This fact sheet does not reflect recent changes that have been implemented by the Trump administration, including a foreign aid review and restructuring. For more information, see KFF’s Overview of President Trump’s Executive Actions on Global Health.

Key Facts

• The Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), founded in 2002, is an independent, multilateral financing entity designed to raise significant resources and accelerate efforts to end the HIV, tuberculosis (TB), and malaria epidemics.
• The U.S. government (U.S.), which provided the Global Fund with its founding contribution, is its largest single donor; between FY 2001 and FY 2024 regular Congressional appropriations to the Global Fund totaled approximately $26 billion. In FY 2021, an additional $3.5 billion was provided by Congress as emergency funding to respond to the COVID-19 pandemic.
• The U.S. also plays a key role in the organization’s governance and oversight, having its own Board seat and sitting on two of the Board’s committees.
• As of October 2024, the Global Fund had approved more than $78 billion in funding to almost 130 countries for its core HIV, TB, and malaria programs; the Global Fund estimates these investments have helped to save 65 million lives. In addition to its core programmatic activities, the Global Fund played a major role in COVID-19 response efforts, awarding over $5 billion to respond to COVID-19 as of July 2024, and continues to support countries as they shift from emergency pandemic response to longer-term health systems strengthening and pandemic preparedness efforts.
• The Global Fund’s eighth replenishment cycle, where it will mobilize resources from donors for its next funding cycle, will take place in 2025.

What is the Global Fund?

Overview

The Global Fund is an independent, multilateral financing entity designed to raise significant new resources to combat HIV, tuberculosis (TB), and malaria in low- and middle- income countries. First proposed in 2001, the Global Fund began operations in January 2002 and receives funding from both public and private donors to finance programs developed and implemented by recipient countries. The Global Fund uses a “country-defined” and “results-based financing” model that focuses on country ownership and is supported by investments from both donors and implementing countries (by contrast, bilateral support is provided from donors directly to recipient country governments, non-governmental organizations, and other entities and often reflects donor-defined priorities). To date, approximately $89 billion¹  has been pledged by all donors (governments, the private sector, and private foundations) to the Global Fund, including $15.7 billion at the latest replenishment conference for the 2023-2025 funding cycle. Using these resources, the Global Fund has approved more than $78 billion in grants to almost 130 countries²  for its core HIV, TB, and malaria programs, and awarded over $5 billion in funding to respond to the COVID-19 pandemic’s impact on efforts related to these three epidemics.³  The Global Fund’s eighth replenishment cycle, where it will mobilize resources from donors for its next funding cycle, will take place in 2025.

The U.S. has played an integral role in the Global Fund since its inception. Under the George W. Bush administration, the U.S. provided the Global Fund with its founding contribution and was involved in the initial negotiations on the multilateral organization’s design. Under the Obama administration, the U.S. pledged $12.3 billion to the Global Fund over three replenishment periods.⁴  The Trump administration had proposed funding cuts to the Global Fund and a reduced pledge amount, although Congress rejected these proposals.⁵  The Biden administration signaled increased support for the Global Fund, particularly given its direct role in responding to the COVID-19 pandemic (see the Global Fund & COVID-19 section below), and pledged $6 billion over a three-year period⁶  at the latest replenishment conference in September 2022. The U.S. also provided an additional $3.5 billion in FY 2021 emergency funding to the Global Fund to address the impact of COVID-19 on HIV, TB, and malaria programs.

In addition to being the Global Fund’s single largest donor (see Table 1), the U.S. has a permanent seat on the Board of the Global Fund, giving it a key role in governance and oversight.⁷  The Global Fund has been called the “multilateral component” of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), the U.S. government’s global effort to combat HIV (see the KFF fact sheet on PEPFAR), serving as a significant part of the U.S. government’s global health response, expanding its reach to more countries, and leveraging additional donor resources.

Still, long-ongoing discussions include the appropriate balance of U.S. funding between the Global Fund and U.S. bilateral programs, how to ensure the Global Fund’s sustainability and ability to provide the needed level of support (particularly given continued high demand for its support from countries, even amid a shortfall in available resources), and more broadly, the role of multilateralism in U.S. global health policy.⁸  Further, the appropriate shape of its role in strengthening health and community systems and, more broadly, pandemic preparedness and response, (its latest strategy includes a new pandemic preparedness and response objective) is also the subject of discussion.⁹ 

Funding Model & Organizational Structure¹⁰ 

The Global Fund was established as an independent foundation under Swiss law and operates as a multilateral financing entity. Funding is pooled from multiple sources, including from donor governments, the private sector, and private foundations. Countries submit proposals to the Global Fund, and if approved, funding is provided using a performance-based system where a grant is regularly monitored and evaluated to determine if it should be extended or discontinued based on the effectiveness of the program. Eligibility for funding is based on a country’s income classification and disease burden.¹¹  Also, in order to incentivize recipient countries to increase their domestic investments and increase country ownership (ultimately preparing countries for graduation from Global Fund support), the Global Fund includes a policy that at least 15% of funding is conditional upon increases in co-financing (see KFF brief on co-financing for more).¹² 

The Global Fund’s organizational structure includes a broad set of stakeholders, and the U.S. government is involved in many of its core structures:

• Board. The Board guides policy and strategic decisions and approves all funding. There are 20 voting members (10 implementers and 10 donors) and 8 non-voting members as follows:
  • Implementers:
    • Developing countries: seven members, one from each of the six WHO regions and an additional member from Africa.
    • Civil Society: three members, one from a developing country non-governmental organization (NGO), one from a developed country NGO, and one representative from an NGO who is a person living with HIV/AIDS or from a community living with TB or malaria.
  • Donors:
    • Government: eight members, including the U.S., which has a permanent Board seat. The U.S. also sits on the Audit & Finance and Ethics & Governance Committees.
    • Private Sector: one member.
    • Private Foundation: one member.
  • Non-voting: eight members, including the Global Fund Executive Director, the Board Chair and Vice-Chair, one representative from Global Fund partner organizations, one representative each from WHO, UNAIDS, and the World Bank, and one representative from certain public donors that are not part of a voting donor constituency.
• Secretariat. Based in Geneva, the Secretariat manages day-to-day operations. Because the Global Fund finances but does not implement programs, it does not maintain any in-country staff.
• Office of the Inspector General. An independent body of the Global Fund that reports directly to the Board through its Audit and Finance Committee, the Office of the Inspector General provides the Board with audits and investigations of the Fund’s activities, in an effort to promote good practices, reduce funding risks, and report on potential abuse.
• Technical Review Panel (TRP). An independent body of global health and development experts (which has included U.S. government experts) appointed by the Board to evaluate the merits of all proposals and make funding recommendations to the Board.
• Independent Evaluation & Learning. An independent body consisting of an Evaluation & Learning Office and Independent Evaluation Panel (IEP) that provides advisory services and oversight on the Fund’s evaluation efforts, including progress toward achieving the goals laid out in its strategy.¹³ 
• Country Coordinating Mechanisms (CCMs). The country-level entity comprised of public and private sector representatives, such as governments, businesses, and NGOs, that submits proposals to the Global Fund and oversees funded grants within a country. U.S. representatives sit on CCMs in almost all PEPFAR focus countries and often help with proposal development. The U.S. has also entered into a memorandum of understanding (MOU) in several countries to bring together PEPFAR with Ministries of Health and the Global Fund to clarify collaboration and partnership activities, particularly in the area of antiretroviral drug procurement.
• Principal Recipients (PR). The legal entity chosen by the CCM to receive Global Fund disbursements, implement programs or contract with sub-recipients, and provide regular reports and progress updates to the Secretariat.
• Local Funding Agents (LFA). Since it does not have an in-country presence, the Global Fund contracts with a local entity (usually an accounting firm) to monitor program implementation, ensure financial accountability, and provide funding recommendations to the Secretariat.

Results

The Global Fund, which was the second largest donor to global health programs in 2022 (the U.S. was the largest),¹⁴  estimates that, since 2002, its grants have helped save the lives of 65 million people who would have otherwise died due to complications from AIDS, TB, or malaria and reduced the combined death rate from these three diseases by 61%. As of October 2024, the Global Fund had approved more than $78 billion in funding for its core HIV, TB, and malaria activities and, as of July 2024, awarded over $5 billion in funding to respond to COVID-19 (see the Global Fund & COVID-19 section below).¹⁵  Funding supports a wide range of prevention, treatment, and care activities and health systems development and strengthening. Most approved funding has supported HIV programs, followed by malaria and TB (see Table 2). This funding has reached almost 130 countries,¹⁶  including not only countries that also have received U.S. bilateral support for HIV, TB, and/or malaria but also many others that have not.¹⁷  The African region has received the largest share of approved funding (68%), followed by South-East Asia (11%).¹⁸ 

U.S. Engagement with the Global Fund

In addition to U.S. engagement in governance and oversight of the Global Fund, U.S. financial support has been significant and is a key component of U.S. involvement (see figure).¹⁹  The U.S. first contributed to the Global Fund in FY 2001, and then upon the creation of PEPFAR in 2003, Congress incorporated all U.S. support for the Global Fund under the PEPFAR umbrella. At that time, Congress authorized up to $1 billion for the Global Fund for FY 2004 and “such sums as may be necessary” for FY 2005-FY 2008. In the 2008 reauthorization of PEPFAR, Congress authorized up to $2 billion in FY 2009 and “such sums as may be necessary” for FY 2010-FY 2013.” In 2013, 2018, and 2024, Congress again reauthorized PEPFAR, and while those reauthorizations included provisions related to U.S. support for the Global Fund (see below), they did not include specific funding authorization amounts. Since the 2024 reauthorization was a short-term extension (through March 2025), discussions about the next reauthorization of PEPFAR, including expiring provisions related to the Global Fund, are ongoing. See the KFF policy watch on PEPFAR reauthorization key issues as well as the KFF brief on PEPFAR legislation over time.

Congress specifies support for the Global Fund each year as part of PEPFAR appropriations, and funding is typically provided through the Department of State, although funding has also been provided through USAID and NIH in past years. Between FY 2001 and FY 2024, regular Congressional appropriations to the Global Fund totaled approximately $26 billion.²⁰  In FY 2021, an additional $3.5 billion was provided as emergency funding to respond to the COVID-19 pandemic.²¹  Congress has historically matched or provided more to the Global Fund each year than the President has requested. (See the KFF budget tracker and the KFF fact sheet on the U.S. Global Health Budget: Global Fund for details on historical appropriations for the Global Fund.)

While Congress has provided strong funding support for the Global Fund, it has also regularly passed provisions that placed restrictions on U.S. contributions:²² 

• Requiring that total U.S. contributions do not exceed 33% of total contributions from all donors, a provision that was part of the original PEPFAR authorization and maintained in the reauthorizations. Designed to leverage U.S. contributions to increase support from other donors and to limit the U.S. from becoming the predominant donor to the Global Fund, it was invoked only once, in FY 2004 when appropriated funds were held back until the following fiscal year when the 33% cap would not be exceeded.
• Setting aside 5% of U.S. contributions to cover the cost of technical assistance to Global Fund grantees, a provision first included in foreign operations appropriations bill language in 2005 and in subsequent years.
• Authorizing the Secretary of State to withhold a percentage of the U.S. contribution until the Global Fund could demonstrate improved oversight and accountability in grant disbursement.
• Requiring, as part of the FY 2012 through FY 2024 appropriations bills, that the administration consult with Congress prior to making multi-year funding pledges.

The Global Fund & Emergency Responses

COVID-19

Since the beginning of the COVID-19 pandemic, the Global Fund acted to support countries in their efforts to address COVID-19’s impact on HIV, TB, and malaria programs. The Global Fund established a “COVID-19 Response Mechanism” (C19RM) in April 2020, and also allowed for grant flexibilities that gave countries the ability to use a certain percentage of their current grants for COVID-19 response activities. As of July 2024, the Global Fund had awarded over $5 billion in funding to more than 100 countries to support countries’ responses to COVID-19.²³  Support from the Global Fund to countries was used to:

1. support national COVID-19 response efforts, including purchasing tests, treatments, and medical supplies;
2. mitigate COVID-19’s impact on Global Fund-supported programs; and
3. improve health and community-led response systems.

As countries shifted from emergency pandemic response to longer-term efforts, the Global Fund allowed countries to reprogram their C19RM funds for health systems strengthening and pandemic preparedness activities. Today, the Global Fund reports that its partner countries have made a full recovery from the impacts of the COVID-19 pandemic and that service delivery metrics have surpassed pre-COVID-19 levels.

Mpox

Since Mpox was first declared a public health emergency of international concern in 2022, the Global Fund has worked to strengthen partner countries’ response to Mpox outbreaks by allowing grant flexibilities and repurposing of funds from HIV grants and C19RM funding. Specifically, countries may request support from Global Fund grants for activities such as disease surveillance, laboratory system strengthening, strengthening the workforce, as well as community engagement.

1. Includes pledges through 2025. Includes COVID-specific emergency contributions. ↩︎
2. Does not include countries that may have received funding through multi-country or regional programs. Additional countries may be reached through multi-country or regional programs. ↩︎
3. Core activities represent HIV, TB, HIV/TB, malaria, multi-purpose, and Resilient & Sustainable Systems for Health (RSSH) funding only; the more than $78 million in approved funding does not include a breakdown of COVID-specific amounts as they cannot be attributed to a specific area, such as HIV, TB, or malaria. KFF analysis of The Global Fund Data Service: https://data-service.theglobalfund.org/downloads; accessed October 2024. The Global Fund, Dataset: Funding Approved for COVID-19 Response; July 2024. ↩︎
4. The U.S. pledged $4 billion in both the FY11-FY13 and FY14-16 replenishment cycles and $4.3 billion in the FY17-FY19 replenishment cycle. U.S. State Department, Obama Administration’s Pledge to Global Fund to Fight HIV/AIDS, Malaria and Tuberculosis, October 5, 2010. The Global Fund, Fourth Voluntary Global Fund Replenishment Pledges, December 2013. White House, Office of the Press Secretary. Statement by National Security Advisor Susan E. Rice on the United States’ Global Fund Pledge; August 31, 2016. ↩︎
5. Fulfillment of a pledge is dependent on annual Congressional appropriations. The Trump administration proposed reducing U.S. contributions to the Global Fund in each of its annual budget requests to Congress. In addition, the Trump administration proposed a pledge of $3.3 billion, matching $1 for every $3 contributed by other donors for the next replenishment period, a decline of more than $1.0 billion compared to the U.S. pledge during the prior replenishment period under the Obama administration (up to $4.3 billion, matching $1 for every $2 provided by other donors). See U.S. Department of State, FY2021 Congressional Budget Justification – Department of State, Foreign Operations, and Related Programs, February 2020. ↩︎
6. The pledge period for the Global Fund’s seventh replenishment is 2023-2025. ↩︎
7. Global Fund: http://www.theglobalfund.org/; as of September 2024. KFF analysis. White House, President Announces Proposal for Global Fund to Fight HIV/AIDS, Malaria and Tuberculosis; May 11, 2001. ↩︎
8. Global Fund, The Global Fund Strategy 2023-2028, November 2021. The Global Fund, Thematic Report: Pandemic Preparedness and Response, May 2022. ↩︎
9. Global Fund, Results Report 2024, September 2024. ↩︎
10. Center for Global Development, Overview of the Global Fund to Fight AIDS, Tuberculosis and Malaria. ↩︎
11. All low- and lower-middle-income countries are eligible for Global Fund grants regardless of disease burden; disease burden criteria only apply to upper-middle-income countries to determine their eligibility. ↩︎
12. The Global Fund funding model includes a co-financing requirement for countries to show progressive government spending on health and progressive up-take of recurrent costs associated with key programs, as well as a co-financing incentive that at least 15% of a country’s allocation is withheld until the country has committed to additional investments over and above previous levels of spending. Global Fund, Website: Funding Model: Throughout the Cycle: Co-financing, available at: https://www.theglobalfund.org/en/funding-model/throughout-the-cycle/co-financing/. ↩︎
13. The Independent Evaluation & Learning function replaces the Technical Evaluation Reference Group (TERG). Global Fund, Website: Independent Evaluation & Learning, available at: https://www.theglobalfund.org/en/iel/; accessed September 2024. ↩︎
14. KFF analysis of OECD DAC CRS database, June 2024. ↩︎
15. KFF analysis of the Global Fund Data Explorer: https://data.theglobalfund.org/home; accessed September 2024. The Global Fund, Dataset: Funding Approved for the COVID-19 Response; July 2024. ↩︎
16. Does not include countries that may have received funding through multi-country or regional programs. Additional countries may be reached through multi-country or regional programs. ↩︎
17. KFF analysis of the Global Fund Data Explorer: https://data.theglobalfund.org/home; accessed October 2024. ↩︎
18.  KFF analysis of the Global Fund Data Explorer: https://data.theglobalfund.org/home; accessed October 2024. Regions based on WHO regional classifications. ↩︎
19. KFF analysis of data from the Office of Management and Budget, Agency Congressional Budget Justifications, Congressional Appropriations Bills, and U.S. Foreign Assistance Dashboard [website], available at: www.foreignassistance.gov. ↩︎
20. This amount ($26 billion) represents the total amount of funding specified by Congress through FY 2024. However, the $32 billion pledged by the U.S. (seen in Table 1) includes the latest replenishment which runs through 2025, so the amounts will not match. ↩︎
21. KFF analysis. The American Rescue Plan Act of 2021 included $3.75 billion “to support programs for the prevention, treatment, and control of HIV/AIDS in order to prevent, prepare for, and respond to coronavirus, including to mitigate the impact on such programs from coronavirus and support recovery from the impacts of the coronavirus,” of which not less than $3.5 billion was for the Global Fund. U.S. Congress, Public Law No: 117-2; March 11, 2021. KFF, Global Funding Across U.S. COVID-19 Supplemental Funding Bills, March 2021. ↩︎
22. KFF analysis. U.S. Congress, Public Law No: 110-293; July 30, 2008. U.S. Senate Committee on Foreign Relations (Minority Staff Report), Fraud and Abuse of Global Fund Investments at Risk without Greater Transparency; April 5, 2011. U.S. Congress, Public Law No: 112-74; December 23, 2011. KFF, PEPFAR Reauthorization: Side-by-Side of Legislation Over Time, August 18, 2022. ↩︎
23. Global Fund, Dataset: Funding Approved for COVID-19 Response; July 2024. ↩︎

• Overview of NHPI People in the U.S.
• Health Coverage, Access, and Use
• Health Outcomes of NHPI People
• Social And Economic Factors that Influence Health

Introduction

Native Hawaiian or Pacific Islander (NHPI) people experience substantial and enduring disparities in health and health care. These, in part, reflect specific challenges in accessing health care such as geographic isolation, economic challenges, and limited availability of culturally appropriate care. Furthermore, NHPI communities are often excluded from data and analysis due to their smaller population sizes. This limits the visibility and understanding of their health outcomes and experiences accessing health care, impeding efforts to address their health care needs and eliminate disparities.

Given the importance of increasing the understanding of experiences among these groups as part of advancing equity, this brief provides an overview of NHPI experiences across key measures of health, health access, and social and economic factors that influence health. It is based on KFF analysis of data from multiple datasets including the 2018-2022 American Community Survey, the 2022 Behavioral Risk Factor Surveillance System, and the Centers for Disease Control and Prevention (CDC) WONDER online database. This report also incorporates analysis from Key Data on Health and Health Care by Race and Ethnicity, which examines how people of color fare compared to White people across 64 measures of health, health care, and social determinants of health. Racial and ethnic groupings for each measure vary depending on the data source. Data reported by ethnic identity are limited to people who identify as NHPI alone. Data reported for the continental U.S. refers to the 48 contiguous states, District of Columbia (DC), and Alaska. Data for many health outcome measures are not available by ethnic subgroup. Data are limited to NHPI people residing within the 50 states and DC¹ .

Key takeaways include:

NHPI people represent people from diverse backgrounds. The majority of NHPI people identify with more than one race and ethnicity. NHPI people have ethnic origins tracing back to several islands in the Pacific Ocean that have varying relationships with the U.S. Among NHPI people residing in the 50 states and DC, most live in Hawaii and California.

NHPI people fare worse than White people across the majority of examined measures of health, health care, and social determinants of health. Reflective of lower rates of private coverage, NHPI (9%) people under age 65 are somewhat more likely to be uninsured than White people (7%). Roughly a quarter of NHPI adults (24%) under age 65 report not having a personal provider compared to 17% of White adults. Additionally, similar shares of NHPI adults (20%) report fair or poor health status as White adults (16%). NHPI people have higher birth risks and worse birth outcomes compared to White people. This may in part reflect limited access to prenatal care, as NHPI women (22%) are over four times more likely to receive late or no prenatal care than White women (5%). NHPI people also have higher rates of pregnancy-related mortality (62.8 per 100,000) and infant mortality (8.5 per 100,000) compared to their White counterparts (14.1 per 100,000 and 4.5 per 100,000, respectively). Although the majority of NHPI people under age 65 are in working families, they have higher rates of poverty than White people (15% vs. 10%). Roughly half of NHPI people (54%) own a home compared to about three quarters of their White counterparts (76%). NHPI people have similar or better health outcomes compared to White people across a few health measures. NHPI people (both at 20%) have a similar likelihood of reporting fair or poor health and 14+ mentally unhealthy days compared to White people (16% and 15%, respectively). NHPI adults (6%) are less likely to have a heart attack or heart disease than White people (8%) yet have similar rates of heart disease-related mortality (173.2 per 100,000 vs. 173.1 per 100,000, respectively).

Among NHPI people, there is significant variation in key factors that influence health, including health coverage, income, and homeownership, with Marshallese people faring the worst across all examined measures. Among NHPI people under age 65, uninsured rates range from less than one in ten of Chamorro (8%), Samoan (9%), and Native Hawaiian (9%) people to nearly one in four (24%) Marshallese people. Homeownership rates also vary from roughly two-thirds of Fijian people (65%) to 14% of Marshallese people.

Data gaps prevent the ability to fully identify and understand health disparities for NHPI people. Data are insufficient or not disaggregated for NHPI people for many health and health care measures. Among available data, NHPI people fare worse than White people for the majority of measures. For some measures there is no significant difference, but this sometimes may reflect the smaller sample size for NHPI people in many datasets, which limits the power to detect statistically significant differences.

These data highlight the importance of continued efforts to address disparities in health and health care for NHPI people in ways that account for the diversity of the population and their experiences. Continued efforts to increase the availability of disaggregated data for NHPI people overall and by ethnicity, such as oversampling to generate adequate sample sizes to produce reliable estimates and changes to the collection and reporting of data on race and ethnicity, will also be important for improving the ability to identify and understand the disparities they face and assessing the impact of interventions to address them.

Overview of NHPI People in the U.S.

The NHPI population has grown and become more diverse over time. As of 2022, there were roughly 1.5 million people in the U.S. who identify as NHPI alone or in combination with another racial or ethnic group. The majority of NHPI people identify as NHPI and at least one other race, while just about one in three NHPI people identify as NHPI alone (36%) (Figure 1).

NHPI people trace their family origins to several islands in the Pacific Ocean with varying relationships with the U.S. Among people who identify as NHPI alone, 28% are Native Hawaiian. About one in five (18%) are Samoan, about one in eight are Chamorro (12%), and less than one in ten identify as Fijian (7%), Tongan (7%), or Marshallese (7%) (Figure 2). The remaining 22% identify as one of the remaining other Pacific Islander groups, including Palauan, Tahitian, Chuukese, Pohnpeian, Yapese, and other groups.

There is significant variation in the ethnic identity among NHPI people living in Hawaii compared to the continental U.S. Not surprisingly, among those who identify as NHPI alone, the majority of those residing in Hawaii are Native Hawaiian (58%), while ethnic identity is more mixed among those living in the continental U.S. (Figure 3).

Among NHPI people (alone or in combination with another race or ethnicity) living within the 50 states and DC, nearly half reside in Hawaii (26%) and California (22%) alone (Figure 4). Washington state (7%) accounts for the next largest share of NHPI people in the U.S., followed by Utah (4%) and Texas (4%). Many NHPI people also reside in their homelands and across the U.S. territories of Guam, Samoa, the Commonwealth of the Northern Mariana Islands, and the Freely Associated States (FAS) that include the Federated States of Micronesia, the Republic of the Marshall Islands, and the Republic of Palau. However, data for NHPI people living in the territories and FAS are limited and not reflected in this analysis.

Most NHPI people (92%) living in the U.S. are. citizens, however, citizenship status varies among NHPI ethnic groups, reflecting differences in birth citizenship rights across locations to which they trace their origins. Specifically, people born in Hawaii and the U.S. territories of Guam (Chamorro people), and Northern Mariana Islands are U.S. citizens by birth. People born in the U.S. territory of American Samoa are not granted citizenship but are considered U.S. nationals. People born in the FAS, which are part of the Compact of Free Association with the U.S., are not conferred U.S. citizenship at birth, but are guaranteed the right to live, work, and access health care in the U.S. Other Pacific Islands are independent nations and therefore people born in these countries are not provided U.S. citizenship at birth. Reflecting these differences, among NHPI people living in the U.S., Native Hawaiian and Chamorro people have small shares of noncitizens (both at 1%). A larger share of Samoan (11%), Tongan (18%), and Fijian (29%) people are noncitizens, while more than half (52%) of Marshallese people are noncitizens (Figure 5).

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Health Coverage, Access, and Use

Overall, uninsured rates among NHPI people under age 65 are somewhat higher than uninsured rates among their White counterparts (9% vs. 7%) (Figure 6). This reflects lower rates of private coverage (67%) compared to White people (78%). Public coverage helps fill but does not fully offset this gap. Among people under age 65 who identify as NHPI alone, uninsured rates vary by ethnicity, ranging from about one in ten Chamorro (8%), Samoan (9%), Native Hawaiian (9%), and Fijian people (10%) to about one in seven (15%) Tongan people and about one quarter (24%) of Marshallese people.

Health coverage patterns also vary based on where NHPI people live. The uninsured rate for NHPI people living in Hawaii is about half that of those living in the continental U.S. (4% vs. 10%). This pattern is largely driven by more expansive Medicaid coverage, reflecting the state’s adoption of the Affordable Care Act (ACA) Medicaid expansion for low-income adults and other eligibility expansions. Hawaii also has a longstanding mandate for employers to offer health insurance to eligible employees which facilitates access to private coverage. Uninsured rates also vary across geographic regions, ranging from 7% in the Western U.S. to 16% in the Southern U.S. These geographic patterns in part reflect differences in Medicaid expansion status among states. Many of the remaining states that have not yet adopted the ACA expansion to low-income adults are in the South. NHPI people under age 65 living in non-expansion states are twice as likely to be uninsured as those in expansion states (16% vs. 8%) (Figure 7).

NHPI adults are more likely to report not having a usual doctor or provider or going without care due to cost than White adults but are less likely to say they went without an annual check-up. About a quarter of NHPI adults (24%) under age 65 report not having a personal provider compared to 17% of White adults (Figure 8). NHPI adults (18%) also are more likely to report not seeing a provider due to cost compared to 11% of White adults. However, NHPI adults are less likely to say they went without a routine checkup in the past 12 months than White adults (24% vs. 28%).

NHPI people are more likely to report going without colorectal cancer screening compared to White people but are as likely to receive a mammogram or pap smear. Among those recommended for colorectal cancer screening, about four in ten (42%) NHPI people did not receive a colorectal cancer screening compared to about three in ten (30%) White people (Figure 9). As of 2022, among women ages 50-74 (the age group recommended for screening for breast cancer prior to updates in 2024, which lowered the starting age to 40), the share of NHPI women (34%) who did not receive a mammogram in the past two years was not significantly different from the share of White women (29%). Similarly, the difference in the share of NHPI women (31%) ages 21 to 65 years (the age group recommended for screening for cervical cancer) who did not receive a pap smear was not significantly different from their White counterparts (22%).

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Health Outcomes of NHPI People

One in five NHPI adults report fair or poor health status (20%) and having 14+ mentally unhealthy days (20%), which are similar to the rates for White people (Figure 10).

Pregnancy-Related Outcomes and Infant Mortality

NHPI women fare worse than their White counterparts across multiple measures of birth risks and outcomes. NHPI women have higher shares of preterm births (12% vs. 9%) and low birthweight births compared to White women (9% vs. 7%) (Figure 11). Notably, NHPI women (22%) are four times more likely than White women (5%) to begin receiving prenatal care in the third trimester or to receive no prenatal care at all. Additionally, NHPI teen birth rates (20.5 per 1,000) are more than two times higher than the rate among White teens (9.1 per 1,000) (Figure 12).

NHPI people have higher rates of pregnancy-related and infant mortality than White people. NHPI people have nearly five times higher pregnancy-related death rate than White people (62.8 vs. 14.1 per 100,000) (Figure 13). NHPI infants are nearly twice as likely to die as White infants (8.5 vs. 4.5 per 1,000) (Figure 14).

Chronic Disease

NHPI adults are more than two times as likely to die from diabetes than White adults (Figure 15). Diabetes rates for NHPI people (15%) do not statistically differ from the rate for White adults (11%), but the diabetes death rate for NHPI people is more than twice as high as the rate for White adults (49.9 vs. 21.3 per 100,000). The diabetes mortality rate for NHPI people is based on a small number of observations and should be interpreted with caution.

NHPI adults are less likely to have a heart attack or heart disease than White adults but are at similar risk of dying due to heart disease. While rates of heart attack or heart disease are lower for NHPI adults (6%) compared to White adults (8%), the rate of heart disease-related mortality is similar (173.2 per 100,000 vs. 173.1 per 100,000, respectively).

Cancer

During 2015-2019, the latest period for which disaggregated data for NHPI people were available, there were over 18,000 new cancer cases among NHPI people. Breast cancer is the most diagnosed cancer type among women across NHPI ethnic groups, as is the case for most other racial and ethnic groups, ranging from 25% among Samoan women to 44% among Fijian women. For Native Hawaiian, Samoan, Tongan, and Fijian men, the most commonly diagnosed cancer type is prostate cancer, while the most commonly diagnosed cancer for Chamorro men is lung cancer. While updated data as of 2021 is available for other racial and ethnic groups, disaggregated data on rates of cancer incidence are unavailable for NHPI people.

Overall, NHPI people have lower rates of cancer mortality than White people across most types of cancer. NHPI people have lower rates of all cancer-related deaths than White people (157.2 per 100,000 versus 171.6 per 100,000) (Figure 16). NHPI people have similar rates of female breast cancer mortality than White people (10.6 vs. 10.3 per 100,000). They have lower mortality rates of colon and rectum cancer (7.8 vs. 9.6 per 100,000), lung and bronchus cancer (29 vs. 33.2 per 100,000), and prostate cancer (6.3 vs. 7.5 per 100,000).

Mental Health

Reported rates of mental illness among NHPI people are similar to White people, but research suggests mental illness could be underdiagnosed among NHPI people. About one quarter of NHPI adults (23%) report experiencing any mental illness in the past year, similar to their White counterparts (27%). The share of NHPI adults reporting serious mental illness is also similar to White adults (5% vs 7%) (Figure 17). NHPI people (17%) are nearly half as likely to report ever having mental illness compared to White people (32%). However, research suggests that a lack of culturally sensitive screening tools that detect mental illness, coupled with structural barriers could contribute to underdiagnosis of mental illness among people of color.

NHPI people are less likely to receive treatment compared with White people. 16% of NHPI people report receiving treatment in the past year compared to over one in four White people (26%) (Figure 18).

NHPI adults have lower rates of deaths by suicide and drug overdose than White people (Figure 19). As of 2022, the suicide death rate for NHPI adults (14.3 per 100,000) is lower than the rate for White adults (17.6 per 100,000). Between 2011 and 2021, Asian or Pacific Islander people experienced a faster increase in suicide death rates than White people. The data was not disaggregated and therefore the changes observed cannot specifically be attributed to Asian or NHPI racial groups, alone. Suicide data are not available for NHPI adolescents. NHPI adults have roughly half the rate of drug overdose deaths than their White counterparts (18.8 vs. 35.6 per 100,000). Between 2022 and 2023, the number of opioid overdose deaths among Asian or Pacific Islander people declined by 2%, a smaller decline than that of White people (-14%). Opioid overdose death data are combined for Asian and Pacific Islander people.

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Social And Economic Factors that Influence Health

Across ethnic groups, most NHPI people are in working families, but there is significant variation in family income among NHPI people. Most NHPI people under age 65 are in a family with at least one worker (77%). Although the majority are in working families, NHPI people under age 65 are more likely to have income below the poverty level than their White counterparts (15% vs. 10%), with the share ranging from 11% among Tongan and Fijian people to 27% among Marshallese people (Figure 20).

NHPI people have lower educational attainment compared to White people, but there is significant variation among NHPI people. Among adults ages 25 and older, one in five adults who are NHPI alone (19%) and one quarter of all NHPI adults (25%) report having a bachelor’s degree or higher compared to nearly four in ten White adults (38%) (Figure 21). Among NHPI people, the share with a bachelor’s degree ranges from 5% of Marshallese people to nearly one quarter (23%) of Chamorro people.

About one in ten (8%) NHPI people report speaking English less than very well compared to one percent of White people (Figure 22). Among NHPI people, limited English proficiency varies by ethnicity, ranging from about 2% of Native Hawaiian people to 5% of Chamorro people and one third of Marshallese people (32%). 17% of Tongan people and about one in five Fijian people (21%) report speaking English less than very well.

Overall, NHPI households (54%) have lower rates of homeownership compared to White households (76%) (Figure 23). Homeownership rates vary among NHPI people, ranging from about one in seven Marshallese households (14%) to about roughly half of Tongan households (51%), six in ten Native Hawaiian households (60%), and about two thirds of Fijian households (65%). Despite U.S. promises to return ancestral lands to Native Hawaiian people under the Hawaiian Homes Commission Act of 1920, home ownership rates among NHPI people in Hawaii remain at 56%. Some of the barriers to homeownership faced by Native Hawaiians include the high cost of living and the failures and long waitlists under the Hawaiian Homes Commission Act. The Maui wildfires have further increased housing demand and may exacerbate barriers to homeownership.

NHPI people are more likely to live in “crowded” housing compared to White people, and this share is higher among NHPI people living in Hawaii compared to those living in the continental U.S. (Figure 24). Nearly one in five (18%) people who identify as NHPI alone or in combination with another race or ethnicity and about a quarter of people who identify as NHPI alone (27%) report living in crowded housing compared to 3% of White people. “Crowded housing” is defined as housing with more than one occupant per room (not counting bathrooms, porches, balconies, hallways, or unfinished basements, etc.). Among NHPI people, the share of people living in crowded housing ranges from 14% for Chamorro people to 64% for Marshallese people. About three in ten (29%) NHPI people living in Hawaii report living in crowded housing compared 7% of White people living in Hawaii and to 15% of NHPI people in the continental U.S. NHPI people have the highest share of people living in multigenerational housing —households containing three or more generations— compared to other racial and ethnic groups, which may contribute to the higher share reporting crowded housing. Family is considered a core value in NHPI culture and is defined very broadly to include extended family. Consequently, living in multigenerational households is more common among NHPI people and is considered a strength within the community. Additionally, Hawaii consistently ranks as the most expensive state to live in, which can also lead to crowded housing conditions.

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1. Data and research often assume cisgender identities and may not systematically account for people who are transgender and non-binary. The language used in this brief attempts to be as inclusive as possible while acknowledging that the data we are citing uses gender labels that we cannot change without misrepresenting the data. ↩︎

Although health care did not figure prominently in the 2024 presidential election, with President-elect Trump returning to the White House and Republicans controlling Congress, significant changes to Medicaid are expected. One potential target for federal spending reductions is the Affordable Care Act’s (ACA) Medicaid expansion. The ACA expanded Medicaid coverage to nearly all adults with incomes up to 138% of the Federal Poverty Level ($20,783 for an individual in 2024) and now provides states with an enhanced federal matching rate (FMAP) of 90% for their expansion populations. While the expansion was originally mandatory for states, a Supreme Court decision in 2012 effectively made it optional and as of November 2024 all but 10 states have adopted the expansion. Twelve states have “trigger” laws in place that would automatically end expansion or require other changes if the federal match rate were to drop below 90%.

Rather than repealing the ACA outright, some conservative and Republican proposals would instead lower the federal match rate for the expansion population from 90% to the standard Medicaid match rate, which is calculated based on a state’s per capita income and ranges from 50% to 83%. The Congressional Budget Office estimated in 2022 that reducing the match rate for the expansion group would save the federal government $631 billion over 10 years. This financing change would shift a substantial amount of Medicaid spending from the federal government to states. States would then need to decide whether to use states funds to make up for the lost federal funding or cut coverage. Given the challenges states would face replacing substantial lost federal funds, the health coverage implications would likely be significant and could reverse gains in financial security, access to care, and health outcomes. A large body of prior research shows that Medicaid expansion has helped to reduce the uninsured and improve access, affordability, and financial security among the low-income population. More recent research shows improvements in health outcomes and continues to show positive effects for providers (particularly rural hospitals) and for sexual and reproductive health.

Because of the widespread adoption of the Medicaid expansion across states, the financial and coverage impacts will be felt by both states that voted for President-elect Trump and those that voted for Vice President Harris. This data note provides key facts on the Medicaid expansion using enrollment data as of March 2024 and FY 2023 spending data from the Medicaid Budget and Expenditure System (MBES).

Medicaid expansion has been adopted by 41 states including the District of Columbia, split nearly evenly between states that voted for Trump (21 states) and those that voted for Harris (20 states) (Figure 1). Over the past ten years, Medicaid expansion has been broadly adopted by states led by Republicans and Democrats. Consequently, any changes to the Medicaid expansion authority or financing structure will affect both red and blue states. While the data are presented by states that voted for Trump or Harris in the November 2024 elections, there are five states with Democratic governors that voted for Trump (Arizona, Kentucky, Michigan, North Carolina, and Pennsylvania) and three Republican-led states that voted for Harris (New Hampshire, Virginia, and Vermont). In total, there are 19 expansion states with Republican governors, and 22 expansion states (including DC) headed by Democrats. Ultimately, it will be state governors and legislatures that will respond to any federal policy changes.

As of March 2024, over 21 million people were enrolled through the Medicaid expansion representing nearly a quarter of enrollment across all states and about three in ten Medicaid enrollees in expansion states (Figure 2). Medicaid expansion enrollment totaled 7.3 million in states that voted for Trump and 13.7 million in states that voted for Harris. Across all Medicaid expansion states, total Medicaid enrollment was 68.2 million and the majority of people (69%) were enrolled through traditional eligibility pathways. Medicaid expansion enrollment comprised a slightly larger share of enrollment in states that voted for Harris (33%) than in states that voted for Trump (28%). Expansion enrollment ranged from a high of 53% of total enrollment in Oregon to a low of 13% in North Carolina, which implemented Medicaid expansion coverage in December 2023 (Appendix Table 1). The variation across expansion states likely reflects several factors, including different poverty distributions and economic conditions across states as well as variation in state Medicaid eligibility levels for expansion and traditional groups.

About 4.3 million expansion enrollees live in states with some type of trigger law that would end expansion coverage or require review of expansion coverage to mitigate increases in state costs if federal funding for the expansion is reduced. Trigger laws require states to automatically end Medicaid expansion coverage or require them to take actions to ensure state costs do not increase if the federal matching rate for the Medicaid expansion drops below 90% or below a specified threshold. Not all of the laws would immediately end the Medicaid expansion, but enrollees in states with trigger laws are at greater risk of losing coverage, although some may be able to maintain coverage through other eligibility pathways in some states. Currently, nine states (Arizona, Arkansas, Illinois, Indiana, Montana, New Hampshire, North Carolina, Utah, and Virginia) have laws that require termination of the expansion if the share of federal funding drops. Laws in three additional states (Idaho, Iowa, and New Mexico) require the states to take some action to mitigate the fiscal impact of the loss of federal funds. Of the 12 states with trigger laws, eight states voted for Trump (Arizona, Arkansas, Idaho, Indiana, Iowa, Montana,  North Carolina, and Utah) and four states voted for Harris (Illinois, New Hampshire, New Mexico, and Virginia). While laws in the so-called “trigger” states require action, the substantial loss of federal funding would likely force all states to reassess whether to continue the expansion coverage.

In FY 2023, spending on the expansion group represented 20% of Medicaid spending across all states and over a quarter of Medicaid spending in expansion states (Figure 3). Medicaid spending totaled $863.9 billion for all states and $686.9 billion in the 40 states that had implemented expansion in 2023 (North Carolina did not implement expansion until December 2023 and, consequently, is not counted as an expansion state during FY 2023). Spending on the expansion group totaled $178.2 billion, or 26% of total Medicaid spending in those states, and federal spending was $158.3 billion. Due to the 90% federal match for expansion, federal spending represents a larger share of spending for the expansion group than for traditional enrollees. The share of spending for the expansion group is lower than its share of enrollment (26% vs. 31%), in part, because the traditional Medicaid group includes populations such as those with disabilities and seniors who have higher per-enrollee spending. Similar to enrollment, expansion spending as a share of total spending varied across states from a high of 43% in Montana to a low of 16% in Massachusetts (Appendix Table 2).

Appendix Tables

The Biden administration has proposed to allow Medicare and require Medicaid to cover drugs used to treat obesity by reinterpreting the statutory language that currently prohibits coverage of drugs used for weight loss under Medicare and permits but does not require states to cover these drugs for weight loss under Medicaid. This reinterpretation reflects an evolution in the understanding of obesity as a disease and weight loss as conferring real health benefits in people with obesity rather than being merely for cosmetic purposes. It also comes amidst high and growing demand for and use of a relatively new class of highly effective, but also very expensive, drugs being used to treat obesity, known as GLP-1s.

Under current law, people on Medicare can get anti-obesity drugs covered by Part D, Medicare’s outpatient drug benefit, only if they are used for a medically accepted FDA-approved indication other than obesity, like diabetes or cardiovascular disease risk reduction. State Medicaid programs also have to cover these drugs for indications such as diabetes or cardiovascular disease risk reduction, but only 13 states currently cover these drugs for obesity treatment as well. These limitations on coverage in Medicare and Medicaid mean that millions of people who have obesity and might benefit from these drugs may be unable to access them due to their high prices. But even with these coverage limits in place, gross spending on these drugs for approved uses in Medicare and Medicaid has skyrocketed in recent years, totaling $4 billion in Medicaid in 2023 and close to $6 billion in Medicare in 2022 for selected GLP-1s.

The new Biden administration proposal would authorize Medicare and Medicaid coverage of anti-obesity medications for people with obesity but not people who are overweight. While coverage would be available for Medicare and Medicaid enrollees with obesity, Medicare Part D drug plans and state Medicaid programs could still apply utilization management tools such as prior authorization, which could limit access. According to the Centers for Medicare & Medicaid Services, the proposal would increase Medicare spending by $25 billion and Medicaid spending by $15 billion over 10 years (net of rebates) and would apply to around 3.4 million people with Medicare and 4 million people with Medicaid. Because Medicaid is jointly financed by the states and the federal government, CMS estimates the federal government would pay $11 billion and states would pay nearly $4 billion.

Rising prescription drug costs are an ongoing concern for states, and state Medicaid programs reported the high cost of obesity drugs as key reason for not expanding coverage prior this proposal. The potential cost to Medicare is lower than some other estimates because it assumes many people with obesity can already get Medicare coverage of these drugs for other medically accepted indications, and CMS’s proposal would not apply to people who are overweight. Nonetheless, the combination of high demand, new uses, and high prices for these treatments is likely to place tremendous pressure on Medicare spending, Part D plan costs, and premiums for Part D coverage over time.

KFF analysis has found most large employer firms currently do not cover GLP-1 drugs for weight loss and coverage in ACA Marketplace plans remains limited, but if finalized, the proposed change to Medicare and Medicaid coverage could put pressure on other payers to expand access. If it becomes official coverage policy, this change would also lift the burden off lawmakers in Congress who have repeatedly introduced legislation to authorize Medicare coverage of anti-obesity drugs but who may have been stymied by the potential cost of doing so. But as the Biden administration prepares to hand the reins over to the incoming Trump administration, a key question is whether the rule will be finalized as proposed under new leadership at CMS, changed in some way, or pulled back altogether.

Background

Youth access to gender affirming care has become an increasingly politicized and contentious issue in recent years. Today, 26 states have enacted laws restricting youth access to gender affirming care, most of which are facing legal challenges. On December 4^th, the Supreme Court will hear a case challenging the constitutionality of such state restrictions for the first time. The case before the Supreme Court challenges the Tennessee ban (United States v. Skrmetti) under the Equal Protection Clause of the 14th Amendment. Both the plaintiffs, three families and a provider, who originally challenged the law (L. W. et al v. Skrmetti et al) and the Biden administration, as an intervener, requested review and the Court granted  certiorari in the challenge brought by the Biden administration.

The case has garnered significant attention with 84 amicus briefs having been filed, 32 in support of the petitioners, 51 in support of the respondents, and one in support of neither party. Amicus briefs in support of the petitioner include those from The American Academy of Pediatrics, The American Psychological Association, and the State of California with 19 other states, among others. Briefs filed in support of the respondents include those from the State of Kentucky with 21 other states, The Alliance Defending Freedom, and the Family Research Council, among others.

This brief provides background on gender affirming care and state bans, explains the legal challenge to the Tennessee law, and explores the potential Court ruling and impact on access across the country.

What is the status of minor access to gender affirming care in the United States?

Access to gender affirming care for youth has been increasingly limited in the U.S. Arkansas became the first state to enact a youth gender affirming care ban in April 2021, with Arizona and Alabama following about a year later. Beginning in January 2023, the number of states enacting these policies rapidly proliferated and by August, it had reached 22 – a seven-fold increase in an eight-month period. As of November 2024, 26 states have such restrictions. While these laws mainly impact youth access to health care, some impact adult access too, and a majority of the laws include professional and/or civil penalties for health care practitioners who provide gender affirming care. Additionally, legal challenges are piling up, and laws in 17 of the 26 states are being challenged in court. The majority of cases are filed in federal courts and most have reached appellate courts.  Like the Tennessee case before the Supreme Court, most other cases also challenge state laws on 14^th Amendment Equal Protection grounds, though other grounds are common as well. All of the cases filed in federal court that bring 14^th Amendment Equal Protection claims, also bring 14^th Amendment Due Process claims, largely focused on parental autonomy rights (i.e., the rights of parents to make decisions for their children). In some cases, alternate grounds are tied to provisions specific to an individual state’s law (e.g., if the state law includes provisions restricting gender affirming care in Medicaid) and some cases filed in state courts base claims on violation of state constitutional provisions.

What are the key provisions in the Tennessee law (SB1)?

Tennessee law SB1 is the law prohibiting minor access to gender affirming care in the state that is being challenged at the Supreme Court. It was enacted on March 22, 2022, became effective July 1, 2023, and includes the following provisions:

• Prohibits health care providers from providing or offering gender affirming care —  including puberty blockers, hormone therapy, and surgery — to minors. Additionally, “any person” is prohibited from providing puberty blockers or hormone prescriptions. The prohibition is inclusive of care provided via telehealth.
• Providers violating SB1 are subject to discipline under Title 63 of TN code regulating health professionals (class B misdemeanor).
• Creates a private right of action for minors/parents (when consent was not given) and outlines direct enforcement authority for the attorney general (regardless of consent given). Provides right to wrongful death action specifically when a minor’s death results from physical or emotional harm and there was no consent from parents.
• As with all states with similar restrictions, provides an exclusion for care “to treat a minor’s congenital defect, precocious puberty, disease, or physical injury” unrelated to gender affirming care.
• Provided a temporary period for minors to continue receiving care if they were already receiving prohibited care prior to the law’s enactment through March 31, 2024.

What happened with the case in the lower courts?

In the Spring of 2023, prior to the law’s effective date, three families and a provider challenged SB1 in federal court (U.S. District Court for the Middle District of Tennessee) on multiple grounds, including for violating the 14^th Amendment Equal Protection Clause. The U.S. Department of Justice (DOJ) intervened in the case in support of the plaintiffs. The District Court granted in part and denied in part the plaintiffs request for a preliminary injunction, allowing minors in the state to retain access to gender affirming hormones and puberty blockers, but allowing the part of the law blocking surgeries and creating a right of action to be implemented. The state appealed the injunction to the 6th Circuit Court of Appeals and the appellate court reversed and remanded the District Court’s preliminary injunction, reinstating the ban in Tennessee (as well as the ban in Kentucky). In November 2023, both the plaintiffs and the US DOJ petitioned the Supreme Court to review their case.  (As noted above, the Supreme Court took the case based on the DOJ request.)

What is before the Supreme Court?

While the plaintiffs raised several legal theories in the original filing, the Supreme Court will only be reviewing one question:

“Whether Tennessee Senate Bill 1 (SB1), which prohibits all medical treatments intended to allow “a minor to identify with, or live as, a purported identity inconsistent with the minor’s sex” or to treat “purported discomfort or distress from a discordance between the minor’s sex and asserted identity,” Tenn. Code Ann. § 68-33-103(a)(1), violates the Equal Protection Clause of the Fourteenth Amendment.” (Emphasis added.)

The U.S. government contends that the Tennessee’s law violates the 14^th Amendment’s Equal Protections Clause because the law explicitly classifies minors based on sex and discriminates based on transgender status. The law prohibits treatment to minors classified as girls at birth that is available to minors classified as boys at birth and vice versa. For example, the government writes, “a teenager whose sex assigned at birth is male can be prescribed testosterone to conform to a male gender identity, but a teenager assigned female at birth cannot.“ The U.S. government cites the Tennessee law as evidence of the legislature’s intent: “SB1 bluntly declares that it draws those sex-based lines to “encourag[e] minors to appreciate their sex” assigned at birth.” Because the classification is based on sex, the law needs to be reviewed with heightened scrutiny and the U.S. government claims that the law does not pass this standard: “Tennessee has made no attempt to tailor the law to the State’s asserted health concerns.”

Tennessee contends that the ban does not constitute a sex-based classification: “SB1 includes no sex classification. It draws a line between minors seeking drugs for gender transition and minors seeking drugs for other medical purposes. And boys and girls fall on both sides of that line.”  Tennessee draws an analogy to reproductive rights cases that distinguish pregnancy and abortion from a sex classification, including Geduldig v. Aiello (in which the Supreme Court found pregnancy is not a sex-based classification), Bray v. Alexandria Women’s Health Clinic (in which the Supreme Court found that anti-abortion protesters were not in violation of the Equal Protection Clause because animus was to abortion, not women), and Dobbs v. Jackson Women’s Health Organization (in which the court wrote that state regulation of abortion is not a sex-based classification, despite equal protection claims not being before the court). Leaning on these cases, the state argues the law regulates medical care and is not sex discrimination, and therefore is not in violation of the 14^th Amendment equal protection clause.

What is at stake with a Supreme Court decision?

The Court’s ruling in this case will impact laws restricting gender affirming care across the country and any future legal challenge to bans, at least on equal protection grounds.  Allowing the ban to stand would effectively leave the current patchwork of access to gender affirming care for minors, with different states permitting different levels of access to care. The 26 states with bans currently in place would likely keep them and others may follow suit. Under this scenario, where a young person lives will continue to dictate the access they have to gender affirming care and the number of those with limited access could increase.  If the Court rules this way, plaintiffs in other cases may continue to pursue legal challenges to the bans based on other grounds, such as the 14^th Amendment Due Process clause.

If the Court rules that the Tennessee ban is unconstitutional, similar bans in other states would also be unconstitutional and minors would gain greater protections in accessing gender affirming care nationwide.

The court could also rule that the Tennessee law does classify minors based on sex and remand the case back to the lower court for further review.

The Court’s decision is expected in June 2025.

What might the impact of the incoming Trump Administration be?

The Supreme Court is hearing the case challenging the Tennessee ban at a time when state and federal actions around gender affirming care have become increasingly politicized. The court took the case at the request of the Biden administration. However, just over a month after hearing the case, President-elect Trump will take office and the Trump-Vance team has made clear that it will seek to limit access to gender affirming care through multiple mechanisms.

If the Court rules the Tennessee law is constitutional, it may be harder to challenge any new federal restrictions the Trump administration imposes.  Indeed, even if the Court rules the Tennessee law is unconstitutional because it is sex discrimination, the Trump administration may still put forward other restrictions to care, such as in Medicaid and Medicare, contending these are not addressed by the Tennessee case.

NOTE: This analysis was updated in November 2024 to reflect changes in the most recent Physician Fee Schedule Final Rule.

Medicare does not offer broad coverage of dental services under traditional Medicare, but through recent regulatory action, the Biden Administration has taken steps to modify Medicare payment policies to expand the types of dental services that are covered. In Medicare Physician Fee Schedule Final Rules from recent years, the administration made changes to Medicare payment policies for certain dental services, in addition to other payment and policy changes. The 2023 rule clarified CMS’s interpretation of when medically necessary dental services can be covered and codified certain payment policies, and the 2023, 2024, and 2025 rules define new clinical scenarios for which Medicare payment can be made for dental services. This brief describes current law related to coverage and payment for dental services under Medicare and the rationale for changes to current policy, explains changes to dental payment and coverage included in these rules, and discusses the impact on Medicare and beneficiaries.

As explained in more detail below, these rules modestly expand the types of dental services that are covered under Medicare, including dental or oral examinations prior to any organ transplant surgery, cardiac valve replacement or valvuloplasty procedures, beginning in 2023, and dental or oral examinations prior to treatment for head and neck cancer beginning in 2024. Based on changes in the 2024 rule, Medicare will cover treatment to address dental complications after radiation, chemotherapy, and/or surgery for head and neck cancer, as well as dental or oral examinations prior to chemotherapy, chimeric antigen receptor (CAR) T-cell therapy, and the administration of high-dose bone-modifying agents when used in the treatment of cancer. Further, based on changes in the 2025 rule, Medicare will cover dental or oral examinations as well as diagnostic and treatment services to eliminate an oral or dental infection prior to or at the same time as Medicare-covered dialysis services for the treatment of end-stage renal disease.

While these changes are projected to benefit a small number of Medicare beneficiaries, they do not represent a broad expansion of Medicare coverage of dental services. Traditional Medicare does generally not cover routine preventive services including exams and x-rays, or coverage of more extensive services, including root canals and dentures. These changes will not substantially increase Medicare spending or covered dental services for a large number of Medicare beneficiaries. Absent a broader expansion of dental coverage under Medicare, people on Medicare who do not have a comprehensive source of dental coverage will continue to face relatively high out-of-pocket costs, particularly if they need extensive dental care that is unrelated to other covered medical services.

Medicare coverage of dental services is generally very limited

Since its establishment in 1965, Medicare has explicitly excluded coverage for dental services, except under limited circumstances. Limited or no dental coverage contributes to Medicare beneficiaries foregoing routine and other dental procedures. For example, in 2018, half of Medicare beneficiaries did not have a dental visit (47%), and cost was a major barrier to care for those who reported they couldn’t get dental care in the past year. Among those who used dental services, average out-of-pocket spending was $874 in 2018. Lack of dental care can exacerbate chronic medical conditions, such as diabetes and cardiovascular disease, and contribute to delayed diagnosis of serious medical conditions. While routine dental services are not covered by Medicare, many Medicare beneficiaries have access to some dental coverage through other sources: nearly half of all Medicare beneficiaries are enrolled in Medicare Advantage plans, almost all of which offer dental coverage as an extra benefit, but the scope of coverage varies by plan.

Under current law, Section 1862(a)(12) of the Social Security Act, Medicare is prohibited from making payments for “…services in connection with the care, treatment, filling, removal, or replacement of teeth or structures directly supporting teeth.” However, exceptions to this prohibition can apply in the context of inpatient hospital services “in connection with the provision of such dental services if the individual, because of his underlying medical condition and clinical status or because of the severity of the dental procedure, requires hospitalization in connection with the provision of such services.”

Current CMS policy has interpreted the Medicare statute to cover medically necessary dental services under both Parts A and B if they are “incident to and as an integral part” a covered procedure. For example, Medicare currently covers dental procedures, such as:

• when the reconstruction of a ridge is performed as a result of and at the same time as the surgical removal of a tumor (for other than dental purposes);
• extraction of teeth to prepare the jaw for radiation treatment of neoplastic disease; and
• an oral or dental examination performed on an inpatient basis as part of a comprehensive workup prior to renal transplant surgery.

Interested stakeholders, including patient advocates, providers, and members of Congress have asked CMS to use its authority to expand Medicare coverage of medically necessary dental services. CMS has also received feedback that its interpretation of Section 1862(a)(12) of the Social Security Act has been “unnecessarily restrictive” and may contribute to inequitable care, particularly for older adults who are at high risk of poor oral health, which can exacerbate and complicate the treatment of other medical issues. Further, these stakeholders have asserted there are additional clinical scenarios where dental services are directly related to the clinical success of a covered service under Medicare Parts A and B.

To provide greater clarity on current dental coverage under Medicare and to respond to these stakeholders, in the 2023 physician payment final rule, CMS clarified its interpretation of the statute, codified certain payment policies, defined new scenarios where payment can be made for dental services, and outlined a process for more medically necessary dental services to potentially be covered under Medicare. In the 2024 and 2025 rules, CMS included additional scenarios where payment can be made for dental services and covered by Medicare.

The 2023 final rule clarifies CMS’s interpretation of when medically necessary dental services can be covered and codifies certain payment policies

In the 2023 final rule, CMS clarified its interpretation of the statute and permitted Medicare to make payment for dental services under Medicare Part A and B “that are inextricably linked to, and substantially related and integral to the clinical success of, certain other covered medical services” regardless of the setting, whether inpatient or outpatient.

With this clarification of the statute, the rule codified that dental services can continue to be made based on the interpretation that these services “are inextricably linked to, and substantially related and integral to the clinical success of, an otherwise covered medical service”, including:

• dental or oral examination as part of a comprehensive workup prior to a renal organ transplant surgery;
• reconstruction of a dental ridge performed as a result of and at the same time as the surgical removal of a tumor;
• wiring or immobilization of teeth in connection with the reduction of a jaw fracture;
• extraction of teeth to prepare the jaw for radiation treatment of neoplastic disease; and
• dental splints only when used in conjunction with medically necessary treatment of a medical condition.

The 2023 final rule clarified that Medicare Parts A and B payment for dental services can occur only when dental and medical services are integrated, meaning medical and dental professionals must coordinate care. The rule also finalized a policy whereby Medicare can pay for ancillary services that are critical to the success of dental services, such as X-rays, administration of anesthesia, and use of an operating room.

Currently, for the limited circumstances under which Medicare pays for some dental services, Medicare payments to dentists are generally based on the physician fee schedule. For services that are not included on the fee schedule, regional Medicare Administrative Contractors (MACs), which are responsible for administering Medicare claims, determine the amount to be paid. The 2023 final rule continued this policy, allowing MACs to determine that payment can be made for dental services and the payment amount itself in other circumstances not specifically addressed in the rule.

The final rules define new clinical scenarios for which Medicare payment can be made for dental services

CMS evaluated clinical evidence for additional dental services to determine whether they are substantially related and integral to the clinical success of other covered services. Based on this evidence, payment can now be made under Medicare Parts A and B for:

2023 Rule

• dental or oral examinations, including necessary treatment, performed as part of a comprehensive workup prior to any organ transplant surgery (rather than only renal organ transplant surgery), or prior to cardiac valve replacement or valvuloplasty procedures (beginning in 2023).
• dental or oral examination, including necessary treatment, performed as part of a comprehensive workup in either the inpatient or outpatient setting prior to or at the same time as Medicare-covered treatments for head and neck cancer (beginning in 2024).

2024 Rule

• diagnostic and treatment services to address dental or oral complications after radiation, chemotherapy, and/or surgery when used in the treatment of head and neck cancer (beginning in 2024).
• dental or oral examinations, including necessary treatment, performed as part of a comprehensive workup prior to or at the same time as chemotherapy, chimeric antigen receptor (CAR) T-cell therapy, and the administration of high-dose bone-modifying agents (antiresorptive therapy) when used in the treatment of cancer (beginning in 2024).

2025 Rule

• dental or oral examination as part of a comprehensive workup prior to, or at the same time as Medicare-covered dialysis services for the treatment of end-stage renal disease (ESRD) (beginning in 2025).
• diagnostic and treatment services to eliminate an oral or dental infection prior to, or at the same time as, Medicare-covered dialysis services for the treatment of ESRD (beginning in 2025).

As part of the 2023 final rule, CMS described how it will use the Physician Fee Schedule annual rulemaking process to determine whether additional dental services should be considered for payment under Medicare. CMS will make this determination based on evidence from relevant peer-reviewed medical literature and research studies, clinical guidelines, or generally accepted standards of care for the suggested clinical scenario, and other supporting documentation. CMS used this process to determine that payment should be made for the dental services described above that were finalized in the 2024 and 2025 rules.

Impact on Medicare beneficiaries and payments

CMS has estimated that these changes will not result in a significant increase in Medicare spending or covered dental services for a large number of Medicare beneficiaries.

• CMS estimated that approximately 190,000 additional dental services could be covered by Medicare prior to organ transplants, cardiac valve replacement, or valvuloplasty procedures beginning in 2023, at an additional annual cost of $200,000 to $2.55 million, depending on utilization.
• CMS estimated an additional 155,000 beneficiaries might receive dental services for which Medicare could be paid relating to chemotherapy, Car T-cell therapy, and bone-modifying agents for cancer as well as treatment for head and neck cancers, beginning in 2024, at an additional annual cost of $130,000 to $2 million, depending on utilization.
• CMS estimated the potential cost of the payment for dental services for beneficiaries with ESRD, which would apply to approximately 30,000 patients in traditional Medicare, would represent a small cost to the Medicare program of less than $1 million in any given year, even at varying levels of utilization.

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

Introduction

While much of health policy will be shaped by executive and legislative action under the incoming Trump administration, a variety of pending lawsuits also may be affected by the incoming administration, as it may choose to drop litigation that the Biden administration defended or pursued. The outcomes of these lawsuits could have significant impacts across many aspects of health care, including preventive services, abortion care, gender affirming care, Medicare drug price negotiations, nursing home staffing rules, private coverage consumer protections, and protections and health coverage for Deferred Action for Childhood Arrivals (DACA) recipients. While in many cases President-elect Trump has not commented publicly on the issues in these lawsuits, his record as president, comments on the campaign trail, and proposals from conservative groups suggest he might view these cases differently from the Biden administration. This brief provides an overview of these legal challenges, how they may be affected by the incoming Trump administration, and the implications of their potential outcomes.

Affordable Care Act

ACA Preventive Services

The outcome of a pending federal lawsuit, Braidwood Management Inc v Becerra, which challenges the ACA preventive services requirements, could put coverage of many preventive services at risk. The Biden administration is defending the ACA requirement and fighting the case. President-elect Trump has not publicly voiced an opinion on the case, but Project 2025, a set of policy proposals from conservative groups, calls for the federal government to issue new requirements for contraceptives and other women’s preventive services because of the pending case.

The ACA requires most private health insurance plans to cover a range of preventive services without any patient cost-sharing. In the case, Braidwood Management v. Becerra, Christian owned businesses and six individuals in Texas assert that (1) the requirements in the law for specific expert committees and a federal government agency to recommend covered preventive services is unconstitutional, and that (2) the requirement to cover preexposure prophylaxis (PrEP), medication for HIV prevention, violates their religious rights. In June 2024, the 5th Circuit Court of Appeals affirmed the district court’s ruling that the part of ACA’s preventive services coverage requirement (services recommended by United States Preventive Services Task Force (USPSTF) is unconstitutional) but that only the plaintiffs are permitted to exclude USPSTF recommended services from their plans. The plaintiffs’ claim that the Secretary of HHS’s ratification of HRSA and ACIP recommendations violates the Administrative Procedure Act was sent back to the lower court for further briefing and a judgment. In September 2024, the Biden Administration petitioned the Supreme Court to review the 5^th Circuit’s decision. The Supreme Court has not yet decided whether to take the case. If the Trump administration does not defend the case, a state might join the lawsuit to defend the ACA’s preventive services requirement just as California intervened in the case brought by Texas challenging the ACA when the first Trump administration did not defend the federal law.

Private Coverage Consumer Protection Regulations

Lawsuits have recently been filed challenging Biden administration rules that regulate so-called “junk” insurance products that do not provide comprehensive health insurance coverage, which the Trump administration may not defend. For example, designed for people who experience a temporary gap in health insurance coverage, short-term, limited duration (short-term plans) plans typically offer fewer covered benefits and consumer protections compared to plans that meet ACA standards. The duration and renewability of short-term plans have been the subject of changing federal regulations, with the Obama administration in 2016 restricting coverage to less than three months without renewability, and the Trump administration in 2018 expanding the permitted coverage duration to less than 12 months with the ability to renew coverage for up to an additional 24 months. The Biden administration’s 2024 regulation limits short-term plan coverage to three months plus a one-month extension. A lawsuit was recently filed in a Texas federal court, American Association of Ancillary Benefits v. Becerra et. al, challenging this regulation as beyond the authority of the agency under the Administrative Procedure Act. That lawsuit also challenges new standards in the regulation that add consumer protections for fixed indemnity products. Fixed indemnity plans pay a specific amount if someone is sick or hospitalized. Like short-term plans, fixed indemnity plans do not have to meet most of the ACA’s consumer protections. Another lawsuit challenges the same regulation, questioning new consumer notice requirements for fixed indemnity products. The new Trump administration may not defend these actions, instead reinstating Trump-era rules for these plans or seeking to incorporate them into legislation.

Less clear is the what the Trump administration will do to defend various lawsuits challenging Biden administration regulations that implement surprise billing protections in the 2020 No Surprises Act. The No Surprises Act (NSA), signed into law by President Trump in 2020, protects patients with private insurance from surprise medical bills in certain situations when the patient receives care from an out-of-network hospital or clinician that they did not choose. The law requires health plans to cover surprise bills at in-network rates and prohibits out-of-network providers at certain in-network facilities from billing patients directly for the remainder of the bill. Biden administration regulations implementing these protections have been challenged in several lawsuits. Many of these cases are still working their way through lower courts, but two recent Fifth Circuit decisions in separate lawsuits brought by the Texas Medical Association throw out some parts of Biden administration regulations that set out how disputes between providers and insurers about out-of-network rate are resolved, while retaining other parts of Biden administration regulations on other aspect of the NSA. While consumers are still shielded from receiving surprise balance bills in many instances, the end result of these legal challenges could be an increase in insurance premiums and out-of-pocket costs for consumers.

DACA Program and ACA Marketplace Coverage Expansion

The future of the DACA program remains uncertain due to ongoing litigation, and the Trump Administration has finalized regulations to eliminate the ACA health coverage expansion for DACA recipients. DACA was established via executive action in June 2012 to protect certain undocumented immigrants who were brought to the U.S. as children from removal proceedings and provide them work authorization. The first Trump administration sought to end DACA but was blocked by the Supreme Court in 2020. The Biden administration issued regulations in 2022 to preserve DACA, but in September 2023, a district court in Texas ruled the DACA program unlawful, preventing implementation of the regulations while the case awaits a decision in the Fifth Circuit Court of Appeals. Under the pending ruling, the Department of Homeland Security is processing DACA renewal requests and related employment authorizations but not initial DACA requests. In May 2024, the Biden administration issued regulations to extend eligibility for ACA Marketplace coverage with subsidies to DACA recipients, who were previously ineligible for federally funded health coverage. The regulation became effective November 1, 2024. In August 2024, a group of 19 states filed a lawsuit against the federal government alleging that the coverage expansion for DACA recipients violates the Administrative Procedure Act. On December 9, 2024, a federal court in North Dakota granted the plaintiffs’ motion by blocking the ACA coverage expansion from being implemented in the 19 states that filed the lawsuit (AL, AR, FL, IA, ID, IN, KS, KY, MS, MT, ND, NE, NH, OH, SC, SD, TN, TX, VA). On December 16, 2024, the U.S. Court of Appeals for the Eighth Circuit issued a temporary stay of the federal court’s injunction, temporarily allowing DACA recipients in all states to sign up for ACA Marketplace coverage. However, on December 23, 2024, the U.S. Court of Appeals for the Eighth Circuit vacated the administrative stay, thereby making DACA recipients in the aforementioned 19 states ineligible for ACA Marketplace coverage again. The Trump administration said that it would try again to eliminate DACA protections after the first attempt failed in 2020. Given its views generally on immigration issues and DACA specifically, the Trump administration is presumably unlikely to appeal any ruling against DACA or the coverage expansion. In an interview prior to his inauguration, President-elect Trump indicated that he would work on addressing the status of “Dreamers” and indicated a willingness to work with Democrats on the issue, although the details of this proposed plan remain unclear. On June 25, 2025, the Centers for Medicare and Medicaid Services (CMS) finalized a rule that will once again exclude DACA recipients from the definition of “lawfully present” immigrants for the purposes of health coverage, making them ineligible to purchase coverage through the ACA Marketplaces beginning 60 days after the final rule’s publication. Elimination of the coverage expansion could leave thousands of DACA recipients without an affordable coverage option while elimination of the DACA program would put the over half a million DACA recipients, a majority of whom are working and many of whom have U.S.-born children, at risk of deportation.

Reproductive Health and Abortion Care

Medication Abortion

Access to mifepristone, one of the pills used in the medication abortion regimen, could be limited if the Trump administration does not defend pending litigation, amends the FDA rules, or enforces the Comstock Act. In November 2022, Alliance for Hippocratic Medicine (a group of anti-abortion medical organizations) challenged the FDA’s 2000 approval of mifepristone on procedural grounds, as well as recent changes to the regulation of the medication that eliminated the in person dispensing requirement by a physician and enabled to be mailed to patients following a telehealth consultation, as being beyond the FDA’s authority. In addition, they contended that an 1873 anti-obscenity law, the Comstock Act, prohibits the mailing of medications used for abortion. In June 2024, the Supreme Court unanimously ruled that the Alliance for Hippocratic Medicine and the individual doctors lacked legal standing to sue the FDA, but did not address the claims made by the anti-abortion challenges. However, the case continues at the district court with three state interveners (Kansas, Idaho, and Missouri) who may have legal standing. The Trump administration is not expected to defend the FDA’s actions challenged in this lawsuit. While President-elect Trump does not have a stated position on the case or on medication abortion, Project 2025 is clear in its opposition to the FDA’s approval of mifepristone and also endorses enforcement of the Comstock Act, which would effectively ban the mailing and distribution of abortion pills within the country, even in states that currently allow abortion without restrictions.

Emergency Medical Treatment and Labor Act (EMTALA) and Emergency Abortion Care

Pending litigation could determine whether states can implement abortion bans without health exceptions. Shortly after Roe v Wade was overturned, the Biden administration issued guidance in July 2022 regarding the enforcement of EMTALA, a federal law requiring hospitals to provide stabilizing treatment to patients. The guidance clarified that hospitals and physicians have obligations to provide stabilizing care, including abortion, to preserve the health of a pregnant person, not only in situations where abortion is necessary treatment to save a patient’s life. Six states (AR, ID, MS, OK, SD, and TX) have no health exception to their state abortion ban. After the guidance was issued, the Biden administration sued the state of Idaho to block the state law’s enforcement to the extent it conflicts with EMTALA, a challenge that ultimately reached the Supreme Court. In June 2024, the Supreme Court dismissed the case, Moyle v. United States (consolidated with United States v. Idaho) and returned the case to the lower court. While this case proceeds, Idaho is blocked from enforcing its abortion ban when abortion is necessary to prevent serious harm to the patient’s health. However, in a similar case, Texas successfully sued the Biden administration to block enforcement of the EMTALA guidance in Texas. The Biden administration asked the Supreme Court to review the Texas case, but the Court declined. President-elect Trump says he believes in exceptions for “life of the mother” but has not weighed in on health exceptions. Project 2025 authors call for the reversal of the Biden administration’s EMTALA guidance, which the new Trump administration could do right away, and withdrawal of federal lawsuits challenging state abortion bans without health exceptions.

Reproductive Health Privacy Regulation

A Biden administration regulation on reproductive health privacy is at risk, as the Trump administration may not defend legal challenges to the rule, as well as to parts of the HIPAA privacy regulation. In April 2024, HHS finalized a regulation adding a new category of protection to HIPAA privacy regulations for the use and disclosure of reproductive health information in certain circumstances. The rule prohibits health care providers, health plans and others from disclosing, for example, information about reproductive health care such as abortion or contraception counseling obtained legally, to a law enforcement agency seeking to investigate or impose legal liability related to that care. The state of Texas has challenged these rules and existing HIPAA standards as preventing the state from enforcing its own laws restricting abortion and other reproductive health care, including gender affirming care. The state argues in a lawsuit filed in September that HHS went beyond its authority provided in the HIPAA law and seeks to set aside these protections. Another lawsuit by a Texas physician against HHS makes similar allegations, and is also pending in a Texas federal court. Most of the reproductive health privacy rule will be effective on December 23, 2024, unless blocked by the court in these cases. If the rule becomes effective, the Trump administration could take administrative action to rescind this rule and perhaps alter existing HIPAA protections so states have greater leeway to require disclosure of reproductive health information.

Pregnant Workers Fairness Act

The outcome of pending litigation and potential regulatory changes under the new Trump administration will determine whether employers must provide accommodations to employees after an abortion. The Biden administration issued a final rule and interpretive guidance to implement the Pregnant Workers Fairness Act, which requires a covered entity to provide reasonable accommodations to a qualified employee’s or applicant’s known limitations related to, affected by, or arising out of pregnancy, childbirth, or related medical conditions, unless the accommodation will cause an undue hardship on the operation of the business of the covered entity. The Biden administration includes abortion in the definition of “pregnancy, childbirth or related medical conditions.” There are several ongoing lawsuits in federal courts challenging this rule that the incoming Trump administration is not likely to defend. The Trump administration may issue new rules that do not include abortion in the definition of “pregnancy, childbirth or related medical conditions.”

Federal Title X Family Planning Program

The structure of the Title X program could be reshaped by ongoing litigation, and the incoming Trump administration could reinstate their prior regulations that were rescinded by Biden. For more than 50 years, the federal Title X program has provided family planning services to nearly four million low-income people a year through a national network of clinics. The first Trump administration issued Title X regulations that prohibited grantees from referring clients for abortion services or having co-located family planning and abortion services which led to the withdrawal or disqualification of almost a quarter of the sites from the Title X network. The Biden administration issued regulations to reverse the first Trump administration’s policies.

The ability of states to ban abortion has added a new layer of litigation to the program. Several states that ban abortion are challenging counseling and referrals for abortion requirements under Title X. There is also ongoing litigation brought by Ohio and 11 other states contending that the Biden administration rules violate a section of the Title X law that states “none of the funds appropriated under Title X can be used in programs where abortion is a method of family planning.” In a 1991 decision, Rust v Sullivan, the Supreme Court deferred to the agency’s interpretation of that provision. However, in June 2024, the Supreme Court overturned the Chevron deference to agency interpretation of federal laws, and it is likely that the Supreme Court will ultimately decide the “correct” interpretation of that provision in a future case.

Finally, a provision requiring confidentiality–including for minors–as a criterion for receiving federal Title X funding nationally could be at risk. As a result of a privately filed lawsuit (Deanda v. Becerra) minors in Texas must receive parental consent before obtaining contraceptive services at Title X clinics to comply with the state’s parental consent law. The Texas Attorney General recently filed a new lawsuit seeking to block nationwide enforcement of this provision. Some states, including Texas, require parental consent to get contraception for those who are not married or legally emancipated. Project 2025 calls for the reinstatement of the first Trump administration rules. The new administration could also revise the rules to eliminate the requirement for confidential services to minors, which would likely end the litigation on all these cases.

Gender Affirming Care

Gender Affirming Care Ban

The Trump administration may not support a pending challenge to a Tennessee law prohibiting gender affirming care services for minors. In the wake of a proliferation of laws curtailing minor access to gender affirming care and litigation challenging these state restrictions, the Supreme Court agreed to hear a case challenging the Tennessee ban (United States v. Skrmetti). Both the plaintiffs in the Tennessee case and the Biden administration, as an intervener, requested review. The Supreme Court granted the Biden administration’s request for review and scheduled oral argument on December 4, 2024. The Court is presented with the question of whether Tennessee’s law, which prohibits core gender affirming care services for minors, violates the equal protection clause of the 14th Amendment. Given President-elect Trump’s record to date, his administration would presumably be unlikely to support the plaintiffs as the Biden administration has. As the Court accepted the petition from the Biden administration’s Department of Justice, the future of the case is uncertain. The Court might hear the case as scheduled in December, before the administration changes, and issue its’ decision in June 2025. It’s also possible that the state of Tennessee will ask for the court to reconsider its review given the impending change of administrations.

Gender Identity Protections (Section 1557)

The outcome of pending litigation, and how the incoming Trump administration engages with it, as well as regulatory changes, will determine the reach of nondiscrimination protections for LGBTQ people. A group of 15 states sued HHS (Tennessee et al. v. Becerra et al.), challenging the Biden administration’s final rule implementing section 1557 of the ACA. Section 1557 holds the law’s major nondiscrimination protections, including those on the basis of sex, which the Biden administration interpreted to include protections on the basis of sexual orientation and gender identity. In July 2024, the district court (S.D. Miss) granted the plaintiffs’ request to block HHS from enforcing provisions of the rule related to gender identity nationwide while the case proceeds. HHS ﷟appealed the ruling to the 5th Circuit and also asked the lower court to stay proceedings pending the outcome of their appeal. The Trump administration could drop the appeal and halt any intervention with the lower court, favoring the ruling currently in place, at least until the administration issues a revised regulation.

Gender Dysphoria Disability Protections

Disability law nondiscrimination protections for people with gender dysphoria could be weakened if the Trump administration chooses not to defend a Biden regulation currently being challenged and/or issues new rules without protections. A group of 17 states sued HHS (State of Texas et al v. Becerra et al), over a nondiscrimination rule implementing amendments to its section 504 of the Rehabilitation Act of 1973 (section 504) regulation. In the preamble to the final rule, HHS states that in certain circumstances, gender dysphoria may be protected under section 504, a federal law proving nondiscrimination protections for people who have disabilities. In adopting this protection, HHS agreed with a recent Fourth Circuit case, Wiliams v. Kincaid, which concluded that gender dysphoria may constitute a disability under section 504 and the Americans with Disabilities Act, if certain conditions are met. The plaintiffs challenging the regulation argue that HHS exceeded its statutory authority with the rule, that the rule was arbitrary and capricious, and unconstitutional. The Trump administration could choose not to defend the regulation and/or issue new rules without explicitly naming these protections.

Medicare

Medicare Drug Price Negotiation Program

The new Medicare drug price negotiation program is the subject of several pending lawsuits, and it is uncertain whether the Trump administration will continue to defend the program. The Inflation Reduction Act of 2022, signed into law by President Biden in August 2022, includes a requirement for the Secretary of HHS to negotiate prices with drug companies for certain drugs covered under Medicare. The Centers for Medicare & Medicaid Services is due to announce the list of up to 15 Part D drugs to be selected for the second round of price negotiation by February 1, 2025, after concluding the first round of negotiation for 10 Part D drugs in August 2024.

Since June 2023, several lawsuits have been filed challenging the drug price negotiation program by manufacturers of selected drugs and entities representing the pharmaceutical industry. These lawsuits – nine of which remain, as of November 2024 – have raised several constitutional and statutory challenges against the program. To date, none of these lawsuits have been decided in favor of the pharmaceutical industry plaintiffs and HHS has prevailed on the substantive questions at hand, but most cases are either in the briefing stage or awaiting decisions before various U.S. appellate courts. In the event of conflicting rulings, an eventual hearing of one or more of these cases by the Supreme Court would likely be the outcome, but the timing of that is uncertain. If the plaintiffs were to prevail in one or more of these lawsuits, HHS could be blocked from continuing to implement some or all aspects of the program, which would negate savings to the Medicare program and people with Medicare associated with drug price negotiation. It is unknown to what extent HHS under the incoming Trump administration will continue to defend the Medicare drug price negotiation program in court, since the Trump campaign articulated no position on it.

Nursing Homes

Nursing Home Staffing

Several ongoing lawsuits are challenging new nursing home staff rules issued by the Biden administration, and it is unclear whether the Trump administration will defend the rule, support litigation opposing the rule, or issue new regulations. In response to longstanding staffing shortages in nursing facilities and quality concerns, the Centers for Medicare & Medicaid Services released a highly anticipated final rule in April 2024 that created new requirements for nurse staffing levels in nursing facilities. The final rule requires facilities to have a registered nursing on staff 24 hours per day, 7 per days per week and to meet minimum levels of nursing care per resident per day starting in 2026 for urban facilities and in 2027 for rural facilities. KFF estimates that only 19% of nursing facilities would currently meet the required number of staffing hours in the final rule if it took effect immediately.

Several lawsuits have been filed in opposition to the final rule, including lawsuits filed by nursing home industry groups, Texas’ attorney general, and a group of Republican state attorneys general. The legal challenges have overlapping claims including that the rule exceeds CMS’s statutory authority, the rule needs Congressional rather than agency action, and the rule is arbitrary and capricious, in violation of the Administrative Procedure Act. Opponents of the staffing rule have expressed concerns about the expected impact of the rule on costs for nursing homes and states. It is not clear whether the Trump administration will defend the nursing home staffing final rule in court, support the litigation in opposition to the rule, or issue new regulations to scale back the provisions in the staffing rule.