With President-elect Donald Trump announcing his intention to nominate Robert F. Kennedy, Jr. as Secretary of Health and Human Services (HHS), and several other nominations expected soon, including for the heads of the Food and Drug Administration (FDA) and Centers for Disease Control and Prevention (CDC), questions have been raised about what influence these appointed health officials have over U.S. vaccine policy. Kennedy, for example, has expressed doubts about the safety and effectiveness of many vaccines, falsely claimed that vaccines are linked to autism, and voiced opposition to vaccine requirements for children, among other policy positions. Does this mean he or other federal officials could change recommendations or remove vaccines from use? Could these officials impose a different set of vaccine requirements for school-age children? To help answer these questions, this policy brief highlights several areas in which HHS, FDA, and CDC have authority to shape U.S. vaccine policy with a specific focus on vaccine approvals and recommendations for the public. Ultimately, while there are limits, federal officials have significant authority to influence and alter vaccine policy, which could affect vaccine availability, views about vaccines, and vaccine use in the U.S. However, this does not include imposing mandates on or changing local vaccination requirements, as those authorities rest with state and local governments.

What Federal Agencies Approve and Recommend Vaccines?

The Department of Health and Human Services (HHS) is the core federal department responsible for improving the health and well-being of Americans. It is headed by a Secretary (a cabinet-level, Senate-confirmed position), and has 13 operating divisions including key federal agencies related to vaccines and vaccination policy in the U.S.:

• The Food and Drug Administration (FDA) oversees review of the safety and efficacy of candidate vaccines, and is authorized to determine whether or not to approve vaccines for use; only vaccines that have been FDA-approved can be legally administered in the U.S. (although FDA can also provide emergency use authorization for select vaccines under certain circumstances, as was done during the COVID-19 pandemic). FDA may also engage in post-market surveillance of approved vaccines to track their safety, effectiveness and/or possible side effects, and revisit approval decisions if new evidence is warranted. FDA is led by a Commissioner, a Senate-confirmed position, who reports to the Secretary of HHS; the office that oversees vaccine approvals at FDA is the Center for Biologics Evaluation and Research (CBER).
• The Centers for Disease Control and Prevention (CDC) is responsible for providing recommendations to the public about when and how to use approved (or authorized) vaccines. This includes issuing the U.S. adult and childhood immunization schedules, which gives guidance on the age(s) when vaccines should be given, the number of doses recommended, timing of doses, and other information. CDC also oversees the Vaccines for Children (VCP) program, which provides free vaccines to Medicaid eligible, uninsured and underinsured children. CDC is headed by a Director who, due to legislation passed by Congress in 2023, is a Senate-confirmed position as of January 2025). Recommendations related to vaccines are determined by the CDC Director, who reports to the Secretary of HHS.
• In addition to FDA and CDC, there are several other federal agencies and programs that play a role in vaccine development and use in the U.S., including: the National Institutes of Health which support basic vaccine research and clinical studies; the Health Resources and Services Administration, which oversees the National Vaccine Injury Compensation Program (VICP) and the Countermeasures Injury Compensation Program (CICP), each of which can compensate individuals determined to have been harmed by vaccinations; and the Center for the Biomedical Advanced Research and Development Authority (BARDA), which promotes development medical countermeasures, including vaccines, for use in public health emergencies.

Importantly, the HHS Secretary oversees these programs, placing them in a crucial position to influence many aspects of federal vaccine policy. For one, under the Public Health Service Act, the HHS Secretary is authorized to establish a National Vaccine Program, which develops a strategic vaccination plan for the nation and coordinates across multiple agencies. The Secretary also has some ability to shift funding, re-organize offices, and make staffing decisions, but only up to a point because major HHS offices and programs are mandated by law and funded through Congressional appropriations. Further, the HHS Secretary generally has the authority to overrule decisions and recommendations of the FDA Commissioner and CDC Director, though this has happened only rarely in the past.

What is the Relationship Between State and Federal Authority on Vaccination Policy?

Despite the important role played by the federal government in vaccine policy, neither HHS nor any other part of the federal government may impose or revoke vaccine requirements for children in school, or enforce other broad vaccine mandates at the national level, with the potential exception of during a declared health emergency (federal courts have been mixed in their decisions regarding the extent of federal authority in these circumstances). Under the U.S. Constitution’s 10^th Amendment’s “police powers” clause, states are granted primary responsibility for enacting and enforcing laws to promote the health, safety, and general welfare of people in their jurisdictions, which includes public health activities generally and (as upheld in multiple Supreme Court and circuit court decisions) vaccine mandates specifically. Therefore, federal guidance on vaccines and recommended vaccine schedules are guidance, not mandates. State and local decision-makers take this information and determine if a vaccine should be required and for what purpose, and whether individuals may opt out of requirements.

How Can HHS Influence Vaccine Approvals and Recommendations?

While the HHS Secretary, FDA Commissioner, and CDC Director cannot impose a national vaccine mandate (outside of a declared public health emergency, and only then under limited circumstances) or revoke existing state and local level vaccine requirements, here are some ways in which they can influence vaccine policy decisions by states, localities, pediatricians, parents, and individuals:

Influencing or Bypassing Federal Advisory Committee Recommendations

The FDA and CDC each have external expert advisory committees that provide important input into vaccine policy decisions. FDA commonly seeks input from the Vaccines and Related Biological Products Advisory Committee (VRBPAC) during vaccine reviews, and the FDA Commissioner uses VRBPAC recommendations when weighing approvals and other regulatory decisions about vaccines. CDC receives input from the Advisory Committee on Immunization Practices (ACIP), which reviews available evidence and makes recommendations to the CDC Director on individual vaccines and immunization schedules for children and adults. In addition, vaccines recommended by ACIP and adopted by CDC for children ages 18 and younger are automatically covered by the Vaccines for Children (VCP) program, and, per a provision of the Affordable Care Act, ACIP recommendations that have been adopted by the CDC must be covered at no cost by most health plans.

Given their roles in informing federal vaccine decisions, it is possible to exert policy influence through changes in the work of these committees. According to the committee charters and existing legal authorities, HHS leaders have the discretion to:

• Determine advisory committee memberships: Members of the VRBPAC are selected by the FDA Commissioner while members of ACIP are selected by the HHS Secretary. Sitting advisory committee members can be replaced at the discretion of the FDA Commissioner and HHS Secretary.
• Terminate or re-work committee charters. Both VRBPAC and ACIP charters require that these committees be terminated after two years, unless they are renewed, and agencies have discretion over whether to do so. Agencies can also re-write the charters that adjust the rules under which the committees function.
• Bypass advisory committee recommendations. The FDA does not have to request input from VRBPAC for vaccine approval decisions; in addition, where recommendations and input are provided, the final decision ultimately rests with the FDA. Similarly, the CDC director makes the decision on whether a vaccine should be recommended to the public and the content of those recommendations and does not have to follow recommendations issued by ACIP. There is precedent for the FDA and CDC breaking with advisory committee recommendations and issuing their own. Moreover, in all cases, the Secretary of HHS has ultimate authority over vaccine approvals and recommendations and can choose to overrule recommendations from the committees and even FDA and/or CDC leadership.

Adjusting Criteria for Vaccine Approvals and Reviews

The FDA Commissioner and CDC Director (and HHS Secretary), as part of their authorities related to vaccines, have discretion over aspects of the review process and can adjust criteria and timelines to aid or hinder vaccine licensing applications and criteria used for approvals and recommendations. For example:

• FDA evaluates the safety and effectiveness of vaccine candidates, as well as their benefits and risks, and whether the manufacturing and facility information assure product quality and consistency before deciding to recommend a vaccine for approval. As such, the agency has discretion over how it evaluates and weighs these criteria, including whether to put in place different or more or less stringent requirements. FDA could potentially speed up or slow down the pace of review, placing candidate vaccines that are high priorities for the Commissioner (and/or HHS Secretary) on a faster track and lower priority vaccines on a slower track. The FDA also help oversee safety surveillance for vaccines currently approved or authorized for use and can require manufacturers to submit post-market safety and effectiveness studies for vaccines. FDA could seek to remove a vaccine from the market if significant safety concerns were to be identified (or other issues such as concerns about manufacturing practices). However, there is a process for doing so and without new information and sufficient evidence of harms or other concerns there would likely be legal challenges to any attempt to remove an existing approved vaccine.
• In addition to reviewing FDA safety, efficacy, and effectiveness data, CDC and ACIP consider several other factors when assessing whether to recommend a vaccine to the public, including disease epidemiology and burden of disease, the quality of evidence reviewed, economic analyses, and implementation issues. The ACIP uses an evidence-based approach, called the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) and develops guidance for evaluating the evidence. This affords some discretion to ACIP committee members, and CDC, in weighing different factors for determining whether to recommend a vaccine, and the public health guidance provided on how best to use a vaccine.
• FDA and CDC also have some discretion over what data are made available about vaccine safety and efficacy. Currently, vaccine safety and efficacy data are made available at different stages of the vaccine review, approval, and recommendation process, as well as after vaccines are in use. Typically, FDA and vaccine manufacturers publicly make available briefing documents used to summarize what is known about vaccine safety and efficacy and to inform decisions for approval or authorization, as was done for COVID-19 vaccines, though some data is not released publicly. This kind of safety and efficacy data are also released by CDC as part of its process for making recommendations to the public, as has been done for influenza and many other vaccines. Further, the U.S. government maintains a database of clinical trial information and results, which relies on investigators and sponsors choosing to submit such information; some, but not all submissions, include study results. Finally, there are a number of government supported vaccine safety systems used to monitor vaccines after approval (or authorization): MedWatch, the Vaccine Adverse Event Reporting System (VAERS), V-safe, the Vaccine Safety Datalink (VSD) and the Clinical Immunization Safety Assessment (CISA) Project, each of which serves different purposes. VAERS, for example, is a “passive” surveillance system, dependent on people submitting their experiences after vaccination and submitted events cannot on their own determine if the event was related to a vaccine. VAERS Data are accessible to the public on the CDC website.

Communicating to the Public

Beyond its role in determining vaccine approvals and recommendations, the federal government plays a critical role in communicating to the public about vaccines, and these communications may influence public behavior. In recent years, particularly in the wake of the COVID-19 pandemic, there has been increased vaccine hesitancy among the public and reduced trust in federal health authorities including the CDC and FDA, and these views have often diverged along partisan lines. As a result, routine vaccination rates have fallen, including among kindergarten age children. Moreover, the number of states allowing for non-medical vaccine exemptions has risen. In some cases, reductions in vaccination coverage have been associated with outbreaks in parts of the country. Should federal officials choose to communicate doubt about vaccine safety and effectiveness, that is not supported by the data, or to not communicate about vaccines, it could provide momentum to state and local authorities seeking to loosen or eliminate school vaccine requirements, and could lead to a growing share of the public choosing not to get vaccinated or not to have their children vaccinated, which could have significant implications for individual and population health.

In October 2024, the Centers for Medicare and Medicaid Services (CMS) approved the first ever Section 1115 waiver demonstration amendments that would allow Medicaid and the Children’s Health Insurance Program (CHIP) coverage of traditional health care practices provided by the Indian Health Service (IHS), Tribal facilities, and urban Indian organizations for American Indian or Alaska Native (AIAN) people. This follows guidance from the Biden administration for federal agencies to include Indigenous knowledge in federal policy and a strategic plan from CMS to support work that would inform states on how to use section 1115 demonstrations to improve access to health care services for AIAN people. AIAN people face persistent disparities in health and health care, and the IHS has historically not met their health care needs. Traditional healing practices are an important component of AIAN culture, and research shows that increasing access to traditional health care practices may improve mental health and substance use disorder (SUD) outcomes among AIAN people utilizing these services.

As of November 2024, CMS has approved Section 1115 waiver amendments from four states: Arizona, California, New Mexico, and Oregon. This Waiver Watch reviews disparities in health and health care for AIAN people and summarizes the key features of the approved 1115 waivers. Section 1115 waivers generally reflect priorities identified by the states and CMS, as well as changing priorities from one presidential administration to another. It is uncertain whether new approvals or renewals of these waivers would be a priority during the next Trump administration.

What disparities in health and health care do AIAN people face?

AIAN people face persistent disparities and barriers to obtaining health care and fare worse than their White counterparts across a range of health measures. AIAN people fare worse on many social and economic measures that impact health, such as having higher poverty rates, lower educational attainment, and lower rates of English proficiency compared to White people. Nonelderly AIAN people are more likely to be uninsured and to report postponing or skipping health care due to cost than their White counterparts. AIAN people also have the shortest life expectancy across racial and ethnic groups, are more likely than White people to report fair or poor health, and have higher incidence and prevalence of obesity, diabetes, cancer, and infectious diseases. Additionally, AIAN people experience higher rates of pregnancy-related deaths, infant mortality, and other adverse birth outcomes compared to White people. AIAN people also face challenges with mental health, including high rates of suicide and drug overdose deaths. Despite these significant health challenges, AIAN groups are often excluded from data and analysis due to their smaller population sizes, limiting the understanding of their unique barriers to accessing health services and development of interventions to address them.

What is the role of the IHS for AIAN people?

The IHS is responsible for providing health care and prevention services for AIAN people but historically has been underfunded to meet their needs. Under treaties and laws, the U.S. has a unique responsibility to provide certain rights, protections, and services to AIAN people, including health care. The federal government provides health services through facilities that are managed directly by IHS, by Tribes or Tribal organizations under contract or compact with the IHS, and urban Indian health programs. AIAN people receiving services through IHS providers are not charged or billed for the cost of their services. Direct services provided through IHS and Tribally operated facilities generally are limited to members or descendants of members of federally recognized Tribes who live on or near federal reservations. Urban Indian health programs serve a wider group of AIAN people, including those who are not able to access IHS or Tribally operated facilities because they do not meet eligibility criteria or because they reside outside their service areas. While IHS is the primary vehicle the U.S. government uses to provide health care to AIAN people, it is not health insurance and inadequate funding levels, estimated to address less than half of AIAN health care needs, and uncertainty caused by the funding process continue to limit access and lead to gaps in care.

Why is health coverage important for AIAN people?

Given the limitations of the IHS, health coverage under Medicaid remains important for facilitating access to health care for AIAN people and protecting them from high medical costs. AIAN individuals may qualify for Medicaid in their state regardless of Tribal membership, whether they live on or off a reservation, and whether they receive services (or are eligible to receive services) at an IHS or Tribally-operated facility. Due to their lower incomes, Medicaid and CHIP are important sources of health coverage for AIAN people, covering about 23% of all nonelderly AIAN adults and about 44% of AIAN children. The ACA Medicaid expansion led to coverage gains among AIAN people, and nonelderly AIAN people have a higher uninsured rate in states that have not implemented the expansion (20%) compared to the rate in those that have (14%) (Appendix Figure 1).

Medicaid also provides an important source of financing for IHS and Tribal providers. Medicaid is the largest source of third-party payment for services billed by IHS and Tribal facilities, accounting for nearly two-thirds (67%) of total third-party revenues as of 2021. In contrast to IHS funds, Medicaid funds are not subject to annual appropriation limits and, since Medicaid claims are processed throughout the year, facilities receive Medicaid funding on an ongoing basis for covered services. Unlike other Medicaid costs which are shared by the federal government and states, the federal government covers 100% of costs for services provided to AIAN Medicaid enrollees through an IHS or Tribally operated facility, whether operated by the IHS or on its behalf by a Tribe. Urban Indian health programs do not currently receive this 100% federal Medicaid match. The American Rescue Plan authorized a 100% match for urban Indian health programs for a temporary period that expired in 2023, and there have been calls for and proposed legislation to permanently extend 100% funding to urban Indian health programs. CMS cannot change statutorily set federal Medicaid match rates for urban Indian programs through section 1115 waivers.

What are traditional health practices?

Traditional healing practices are an important part of AIAN culture, and research shows that access to traditional health care practices can improve mental health and SUD outcomes. Traditional health care practices in AIAN communities include talking circles, sweat lodges, smudging, music therapy, and ceremonies by traditional healers that are deeply rooted in cultural beliefs and may vary between different AIAN communities. These practices may address mental, emotional, and spiritual well-being. While research studying interventions among AIAN populations is limited, studies have demonstrated that traditional health care practices may improve mental health outcomes, including for depression and anxiety, SUD, and quality of life. Traditional health care has not been covered by Medicaid or other public or private insurance and historically has been funded and delivered by IHS and Tribal facilities, various pilot programs, and grant funding.

How are states using 1115 waivers to provide Medicaid coverage for traditional health practices?

In October 2024, CMS approved section 1115 demonstration amendments that allow for Medicaid and CHIP coverage of traditional health care practices for the first time in four states: Arizona, California, New Mexico, and Oregon. Nearly three in ten (27%) AIAN people resided in the approved states in 2022 (Figure 1). CMS traditionally applies public notice and comment period requirements at the state and federal levels before approving Section 1115 waiver amendments. Along with the public comment process, CMS consulted the CMS Tribal Technical Advisory Group and held an All Tribes Consultation Webinar for advice and input on these waivers. As these are amendments to existing waivers, expiration dates vary with the earliest expiring at the end of 2026 in California (Appendix Table 1). Given that Medicaid is a significant payer for IHS, Tribal, and urban Indian organization facility services, Medicaid coverage of traditional health care practices may improve access to culturally appropriate practices and otherwise support these facilities’ ability to serve their patients.

Traditional health care practices will be provided by IHS, Tribal, and urban Indian organization facilities, and coverage will be available to Medicaid enrollees eligible to receive services at these facilities. California will initially only cover services for AIAN enrollees with SUD in the Drug Medi-Cal Organized Delivery System but has the option to expand to all AIAN people in the future. Providers may be able to begin requesting reimbursement for traditional health services as early as January 2025 in California. Other key details include:

• Practice Definition. CMS encourages states to consult with Tribal organizations to determine how to define traditional health care practitioners and traditional health practices. Traditional health care practices must be provided by practitioners or providers who are employed by or contracted with one of these facilities with the necessary experience and training to provide traditional health services.
• Federal Match. Consistent with current law, practices will be reimbursed at 100% service match for services provided to AIAN individuals at IHS or Tribal facilities. Services delivered to Medicaid beneficiaries by urban Indian organization facilities will be federally matched at the otherwise applicable state service match.
• Implementation Expenditures. States may also receive federal match for expenditures related to provider development and implementation of traditional health care practices (e.g., for accounting and billing systems, electronic health records and modifications to internal systems to accept referrals from other providers, workforce development, and outreach and community engagement). New Mexico and Oregon have taken up the option to receive federal match for infrastructure spending related to implementing traditional health care practices.
• Attestation of Secular Alternatives. As some of the traditional health care practices covered under the demonstrations may contain elements of religious or spiritual practices, states cannot begin claiming traditional health care expenditures until they attest to providing adequate access to secular alternatives (e.g., preventative services, primary care, SUD services) and that beneficiaries have access to and the choice to use other Medicaid and CHIP services.

Appendix

Employer and union-sponsored retiree health plans play an important role in providing supplemental benefits to about a quarter (24%) of all people with Medicare or 14.5 million Medicare beneficiaries. However, the share of employers offering retiree health benefits has been shrinking. Among large employers that offer health benefits to active workers, the share offering retiree health benefits has dropped from 66% in 1988 to 24% in 2024, according to the latest KFF Employer Health Benefits Survey. And among large firms offering health benefits to active workers and retirees, 64 percent offer retiree health benefits to Medicare-age retirees in 2024. Among the declining share of large firms that offer retiree health benefits to Medicare-age retirees, Medicare Advantage has become more popular.

This analysis examines the extent to which large private and non-federal public employers that offer retiree health benefits are turning to Medicare Advantage, using data from the 2024 KFF Employer Health Benefits Survey (see methods).

Highlights:

• Slightly more than half (56%) of large employers offering retiree health benefits to Medicare-age retirees in 2024 offer coverage to at least some retirees through a Medicare Advantage plan, more than double the share in 2017 (26%).
• About half of large employers (53%) that offer Medicare Advantage coverage to their retirees in 2024 do not give retirees a choice in coverage options.
• Slightly more than half (56%) of large employers offering retiree benefits through a Medicare Advantage plan believe the shift to Medicare Advantage lowered the cost per retiree.
• Among large firms that offer retiree health benefits but do not offer benefits through a Medicare Advantage plan in 2024, 6% are very likely or somewhat likely to do so in the next two years.

Employer or union-sponsored retiree health benefits cover some or all of Medicare’s cost-sharing requirements and may provide supplemental benefits that are not covered by traditional Medicare. Until fairly recently, employer and union-sponsored retiree health benefits were typically designed to coordinate or wrap around traditional Medicare.

Concerns about retiree health benefit costs have led employers and unions to implement a variety of changes to limit their financial obligations, such as imposing caps on their retiree health liability, shifting toward defined contribution approaches, increasing retirees’ premium contribution, and more recently, by offering their Medicare-eligible retirees coverage through Medicare Advantage plans. Medicare Advantage plans, mainly HMOs and PPOs, provide all Medicare-covered benefits, typically include Part D drug coverage, and often include supplemental benefits such as lower cost sharing and vision, dental, and hearing benefits. Medicare Advantage enrollees continue to pay the Medicare Part B premium, but often pay no additional premium for covered benefits.

Unlike other Medicare Advantage plans, employer plans are not required to provide detailed information about their benefit design, including supplemental benefits. Therefore, it is not possible to assess how benefits and cost sharing compare for those enrolled in a group plan versus those enrolled in a plan that is generally available for individual purchase or a special needs plan. While group enrollment as a share of total Medicare Advantage enrollment has fluctuated between 17% to 20% since 2010, the actual number of group enrollees has increased from 1.8 million in 2010 to 5.7 million in 2024 as Medicare Advantage enrollment overall has grown.

Under this approach, employers and unions contract with a Medicare Advantage private insurer to provide all Medicare-covered benefits as well as any supplemental benefits for their Medicare-eligible retirees (and spouses). The employer (or union) and/or private insurer (acting on behalf of an employer) receives a payment from the federal government (Medicare) and agrees to cover all Medicare-covered benefits, along with a package of supplemental benefits for retirees in their group. Payments are based on the bids of other Medicare Advantage plans available to individual (non-group) enrollees, and set as a percentage of the area benchmark, adjusted for geography and risk. Employer plans are eligible to receive rebates and bonus payments from Medicare, both of which help cover the costs associated with supplemental benefits for their retirees and contribute to the growth in Medicare spending. Bonus payments for group Medicare Advantage plans accounted for $2.6 billion in spending in 2024.

Slightly more than half (56%) of all large firms (firms with 200 or more workers) that offer retiree health benefits to Medicare-age retirees do so through a Medicare Advantage plan in 2024, more than double the share in 2017 (26%) (Figure 1).

For retirees, the shift to Medicare Advantage can mean similar or better benefits and lower costs but can also mean more limited access to doctors and hospitals in the plan’s network and greater exposure to cost management tools, such as prior authorization, that may limit access to Medicare-covered services. These limitations are, in part, why public sector retirees in New York City sued to stop being moved to a Medicare Advantage plan in 2022 and may explain why a Manhattan Supreme Court Judge prohibited the implementation of this plan.

Among large firms (200 or more workers) offering retiree benefits through a contract with a Medicare Advantage plan, about half (53%) provide at least some retirees no choice but to receive their retiree health benefits through a Medicare Advantage plan in 2024 (Figure 2).

Retirees in firms that offer health benefits exclusively through Medicare Advantage plans have the option to enroll in traditional Medicare, but if they do, they may be required to give up retiree benefits in perpetuity. They may or may not be able to purchase a Medigap policy to supplement traditional Medicare, depending on their health condition, since most states do not have guaranteed issue protections for Medigap.

Among large firms (200 or more workers) offering retiree benefits through a contract with a Medicare Advantage plans, 56% believe that the shift to offering Medicare Advantage plans lowered their per retiree costs.

Further, 11% of large firms said the shift to Medicare Advantage plans did not lower their per retiree costs, while 33% did not know the answer.

More than half of all large employers offering Medicare Advantage to their retirees say the shift to Medicare Advantage plans lowered their per retiree costs, which may be a strategy to maintain benefits for their retirees, rather than terminate or scale back coverage. For example, in 2022, the state of Connecticut estimated the state would save $400 million over the following three years by switching retirees to a different Medicare Advantage administrator. Similarly, in 2023, New York City estimated that it would save $600 million annually by switching its city retirees to Medicare Advantage.

However, the rising number of Medicare-eligible retirees into Medicare Advantage plans has implications for Medicare spending because Medicare pays more for enrollees in Medicare Advantage plans (including for group plans) than it pays for similar people in traditional Medicare, which contributes to higher Medicare spending that ultimately affects the solvency of the Medicare Trust Fund and higher Medicare premiums paid by all beneficiaries, raising questions as to whether employers are limiting their liability for retiree health benefits at the expense of the Medicare program.

Among large firms (200 or more workers) offering retiree health benefits but do not offer benefits through a Medicare Advantage plan in 2024, 6% are very likely or somewhat likely to do so in the next two years.

In contrast, 73% of firms say they were somewhat unlikely or very unlikely to offer retiree benefits through a Medicare Advantage plan in the next two years, while 21% of firms said they do not know whether they are likely to do so.

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

• Tuberculosis, an infectious disease caused by bacteria, is the leading cause of death from a single infectious agent worldwide, despite being preventable and often curable. Since the World Health Organization declared tuberculosis (TB) to be a global health emergency in 1993, global efforts to address TB have become more prominent, and worldwide TB incidence and mortality rates have fallen. Still, in 2023, there were an estimated 10.8 million new cases of TB globally, including 662,000 new cases in people living with HIV, and an estimated 1.25 million people died from TB, including an estimated 161,000 people who were HIV-positive.
• In response to the persistent challenges related to TB, including drug-resistant TB, the U.N. General Assembly has held two high-level meetings on TB – in 2018 and 2023 – to discuss these challenges and examine progress toward global goals, including ending the epidemic by 2030.
• U.S. government (U.S.) involvement in global TB efforts was relatively limited until the late 1990s. Since that time, its efforts to address TB have grown, and now the U.S. is one of the largest donors to global TB control.
• U.S. TB activities reach approximately 50 countries (including at least 20 of the 30 high burden countries where most new cases are occurring), and focus on preventing, detecting, and treating TB, including drug-resistant TB, as well as research and development.
• U.S. funding for global TB efforts was $406 million in FY 2024, up from $242 million in FY 2015. Additionally, the U.S. is the largest donor to the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), which has approved over $11 billion in funding for TB programs worldwide.

Global Situation¹ 

Tuberculosis, an infectious disease caused by bacteria, is the leading cause of death from a single infectious agent worldwide, despite being preventable and often curable. Approximately a quarter of the world’s population has “latent” TB, meaning they have been infected by TB bacteria but are not yet ill with the disease and cannot transmit it (see box below); about 5-10% of people infected with TB will, at some point during their lifetime, develop symptoms of “active” TB, which can be spread to others. When a person with active TB coughs, sneezes, or spits, the bacteria spreads into the air where it may be inhaled by and infect others. TB is found all over the world, though the vast majority of TB cases are concentrated in a handful of countries in Southeast Asia, Africa, and the Western Pacific region. People in resource-poor settings, especially those living in poverty or in crowded living conditions with poor ventilation (e.g., prisons or mines), are disproportionately affected.

In the 1990s and early 2000s, concern about rising incidence in some areas, new outbreaks, TB/HIV co-infection, and the emergence of TB drug resistance prompted key global health actors and governments, including the U.S. government, to make preserving and advancing the progress of global efforts against TB a priority.²  In 1993, WHO declared TB to be a global health emergency. Since then, global efforts to address TB have become more prominent, and global TB incidence and mortality rates have fallen overall. Still, significant challenges remain, as TB returned to being the world’s leading cause of death from a single infectious agent in 2023 (following a 3-year hiatus during which COVID-19 displaced it). It is also the leading cause of death in people living with HIV and a major cause of death related to antimicrobial resistance (i.e., drug resistance). The second U.N. high-level meeting on TB, held in 2023, reviewed progress toward ending TB and set new targets for achievement by 2027 after targets set during the first U.N. high-level meeting, held in 2018, were not achieved.³ 

Morbidity and Mortality⁴ 

• In 2023, there were 10.8 million new cases (i.e., incident cases) of people who developed active TB disease. Although active TB is treatable and curable in most cases,⁵  an estimated 1.25 million people died from TB in 2023, including an estimated 161,000 people who were HIV-positive. Globally, between 2015 and 2023, TB incidence fell by 8.3% and TB-related deaths fell by 23%.⁶  While progress has been made, these reductions fall short of global targets (see Global Goals), and detecting TB cases — and then linking diagnosed cases to treatment — remains a significant challenge, one that had been made even more complicated in the context of COVID-19. The pandemic disrupted TB case detection and treatment services and resulted in an increase in the number of people with undiagnosed and untreated TB, as well as increased transmission and mortality.
• People who suffer from other conditions that impair the immune system (e.g., HIV) are at a higher risk of developing active TB, as are people who use tobacco. TB and HIV are frequently referred to as co-epidemics (or dual epidemics) due to their high rate of co-infection. TB is the leading cause of death among people living with HIV, especially in developing countries. In 2023, among the 10.8 million new active TB cases, about 6% were people who were also HIV-positive, and of the 1.25 million people who died from TB, about 13% were HIV-positive.
• Drug-resistant TB has emerged as a major challenge to global TB control efforts. Cases that fail to respond to standard first-line drugs are known as multidrug-resistant TB (MDR-TB), while those that fail to respond to both first- and second-line drugs are known as extensively drug-resistant TB (XDR-TB).⁷  In 2023, an estimated 400,000 people developed MDR-TB or resistance to rifampicin (RR-TB), the most effective first-line drug.⁸  MDR/RR-TB has been reported in most countries, with 30 countries identified as having a high burden of MDR/RR-TB specifically and five countries — India, Russia, Indonesia, China, and the Philippines — accounting for over half of the global number of people who developed MDR/RR-TB in 2023.

Interventions

The End TB Strategy, the internationally-recognized strategy for ending the TB epidemic, outlines interventions aimed at decreasing TB-related morbidity, death, and transmission. They include:

• early diagnosis of TB via sputum-smear microscopy,
• treatment (usually a six-month course of antibiotics for drug-sensitive TB) and patient support for all people with TB,
• scaled-up diagnosis and management of MDR- and XDR-TB,
• systematic screening for and management of TB among people living with HIV and others in high-risk groups,
• preventive treatment, including TB preventive treatment (TPT) and vaccination⁹  for high-risk groups, and
• research and development (R&D) of new tools (e.g., new TB diagnostics, drugs, and vaccines) and improved approaches.

Other interventions include the development of policies and systems that support TB activities, such as improved standardized data collection, quality assurance and rational use of drugs, and monitoring and evaluation of outcomes; sustained political and financial commitment to TB efforts; health systems strengthening; and increased health workforce capacity to respond to TB.

Global Goals

Since the 1993 declaration of TB as a global health emergency by WHO, major global TB goals have most recently been set through the following:

• Adopted in 2015, the Sustainable Development Goals (SDGs) aim to end the TB epidemic by 2030 under SDG Goal 3, which is to “ensure healthy lives and promote well-being for all at all ages.”
• Endorsed by governments at the 2014 World Health Assembly, the End TB Strategy set an overarching goal of ending the global TB epidemic as well as targets for achieving, by 2035, a 95% reduction in TB deaths and a 90% reduction in TB incidence (compared with 2015 levels).¹⁰  It builds on the earlier 2006 international Stop TB Strategy, in which WHO outlined the goal of eliminating TB as a public health problem by 2050.¹¹  The Global Plan to End TB outlines the steps and resources needed to achieve the End TB Strategy’s goals and is periodically updated by the Stop TB Partnership (an international network of public and private entities working to eliminate TB).
• In 2018, the U.N. General Assembly held its first-ever high-level meeting (HLM) on TB, where world leaders adopted a new Political Declaration that reaffirmed global TB commitments. The Political Declaration also articulated commitments on TB research and innovation, and a framework to help countries implement these commitments – the Global Strategy for Tuberculosis Research and Innovation – was adopted by governments at the 2020 World Health Assembly. The second U.N. HLM on TB took place in September 2023, reviewing progress since the first HLM and setting new targets for achievement by 2027.¹² 

U.S. Government Efforts

U.S. involvement in global TB efforts was relatively limited until the late 1990s. Since that time, its efforts to address TB have grown, and now the U.S. is one of the largest donors to global TB control.¹³ 

History and Goals¹⁴ 

In 1998, the U.S. Agency for International Development (USAID) began a global TB control program, and over the following decade, the U.S. assigned a heightened priority to and provided greater funding for bilateral and multilateral TB efforts.

The passage of the legislation that launched the President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003 placed a heightened priority on U.S. global TB efforts that continues to this day. The U.S. Leadership Against HIV/AIDS, Tuberculosis, and Malaria Act of 2003 (the legislation that created PEPFAR) included TB under its umbrella, authorizing five years of funding for bilateral TB efforts and the Global Fund to Fight AIDS, Tuberculosis and Malaria (an independent, international financing institution created in 2001 that provides grants to countries to address TB, HIV, and malaria). The Lantos-Hyde U.S. Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008, which reauthorized PEPFAR, set targets for U.S. bilateral TB efforts and authorized another five years of funding. Subsequent reauthorizations of PEPFAR – under the 2013 PEPFAR Stewardship Act, 2018 PEPFAR Extension Act, and 2024 short-term reauthorization of PEPFAR (“Extension of Certain Requirements of PEPFAR“) – did not specify authorization for funding for TB (however, Congress effectively authorizes funding when it appropriates funding for a purpose) (See the KFF fact sheet on PEPFAR, the KFF fact sheet on the Global Fund, and the KFF brief on PEPFAR reauthorization.)

In 2022, USAID released its eight-year Global Tuberculosis (TB) Strategy 2023-2030, which outlines current U.S. global TB goals.¹⁵  These goals include, by 2030, to contribute to:

• a 35% reduction in TB incidence relative to a 2019 baseline,
• a 52% reduction in TB mortality relative to a 2019 baseline,
• diagnosing and initiating treatment on 90% of incident (new cases of) TB and drug-resistant TB,
• maintaining treatment success rates of 90% for individuals with drug-sensitive TB and drug-resistant TB, and
• providing TB preventive treatment (TPT) to 30 million people.

These goals overlap with and reaffirm the U.S. commitment to the WHO End TB Strategy 2030 targets and SDG goal for TB.

The U.S. has also placed a heightened emphasis on addressing antimicrobial resistance.¹⁶  At the first U.N. TB HLM in 2018, the National Institutes of Health (NIH) released the Strategic Plan for Tuberculosis Research, which aims to accelerate its TB research including MDR-TB research; it was recently updated in 2024. In addition in 2020, the U.S. released its updated National Action Plan for Combating Antibiotic-Resistant Tuberculosis, which identifies interventions and articulates a strategy to respond to the domestic and global challenges of MDR-TB from 2020 through 2025.¹⁷ 

Organization

The U.S. Agency for International Development (USAID) serves as the lead implementing agency for U.S. global TB efforts, with other agencies also carrying out TB activities. Collectively, these efforts reach approximately 50 countries, including at least 20 of the 30 high burden countries (HBCs, which are designated by WHO as having high numbers of TB cases and collectively account for approximately 87% of new TB cases globally).¹⁸  All U.S. global TB efforts are coordinated under the international working group of the Federal Tuberculosis Task Force (a coalition of federal agencies involved in U.S. global and domestic TB efforts).

USAID TB Program

USAID’s bilateral TB program aims to support specific country needs¹⁹  in its 24 priority countries (which are mainly in sub-Saharan Africa, South Asia, and Southeast Asia) and to focus on key interventions, including:

• accelerated detection and treatment of TB for all patients,
• scaled up prevention and treatment of MDR-TB,
• expanded coverage of interventions for TB-HIV co-infection (in coordination with U.S. HIV efforts under PEPFAR; see below²⁰ ),
• improvements in the TB service delivery platforms and overall health system, and
• support for accelerated research and innovation.

The agency reported that in USAID TB priority countries, TB-related mortality decreased by 9% in 2023 compared to 2019, representing the second year in a row that mortality decreased below pre-pandemic levels.²¹ 

Other U.S. TB Efforts

The U.S. also supports TB activities through several other agencies, including:

• the Centers for Disease Control and Prevention (CDC), which provides technical support on epidemiology and surveillance, laboratory strengthening, and clinical and program operations, and also supports clinical and operational research;
• NIH, which, as the leading funder of TB research and development (R&D), supports basic, applied, and clinical R&D of new drugs, vaccines, and diagnostics;
• the State Department’s Bureau of Global Health Security and Diplomacy, which leads U.S. efforts to address TB-HIV co-infection through PEPFAR; and
• the Department of Defense (DoD), whose overseas laboratories help to monitor the quality of TB diagnostic services and conduct operational research.

Multilateral Efforts

The U.S. partners with international institutions and supports global TB funding mechanisms. Key partners include WHO and the Stop TB Partnership. Additionally, the U.S. government is the largest donor to the Global Fund, which has approved over $11 billion in funding for TB programs worldwide, and one of the largest donors to the Global Drug Facility (a mechanism of the Stop TB Partnership that provides grants to countries for TB drugs).²² 

Funding²³ 

U.S. funding for global TB has grown over the past decade, with much of the increase occurring in more recent years; U.S. funding for TB rose from $242 million in FY 2015 to $406 million in FY 2024 (see figure for the latest information).²⁴  Additional U.S. support for TB activities is provided through its contribution to the Global Fund. (See the KFF fact sheet on the U.S. Global Health Budget: Tuberculosis and the KFF budget tracker for more details on historical appropriations for global TB.)

Most U.S. bilateral funding for TB is provided through the Global Health Programs account at USAID with additional funding provided through the Economic Support Fund account, as well as funding through CDC.²⁵  It includes U.S. contributions to the Global Drug Facility.²⁶ 

1. WHO, “Tuberculosis,” fact sheet, Oct. 2024; WHO, Global TB Report 2024, 2024; USAID, Renewing Global Efforts to End TB: Tuberculosis Report to Congress, FY 2023, Jan. 2024. ↩︎
2. WHO, “Global Tuberculosis Programme,” World Health Assembly Resolution 44.8, 1991; WHO, WHO Report on the Global TB Epidemic 1998, 1998; WHO, “Tuberculosis,” fact sheet, August 2002; TB Alert, “TB Timeline,” webpage, http://www.tbalert.org/about-tb/tb-in-time/tb-timeline/. ↩︎
3. Global targets set at the first U.N. high-level meeting (HLM) on TB, for achievement between 2018-2022, include treatment and preventative treatment targets, as well as annual funding targets for TB research and universal access to TB services. The world fell short on all but one (preventative treatment for people living with HIV) of these targets. The new targets set at the second HLM include coverage targets for treatment, preventative treatment, rapid diagnostic testing, and health and social benefits; the rollout of safe and effective TB vaccines; and annual funding targets for TB research and universal access to TB services, all to be achieved between 2023-2027. ↩︎
4. WHO, Global Tuberculosis Report 2024, 2024; WHO, “Tuberculosis,” fact sheet, Oct. 2024. ↩︎
5. Treatment in most cases is usually a six-month course of antibiotics. ↩︎
6. Globally, between 2010 and 2020, TB incidence fell by approximately 2% per year but then increased by 4.6% between 2020 and 2023 due to impacts of the COVID-19 pandemic. Increases in incidence may be due to increases in the number of people having undiagnosed and untreated TB (due to COVID-related service disruptions) and the subsequent development of disease among those newly infected. ↩︎
7. Treatment options for these forms of TB are very limited. ↩︎
8. That is, people with MDR-TB have a combined resistance to rifampicin and isoniazid (another key first-line TB drug). ↩︎
9. No effective vaccine currently exists to prevent transmission of TB. The BCG (Bacillus Calmette-Guérin) vaccine is partially effective in preventing some serious TB complications in children and is recommended by WHO as a component of routine childhood immunization in countries with a high TB burden. ↩︎
10. This means the incidence rate will be an average of less than 10 TB cases per 100,000 population. WHO: “Post-2015 Global TB Strategy and targets,” fact sheet, Dec. 2014; “Implementing the End TB Strategy: The Essentials, 2022” Dec. 2022, https://www.who.int/publications/i/item/9789240065093 ↩︎
11. This means that “the global incidence of TB disease will be less than 1 case per million population per year.” ↩︎
12. Global targets set at the first U.N. high-level meeting (HLM) on TB, for achievement between 2018-2022, include treatment and preventative treatment targets, as well as annual funding targets for TB research and universal access to TB services. The world fell short on all but one (preventative treatment for people living with HIV) of these targets. The new targets set at the second HLM include coverage targets for treatment, preventative treatment, rapid diagnostic testing, and health and social benefits; the rollout of safe and effective TB vaccines; and annual funding targets for TB research and universal access to TB services, all to be achieved between 2023-2027. ↩︎
13. KFF analysis of OECD DAC CRS database, October 2024. ↩︎
14. USAID: USAID, Expanded Response to TB, Sept. 2004 and updated Jan. 2009; USAID, Fast Facts: Tuberculosis, Oct. 2010. ↩︎
15. This succeeds the prior five-year USG Global TB Strategy 2015-2022 and five-year Lantos-Hyde USG TB Strategy (March 2010). ↩︎
16. In 2014, the White House announced the National Strategy for Combating Antibiotic-Resistant Bacteria (CARB) and issued an executive order directing the U.S. government to “work domestically and internationally to reduce the emergence and spread of antibiotic-resistant bacteria.” USAID, “Antimicrobial Resistance and the Threat of Multidrug-Resistant TB,” webpage, https://2012-2017.usaid.gov/what-we-do/global-health/tuberculosis/antimicrobial-resistance-and-threat-multidrug-resistant-tb; White House, Executive Order – Combating Antibiotic-Resistant Bacteria, 2014. See also: USG, National Strategy for Combating Antibiotic-Resistant Bacteria, 2014, https://www.cdc.gov/drugresistance/pdf/carb_national_strategy.pdf; White House, “Fact sheet: Obama Administration Releases National Action Plan to Combat Antibiotic-Resistant Bacteria, 2015, https://obamawhitehouse.archives.gov/the-press-office/2015/03/27/fact-sheet-obama-administration-releases-national-action-plan-combat-ant. ↩︎
17. The National Action Plan for Combating Multidrug-Resistant Tuberculosis was first released in 2015 and then updated in 2020 to reflect its 2020-2025 strategy. ↩︎
18. USAID and CDC’s TB efforts together reach approximately 50 countries, including those reached through regional efforts as well as PEPFAR-supported TB/HIV efforts. USAID, USAID’s Global Tuberculosis (TB) Strategy 2023–2030, 2022; USAID, Tuberculosis Report to Congress FY 2023, January 2024; USAID, “Tuberculosis: Countries,” webpage, accessed October 2024, https://www.usaid.gov/global-health/health-areas/tuberculosis/countries; CDC, “Global HIV & TB: Where We Work,” webpage, updated June 10, 2024, https://www.cdc.gov/global-hiv-tb/php/where-we-work/index.html; WHO, Global Tuberculosis Report 2024, 2024; WHO, “Tuberculosis,” fact sheet, Oct. 2024. ↩︎
19. As outlined in a partner country’s national TB strategic plan, per the current and prior USG global TB strategies. ↩︎
20. In 2023, as part of the U.S. commitment toward achieving the U.N. High Level Meeting 2027 target to detect and treat TB among 90% of those who develop TB, PEPFAR launched an effort to detect 2 million active TB cases over the next five years and prevent at least 500,000 TB-related deaths among people living with HIV. PEPFAR, Press release: PEPFAR Launches New Effort to Fight TB: Goal to Detect Two Million Cases and Prevent 500,000 Deaths, September 2023. ↩︎
21. At the same time, TB incidence increased by 8 percent in 2023 compared to 2019 (though the rate of this increase has been slowing); USAID reports this increase is indicative of the residual impact of continuing to identify people with TB who were missed during the pandemic. ↩︎
22. Global Fund: “Data Explorer,” accessed October 2024,https://data.theglobalfund.org/ ↩︎
23. 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, ForeignAssistance.gov. ↩︎
24. FY24 is based on funding provided in the “Further Consolidated Appropriations Act, 2024” (P.L. 118-47) and is a preliminary estimate. ↩︎
25. Represents specified funding for international TB programs in the President’s budget request, ForeignAssistance.gov, and Congressional appropriations bills. Additional support for international TB programs is provided through bilateral HIV programs at the State Department to address TB/HIV co-infection, for technical support and research activities through the CDC, and for research activities at the NIH. Prior to FY20, global TB funding at CDC was provided through the “HIV/AIDS, Viral Hepatitis, STI and TB Prevention” funding line; in the FY20 Request, the administration proposed to create a new “Global Tuberculosis” funding line under global health programs at CDC and to transfer $7.2 million from the “HIV/AIDS, Viral Hepatitis, STI and TB Prevention” funding line to “Global Tuberculosis” for both FY18 and FY19. The FY20 appropriations bill formalized this transfer. Funding amounts provided through this transfer are not currently available for the years prior to FY18. ↩︎
26. Funding for the Global Drug Facility is provided through the Global Health Programs (GHP) account at USAID. ↩︎

Note: This analysis was updated on November 25th to reflect the October version of the 2025 CMS Landscape file.Over the last decade, Medicare Advantage, the private plan alternative to traditional Medicare, has taken on a prominent role in the Medicare program. In 2024, nearly 33 million Medicare beneficiaries are enrolled in a Medicare Advantage plan, more than half, or 54%, of the eligible Medicare population.

Despite concerns that modifications to the payment formula and higher utilization would impact the number of Medicare Advantage plans offered in 2025, the Medicare Advantage market appears to be relatively stable. While Medicare Advantage insurers have made some adjustments in their offerings, the average Medicare beneficiary has a choice of more than 30 Medicare Advantage prescription drug (MA-PD) plans, and virtually all plans provide multiple extra benefits like vision, hearing and dental benefits, similar to last year.

This brief provides an overview of the Medicare Advantage plans that are available for 2025 and key trends over time. This analysis uses data from the CMS Landscape files. In general, this brief refers to individual Medicare plans available for general enrollment, excludes Special Needs Plans (SNPs), except where noted, and excludes employer plans. (See methods for more details.) A second, companion analysis, describes premiums and benefits that are available for 2025 Medicare Advantage plans and over time.

Medicare Advantage Highlights for 2025

• The average Medicare beneficiary will have the option of 34 Medicare Advantage prescription drug (MA-PD) plans in 2025, 2 fewer than the 36 options available in 2024. Across all plans for individual enrollment, including those with and without prescription drug coverage, the average beneficiary has 42 options in 2025, compared to 43 options in both 2023 and 2024.
• The number of plans available to the average beneficiary varies across states. In 27 states and Puerto Rico, the average beneficiary has a choice of fewer plans in 2025 than in 2024, while in 16 states and DC, the average beneficiary has a choice of more plans, and in six states the number of plans available, on average, stayed the same.
• Nearly one-third of Medicare beneficiaries (32%) live in a county with more than 50 Medicare Advantage plans available in 2025, up from 7 percent in 2020, and similar to 2024 (33%). Less than 0.5 percent live in a county with no plans available.
• The average Medicare beneficiary can choose among plans offered by 8 firms in 2025, the same as in 2024. Three new insurers entered the Medicare Advantage market in 2025, while eight firms exited the market in 2025.
• Major insurers are both expanding into new counties and exiting others. For example, Humana is entering 12 new counties and exiting 70 counties, while UnitedHealthcare is entering 42 new counties and exiting 38 counties. Both insurers are offering plans in nearly 90% of all U.S. counties.
• About 5% of current Medicare Advantage enrollees in individual MA-PDs (or about 1.4 million people) are in a plan that has been terminated for 2025, while up to 7% of enrollees in MA-PDs (or as many as 1.8 million people) may be affected by a consolidation, meaning they are in a plan where some portion of the 2024 enrollment will be automatically assigned to a different plan in 2025.
• More than half (58%) of Medicare beneficiaries live in a county (1,188) where at least one firm is offering 10 or more plans for individual enrollment.

Plan Offerings in 2025

Number of Plans

Number of Plans Available to Beneficiaries. For 2025, the average Medicare beneficiary will have access to 34 Medicare Advantage prescription drug (MA-PD) plans, just 2 fewer than the 36 in 2024 (Figure 1). Across all plans for individual enrollment, including those with and without prescription drug coverage, the average beneficiary has 42 options in 2025, compared to 43 options in both 2023 and 2024. Since 2018, the number of plans available to the average beneficiary has doubled. These numbers exclude employer- or union-sponsored group plans, Special Needs Plans (SNPs), PACE plans, cost plans, and Medicare-Medicaid plans (MMPs) that are only available to select populations.

Total Number of Plans. In total, 3,719 Medicare Advantage plans are available nationwide for individual enrollment in 2025 – a 6% decrease from the number of plans (240 fewer plans) offered in 2024 (Appendix Figure 1).

HMOs account for more than half (56%) of all Medicare Advantage plans offered in 2025 but have declined as a share of all Medicare Advantage plans since 2017 (71% of plans), while during this period local PPOs rose as a share of all plans (Appendix Figure 1). During this period, the share of plans that are local PPOs increased from 24% to 43%. The share of plans that are regional PPOs has slowly declined from around 3% of plans offered in 2017 to 1% in 2025.

While many employers and unions also offer Medicare Advantage plans to their retirees, no information about these 2025 plan offerings is made available by CMS to the public during the Medicare open enrollment period. Employer and union plans are administered separately and may have enrollment periods that do not align with the Medicare open enrollment period.

Special Needs Plans (SNPs). In 2025, 1,445 SNPs will be offered nationwide, an 8 percent increase between 2024 and 2025 (Figure 2).

D-SNPs. Nearly two-thirds of SNPs (63%) are designed for people dually eligible for Medicare and Medicaid (D-SNPs). The number of D-SNPs has increased substantially since 2018, increasing from 401 D-SNPs in 2018 to 909 D-SNPs in 2025 (up from 851 D-SNPs in 2024), suggesting insurers continue to be drawn to this high-need population. In 2024, 5.9 million Medicare beneficiaries are enrolled in D-SNPs.

I-SNPs. The number of SNPs for people who require an institutional-level of care (I-SNPs) nearly doubled from 97 plans in 2018 to 189 plans in 2023, before dropping modestly to 173 plans for 2024 and 160 in 2025. In 2024, about 115,000 Medicare beneficiaries are enrolled in I-SNPs.

C-SNPs. The number of SNPs offered for people with chronic conditions (C-SNPs) has nearly tripled since 2018, from 132 plans that year to 376 plans in 2025 (an increase of 67 plans since 2024). Most C-SNPs focus on people with diabetes, heart disease, or lung conditions, as has been the case since the inception of C-SNPs. For 2025, one firm is offering a C-SNP for people with dementia (different than the one firm offering one in 2024). Two firms are offering C-SNPs for people with mental health conditions (compared to no firms in 2024), and one firm is offering a C-SNP for people with HIV/AIDS, the same one as in 2024. Ten firms are offering C-SNPs for people with end-stage renal disease (up two from 2024). In 2024, 675,000 Medicare beneficiaries are enrolled in C-SNPs.

Variation in Medicare Advantage Plans, by State and County. The number of plans available to the average beneficiary varies across states (Figure 3; Appendix Table 1). In 27 states and Puerto Rico, the average beneficiary has a choice of fewer plans in 2025 than in 2024. In 16 states and DC, the average beneficiary has access to more plans in 2025 than in 2024. In the remaining six states, the number of plans available to the average beneficiary stayed the same. This includes Alaska, which had no plans available in 2025, as in 2024. Connecticut is not included in this calculation – see methods for more details.

Nearly 2.2 million beneficiaries in 26 counties can choose from 75 or more Medicare Advantage plans in 2025 (down slightly from 29 counties in 2024). In the same 26 counties, beneficiaries can choose from 63 to 73 Medicare Advantage plans with Part D coverage. Similar to the last three years, the counties with the most plan options are predominantly in Pennsylvania and Ohio. In Pennsylvania, for example, beneficiaries can choose from 80 or more Medicare Advantage plans in 10 counties, including Dauphin County (Harrisburg). Beneficiaries in Cumberland, Pennsylvania can choose from 87 Medicare Advantage plans – the most offerings of any county in the U.S. In Ohio, beneficiaries can choose from 80 or more Medicare Advantage plans in 4 counties, including Summit County (Akron) and Cuyahoga County (Cleveland). In Michigan, beneficiaries in Oakland County (Detroit metro area) can choose from 75 plans (Figure 4).

In 2025, nearly one-third (32%) of Medicare beneficiaries (in 9 percent of counties) can choose from more than 50 Medicare Advantage plans (Figure 5).

Nearly one-third of Medicare beneficiaries (32%) have a choice of at least 50 Medicare Advantage plans in 2025, roughly the same as 2024 (33%). In 2025, less than 0.5 percent of beneficiaries live in a county with one to four Medicare Advantage plans available, while less than 0.5 percent of beneficiaries live in a county without any plans available. Similar to 2024, there are no Medicare Advantage plans for individual enrollment being offered in any county in Alaska in 2025, which includes about 99,000 beneficiaries. In 81 counties, about 250,000 Medicare beneficiaries (including those in Alaska) will not have access to a Medicare Advantage plan (an increase from 58 counties and about 196,000 Medicare beneficiaries in 2024). Additionally, no Medicare Advantage plans are available in territories other than Puerto Rico.

Variation in Medicare Advantage Plans by Geographic Status. Medicare beneficiaries living in metropolitan areas – counties with at least 50,000 people – can choose from 45 Medicare Advantage plans in 2025 on average (down from 47 in 2024), including 37 with Part D coverage, substantially more than beneficiaries living in rural or micropolitan areas. Beneficiaries in micropolitan areas (10,000 to 50,000 people) can choose from an average of 31 plans (1 fewer plan than in 2024), including 24 with Part D coverage.

Beneficiaries in rural areas – counties with less than 10,000 people – can choose from an average of 27 plans (the same as in 2024), including 21 with Part D coverage. Since 2020, when 14 plans were available on average to beneficiaries living in rural areas, the availability of plans in rural areas has nearly doubled.

As in recent years, virtually all Medicare beneficiaries (99.6%) have access to a Medicare Advantage plan as an alternative to traditional Medicare, including almost all beneficiaries in metropolitan areas (99.9%), micropolitan (99.0%) and rural (97.8%) areas.

Medicare Advantage Plan Availability by Firm

The average Medicare beneficiary is able to choose from plans offered by 8 firms in 2025, the same as in 2024 (Figure 6). Despite most beneficiaries having access to plans operated by several different firms, enrollment is concentrated in plans operated by UnitedHealthcare and Humana, and together UnitedHealthcare and Humana account for nearly half (47%) of Medicare Advantage enrollment in 2024.

In 2025, nearly one-third of beneficiaries (31%), in 169 counties, are able to choose from plans offered by 10 or more firms or other sponsors (a decline from 33% in 2024). In contrast, nearly 5 percent of beneficiaries live in a county where one to three firms offer Medicare Advantage plans (501 counties).

Further, in 126 counties, only one firm will offer Medicare Advantage plans in 2025. These are mostly rural counties with relatively few Medicare beneficiaries (less than 1 percent of total). In some of these counties, there were no firms offering Medicare Advantage in 2024, e.g., 5 counties in Idaho (Benewah, Clearwater, Custer, Lemhi, and Lewis). In contrast, Medicare beneficiaries in some counties had access to plans offered by two or three firms in 2024 but only one firm in 2025, such as people living in Coos County, Oregon.

Availability of Plans by Firm and County. UnitedHealthcare and Humana, the two firms with the most Medicare Advantage enrollees in 2024, have large footprints across the country, offering plans in most counties, similar to 2024 (Figure 7).

Some major insurers are expanding into new counties, while leaving others (Figure 8).

Humana is offering plans in more counties than any other large Medicare Advantage insurer – 2,848 counties in 2025 – though that represents a decrease of 58 counties from 2024. Humana is exiting 70 counties, while entering 12 new counties. UnitedHealthcare is offering plans in 2,808 counties in 2025, an increase of 4 counties from 2024. UnitedHealthcare entered more counties (42 new counties) than it exited (38 counties).

Blue Cross Blue Shield Affiliates are offering plans in 2,639 counties in 2025, an increase of 35 counties from 2024. Blue Cross Blue Shield Affiliates are exiting 44 counties, but are entering 79 new counties. CVS is offering plans in 2,249 counties, an increase of 22 counties. CVS exited 65 counties, but is entering 87 new counties.

Insurer decisions to exit some counties while entering new ones may suggest that local market factors impact insurer evaluations about their potential to attract enrollees and earn a profit.

Multiple Plan Offerings by Firms in the Same County. Many Medicare Advantage firms are also offering more than one plan option in each county.

More than half (58%) of Medicare beneficiaries live in a county (1,188) where at least one firm is offering 10 or more plans for individual enrollment. For example, in Cumberland County, Pennsylvania (the county with the most plan offerings – 87), four firms are offering 10 or more plans (Humana, Blue Cross Blue Shield Affiliates, UPMC Health Plan, and CVS Health). In 125 counties, two firms are offering 10 or more plans, and in 50 counties, three firms are offering 10 or more plans.

In 2025, Humana is increasing the number of plan options available in 631 counties, while decreasing the number of plan options in 1,192 counties. UnitedHealthcare is increasing the number of plans in 381 counties but decreasing plan offerings in 693 counties. Blue Cross Blue Shield Affiliates are increasing the number of plans options in 698 counties, while decreasing plan options in 630 counties. CVS Health is increasing the number of plan options in 667 counties, while decreasing them in 775 counties. This also suggests that insurers evaluate local markets when making decisions about the number of plans to offer and different county characteristics may make the market more or less attractive in a given year to a particular insurer.

Plan Renewals and Terminations

In 2025, 5% of Medicare Advantage enrollees in MA-PDs or about 1.4 million people, are in a plan that has been terminated for the coming year and will not be automatically assigned to another plan. (This number includes people enrolled in SNPs but excludes people in MA-only plans or people with employer coverage). People in this group will be able to enroll in another Medicare Advantage plan if one is available or choose traditional Medicare. If they choose traditional Medicare, they will qualify for a special enrollment period for Medigap with guaranteed issue rights, meaning they can switch to traditional Medicare and will not be denied a Medigap policy due to a pre-existing condition.

Another 7% of Medicare Advantage enrollees in MA-PDs or about 1.8 million people, are in plans that have been affected by a consolidation. In this situation, some portion of this 1.8 million people will be moved into another plan under the same insurer automatically if the contract includes another plan of the same type (i.e., HMO or PPO) in the same county. (Some enrollees in consolidated renewal plans will not see changes in their plan because they were already in the plan that other enrollees are now being assigned to.) They may still enroll in another Medicare Advantage plan if one is available or choose traditional Medicare. However, they do not qualify for a special enrollment period under federal law for Medigap.

New Market Entrants and Exits

In 2025, three firms (Healthy Mississippi, SECUR Health Plan and UCLA Health Medicare Advantage plan) entered the market for the first time, while eight firms exited the market (Appendix Table 2). Healthy Mississippi has one new HMO plan available for general enrollment in Mississippi, while UCLA Health is offering two HMO plans available for general enrollment in California. SECUR Health Plan is offering two I-SNPs in Florida.

In the last few years, some firms have introduced plans that are either co-branded or are in partnership with another company. For example, in 2025, Alignment Health is offering three plans co-branded with Instacart in 7 counties in California and Nevada. These plans will offer groceries to qualifying beneficiaries with chronic conditions. Alignment Health also partners with Walgreens and Rite Aid. Other companies with a partnership that are offering plans in 2025 include Select Health and Kroger and Humana and USAA though this is not an exhaustive list.

Eight firms that participated in the Medicare Advantage market in 2024 are not offering plans in 2025. Six of the firms had low enrollment in 2024 (around 10,000 or fewer enrollees per firm). Two of the firms had contracts taken over by other insurers.

Appendix

Note: This analysis was updated on November 25th to reflect the October version of the 2025 CMS Landscape file.

Medicare Advantage plans, which enrolled nearly 33 million Medicare beneficiaries or 54% of the eligible Medicare population in 2024, because they typically offer extra benefits, such as dental, vision and hearing, often for no additional premium, as well as lower cost sharing compared to traditional Medicare without supplemental insurance, with the trade-off of more restrictive provider networks and greater use of cost management tools, such as prior authorization.

This brief provides an overview of premiums and benefits in Medicare Advantage plans that are available for 2025 and key trends over time. This brief uses data from the CMS Landscape and Benefit files. See methods for more details. In general, this brief refers to Medicare plans available for general enrollment, excludes Special Needs Plans (SNPs), except where noted, and excludes employer plans. A companion analysis describes trends in plan offerings.

Medicare Advantage Highlights for 2025

• Two-thirds of all Medicare Advantage plans with Part D prescription drug coverage (MA-PDs) (67%) will charge no premium (other than the Part B premium) in 2025, similar to 2024 (66%).
• Nearly one-third (32%) of Medicare Advantage plans will offer some reduction in the Medicare Part B premium in 2025, an increase compared to 2024 (19%).
• Nearly all Medicare Advantage plans (97% or more) are offering vision, dental and hearing, as they have in previous years. However, the share of plans offering certain benefits has declined, such as over-the-counter benefits (85% in 2024 vs. 73% in 2025), remote access technologies (74% in 2024 vs. 53% in 2025), meal benefits (72% in 2024 vs. 65% in 2025) and transportation (36% in 2024 vs. 30% in 2025).
• The share of Special Needs Plans (SNPs) offering transportation, remote access technologies and in-home support services declined slightly in 2025, while the share offering bathroom safety devices and the Part B rebate increased.
• A larger share of SNPs than other Medicare Advantage plans are offering Special Supplemental Benefits for the Chronically Ill, which are extra benefits available to a subset of a plan’s enrollees, particularly food and produce (84% in SNPs; 15% in individual plans) and general supports for living, such as housing and utilities (67% in SNPs; 11% in individual plans).

Premiums

The vast majority of Medicare Advantage plans for individual enrollment (88%) will include prescription drug coverage (MA-PDs), similar to 2024 (89%), and the share of MA-PDs that charge no premium (other than the Part B premium of $185 per month) is 67% in 2025, similar to 2024 (66%). Nearly all beneficiaries (99%) have access to a MA-PD with no additional monthly premium in 2025, the same as in 2024 (99%).

In 2024, 75% of enrollees in MA-PD plans pay no premium other than the Medicare Part B premium. Based on enrollment in March 2024, 10% of enrollees pay at least $50 a month, including 3% who pay $100 or more. CMS estimates that the average monthly plan premium among all Medicare Advantage enrollees in 2025, including those who pay no premium for their Medicare Advantage plan, will be $17.00 a month. In 2024, 12 percent of Medicare Advantage enrollees are in a plan that offered some reduction in Medicare Part B premiums.

In 2025, 32% of Medicare Advantage plans will offer some reduction in the Part B premium, higher than the share in 2024 (19%) (Figure 1).

Among plans that are offering a monthly reduction in the Part B premium ($185 per month in 2025), 28% are offering a monthly reduction of $100 or more, 25% are offering a reduction of $50.01 to $100, 17% are offering a reduction of $10.01 to $50, and 30% are offering a monthly reduction of $10 or less.

In previous years, a smaller share of Medicare Advantage enrollees has typically ended up in plans that reduced the Part B premium. For example, for the 2024 plan year, 19% of plans offered a reduction in the Part B premium, but ultimately only 12% of Medicare Advantage enrollees were enrolled in plans with this benefit.

While many employers and unions also offer Medicare Advantage plans to their retirees, no information about these 2025 plan offerings is made available by CMS to the public during the Medicare open enrollment period. Employer and union plans are administered separately and may have enrollment periods that do not align with the Medicare open enrollment period.

Extra Benefits

Medicare Advantage plans may provide extra benefits that are not available in traditional Medicare, are considered “primarily health related,” and can use rebate dollars (including bonus payments) to help cover the cost of these extra benefits. Beginning in 2019, CMS expanded the definition of “primarily health related” to allow Medicare Advantage plans to offer additional supplemental benefits. Medicare Advantage plans may also restrict the availability of these extra benefits to certain subgroups of beneficiaries, such as those with diabetes or congestive heart failure, making different benefits available to different enrollees.

Availability of Extra Benefits in Individual Plans for General Enrollment. In 2025, 97% or more individual plans offer some vision, dental or hearing benefits, similar to 2024 (Figure 2). Though these benefits are widely available, the scope of coverage for these services varies. For example, a dental benefit may include cleanings and preventive care or more comprehensive coverage, and often is subject to an annual dollar cap on the amount covered by the plan. From year to year, plans may change the parameters of this coverage, such as increasing or decreasing annual maximums the plan will pay toward the benefit or adjusting cost sharing for services. There is not yet data available about utilization of these benefits or associated costs, so it is not clear the extent to which supplemental benefits are used by enrollees.

As of 2020, Medicare Advantage plans have been allowed to include telehealth benefits as part of the basic benefit package – beyond what was allowed under traditional Medicare prior to the COVID-19 public health emergency, which was extended to December 2024. Therefore, these benefits are not included in the figure above because their cost is not covered by either rebates or supplemental premiums. Medicare Advantage plans may also offer supplemental telehealth benefits via remote access technologies and/or telemonitoring services, which can be used for those services that do not meet the requirements for coverage under traditional Medicare or the requirements for the telehealth benefits as part of the basic benefit package (such as the requirement of being covered by Medicare Part B when provided in-person). In 2025, 53% of plans are offering remote access technologies, a decline from 74% in 2024. A similar share of plans are offering telemonitoring services (2% in 2025 vs 3% in 2024).

Some benefits are being offered by a smaller share of plans in 2025 than in 2024. For example, 73% of plans are offering an allowance for over-the-counter items (vs. 85% in 2024), while 65% are offering meal benefits (vs. 72% in 2024), and 30% are offering transportation benefits for medical needs (vs. 36% in 2024). A similar share of plans is offering acupuncture (32% in 2025 vs. 34% in 2024), bathroom safety devices (24% in 2025 vs 22% in 2024), and support for caregivers of enrollees (5% in 2025 and 2024). A smaller share of plans are offering in-home support services (6% in 2025 vs 9% in 2024). This is not an exhaustive list of extra benefits that plans offer, and plans may provide other services such as home-based palliative care, therapeutic massage, and adult day health services, among others.

Access to Medicare Advantage Plans with Extra Benefits. Virtually all Medicare beneficiaries live in a county where at least one Medicare Advantage plan available for general enrollment (excluding SNPs) has some extra benefits not covered by traditional Medicare, with over 99% having access to at least one or more plans with dental, fitness, vision, and hearing benefits for 2025, the same as in 2024. The vast majority of beneficiaries also have access to one or more plans that offer an allowance for over-the-counter items (over 99%), a meal benefit (over 99%), remote access technologies (99%), acupuncture (98%), bathroom safety devices (96%), transportation assistance (94%) but fewer have access to one or more plans that offer in-home support services (60%), caregiver support (41%), or telemonitoring services (16%).  (Connecticut is not included in these estimates – see methods for more details.)

Availability of Extra Benefits in Special Needs Plans. SNPs are designed to serve a disproportionately high-need population, and a somewhat larger percentage of SNPs than plans for other Medicare beneficiaries provide their enrollees over-the-counter benefits (92%; similar to 2024 – 94%), transportation benefits for medical needs (81%; a decline from 88% in 2024), meals (73%, similar to 2024 – 75%), bathroom safety devices (54%; up from 34% in 2024), and in-home support services (17%; down from 25% in 2024) (Figure 3). Compared to individual plans, a smaller share of SNPs offer fitness benefits (83%, similar to 2024 – 84%), remote access technologies (50%; a decline from 66% in 2024), and the Part B rebate (29%; up from 7% in 2024). Similar to plans available for individual enrollment, a relatively small share of SNPs offer support for caregivers (5%) or telemonitoring services (2%).

Availability of Special Supplemental Benefits for the Chronically Ill (SSBCI). Beginning in 2020, Medicare Advantage plans have also been able to offer extra benefits to a subset of a plan’s enrollees, that are not primarily health related and are specifically for chronically ill beneficiaries, known as Special Supplemental Benefits for the Chronically Ill (SSBCI). In addition, Medicare Advantage plans participating in the Value-Based Insurance Design Model may also offer these non-primarily health related supplemental benefits to their enrollees, but can use different eligibility criteria than required for SSBCI, including offering them based on an enrollee’s socioeconomic status (e.g., LIS eligibility) or whether the enrollee lives in an underserved area.

Most individual and SNP Medicare Advantage plans still do not offer these benefits, though more SNP plans generally offer these benefits, particularly food and produce. SSBCI benefits offered in 2025 include food and produce (15%% for individual plans and 84% for SNPs), general supports for living (e.g., housing, utilities) (11% in individual plans and 67% for SNPs), transportation for non-medical needs (8% for individual plans and 46% for SNPs), and pest control (3% for individual plans and 23% for SNPs) (Figure 4).

Like for other types of supplemental benefits, the scope of services for SSBCI benefits varies. For example, many plans offer a specified dollar amount that enrollees can use toward a variety of benefits, such as food and produce, utility bills, rent assistance, and transportation for non-medical needs, among others. This dollar amount is often loaded onto a flex card or spending card that can be used at participating stores and retailers, which can vary depending on the vendor administering the benefit. Depending on the plan, this may be a monthly allowance that expires at the end of each month or rolls over month to month until the end of the year, when any unused amount expires.

With Donald Trump returning to the presidency, the future of Medicaid is uncertain. While Medicaid did not receive a lot of attention directly during the campaign, Trump’s first term can shed light on potential changes that could be implemented administratively without Congress.

1. Trump administration could encourage and approve Medicaid waivers to advance priorities, including work requirements.

The previous Trump administration’s Section 1115 waiver policy emphasized work requirements, other eligibility restrictions, and capped financing. The Trump administration approved 13 waivers that allowed states to condition Medicaid eligibility on meeting work and reporting requirements and also approved waivers that restricted eligibility, including by permitting states to charge premiums and lock out enrollees who are disenrolled for unpaid premiums. Although previous work requirements in Medicaid were challenged in court and the waivers imposing work requirements were rescinded by the Biden administration, a number of states continue to be interested in adopting them. Although CMS withdrew work and premium requirements in Georgia’s “Pathways” waiver, these provisions remain in place after a federal judge vacated the CMS rescission.

Trump also introduced a demonstration opportunity, the “Healthy Adult Opportunity” (HAO), that would have allowed states “extensive flexibility” to use Medicaid funds to cover certain adults – including those who qualify under the Affordable Care Act’s expansion — without being bound by federal standards related to eligibility, benefits, delivery systems, and oversight in exchange for annual limits on federal financing. While no state took up this option during the first administration, these waivers restructure Medicaid financing in ways similar to block grant and per capita cap proposals and promoting the waivers in a second administration would enable Trump to advance that policy even in the absence of Congressional action. However, unlike legislative proposals that would alter Medicaid financing and significantly cut federal spending, it is unlikely that states would opt for such deals if federal financing would be cut significantly.

The new Trump administration’s waiver priorities will differ significantly from those of the Biden administration and it is unclear how the Trump administration will treat certain waivers promoted and approved by the Biden administration, such as those focused on addressing health-related social needs, multi-year continuous eligibility, and leveraging Medicaid to help individuals leaving incarceration transition to the community. The Trump administration could choose not to approve waivers that remain pending, rescind existing waiver guidance, or withdraw approved waivers, although some of these waivers, particularly ones using Medicaid to assist with reentry from incarceration, have been pursued by both Republican and Democratic governors.

2. Trump administration could choose not to implement or rewrite recent regulations.

The Biden administration finalized a number of major Medicaid regulations designed to promote quality of care and advance access to care for Medicaid enrollees as well as to streamline eligibility and enrollment processes in Medicaid and the Children’s Health Insurance Program (CHIP).

• The Access rule addresses several dimensions of access: increasing provider rate transparency and accountability, standardizing data and monitoring, and creating opportunities for states to promote active enrollee engagement in their Medicaid programs. The rule also included many provisions governing access to home care (also known as home- and community-based services or HCBS), which include ensuring that at least 80% of spending on certain services be spent on compensation for direct care workers and requiring states to report the number of people on waiting lists for care.
• The Managed Care rule addresses Medicaid managed care access, financing, and quality, including strengthening standards for timely access to care and states’ monitoring and enforcement efforts.
• The Long-Term Care Facility (LTC) Staffing rule requires minimum staffing standards for nursing facilities.
• Two rules streamline Medicaid enrollment and renewal processes for the Medicare Savings Program (MSP) and for Medicaid, CHIP and the Basic Health Program. The first rule helps eligible Medicare beneficiaries more easily access Medicaid coverage of Medicare premiums and cost sharing through the MSP while the second rule simplifies application, enrollment, and renewal processes and removes access barriers for children in CHIP. Each rule is expected to increase Medicaid enrollment by about one million people.

These rules are complex and are set to be implemented over several years. The Trump administration could delay implementation of certain provisions, which would reduce regulation of managed care companies, nursing facilities, and other providers, while rolling back enrollee protections, payment transparency, and improved access. Alternatively, the Trump administration could issue new regulations that would undo these final regulations.

3. Trump administration could issue guidance and implement policy to make it more difficult for people to obtain and maintain coverage, reducing enrollment and spending.

The Trump administration could also issue sub-regulatory guidance to change eligibility or renewal policies to restrict coverage by tightening verification of eligibility. Previously, the Trump administration sought to reduce Medicaid enrollment by encouraging states to conduct eligibility verification processes in between annual renewal periods. While some states conduct these periodic data checks, the administration could encourage more states to adopt the policy as a program integrity strategy. The Trump administration could also eliminate flexibilities granted under the Biden administration that allow states to streamline renewal procedures. Getting rid of these flexibilities would likely make it harder for some enrollees to renew their Medicaid coverage, while providing greater certainty that people who are ineligible do not obtain coverage.

Beyond waivers, regulations, and enrollment policy, if the Republicans gain control of both the House and the Senate, Trump could work with Congress to enact legislation that would more fundamentally change the financing structure of Medicaid and make significant cuts to federal Medicaid spending, similar to policies Trump has supported in the past.

Abortion drove many voters to turn out for Tuesday’s election, but not always for Vice President Kamala Harris, while concerns about the economy weighed more heavily on voters’ minds, according to polling data from KFF and the Associated Press.

About a quarter of voters said abortion was the “single most important” factor in their vote, about 4 in10 said it had a major impact on their decision to turn out (similar to the shares who said so in the 2022 midterm elections), and over half said it had a major impact on which candidates they supported, according to the Associated Press’s VoteCast survey. In partnership with the AP, KFF added supplemental questions to the survey of the 2024 electorate to gauge how voters were weighing health care issues as they exited the polls.

But Vice President Harris’s strong advantage on abortion was not enough to override negative views of the economy and immigration, issues where President- Elect Donald Trump held the edge, the polling data shows. Forty percent of voters said high prices for gas, groceries and other goods was the single most important factor to their vote, including 51% of Republicans, 41% of independents, and 28% of Democrats.

KFF’s analysis shows that Trump did much better than Harris among the majorities of voters who reported being very concerned about the cost of groceries, gas, and housing. He also did better than Harris among the more than half of voters who said they were very concerned about the cost of health care.

Moreover, on the issue of abortion, Trump managed to garner small but important shares of votes among those who voted in favor of abortion ballot measures in their state, winning four states where voters also chose to expand or protect abortion access. Trump won support from about three in ten voters who voted in favor of abortion access in the battleground states of Nevada and Arizona, a similar share in Missouri, and about a quarter in Montana.

In an online interactive dashboard, KFF examines the role that abortion, the economy and health care costs played in the 2024 election, providing a deep dive into voters’ thinking on health care issues as they made their decisions about whether to vote and whom to vote for.

KFF provides data and analysis of the overall AP VoteCast survey and these supplemental questions at both the national and state level.

The dashboard includes:

• An interactive map that provides a more detailed look at states with abortion-related ballot measures.
• Analysis and charts examining the motivations of voters and the impact of concerns about abortion policy and health care costs nationally and across states, including some data breakouts by demographic groups and political party.
• A curated set of charts providing key analysis among subgroups of voters on topics like abortion ballot measures, health care as an economic concern, and voters’ views of the most important issues facing the U.S.

The AP VoteCast is a national and 48 state surveys of more than 115,000 voters conducted by NORC at the University of Chicago for The Associated Press, Fox News, PBS NewsHour, and The Wall Street Journal beginning on Oct. 28 and concluding as polls closed on Nov. 5, 2024, in English and Spanish. The national survey was conducted using NORC’s probability-based AmeriSpeak panel, while the individual state surveys were conducted from a random sample of state voter files and from self-identified registered voters selected from non-probability online panels. More details are available about AP VoteCast’s methodology here.