In this viewpoint article in the Journal of the International AIDS Society written ahead of World AIDS Day (December 1), KFF’s Jennifer Kates and co-authors Brian Honermann and Gregorio Millett of amfAR explore the implications of shifts in the global economic and political environment for the future of PEPFAR, the U.S government’s global HIV program created under President George W. Bush and credited with changing the trajectory of the global HIV/AIDS pandemic.

Summary

In recent years, there has been a growing focus on addressing health disparities and advancing health equity. This growth was spurred by incidents in 2020, including the COVID-19 pandemic, which highlighted the disproportionate impact of the virus on low-income people and people of color in the U.S. in addition to the police killings of George Floyd, Breonna Taylor, and others that increased attention to systemic racism that contributes to inequities such as health disparities. While the federal government can play a key role in addressing inequities, states also play a pivotal role, as they set policies, allocate resources, and administer many services and programs that are important for addressing the conditions that determine health both within and beyond the health care system. Moreover, states have varying demographics, population needs, and political leadership, which may shape efforts to address health disparities and promote health equity. Efforts at the federal level are expected to shift under the Trump Administration, given that, during his first term, he took executive action to prohibit federal agencies and contractors from providing training addressing racism and sexism and has proposed policies that may widen disparities in coverage and access to care. As such, understanding state actions in this area may be of increasing importance.

This analysis focuses on current state efforts, many of which were implemented during or after 2020, to address health disparities and advance health equity based on a review of publicly available materials from all 50 states and DC. In addition, case study interviews were conducted with 14 stakeholders in three states (California, North Dakota, and Michigan) to increase understanding of the factors contributing to success of these state initiatives, lessons learned, and potential implications for other states. The case study initiatives reflect some of the broad themes of state-level activities identified through the analysis of publicly available materials and include states with varied geography, racial and ethnic demographics, and political leadership (See Methods for more details.) Key takeaways from the review include the following:

• Nearly all states identify health equity and/or addressing health disparities as a strategic priority, and most have established infrastructure to lead this work. States vary in the level of governance they have established, how the positions or offices were created, and their scope and areas of responsibility. A few states do not have governance dedicated to addressing health disparities or health equity, although most of these states still have efforts focused on addressing health disparities. In contrast, a small number of states have passed legislation or instituted policies that prohibit activities related to diversity, equity, and inclusion (DEI) and/or that refer to structural racism. In addition to establishing infrastructure, some states describe shifts in their internal operations to address disparities and/or advance equity, including developing cross-agency collaboratives to embed equity into institutional practices and codifying these operational procedures into policy; mandating equity training for state staff; and stipulating equity-related requirements for budget, funding, and contracting decisions.
• Nearly all states include community engagement as part of their approach to addressing health disparities and/or equity. However, states vary in how they define community and the extent to which they share decision-making and resources with communities. Approaches range in the degree of engagement, as well as in the extent of power and resource sharing with communities, from soliciting input and feedback from communities; to having community representation on advisory councils, task forces, or similar groups to inform state planning and decision-making; to providing resources to support increased capacity of communities; to facilitating and funding community-defined and led strategies. States often are implementing multiple types of community engagement approaches, which may address different health or population needs and/or facilitate greater reach and impact.
• Many states describe cross-sector initiatives to address health disparities, recognizing the role social and economic factors play in determining health. States are incorporating a health equity focus across sectors in various ways. For example, several states have adopted place-based initiatives to address social determinants of health (SDOH) in specific geographic areas. Some states indicate that they employ a Health in All Policies (HiAP) approach and/or use Health Impact Assessments (HIAs) to incorporate health equity considerations into decision making across sectors beyond health. Many states also report using Medicaid managed care contracts to promote strategies to address SDOH.
• States also point to training and diversifying the health care workforce as part of efforts to address disparities and advance equity. These efforts include optional or mandated equity-related training for health care workers; efforts to increase diversity in the pipeline of health care workers; and recruitment, training, and support for community-based providers, including doulas and community health workers. Expanding access to and creating infrastructure to support doulas and community health workers are common areas of focus as part of state efforts to address disparities in maternal and infant health. A growing number of states are providing Medicaid reimbursement for doula services and/or providing funding and infrastructure to support doula training and credentialing and community health workers.
• States are implementing data collection, analysis, and reporting strategies aimed at addressing health disparities and/or equity. Most states are publicly reporting data to support efforts to address disparities, but there is wide variation in the timeliness, format, and scope of these data. A number of states have also developed or indicated that they are in the process of developing indices or datasets related to measuring equity and/or social vulnerability. Beyond increasing access to data through public reporting, some states also report changing data collection practices to support greater disaggregation of data and increased data sharing, including with communities.

This analysis shows that states with varying geography, demographics, and political leadership are pursuing work to address health disparities. However, states range in the level of commitment and resources focused on this work. While some states are taking more incremental steps, others have identified this work as a major cross-sector strategic priority, established dedicated infrastructure and resources to support this work, taken steps to empower and support impacted communities, and are working toward broader systems and policy changes to mitigate disparities.

As a result of these efforts, states have directed increased staff and resources to this work, established infrastructure and/or policies that facilitate community input to inform state decision-making and program implementation, increased funding to community-based organizations, and enhanced data available to identify and direct efforts to address disparities. In particular, the establishment of new infrastructure and policies to address disparities and advance equity may facilitate sustainability of this work amidst potential turnover in staff and leadership. Case study respondents highlighted factors that contributed to the success of initiatives and potential lessons for other states, including the presence of strong state leaders and champions, developing trusted and authentic relationships between the state and community, state leadership being open to innovative community-led approaches, and using evaluation data to support sustainability of initiatives over time.

This information may help inform state efforts to address health disparities and advance health equity by identifying potential strategies and approaches states may consider and factors that contribute to success. It is subject to limitations. While we sought to be comprehensive in our review, states may have activities underway that are not reflected in public-facing materials. It is also possible that new activities have begun, concluded, or been retracted after our data collection period. Moreover, while this analysis provides greater insight into the range of state-reported activities to address health disparities and/or equity, it does not give insight into the effectiveness or outcomes associated with these actions. Future work examining the impacts of these efforts on state operations and disparities in health care and health outcomes will be important to help guide ongoing efforts to address health disparities and advance greater health equity.(Back to top)

Publicly Reported State Activities

State Infrastructure and Governance

Nearly all states have an office or division focused on health equity or disparities (Table 1). States vary in the level of governance they have established, how positions or offices were created, and in their scope. However, these offices are generally located within the states’ Departments of Health or Health and Human Services. While some are longstanding offices focused on minority health or disparities, others were more recently established or refocused in the wake of the disparate health impacts of the COVID-19 pandemic. As such, in a number of states the levels of staff and resources focused on addressing disparities and advancing equity have increased in recent years. The few states without an office or division dedicated to health disparities or health equity generally still have resources and initiatives aimed at addressing disparities or advancing equity. For example, although Vermont does not have a dedicated health equity office, health equity is a primary strategic goal, and it has an Office of Health Equity under development.

Some states also have equity branches or divisions within agencies or divisions of their Departments of Health or Health and Human Services, such as their Medicaid agencies and/or Behavioral Health agencies. Additionally, a number of states have health equity task forces, councils, or commissions, which vary in composition and roles. Some include membership from community members and experts outside the state to provide feedback and information to guide state efforts. Others bring together state employees across sectors to collaborate on equity efforts across the state and/or to coordinate regional or local activities. Some include a combination of external experts, community representatives, and state employees.

In contrast, a small number of states have passed legislation or instituted policies that prohibit activities related to diversity, equity, and inclusion (DEI), and/or refer to structural racism. In these states, health equity and disparities related activities and content do not exist in their public materials, are being scaled back, or have been eliminated. For example Texas‘ previous Center for Minority Health Statistics and Engagement was defunded in 2017, and a legislative proposal to establish a new Office of Health Equity failed due to Republican opposition. In 2022, Florida’s state health goals removed equity as a state priority. The new state health improvement plan did not reference equity and made no mention of race or ethnicity. In July 2024, the Utah legislature passed a bill prohibiting DEI training, hiring, and inclusion programs in higher education and government employment. In Arizona, SB1005 prohibits public institutions from spending funds on DEI programming and removes requirements for employees to engage in DEI programming or training.

Less than a third of states have an overarching equity office or position (not specific to health) that was identifiable through public-facing materials. Many of these were established in 2019 or later. In California, Governor Newsom established a Chief Equity Officer through an Executive Order, who is housed within the Government Operations Agency. Similarly, in Illinois, an Office of Equity within the Office of the Governor was established via Executive Order, and New Jersey has an Office of Diversity, Equity, Inclusion, and Belonging (Office of Equity) that was created by Executive Order. Vermont’s Office of Racial Equity was formed in 2019 through legislation and has since grown in scope. Washington State’s Office of Equity was established by legislation in 2020 in response to the growing diversity of the population, disparities in opportunities across groups, and the economic and social costs of inequities.

The scope of these offices varies across states. For example, in DC, the Office of Racial Equity, which was established in 2021, focuses on developing an infrastructure to ensure policy decisions and programs are evaluated through a racial equity lens and to implement the Racial Equity Achieves Results (REACH) Act. In New Jersey, the Office of Equity is charged with increasing the presence and participation of historically underrepresented groups in state government; developing equity frameworks to guide state policy decisions; directing diversity, equity, inclusion, and belonging efforts in the Governor’s Office; guiding and coordinating state agency initiatives to strengthen diversity, equity, inclusion, and belonging within the state workforce; and monitoring implementation of these measures. Other offices, such as the Office of Diversity, Opportunity, and Inclusion in Virginia and Division of Equity, Diversity, and Inclusion in Rhode Island, are primarily focused on promoting diversity and inclusion among the state workforces.

A number of states, particularly those that are home to larger populations of American Indian or Alaska Native (AIAN) people, have established positions, offices, or other organizational infrastructure focused on communicating and consulting with Tribes and/or addressing AIAN health. Some of these states have Tribal liaisons who serve as a link to exchange information between the state and Tribal nations and facilitate Tribal consultation processes. For example, in Arizona, the Department of Health Services Tribal Liaison serves as an “advocate, resource, and communication link between the Department and Arizona’s Native American health care community.” North Dakota has four Tribal health liaisons who facilitate community engagement with five Tribes throughout the state (Box 1.) The liaisons also serve as an internal resource to the state’s Indian Affairs Commission. Other states have established leadership positions or offices focused on AIAN health. For example, Montana has an American Indian Health Director who directs the Office of American Indian Health, which serves as a communication link between the state and American Indian communities. A few states have councils or commissions that serve similar roles. In Oklahoma, the Tribal Behavioral Health Coalition specifically focuses on providing guidance on mental health and substance abuse issues for Tribal nations co-located in the state. Beyond this infrastructure, some states have clearly outlined policies and processes for Tribal consultation. For example, in 2020, Michigan established a formal Tribal Consultation policy that was developed with feedback from Tribal representatives.

Many states have also established ancillary governance structures such as commissions, task forces, councils, and workgroups to support state efforts to address health disparities and/or equity. While some of these structures include state staff persons, they often facilitate engagement of non-governmental leaders, such as subject matter experts, advocates, health care practitioners, and community-based organizations, in the development and implementation of the state’s strategy. These structures can help inform an agency’s decision-making process and/or be responsive to specific information or advisory needs. In April 2020, for example, the Tennessee Department of Health’s Division of Health Disparities Elimination launched the Tennessee Health Disparities Advisory Group to address the disproportionate number of individuals in communities of color affected by COVID-19 by examining data, monitoring trends, and generating responsive solutions during the pandemic. In Minnesota, the Department of Health formed the Health Equity Advisory and Leadership Council to serve as a voice for communities impacted by health inequities throughout the state and provide guidance on policies, programs, performance metrics geared toward the promotion of \health equity. Similarly, the Oregon Health Policy Board established a Health Equity Committee to coordinate, develop, and recommend policy designed to eliminate health inequities.(Back to top)

Strategic Priorities

Nearly all states have identified addressing health disparities and/or advancing health equity as a strategic priority, with most framing their goals around improving health for all residents. These include aims of advancing health equity, promoting optimal health for all residents, enabling all residents to achieve their full health potential, providing equitable opportunities for people to be healthy and have access to health services, and reducing or eliminating health disparities. While these goals typically encompass all residents, some states identify specific types of disparities or population groups that are of particular focus, including those that face inequities by demographic factors such as race and ethnicity, age, socioeconomic status, sexual orientation, gender, ability, immigration status, religion, and/or geographic location. State strategic goals commonly reference the role of SDOH and importance of engaging with the community as part of their efforts. A smaller number of states explicitly identify addressing racism and recognizing historical discrimination, disparities in behavioral and mental health, or environmental justice as components of this work. Some states also identify addressing internal capacity and workforce diversity as key components of these efforts.

Most states have a definition of health equity in their publicly posted materials, and about half have a publicly posted definition of health disparities. How states define health equity and health disparities may shape the directions and focus of their work in this area, as they vary in recognition of factors that drive disparities and potential mechanisms to advance equity. State definitions of health equity most commonly refer to or draw on definitions from the CDC, including the Healthy People 2030 definition, which recognize that achieving health equity requires addressing social and economic factors that contribute to disparities and historical and contemporary injustices. Some also reference or draw on definitions from the World Health Organization or the Robert Wood Johnson Foundation. Oregon’s definition of health equity is unique in that it identifies “equitable distribution or redistribution of resources and power” as a component for achieving health equity. State definitions of health disparities generally refer to or draw on definitions from Healthy People, the CDC, and the National Institutes of Health. These definitions all recognize that disparities impact groups of people who are socially disadvantaged or experience more obstacles to health. The Healthy People definition identifies health disparities as linked to social, economic, and environmental disparities, although states vary in the extent to which their definitions identify root causes of disparities and the role of social and economic factors. Minnesota’s definition specifies that disparities are not explained by genetic or biological factors and highlights that they are life-threatening and urgent to address. By contrast, Missouri identifies genetics as a contributing factor to disparities. Oklahoma’s definition highlights root causes of disparities as “poverty, racism, class and gender discrimination, and other factors.” California’s definition is unique in its inclusion of mental health disparities.

Areas of focus related to addressing health disparities spanned a wide array of health needs and conditions, with some areas of common focus, including maternal and infant health and chronic disease. For example, Michigan has prioritized addressing disparities in maternal and infant health through its 2024 strategic plan (Box 2). Ohio created the Eliminating Racial Disparities in Infant Mortality Task Force to work with local, state, and national leaders. Arizona’s AZ Health Start Program supports home visits for at-risk pregnant or postpartum women and its Tribal Maternal Task Force was established to develop a culturally relevant Tribal maternal health plan. The North Dakota Diabetes Prevention and Control Program (NDDPCP) established a collaborative between health systems, health centers, and pharmacies to increase point-of-care testing in community pharmacies. Some states also identified a focus on addressing disparities in behavioral health. The California Reducing Disparities Project is a statewide initiative designed to address disparities in behavioral and mental health among certain populations. Colorado established the Behavioral Health Administration, which focuses on addressing the social and structural determinants of behavioral health. Environmental health justice and addressing disparities in health-related environmental impacts is also an emerging focus area. For example, California developed Climate Change and Health Vulnerability indicators to identify people and places more susceptible to adverse health impacts associated with climate change. Wisconsin is developing an Environmental Equity Tool, which will help identify communities impacted by pollution, climate change, socioeconomic factors, and other environmental and health hazards.

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Community Engagement

Nearly all states are engaging with or have reported plans to engage with communities to address health disparities and/or equity, although they vary in how they identify community as well as in their approaches and the extent to which they share decision-making with communities. States varied in their references to community, with some defining community as local public health agencies or other local government partners, whereas others included community-based organizations. Some further sought to engage directly with individuals impacted by disparities. How states defined community informed their engagement approaches. State community engagement approaches range in level of engagement and sharing of power and resources, from more incremental efforts that solicit feedback to more comprehensive and deeper efforts that support the increased capacity of communities and community-defined and -led strategies to address disparities. States often implement multiple community engagement approaches, which may address different health or community needs. States engaged in efforts to share power and decision-making with communities tend to have more comprehensive and multi-pronged approaches (See Box 3).

States described gaining input from communities by hosting listening sessions or town halls, administering surveys and/or focus groups, or by requesting public comments. For example, when Michigan sought to improve how it collected race and ethnicity data for its health surveys, it posted its proposed changes on its website and requested feedback and held meetings with community groups across the state to raise awareness and garner feedback. Similarly, to inform the development of its Health in All Policies (HiAP) agenda, the New Jersey’s Department of Health worked with Rutgers University to conduct listening sessions with experts and community leaders across the state. To center the voices of Wisconsinites, the state conducted a series of community conversations to understand needs and resources in developing its state health improvement plan.

Beyond soliciting feedback, some states have included community-based organizations, Tribal members, local health departments, faith-based institutions, and other local organizations in strategic planning processes and on task forces, work groups, committees, advisory councils, and boards to inform decision-making. For example, in developing its strategic plan, Hawaii included contributions from universities, physicians, community-based organizations, and other local stakeholders. Oregon’s Healthier Together strategy was led by a community-based steering committee called the PartnerSHIP, which made final decisions about the plan’s priorities and strategies. Nevada’s Health Equity plan outlines efforts to form a data advisory committee to assess data needs and gaps and identify communities for inclusion  in efforts to identify, analyze and report data.

Many states also are providing resources and assets to support community-level efforts and increase the capacity of organizations serving the community. These efforts include strengthening community networks; utilizing community health workers; increasing local health services capacity; and providing training, technical assistance, and culturally tailored communications and resources to community-based organizations. South Carolina’s Cancer Alliance, for example, brings together a network of leaders, communities and organizations to coordinate, collaborate, and provide education and research on cancer disparities and solutions to communities in partnership with the state’s Department of Health and Environment Control. With its COVID Community Partnership (CCP), Utah deployed community health workers to connect under-resourced communities to provide credible health information and COVID-19 vaccines. Moreover, through its Embrace Project Study, it sought to build trust with the Native Hawaiian and Pacific Islander communities by having community health workers provide biometric screenings and health coaching sessions for diabetes and maternal mortality and morbidity prevention. Illinois has focused on increasing the capacity of local health services for behavioral health through its Recovery Oriented Systems of Care (ROSC). This statewide network program geographically distributes councils that assist communities with building local recovery systems of care, including local primary care, law enforcement, hospitals, prevention and recovery services, and a variety of community stakeholders.

Some states have demonstrated a deeper commitment to community engagement by sharing decision-making with the community and supporting community-led initiatives. In some cases, this is via government-to-government partnerships between states and Tribal nations and/or by having a dedicated state infrastructure to partner in Tribal affairs. For example, Alaska’s state health improvement plan (SHIP) is led by a state and Tribal partnership between the Alaska Native Tribal Health Consortium and the state’s Department of Public Health. In other cases, such as Minnesota’s Community Voices and Solutions infant mortality reduction initiative in Hennepin County and the Health Equity Zones in Pennsylvania, Rhode Island, and Washington, the states facilitate and fund initiatives. These initiatives are determined and led by the local communities themselves. In California, the California Reducing Disparities Project was developed specifically to support the design, implementation, and evaluation of community-led approaches to address behavioral and mental health disparities among certain populations (Box 4).

Some states have demonstrated a long-term commitment to community engagement through the establishment of staff, infrastructure, and/or strategic plans dedicated to leading and implementing community engagement initiatives. Louisiana’s community engagement strategy is guided by its Community Engagement Framework, which aims to build the health agency’s capacity to engage people and communities equitably. Colorado’s Community Action and Engagement Unit works to identify and support community organizations, healthcare entities, and public health agencies to promote health equity and address SDOH related to COVID-19. Similarly, North Dakota’s Community Engagement Unit is dedicated to community-engaged strategies and serves as a resource for addressing health disparities and advancing health equity.(Back to top)

Cross-Sector Approaches

As part of efforts to address health disparities, many states are implementing initiatives that focus on broader social, economic, and environmental factors that influence health. For example, Connecticut’s Healthy Connecticut 2025 plan addresses SDOH through strategies focused on economic stability, healthy food and housing, and community resilience, while incorporating areas of structural racism, transportation, and education. In Washington State, the Governor’s Interagency Council on Health Disparities, which was created by legislative action, emphasizes equity and community engagement in addressing SDOH, including improving access to healthy food and educational opportunities and reducing environmental hazards. In North Dakota, the state is implementing a new Multi-Partner Health Collaborative, which includes state leaders across sectors and focuses on areas outlined in the State Health Improvement Plan (SHIP) (Box 5).

Several states have adopted place-based initiatives to address SDOH in specific geographic areas. Get Healthy Idaho’s place-based initiatives engage residents in local areas to identify priorities, challenges, and opportunities to ensure community voices guide the strategy development and implementation process. In Pennsylvania, North Philadelphia’s Health Enterprise Zones and Regional Accountable Health Councils collaborate using health and SDOH assessments to inform population health planning and develop long-term public health strategies, particularly for areas with high disease burden and health disparities. Rhode Island’s Health Equity Zones (HEZs) focus on addressing health inequities in geographic zones through community-led assessments and action plans, with a focus on integrated healthcare, community resilience, the physical environment, socioeconomics, and community trauma.

Some states indicate that they employ a HiAP approach and use Health Impact Assessments to incorporate health equity considerations into decision making across sectors. Nevada’s Health Equity Action Plan recommends adoption of an HiAP approach and utilization of tools like Health Impact Assessments, Racial Equity Impact Assessments, and the Office of Minority Health Equity’s Health Equity Lens to measure the effects of proposed policies, programs, and plans on health equity and community health. Additionally, Nevada promotes the use of health impact notes, similar to fiscal notes, to evaluate the potential health outcomes of proposed legislation across different sectors. In Washington, DC, the Office of Health Equity implements the Calling All Sectors Initiative, which is a multisector approach to operationalize health equity by using a HiAP approach and engaging stakeholders across sectors to promote health, wellness, and equity, recognizing the impacts of housing affordability, insecurity, and homelessness on maternal and infant health.

A growing number of states also are addressing health-related social needs (HRSNs) through their Medicaid programs. Most states that contract with managed care plans to deliver care to Medicaid enrollees report leveraging managed care organization (MCO) contracts to promote at least one strategy to address SDOH in FY 2024. These included requiring MCOs to screen enrollees for behavioral health needs, screen enrollees for social needs, provide referrals to social services, and partner with community-based organizations. States also report requiring MCOs to encourage or require providers to capture SDOH data, incorporate uniform SDOH questions within screening tools, employ community health workers, and track outcomes of referrals to social services. In addition to these MCO activities, as of October 2024, CMS approved ten states (Arizona, Arkansas, California, Illinois, Massachusetts, New Jersey, New Mexico, New York, Oregon, and Washington) under the new Health-Related Social Needs (HRSN) Section 1115 framework. These waivers authorize evidence-based housing and nutrition services for specific populations with unmet social needs. For example, Arizona’s AHCCCS Whole Person Care Initiative provides housing and other supports to individuals at risk of homelessness with health needs. States can also obtain “infrastructure” funding to support the implementation of HRSN waivers or build state or regional capacity to manage population health. For example, New York’s Health Equity Regional Organization is designed to develop regionally focused approaches to reduce health disparities, advance quality and health equity, and make recommendations to incorporate HRSN into value-based payments.(Back to top)

Training and Diversifying the Health Workforce

A number of states identified health equity-related training initiatives for health care providers, although they varied in scope and implementation, with some optional and others required. For example, Alabama has an optional on demand web-based training for nurses, social workers, clinicians, health educators, and other healthcare professionals and administrators to better understand health equity and why it is important to their daily work. Other states have mandated equity-related training through executive action or legislation. For example, a 2019 law in California seeks to reduce Black maternal mortality by requiring all perinatal health care providers to undergo implicit bias training. Colorado passed legislation in 2022 requiring the Office of Health Equity and The Department of Public Health and Environment to create a culturally relevant and affirming health care training grant program aimed at increasing provider capacity to provide culturally responsive care. Maryland passed legislation requiring applicants for the renewal of a health occupations board license or certificate to attest to the completion of an approved implicit bias training program. Maryland also is in the process of creating a maternal health equity advisory group that will produce recommendations to educate non-obstetric providers of care to pregnant and postpartum patients on the topics of maternal morbidity, racial bias, and the importance of respecting the patient’s voice.

Some states reported efforts to increase the diversity of the health care workforce. For example, California’s Medicine Scholars Program, which was established, in part, through state funding, seeks to reduce barriers students of color face as they move through the pipeline to jobs in the medical workforce. Similarly, New York provides funding for student support programs designed to increase the diversity of providers in the state, including its longstanding diversity in medicine program.

Another area of focus for states is increasing access to and availability of community-based providers, including community health workers and doulas. Some states are seeking to increase access to these providers by providing patient education about these services, supporting training to increase the supply of these providers, and providing reimbursement for their services. For example, the intends to increase the number of Black birthing people who are informed about the benefits of doula care and offered the opportunity to work with doulas; improve the prenatal, labor, and delivery, and postpartum care of Black birthing people; and support the development of a culture of understanding and mutual respect between doulas and clinical staff. Other analysis shows, as of early February 2024, 12 states reimburse services provided by doulas under Medicaid , with two states, Louisiana and Rhode Island, also implementing private coverage of doula services. Additionally, states are funding grants or scholarships to support doula training and credentialing. Michigan launched a Doula Initiative that includes Medicaid reimbursement for doulas and efforts to increase and support doula providers, which is informed by a Doula Advisory Committee (Box 6). Other states identified efforts to enhance access to community health workers. For example, the Indiana Department of Health is using a place-based approach in which districts experiencing disparities are allocated community engagement funds to be used by community health workers to address the needs of underserved populations in the area. Montana is investing in the ongoing training for community health workers on issues related to health equity, cultural competencies, and SDOH.

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Data Equity Initiatives

Most states are publicly reporting data to support efforts to address disparities, but there is wide variation in the timeliness, format, and scope of these data. Many states have static reports with measures of health and, in some cases, health-related social and economic factors broken out by race and ethnicity and other demographic factors, which may be updated on a regular basis. For example, in California, the Office of Health Equity produces a biannual demographic report on health and behavioral and mental health inequities for the state legislature and residents. The scope of measures included in these reports, as well as the timeliness of the data included, varies across states. In some states, the latest publicly available reports have outdated data, while others are updated on a regular and timely basis. Beyond these static reports, a growing number of states are developing interactive data dashboards, data portals, or maps that allow users to explore a wide variety of measures, sometimes including social, economic, and/or environmental measures, by various demographic factors. For example, Washington’s Tracking Network was developed to make public health data more accessible by featuring a variety of data tools, including an Environmental Health Disparities map, which depicts where environmental health disparities are occurring to prioritize public investments. Similarly, in a partnership between the Division of Public Health, Delaware Racial Justice Collaborative, and United Way, Delaware’s Equity Counts Data Center provides multiple data points (i.e., indicators in health, education, criminal justice, and economics) that can be used to examine disparities by race, ethnicity, gender, and age across the state and at the zip code level.

Several states also have developed or indicated that they are in the process of developing indices or datasets related to measuring equity and/or social vulnerability. For example, the Get Healthy Idaho Index and Community Data tool measures and ranks neighborhoods’ health and well-being based on factors like access to healthy food, parks, clean air, and healthcare services, to provide a holistic view of community health. The index aims to guide policymakers and community leaders to improve the overall health of Idaho. Arizona indicates that it is adapting the CDC’s Social Vulnerability Index into an Arizona-specific index. Utah’s Health Improvement Index includes nine determinants of health including demographics, socioeconomic deprivation, economic inequality, resource availability, and opportunity structure. Michigan reports it is developing a health equity data set that will include indicators for social and economic conditions; environmental conditions; health status, behaviors, and healthcare; and priority health outcomes to monitor racial health disparities. In addition to SDOH, some states also are reporting measures related to environmental quality and conditions in their data dashboards or indices. For example, Rhode Island provides a map of extreme heat impacts in their Health Equity Zones.

Beyond efforts to increase accessibility of data through public reporting, some states also report changing data collection practices to support greater disaggregation of data. For example, through its REALD (race, ethnicity, language, and disability) and SOGI (sexual orientation and gender identity) efforts, Oregon is working to increase and standardize the collection of these data across health agencies. Utah’s Department of Health and Human Services has developed guidelines to promote a uniform set of data collection standards for race and ethnicity. Several other states have indicated plans to enhance their data collection and reporting practices. For example, North Dakota is examining how to improve data for multiracial people and incorporate race and ethnicity questions into its data collection practices. California also has pending legislation to use more detailed racial and ethnic categories. Michigan is prioritizing expanding the collection of race, ethnicity, and preferred language data. It is also working to implement reliable survey tools to collect data from smaller racial and ethnic groups and communities not represented in standard data collection systems.

Additionally, some states are working to increase data accessibility through data sharing. For example, some are putting data sharing agreements in place and/or improving the interoperability of datasets within and across state agencies, healthcare organizations, and with Tribes. Some states have also established data committees or advisory groups that oversee data coordination between agencies and sectors. For example, Connecticut is working to establish a cross-sector data committee that would act as a technical body to provide support to agencies across the department and advise the State Health Improvement Plan Advisory council.

Some states include a focus on equity as part of their Maternal Mortality Review Committees (MMRCs). Nearly all states have MMRCs, many of which are funded through the CDC, that review pregnancy-associated deaths and offer recommendations to prevent future deaths. However, state MMRCs vary in the extent to which they examine racial disparities, with some identifying and addressing disparities as a key focus. For example, in California, each death is examined through a health equity lens and considerations include how SDOH, discrimination, and racism may have contributed to the death. Similarly, Vermont amended the charge of its committee in 2020 to include considerations of disparities and SDOH, including race and ethnicity in perinatal death reviews. Rhode Island recently replaced its MMRC with the Pregnancy and Post-Partum Death Review Committee and noted that the name acknowledges the breadth of gender identity of individuals who may become pregnant. States also vary in the membership of their committees, with some having requirements related to Tribes and/or doulas or midwives. For example, Colorado’s MMRC includes experts with lived experience in the drivers of maternal mortality, including doulas, midwives, and patient advocates.(Back to top)

Internal Operations

Some states have created cross-agency learning collaboratives to embed equity into their institutional practices among their state workforces. Through its Capitol Collaborative on Race and Equity, California established a 15-month learning cohort of 25 of the state’s departments, agencies, offices, commissions, and conservancies to embed racial equity into their respective institutional culture, policies, and practices with the aim that race will no longer be a factor in determining life outcomes or well-being for communities of color. The Minnesota Department of Health Equity Learning Community helped teams from local public health departments integrate health equity practices into their work. It identified several areas of suggested changes to existing practice, including data collection, analysis, and use; community engagement; organizational operations, like policies, budgets, and hiring; and policy work. Rhode Island’s Capacity Building for Policy Change Workshop Series is designed to support their Health Equity Zones in enhancing their capacity to engage in policy and systems change efforts that include making equity improvements to ordinances, state and local regulations, and agreements with municipal agencies and/or institutions like hospital systems.

States are also shifting internal operations by providing and, in some cases requiring, equity-related training for their staff. In Louisiana, Initiative 16 was developed to train and build the capacity of staff to have an understanding of systemic health equity, translate this to their daily work, and incorporate equity practice expectations into annual performance reviews. Maine’s Department of Health and Human Services developed a plan to increase DEI capacity within the department through a range of strategies, including publicly reporting staff demographics and providing staff training on best practices for hiring a diverse workforce and education about Equal Employment Opportunity and implicit bias in hiring. Some states are mandating training among the state workforce. For example, through executive order in Colorado, the Department of Personnel and Administration was tasked with developing and delivering required training for all state employees, with additional requirements and expectations for agency executives on DEI issues, including education on implicit bias, historical injustices and trauma, community engagement practices, and new assessment tools. Similarly, in Washington, the Secretary of Health’s directive mandates that leadership, management, and supervisors adhere to the recruitment policy and implement “hiring best practices” which include the requirement to complete implicit bias training and encourage ongoing training in the areas of diversity, inclusion, cultural humility, oppression, and equity.

In contrast, other states are moving to ban or restrict DEI-related activities. For example, under SB 266, public institutions in Florida are prohibited from funding or maintaining DEI programs. Similar legislation was passed in Texas under HB 5127, which bans DEI offices and diversity training for students and employees at public institutions as of January 1, 2024. Utah passed HB 261, which bans DEI offices and training requirements and prohibits race being considered in hiring practices for state board and government employees. In December of 2023, the Oklahoma governor signed an executive order banning DEI programs at state agencies; effective immediately, the order eliminated funding for all DEI positions. Some state medical boards have also been moving to limit DEI actions. A lawsuit against the Tennessee medical board challenges the legality of policies to ensure representation from minority groups through racial quotas. A similar lawsuit has been filed in Louisiana against the medical board for the use of racial quotas.

States are also stipulating requirements in operational procedures such as budgetary decisions, funding criteria, and contracting to support equity. For example, states like Minnesota, New York, Illinois, and Michigan dedicate specific budget lines to allocate funding for programs to reduce racial health disparities in areas including maternal health, HIV prevention, and mental health services. California established a Racial Equity Commission to develop tools for assessing how budget allocations impact communities of color, and Rhode Island is exploring incorporating community participatory budgeting practices. Some states are leveraging budgetary and funding requirements to expand state capacity to address disparities in social and environmental determinants of health. For example, Washington’s HEAL Act instructs covered agencies to incorporate environmental justice into funding and budgeting processes with the goal of directing 40% of funding for programs that create environmental benefits to go to “overburdened communities and vulnerable populations.” Other states stipulate requirements for contractors and procurement procedures that support equitable practices. Arizona’s Community Reinvestment policy, for example, requires contractors to designate and spend a minimum share of profits for community reinvestment activities (e.g., housing, non-medical transportation services, activities to combat social isolation or enhance social support, activities that reduce recidivism, employment or educational supportive activities, social programs that promote health and wellness and/or research activities that support a specific community activity that improves health outcomes).

Within Medicaid, many states leverage managed care contracts to promote reducing health disparities. As noted above, this includes adopting contract requirements related to addressing SDOH. Additionally, some state managed care organization (MCO) contracts incorporate requirements to advance health equity and/or tie MCO financial quality incentives to reducing health disparities. In a KFF survey, about one-third of responding MCO states reported at least one MCO financial incentive tied to reducing racial and ethnic disparities in place in FY 2024, including linking capitation withholds or pay-for- performance incentives to improving health disparities. Additionally, nearly all responding MCO states also reported at least one specified MCO requirement related to reducing disparities in FY2024, including requiring MCOs to have a health equity plan in place and train staff on health equity and/or implicit bias. Over half of states reported requiring MCOs to meet health equity reporting requirements and seek enrollee input or feedback to inform health equity initiatives. Fewer states reported requiring MCOs to achieve national accreditation standards or to have a health equity officer.(Back to top)

Lessons Learned

In addition to the review of public materials, we conducted 14 case study interviews with stakeholders in three states to increase understanding of lessons learned from state efforts to address disparities. The case study initiatives reflect some of the broad themes of state activities identified through the analysis of publicly available materials and represent states with varied geography, racial and ethnic demographics, and political leadership. They include California’s Reducing Disparities Project (CRDP), which implements  community defined practices to reduce mental health disparities; North Dakota’s Community Engagement Unit, which prioritizes a community engagement approach to reducing disparities and includes a focus on Tribal relations; and Michigan’s efforts to narrow disparities in maternal and infant health through its Advancing Healthy Births equity plan and its Doula Initiative. (See Methods for more details.) Lessons learned from the case study interviews include the following.

Having strong leaders and champions within the state is important for success. Respondents noted that supportive leadership at the state executive level and within key state agencies has been key for facilitating the vision and funding necessary to support these initiatives. For example, in Michigan, respondents highlighted the importance of the Governor’s prioritization of maternal and infant health equity, which was backed by investment in the work. Respondents also referenced the importance of having champions within state legislature and at the local level, particularly in cases in which initiatives have required ongoing legislative funding. For example, respondents in California noted that having champions within the state legislature and county behavioral health offices was important for establishing the CRDP and maintaining it over multiple legislative funding cycles. Respondents further emphasized the importance of such leaders being supportive of addressing upstream drivers of disparities, including social and economic factors, and openness to systems change. At the same time, one respondent noted the importance of institutionalizing changes through policy or operations so that efforts are not contingent on specific leadership being in place and are more likely to continue amidst staff turnover or changes in leadership.

Authentic long-term trusted relationships between the state and community are an integral piece of this work. Respondents noted the importance of establishing authentic community engagement by meeting communities where they are, demonstrating responsiveness to their interests and needs, and maintaining ongoing, long-term conversations. For example, in North Dakota, the community engagement team travels to meet with communities, including Tribes, on an ongoing basis. This allows them to respond to issues raised by the community and deepen relationships over time. In Michigan, the state participates in regular meetings hosted by regional collaboratives in locations chosen by the community that are usually held in the evenings when families can attend. Families drive the conversation, and the state takes advisement and then reports back on issues raised in subsequent meetings. Respondents noted that authentic community engagement often involves a shift in dynamics from one in which communities used to have to come to the state to now the state traveling out to meet communities and from the state just taking data previously versus now sharing it back with the community.

Openness to innovation and community-led approaches facilitates development of new models and strategies.  Community defined and led approaches are core features across the initiatives being implemented in the case study states. Respondents highlighted the importance of state leadership being open to innovative models that do not fit within current systems and structures and supporting their implementation by allowing communities to design and lead efforts and providing funding to support these efforts. It was recognized that this sometimes requires being creative and finding ways to work within existing limits of system structures to implement new approaches. In California, the CRDP model recognizes that community-defined practices can be viable and valuable and that prevention and services do not need to adhere to a one-size-fits-all approach. This model recognizes that a particular approach may not work for everyone but can be effective at addressing the specific needs of the community being served. In North Dakota, respondents noted that the state is engaging with the community and key stakeholders to work toward the goals outlined in its SHIP. Respondents also pointed to the value of investing directly in the community. For example, in Michigan, the state increased funding directed to community-based organizations as part of its Advancing Healthy Births initiative. One respondent noted that the experts are the families and that solutions to challenges often can be found from the people you are serving.

Terminology used to describe this work can be important for garnering broad-based support amid opposition to DEI efforts and race-based interventions. Several respondents noted that describing initiatives as equity-focused can jeopardize broad support for this work amid the rising anti-DEI movement. They felt that implementing the work is more important than what it is called and noted that using terminology that is truthful to the work being done but intentional in avoiding potential opposition can be key for maintaining broad-based support. Some emphasized, for example, that health equity is not just about race, it is about working with a wide variety of populations, including rural and low-income populations, and about focusing on access to health care and addressing SDOH. Moreover, work to mitigate health disparities can elevate the entire system and benefit all residents of the state, not just populations of focus.

Having strong evaluation data can help maintain support for initiatives and facilitate their sustainability over time. Respondents highlighted the importance of having data to document the impacts and successes of initiatives, which can help counter potential opposition to equity-focused efforts and makes the case for sustaining the work. In California, each of the CRDP initiatives is being evaluated individually and as a whole, which helps demonstrate the impacts of the work and the value of community-designed approaches. Respondents also noted that having data can help guide programs to adapt and change over time by providing insight into what is working and what is not.

Establishing long-term funding strategies will be key to sustaining these initiatives over time. Much of the work under these initiatives in the case study states has been supported through limited funding streams, including time-limited appropriations and grants. Respondents recognized that to support long-term sustainability and increased scalability over time, it will be important to embed the efforts into systems and support them through reimbursement mechanisms. They identified challenges to integrating community practices into public health systems and suggested it will be important to consider how existing systems could adapt to integrate a broader array of models through a combination of cultural and systems change. For example, in Michigan, the Medicaid program has expanded to provide reimbursement for doulas and to create the doula registry. Respondents in California noted how identifying Medicaid and other reimbursement models could evolve to include community-designed approaches demonstrated through the CRDP will be important for long-term sustainability of these efforts.(Back to top)

Looking Ahead

This analysis shows that states with varying geographies, demographics, and political leadership are pursuing work to address health disparities. However, states differ in the level of commitment and resources focused on this work. While some states are taking more incremental steps, others have identified this work as a major cross-sector strategic priority, establishing dedicated infrastructure and resources to support this work, taken steps to empower and support impacted communities, and are working toward broader systems and policy change to mitigate disparities. In these cases, case study respondents shared that certain facilitating factors have been vital to establishing and working toward sustaining health equity initiatives including having supportive leadership, building trust with communities, prioritizing community-driven innovations, considering the political context for messaging, demonstrating impact with data, and planning for sustainability.

As a result of these efforts, states have directed increased staff and resources to this work, established infrastructure or policies that facilitate community input to inform state decision-making and program implementation, directed increased financing to community-based organizations, and enhanced the data available to identify and direct efforts to address disparities. In particular, the establishment of new infrastructure and policies to address disparities and advance equity may facilitate the sustainability of this work amidst potential turnover in staff and leadership.

While this analysis provides greater insight into the range of state-reported activities to address health disparities and/or equity, it does not give insight into the effectiveness or outcomes associated with these actions. Future work examining the impacts of these efforts on both state operations and disparities in health care and health outcomes will be important to help guide continued efforts to address health disparities and advance greater health equity.(Back to top)

During the Medicare open enrollment period from October 15 to December 7 each year, people with Medicare can enroll in a plan that provides Part D prescription drug coverage, either a stand-alone prescription drug plan (PDP) for people in traditional Medicare, or a Medicare Advantage plan that covers all Medicare benefits, including prescription drugs (MA-PD). In 2024, 53 million of the 67 million Medicare beneficiaries are enrolled in Medicare Part D plans, including employer-only group plans; of the total, 57% are enrolled in MA-PDs and 43% are enrolled in stand-alone PDPs. This analysis provides an overview of Part D plan availability, premiums, and cost sharing in 2025 and key trends over time. (Separate analyses of 2025 Medicare Advantage plans, premiums and benefits are also available.) (See Methods box for details on this analysis.)

Overall, KFF analysis shows that the market for Part D coverage remains robust based on the overall number of plan options, but the number of sponsors, plans, and enrollees in the stand-alone PDP market has trended downward over time, while the MA-PD market remains stable and continues to experience steady enrollment growth. In part, this reflects the predominance of low- or zero-premium MA-PDs and the availability of extra benefits, which are enabled by rebates in the Medicare Advantage payment system and amplified by aggressive marketing. Monthly premiums for stand-alone PDPs are substantially higher than for MA-PDs.

Changes to the Part D benefit in the Inflation Reduction Act, including a new $2,000 out-of-pocket drug spending cap, will mean lower out-of-pocket costs for some Part D enrollees but higher costs for Part D plans overall. Some stand-alone PDPs are increasing monthly premiums for 2025 by up to $35, the maximum increase allowed for plans participating in a new premium stabilization demonstration, while a larger share of MA-PD plans are imposing deductibles for drug coverage and coinsurance for certain types of drugs in 2025 compared to 2024. Part D plans often make other changes from one year to the next that could affect drug coverage and costs, including changes to formularies and preferred pharmacies, re-enforcing the value for Part D enrollees in comparing plans during the annual open enrollment period.

Medicare Part D Highlights for 2025

• The average Medicare beneficiary has a choice of 48 Medicare plans with Part D drug coverage in 2025, including 14 Medicare stand-alone prescription drug plans (7 fewer than in 2024) and 34 Medicare Advantage drug plans (2 fewer than in 2024). Over the past 10 years, the number of PDPs available to the average beneficiary has decreased by 52% while the number of MA-PDs has increased by 143%.
• The number of firms offering stand-alone PDPs has dropped from 11 in 2024 to 7 in 2025, along with a reduction in the overall number of PDPs (down from 709 to 464).
• In 2025, a smaller number of PDPs will be “benchmark” plans – that is, PDPs available for no monthly premium to Medicare Part D enrollees receiving the Low-Income Subsidy (LIS) – than in any year since Part D started. Medicare beneficiaries will have access to 1 less benchmark PDP in 2025 than in 2024, on average – two out of the average 14 PDPs available overall. An estimated 1.1 million LIS enrollees (26% of all LIS PDP enrollees) need to switch plans during the 2024 open enrollment period if they want to be enrolled in a benchmark plan in 2025.
• The estimated average enrollment-weighted monthly premium for Medicare Part D stand-alone PDPs is projected to be $45 in 2025, a modest increase from $42 in 2024 (based on June 2024 enrollment). After accounting for enrollment choices by new enrollees and plan changes by current enrollees, the actual average weighted PDP premium for 2025 is likely to be lower than the estimated average of $45.
• Monthly premiums for drug coverage are estimated to be six times higher for PDPs compared to MA-PDs in 2025 – $45 versus $7. The average monthly premium is projected to increase for PDPs but decrease for MA-PDs. MA-PD sponsors can use rebate dollars from Medicare payments to lower or eliminate their Part D premiums, as well as provide extra benefits, but there is no equivalent rebate system for PDPs.
• Average monthly premiums for the 12 national PDPs are projected to range from around $3 to $128 in 2025. Premium variation across plans is in part related to whether plans offer basic or enhanced benefits and the value of benefits offered, as well as variation in the underlying costs that plans incur for their enrollees.
• More than half of non-LIS Part D PDP enrollees (7.0 million out of 13.1 million) will see a reduction or no change in their monthly premium in 2025 if they make no changes during open enrollment, but 1 in 5 non-LIS PDP enrollees (2.6 million) will see their monthly premium increase by $35 if they stay in their same plan for 2025. This is the maximum increase allowed for PDPs participating in the new Part D premium demonstration, which includes measures intended to stabilize the PDP market as major changes to the Part D benefit take effect in 2025, including a new $2,000 out-of-pocket drug spending cap.
• The share of MA-PD enrollees who will be in plans that charge a deductible for Part D coverage will nearly triple from 21% in 2024 to 60% in 2025 if they do not switch plans. Most stand-alone PDP enrollees (84%) will also be enrolled in plans that charge a deductible for drug overage in 2025, similar to the share in 2024 (87%). (Some of the enrollees in these plans receive low-income subsidies that cover their deductible.) The average deductible in 2025 will be more than twice as large for PDP enrollees as for MA-PD enrollees ($486 versus $225) (the standard deductible in 2025 is $590).
• Many Part D enrollees will face coinsurance rather than copayments for both preferred brands and non-preferred drugs, which can mean less predictable out-of-pocket costs. This includes a larger share of MA-PD enrollees compared to 2024: 28% will be in plans that charge coinsurance for preferred brands versus 2% in 2024, and 57% will be in plans that charge coinsurance for non-preferred drugs versus 11% in 2024. Among PDP enrollees, 83% will be in plans that charge coinsurance for preferred brands and 100% in plans charging coinsurance for non-preferred drugs in 2025. For specialty tier drugs (those that cost more than $950 per month), median coinsurance will be 25% for PDP enrollees and 30% for MA-PD enrollees.

Part D Plan Availability

For 2025, the Average Medicare Beneficiary Has Fewer Stand-Alone Prescription Drug Plan Options Than in Prior Years but a Similar Number of Medicare Advantage Drug Plan Options

The Part D market for 2025 offers the average Medicare beneficiary fewer choices for drug coverage from stand-alone prescription drug plans than in prior years, but a similar number of choices for coverage from Medicare Advantage drug plans. The average Medicare beneficiary has a choice of 48 options for Part D coverage in 2025, including 14 PDPs (7 fewer than in 2024) and 34 MA-PDs (2 fewer) (Figure 1). Over the past 10 years, the number of PDPs available to the average beneficiary has decreased by 52% while the number of MA-PDs has increased by 143%.

Of the 14 PDPs available to the average beneficiary in 2025, 12 are national PDPs (available in all 34 PDP regions nationwide) (Appendix Table 1). This reduction of two national PDPs from 2024 is the result of one plan sponsor (CVS Health/Aetna) consolidating its 3 PDP offerings in 2024 (SilverScript Choice, Plus, and SmartSaver) to 1 PDP in 2025 (SilverScript Choice). The 2.0 million enrollees in the SilverScript Plus and SmartSaver PDPs (as of June 2024) will be automatically enrolled in SilverScript Choice for 2025 unless they choose a different plan during open enrollment.

A Total of 7 Firms Will Offer 464 Stand-Alone Prescription Drug Plans in 2025, the Lowest Number of PDP Sponsors and Plans Since Part D Started

The number of firms sponsoring stand-alone PDPs is decreasing from 11 firms in 2024 to 7 firms in 2025, the smallest number since the Part D benefit was launched (Figure 2). Due to the market withdrawal of Mutual of Omaha from the PDP market and the termination of Clear Spring Health PDPs by the Centers for Medicare & Medicaid Services (CMS) due to low quality ratings over three years, the 537,000 enrollees in these firms’ PDPs (as of June 2024) will need to select a new Part D plan from a different plan sponsor during the 2024 open enrollment period if they want their Part D coverage to continue in 2025.

A total of 464 PDPs will be offered by these 7 firms in the 34 PDP regions (plus another 10 PDPs in the territories), a decrease of 245 PDPs (-35%) from 2024, and the lowest number of PDPs available in any year since Part D started in 2006.

Despite the reduction in PDP availability overall, beneficiaries in each state will have a choice of multiple plans, ranging from 12 PDPs in 12 states and the District of Columbia to 16 PDPs in California, plus multiple MA-PDs offered at the local level (Figure 3, Appendix Table 2).

Premiums

Stand-Alone Prescription Drug Plan Enrollees Will Pay Higher Monthly Premiums Than Medicare Advantage Drug Plan Enrollees in 2025 – $45 versus $7, on Average

The estimated national average monthly PDP premium is projected to be $45 in 2025, which is six times higher than the average $7 monthly premium for drug coverage in MA-PDs (Figure 4). Between 2024 and 2025, the average monthly premium is increasing by $3 for PDPs but decreasing by $2 for MA-PDs. MA-PD sponsors can use rebate dollars from Medicare payments to lower or eliminate their Part D premiums and offer extra benefits, but there is no equivalent rebate system for PDPs. According to MedPAC, Medicare Advantage monthly rebates per enrollee have more than doubled since 2018, from $95 to $194 in 2024, and of the $194 total monthly rebate amount in 2024, $24 was used to reduce MA-PD Part D premiums.

It is likely that, after accounting for enrollment choices by new enrollees and plan changes by current enrollees, the actual average weighted PDP premium for 2025 will be lower than the estimated weighted average of $45 but still well above the average MA-PD premium.

There are two mechanisms in place that are helping to constrain Part D premium increases for PDPs between 2024 and 2025:

• One is a premium stabilization provision in the Inflation Reduction Act that capped annual growth in the Part D base beneficiary premium at 6% beginning in 2024. (The base beneficiary premium is not the same as the amount that Part D enrollees pay for coverage, and the law did not cap the growth in individual plan premiums to 6%.)
• The other is a new voluntary Part D premium stabilization demonstration for PDPs, which capped premium increases at $35 per month, along with other measures intended to stabilize the PDP market as changes to the Part D benefit take effect in 2025, including a new $2,000 out-of-pocket drug spending cap. MA-PDs are not eligible for this demonstration.

Without these mechanisms in place, it is likely that the average PDP premium increase, and monthly PDP premium amounts in 2025, would have been larger.

Average Monthly Premiums for the 12 National PDPs Are Projected to Range from $3 to $128 in 2025

Actual Part D premiums for 2025 vary widely across plans, as in previous years, and may be increasing by more or less than the national average (or even decreasing). Among the 12 national PDPs, there is a difference of more than $1,500 in average annual premiums between the highest-premium PDP and the lowest-premium PDP. At the high end, the monthly premium for Humana Premier Rx Plan (the 8^th largest plan by overall enrollment) will be $128, totaling more than $1,500 annually. At the low end, the monthly premium for Wellcare Value Script (the largest plan) will average just over $3, or $38 annually (Figure 5).

In addition to Humana Premier Rx Plan, two other national PDPs will charge monthly premiums of more than $100 in 2025, on average: Cigna Healthcare Extra Rx, the 12^th largest plan ($102), and Wellcare Medicare Rx Value Plus, the 10^th largest plan ($107). An estimated 1.3 million people will be enrolled in the 3 national PDPs that charge more than $100 per month in premiums in 2025 if they make no changes to their coverage during open enrollment. Another 2.0 million enrollees will pay an average $95 monthly premium for the AARP Medicare Rx Preferred PDP in 2025, unless they switch plans.

Monthly premiums for several national PDPs vary widely around each plan’s national average (Figure 5). For 6 of the 12 national PDPs, there is a difference of $90 or more across the 34 PDP regions between the plan’s lowest and highest premiums. For example, the monthly premium for the AARP Medicare Rx Saver PDP averages $67 but ranges from $0 to $128 across regions; and for Humana Basic Rx, the average premium is $43 but ranges across regions from $0 to $121. For most of these 12 national plans, monthly premiums are consistently higher in New York and California relative to other regions.

More Than Half of Stand-Alone PDP Enrollees Will See a Reduction or No Change in Their Monthly Premium in 2025 if They Stay in Their Current Plan

Of the 13.1 million Part D PDP enrollees who are responsible for paying the entire premium, which excludes Low-Income Subsidy (LIS) recipients, more than half (54%), or 7.0 million enrollees, will see either a reduction in their monthly premium (41%) or no change (13%) if they stay in their current plan for 2025 (Figure 6). Just under half of Part D stand-alone plan enrollees (46%, or 6.0 million) will see their monthly premium increase in 2025 if they make no change to their coverage during open enrollment for 2025. This is lower than the two-thirds of non-LIS PDP enrollees (66%, or 8.6 million) who were projected to pay higher monthly premiums if they remained in their plan for 2024.

Of the 6 million non-LIS PDP enrollees who will see an increase in their Part D premium if they stay in their current plan, 3.4 million (26% of non-LIS PDP enrollees overall) will see an increase of less than $35 and 2.6 million (20% overall) will see an increase of exactly $35. This is the maximum monthly premium increase allowed for PDPs participating in the new Part D premium stabilization demonstration. According to CMS, virtually all PDP enrollees are in plans sponsored by insurers that opted to participate in the voluntary demonstration.

Medicare Part D enrollees in national PDPs in 2024 will face a range of premium increases and decreases if they make no change to their coverage for 2025 during open enrollment (Figure 7). Notably, enrollees in two of the three PDPs sponsored by CVS Health-Aetna could see substantial premium changes, with the consolidation of SilverScript Plus and SilverScript SmartSaver PDPs into one PDP for 2025 (SilverScript Choice). If they make no changes during open enrollment, the 0.3 million enrollees in SilverScript Plus in 2024 will see their monthly premiums reduced by more than half when they are crosswalked to SilverScript Choice, from $103 to $45. On the other hand, the 1.7 million enrollees in SilverScript SmartSaver will face a substantial increase, from $11 to $44, on average.

Deductibles and Cost Sharing

6 in 10 Medicare Advantage Drug Plan Enrollees Will Be in Plans That Charge a Deductible for Drug Coverage in 2025, up from 1 in 5 in 2024, and the Average Deductible is Increasing Four-Fold for MA-PD Enrollees

Among MA-PD enrollees, 60% (10.9 million) will be in a plan that charges a deductible for drug coverage if they stay in their same plan, though only 11% will be in a plan that charges the standard $590 deductible (Figure 8). The share of MA-PD enrollees who will be in plans charging a deductible for drug coverage in 2025 is increasing substantially over 2024 levels, when only 21% of MA-PD enrollees were in a plan charging a drug deductible, including 3% in plans charging the standard deductible amount.

A majority of PDP enrollees (84% or 14.5 million) will be in plan that charges a drug deductible in 2025, including three-fourths (76%) who will be in a plan that charges the standard deductible of $590, assuming no change in enrollment (Figure 8). (These estimates include Part D enrollees receiving Low-Income Subsidies, who do not pay a deductible regardless of whether their plan charges one.)

The average drug deductible charged by MA-PD plans is increasing four-fold from $59 in 2024 to $225 in 2025 (Figure 9). Of the 34 MA-PD plan choices available to the average beneficiary in 2025, 7 will charge the standard $590 deductible, while 13 will charge no deductible. In contrast, only 3 of the 36 MA-PD plan options available to the average beneficiary in 2024 charged the standard deductible and 21 MA-PDs charged no deductible.

For PDP enrollees, the average deductible is increasing from $423 in 2024 to $486 in 2025 – a higher average deductible amount but a smaller increase than for MA-PD enrollees, reflecting the fact that most PDP enrollees were already (and will continue to be) enrolled in plans that charge the standard deductible. Of the 12 national PDPs in 2025, 8 will charge the standard $590 deductible, 2 will charge a lower deductible, and 2 will charge no deductible.

A Larger Share of MA-PD Enrollees Will Face Coinsurance Rather Than Copayments for Preferred Brands and Non-Preferred Drugs in 2025 Compared to 2024

In 2025, as in prior years, Part D enrollees will face much higher cost-sharing amounts for brands and non-preferred drugs (which can include both brands and generics) than for drugs on a generic tier, and a mix of copayments and coinsurance for different formulary tiers. Coinsurance can mean less predictable out-of-pocket costs than copayments. The typical five-tier formulary design in Part D includes tiers for preferred generics, generics, preferred brands, non-preferred drugs, and specialty drugs.

In a notable change for 2025, a larger share of MA-PD enrollees is in plans charging coinsurance rather than flat copayments for preferred brands and non-preferred drugs compared to 2024 levels. The share of MA-PD enrollees facing coinsurance for preferred brands is increasing from 2% in 2024 to 28% in 2025, and the share facing coinsurance for non-preferred drugs is increasing from 11% in 2024 to 57% in 2025.

Among all Part D plans, median standard cost sharing in 2025 for different types of drugs is (Figure 10):

• Generics: $0 for preferred generics and $5 for other generics in both PDPs and MA-PDs.
• Preferred brands: a copayment of $47 in both PDPs and MA-PDs, or coinsurance of 20% in PDPs and 24% in MA-PDs); 83% of PDP enrollees and 28% of MA-PD enrollees face coinsurance rather than copayments for preferred brands.
• Non-preferred drugs: For non-preferred drugs, which can include both brands and generics, all PDP enrollees face a median coinsurance of 40%; 57% of MA-PD enrollees face a median coinsurance rate of 42%, and 43% of MA-PD enrollees face a median copayment of $100.
• Specialty drugs: Median coinsurance for specialty drugs is 25% for PDP enrollees and 30% for MA-PD enrollees.

Among the 12 national PDPs, 8 PDPs will charge $0 for preferred generics in 2024, but copays of $45 to $47 or coinsurance of 15% to 25% for preferred brands, and coinsurance ranging from 31% to 50% for non-preferred drugs; 4 out of the 12 national PDPs are charging the maximum 50% coinsurance for non-preferred drugs. Coinsurance for specialty tier drugs ranges from 25% to 33% in these plans, with 8 of the 12 national PDPs charging 25% and 2 charging 33%. (Plans that charge the standard deductible amount of $590 cannot charge more than 25% for specialty tier drugs.)

Low-Income Subsidy Plan Availability

In 2025, a Smaller Number of Stand-Alone PDPs Will Be Premium-Free to Enrollees Receiving the Low-Income Subsidy Than in Any Year Since Part D Started

Through the Part D LIS program, enrollees with low incomes and modest assets are eligible for assistance with Part D plan premiums and cost sharing. Nearly 14 million Part D enrollees are receiving LIS, including 9 million (66%) in MA-PDs and 4.7 million (34%) in PDPs.

In 2025, a smaller number of PDPs will be premium-free benchmark plans – that is, PDPs available for no monthly premium to Medicare Part D enrollees receiving the Low-Income Subsidy (LIS) – than in any year since Part D started, with 90 premium-free benchmark plans, or 19% of all PDPs in 2025 (Figure 11). The number of benchmark plans available in 2025 will vary by region, from one to five (Appendix Table 2).

PDPs offering basic benefits qualify to be benchmark plans if they have premiums below the benchmark amount in a region. The benchmark is calculated as a weighted average of the beneficiary premiums for basic drug coverage offered by both PDPs and MA-PDs in a region (calculated before taking MA rebates into account). (MA-PD premiums are included in this calculation even though MA-PDs do not qualify as benchmark plans.)

On average, LIS beneficiaries will have 2 benchmark plans available to them out of the average 14 PDPs available overall for 2025 – one fewer than the average number of benchmark plan options in 2024. All LIS enrollees can select any plan offered in their area, but if they enroll in a non-benchmark plan, they must pay some portion of their chosen plan’s monthly premium.

One quarter (26%) of all LIS PDP enrollees who are eligible for premium-free Part D coverage (1.1 million LIS enrollees) will pay Part D premiums averaging $30 per month in 2025 unless they switch or are reassigned by CMS to premium-free plans during the open enrollment period.

Appendix

With Donald Trump returning to the presidency and Republican control of the Senate and House, work requirements are likely to be back on the agenda—through federal legislation or Medicaid waivers. Although past legislative attempts to incorporate work requirements into Medicaid statute failed, plans from Republican and conservative groups continue to support federal legislation to allow or require work requirements in Medicaid. A Congressional Budget Office analysis of a recent work requirement proposal shows that the policy would reduce federal spending due to reductions in enrollment and increase the number of people without health insurance but would not increase employment. Several states have also continued to pursue work requirement Section 1115 waivers, often tied to Medicaid expansion efforts. South Dakota just passed a ballot measure allowing the state to pursue a work requirement for its (newly implemented) Medicaid expansion population. The makeup of state legislatures and governor control are important, as Medicaid policy changes may require state legislative action or may be authorized at the direction of the governor. While a focus on work requirements remains, data show most Medicaid adults are working or face barriers to work. Among adults with Medicaid who are under age 65 and do not have Medicare or SSI, 91% are working, or are not working due to an illness, caregiving responsibilities, or school attendance.

This issue brief briefly highlights the history of Medicaid work requirements, describes recent state activity to advance work requirement policies, and recaps the landscape of work requirement approvals and pending requests at the end of President Trump’s first term.

Work Requirement Waiver History

For the first time in the history of the Medicaid program, the Trump administration encouraged and approved Section 1115 waivers that conditioned Medicaid coverage on meeting work and reporting requirements, approving 13 state work requirement waivers. Only Arkansas implemented such requirements with consequences for noncompliance, which resulted in over 18,000 people losing coverage before a federal court deemed the work requirement unlawful. While the vast majority of enrollees were working or qualified for exemptions, barriers with meeting reporting requirements led to people getting dropped from the program. Other states that began implementation did not disenroll those who did not comply and instead paused implementation due to litigation and/or the COVID-19 pandemic.

The Biden administration withdrew Medicaid work requirement waivers in all states that had approvals, concluding that these provisions do not promote the objectives of the Medicaid program, such as promoting coverage for low-income people. Although CMS withdrew work and premium requirements in Georgia’s waiver, these provisions remain in place after a federal judge overturned the CMS withdrawal. While work requirements waivers were the subject of litigation during the Trump and Biden administrations, the Supreme Court never ruled on the issue leaving it open for future administrations; however, any future waivers with work requirements would likely face legal challenges.

Work Requirement Waiver Activity

Work Requirements Currently Implemented

Georgia’s “Pathways” waiver expands eligibility to 100% of the federal poverty level (FPL) ($25,820 for a family of three, $15,060 for an individual in 2024) for parents and childless adults, with initial and continued enrollment conditioned on meeting work requirements. This is not a full Medicaid expansion under the ACA and does not qualify for enhanced federal matching funds. The waiver was implemented in July 2023. Over a year into the demonstration, enrollment remains low—as of October 2024, the state had only enrolled about 5,100 adults, a fraction of the estimated 175,000 adults in the Medicaid “coverage gap” in Georgia (individuals who did not qualify previously for Medicaid with incomes below poverty, making them ineligible for premium subsidies in the ACA Marketplace). As of the end of CY 2023, over 90% of the $26.6 million spent on the Pathways program was spent on administrative and consulting costs (largely through contracts with Deloitte consulting), as opposed to spending on health care costs. The demonstration is set to expire on September 30, 2025.

Recent State Legislative Consideration of Work Requirements Tied to Medicaid Expansion

A few states have introduced or passed legislation tying the implementation or adoption of the ACA Medicaid expansion to work requirements (also see Appendix table for additional state-by-state details).

• South Dakota adopted the Medicaid expansion through a ballot initiative in 2022; coverage began on July 1, 2023. In early 2024, the state legislature passed a resolution adding a 2024 ballot measure that asked voters for approval to allow the state to impose work requirements on certain adults eligible for Medicaid expansion coverage. The measure passed (with 56% of voters in favor). The state must still seek CMS approval to implement work requirements.
• The March 2023 legislation that adopted the ACA Medicaid expansion in North Carolina includes a provision to seek approval for work requirements if there is any indication that CMS would approve such a waiver. Medicaid expansion coverage in North Carolina began on December 1, 2023. In less than a year, nearly 580,000 expansion adults have enrolled.
• After a failed effort in 2024, the Mississippi legislature may revisit whether to adopt and implement the ACA Medicaid expansion with a work requirement during the 2025 legislative session (which starts in January).
• In January 2024, bills to introduce the Kansas governor’s proposal to expand Medicaid, which for the first time included a work requirement, were referred to the legislature. While the legislature held a hearing on the governor’s proposed legislation, both the House and Senate bills died in committee.
• In January 2024, legislators in Idaho introduced a bill that would have repealed the state’s Medicaid expansion if work requirements and other conditions were not met, but it failed to advance after a House committee voted to hold the bill.

Work Requirement Requests Submitted During Biden Administration

In June 2023, Arkansas requested federal approval to condition Medicaid expansion QHP coverage (expansion adults in Arkansas are enrolled in ACA Marketplace plans) on meeting a work requirement. Individuals that do not comply with workforce activity requirements, including following individualized plans created by assigned “care coordinators,” would be transitioned from Marketplace coverage to fee-for service coverage (where individuals may face different provider networks). This waiver remains pending at CMS.

Recap: Work Requirement Approvals & Pending Requests at End of President Trump’s First Term

CMS under the Trump administration approved waivers with work requirements in 13 states. Across states, work requirement waivers were generally similar in conditioning Medicaid coverage for certain adults on reported employment or other qualifying activities, with some variation in technical details. For example, waivers varied by population (with most applying to expansion adults), exemptions (e.g., for older age or medical frailty), qualifying activities, number of required hours, reporting methods/requirements, and consequences for noncompliance. Nine additional state work requirement requests were pending (i.e., had not been approved) at the end of President Trump’s first term. For state-level detail on the approved waivers as well as additional requests that were not approved by the end of the Trump administration, see KFF’s 1115 waiver tracker.

Note that work requirement waivers submitted to the Trump administration date back several years. Changes in the makeup of state legislatures and governors will impact state interest in pursuing these policies. Some states require state legislative action before state plan amendments or Section 1115 waiver requests can be submitted by the state Medicaid agency to CMS for federal approval and others do not.

Appendix

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

Introduction

Immigration was a central campaign issue during the 2024 Presidential election with President-elect Trump vowing to take strict action to restrict both lawful and unlawful immigration into the U.S. Such actions would have stark impacts on the health and well-being of immigrant families as well as major economic consequences for the nation. As of 2023, there were 47.1 million immigrants residing in the U.S., and one in four children had an immigrant parent.¹  Increased immigration boosts federal revenues and lowers the national deficit through immigrants’ participation in the country’s economy, workforce, and through billions of dollars in tax contributions.

This issue brief discusses key changes to immigration policies that may take place under the second Trump administration based on his previous record and campaign statements, and their implications. President-elect Trump has indicated plans to restrict and eliminate legal immigration pathways, including humanitarian protections, and deport millions of immigrants, which would likely lead to separation of families, negative mental and physical impacts for immigrant families, and negative consequences on the nation’s workforce and economy.

Expected Policy Changes

Elimination of Deferred Action for Childhood Arrivals (DACA) Program

The future of the DACA program remains uncertain due to pending litigation, and President-elect Trump tried to eliminate DACA during his first term; over half a million DACA recipients would lose protected status if it is eliminated. DACA was originally established via executive action in June 2012 to protect certain undocumented immigrants who were brought to the U.S. as children from removal proceedings and receive authorization to work for renewable two-year periods. During his prior term, President-elect Trump sought to end DACA but was blocked by the Supreme Court in 2020. The Biden administration issued regulations in 2022 to preserve DACA protections. In September 2023, a district court in Texas ruled the DACA program unlawful, preventing the Biden administration from implementing the new regulations while the case awaits a decision in the Fifth Circuit Court of Appeals. Under pending court rulings, while the Department of Homeland Security (DHS) is accepting first-time DACA requests, it is unable to process them. DHS is continuing to process DACA renewal requests and related requests for employment authorization. After the attempt to end DACA failed in 2020, the Trump administration said that it would try again to eliminate DACA protections, and, if the pending court ruling finds the program unlawful, the administration is unlikely to appeal the decision. However, in a recent interview, President-elect Trump indicated that he would work on addressing the status of “Dreamers” and indicated a willingness to work with Democrats on the issue, although the details of this proposed plan remain unclear. There are over half a million active DACA recipients, a majority of whom are working and many of whom have U.S.-born children, who could be at risk of deportation if the program is eliminated.

A recent health coverage expansion to DACA recipients has also been eliminated by the Trump administration. In May 2024, the Biden administration published regulations to extend eligibility for Affordable Care Act (ACA) Marketplace coverage with premium and cost-sharing subsidies to DACA recipients, who were previously ineligible for federally funded health coverage options. The regulation became effective November 1, 2024, allowing for enrollment during the 2025 Open Enrollment Period. In August 2024, a group of 19 states filed a lawsuit against the federal government alleging that the ACA Marketplace coverage expansion to DACA recipients violates the Administrative Procedure Act. On December 9, 2024, a federal court in North Dakota granted the plaintiffs’ motion by blocking the ACA coverage expansion from being implemented in the 19 states that filed the lawsuit (AL, AR, FL, IA, ID, IN, KS, KY, MS, MT, ND, NE, NH, OH, SC, SD, TN, TX, VA). On December 16, 2024, the U.S. Court of Appeals for the Eighth Circuit issued a temporary stay of the federal court’s injunction, temporarily allowing DACA recipients in all states to sign up for ACA Marketplace coverage. However, on December 23, 2024, the U.S. Court of Appeals for the Eighth Circuit vacated the administrative stay, thereby making DACA recipients in the aforementioned 19 states ineligible for ACA Marketplace coverage again. On June 25, 2025, the Centers for Medicare and Medicaid Services (CMS) finalized a rule that will exclude DACA recipients from the definition of “lawfully present” immigrants for the purposes of health coverage, making them ineligible to purchase coverage through the ACA Marketplaces beginning 60 days after the final rule’s publication.  Elimination of the coverage expansion could leave thousands of DACA recipients without an affordable coverage option.

Changes to Public Charge Policy

President-elect Trump could reinstate changes to public charge policy that he made during his first term, which led to increased fears and misinformation among immigrant families about accessing programs and services, including health coverage. Under longstanding immigration policy, federal officials can deny entry to the U.S. or adjustment to lawful permanent resident (LPR) status (i.e., a “green card”) to someone they determine to be a public charge. During his prior term, President-elect Trump issued regulations in 2019 that broadened the scope of programs that the federal government would consider in public charge determinations to newly include the use of non-cash assistance programs like Medicaid and the Children’s Health Insurance Program (CHIP). Research suggests that these changes increased fears among immigrant families about participating in programs and seeking services, including health coverage and care. Prior KFF analysis estimated that the 2019 changes to public charge policy could have led to decreased coverage for between 2 to 4.7 million Medicaid or CHIP enrollees who were noncitizens or citizens living in a mixed immigration status family. The Biden administration rescinded these changes. However, as of 2023, a majority of immigrant adults said in a KFF survey that they were “not sure” about public charge rules, and roughly one in ten (8%), rising to about one in four (27%) of likely undocumented immigrant adults, said they have avoided applying for assistance with food, housing, or health care in the past year due to immigration-related fears (Figure 1). As of November 2024, President-elect Trump has not indicated whether his administration plans to reinstate his first term changes to public charge policy.

Expanded Interior Enforcement Actions

President-elect Trump has indicated that his administration plans to carry out mass detentions and deportations of millions of immigrants, including long-term residents, which could lead to family separations and negative mental and physical health consequences. President-elect Trump has stated that he will declare a national emergency and use the U.S. military to carry out mass deportations of tens of millions of undocumented immigrants residing in the U.S., many of whom have been living and working in the country for decades. Such a policy could lead to family separations as well as mass detentions, which can have negative implications for the mental health and well-being of immigrant families and also put their physical health at risk. Tom Homan, who was the director of U.S. Immigration and Customs Enforcement (ICE) during the first Trump administration and has been selected as the incoming administration’s “border czar”, has said that it is possible to carry out mass deportations without separating families by deporting an entire family unit together, even if the child may be a U.S. citizen. As was the case during his first term, he may also carry out workplace raids as part of mass deportation efforts. Research shows that such raids can lead to family separations, poor physical and mental health outcomes for immigrant families, negative birth and educational outcomes for the children of immigrants, and financial hardship due to employment losses. Prior KFF research shows that restrictive immigration policies implemented during the first Trump administration, including detention and deportation led to increased fears and stress among immigrant families and negatively impacted the health and well-being of children of immigrants, most of whom are U.S. citizens.

Mass deportations could also negatively impact the U.S. workforce and economy, where immigrants make significant contributions. Immigrants have similar rates of employment as their U.S.-born counterparts and play outsized roles in certain occupations such as agriculture, construction, and health care. Research has found that immigrants do not displace U.S.-born workers and help foster job growth through entrepreneurship and the consumption of goods and services. Further, federal data show that unemployment rates for U.S.-born workers have not decreased between 2022 and 2023 and have remained similar to those for immigrant workers. In addition, immigrants, including undocumented immigrants, pay billions of dollars in federal, state, and local taxes each year. Mass deportation of immigrants could lead to workforce shortages in key sectors which could have negative economic consequences including an increase in the cost of essential goods such as groceries. Vice President-elect Vance has stated that immigrants are responsible for the U.S. housing crisis. While some studies show a link between immigration and rising housing costs, in general, economists are skeptical of immigration being a primary driver. Mass deportation of immigrants could also worsen housing shortages since immigrants make up a significant share of construction workers. Workplace raids can exacerbate existing labor shortages and have a negative impact on the local economies of the communities where they take place. Further, research shows that without the contributions undocumented immigrants make to the Medicare Trust Fund, it would reach insolvency earlier, and that undocumented immigrants result in a net positive effect on the financial status of Social Security. There also is likely to be a significant cost to taxpayers for the government to carry out large-scale detention and deportations.

Ending Birthright Citizenship

President-elect Trump has stated that he will sign an executive order to end birthright citizenship for the children of some immigrants despite it being a guaranteed right under the U.S. Constitution, which would negatively impact the health care workforce and economy. This proposed action would limit access to health coverage and care for the children of immigrants since they may not have lawful status. It could also have broader ramifications for the nation’s workforce and economy, potentially exacerbating existing worker shortages, including in health care. KFF analysis of federal data shows that adult children of immigrants have slightly better educational and economic outcomes than adult children of U.S.-born parents and make up twice the share of physicians, surgeons, and other health care practitioners as compared to their share of the population (13% vs. 6%) (Figure 2). Other research also has found that children of immigrants contribute more in taxes on average than their parents or the rest of the U.S.-born population, and that their fiscal contributions exceed their costs associated with health care, education, and other social services.

Reinstatement of “Remain in Mexico” Policy

President-elect Trump has stated that he will reinstate the “Remain in Mexico” border policy and that he may use military spending to carry out stricter border enforcement, which would leave an increased number of asylum seekers facing unsafe conditions at the border. The first Trump administration implemented Migrant Protection Protocols, often referred to as the “Remain in Mexico” policy, in 2019. Under this policy, asylum seekers were required to remain in Mexico, often in unsafe conditions, while they awaited their immigration court hearings. The Biden administration ended this policy in 2022, following some legal challenges, although it implemented a series of increasingly restrictive limits on asylum eligibility in 2023 and 2024 in response to a high number of border encounters. President-elect Trump said he plans to reinstate the Migrant Protection Protocols. He also has indicated that he will deploy the National Guard, as well as active duty military personnel, if needed, to the U.S.-Mexico border, although details of the plan remain unclear. Heightened military presence at the border can lead to increased fears among immigrant families living in border areas and using part of the military budget for border security could face legal challenges.

Restrictions on Humanitarian Protections

President-elect Trump said he plans to significantly limit the entry of humanitarian migrants into the U.S. during his second term by restricting refugee limits, shutting down the CBP One application for asylum seekers, and eliminating Temporary Protected Status (TPS) designations for immigrants from some countries.  During his first term, President Trump set the annual refugee admissions ceiling at its lowest levels, ranging from 50,000 in 2017 to a historic low of 18,000 in 2020. The Biden administration increased the limit to 65,000 in 2021, a level close to the annual ceilings prior to the first Trump term, and further increased the limits in 2022 and 2024 in response to humanitarian concerns. It is likely that President-elect Trump will reduce the admissions ceiling for refugees in his second term. The President-elect has also said that he will close the CBP One application created by the Biden administration which allows asylum seekers to seek lawful entry to the U.S. by making an interview appointment with the DHS. While there have been implementation challenges with the CBP One application, shutting down the application could lead to “mass cancellation of appointments” and possibly an increase in attempts to cross the border outside of ports of entry. President-elect Trump also has indicated that he will roll back TPS designations for some immigrants, including those from Haiti. TPS designations protect immigrants from countries deemed unsafe by the DHS from deportation and provide them with employment authorization but do not provide a pathway to long-term residency or citizenship. As of March 2024, over 860,000 immigrants from 16 countries were protected by TPS. Loss of TPS would put people at risk for deportation, which could contribute to family separation which in turn can have negative impacts on the mental and physical health of immigrant families, and broader negative consequences for the workforce and economy.

1. KFF analysis of 2023 American Community Survey 1-year Public Use Microdata Sample. ↩︎

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. ↩︎