exercise habits. Like BRFSS, the landing page and associated materials were offline but, as of the time of this writing, have returned without questionnaires or codebooks. This survey is particularly useful because it asks questions to teenagers directly, rather than surveying their parents, who may be unable or unwilling to answer questions accurately. KFF analysis of YRBS data has shown that large shares of teenagers experience persistent sadness and hopelessness, and that teenage girls experienced a sharp rise in suicidal ideation during the pandemic. Recently, the YRBS has asked respondents about their sexual orientation and gender identity, and the data has been used to highlight substantial mental health disparities among LGBTQ+ high school students, compared to their non-LGBTQ+ peers.

Several of the other datasets taken down (at least temporarily) relate to HIV/AIDS in the U.S. as well as global health efforts around the world in low and middle-income countries, including but not limited to:

• CDC AtlasPlus: an interactive database with about 15 years of surveillance data for HIV, viral hepatitis, STD, and TB, as well as data on the social determinants of health. Additionally, CDC HIV surveillance reports dating back to the beginning of the epidemic were also removed.
• PEPFAR Data Dashboards: PEPFAR, the U.S. global HIV/AIDS Program, comprehensive, up-to-date online data portal of program budgets and expenditures by country and service category, among other variables
• Demographic and Health Surveys (DHS) databases: data downloads from the DHS, an ongoing set of nationally representative household surveys supported by USAID, the U.S. international development agency, with population, health, HIV, and nutrition data from more than 90 countries. Separately, the entire website for USAID has been taken down resulting in the removal of countless reports and other data sources.
• foreignassistance.gov: The U.S. government’s website with all foreign assistance data by country, budget, expenditure, program, going back more than two decades and created to increase aid transparency.

Other federal dashboards and indices were also offline, at least temporarily, including but not limited to: Area Health Resource Files (a resource of data on health professionals, hospitals, and economic indicators), CDC’s Social Vulnerability Index (Census-based socioeconomic data used for disaster planning, response and recovery), and the Environmental Justice Index (Census tract-level data used to identify populations facing negative environmental, social and health factors).

While not the focus of this brief, other health information intended for the public has also been removed or changed, which could have implications for access to and receipt of services and other interventions.

Section 1115 Medicaid demonstration waivers offer states an avenue to test new approaches in Medicaid that differ from what is required by federal statute, so long as 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. Section 1115 waivers generally are approved for an initial five-year period and can be renewed, typically for three-to-five-year periods. The Biden administration encouraged states to propose waivers that expand coverage, reduce health disparities, advance whole-person care, and improve access to behavioral health care. Some waiver initiatives, including using Medicaid to assist with reentry from incarceration, have been pursued by both Republican and Democratic governors. This waiver watch recaps key Biden administration 1115 waiver priorities and initiatives, and highlights states that received approval in each area. For the latest on Medicaid waiver activity (pending applications and approvals), visit KFF’s 1115 tracker.

Looking ahead, the new Trump administration’s waiver priorities will likely differ significantly from those of the Biden administration. However, it is unclear how the Trump administration will treat certain waivers promoted and approved by the Biden administration. The Trump administration could choose not to approve waivers that remain pending or come up for renewal (as many existing waivers are due to expire during the Trump administration) or rescind existing waiver guidance. Additionally, outlined in waiver approval terms and conditions, CMS reserves the right to withdraw 1115 waiver or expenditure authorities at any time (including those already in operation under an active/approved waiver). Although this authority has been infrequently used in the past, the Biden administration withdrew Medicaid work requirement waivers in all states that had approvals, concluding that the provisions do not promote the objectives of the Medicaid program. States can appeal withdrawal decisions to the HHS Department Appeals Board and/or challenge recissions in court.

Health-Related Social Needs

The Biden administration approved 18 waivers authorizing evidence-based housing and nutrition services for specific high-need populations under a new “health-related social needs” (HRSN) 1115 framework. The Centers for Medicare and Medicaid Services (CMS) defines health-related social needs as an individual’s unmet, adverse social conditions (e.g., housing instability, homelessness, nutrition insecurity) that contribute to poor health and are a result of underlying social determinants of health (SDOH). In 2022, CMS announced a Section 1115 demonstration waiver opportunity to expand the tools available to states to address enrollee health-related social needs (building on guidance released at the end of the first Trump administration in 2021). In 2023, CMS issued a detailed Medicaid and CHIP HRSN framework accompanied by an Informational Bulletin, which was updated in 2024. Approvals under the HRSN framework include coverage of rent/temporary housing and utilities for up to 6 months and meal support up to three meals per day (for up to 6 months), departing from longstanding prohibitions on payment of “room and board” in Medicaid. North Carolina’s “Healthy Opportunities” pilots was originally approved during the first Trump administration (allowing the state to provide certain non-medical services targeting SDOH in limited regions of the state) but was recently renewed under the Biden administration’s HRSN framework (extending the scope of services and geographic reach). Some 1115 SDOH-related requests for housing and/or nutrition services remain pending with CMS, including Connecticut, DC, Maine, Nevada, and Rhode Island. Many HRSN waivers will face renewal during the Trump administration, with Colorado’s waiver set to expire at the end of 2025 and others (e.g., California, New York) due for renewal starting in late 2026/early 2027.

Medicaid Pre-release Coverage for Individuals Who Are Incarcerated

The Biden administration approved 19 state waivers to facilitate reentry for individuals who are incarcerated. In April 2023, CMS released guidance encouraging states to apply for a new Section 1115 demonstration opportunity to test transition-related strategies to support community reentry for people who are incarcerated—as directed by the 2018 SUPPORT Act (which was signed into law during the first Trump administration). This demonstration allows states a partial waiver of the inmate exclusion policy, which prohibits Medicaid from paying for services provided during incarceration (except for inpatient services). Reentry services aim to improve care transitions and increase continuity of health coverage, reduce disruptions in care, improve health outcomes, and reduce recidivism rates. At a minimum, states must provide case management, medication-assisted treatment for all types of substance use disorders (with accompanying counseling), and a 30-day supply of prescription medications at the time of release. Nine states (including DC) have waivers to provide reentry services pending with CMS.

Multi-year Continuous Eligibility for Children

The Biden administration approved 9 waivers that allow states to provide multi-year continuous eligibility for children (e.g., from birth to age six). The Consolidated Appropriations Act, 2023 required all states to implement 12-month continuous eligibility for children beginning on January 1, 2024. States may request Section 1115 waiver authority to provide continuous eligibility for children for longer than 12 months. Continuous eligibility has been shown to reduce Medicaid disenrollment and “churn” rates (rates of individuals temporarily losing Medicaid coverage and then re-enrolling within a short period of time). When individuals churn on and off coverage, the gaps in coverage may limit access to care or lead to delays in getting needed care, which can be especially problematic for young children who receive frequent screenings and check-ups. Most states with waivers are approved to provide continuous coverage for young children from birth to age six; some states are also approved to provide 24 months of continuous eligibility for children ages six to 19. While no additional multi-year continuous eligibility waivers for children are pending with CMS, some may remain under consideration at the state-level.

Between 2019 and 2022, the U.S. experienced a sharper decline and a slower rebound in life expectancy than peer countries, on average, due to increased mortality and premature death rates in the U.S. from the COVID-19 pandemic. Updated life expectancy estimates in this chart collection show that in 2023, life expectancy in the U.S. returned to pre-pandemic levels, but remains lower than that of comparable countries.

This chart collection examines how life expectancy in the U.S. compares to that of other similarly large and wealthy countries in the Organisation for Economic Co-operation and Development (OECD). The countries included in the comparison are Australia, Austria, Belgium, Canada, France, Germany, Japan, Netherlands, Sweden, Switzerland, and the United Kingdom.

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.

Medicaid represents nearly $1 out of every $5 spent on health care in the U.S. and is the major source of financing for states to provide health coverage and long-term care for low-income residents. Medicaid is administered by states within broad federal rules and jointly funded by states and the federal government through a federal matching program with no cap. With Donald Trump returning to the presidency and Republican control of the Senate and House, discussions are ramping up about major cuts to federal spending, including federal Medicaid spending, through a new government efficiency initiative and to help pay for an extension of tax cuts in the 2017 Tax Cuts and Jobs Act. Restricting federal Medicaid spending could leave states with tough choices about whether to offset reductions with state dollars, limit Medicaid utilization or benefits, or reduce coverage. Amid uncertainty for Medicaid financing at the federal level, states have also reported uncertainty regarding post-unwinding Medicaid spending and enrollment trends and recent shifts in state fiscal conditions. This brief examines the following key questions ahead of potential proposals to change Medicaid financing:

• How does Medicaid financing work?
• How much does Medicaid cost and how are funds spent?
• How does Medicaid relate to federal and state budgets?
• What factors affect Medicaid spending changes?

How does Medicaid financing work?

Medicaid financing is shared by states and the federal government with a guarantee to states for federal matching payments with no pre-set limit. The percentage of costs paid by the federal government (known as the federal medical assistance percentage or “FMAP”) varies across states, for specific services and types of enrollees, and depending on whether the costs are for medical care or program administration. The match rate has also been temporarily adjusted during economic downturns and most recently during the COVID-19 pandemic.

The FMAP for services used by people eligible through traditional Medicaid, which includes individuals who are eligible as children, low-income parents, because of disability, or because of age (65+), 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. The resulting FMAP varies by state and ranged from 50% (the FMAP “floor”) in ten states (California, Colorado, Connecticut, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Washington, and Wyoming) to 77% in Mississippi for federal fiscal year (FFY) 2026 (Figure 1).

To participate in Medicaid and receive federal matching dollars, states must meet core federal requirements. States must provide certain mandatory benefits (e.g., hospital, physician, and nursing home services) to core populations (e.g., low-income pregnant women, children, people with disabilities, and people ages 65 and older) without waiting lists or enrollment caps. States may also receive federal matching funds to cover “optional” services (e.g., adult dental care and home care, also known as home and community based services) or “optional” groups (e.g. people with income above the limits established for core populations). States also have discretion to determine how to purchase covered services (e.g., through fee-for-service or capitated managed care arrangements) and to establish provider payment methods and rates.

Medicaid also provides “disproportionate share hospital” (DSH) payments to hospitals that serve a large number of Medicaid and low-income uninsured patients to offset uncompensated care costs. DSH payments totaled over $17 billion in FFY 2023. Federal DSH spending is capped for each state and facility but within those limits, states have considerable discretion in determining the amount of DSH payments to each DSH hospital. The Affordable Care Act (ACA) called for a reduction in federal DSH allotments starting in FFY 2014 based on the assumption of reduced rates of uninsurance, but the cuts have been delayed several times (most recently delayed until April 1, 2025). DSH is one type of a broader set of “supplemental” payments that states make to supplement Medicaid “base” payment rates that often do not fully cover provider costs; unlike other supplemental payments, DSH payments can also be used to pay for unpaid costs of care for the uninsured.

There are special match rates for the ACA expansion group, administration, and other services. While the traditional FMAP applies to the vast majority of Medicaid spending, there are a few exceptions that provide higher match rates for specific services or populations, such as family planning and most notably people covered under the ACA Medicaid expansion. States that have implemented the expansion currently receive a 90% FMAP for adults covered through the ACA Medicaid expansion. States that had not adopted the expansion as of 2021 when the American Rescue Plan Act was enacted are eligible for a 5% increase in the state’s traditional FMAP for two years if they implement the expansion. Administrative costs incurred by states are usually matched by the federal government at a 50% rate, but some functions such as eligibility and enrollment systems receive higher match rates. Medicaid administrative costs are less than 4% of total Medicaid spending.

Unlike in the 50 states and D.C., annual federal funding for Medicaid in the U.S. territories is subject to a statutory cap and fixed matching rate. Once a territory exhausts its capped federal funds, it no longer receives federal financial support for its Medicaid program during that fiscal year. Over time, Congress has provided increases in federal funds for the territories broadly and in response to specific emergency events. Various pieces of legislation during the pandemic significantly increased the allotments for each of the territories and also raised the FMAP rates from the statutory level of 55% to 76% for Puerto Rico and 83% for the other territories. The 2023 Consolidated Appropriations Act extended the 76% FMAP for Puerto Rico through FFY 2027 and made the 83% match rate for other territories permanent.

Both the federal government and states are responsible for promoting program integrity. Program integrity broadly refers to the proper management and function of the Medicaid program to ensure it is providing quality and efficient care while using funds–taxpayer dollars–appropriately, with minimal waste. Improper payment reports in recent years have highlighted program integrity issues, and both the previous Trump Administration and the Biden Administration worked to advance program integrity, though through different means. Improper payments, which are often cited when discussing program integrity, are payments that do not meet Centers for Medicare and Medicaid Services (CMS) program requirements (they can be overpayments, underpayments, or payments with insufficient information to determine whether the payment was proper). Improper payments are not the same as criminal activities like fraud and abuse, which may be a subset of improper payments. CMS estimated the overall Medicaid improper payment rate was about 5% in 2024, the lowest rate since the COVID-19 pandemic began due, in part, to flexibilities granted during that time. Most improper payments (79%) were due to insufficient information (or missing administrative steps), not necessarily due to payments for ineligible enrollees, providers, or services (i.e., since they may have been payable if the missing information had been on the claim and/or the state had complied with requirements). The improper payment estimation process is not designed to detect or measure fraud. Program integrity efforts focused on areas identified as major contributors of improper payments, such as monitoring provider screening and enrollment for noncompliance, likely yield greater returns than focusing on reducing errors in eligibility determinations that could make it more difficult for eligible people to obtain and maintain coverage.

How much does Medicaid cost and how are funds spent?

Capitated payments to Medicaid managed care organizations (MCOs) accounted for more than half of Medicaid spending in FFY 2023 (Figure 2). Managed care and health plans accounted for the largest share (55%) of Medicaid spending, with capitated payments to comprehensive MCOs accounting for 52% of Medicaid spending in FFY 2023 and other Medicaid managed care (e.g., primary care case management (PCCM) arrangements or payments to specialty plans) accounting for another 3%. Smaller shares of total Medicaid spending in FFY 2023 were for fee-for-service acute care (21%), fee-for-service long-term care (19%), Medicaid spending for Medicare premiums on behalf of enrollees who also have Medicare (3%), and DSH payments (2%).

Enrollees eligible based on disability or age (65+) comprise 23% of all enrollees but account for over half of total spending due to higher per person costs (Figure 3). Children account for 34% of enrollees but only 14% of spending. Adult enrollees (those made eligible under the ACA Medicaid expansion, as well as low-income parents) account for 43% of all enrollees and 34% of spending. The disproportionate spending on certain eligibility groups stems from variation in spending per enrollee across the eligibility groups, reflecting differences in health care needs and utilization. Spending per enrollee for individuals eligible based on age (65+) and disability, the two groups with the highest per enrollee costs, is approximately six times higher than spending per enrollee for children, who had the lowest spending of any eligibility group. Those eligible on the basis of age or disability tend to have higher rates of chronic conditions, more complex health care needs and are more likely to utilize long-term care than other enrollees, contributing to higher spending.

Total spending per full-benefit enrollee ranged from a low of $3,750 in Tennessee to $12,425 in the District of Columbia in 2021 (Figure 4). 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. Within each state, there is also substantial variation in the average costs for each eligibility group and within each eligibility group, per enrollee costs may vary significantly. Overall, Medicaid spending has experienced slower cumulative growth since 2008 compared to Medicare and private insurance on a per-enrollee basis.

Overall, Medicaid spending totaled $880 billion in FFY 2023 with the federal government paying 69% ($606 billion) and states paying 31% ($274 billion). This share is slightly higher than historic shares due to the enhanced pandemic match rate, but there is variation across states (Figure 5). The combination of low per capita income and adopting the ACA expansion are both factors in determining the overall share of federal spending on Medicaid. While the federal share of Medicaid spending varies across states, so does the total amount of federal Medicaid dollars coming into the state. States with the largest populations (California, New York, Texas, Pennsylvania, Ohio) receive the most federal Medicaid funding.

How does Medicaid relate to federal and state budgets?

Social Security, Medicare, and Medicaid are the three main entitlement programs and accounted for 41% of all federal outlays in FFY 2024 (Figure 6). Of these three programs, Medicaid is smallest in terms of federal outlays, though it covers a larger number of people than Medicare or Social Security. Overall, federal spending on domestic and global health programs and services accounted for more than one-fourth of net federal outlays in FFY 2024, including spending on Medicare (12%), Medicaid and CHIP (8%), and other health spending (6%). It is expected that in 2025, the new Congress and Administration will leverage reconciliation to make major reductions in spending which can offset some of the costs of extending the expiring tax cuts. Budget reconciliation is a special legislative process used to make changes to taxes and mandatory spending that allows the Senate to pass legislation with only 50 votes rather than the customary 60 votes. To begin the reconciliation process, Congress must develop a budget resolution, which establishes spending levels including any large deficit or spending reduction targets. With President-elect Trump taking substantial cuts to Medicare and Social Security off the table, there will be significant pressure to reduce spending on Medicaid.

Medicaid is a spending item and at the same time the largest source of federal revenues for state budgets. As a result of the federal matching structure, Medicaid has a unique role in state budgets as both an expenditure item and a source of federal revenue for states. According to data from the National Association of State Budget Officers (NASBO), in state fiscal year (SFY) 2023, Medicaid accounted for 30% of total state spending for all items in the budget (Figure 7). Medicaid accounted for only 15% of expenditures from state funds (including state general funds and other state funds), second to K-12 education (23%). On the other hand, Medicaid accounted for 57% of all expenditures from federal funds. States have an incentive to control Medicaid spending because they pay a share of Medicaid costs. At the same time, research shows that federal matching dollars from Medicaid spending have positive effects for state economies. A number of studies show that states that have adopted the ACA Medicaid expansion have realized budget savings, revenue gains, overall economic growth as well as observed positive effects on the finances of hospitals and other health care providers.

States can use provider taxes and IGTs (intergovernmental transfers) to help finance the state share of Medicaid. States have flexibility in determining how to finance the non-federal share of state Medicaid payments, within certain limits. In addition to state general funds appropriated directly to the Medicaid program, most states use funding from local governments or revenue collected from provider taxes and fees to help finance the state share of Medicaid. While data are limited, the Government Accountability Office (GAO) estimated that provider taxes accounted for approximately 17% of the non-federal share of total Medicaid payments in SFY 2018 though the share varies by state. All states (except Alaska) have at least one provider tax in place and many states have more than three (Figure 8). The most common provider taxes are on nursing facilities (46 states) and hospitals (45 states). As of July 1, 2024, 48 states including DC also reported at least one provider tax that is above 3.5% of net patient revenues, and 38 states including DC also reported at least one provider tax that is above 5.5%, which is close to the maximum federal safe harbor or allowable threshold of 6%. Provider taxes and funds from local governments are often used by states to help finance DSH payments, non-DSH supplemental payments like upper payment limit (UPL) payments, and MCO state directed payments (uniform payment increases through managed care that are similar to supplemental payments). New Medicaid managed care rules finalized in 2024 permit states to pay hospitals and nursing facilities at the average commercial payment rate (ACR) when using directed payments, contributing to expected increases in federal Medicaid spending projections.

What factors affect Medicaid spending changes?

Medicaid enrollment and spending typically increase during recessions. Medicaid is a counter-cyclical program, meaning that more people become eligible and enroll during economic downturns. At the same time, states typically may face declines in revenues that make it difficult to finance the state share of funding for the program. As in past economic downturns, Congress enacted legislation during the recent pandemic-induced recession that temporarily increased the federal share of Medicaid spending to help states maintain their Medicaid programs. In exchange, states were required to keep individuals continuously enrolled in Medicaid, contributing to historic growth in Medicaid enrollment. High enrollment growth rates, tied first to the Great Recession, then ACA implementation, and later the pandemic, were the primary drivers of total Medicaid spending growth over the last decade (Figure 9). The continuous enrollment provision ended on March 31, 2023, and Medicaid enrollment growth has since declined and total spending growth has slowed.

Medicaid spending is also driven by other external factors and policy choices. Other external factors can include state fiscal conditions and the costs of providing health services and long-term care. In KFF’s latest annual budget survey, states reported inflation and workforce shortages were driving higher labor costs, resulting in pressure to increase provider rates. State policy choices include changes to eligibility, benefits, or provider reimbursement as well as delivery system reforms. Recent eligibility changes include the adoption of the ACA Medicaid expansion in seven states since 2020 as well as other expansions for children. KFF’s annual budget survey also found many states were implementing benefit enhancements, particularly for mental health and/or substance use disorder services, as well as authorizing a wide range of provider rate increases, particularly for direct care workers in nursing facilities and those providing home care to help address workforce shortages.