This factsheet has been updated to reflect the Trump Administration’s Executive Order on Withdrawing the United States from the World Health Organization, issued on January 20, 2025.

Key Facts

• The World Health Organization (WHO), founded in 1948, is a specialized agency of the United Nations with a broad mandate to act as a coordinating authority on international health issues, including helping countries mount responses to public health emergencies.
• The U.S. government (U.S.) has been actively engaged with WHO throughout its history, providing financial and technical support as well as participating in its governance structure. However, on January 20, 2025, President Trump announced the U.S. would withdraw as a member of WHO and halt funding to the organization. In 2020, during the first Trump administration, the U.S. temporarily suspended funding and initiated a process to end membership, actions that were reversed by the Biden administration in 2021.
• Historically, the U.S. has historically been one of the largest funders of WHO. U.S. contributions have ranged between $163 million and $816 million annually over the last decade.
• Over the last several years WHO has overseen negotiation processes to update an existing agreement known as the International Health Regulations (IHR), and to establish a potential new “pandemic agreement”. In May 2024, member states approved a set of revisions to the IHR but decided to extend the negotiation timeline for a pandemic agreement into 2025. By executive order from President Trump the U.S. will no longer participate in pandemic agreement negotiations, and its future is uncertain.
• In 2024, WHO launched its first ever “investment round,” seeking to mobilize an additional $7 billion from existing and new donors to support its operations through 2028. As of the end of 2024, the organization reported it received $3.8 billion in additional donor pledges, amounting to 53% of its fundraising goal. The Biden administration did not announce a pledge to WHO at that time and the Trump administration has already said that it will cease funding the organization.

What is the World Health Organization?

WHO, founded in 1948, is a specialized agency of the United Nations. As outlined in its constitution, WHO has a broad mandate to “act as the directing and coordinating authority on international health work” within the United Nations system. It has 194 member states.

The agency has played a key role in a number of past global health achievements, such as the Alma-Ata Declaration on primary health care (1978), the eradication of smallpox (formally recognized in 1980), the Framework Convention on Tobacco Control (adopted in 2003), and the 2005 revision of the International Health Regulations (IHR), an international agreement that outlines roles and responsibilities in preparing for and responding to international health emergencies.  WHO has regularly provided member states with technical guidance and support during responses to epidemics and pandemics, such as Ebola, Zika, mpox, and COVID-19.

Mission and Priorities

WHO’s overarching mission is “attainment by all peoples of the highest possible level of health.” It supports its mission through activities such as:

• providing technical assistance to countries;
• setting international health standards and providing guidance on health issues;
• coordinating and supporting international responses to health emergencies such as disease outbreaks; and
• promoting and advocating for better global health.

The organization also serves as a convener and host for international meetings and discussions on health issues. While WHO is generally not a direct funder of health services and programs in countries, it does provide supplies and other support during emergencies and carries out programs funded by donors.

WHO’s overarching objective for its current work period (2019-2025) has been “ensuring healthy lives and promoting well-being for all at all ages.” In pursuit of this objective, it has been focusing on three strategic priorities (the “triple-billion targets”): helping 1 billion more people benefit from universal health coverage; ensuring 1 billion more people are better protected against health emergencies; and helping 1 billion more people enjoy better health and well-being.

As part of its work to help countries be better protected against health emergencies – and propelled by the issues and challenges faced during the COVID-19 pandemic – WHO has been overseeing two sets of international negotiations among member states:

• a process to potentially update and amend the International Health Regulations (IHR) agreement, and
• the drafting of a new “pandemic agreement” that aims to institute a number of common principles and mechanisms that would contribute to global prevention, preparedness, and response capacities.

At the May 2024 World Health Assembly (WHA) meeting, member states did reach consensus and approved a set of revisions to the IHR. On the pandemic agreement, member states have not yet reached consensus and decided to continue negotiations into 2025 with a goal of completing negotiations and voting on the agreement at the May 2025 WHA meeting.

Organization

WHO has a global reach, with a headquarters office located in Geneva, Switzerland, six semi-autonomous regional offices that oversee activities in each region,¹  and a network of country offices and representatives around the world. It is led by a Director-General (DG), currently Dr. Tedros Adhanom Ghebreyesus, who was first appointed in 2017 and was re-elected to a second five-year term in May 2022. Dr. Tedros has indicated that his priorities include continuing to strengthen WHO’s financing, staffing, and operations; building pandemic preparedness and response capacities at WHO and elsewhere; and helping countries re-orient health systems toward primary health care and universal health coverage.

World Health Assembly

The World Health Assembly (WHA), comprised of representatives from 194 member states, is the supreme decision-making body for WHO and is convened annually. It is responsible for selecting the Director-General, setting priorities, and approving WHO’s budget and activities. The annual WHA meeting in May also serves as a key forum for nations to debate and make decisions about health policy and WHO organizational issues. Every four years, the WHA negotiates and approves a work plan for WHO, known as the general programme of work (GPW). The current GPW, for 2019-2023, has been extended by the WHA through 2025. Every two years the WHA also approves WHO’s programme budget in support of its work plan; the current programme budget covers the 2024-2025 biennium. More information about WHO’s budget provided below.

Executive Board

WHO’s Executive Board, comprised of 34 members technically qualified in the field of health, facilitates the implementation of the agency’s work plan and provides proposals and recommendations to the Director-General and the WHA. The 34 members are drawn from six regions as follows:

• 7 represent Africa,
• 6 represent the Americas,
• 5 represent the Eastern Mediterranean,
• 8 represent Europe,
• 3 represent South-East Asia, and
• 5 represent the Western Pacific.

Member states within each region designate members to serve on the Executive Board on a rotating basis. The U.S. currently holds a seat on the Executive Board.

Activities

WHO supports activities across a number of key areas, organized into several “budget segments,” including “base programmes,” emergency operations, polio eradication, and “special programmes” (see Table 1). “Base programmes” refers to the core support provided for WHO headquarters activities, regional operations, and efforts such as improving access to quality essential health services, essential medicines, vaccines, diagnostics, and devices for primary health care. “Emergency operations” includes WHO efforts to help countries prepare for and respond to epidemics and other health emergencies such as COVID-19, mpox, and natural disasters. “Special programmes” includes a number of WHO-led initiatives such as the Research and Training in Tropical Diseases program and Pandemic Influenza Preparedness (PIP) Framework activities.

Funding

Programme Budget

WHO has a programme budget set in advance by member states, which is meant to outline planned activities to meet its work plan over a two-year period (biennium) and describes the “resource levels required to deliver that work.” The current programme budget of $6.834 billion covers the period 2024-2025, and was approved by member states in May 2023. This amount represents a slight (2%) increase over WHO’s previous 2022-2023 programme budget of $6.726 billion. See Table 1.

The programme budget represents a plan for the organization’s anticipated resources, but actual resources may deviate from the initial budgeted amounts over course of the biennium due to changing or unexpected circumstances, such as additional resources (revenue) provided to WHO for emergency responses or lower levels of support than expected. For example, in the previous biennium (2022-2023) WHO reported programme resources that totaled $8.4 billion due to additional funding in support of emergency operations, including COVID-19 response and polio eradication activities.

Revenue

WHO has two primary sources of revenue:

• assessed contributions (set amounts expected to be paid by member-state governments, scaled by income and population) and
• voluntary contributions (other funds provided by member states, plus contributions from private organizations and individuals).

Most assessed contributions are considered “core” funding, meaning they are flexible funds that are often used to cover general expenses and program activities. Voluntary contributions, on the other hand, are often “specified” funds, meaning they are earmarked by donors for certain activities. Although decades ago the majority of WHO’s revenue came from assessed contributions, more recently voluntary contributions have comprised the larger share of WHO’s budget. For example, in the previous budget period (2022-2023) assessed contributions totaled $956.9 million (12.1% of total revenue), voluntary contributions totaled $6.92 billion (87.5% of total revenue), and “other revenue” totaled $28.1 million (0.4%).²  See Figure 1.

Reliance on voluntary, relatively inflexible funding has, in WHO’s view, hampered its operations and effectiveness. In 2022, member states, including the U.S., agreed in principle to move toward more predictable, flexible funding for WHO and to reduce the role of specified voluntary contributions. Since then, member states have approved a 20% increase in assessed contributions for the 2024-2025 biennium, and instituted a goal to have 50% of WHO’s programme budget be financed through assessed contributions by 2030 (which could be linked to WHO first meeting certain organizational benchmarks). However, following the Trump Administration’s decision to withhold U.S. funding and withdraw from WHO altogether, some countries such as China have expressed opposition to the previously agreed-to increases in member contributions, raising concerns about the extent to which these increases will actually be enacted.

In 2024, member states also approved the launch of WHO’s first-ever “investment round, which aims to mobilize additional funding for WHO over the next four years. In its investment case for 2025-2028, WHO estimates it will need $11 billion to implement its global program of work (GPW) over this period, but member state assessments (core contributions) are likely to amount to $4 billion, leaving a $7 billion gap to fill with voluntary contributions and other donations. To help fill this gap, WHO held a series of meetings and “pledging moments,” culminating in a high-level event around the G20 leaders’ summit in Brazil in November 2024. Through this process, WHO reports it was able to generate an additional $3.8 billion in donor pledges through 2028, or 53% of its original goal of $7 billion. The Biden administration did not announce any additional pledges to WHO through the investment round, and now the Trump administration has said that it will cease funding the organization.

Challenges

WHO faces a number of institutional challenges, including:

• a scope of responsibility that has expanded over time with little growth in core, non-emergency funding;
• an inflexible budget dominated in recent years by less predictable voluntary contributions often earmarked for specific activities;
• a cumbersome, decentralized, and bureaucratic governance structure; and
• a dual mandate of being both a technical agency with health expertise and a political body where states debate and negotiate on sometimes divisive health issues.

These and other challenges were particularly evident during and after perceived failures of the agency in the response to the Ebola epidemic in West Africa (2014-2015), and in the criticisms directed at WHO as it tried to help coordinate a global response to the COVID-19 pandemic. Even as many member states continue to support WHO and recognize its importance for global health, many are also calling for reforms to the organization that would help address its weaknesses. WHO itself supports reforms in several areas and has taken some internal reform actions, while also launching its new “investment round” and ushering negotiation processes to revise the International Health Regulations and establish a new pandemic accord, each of which includes reforms to WHO practices.

U.S. Engagement with WHO

The U.S. government has long been engaged with WHO in multiple ways including through financial support, participation in governance and diplomacy, and joint activities (see below). In 2020, after the onset of the COVID-19 pandemic, the first Trump administration suspended financial support and initiated a process to withdraw the U.S. from membership in the organization.³  Under the Biden administration, U.S. relations with the organization were re-established in January 2021, and U.S. funding to WHO was restored.⁴  However, on January 20, 2025 President Trump signed an Executive Order in his first day of office to once again suspend U.S. contributions to WHO, withdraw U.S. membership, and recall all U.S. personnel working with the organization. Under the guidelines in the WHO Constitution, the withdrawal of a member state from the organization becomes official after one year after notice is given. The Trump Administration submitted a formal letter of withdrawal, and the United Nations has said U.S. membership in WHO will officially end on January 23, 2026.

Financial Support

One of the main ways in which the U.S. government supports WHO is through its assessed and voluntary contributions (which have now been halted under the new Executive Order from President Trump). The U.S. has historically been the single largest contributor to WHO. In the 2020-2021 period (when the Trump administration withheld some U.S. funding during the COVID-19 pandemic), it was the third largest since other donors, notably Germany and the Bill and Melinda Gates Foundation, increased their contributions in response to COVID-19.  The Biden administration restored funding starting in 2021 and in the 2022-2023 period the U.S. was once again the largest contributor to WHO.

For many years, the assessed contribution for the U.S. has been set at 22% of all member state assessed contributions, the maximum allowed rate. Between FY 2015 and FY 2024, the U.S. assessed contribution has been fairly stable, fluctuating between $109 million and $122 million (in FY 2019 and FY 2020 the U.S. actually paid less than its assessed amount, and in FY 2021 it paid more than that amount due to payments made toward outstanding arrears). See Figure 2.

Voluntary contributions for specific projects or activities, on the other hand, have varied to reflect changing U.S. priorities and/or support during international crises. Over the past decade, U.S. voluntary contributions have ranged from a low of $105 million in FY 2020 to a high of $694 million in FY 2022. Higher amounts of voluntary contributions can be reflective of increased U.S. support for specific WHO activities such as emergency response. U.S. voluntary contributions also support a range of other WHO activities such as polio eradication; maternal, newborn, and child health programs; mental health services for victims of torture and trauma; health coordination in COVID-19 response; and other infectious diseases.

WHO reports that U.S. assessed and voluntary contributions together represented 15.6% of WHO’s total revenue in the 2022-2023 biennium, making the U.S. the largest donor to WHO during that period.

Governance Activities

In the past, the U.S. had been an active participant in WHO governance, including through the Executive Board and the World Health Assembly (WHA), though under the new Executive Order from President Trump, all official U.S. participation in WHO has been halted. The U.S. held a seat on the WHO Executive Board when the Executive Order was issued in January 2025.⁵  The U.S. had historically been an active and engaged member of the WHA, sending a large delegation each year that has typically been led by a representative from the Department of Health and Human Services, with multiple other U.S. agencies and departments also participating. The U.S. was also actively participating in the negotiations to develop a new pandemic agreement and participated in the recent process to update and amend the IHR agreement.

Technical Support

The U.S. had, in the past, provided technical support to WHO through a variety of activities and partnerships. This includes U.S. government experts and resources supporting research and reference laboratory work via WHO collaborating centres⁶  and participation of U.S. experts on advisory panels and advisory groups convened by WHO. The U.S. contributions to WHO collaborating centres have included technical areas such as cancer, occupational health, nutrition, chronic diseases, and improving health technologies.⁷  In addition, U.S. government representatives were often seconded to or have served as liaisons at WHO headquarters and WHO regional offices, working day-to-day with staff on technical efforts, though those personnel have been recalled under the new Trump Administration Executive Order.⁸ 

Partnering Activities

The U.S. has also worked in partnership with WHO before and during responses to outbreaks and other international health emergencies, including participating in international teams that WHO organizes to investigate and respond to outbreaks around the world. For example, the U.S. worked with WHO and the broader multilateral response to the Ebola epidemic in West Africa that began in 2014, and U.S. scientists were part of the WHO delegation that visited China in February 2020 to assess its response to COVID-19. To help further develop areas of partnership and coordination, the Biden administration had instituted semi-regular “strategic dialogue” meetings to create a regular forum for discussions between key U.S. and WHO officials.

1. These include: AFRO (Africa), EMRO (Eastern Mediterranean), EURO (Europe), PAHO (The Americas), SEARO (Southeast Asia), and WPRO (Western Pacific). ↩︎
2. WHO. Contributors 2022-2023. http://open.who.int/2022-23/contributors/contributor. Data through December 2023. Accessed April 2, 2024. “Other revenue” includes contributions to the PIP (pandemic influenza preparedness) partnership. ↩︎
3. Trump Administration/White House. “President Donald J. Trump Is Demanding Accountability From the World Health Organization.” Fact Sheet. April 15, 2020; Trump Administration/White House. Letter to Dr. Tedros Adhanom Ghebreyesus, WHO Director-General from President Trump. May 18, 2020.; Trump Administration/White House. “Remarks by President Trump on Actions Against China.” Remarks by President Trump on May 29, 2020. May 30, 2020; Trump Administration/U.S. Department of State. “Update on U.S. Withdrawal from the World Health Organization.” Press Statement by Morgan Ortagus, Department Spokesperson. Sept. 3, 2020. https://2017-2021.state.gov/update-on-u-s-withdrawal-from-the-world-health-organization/index.html. ↩︎
4. White House, “Letter to His Excellency António Guterres,” correspondence from President Biden, Jan. 20, 2021, https://www.whitehouse.gov/briefing-room/statements-releases/2021/01/20/letter-his-excellency-antonio-guterres/; Associated Press. ‘Biden’s US revives support for WHO, reversing Trump retreat’. January 2021. https://apnews.com/article/us-who-support-006ed181e016afa55d4cea30af236227; HHS, “Dr. Anthony S. Fauci Remarks at the World Health Organization Executive Board Meeting,” Jan. 21, 2021, https://www.hhs.gov/about/news/2021/01/21/dr-anthony-s-fauci-remarks-world-health-organization-executive-board-meeting.html. ↩︎
5. WHO. “Composition of the Board: Members of the Executive Board and Term of Office.” Webpage. https://apps.who.int/gb/gov/en/composition-of-the-board_en.html; White House. Fact Sheet: The Biden Administration’s Commitment to Global Health. February 2022. https://www.whitehouse.gov/briefing-room/statements-releases/2022/02/02/fact-sheet-the-biden-administrations-commitment-to-global-health/. ↩︎
6. WHO collaborating centres are “institutions such as research institutes, parts of universities or academies, which are designated by the Director-General to carry out activities in support of” WHO programs; see: WHO. “Collaborating centres” https://www.who.int/about/collaboration/collaborating-centres . ↩︎
7. For example, the U.S. CDC activities support centres such as the WHO Collaborating Centre for International Monitoring of Bacterial Resistance to Antimicrobial Agents (https://apps.who.int/whocc/Detail.aspx?mDXUc+J7YSsPRDN4ElrZNw==), the WHO Collaborating Centre for Injury Control (https://apps.who.int/whocc/Detail.aspx?XidWfagjyJM57zUuxiHDVg==). (https://apps.who.int/whocc/Detail.aspx?xIVob4SPT2jc+ZYjM7fcSQ==) and the WHO Centre for Surveillance, Epidemiology and Control of Influenza (https://www.cdc.gov/flu/weekly/who-collaboration.htm). ↩︎
8. CDC. Global Health Partnerships. https://www.cdc.gov/global-health/partnerships/. ↩︎

With President Trump now in office, his cabinet nominees continue to testify at congressional hearings as part of the nomination process. Robert F. Kennedy Jr. is the nominee to be the secretary of the Department of Health and Human Services (HHS), and his nomination hearings will spotlight a range of HHS activities but may not touch on the full scope of the department’s responsibilities. To better understand HHS’s impact on the health care system and the American people’s coverage, public health, safety, and well-being, what follows is an overview of the activities of the department.

Overview of HHS

The Department of Health, Education, and Welfare was established in 1953 and evolved into the Department of Health and Human Services in 1980 after the Department of Education was established as an independent entity. A relatively new department of the 15 current executive branch departments, HHS has a Fiscal Year (FY) 2024 budget funding estimated at $1.7 trillion, and the department’s budget is about a quarter of the total FY 2024 U.S. federal budget. It has the largest budget of any federal agency and is the largest grant-making agency.

Most federal executive branch health policy is implemented and managed within HHS, though the White House typically plays a major role in policymaking. The department has 13 operating divisions, most of which have a health focus in areas of coverage, research, regulation, resource delivery, and training. Others are focused on social assistance and support for families and communities in need. More than 80,000 HHS employees are located across the U.S. and the world and half of the workforce is outside the greater Washington, D.C. area.

The Public Health Service (PHS) predates HHS and now exists across ten of the 13 operating divisions within the department:

• The Administration for Strategic Preparedness and Response (ASPR)
• The Advanced Research Projects Agency for Health (ARPA-H)
• The Agency for Healthcare Research and Quality (AHRQ)
• The Agency for Toxic Substances and Disease Registry (ATSDR)
• The Centers for Disease Control and Prevention (CDC)
• The Food and Drug Administration (FDA)
• The Health Resources and Services Administration (HRSA)
• The Indian Health Service (IHS)
• The National Institutes of Health (NIH)
• The Substance Abuse and Mental Health Services Administration (SAMHSA)

Led by the Assistant Secretary of Health and the U.S. Surgeon General, the more than 6,000 United States Public Health Service Corps work across HHS and several other federal departments in everyday roles involving their health expertise, but they are also the country’s frontline workers for emergency response including public health emergencies.

Health Care Coverage and Affordability

The largest division of HHS is the Centers for Medicare and Medicaid Services (CMS), responsible for administering or overseeing health insurance coverage for Medicare, Medicaid, the Children’s Health Insurance Program, and the Affordable Care Act’s Health Insurance Marketplaces. Together, these programs provide health coverage access to 170 million Americans—more than half the population. However, the impact of HHS on the nation’s health insurance system goes well beyond the programs it administers, as it is heavily involved in the federal regulation of private health insurance, including employer-sponsored health insurance covering more than 150 million people, in conjunction with the Departments of Labor and the Treasury.

Beyond the core health insurance programs CMS administers, HHS also supports access to health care services in several other ways. Community health centers provide primary care and some additional services to low-income and uninsured populations and often serve special populations, e.g., people experiencing homelessness, migratory agricultural workers, and rural residents. HHS has a central role in setting standards and providing significant funding through various sources. HHS also provides medical and public health care to American Indians and Alaskan Natives through a network of providers run or contracted by the Indian Health Service. It has programs addressing the needs of specific populations, including the Ryan White HIV/AIDS program, refugee health, mental health and substance use treatment programs, and maternal and child health, to name a few.

Public Health and Disease Control

The public health role of HHS has been in the spotlight due to the COVID-19 pandemic, but its role during the crisis was based on pre-existing infrastructure and routine activities that adapt to the needs of the day. The department has a long-standing role in monitoring, preventing, and reducing the spread of infectious and non-communicable diseases. Its role encompasses a wide range of responsibilities, including research, screening, policy development and guidance, public education, treatment, and funding for state and local health departments.

Aside from COVID-19, HHS has been active in addressing infectious disease outbreaks of H5N1 avian flu, mpox, and hepatitis A in the past five years and works on long-term challenges like the HIV/AIDS epidemic. The role of HHS in vaccination dates back to the 1950s polio vaccine and it continues to have a substantial role in influencing the country’s vaccine policy.

Emergency Preparedness and Response

The routine health activities of HHS often merge with its role in addressing the health impacts of public emergencies and disasters. Events like the September 11, 2001, terrorist attacks, the opioid epidemic, the Flint, Michigan water crisis, natural disasters of hurricanes, tornadoes, and wildfires, and disease outbreaks have all triggered an HHS response in conjunction with other federal agencies.

HHS has provided emergency coordination and strategic planning to set up shelters for acute medical care and mental health support, sometimes utilizing the National Disaster Medical System, accessed stockpiles of critical equipment and medicine, led investigations and expanded on testing and monitoring activities, and assisted with survivor and community recovery including continuity of health care services.

Food and Drug Safety

Arguably, the broadest touch point for HHS’ impact on Americans’ daily lives is its role in food safety. The Food and Drug Administration (FDA) oversees most food safety aside from meat and poultry and shares responsibility for egg products with the Department of Agriculture. It also regulates the information about dietary supplements provided to consumers, though it does not have authority to approve them for safety and effectiveness. Among the activities related to food safety are conducting inspections of facilities, labeling requirements, issuing food recalls and alerts, and ensuring imported food meets U.S. standards. However, the FDA isn’t the only HHS agency that plays a significant role in food safety, as the Centers for Disease Control’s broad role of monitoring and responding to disease outbreaks also includes those related to consuming contaminated food.

HHS has a major role in regulating medical drugs and devices, mainly through the FDA. This includes pre-market testing for the safety and effectiveness of a product’s intended use, monitoring of approved products for any harm to consumers, and regulations for producing and labeling such products.

Scientific Research and Innovation

HHS, primarily through the National Institutes of Health, is the world’s largest public funder of health research. While the research often conducted can center on the basics of science and biomedicine, it has led to breakthroughs like the first successful polio vaccine, treatments for cancer and HIV/AIDs, the development of MRI technology, and the ability to personalize medicine because of the mapping of the human genome.

Supporting Families and Communities

The health of individuals can be impacted by several non-medical factors often categorized as social determinants of health. HHS has a range of social service programs that may not be typically considered health services, but usually factor in the stability of individual and family lives.

Financial assistance for low-income families with children has long been a federal program, and Temporary Assistance for Needy Families (TANF) is the primary cash assistance program for this population. TANF is administered by the HHS Administration of Children and Families (ACF) which also has programs related to child support enforcement, foster care, adoption, and child care. It also promotes early childhood development in low-income children under the age of five through Head Start.

One element of the department’s support services that has gained significant attention over the past decade, particularly as refugee resettlement submissions to the U.S. have sharply increased, is the array of services offered by the Office of Refugee Resettlement (ORR). Established 45 years ago, ORR aims to integrate individuals, including unaccompanied minors, and families into American society and provide a pathway to self-sufficiency. Services offered include financial assistance, housing, medical care, and employment services.

The Medicaid program finances about 4 in 10 births in the U.S. Federal law requires states to provide pregnancy-related Medicaid coverage through 60 days postpartum. After that period, some postpartum individuals may qualify for Medicaid through another pathway, but others may lose coverage, particularly in non-expansion states. To help improve maternal health and coverage stability and to help address racial disparities in maternal health, a provision in the American Rescue Plan Act of 2021 gave states a new option to extend Medicaid postpartum coverage to 12 months via a state plan amendment (SPA). This new option took effect on April 1, 2022 and was originally available for five years; however, the option was made permanent by the Consolidated Appropriations Act 2023. The Centers for Medicare and Medicaid Services (CMS) released guidance on December 7, 2021 on how states could implement this option.

States that sought to implement extended postpartum coverage prior to April 1, 2022 have done so through a section 1115 waiver or by using state funds. This page tracks state actions to implement extended Medicaid postpartum coverage, including states that have implemented a 12-month postpartum extension, states that are planning to implement a 12-month extension, states with pending legislation to seek federal approval through a SPA or 1115 waiver, and states that have proposed or received approval for a limited coverage extension.

Medicaid Postpartum Coverage Extensions: Approved and Pending State Action as of January 17, 2025

Medicaid Postpartum Coverage Extensions: Approved and Pending State Action as of January 17, 2025

Medicare provides health insurance coverage to 67 million adults—20% of the U.S population—and is a major source of revenue for physicians and other health providers. In 2024, Medicare spending on Part B services (including physician services, outpatient services, and physician-administered drugs) accounted for nearly half (49%) of total Medicare benefit spending. Physicians are not required to participate in Medicare, though the vast majority of them choose to do so.

In recent years, physician groups and some policymakers have raised concerns that physicians would opt out of Medicare due to reductions in Medicare payments for many Part B services, potentially leading to a shortage of physicians willing to treat people with Medicare. Medicare payments are lower, on average, than payments from private insurers and are not automatically indexed to keep pace with inflation in medical practice costs. Every year, as required by law, the Centers for Medicare & Medicaid Services (CMS) updates Medicare payments to physicians under the physician fee schedule through rulemaking. Since 2021, Congress has enacted four temporary, one-year increases to physician payment rates to soften scheduled cuts. However, Congress has not enacted a payment increase for 2025, and a 2.93% drop in average Medicare payments to physicians went into effect on January 1.

Despite these ongoing concerns, virtually all (98%) of non-pediatric physicians participate in the Medicare program. Furthermore, Medicare beneficiaries report access to physician services that is equal to, or better than, that of privately-insured individuals, with similar shares reporting delays in needed care or difficulty finding a physician who takes their insurance.

This brief uses the most recent CMS data to document the extent to which non-pediatric physicians have opted out of Medicare, by specialty and by state, as of November 2024, updating prior KFF analyses. (See Methods for details).

Key Takeaways:

• About one percent of all non-pediatric physicians have formally opted out of the Medicare program in 2024. The share was highest for psychiatrists (8.1%), followed by plastic and reconstructive surgeons (4.5%) and neurologists (3.2%).
• In 11 specialties, the share of physicians who have opted out of Medicare is 0.5% or lower, with the lowest shares seen among emergency medicine physicians (0.1%), oncologists (0.1%), radiologists (0.1%), and pathologists (<0.1%).
• Psychiatrists account for the largest share (39.0%) of all non-pediatric physicians who have opted out of Medicare in 2024, followed by family medicine physicians (21.5%) and internal medicine physicians (13.0%).
• Less than two percent of non-pediatric physicians have opted out of Medicare in 47 states. The rate is slightly higher in three states and the District of Columbia: Alaska (2.8%), Colorado (2.3%), Idaho (2.2%), and the District of Columbia (2.9%).

Three options for physicians

Currently, physicians and other health providers seeking payment from Medicare for Part B services must enroll as a Medicare provider. Physicians may either agree to be a participating provider or non-participating provider. Providers who do not want to enroll in Medicare or receive Medicare payments are required to sign an “opt out” agreement with their patients.

• Participating providers agree to accept “assignment” on all Medicare claims for all of their Medicare patients, which means that they have signed a participation agreement with Medicare, agreeing to accept Medicare’s fee schedule amounts as payment-in-full for all Medicare covered services. Medicare beneficiaries seeing a participating provider can only be liable for the cost sharing required by Medicare. Providers have several incentives to be participating providers, such as being paid higher rates (5% higher) than the rates paid to non-participating providers. In 2022, the vast majority (98%) of physicians and practitioners billing Medicare were participating providers.
• Non-participating providers accept Medicare patients, but can choose whether to take assignment (i.e., Medicare’s approved amount) on a claim-by-claim basis. Unlike participating providers, who are paid the full Medicare-allowed payment amount, non-participating physicians who take assignment are limited to 95% of the Medicare approved amount. In 2022, 7% of fee schedule claims were paid on assignment. Physicians who choose to not accept assignment can charge beneficiaries up to 15% more than the Medicare-approved amount, a process known as “balance billing.” Medicare patients are financially liable for this additional amount plus applicable deductibles and coinsurance.
• Opt-out physicians and other practitioners must sign an affidavit to “opt out” of the Medicare program entirely. These providers enter into private contracts with their Medicare patients, allowing them to bill any amount they determine is appropriate. Providers who have opted out of the Medicare program must opt out for all of their Medicare patients, including those enrolled in Medicare Advantage. Medicare patients seeing a provider who has opted out of the Medicare program must sign this agreement and agree to be financially responsible for the entire cost of any services received. Neither the provider nor the patient can submit a bill to Medicare for reimbursement of any service covered under Medicare Part B. Opt-out agreements last for two consecutive years and are automatically renewed at the end of each two-year period.

What share of physicians have opted out of Medicare?

1.2 percent of non-pediatric physicians have formally opted out of the Medicare program. As of November 2024, 12,244 non-pediatric physicians have opted out of Medicare, representing a very small share (1.2%) of the total number active physicians, similar to the shares reported in 2013 and 2022 (Figure 1).

While the overall opt-out rate is low, opt-out rates are somewhat higher for certain specialties, such as psychiatry and plastic and reconstructive surgery. In 2024, 8.1% of psychiatrists have opted out of Medicare, followed by 4.5% of physicians specializing in plastic and reconstructive surgery and 3.2% of physicians specializing in neurology (Figure 2).

On the other hand, of the 26 specialty groups included in this analysis, 11 have opt-out rates that are 0.5% or lower, with the lowest rates seen among physicians specializing in emergency medicine (0.1%), oncology (0.1%), radiology (0.1%), and pathology (<0.1%) (Appendix Table 1).

Psychiatrists are disproportionately represented among the 1.2 percent of active physicians who have opted out of Medicare. Psychiatrists account for the largest share (39.0%) of opt-out physicians, followed by physicians in family medicine (21.5%), internal medicine (13.0%), and obstetrics/gynecology (5.9%) (Figure 3). This is consistent with prior analyses that found that psychiatrists are less likely than other physician specialties to accept new patients with Medicare or private insurance, suggesting that psychiatrists may prefer to be paid directly by their patients, in order to avoid the administrative burden of submitting claims to insurers and maintain the flexibility to charge higher fees.

In addition to physicians, another 4,474 select clinical professionals with doctorate degrees (i.e. oral surgeons, podiatrists, and optometrists) have also opted out of the Medicare program, with oral surgeons accounting for the vast majority (93.9%) of this group (Appendix Table 1).

Less than two percent of physicians have opted out of Medicare in all but three states and the District of Columbia. As of November 2024, the District of Columbia (2.9%), Alaska (2.8%), Colorado (2.3%), and Idaho (2.2%) have the highest rates of non-pediatric physicians who have opted out of Medicare (Figure 4). In twelve states (Alabama, Arkansas, Iowa, Kentucky, Minnesota, Mississippi, Nebraska, North Dakota, Ohio, South Dakota, West Virginia, and Wisconsin) the opt-out rate is 0.5% or lower (Appendix Table 2).

Due to data limitations, this analysis only includes opt-out rates at the state level. Opt-out rates may vary based on rural status and other county-level factors, and some counties may have opt-out rates that are higher than the state average.

Appendix

Supplemental Tables

Introduction

Title 42 of the Public Health Services Act is a public health authority that authorizes the Director of the Centers for Disease Control and Prevention (CDC) to suspend entry of individuals into the U.S. to protect public health. This rarely utilized authority was implemented by the Trump administration in March 2020 in response to the COVID-19 pandemic to allow for quick expulsion of migrants, including asylum seekers, seeking entry into the U.S. at the land borders. After a series of delays due to court challenges, the restrictions were lifted when the Biden Administration declared an end to the COVID-19 public health emergency (PHE) on May 11, 2023. The Biden administration subsequently took increasingly restrictive executive action to restrict border entry.

Land border entries into the U.S. decreased as a result of Title 42 since individuals who had border encounters under this authority were immediately expelled due to the public health threat outlined by the Trump administration. However, research suggests that Title 42 restrictions did not result in a “better managed border” and increased cases of unauthorized re-entry, and public health experts stated that it put the health and well-being of migrants at risk. Recent reports suggest President-elect Trump may reinvoke Title 42 restrictions during his second term to close the border between the U.S. and Mexico, along with a number of other actions to restrict immigration.

This brief provides an explanation of Title 42 and its application in border regions, the impact of Title 42 on border expulsions and the health and well-being of migrants during COVID-19, and a discussion of the potential implications of reinvoking Title 42 restrictions for immigration and the health of migrants.

What are policies for migrants seeking entry at the U.S. border?

Under U.S. immigration law, individuals have a legal right to claim asylum when presenting at U.S. ports of entry. An asylee is an individual already present in the U.S. or seeking admission at a port of entry who is seeking protection based on “persecution or a well-founded fear of persecution on account of their race, religion, nationality, membership in a particular social group, or political opinion.” In fiscal year (FY) 2023, the U.S. granted asylum to over 54,000 individuals from close to a dozen different countries. However, as of October 2024, over 90% of asylum cases filed in FY 2023 were still pending with only 2% being granted approval due to immigration backlogs.

Migrants encountered at the border are processed and screened for asylum under Title 8 of the U.S. Code addressing “Aliens and Nationality.” Under Title 8, those determined to have a credible fear of persecution or other threats in their home country are either held in custody or released into the U.S. while their case is pending in immigration court. Those who the U.S. Citizenship and Immigration Services (USCIS) determine not to have a credible fear are permitted to appeal this decision to an immigration judge. If an individual chooses not to appeal or the immigration judge did not find fear, then the individual is removed.

In June 2024, the Biden administration took executive action to suspend and limit the entry of migrants at the southern border, including asylum seekers, to “address the historic levels of migration and more efficiently process migrants arriving at the southern border.” Under this rule, the suspension of entry will go into effect immediately after there have been 2,500 or more average daily border encounters (not including unaccompanied children) over seven consecutive days and can be lifted once there have been fewer than 1,500 average daily border encounters over seven consecutive days. As of April 2024, there were about 4,000 average daily border encounters, leaving the restrictions in place. U.S. Customs and Border Patrol (CBP) data show that border encounters following the executive order were at a three-year low with there being a 29% reduction in encounters between May and June 2024.

How did Title 42 change policy for migrants seeking entry at the border during the COVID-19 pandemic?

In March 2020, the Trump administration implemented Title 42 under the Public Health Service Act, which allowed for the immediate expulsion of migrants without screening for asylum. This order applied to all migrants arriving to the U.S. from Canada or Mexico regardless of their country of origin who would otherwise be held in a congregate setting at a port of entry or border patrol station. It did not apply to lawful permanent residents and their families, members of the armed forces or their families, or people who hold valid travel documents such as tourists or those in a visa waiver program. Officials also had authority to make exceptions for individuals on a case-by-case basis. Under this order, the CDC Director was authorized to “suspend the introduction of persons into the United States” and CBP officials were directed to process migrants promptly (within 15 minutes in an outdoor setting) without screening for asylum and expel them back to Mexico or Canada or their country of origin. The CDC stated the purpose of the order was to protect CBP personnel, U.S. citizens, lawful permanent residents, and other individuals from an increase in COVID-19 spread at land ports of entry, Border Patrol stations, and in the interior of the country. The order pointed to the introduction of individuals into congregate settings at the border and the increased strain this would put on the U.S. health care system during a public health emergency as primary reasons for implementing the restrictions on entry.

Title 42 continued to be enforced under the Biden administration until the end of the COVID-19 PHE declaration in May 2023. However, unaccompanied minors were exempted from the order based on a district court ruling in November 2020 and by a CDC order issued under the Biden administration in February 2021. The CDC order continued to apply the original Title 42 order to single adults and families. After facing legal challenges, Title 42 restrictions were lifted in May 2023 following the end of the COVID-19 PHE declaration.

How did implementation of Title 42 impact immigration and the health of migrants?

Between FY 2021¹  and 2023, there were over 6.5 million encounters at the Southwest land border of which about four in ten (41%) were under Title 42 authority. Enforcement encounters refer to “apprehensions or inadmissibles processed under CBP’s immigration authority;” these include individuals apprehended under Title 8 as well as individuals expelled under Title 42. While Title 42 applies to both the Northern and Southwestern Borders, nearly all Title 42 encounters occurred at the Southwestern Border. Between FY 2021 and FY 2023, Title 42 encounters at the Southwest Border accounted for about four in ten (41%) of all Southwest Border encounters. The share of encounters that were under Title 42 varied by demographic group with Title 42 accounting for a majority (56%) of single adult encounters and one in six (17%) family encounters, while Title 8 accounted for virtually all (99%) encounters with unaccompanied minors reflecting their exemption from expulsion under Title 42 (Figure 1).

As of May 2023, there were over 2.5 million single adult expulsions, nearly 320,000 expulsions of individuals in a family unit, and nearly 16,000 expulsions of unaccompanied minors under Title 42. The number of family expulsions under Title 42 grew between FY 2020 and FY 2021, while expulsions of unaccompanied minors decreased, reflecting their exemption beginning in February 2021. These encounter counts reflect repeat encounters with individuals, as each attempt by the same individual to cross the border is counted as a new encounter.

Data indicate that Title 42 did not lead to a reduction in border encounters, but border entries into the U.S. went down due to the nature of the authority. While Title 42 was intended to reduce COVID-19 exposure risk at the border, it led to an increasing number of encounters at the border largely due to repeat encounters. This is in large part because, unlike Title 8, migrants apprehended under Title 42 were immediately expelled and those with repeat encounters did not face any penalties. Data from 2020 through 2023 suggest that while there were close to 3 million Southwest border expulsions under Title 42 authority, many of those expulsions were of the same individuals making repeated attempts to cross the border. In the last 6 months of 2021, a quarter of the encounters under Title 42 were of the same individuals on multiple occasions, with recidivism rates under the authority being at their highest levels in over a decade. In addition, there has not been a significant increase in border encounters since Title 42 was lifted with border encounters in FY 2024 (2.1 million) being lower than border encounters in FY 2022 (2.4 million) and FY 2023 (2.5 million). However, entries into the U.S. through land borders decreased as a result of Title 42 since individuals who had border encounters under this authority were immediately expelled due to the public health threat outlined by the Trump administration.

Research suggests Title 42 expulsions negatively impacted the health and well-being of migrant families while having little to no impact on preventing the spread of COVID-19 in the U.S. Physicians, epidemiologists, and public health experts repeatedly stated that Title 42 was counterproductive to preserving health and protecting individuals from COVID-19. Physicians suggested that being in close proximity with other individuals while being temporarily detained or transported back to Mexico, lack of medical screenings, and lack of provision of necessary medication could have adverse impacts on physical and mental health. Typically, the CDC recommends that asylees be provided an initial medical screening within 30-60 days of arriving in the U.S., but since Title 42 called for immediate expulsion, such screenings were not provided. Interviews conducted with over two dozen asylum seekers who were expelled under Title 42 authority found that a vast majority reported symptoms of depression, anxiety, and post-traumatic stress disorder (PTSD), and many reported that their children’s mental health was also impacted. Sending individuals back to potentially dangerous situations they were fleeing also poses risks. Title 42 may also have contributed to increases in family separations at the border. Media reports suggested that some families were separating from their children so that the children could seek entry as unaccompanied minors, who were exempt from Title 42 expulsions. These separations may have led to children facing dangerous situations traveling to the border and expose them to trauma and toxic stress. The impact of Title 42 on migrant families may also have been exacerbated by the “Remain in Mexico” or Migrant Protection Protocols program implemented under the first Trump administration, which required thousands of migrants (including children) to wait for their U.S. immigration court hearings in Mexican border towns that can be dangerous and unsafe. Close to 80% of migrants receiving medical treatment from Doctors without Borders/Medecins Sans Frontieres at border locations in Nuevo Laredo, Mexico, reported being victims of violence, with many experiencing depression, severe anxiety, and post-traumatic stress.

What are the potential implications of reinvoking Title 42?

The incoming Trump administration has indicated plans to reinvoke Title 42. President-elect Trump has proposed an array of policies focused on restricting immigration. Recent reports suggest that the incoming Trump administration is planning to reinvoke Title 42 to restrict immigration under the rubric of public health protection. Experiences during COVID-19 suggest Title 42 was not effective at reducing border encounters or preventing COVID-19 and had negative health impacts for migrants. Reinvocation of such a policy also raises questions about its use as a border enforcement tool and could potentially fuel xenophobic sentiment towards immigrants.

1. U.S. Customs and Border Protection, “Nationwide Enforcement Encounters: Title 8 Enforcement Actions and Title 42 Expulsions Fiscal Year 2021”. Accessed January 2025. ↩︎

With the incoming Trump administration and Republican-led Congress looking to ways to reduce federal spending, a new KFF Health Tracking Poll finds that the Medicare and Medicaid programs remain broadly popular, and more people favor more spending on those programs than less spending.

About eight in 10 Americans overall view Medicare (82%) and Medicaid (77%) favorably. This includes majorities across partisans, including most Republicans (75% view Medicare favorably and 63% view Medicaid favorably).

About half (46%) of the public say the federal government doesn’t spend enough on Medicaid, more than twice the share (19%) who say the government spends “too much.” The gap is even larger for Medicare, with half (51%) of the public saying the government doesn’t spend enough compared to 15% who say the government spends too much.

The Affordable Care Act (ACA), sometimes called Obamacare, also remains popular, with nearly two thirds (64%) of the public holding favorable views, though with more of a partisan divide. Most Democrats and independents hold favorable views of the ACA, while about three quarters of Republicans (72%) hold unfavorable views.

Large majorities also say they are “very” or “somewhat” worried that people covered by each of the three programs in the future won’t get the same benefits available today. This includes 81% who say so about Medicare, 72% who say so about Medicaid, and 70% who say so about the ACA marketplaces. Republicans are less worried than other partisans about Medicaid and the ACA.

Ahead of President Trump’s inauguration, the poll also assesses how the public prioritizes 11 potential actions on health that the new administration and Congress could take.

About six in 10 say that boosting price transparency rules (61%) and limiting chemicals in the food supply (58%) are both a “top priority.” This includes majorities of Republicans, independents and Democrats.

During his first administration, President Trump issued federal regulations establishing price transparency requirements for hospitals and insurers, and Robert F. Kennedy Jr., his pick to head the U.S. Department of Health and Human Services, has long advocated against chemicals in food.

In contrast, few among the public rank several other health policies associated with President Trump and his allies as top priorities.

For example, about one in seven say that reducing federal spending on Medicaid (13%) or limiting access to abortion (14%) is a top priority, while much larger shares say each of these “should not be done” (44% and 51%, respectively). Other low-ranking priorities include cutting funding to schools that require students to get vaccinated (15%), encouraging communities not to add fluoride to their water supply (23%), and repealing and replacing the ACA (27%).

Among other health priorities:

• Medicare drug price negotiations. More than half (55%) of the public say it is a top priority to expand the number of prescription drugs subject to Medicare drug price negotiations, including most Democrats (65%) and about half of Republicans (48%). Only 3% say this shouldn’t be done.
• Regulating insurance claim denials. Most people (55%) say more closely regulating insurers’ decisions to approve or deny claims for health services or prescription drugs should be a top priority. This includes most Democrats (61%) and independents (59%), along with nearly half (45%) of Republicans. Overall, just 5% oppose this.
• Enhanced ACA subsidies. About a third (32%) say that extending the expanded financial assistance that helps make ACA marketplace health insurance affordable should be a top priority. This includes half of Democrats (50%) but few Republicans (16%). Only 7% say this shouldn’t be done.

The incoming Trump administration has established a new “Department of Government Efficiency,” or DOGE, charged with developing plans to cut federal spending and reduce regulations.

Most Americans (73%) say that reducing fraud and waste in government health programs would lead to “major” or “minor” reductions in federal spending overall. This includes most Republicans (80%), independents (72%), and Democrats (68%).

At the same time, more than half (55%) of the public also say that reducing fraud and waste would lead to reductions in the benefits that people receive from government health programs. At least half of Republicans (60%), Democrats (55%), and independents (51%) hold this view.

Other findings include:

• Most of the public say the government is not spending enough on the prevention of chronic diseases (60%) or prevention of infectious diseases and preparing for future pandemics (54%). Much smaller shares say the government spends “too much” on each of these.
• More than half (57%) of the public say they expect health care to become less affordable for their families over the next few years. This includes most (54%) Trump voters and half (51%) of Republicans despite the campaign’s emphasis on addressing rising costs, including in health care.

Designed and analyzed by public opinion researchers at KFF. The survey was conducted Jan. 7-14, 2025, online and by telephone among a nationally representative sample of 1,310 U.S. adults in English and in Spanish. The margin of sampling error is plus or minus 3 percentage points for the full sample. For results based on other subgroups, the margin of sampling error may be higher.

Note: This brief was updated on April 10, 2025 to update state take-up of Medicaid and CHIP options for immigrant children.

Introduction

One in four children aged 18 and under living in the U.S. has at least one immigrant parent. Policies that may be implemented under the incoming Trump administration could have significant implications for these children, the vast majority of whom are citizens. These policies include potentially reinstating changes to public charge policy that were implemented during the first Trump administration, a proposal to end birthright citizenship for the children of some immigrants, and plans to carry out mass detention and deportations of immigrants, potentially including their citizen children and other family members. Birthright citizenship is a right guaranteed under the 14^th amendment of the U.S. Constitution for children born in the U.S. regardless of their parents’ immigration status at the time of the child’s birth. Such actions could increase fears and confusion among children of immigrants and increase reluctance among parents to enroll them in programs for which they are eligible, including health coverage. They may also have long-term ramifications for the nation’s economy and workforce given the significant contributions immigrants and the adult children of immigrants make.

This brief provides key data on socioeconomic characteristics and health coverage among children (aged 18 and under) of immigrants based on KFF analysis of the 2023 American Community Survey 1-year Public Use Microdata Sample. It also examines potential implications of policies and actions that may be implemented by the incoming Trump administration. Key takeaways from the analysis include the following:

One in four children aged 18 and under in the U.S. has an immigrant parent, and the vast majority of these children are U.S. citizens. As of 2023, 19 million, or one in four, children in the U.S. had an immigrant parent. This includes one in ten (12%) who are citizen children with a noncitizen parent, a similar share (11%) who are citizen children with a naturalized citizen parent, and 3% who are noncitizen children.

Most children of immigrants live in households with a full-time worker regardless of parental citizenship status; however, children with a noncitizen parent are more likely than children with citizen parents to live in lower income households. More than eight in ten citizen children live in a household with a full-time worker across parental citizenship statuses, and over three in four (76%) noncitizen children live in a household with a full-time worker. However, noncitizen children (33%) and citizen children with a noncitizen parent (27%) are more likely than those with U.S.-born parents (20%) and naturalized citizen parents (14%) to live in lower income households with annual incomes of less than $40,000.

Uninsured rates among most children of immigrants remain low reflecting that most are citizens and broad coverage options are available for low-income children. As of 2023, fewer than one in ten citizen children with U.S.-citizen parents (4%) and citizen children with noncitizen parent(s) (8%) were uninsured. The small share of children who are noncitizens had a higher uninsured rate (25%). Low uninsured rates among most children reflect broad coverage for lower income children through Medicaid and the Children’s Health Insurance Program (CHIP), including state take-up of options to cover immigrant children and some state-funded coverage programs that cover children regardless of immigration status. However, coverage gaps remain for noncitizen children.

Policies that may be implemented under the incoming Trump administration could negatively affect the health and well-being of children of immigrants and have long-term negative consequences for the nation’s economy and workforce. During the first Trump administration, uninsured rates among children in immigrant families increased and immigrant families experienced negative impacts on health due to changes in public charge policy and enhanced enforcement actions. Potential immigration policies and actions that may be taken under the incoming Trump administration such as mass detention and deportation efforts, ending birthright citizenship, and/or reinstating changes to public charge policy would likely increase fears among immigrant families and negatively impact the health of children in immigrant families. The proposed policies would also likely have broader ramifications for the economy and workforce, given the major role immigrants and their adult children play, particularly in certain industries, including health care.

Overview of Children of Immigrants

As of 2023, 19 million or one in four children aged 18 and under in the U.S. had an immigrant parent. These include one in ten (12%) or 9 million who are citizen children with a noncitizen parent, a similar share (11%) or 8.3 million who are citizen children with a naturalized citizen parent, and 3%, or about 2.3 million, who are noncitizens themselves (Figure 1).

While most children of noncitizen immigrants are U.S. citizens and live in a family with at least one full-time worker, they are more likely to live in lower income households than the children of U.S.-citizen parents. As of 2023, eight in ten or more of citizen children of U.S.-born citizen parents (81%), naturalized citizen parent(s) (89%), and noncitizen parent(s) (84%) lived in a family with at least one full-time worker (Figure 2). Three-quarters of noncitizen children (76%) also lived in a family with at least one full-time worker in 2023. However, citizen children with at least one noncitizen parent (27%) and noncitizen children (33%) were more likely to live in a lower income household (annual household income of less than $40,000) than citizen children with U.S.-born citizen parents (20%) or those with at least one naturalized citizen parent (14%) (Figure 2). Lower household income among children of noncitizen immigrants reflects noncitizen immigrants’ disproportionate employment in lower-wage jobs in industries such as construction, agriculture, and transportation, which are less likely to provide employer-sponsored insurance.

Access to Health Coverage and Care Among Children of Immigrants

Overall, uninsured rates among most children of immigrants remain low reflecting that the majority are citizens and broad-based coverage options are available for low-income children. Among children with citizen parents, 4% are uninsured, while this share rises to 8% among children with at least one noncitizen parent. Among the small group of children who are noncitizens, uninsured rates are significantly higher at 25% (Figure 3). Medicaid and/or CHIP provide broad eligibility for children with a median eligibility level of 255% of the federal poverty level across states. Higher uninsured rates among citizen children with a noncitizen parent and noncitizen children reflect enrollment barriers such as fears and confusion and language access challenges and eligibility restrictions for federally-funded health coverage, including Medicaid and CHIP, for noncitizen immigrants.

Most states have taken up options to expand coverage for immigrant children. As of April 2025, 37 states plus D.C. cover lawfully residing immigrant children without a five-year waiting period in Medicaid and CHIP. As of April 2025, 14 states and D.C. provide comprehensive fully state-funded coverage for children regardless of immigration status (Figure 4).

While public coverage increases spending by states and the federal government, coverage helps ensure children can access needed care and promotes long-term positive outcomes for children. States have taken steps to expand Medicaid and CHIP coverage, reduce enrollment barriers, and implement continuous eligibility for children in face of rising child poverty and uninsured rates. Children without health coverage are more likely than those with coverage to delay or forgo care because of costs. Coverage expansions to immigrant children also increase access to health care and are associated with improved health outcomes. California’s 2016 expansion to cover low-income children regardless of immigration status was associated with a 34% decline in uninsured rates. Similarly, a study found that children who reside in states that have expanded coverage to all children regardless of immigration status were less likely to be uninsured, to forgo medical or dental care, and to go without a preventive health visit than children residing in states that have not expanded coverage. Research suggests that more expansive health coverage for noncitizens does not increase migration of immigrant children from other states.

Potential Implications of Incoming Trump Administration Policies

During the first Trump administration, uninsured rates among children in immigrant families increased and immigrant families experienced negative impacts on health. During his first term, President Trump implemented changes to public charge policies and enforcement actions that increased fears and uncertainty among immigrant families. Uninsured rates increased among citizen children with a noncitizen parent between 2015 to 2019, which reflected an overall decline in use of public benefits. From 2016-2019, participation in public programs such as Medicaid, CHIP, and the Supplemental Nutrition Assistance Program among citizen children with noncitizen household members fell twice as fast as those with only U.S. citizen household members. Research also shows that enrollment in Medicaid among immigrant mothers fell and newborn birth weight declined following the public charge rule changes. Immigrant families also reported increasing mental health issues among their children related to immigration-related fears and stress during the first Trump administration. There was also decreased use of health care among Hispanic children and fewer well-child visits among children of immigrant mothers following actions on immigration during the first Trump administration.

Fears persist among immigrant families. Although President Biden rescinded public charge and other policy changes implemented by President Trump during his first term, KFF survey data show that as of 2023, about a quarter (27%) of likely undocumented immigrant adults said they avoided applying for government programs that help pay for food, housing, or health care for themselves or a family member in the past year due to immigration-related fears. In addition, a majority of immigrant adults regardless of immigration status remain unsure about whether the use of non-cash assistance programs like Medicaid and CHIP can be used to make public charge determinations or incorrectly believe that to be the case.

Policies under the incoming Trump administration could negatively affect the health and well-being of children of immigrants and have long-term negative consequences for the nation’s economy and workforce. Potential immigration policies and actions that may be taken under the incoming Trump administration such as mass detention and deportation efforts, ending birthright citizenship, and/or reinstating changes to public charge policy would likely increase fears among immigrant families and negatively impact the health of children in immigrant families. For example, research shows that workplace raids to carry out enforcement actions can lead to family separations, poor physical and mental health outcomes for immigrant families, negative birth and educational outcomes for the children of immigrants, and financial hardship due to employment losses. Ending birthright citizenship would limit access to health coverage and care for the children of immigrants given eligibility restrictions for noncitizen immigrants. The proposed policies would also likely have broader ramifications for the economy and workforce given the major role immigrants and their adult children play, particularly in certain industries, including health care. Adult children of immigrants have higher educational attainment and incomes than their parents as well as the adult children of U.S.-born parent(s) and play an outsized role in the U.S. health care workforce. Moreover, immigrants and their adult children contribute billions of dollars in federal, state, and local taxes each year and help to create jobs for U.S.-born people. Research further shows that adult children of immigrants contribute more in taxes on average than their parents or the rest of the U.S.-born population and that their fiscal contributions exceed their costs associated with health care, education, and other social services.

Note: This content was updated on June 2, 2025 to include updated state-funded coverage for immigrants as well as immigrant health coverage-related provisions in the budget reconciliation bill.  

Summary

As of 2023, there were 47.1 million immigrants residing in the U.S., including 22.4 million noncitizen immigrants and 24.7 million naturalized citizens, who each accounted for about 7% of the total population. Noncitizens include lawfully present and undocumented immigrants. Many individuals live in mixed immigration status families that may include lawfully present immigrants, undocumented immigrants, and/or citizens. One in four children has an immigrant parent, including over one in ten (12%) who are citizen children with at least one noncitizen parent. This brief provides an overview of health coverage for immigrants based on data from the 2023 KFF/LA Times Survey of Immigrants, the largest nationally representative survey focused on immigrants, and discusses potential implications of incoming Trump administration policies for coverage of immigrants.

As of 2023, half (50%) of likely undocumented immigrant adults and one in five (18%) lawfully present immigrant adults reported being uninsured compared to less than one in ten naturalized citizen (6%) and U.S.-born citizen (8%) adults. Noncitizen immigrants are more likely to be uninsured than citizens because they have more limited access to private coverage due to working in jobs that are less likely to provide health benefits. They also face eligibility restrictions for federally funded coverage options, including Medicaid, the Children’s Health Insurance Program (CHIP), Affordable Care Act (ACA) Marketplace coverage, and Medicare. Moreover, those who are eligible for coverage face a range of enrollment barriers including fear, confusion about eligibility rules, and language access challenges. Reflecting their higher uninsured rate, noncitizen immigrants are more likely than citizens to report barriers to accessing health care and skipping or postponing care. Immigrants have lower health care expenditures than their U.S.-born counterparts reflecting lower use of care due to a combination of them being younger and healthier and facing more barriers to accessing  care.

Some states have expanded access to health coverage for immigrants. At the state-level there has been continued take up of state options to expand Medicaid and CHIP coverage for lawfully present immigrant children and pregnant people, and a small but growing number of states have expanded fully state-funded coverage to certain groups of low-income people regardless of immigration status. However, many immigrants, particularly those who are undocumented, remain ineligible for coverage options.

Many immigrants remain fearful of accessing assistance programs, including health coverage. The Biden administration reversed prior Trump administration changes to public charge rules so that they did not consider participation in non-cash assistance programs, including Medicaid and CHIP. It also increased funding for Navigator programs that provide enrollment assistance to individuals, which is particularly important for helping immigrant families enroll in coverage. However, as of 2023, nearly three-quarters of immigrant adults, including nine in ten of those who are likely undocumented, reported uncertainty about how use of non-cash assistance programs may impact immigration status or incorrectly believed use may reduce the chances of getting a green card in the future. About a quarter (27%) of likely undocumented immigrant adults and nearly one in ten (8%) lawfully present immigrant adults say they avoided applying for food, housing, or health care assistance in the past year due to immigration-related fears.

Fears about accessing assistance programs, including health coverage, will likely increase under the second Trump administration and provisions in the House budget reconciliation bill could eliminate health coverage access for many lawfully present and undocumented immigrants. The Trump administration is undertaking broad enforcement aimed at restricting immigration which will likely increase fears and uncertainty among immigrant families about accessing assistance programs and seeking health care. In addition, provisions in the budget reconciliation bill being considered by Congress would eliminate ACA Marketplace and Medicare coverage for many lawfully present immigrants and would penalize states that use their own funds to provide health coverage to immigrants regardless of immigration status.

Overview of Immigrants

Based on federal survey data, as of 2023, there were 47.1 million immigrants residing in the U.S., including 22.4 million noncitizen immigrants and 24.7 million naturalized citizens, who each accounted for about 7% of the total population (Figure 1). Estimates suggest that about six in ten noncitizens were lawfully present immigrants, such as lawful permanent residents (green card holders) and those with a valid work or student visa, while the remaining four in ten were undocumented immigrants, who may include individuals who entered the country without authorization and individuals who entered the country lawfully and stayed after their visa or status expired.¹  Many individuals live in mixed immigration status families that may include lawfully present immigrants, undocumented immigrants, and/or citizens. A total of 19 million or one in four children living in the U.S. had an immigrant parent as of 2023, and the majority of these children were citizens (Figure 2). About 8.6 million or 12% were citizen children with at least one noncitizen parent.

Uninsured Rates by Immigration Status

The 2023 KFF/LA Times Survey of Immigrants, the largest nationally representative survey focused on immigrants, provides data on health coverage of immigrant adults and experiences accessing health care, including by immigration status.

Although the majority of uninsured people are citizens, noncitizen immigrant adults, particularly likely undocumented immigrants, are significantly more likely to report being uninsured than citizens. As of 2023, half (50%) of likely undocumented immigrant adults and one in five (18%) lawfully present immigrant adults said they were uninsured compared to 6% of naturalized citizen adults and 8% of U.S.-born citizen adults (Figure 3).

Reflecting their higher uninsured rates, noncitizen immigrants, especially those who are likely undocumented, are more likely than citizens to report barriers to accessing health care and skipping or postponing care. Research shows that having insurance makes a difference in whether and when people access needed care. Those who are uninsured often delay or go without needed care, which can lead to worse health outcomes over the long-term that may ultimately be more complex and expensive to treat. Overall, likely undocumented immigrant adults are more likely than lawfully present immigrant adults and naturalized citizen adults to report not having a usual source of care other than an emergency room, not having a doctor’s visit in the past 12 months, and skipping or postponing care in the past 12 months (Figure 4). Lawfully present immigrant adults also are more likely than naturalized citizen adults to say they have not had a doctor’s visit in the past 12 months.

Research also shows that immigrants have lower health care use and expenditures than their U.S.-born counterparts and help to subsidize health care for U.S.-born citizens. Overall, research shows that immigrants, including lawfully present and undocumented immigrants, use less health care than U.S.-born citizens. Lower use of health care among immigrants likely reflects a combination of them being younger and healthier than their U.S.-born counterparts as well as them facing increased barriers to care including a higher uninsured rate, language access challenges, confusion, and immigration-related fears. Reflecting their lower use of health care, immigrants have lower health care expenditures than their U.S.-born counterparts. KFF analysis of 2021 medical expenditure data show that, on average, annual per capita health care expenditures for immigrants are about two-thirds those of U.S.-born citizens ($4,875 vs. $7,277). Recent research further finds that, because immigrants, especially undocumented immigrants, have lower health care use despite contributing billions of dollars in insurance premiums and taxes, they help subsidize the U.S. health care system and offset the costs of care incurred by U.S.-born citizens.

Access to Health Coverage Among Immigrants

Private Coverage

Despite high rates of employment, noncitizen immigrants have limited access to employer-sponsored coverage. Although most noncitizen immigrant adults say they are employed, they are significantly more likely than citizens to report being lower income (household income less than $40,000) (Figure 5). This pattern reflects disproportionate employment of noncitizen immigrants in low-wage jobs and industries that are less likely to offer employer-sponsored coverage. Given their lower incomes, noncitizen immigrants also face challenges affording employer-sponsored coverage when it is available or through the individual market.

Federally Funded Coverage

Lawfully present immigrants may qualify for Medicaid and CHIP but are subject to certain eligibility restrictions. In general, lawfully present immigrants must have a “qualified” immigration status to be eligible for Medicaid or CHIP, and many, including most lawful permanent residents or “green card” holders, must wait five years after obtaining qualified status before they may enroll. Some immigrants with qualified status, such as refugees and asylees, as well as citizens of Compact of Free Association (COFA) nations, do not have to wait five years before enrolling. Some immigrants, such as those with temporary protected status, are lawfully present but do not have a qualified status and are not eligible to enroll in Medicaid or CHIP regardless of their length of time in the country (Appendix A). For children and pregnant people, states can eliminate the five-year wait and extend coverage to some lawfully present immigrants without a qualified status. As of April 2025, 37 states plus D.C. have taken up this option for children and 31 states plus D.C. have elected the option for pregnant individuals.

In December 2020, Congress restored Medicaid eligibility for citizens of COFA nations, and in March 2024, eligibility was restored for additional federally funded programs including CHIP. The U.S. government has COFA agreements with the Republic of the Marshall Islands, the Federated States of Micronesia, and the Republic of Palau. Certain citizens of these nations can lawfully work, study, and reside in the U.S., but they had been excluded from federally funded Medicaid since 1996, under the Personal Responsibility and Work Opportunity Reconciliation Act. As part of a COVID-relief package, Congress restored Medicaid eligibility for COFA citizens who meet other eligibility requirements for the program effective December 27, 2020. On March 9, 2024, Congress further extended eligibility for COFA citizens to newly include other federally funded programs such as CHIP, the Supplemental Nutrition Assistance Program (SNAP), and Temporary Assistance for Needy Families (TANF), among others.

A total of 24 states plus D.C. have also extended coverage to pregnant people regardless of immigration status through the CHIP From-Conception-to-End-of-Pregnancy (FCEP) option. States have the option in CHIP to provide prenatal care and pregnancy related benefits to targeted low-income children beginning from conception to end of pregnancy regardless of their parent’s citizenship or immigration status. While other pregnancy-related coverage in Medicaid and CHIP requires 60 days of postpartum coverage, the CHIP FCEP option does not include this coverage. However, some states that took up this option provide postpartum coverage through a CHIP health services initiative or using state-only funding. Twelve of the states that have implemented the FCEP option (California, Colorado, Connecticut, Illinois, Maine, Massachusetts, Minnesota, New York, Oregon, Rhode Island, Texas, and Washington) plus D.C. have used state funding or CHIP health services initiatives to extend postpartum coverage to 12 months to align with the Medicaid extension established by the American Rescue Plan Act. Maryland extends coverage for four months postpartum, and Alabama and Virigina extend coverage for 60 days postpartum using CHIP health services initiatives.

Lawfully present immigrants can purchase coverage through the ACA Marketplaces and, like citizens, may receive tax credits to help pay for premiums and cost sharing that vary on a sliding scale based on income. Generally, these tax credits are available to people with incomes starting from 100% of the federal poverty level (FPL) who are not eligible for other affordable coverage. In addition, lawfully present immigrants with incomes below 100% FPL may receive tax credits if they are ineligible for Medicaid based on immigration status. This group includes lawfully present immigrants who are not eligible for Medicaid or CHIP because they are in the five-year waiting period or do not have a “qualified” status. Individuals with Deferred Action for Childhood Arrivals (DACA) status were not considered lawfully present for purposes of health coverage eligibility and remained ineligible despite having a deferred action status, which otherwise qualified for Marketplace coverage. On May 3, 2024, the Biden administration published regulations that changed 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. The rule became effective on November 1, 2024, to coincide with the 2025 Open Enrollment Period and the Biden administration estimates that 100,000 DACA recipients will receive coverage under the new rule. Implementation of the coverage expansion remains subject to ongoing litigation with DACA recipients in 19 states (AL, AR, FL, IA, ID, IN, KS, KY, MS, MT, ND, NE, NH, OH, SC, SD, TN, TX, VA) being unable to enroll in ACA Marketplace coverage as of January 2025. Further, in March 2025, the Centers for Medicare and Medicaid Services (CMS) submitted a Notice of Proposed Rulemaking to the Federal Register seeking to exclude DACA recipients from the definition of “lawfully present” immigrants for the purposes of health coverage, which would make DACA recipients across the U.S. ineligible for purchasing coverage through the ACA Marketplaces.

Lawfully present immigrants also can qualify for Medicare subject to certain restrictions. Specifically, they must have sufficient work history to qualify for premium-free Medicare Part A. If they do not have sufficient work history, they may qualify if they are lawful permanent residents and have resided in the U.S. for five years immediately prior to enrolling in Medicare, although they must pay premiums to enroll in Part A.

Undocumented immigrants are not eligible to enroll in federally funded coverage including Medicaid, CHIP, or Medicare or to purchase coverage through the ACA Marketplaces. Medicaid payments for emergency services may be made to hospitals on behalf of individuals who are otherwise eligible for Medicaid but for their immigration status. These include lawfully present immigrants who are subject to a five-year bar for Medicaid and undocumented immigrants. These payments may help cover the costs for emergency care provided to immigrants who remain ineligible for Medicaid but are not coverage for individuals. Much of Emergency Medicaid spending goes towards labor and delivery costs and Emergency Medicaid spending represented less than 1% of total Medicaid spending in fiscal year 2023.

State Funded Coverage

As of April 2025, 14 states plus D.C. provide comprehensive state-funded coverage to children regardless of immigration status (Figure 6). These states include California, Colorado, Connecticut, Illinois, Maine, Massachusetts, Minnesota, New Jersey, New York, Oregon, Rhode Island, Utah, Vermont, Washington, and D.C. Additionally, two of these states (New Jersey and Vermont) also provide state-funded coverage to income-eligible pregnant people regardless of immigration status, with Vermont extending this coverage for 12 months postpartum.

As of April 2025, seven states (California, Colorado, Illinois, Minnesota, New York, Oregon, Washington) plus D.C. have also expanded fully state-funded coverage to at least some income-eligible adults regardless of immigration status (Figure 7). Some additional states cover some income-eligible adults who are not otherwise eligible due to immigration status using state-only funds but limit coverage to specific groups, such as lawfully present immigrants who are in the five-year waiting period for Medicaid coverage, or provide more limited benefits. In addition to these states, Maryland plans to allow income-eligible individuals to purchase Marketplace coverage without subsidies regardless of immigration status starting November 2025 through a section 1332 waiver. Recently, some states have proposed rolling back state-funded health coverage for some groups of immigrants due to budget constraints.

Data suggest that state coverage expansions for immigrants make a difference in their health coverage and health care access and use. The 2023 KFF/LA Times Survey of Immigrants shows that immigrant adults residing in states with more expansive coverage policies for immigrants are less likely to be uninsured compared to their counterparts living in states with less expansive coverage policies. California’s 2016 expansion to cover low-income children regardless of immigration status was associated with a 34% decline in uninsurance rates. Similarly, a study found that children who reside in states that have expanded coverage to all children regardless of immigration status were less likely to be uninsured, to forgo medical or dental care, and to go without a preventive health visit than children residing in states that have not expanded coverage. Other research has found that expanding Medicaid coverage to pregnant people regardless of immigration status was associated with higher rates of prenatal care and improved outcomes including increases in average gestation length and birth weight among newborns, while more restrictive state coverage policies were associated with reduced postpartum care utilization. The cost of providing insurance to immigrant adults through Medicaid expansion was also found to be less than half the per person cost of doing so for U.S-born adults. Recent estimates also suggest that the state-funded expansion to all immigrants regardless of status in California could reduce poverty among noncitizen immigrants and their families.

Enrollment Barriers

Among immigrants who are eligible for coverage, many remain uninsured because of a range of enrollment barriers, including fear, confusion about eligibility policies, difficulty navigating the enrollment process, and language access challenges. Research suggests that changes to immigration policy made by the first Trump administration contributed to growing fears among immigrant families about enrolling themselves and/or their children in Medicaid and CHIP even if they were eligible. In particular, changes to the public charge policy likely contributed to decreases in participation in Medicaid among immigrant families and their primarily U.S.-born children. The Biden administration reversed many of these changes, including the changes to public charge policy, and increased funding for Navigator programs that provide enrollment assistance to individuals, which is particularly important for helping immigrant families enroll in coverage. However, as of 2023, nearly three-quarters of immigrant adults, including nine in ten of those who are likely undocumented, report uncertainty or an incorrect understanding about how use of non-cash assistance programs may impact immigration status or incorrectly believe use may reduce the chances of getting a green card in the future. 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.

Fears about participating in programs, including health coverage, will likely increase under the second Trump administration. Although President-elect Trump has not indicated whether his incoming administration plans to reinstate his first-term changes to public charge policy, doing so could lead to widespread confusion, fears, and broad chilling effects among immigrant families. In addition, broader immigration enforcement actions proposed by President-elect Trump such as mass deportation of immigrants, elimination of the DACA program and its associated ACA health coverage expansion, and ending birthright citizenship for the children of some immigrants could limit access to health care for immigrant families, negatively impact their daily lives and well-being, and increase fears and confusion about participating in programs, including health coverage.

1. The estimate of the total number of noncitizens in the U.S. is based on the 2023 American Community Survey (ACS) 1-year Public Use Microdata Sample (PUMS). The ACS data do not directly indicate whether an immigrant is lawfully present or not. KFF draws on the methods underlying the 2013 analysis by the State Health Access Data Assistance Center (SHADAC) and the recommendations made by Van Hook et. al. This approach uses the Survey of Income and Program Participation (SIPP) to develop a model that predicts immigration status; it then applies the model to ACS, controlling to state-level estimates of total undocumented population from Pew Research Center. For more detail on the immigration imputation used in this analysis, see Technical Appendix B. ↩︎