The pandemic-era coverage policies, including the Medicaid continuous enrollment provision and the enhanced Marketplace subsidies, continued to impact health coverage in the U.S. in 2023. During the pandemic, the coverage expansions put in place by the Affordable Care Act (ACA), including Medicaid expansion and subsidized Marketplace coverage, served as a safety net for people who experienced economic and coverage disruptions. Gains in Medicaid and Marketplace coverage contributed to significant declines in the uninsured rate through 2022. Although states began the process of unwinding continuous enrollment in Medicaid in April 2023 and resumed disenrolling people from Medicaid, the full effect of Medicaid disenrollments were not felt in 2023. In addition, the enhanced Marketplace subsidies, which were extended through 2025, remained in place. Both these factors contributed to maintaining most of the coverage gains experienced during the pandemic period in 2023.

This issue brief describes trends in health coverage in 2023, examines the characteristics of the uninsured population ages 0-64, and summarizes the access and financial implications of not having coverage. Using data from the American Community Survey (ACS), this analysis examines changes in health coverage from 2022 to 2023 and compares data for 2023 to data for 2019 to report on coverage trends during the pandemic and through the start of the unwinding of the Medicaid continuous enrollment provision. Because of disruptions in data collection during the pandemic, the Census Bureau did not release 1-year ACS estimates in 2020. The analysis focuses on coverage among people ages 0-64 since Medicare offers near universal coverage for people ages 65 and older, with just 457,000, or less than 1%, of people over age 65 uninsured.

Key Takeaways

• How many people are uninsured: Despite the unwinding of the Medicaid continuous enrollment provision that began in April 2023, the number of people ages 0-64 who were uninsured held steady at 25.3 million in 2023. However, the number of uninsured children increased from 3.8 million in 2022 to 4.0 million in 2023. Compared to 2019, the number of people who were uninsured declined by 3.6 million.
• Who is uninsured: Most uninsured people are in low-income families and have at least one worker in the family. Reflecting the more limited availability of public coverage in some states, adults ages 19-64 are more likely to be uninsured than children. Despite gains across groups over time, racial and ethnic disparities in coverage persist.
• Why are people uninsured: Many uninsured people cite the high cost of insurance as the main reason they lack coverage. In 2023, 63% of uninsured adults ages 18-64 said that they were uninsured because the cost of coverage was too high. Many uninsured people do not have access to coverage through a job, and some people, particularly poor adults in states that have not expanded Medicaid, remain ineligible for financial assistance for coverage. Although over half of people who are uninsured may be eligible for Medicaid or subsidized coverage in the Marketplaces, they may not be aware of these coverage options or may face barriers to enrolling. In some cases, even with subsidies, Marketplace coverage may not be affordable.
• How does not having coverage affect health care access: People without insurance coverage are less likely to access care and more likely to delay or forgo care because of costs. Although difficult to establish direct causality, research has linked Medicaid expansion to improved health outcomes, including lower mortality rates from cancer, cardiovascular disease, liver disease, and maternal mortality.
• What are the financial implications of being uninsured: Uninsured people often face unaffordable medical bills when they do seek care. Nearly half (49%) of uninsured adults say they have difficulty affording health care costs, more than double the share of those with private insurance (21%). These costs can quickly translate into medical debt since most people who are uninsured have low or moderate incomes and have little, if any, savings. More than six in ten (62%) uninsured adults report having health care debt compared to over four in ten (44%) insured adults.

Although coverage rates for the overall population ages 0-64 held steady in 2023, future changes to Medicaid and Marketplace coverage could have a significant impact on health coverage. Proposals that would alter how Medicaid is financed or that would impose work requirements on certain adults enrolled in the program would likely lead to a loss of Medicaid coverage. Moreover, the temporary enhanced Marketplace subsidies will expire after 2025 unless Congress acts. Without a permanent extension, the Congressional Budget Office estimates that the number of uninsured people will increase by 3.8 million, on average, in each year from 2026 to 2034. The combined Medicaid and Marketplace coverage losses could lead to a sizable increase in the number of people who are uninsured. In turn, the loss of coverage could have implications for access to care and financial stability associated with having health coverage and could lead to a worsening of disparities in health outcomes.

How many people are uninsured?

Among the population ages 0-64, both the number of uninsured (25.3 million) and the uninsured rate (9.5%) remained at historic lows in 2023. A continued decline in the number of uninsured adults ages 19-64 was offset by an increase in the number of uninsured children. Compared to 2019, prior to the start of the pandemic, the number of uninsured and the uninsured rate for the population ages 0-64 were both significantly lower in 2023. Nearly all groups experienced coverage gains, but American Indian or Alaska Native (AIAN) and Hispanic people had larger gains than their White counterparts and low-income individuals and those in working families had bigger gains than those at higher incomes and those without a worker in the family.

Key Details:

• In 2023, 25.3 million people ages 0 to 64 were uninsured, and the uninsured rate for this population was 9.5%, both statistically unchanged from 2022. While the uninsured rate held steady from 2022, it was lower than in 2019 (10.9%) prior to the start of the coronavirus pandemic (Figure 1).

• From 2019-2023, the uninsured rate declined by 1.4%, driven primarily by gains in Medicaid and Marketplace coverage because of pandemic-era coverage protections. The Medicaid continuous enrollment provision required states to keep people enrolled in Medicaid during the pandemic in exchange for enhanced federal funding and enhanced ACA Marketplace subsidies, first enacted in the American Rescue Plan Act (ARPA) and renewed through 2025 in the Inflation Reduction Act of 2022 (IRA). Although the enhanced Marketplace subsidies remained in effect in 2023, Medicaid continuous enrollment ended on March 31, 2023, and states resumed disenrolling people from Medicaid, though the full effects of the disenrollments were not felt in 2023. During this time period, employer coverage declined by 0.5% (Figure 2).
• While there was no change in the uninsured rate for the overall population ages 0 to 64 in 2023, the share of children 18 and younger without insurance increased from 5.1% in 2022 to 5.3% in 2023. At the same time, the uninsured rate for adults ages 19 to 64 decreased to 11.1% in 2023 from 11.3% the previous year (Figure 2). An increase in Medicaid coverage for adults 19-64 from 16.3% to 16.5% in 2023 drove the decline in the uninsured rate for this group. Despite the uptick in the uninsured rate for children in 2023, the share of children without health insurance coverage was still lower in 2023 compared to 2019.

• Although nearly all groups experienced coverage gains during the pandemic-period, they were largest for AIAN and Hispanic people and individuals in low-income families. From 2019 to 2023, the uninsured rate for AIAN people fell 3.0 percentage points (from 21.7% to 18.7%) and the uninsured rate for Hispanic people decreased by 2.1 percentage points (from 20.0% to 17.9%), although these groups remain more likely to be uninsured than their White counterparts. Native Hawaiian or Pacific Islander (NHPI) people did not experience a significant decline in the uninsured rate during this period, which may, in part, reflect the smaller sample size for NHPI people, which limits the power to detect statistically significant differences. While the uninsured rate dropped for people at all income levels, individuals in low-income families¹  experienced the largest declines. From 2019-2023, the uninsured rate for poor individuals dropped 2.2 percentage points (18.0% to 15.8%) and 2.7 percentage points for individuals with income 100-199% FPL (18.2% to 15.5%, Figure 3).

• From 2022 to 2023, the uninsured rate for the population ages 0 to 64 fell in six states (Florida, Hawaii, Illinois, Missouri, North Dakota, and Oregon) but increased in two states, Iowa and Idaho (Appendix Table A). At the same time, the uninsured rate for children increased in six states (Alabama, Idaho, New Mexico, South Carolina, Texas, and Washington). While these changes occurred in both expansion and non-expansion states, the uninsured rate was lower in expansion states (7.6%) compared to non-expansion states (14.1%) in 2023 (Figure 6).

Who is uninsured?

Most of the 25.3 million people ages 0-64 who are uninsured are adults, in working low-income families, and are people of color. Reflecting geographic variation in income and the availability of public coverage, most uninsured people live in the South or West. In addition, most who are uninsured have been without coverage for long periods of time. (See Appendix Table B for detailed data on characteristics of the uninsured population.)

Key Details:

• In 2023, of the total uninsured population ages 0 to 64, nearly three in four (73.7%) had at least one full-time worker in their family, and 11.2% had a part-time worker in their family (Figure 4). More than eight in ten (80.9%) uninsured people were in families with incomes below 400% of the federal poverty level, and nearly half (46.6%) had incomes below 200% FPL. White people made up 37.1% of the uninsured, and the remaining 62.9% included Hispanic (41.1%), Black (12.5%), and Asian (3.7%) people and people of other racial or ethnic backgrounds (Figure 4). Most uninsured individuals (74.2%) were U.S. citizens, while 25.8% were noncitizens. Almost three-quarters (73.9%) of uninsured people lived in the South or West.

• Adults ages 19 to 64 are more likely to be uninsured than children. In 2023, the uninsured rate for children was 5.3%, less than half the rate for adults at 11.1%.
• Uninsured rates in the U.S. still show clear racial and ethnic disparities. In 2023, 17.9% of Hispanic people and 18.7% of AIAN people ages 0 to 64 were uninsured—more than two and a half times the rate for White people (6.5%). Asian individuals had the lowest uninsured rate at 5.8%.

• Noncitizens are more likely than citizens to be uninsured. Nearly one-third of noncitizen immigrants were uninsured in 2023, while the uninsured rate for U.S.-born citizens was 7.5% and 8.9% for naturalized citizens. (Appendix Table B).
• Uninsured rates vary by state and by region; individuals living in non-expansion states are more likely to be uninsured (Figure 6). Six of the ten states with the highest uninsured rates in 2023 were non-expansion states (Figure 5 and Appendix Table A).

• Nearly two-thirds (64%) of people who were uninsured in 2023 have been without coverage for more than a year.²  People who have been without coverage for long periods may be particularly hard to reach through outreach and enrollment efforts.

Why are people uninsured?

Lack of access to affordable health coverage is the main reason many people say they are uninsured. A majority of working age adults in the U.S. obtain health insurance through an employer; however, not all workers are offered employer-sponsored coverage or, if offered, can afford their share of the premiums. Medicaid covers many low-income individuals, especially children, but Medicaid eligibility for adults remains limited in most states that have not adopted the ACA expansion. Marketplace subsidies make coverage more affordable for many, but even subsidized Marketplace coverage can be unaffordable for some, and few people can afford to purchase private coverage without financial assistance.

Key Details:

• Cost is the most commonly cited reason for being uninsured. In 2023, 63.2% of uninsured adults ages 18-64 said they were uninsured because coverage is not affordable (Figure 7). Other reasons included not being eligible for coverage (27.0%), not needing or wanting coverage (26.6%), and signing up being too difficult (23.9%).

• Not all workers have access to coverage through their job. In 2023, 64.7% of uninsured workers worked for an employer that did not offer them health benefits.³  Among uninsured workers who are offered coverage by their employers, cost is often a barrier to taking up the offer. From 2014 to 2024, total premiums for family coverage increased by 52%, outpacing wage growth, and the worker’s share increased by 31%.⁴  Low-income families with employer-based coverage spend a significantly higher share of their income toward premiums and out-of-pocket medical expenses compared to those with income above 200% FPL.⁵  Particularly among people working for small employers , premium contributions for dependents can be unaffordable.
• Medicaid eligibility varies across states and eligibility for adults is limited in states that have not expanded Medicaid. As of December 2024, 41 states including DC had adopted the ACA Medicaid expansion. Two states implemented the expansion in 2023—South Dakota in July and North Carolina in December. In states that have not expanded Medicaid, the median eligibility level for parents is just 34% FPL and adults without dependent children are ineligible in most cases. Additionally, in non-expansion states, millions of poor uninsured adults fall into a “coverage gap” because they earn too much to qualify for Medicaid but not enough to qualify for Marketplace premium tax credits.
• Many lawfully present immigrants must meet a five-year waiting period after receiving qualified immigration status before they can qualify for Medicaid. States have the option to cover eligible children and pregnant people without a waiting period, and as of May 2024, 37 states have elected the option for children and 31 states have taken up the option for pregnant individuals. Lawfully present immigrants, including those who are not eligible for Medicaid because they have not met the five-year waiting period, are eligible for Marketplace tax credits. However, Some states have taken steps to provide fully state-funded coverage to some or all immigrants who are not eligible for federal coverage.
• Though financial assistance is available under the ACA to many of the remaining uninsured, not everyone who is uninsured is eligible for free or subsidized coverage. Nearly six in ten (14.5 million) uninsured individuals in 2023 were eligible for financial assistance either through Medicaid or through subsidized Marketplace coverage (Figure 8). However, over four in ten uninsured (10.9 million) are outside the reach of the ACA because their state did not expand Medicaid, they have an ineligible immigration status, or they were deemed to have access to an affordable Marketplace plan or offer of employer coverage.

How does not having coverage affect health care access?

Health insurance makes a difference in whether and when people get necessary medical care, where they get their care, and ultimately, how healthy they are. Uninsured adults are far more likely than those with insurance to postpone health care or forgo it altogether because of concerns over costs. The consequences can be severe, particularly when preventable conditions or chronic diseases go undetected.

Key Details:

• Uninsured adults are more likely to forgo needed care than their insured counterparts. In 2023, nearly half (46.6%) of uninsured adults ages 18 to 64 reported not seeing a doctor or health care professional in the past 12 months compared to 15.6% with private insurance and 14.2% with public coverage. Part of the reason for not accessing care among uninsured individuals is that many (42.8%) do not have a regular place to go when they are sick or need medical advice (Figure 9). But cost also plays a role. Over one in five (22.6%) adults without coverage said that they went without needed care in the past year because of cost compared to 5.1% of adults with private coverage and 7.7% of adults with public coverage. A KFF survey that asks about cost barriers for individuals and their family members reports higher percentages of both uninsured and insured people delaying or forgoing needed care due to cost.

• Uninsured children were also more likely than those with private insurance or public insurance to go without needed care due to cost in 2023 (9.5% compared to 0.7% and 1.0%, respectively). Furthermore, over a quarter (27.4%) of uninsured children had not seen a doctor in the past year, compared to 4.8% of children with public coverage and 3.7% of those with private coverage (Figure 9).
• Studies repeatedly demonstrate that uninsured individuals are less likely than those with insurance to receive preventive care and services for major health conditions and chronic diseases.^{6 ,7 ,8 ,9}  Because people without health coverage are less likely than those with insurance to have regular outpatient care, they are more likely to be hospitalized for avoidable health problems and to experience declines in their overall health. When they are hospitalized, uninsured people receive fewer diagnostic and therapeutic services and also have higher mortality rates than those with insurance.^{10 ,11 ,12 ,13 ,14} 
• Research demonstrates that gaining health insurance improves access to health care considerably and diminishes the adverse effects of having been uninsured. A review of research on the effects of the ACA Medicaid expansion finds that expansion led to positive effects on access to care, utilization of services, the affordability of care, and financial security among the low-income population.
• More recent research generally shows Medicaid expansion is associated with improved health outcomes, although establishing direct causality between health insurance and health outcomes is complex. For example, Medicaid expansion is associated with increased early-stage diagnosis rates for cancer, lower rates of cardiovascular mortality, and increased odds of tobacco cessation.^15 ,16  Medicaid expansion has also been linked to lower mortality rates, including those from cancer, cardiovascular disease, liver disease, and maternal mortality.^17 ,18  Evidence suggests it also aids long-term recovery for substance use disorders and improves treatment management for conditions such as diabetes and HIV.
• Public hospitals, community clinics and health centers, and local providers that serve underserved communities provide an important health care safety net for uninsured people. However, safety net providers have limited resources and service capacity, and not all uninsured people have geographic access to a safety net provider.^19 ,20 ,21  High uninsured rates contribute to rural hospital closures and greater financial challenges for rural hospitals, leaving individuals living in rural areas at an even greater disadvantage to accessing care.^22 ,23  Research indicates that Medicaid expansion is associated with reductions in uncompensated care costs and improved financial performance for rural hospitals and other providers.

What are the financial implications of being uninsured?

Uninsured individuals often face unaffordable medical bills when they do seek care. These bills can quickly translate into medical debt since most people who are uninsured have low or moderate incomes and have little, if any, savings.

Key Details:

• Those without insurance for an entire calendar year pay for almost 40% of their care out-of-pocket.²⁴  In addition, hospitals frequently charge uninsured patients higher rates than those paid by private health insurers and public programs.^{25 ,26 ,27 ,28} 
• Uninsured adults ages 18 to 64 are much more likely than their insured counterparts to lack confidence in their ability to afford usual medical costs. Nearly half (49%) of uninsured adults said they or a family member had problems paying for health care compared to 21% of insured adults, and over eight in ten (84%) uninsured adults said they worried that health care costs would put them in debt or increase their existing debt, compared to 71% of adults with insurance (Figure 10).

• Unaffordable medical bills can lead to medical debt, particularly for uninsured adults. More than six in ten (62%) uninsured adults report having health care debt compared to over four in ten (44%) insured adults. Uninsured adults are more likely to face negative consequences due to health care debt, such as using up savings, having difficulty paying other living expenses, or borrowing money.^29 ,30 ,31 
• While federal and state laws require certain hospitals to provide some level of charity care, not all eligible patients benefit from these programs. Consequently, charity care costs represent a small share of operating expenses at many hospitals.
• Research suggests that gaining health coverage improves the affordability of care and financial security among the low-income population. Multiple studies of the ACA found declines in trouble paying medical bills and reductions in medical debt in expansion states relative to non-expansion states. More recent research found that Medicaid expansion decreased catastrophic health expenditures and was associated with greater increases in income among low-income individuals.

1. The Federal Poverty Level was $ 24,526 for a family of three in 2023. ↩︎
2. Cohen RA and Sohi IS. “Demographic Variation in Health Insurance Coverage: United States, 2023”, National Center for Health Statistics. October 2024. Available from: https://www.cdc.gov/nchs/health_policy/coverage_and_access.htm. ↩︎
3. KFF analysis of the 2023 National Health Interview Survey. ↩︎
4. 2023 Employer Health Benefits Survey (Washington, DC: KFF, October 2023), https://modern.kff.org/health-costs/report/2023-employer-health-benefits-survey/. ↩︎
5. Gary Claxton, Matthew Rae, Nisha Kurani, and Jared Ortaliza, How affordability of employer coverage varies by family income, (Health System Tracker, Peterson-KFF, March 2022), https://www.healthsystemtracker.org/brief/how-affordability-of-health-care-varies-by-income-among-people-with-employer-coverage/. ↩︎
6. Hailun Liang, May A. Beydoun, and Shaker M. Eid, Health Needs, “Utilization of Services and Access to Care Among Medicaid and Uninsured Patients with Chronic Disease in Health Centres,” Journal of Health Services Research & Policy 24, no. 3 (Jul 2019): 172-181. ↩︎
7. Laura Hawks, et al, “Trends in Unmet Need for Physician and Preventive Services in the United States, 1998-2017,” JAMA Internal Medicine 180, no.3 (Jan. 2020): 439-448, https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2759743 . ↩︎
8. Megan B. Cole, Amal N. Trivedi, Brad Wright, and Kathleen Carey, “Health Insurance Coverage and Access to Care for Community Health Center Patients: Evidence Following the Affordable Care Act,” Journal of General Internal Medicine 33, no. 9 (September 2018): 1444-1446. ↩︎
9. Veri Seo, et al., “Access to Care Among Medicaid and Uninsured Patients in Community Health Centers After the Affordable Care Act,” BMC Health Services Research 19, no. 291 (May 2019). ↩︎
10. Marco A Castaneda and Meryem Saygili, “The health conditions and the health care consumption of the uninsured,” Health Economics Review (2016). ↩︎
11. Steffie Woolhandler, et al., “The Relationship of Health Insurance and Mortality: Is Lack of Insurance Deadly?” Annals of Internal Medicine 167 (June 2017): 424-431. ↩︎
12. Travis Campbell, Alison P Galvani, Gerald Friedman, Meagan C Fitzpatrick, “Exacerbation of COVID-19 mortality by the fragmented United States healthcare system: A retrospective observational study” (Lancet Reg Health Am., May 2022) https://pmc.ncbi.nlm.nih.gov/articles/PMC9098098/ . ↩︎
13. Andrea S. Christopher, et al., “Access to Care and Chronic Disease Outcomes Among Medicaid-Insured Persons Versus the Uninsured,” American Journal of Public Health 106, no. 1 (January 2016): 63-69. ↩︎
14. Michael G. Usher, et al., “Insurance Coverage Predicts Mortality in Patients Transferred Between Hospitals: a Cross-Sectional Study,” Journal of General Internal Medicine 33, no. 12 (December 2018): 2078-2084. ↩︎
15. Aparna Soni, Kosali Simon, John Cawley, and Lindsay Sabik, “Effect of Medicaid Expansions of 2014 on Overall and Early-Stage Cancer Diagnoses,” American Journal of Public Health epub ahead of print (December 2017), http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2017.304166. ↩︎
16. Jonathan Koma et al., “Medicaid Coverage Expansions and Cigarette Smoking Cessation Among Low-Income Adults,” Medical Care 55, no. 12 (December 2017): 1023-1029. ↩︎
17. Sameed Ahmed Khantana et al., “Association of Medicaid Expansion with Cardiovascular Mortality,” JAMA Cardiology epub ahead of print (June2019), https://jamanetwork.com/journals/jamacardiology/fullarticle/2734704. ↩︎
18. Brian Lee, Jennifer Dodge, Norah Terrault, “Medicaid expansion and variability in mortality in the USA: a national, observational cohort study” (The Lancet Public Health, Volume 7, Issue 1, e48 – e55, January 2022) https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(21)00252-8/fulltext ↩︎
19. Akash Pillai, Bradley Corallo, and Jennifer Tolbert, Community Health Center Patients, Financing, and Services, (Washington, DC: KFF, December 2024), ↩︎
20. Allen Dobson, Joan DaVanzo, Randy Haught, and Phap-Hoa Luu, Comparing the Affordable Care Act’s Financial Impact on Safety-Net Hospitals in States That Expanded Medicaid and Those That Did Not, (New York, NY: The Commonweath Fund, November 2017), https://www.commonwealthfund.org/publications/issue-briefs/2017/nov/comparing-affordable-care-acts-financial-impact-safety-net. ↩︎
21. Margaret B. Greenwood-Ericksen and Keith Kocher, “Trends in Emergency Department Use by Rural and Urban Populations in the United States,” JAMA Network Open, April 2019. ↩︎
22. Jane Wishner, Patricia Solleveld, Robin Rudowitz, Julia Paradise, and Larisa Antonisse, A Look at Rural Hospital Closures and Implications for Access to Care: Three Case Studies, (Washington, DC: KFF, July 2016), https://modern.kff.org/report-section/a-look-at-rural-hospital-closures-and-implications-for-access-to-care-three-case-studies-issue-brief/. ↩︎
23. Zachary Levinson, Jamie Godwin, and Scott Hulver, Rural Hospitals Face Renewed Financial Challenges, Especially in States That Have Not Expanded Medicaid, (Washington, DC: KFF, February 2023), https://modern.kff.org/health-costs/issue-brief/rural-hospitals-face-renewed-financial-challenges-especially-in-states-that-have-not-expanded-medicaid/ ↩︎
24. “Total expenditures in millions by source of payment and insurance coverage, United States, 2022,” Center for Financing, Access and Cost Trends, Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey, 2022, https://datatools.ahrq.gov/meps-hc. ↩︎
25. Tim Xu, Angela Park, Ge Bai, Sarah Joo, Susan Hutfless, Ambar Mehta, Gerard Anderson, and Martin Makary, “Variation in Emergency Department vs Internal Medicine Excess Charges in the United States,” JAMA Intern Med. 177(8): 1130-1145 (June 2017), https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2629494%20. ↩︎
26. Stacie Dusetzina, Ethan Basch, and Nancy Keating, “For Uninsured Cancer Patients, Outpatient Charges Can Be Costly, Putting Treatments out of Reach,” Health Affairs 34, no. 4 (April 2015): 584-591, http://content.healthaffairs.org/content/34/4/584.abstract. ↩︎
27. Rebekah Davis Reed, “Costs and Benefits: Price Transparency in Health Care,” Journal of Health Care Finance (Spring 2019). ↩︎
28. Yang Wang, Mark Katz Meiselbach, John S. Cox, Gerard F. Anderson, and Ge Bai, “The Relationships Among Cash Prices, Negotiated Rates, And Chargemaster Prices For Shoppable Hospital Services,” Health Affairs 42, no. 4, (April 2023) ↩︎
29. Alex Montero, Audrey Kearney, Liz Hamel, and Mollyann Brodie, Data Note: American’s Challenges with Health Care Costs, (Washington, D.C.: KFF, July 2022), https://modern.kff.org/health-costs/issue-brief/data-note-americans-challenges-health-care-costs/. ↩︎
30. Lunna lopes, Audrey Kearney, Alex Montero, Liz Hamel, and Mollyann Brodie, Health Care Debt In The U.S.: The Broad Consequences Of Medical And Dental Bills, (San Francisco, CA.: KFF, June 2022), https://modern.kff.org/report-section/kff-health-care-debt-survey-main-findings/ ↩︎
31. Sara R. Collins, Shreya Roy, and Relebohile Masitha, Paying for It: How Health Care Costs and Medical Debt Are Making Americans Sicker and Poorer  (New York, NY: The Commonwealth Fund, October 2023), https://www.commonwealthfund.org/publications/surveys/2023/oct/paying-for-it-costs-debt-americans-sicker-poorer-2023-affordability-survey ↩︎

Hospitals account for 30% of total health care spending—$1.4 trillion in 2022—with expenditures projected to rise rapidly through 2032, contributing to higher costs for families, employers, Medicare, Medicaid, and other public payers. Policymakers have sought to reduce spending on hospital care as part of a broader effort to make health care more affordable and reduce the federal deficit. In recent years, for example, there has been bipartisan interest in site-neutral payment reforms, which would reduce Medicare program and beneficiary spending by aligning Medicare rates for certain outpatient services across care settings. The next Trump administration and Republicans in Congress may also seek to cut Medicaid spending, which could result in fewer dollars flowing to hospitals.

At the same time, there are ongoing questions about the effects of policies that reduce spending on hospital finances and access to care, with particular attention to the implications for rural and safety-net hospitals. For example, Senators Cassidy and Hassan recently released a framework for site-neutral payment reforms that would reinvest savings into rural and high-needs hospitals.

This analysis examines hospital margins for non-federal general short-term hospitals in the U.S from 2018 through 2023, the most recent year with virtually complete cost report data. The analysis is based on RAND Hospital Data, a cleaned version of Medicare cost reports. Total margins are defined as net income (revenues minus expenses) divided by revenues. This analysis focuses on operating margins (instead of total margins) to examine the extent to which hospitals profited or lost money on patient care and other operating activities, rather than on other sources, such as investments. Operating margins are approximated using the same calculation as for total margins after subtracting reported investment income and charitable contributions from revenues. Results for groups of hospitals reflect aggregate margins based on total relevant revenues and expenses, which is equivalent to the average margin after weighting hospitals by their revenue. A number of datasets provide information about hospital finances, though each has limitations, and cost reports are no exception. See Methods for additional information.

Key Takeaways

• Aggregate hospital margins rebounded in 2023 following a large decrease in 2022. This is true for operating margins, which decreased from 8.9% in 2021 to 2.7% in 2022 before increasing to 5.2% in 2023. It is also true for total margins, which decreased from 10.8% in 2021 to 2.3% in 2022 before increasing to 6.4% in 2023. However, both aggregate operating margins and total margins remained below 2019 pre-pandemic levels in 2023.
• Aggregate operating margins were positive in 2023 (5.2%), but about two in five hospitals (39%) had negative margins in that year. About one in five (22%) had operating margins less than -5%.
• Operating margins were higher than average among for-profit hospitals, hospitals with a high share of commercial discharges, and system-affiliated hospitals in 2023. For-profit hospitals had higher operating margins than nonprofit and government hospitals (14.0% versus 4.4% and 3.4%, respectively). Hospitals with a relatively high commercial share of total discharges had higher operating margins than hospitals with low shares (7.5% versus 3.3% among the top versus bottom quarter based on commercial share, respectively) (quartiles are weighted by revenues throughout). System-affiliated hospitals had higher operating margins than independent hospitals (5.8% versus 2.5%).
• Operating margins in 2023 were also higher than average among hospitals with relatively high commercial prices. Operating margins were relatively high among hospitals with commercial prices that were greater than 300% of Medicare rates, especially among hospitals with high commercial shares. In contrast, operating margins were relatively low among hospitals with high Medicaid shares (see below).
• Operating margins were lower than average among hospitals with high Medicaid shares, which was true in both rural and urban areas. Operating margins were lower among hospitals with a relatively high Medicaid share (2.3% among the top quarter of hospitals based on Medicaid shares versus 7.0% among the bottom quarter). Operating margins were relatively low for hospitals with high Medicaid shares in both rural and urban areas (1.7% and 2.3%, respectively).
• Operating margins were lower than average among rural hospitals in 2023. Operating margins were lower among hospitals in rural than urban areas (3.1% versus 5.4%, respectively) and were especially low among hospitals in rural areas that were not micropolitan areas (1.8%), i.e., that did not include and were not closely connected to any substantial population nucleus. However, operating margins were higher among for-profit than nonprofit rural hospitals (8.5% versus 3.5%, respectively). Operating margins were also lower among hospitals with Medicare rural designations, particularly among low-volume hospitals and Medicare dependent hospitals (1.7% and 1.8%, respectively).

Aggregate Hospital Margins Rebounded in 2023 Following a Large Decrease in 2022

Aggregate operating margins decreased from 8.9% in 2021 to 2.7% in 2022 before increasing to 5.2% in 2023 (Figure 1). Similarly, aggregate total margins decreased from 10.8% in 2021 to 2.3% in 2022 before increasing to 6.4% in 2023. While operating and total margins both increased in 2023, they remained below 2019 pre-pandemic levels (6.5% for operating margins and 7.6% for total margins). Operating margins were at a record high in 2021 for hospitals reimbursed under the inpatient prospective payment system (IPPS) but were lower in 2022 than they had been since 2008—i.e., during the Great Recession—according to related analyses from the Medicare Payment and Advisory Commission.

Decreases in operating margins in 2022 were likely due to the erosion of COVID funds, costs associated with labor shortages, and increased supply expenses due to high inflation rates, among other factors. Improvements in 2023 may have been due a number of factors, including stabilizing labor expenses, decreases in average length of stay, and increases in revenue.

Some of the major credit rating agencies have reported relatively stable operating margins among rated not-for-profit health systems from 2022 to 2023 and have projected gradual improvements over time. These trends may differ from the main analysis here because, among other factors, they look at not-for-profit systems and report median (rather than aggregate or weighted average) operating margins. Industry reports, based on a non-representative sample of hospitals, indicate that finances have improved through October 2024 relative to 2022.

Aggregate Operating Margins Were Positive in 2023, But About Two in Five Hospitals (39%) Had Negative Margins

While aggregate operating margins were positive in 2023 (5.2%), operating margins varied substantially across hospitals. On one end of the spectrum, about one in seven hospitals (15%) had relatively high operating margins of at least 15%, while about one in five (22%) had positive but relatively modest margins of less than 5%, including about one in ten (11%) with positive margins of less than 2.5% (not shown). Having positive but modest margins may signal financial challenges for hospitals.

At the same time, about two in five hospitals (39%) had negative margins, and about one in five (22%) had margins of less than -5%. While some of these hospitals may be able to weather financial challenges for a period of time if they have sufficient days of cash on hand, those without sufficient days of cash on hand could be especially challenged to maintain current services or remain open. Based on a prior KFF analysis, the majority of nonprofit hospitals and health systems analyzed with negative operating margins had at least “strong” levels of days cash on hand in 2022, though that analysis was based on data that underrepresent entities likely to be more financially vulnerable.

Operating Margins Were Higher Than Average Among For-Profit Hospitals, Hospitals With High Commercial Discharge Shares, and System-Affiliated Hospitals and Were Lower Than Average Among Hospitals With Low Market Shares in 2023

For-profit hospitals—which accounted for 17% of facilities—had much higher operating margins than nonprofit and government hospitals (14.0% versus 4.4% and 3.4%, respectively) (see Figure 3). For-profit hospitals may have a greater motivation to operate more efficiently and engage in other strategic behaviors to increase their margins, such as focusing on relatively profitable services lines, dropping unprofitable service lines (like obstetrics), or locating in wealthier areas that have more residents with commercial insurance and fewer with public or no insurance. As is the case throughout this analysis, differences in operating margins across groups of hospitals could reflect a variety of factors.

Operating margins were also higher than average among hospitals where commercially-insured patients accounted for a relatively large share of discharges. For example, operating margins were 7.5% versus 3.3% when comparing hospitals in the top versus bottom quarter based on commercial shares (quartiles are weighted by revenues throughout). One factor that likely plays a role in these results is that commercial payers generally reimburse hospital care at higher rates than Medicare and Medicaid, the two other major payers. For instance, a KFF review found that commercial prices were nearly double Medicare rates for hospital services when averaging findings across studies, and one recent analysis found that commercial prices were 254% of Medicare rates for hospital services on average in 2022.

Operating margins were also higher among hospitals affiliated with a health system than independent hospitals (5.8% versus 2.5%). Higher operating margins among system-affiliated hospitals could reflect the effects of consolidation, among other factors. Consolidation might lead to higher margins, for example, to the extent that merging providers are able to reduce operating costs or—as suggested by a large body of evidence—charge higher prices by having greater market power.

Finally, operating margins were lower among hospitals that accounted for a relatively low share of hospital discharges in their market. For example, operating margins were 2.0% versus 7.3% when comparing the bottom versus top quarter of hospitals based on their market share (or the market share of the health system that they are a member of, as applicable). Hospitals with large market shares may be able to negotiate higher rates and, if part of a larger system, benefit from economies of scale, among other factors that could drive higher margins.

Operating Margins in 2023 Were Higher Than Average Among Hospitals With High Prices, Especially Among Those With a Relatively High Commercial Shares

Operating margins were relatively high among hospitals with commercial prices that were greater than 300% of Medicare rates (8.9%) and were even higher (10.5%) among those with a relatively high commercial share of total discharges (i.e., with at least a 25% commercial share) (see Figure 4). In contrast, operating margins were relatively low among hospitals with commercial prices below 200% of Medicare rates (1.0%) and were even lower (0.8%) among those with low commercial patient shares. This aligns with an analysis from researchers at the Urban Institute and Harvard that found that high commercial prices were associated with higher operating margins and more days of cash on hand.

Policymakers have explored a number of options to rein in commercial prices. This analysis suggests that hospitals with the highest prices and largest commercial shares as a group are in a better position to absorb any restraints on prices, though the impact would vary across hospitals.

While Operating Margins Were Higher Than Average Among Hospitals With High Commercial Shares in 2023, They Were Lower Than Average Among Hospitals With High Medicaid Shares, Which Was True in Both Urban and Rural Areas

Hospitals with high commercial shares had relatively high operating margins (e.g., 7.5% versus 3.3% when comparing the top versus bottom quarter of hospitals weighted by revenues based on commercial share) (see Figure 3 above) while hospitals with high Medicaid shares had relatively low operating margins (e.g., 2.3% versus 7.0% when comparing the top versus bottom quarter of hospitals weighted by revenues based on Medicaid share) (see Figure 5).

Operating margins in 2023 were relatively low among hospitals with high Medicaid shares in both rural and urban areas (1.7% and 2.3%, respectively) (see Figure 5). In comparison, the operating margin among all hospitals was 5.2% in 2023. While operating margins were lower among hospitals in rural than urban areas overall (3.1% versus 5.4%, respectively) (see Figure 7 below), hospitals with high Medicaid shares in urban areas stand out as another example of hospitals that were struggling more than others.

Some policymakers are especially attentive to the financial stability of safety-net hospitals given their role in providing access to patients with limited resources and other sources of vulnerability. The share of patients covered by Medicaid may signal the extent to which a given hospital cares for a disproportionate share of low-income patients (see Methods for more detail).

Operating Margins Were Also Lower Than Average Among Hospitals With High Medicare Shares in 2023

Operating margins were 4.3% in 2023 among hospitals in the top quarter based on Medicare share of discharges compared to 5.8% among hospitals in the bottom quarter (see Figure 6). Part of this difference may reflect the fact that hospitals with high Medicare shares were more likely to be in rural areas (54% of hospitals in the top quarter of Medicare shares were in rural areas versus 23% of the hospitals in the bottom quarter). As described below, rural hospitals had lower than average operating margins in 2023.

While operating margins among hospitals in the top quarter of Medicare shares were lower than among hospitals overall, they were higher relative to hospitals in the top quarter of Medicaid shares (4.3% versus 2.3%, respectively).

Operating Margins Were Lower Than Average Among Rural Hospitals in 2023

Operating margins were lower among hospitals in rural versus urban (nonmetropolitan versus metropolitan) areas (3.1% versus 5.4%, respectively) and were especially low among hospitals in rural areas that were not micropolitan areas (1.8%) (Figure 7), i.e., that did not include and were not closely connected to any substantial population nucleus (see Methods for more about urban and rural definitions). While 48 states in this analysis had at least one rural hospital, rural hospitals were distributed unevenly across the country. For example, a quarter of rural hospitals were located in Iowa, Kansas, Minnesota, Nebraska, or Texas. Rural hospitals often face unique financial challenges, such as low patient volume, which may lead to higher costs on average and limit the ability to offer specialized services.

Operating margins varied across rural hospitals in 2023, as was the case when looking at hospitals overall. For example, more than four in ten (44%) rural hospitals had negative operating margins while more than half (56%) had positive operating margins, including one in ten (10%) with operating margins of at least 15%. Operating margins were higher among rural for-profit than rural non-profit hospitals (8.5% versus 3.5%) and lower (0.3%) among rural government hospitals. Operating margins were also higher among system-affiliated versus independent rural hospitals (4.8% versus 0.6%, respectively).

Operating margins were lower among hospitals with Medicare rural designations than other hospitals. Low-volume hospitals (hospitals with few discharges that are a minimum distance from other facilities) and Medicare dependent hospitals (small rural hospitals with high Medicare inpatient shares) had the lowest operating margins (1.7% and 1.8%, respectively) (Figure 7). Operating margins were also lower on average among critical access hospitals (rural hospitals with at most 25 beds that with some exceptions are a minimum distance from other facilities) and sole community hospitals (hospitals that are the only source of short-term, acute inpatient care in a region) relative to hospitals without a Medicare rural designation (4.1% and 4.2%, respectively, versus 5.7%). About half of low-volume, Medicare dependent and sole community hospitals had negative operating margins in 2023 (52%, 52%, and 49%, respectively), as did 40% of critical access hospitals. A smaller share (35%) of hospitals without a Medicare rural designation had negative operating margins.

Senators Cassidy and Hassan recently released a framework for site-neutral payment reforms that some of the savings be reinvested into sole community, low-volume, and Medicare dependent hospitals. As noted above, each of these groups had lower operating margins than did hospitals without a rural designation. The framework does not mention new funds for critical access hospitals, which would likely be exempt from site-neutral payment reforms.

Policymakers have had ongoing concerns about the financial health of rural hospitals and the implications for access to care and the local economy. At the same time, it may be difficult to sustain some rural hospitals—such as those in areas with shrinking populations—and some have argued that care in at least some scenarios should be moved towards other settings, including telehealth, outpatient facilities, and larger regional hospitals.

Operating Margins Were Higher Than Average Among Hospitals With a Large Number of Beds and Among Minor Teaching Hospitals in 2023

Hospitals with greater than 500 beds had higher operating margins (6.3%) than those with fewer beds (e.g., 3.9% among hospitals with 51 to 100 beds) (see Figure 8). Minor teaching hospitals had higher margins (6.2%) than major teaching (4.3%) and non-teaching (5.1%) hospitals. Minor teaching hospitals are defined as facilities with interns or residents but at most one full-time equivalent intern or resident for every four beds, and major teaching hospitals are defined as facilities with more.

Operating Margins Varied Across States in 2023

Aggregate operating margins were at least 10% in five states (Alaska, Florida, Texas, Utah, and Virginia) but negative in four states (Michigan, New Mexico, Washington, and Wyoming) (see Figure 9). Differences likely reflect a variety of unique state circumstances, such as demographics, hospital ownership and cost structure, commercial reimbursement rates, and state and local health and tax policy. For instance, operating margins may have been high in Texas in part because the state has a relatively large number of for-profit hospitals (which have higher operating margins on average), among other factors. The same is true of Florida, which may have also had high operating margins in part due to the relatively high commercial prices in the state. As an example of a state on the other end of the spectrum, margins may have been relatively low in Wyoming in part because the vast majority of hospitals are in rural areas (92% compared to 40% of all hospitals), among other factors. It is also possible that a small number of hospitals with large revenue could have a large impact on aggregate operating margins, especially in states with relatively few hospitals, like Alaska.

Appendix

This report provides an analysis of donor government funding for family planning in low- and middle-income countries in 2023, the most recent year available, as well as trends over time. It includes both bilateral funding from donor governments and their contributions to the United Nations Population Fund (UNFPA). It is part of an effort by KFF to track such funding that began after the London Summit on Family Planning in 2012. Overall, donor government funding for family planning increased in 2023, returning to prior year levels, but still below its peak in 2019.

Key findings include the following:

• Family planning funding from donor governments was US$1.47 billion in 2023. Most funding is provided bilaterally (US$1.4 billion or 95%). The remainder – US$69.6 million (5%) – is for multilateral contributions to UNFPA’s core resources, adjusted for an estimated family planning share.
• This represents an increase of 7% (US$101.1 million) in 2023 compared to US$1.37 billion in 2022 and is a return to prior year levels, but still below its peak reached in 2019 (US$1.58 billion).¹ 
• The overall increase was due to increased bilateral funding from most donor governments; multilateral funding (contributions to UNFPA’s core resources) declined slightly largely due to decreases by Germany, Sweden, and the U.S.² 
• Total funding increased from five donor governments in 2023 (Canada, Germany, the Netherlands, Norway, and the U.K.).³  Funding from the U.S. remained flat, and three countries decreased – Australia, Denmark, and Sweden.⁴  These trends were the same after accounting for exchange rate fluctuations, except for Sweden, which increased in currency of origin.⁵ 
• The U.S. continued to be the largest donor to family planning in 2023, accounting for 40% (US$582.5 million) of total funding from governments, followed by the Netherlands (US$246.5 million, 17%), the U.K. (US$198.6 million, 13%), Sweden (US$124.5 million, 8%) and Canada (US$112.2 million, 8%). However, when family planning funding is standardized by the size of donor economies, the Netherlands ranked first, followed by Sweden, and Norway; the U.S. ranked 7th.

The future of donor government support for family planning, however, is uncertain. A second Trump administration will almost certainly see an end to U.S. support for UNFPA, and proposed cuts to bilateral funding, as was seen in his first term. Moreover, the extent to which other donors will fill in any gaps created by the U.S. is unclear, as they face their own financial pressures and changes in leadership. Such uncertainties, and potential funding reductions, would create new challenges for reaching people in low- and middle-income countries with family planning services.

Introduction

This report provides data on donor government funding for family planning activities in low- and middle-income countries in 2023, the most recent year available, as well as trends over time. It is part of an effort by KFF that began after the London Summit on Family Planning in 2012 and includes data from all 32 members of the Organisation for Economic Co-operation and Development (OECD)’s Development Assistance Committee (DAC). Data are collected directly from the largest donors and supplemented with data from the DAC. Direct data collection was carried out for nine donor governments that account for 97% of total funding for family planning. Both bilateral assistance and core contributions to UNFPA, adjusted for a family planning share, are included. For more detail, see methodology.

Findings

Total Funding

In 2023, donor government funding for family planning through bilateral and multilateral channels totaled US$1.47 billion, an increase of US$101.1 million, or 7%, compared to 2022 (US$1.37 billion). While this marks a return to prior year levels, it is below the peak level reached in 2019 (US$1.58 billion) (see Figure 1 & Table 1). The increase was entirely due to increased bilateral support from the majority of donor governments; multilateral funding decreased slightly (see “Bilateral Funding” and “Multilateral Funding” sections below).

Total funding increased from five donor governments in 2023 (Canada, Germany, the Netherlands, Norway, and the U.K.).⁶  Funding from the U.S. remained flat, and three countries decreased – Australia, Denmark, and Sweden.^7 ,8  These trends were the same after accounting for exchange rate fluctuations, except for Sweden, which increased in currency of origin.⁹  There were, however, some differences among the donor governments in the amount of bilateral and multilateral funding provided between 2022 and 2023 (see Bilateral and Multilateral sections below).

The vast majority of donor government funding for family planning is provided bilaterally (95%). The remainder (5%) is for multilateral contributions to UNFPA’s core resources, adjusted based on the share used to support family planning activities. All donor governments provided a larger share of their family planning funding bilaterally (see Figure 2).

The U.S. continued to be the largest government donor to family planning in 2023, accounting for 40% (US$582.5 million) of total donor government funding (see Figure 3). The Netherlands was the second largest donor (US$246.5 million or 17%), followed by the U.K. (US$198.6 million or 13%), and Sweden (US$124.5 million or 8%).

Bilateral Funding

Bilateral disbursements for family planning from donor governments – that is, funding disbursed by a donor on behalf of a recipient country or region – totaled US$1.40 billion in 2023, an increase of US$111.2 million, or 9%, compared to 2022 (US$1.29 billion) (see Appendix Table 1).

Bilateral funding from six donor governments (Canada, Germany, the Netherlands, Norway, Sweden, and the U.K.) increased in 2023 (see Figure 4).¹⁰  Two donor governments (Australia and Denmark) decreased funding in 2023, while the U.S. remained flat. These trends were the same after accounting for exchange rate fluctuations.

The U.S. and U.K. have been the top two donors over the entire period since the London Summit (2012-2023). However, U.S. funding has been relatively flat while funding from the U.K., which fluctuated over the period, has declined in recent years. When these two are removed, bilateral funding from the other donor governments has generally increased over the period; although, there have been fluctuations (see Figure 5).

Multilateral Funding

While the majority of donor government assistance for family planning is provided bilaterally, donors also provide support for family planning activities through core contributions to the United Nations Population Fund (UNFPA) (where donors direct or earmark funding for specific family planning activities, such as for UNFPA Supplies, these are included as part of bilateral funding). In 2023, UNFPA estimates that 18% of its core funding was directed to family planning activities.¹¹ 

These totaled US$69.6 million in 2023, a decrease of US$10.1 million compared to 2022 (US$79.7 million) (see Appendix Table 2). The decrease was entirely due to a decline in total contributions to UNFPA’s core resources – largely from Germany, Sweden, and the U.S, rather than a change in the share of core resources UNFPA directed to family planning activities.^12 ,13  Norway was the largest donor government to UNFPA’s core resources, followed by Germany, Sweden, and the Netherlands.

Fair Share

We looked at two different measures to assess the relative contributions of donor governments, or “fair share”, to family planning (see Table 2) as follows: rank by share of total donor government disbursements for family planning, and rank by funding for family planning per US$1 million in gross domestic product (GDP).

• Rank by share of total donor government funding for family planning: By this measure, the U.S. ranked first in 2022, followed by the Netherlands, the U.K., Sweden, and Canada. The U.S. has consistently ranked #1 in absolute funding amounts over the entire period since the London Summit (2012-2023).
• Rank by funding for family planning per US$1 million GDP: When funding for family planning is standardized by the size of donor economies (GDP per US$1 million), the Netherlands ranks at the top, followed by Sweden, Norway, and the U.K. (Figure 6); the U.S. ranks 7th.

Methods

Totals presented in this analysis include both bilateral funding for family planning in low- and middle-income countries as well as the estimated share of donor government contributions to UNFPA’s core resources that are used for family planning. Amounts are based on analysis of data from the 32 donor government members of the Organisation for Economic Co-operation and Development (OECD) Development Assistance Committee (DAC) in 2023 who had reported Official Development Assistance (ODA). Bilateral and multilateral data were collected from multiple sources.

Bilateral Funding:

Bilateral funding is defined as any earmarked (family planning designated) amount and includes family planning-specific contributions to multilateral organizations (e.g., non-core contributions to UNFPA Supplies). For purposes of this analysis, funding was counted as family planning if it met the OECD CRS purpose code definition: “Family planning services including counselling; information, education and communication (IEC) activities; delivery of contraceptives; capacity building and training.”

The research team collected the latest bilateral funding data directly from nine governments: Australia, Canada, Denmark, Germany, the Netherlands, Norway, Sweden, the United Kingdom, and the United States during 2023 (see Appendix Table 3). Direct data collection from these donors was desirable because they represent the preponderance of donor government assistance for family planning and the latest official statistics – from the Organisation for Economic Co-operation and Development (OECD) Creditor Reporting System (CRS) (see: http://www.oecd.org/dac/stats/data) – do not include all forms of international assistance (e.g., funding to countries such as Russia and the Baltic States that are no longer included in the CRS database). In addition, the CRS data may not include certain funding streams, such as family planning components of mixed-purpose grants to non-governmental organizations, provided by donors. Data for all other OECD DAC member governments – Austria, Belgium, Czech Republic, the European Union, Estonia, Finland, France, Greece, Hungary, Iceland, Ireland, Italy, Japan, Korea, Lithuania, Luxembourg, New Zealand, Poland, Portugal, the Slovak Republic, Slovenia, Spain, and Switzerland – which collectively accounted for approximately 3 percent of bilateral family planning disbursements, were obtained from the OECD CRS database and are from 2022 calendar year.

For some donor governments, it was difficult to disaggregate bilateral family planning funding from broader population, reproductive and maternal health totals, as the two are sometimes represented as integrated totals. In other cases, funding for family-planning-related activities provided in the context of other official development assistance sectors (e.g., humanitarian assistance, education, civil society) was included if identifiable (e.g., if donors indicate specific family planning percentages for mixed-purpose projects, or if it was possible to identify family planning specific funding based on project titles and/or descriptions).

With some exceptions, bilateral assistance data represent disbursements. A disbursement is the actual release of funds to, or the purchase of goods or services for, a recipient. Disbursements in any given year may include disbursements of funds committed in prior years and in some cases, not all funds committed during a government fiscal year are disbursed in that year. In addition, a disbursement by a government does not necessarily mean that the funds were provided to a country or other intended end-user. Enacted amounts represent budgetary decisions that funding will be provided, regardless of the time at which actual outlays, or disbursements, occur. In recent years, most governments have converted to cash accounting frameworks, and presented budgets for legislative approval accordingly; in such cases, disbursements were used as a proxy for enacted amounts.

Amounts presented are for the fiscal year period, which vary by country. The U.S. fiscal year runs from October 1-September 30. The Australian fiscal year runs from July 1-June 30. The fiscal years for Canada and the U.K. are April 1-March 31. Denmark, Germany, the Netherlands, Norway, and Sweden use the calendar year. The OECD uses the calendar year, so data collected from the CRS for other donor governments reflect January 1-December 31. Most UN agencies use the calendar year, and their budgets are biennial.

All data are expressed in US dollars (USD). Where data were provided by governments in their currencies, they were adjusted by average daily exchange rates to obtain a USD equivalent, based on foreign exchange rate historical data available from the U.S. Federal Reserve (see: http://www.federalreserve.gov/) or in some cases from the OECD. Funding totals presented in this analysis should be considered preliminary estimates based on data provided and validated by representatives of the donor governments who were contacted directly.

Specific notes pertaining to the donor governments where direct data collection was conducted are as follows:

• Project-level data were reviewed for Canada, Denmark, Germany, the Netherlands, Norway, and Sweden to determine whether all or a portion of the funding could be counted as family planning.
• Project-level data were also reviewed for France for 2012-2020, but comparable data were not available for 2021-2023, so totals for these years are based on the OECD DAC CRS database. Totals for 2021-2023 will be updated once comparable data become available. Starting with the report presenting 2022 funding amounts, totals for France were included under the amounts presented for all other DAC members; prior reports presented totals for France separately.
• Funding attributed to Australia and the United Kingdom is based on a revised Muskoka methodology as agreed upon by donors at the London Summit on Family Planning in 2012.
• For the U.S., funding represents final, Congressional appropriations (firm commitments that will be spent) to the U.S. Agency for International Development (USAID), rather than disbursements, which can fluctuate from year-to-year due to the unique nature of the U.S. budget process (unlike most other donors, U.S. foreign assistance funding may be disbursed over a multi-year period). U.S. totals for 2017-2020 also include some funding originally appropriated by Congress for UNFPA that was transferred to the USAID family planning & reproductive health (FP/RH) account due to specific provisions in U.S. law including the Kemp-Kasten amendment (see KFF “UNFPA Funding & Kemp-Kasten: An Explainer”).

Multilateral Funding:

UNFPA core contributions were obtained from United Nations Executive Board documents and correspond to amounts received during the 2023 calendar year, regardless of which contributor’s fiscal year such disbursements pertain to. Data were already adjusted by UNFPA to represent a USD equivalent based on date of receipts. UNFPA estimates of total family planning funding provided from core resources were obtained through direct communications with UNFPA representatives for 2012-2021; family planning funding estimates from UNFPA’s core resources for 2022-2023 are based on amounts reported on UNFPA’s Transparency Portal and designated as for “Ending the Unmet Need for Family Planning”.

UNFPA’s core resources are meant to be used for both programmatic activities (family planning, population and development, HIV/AIDS, gender, and sexual and reproductive health and rights) as well as operational support. Donor government contributions to UNFPA’s core resources were adjusted to reflect the share of core resources supporting family planning activities in a given year based on information from UNFPA. For instance, in 2023, UNFPA reported expenditures totaling US$500 million from core resources including US$92 million for family planning activities, which results in an estimated 18% of a donor government’s core contribution in 2023 being included in its total funding for family planning.^14 ,15 

Other than core contributions provided by governments to UNFPA, un-earmarked core contributions to United Nations entities, most of which are membership contributions set by treaty or other formal agreement (e.g., United Nations country membership assessments), are not identified as part of a donor government’s family planning assistance even if the multilateral organization in turn directs some of these funds to family planning. Rather, these would be considered as family planning funding provided by the multilateral organization and are not included in this report.

1. Family planning totals are different from those reported last year due to updated data received after the 2023 report was published. Donor amounts do not exactly sum up to total amounts due to rounding. ↩︎
2. The U.S. decline in its core contribution to UNFPA in 2023 was due to a one-time increase that occurred in the previous year. In 2022, the U.S. core contribution to UNFPA included the direct appropriation (US$30.6 million) provided by Congress as well as a one-time US$20 million contribution provided by the Biden administration through available funding from the American Rescue Plan Act of 2021 (P.L. 117-2). ↩︎
3. In 2023, the U.K. Foreign, Commonwealth and Development Office (FCDO) undertook an update of its family planning funding data including a move from reporting disbursements by fiscal year to calendar year. Updated data for the entire period were not at the time of publication. As such, U.K. totals for 2021-2023 are based on the calendar year; totals for 2012-2020 are still based on the U.K. fiscal year and will be updated in the next report (overall trends are not expected to change as a result of the forthcoming update). The 2021 and 2022 totals previously reported were considered preliminary estimates and have been revised. All U.K. totals are based on the revised-Muskoka methodology. ↩︎
4. The assessment that total U.S. family planning funding was flat in 2023 compared to 2022 is based on the amounts specified by the U.S. Congress in annual appropriations bills. The family planning amounts specified by Congress were the same in 2022 and 2023. The U.S. family planning total for 2022 as presented in this report is slightly higher than 2023 due to a one-time additional contribution to UNFPA’s core resources provided by the Biden administration (see Multilateral section). ↩︎
5. In most cases, donor governments provide funding data in their currency of origin, which are converted to U.S. dollars for this report (see Methods). ↩︎
6. In 2023, the U.K. Foreign, Commonwealth and Development Office (FCDO) undertook an update of its family planning funding data including a move from reporting disbursements by fiscal year to calendar year. Updated data for the entire period were not at the time of publication. As such, U.K. totals for 2021-2023 are based on the calendar year; totals for 2012-2020 are still based on the U.K. fiscal year and will be updated in the next report (overall trends are not expected to change as a result of the forthcoming update). The 2021 and 2022 totals previously reported were considered preliminary estimates and have been revised. All U.K. totals are based on the revised-Muskoka methodology. ↩︎
7. The assessment that total U.S. family planning funding was flat in 2023 compared to 2022 is based on the amounts specified by the U.S. Congress in annual appropriations bills. The family planning amounts specified by Congress were the same in 2022 and 2023. The U.S. family planning total for 2022 as presented in this report is slightly higher than 2023 due to a one-time additional contribution to UNFPA’s core resources provided by the Biden administration (see Multilateral section). ↩︎
8. “Other DAC Countries”, which includes: Austria, Belgium, Czech Republic, European Union, Finland, France, Greece, Hungary, Iceland, Ireland, Italy, Japan, Korea, Luxembourg, New Zealand, Poland, Portugal, the Slovak Republic, Slovenia, Spain, and Switzerland, is not listed under any assessment of increasing, decreasing, or remaining flat because there may be differences among the donor governments included. ↩︎
9. In most cases, donor governments provide funding data in their currency of origin, which are converted to U.S. dollars for this report (see Methods). ↩︎
10. “Other DAC Countries”, which includes: Austria, Belgium, Czech Republic, European Union, Finland, France, Greece, Hungary, Iceland, Ireland, Italy, Japan, Korea, Luxembourg, New Zealand, Poland, Portugal, the Slovak Republic, Slovenia, Spain, and Switzerland, is not listed under any assessment of increasing, decreasing, or remaining flat because there may be differences among the donor governments included. ↩︎
11. The family planning share of UNFPA’s core resources is based on several sources including: expenditure totals as reported in UNFPA’s annual report; family planning expenditure totals as presented on UNFPA’s Programme Expenses Portal (see here), and direct communication with UNFPA (see Methods). ↩︎
12. The U.S. decline in its core contribution to UNFPA in 2023 was due to a one-time increase that occurred in the previous year. In 2022, the U.S. core contribution to UNFPA included the direct appropriation (US$30.6 million) provided by Congress as well as a one-time US$20 million contribution provided by the Biden administration through available funding from the American Rescue Plan Act of 2021 (P.L. 117-2). ↩︎
13. “Other DAC Countries”, which includes: Austria, Belgium, Czech Republic, European Union, Finland, France, Greece, Hungary, Iceland, Ireland, Italy, Japan, Korea, Luxembourg, New Zealand, Poland, Portugal, the Slovak Republic, Slovenia, Spain, and Switzerland, is not listed under any assessment of increasing, decreasing, or remaining flat because there may be differences among the donor governments included. ↩︎
14. UNFPA, “United Nations Population Fund, Statistical and financial review, 2023 – Annexes, Report of the Executive Director”; April, 2024. ↩︎
15. UNFPA, Transparency Portal (see here); accessed November 2024. ↩︎