Medicaid Enrollment and Unwinding Tracker

Published: Sep 30, 2025
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Enrollment Data

Note: The data presented below are updated monthly as new Medicaid/CHIP enrollment data become available.

The Medicaid Enrollment and Unwinding Tracker presents the most recent data on monthly Medicaid/CHIP enrollment reported by the Centers for Medicare & Medicaid Services (CMS) as part of the Performance Indicator Project as well as archived data on renewal outcomes reported by states during the unwinding of the Medicaid continuous enrollment provision. The unwinding data were pulled from state websites, where available, and from CMS.

Medicaid/CHIP enrollment trends generally use February 2020 as the baseline month because it was the month prior to the start of the COVID-19 pandemic and implementation of the continuous enrollment provision. During continuous enrollment, which was in place during the three years of the pandemic, states paused Medicaid disenrollments. As a result, when the continuous enrollment provision ended in March 2023, national Medicaid/CHIP enrollment had increased to a record high of 94 million enrollees. Beginning April 1, 2023, states could resume disenrolling people after conducting renewals to verify eligibility for the program, though some states delayed the start of their unwinding periods until May, June, or July 2023. Most states took 12 months to complete unwinding renewals and nearly all states completed renewals by August 2024.

The figures below show Medicaid and CHIP enrollment from February 2020 through the most current month of available data. Some figures also include enrollment for adults and children in Medicaid/CHIP. Key enrollment trends as of June 2025 include:

  • There are 77.7 million people enrolled in Medicaid/CHIP nationally (Figure 1). This represents a 18% decline from total Medicaid/CHIP enrollment in March 2023, but is still 9% higher than Medicaid/CHIP enrollment in February 2020, prior to the pandemic (Figure 2 and Table 1).
  • Several factors likely explain why national Medicaid/CHIP enrollment is higher than pre-pandemic enrollment. The pandemic may have encouraged some people who were previously eligible for Medicaid but not enrolled to newly enroll in the program. During the unwinding, many states took steps to improve their renewal processes, which reduced the number of people who were disenrolled despite remaining eligible. In addition, some states expanded eligibility for certain groups since the start of the pandemic, such as the Affordable Care Act’s (ACA) Medicaid expansion.
  • Medicaid/CHIP enrollment is higher than pre-pandemic levels in all but twelve states (AR, AK, CO, ID, IA, LA, MT, NM, SC, TN, TX, and WV). Enrollment changes from pre-pandemic baseline vary from a 15% decrease in Montana to a 54% increase in North Carolina (Figure 2). Many of the states with the largest increases in enrollment expanded eligibility since the start of the pandemic. For example, five states (NE, OK, MO, SD, and NC) implemented the Medicaid expansion between October 2020 and December 2023 and Maine increased the income limit for children to qualify for Medicaid.
  • In the 49 states and DC with complete enrollment data by age, there are 36.2 million children (48%) and 39.7 million adults (52%) enrolled, a change from pre-pandemic (February 2020) enrollment patterns when children made up a slight majority (51%) of Medicaid/CHIP enrollees (Figure 1).
  • Child enrollment in Medicaid/CHIP is below pre-pandemic enrollment in 16 states, while adult enrollment is below pre-pandemic levels in 12 states (Figure 2).
  • There are 70.5 million people enrolled in Medicaid and 7.2 million people enrolled in CHIP (Figure 1). More states report Medicaid enrollment above their pre-pandemic baselines compared to the number reporting CHIP enrollment above the baseline (Figure 2).
National Enrollment in Medicaid/CHIP, February 2020 to April 2025
Cumulative Percent Changes in Enrollment from February 2020 to April 2025
Total Medicaid/CHIP Enrollment, Selected Time Periods

Unwinding Data – Archived

Note: The data on unwinding renewal outcomes presented below were last updated on September 12, 2024; since most states have now completed the Medicaid unwinding, the information will not be updated again.

As of September 12, 2024 and with nearly complete unwinding data for most states: 

  • Over 25 million people were disenrolled (31% of completed renewals) and over 56 million people had their coverage renewed (69% of completed renewals).  
  • Disenrollment rates varied across states from 57% in Montana to 12% in North Carolina, driven by a variety of factors including differences in renewal policies and procedures as well as eligibility expansions in some states.  
  • Among those who were disenrolled, nearly seven in ten (69%) were disenrolled for paperwork or procedural reasons while three in ten (31%) were determined ineligible.  
  • Among those whose coverage was renewed during the unwinding, 61% were renewed on an ex parte, or automated, basis, meaning the individual did not have to take any action to maintain coverage. 

State Data on Renewal Outcomes

The data on unwinding-related renewal outcomes presented in this section rely primarily on monthly reports that states were required to submit to the Centers for Medicare & Medicaid Services (CMS) during the unwinding period. The data also reflect updates to the monthly reports that states submit three months after the original report submission to account for the resolution of pending cases and any other changes in renewal metrics. For 13 states, data were pulled from dashboards or reports published on state websites that provide more complete information, and for a few additional states, updated monthly reports were pulled from state websites because they were more timely than what is reported on the CMS website. 

To view archived data for specific states, click on the State Data – Archived tab.

 

As of August 1, 2024, States Have Reported Renewal Outcomes for Over Eight in Ten People who were Enrolled in Medicaid/CHIP Prior to the Start of the Unwinding

  

Medicaid Disenrollments

  • As of September 12, 2024, at least 25,198,000 Medicaid enrollees had been disenrolled during the unwinding of the continuous enrollment provision. Overall, 31% of people with a completed renewal were disenrolled in reporting states while 69%, or 56.4 million enrollees, had their coverage renewed.
  • There is wide variation in disenrollment rates across reporting states, ranging from 57% in Montana to 12% in North Carolina. A variety of factors contribute to these differences, including differences in renewal policies and system capacity. Some states adopted policies that promote continued coverage among those who remain eligible and/or have automated eligibility systems that can more easily and accurately process renewals while other states have adopted fewer of these policies and have more manually-driven systems. In addition, North Carolina and South Dakota adopted Medicaid expansion and other states increased eligibility levels for certain populations (e.g., children, parents, etc.) during the unwinding, which may have lowered disenrollment rates in these states.

At least <b>24,838,000</b> Medicaid enrollees have been disenrolled with publicly available unwinding data, as of August 1, 2024

 

  • Across all states with available data, 69% of all people disenrolled had their coverage terminated for procedural reasons. However, these rates vary based on how they are calculated (see note below). Procedural disenrollments are cases where people are disenrolled because they did not complete the renewal process and can occur when the state has outdated contact information or because the enrollee does not understand or otherwise does not complete renewal packets within a specific timeframe. High procedural disenrollment rates are concerning because many people who are disenrolled for these paperwork reasons may still be eligible for Medicaid coverage. 

(Note: The first tab in the figure below calculates procedural disenrollment rates using total disenrollments as the denominator. The second tab shows these rates using total completed renewals, which include people whose coverage was terminated as well as those whose coverage was renewed, as the denominator. And finally, the third tab calculates the rates as a share of all renewals due, which include completed renewals and pending cases.)

Of all people who were disenrolled, 69% were terminated for procedural reasons, as of August 1, 2024

Medicaid Renewals

  • Of the people whose coverage has been renewed as of September 12, 2024, 61% were renewed on an ex parte basis while 39% were renewed through a renewal form, though rates vary across states. Under federal rules, states are required to first try to complete administrative (or “ex parte”) renewals by verifying ongoing eligibility through available data sources, such as state wage databases, before sending a renewal form or requesting documentation from an enrollee. Ex parte renewal rates varied across states from 90% or more in Arizona, North Carolina, and Rhode Island to less than 20% in Pennsylvania and Texas. 

Overall, 61% of people who retained Medicaid coverage were renewed through ex parte processes, as of August 1, 2024

Federal Data on Renewal Outcomes

The data presented here are cumulative unwinding metrics published by CMS. These counts and percentages may differ from the above data, which present renewal metrics reported on state websites when state-reported data are more complete.  

Figure 1 below shows cumulative renewal data reported by CMS during states’ unwinding periods. Renewal data for the months after the end of states’ unwinding period are excluded. The data reflect updated unwinding data reported by states three months after the original monthly reports as they become available.   

Cumulative Medicaid Renewal Outcomes for Reporting States through April 2023

For questions about this tracker, please contact KFFTracker@kff.org

State Data – Archived

Note: The state data presented below were last updated on September 12, 2024; since most states have now completed the Medicaid unwinding, the information will not be updated again. 

The data presented here provide state-level data on enrollment trends and renewal outcomes during the unwinding period. Figure 1 shows total Medicaid enrollment by month starting in January 2023 and, once disenrollments resumed in a state, the cumulative percent change in Medicaid enrollment relative to the month before Medicaid disenrollments started (this baseline month will differ across states). Figure 2 shows renewal metrics for each month of a state’s unwinding period (or cumulative data for the unwinding period for some states). 

For total national Medicaid enrollment, click on the Enrollment Data tab.

Related Resources

Resources on unwinding data

Resources on state policies and preparations for the unwinding

Resources on pre-pandemic enrollment patterns and coverage transitions

KFF’s unwinding explainer

More On
Medicaid State Health Policy and Data Uninsured Access to Care Children's Health Insurance Program (CHIP) Enrollment

Also of Interest

Overview of President Trump’s Executive Actions on Global Health

Published: Sep 30, 2025

Note: Originally published on Jan. 28, 2025, this resource is updated as needed, most recently on September 30, 2025, to reflect additional developments. 

Starting on the first day of his second term, President Trump began to issue numerous executive actions, several of which directly address or affect U.S. global health efforts.* This guide provides an overview of these actions, in the order in which they were issued. The “date issued” is date the action was first taken; subsequent actions are listed under “What Happens/Implications.” See an accompanying timeline of events specific to the foreign aid review and USAID dissolution.

President Trump’s Executive Actions on Global Health

Initial Rescissions Of Harmful Executive Orders And Actions, January 20, 2025
PURPOSE: Initial rescissions of Executive Orders and Actions issued by President Biden.

Among these orders are several that addressed the COVID-19 pandemic and global health security, such as Executive Order 13987 (Organizing and Mobilizing the United States Government To Provide a Unified and Effective Response To Combat COVID-19 and To Provide United States Leadership on Global Health and Security),  which among other things established the National Security Council Directorate on Global Health Security and Biodefense and a Senior Director position to oversee it.

What Happens Next/Implications: Given that most of the provisions in the COVID-19 and Global Health Security actions issued by President Biden are no longer current or relevant, the rescissions of these actions are likely to have minimal effect on government policies. One exception may be the elimination of the Directorate of Global Health Security and Biodefense and its Senior Director at the National Security Council, which were responsible for interagency coordination on global health security matters during the Biden Administration. The elimination of this office echoes a similar move made during the first Trump Administration to eliminate an NSC Directorate for Global Health Security, and raises questions about who and which offices at NSC (and across the government) will fill this coordination role in the new Administration. More rescissions of other Biden administration Executive Actions may be issued at a later date.
Withdrawing The United States From The World Health Organization, January 20, 2025
PURPOSE: To withdraw from the World Health Organization (WHO).

“The United States noticed its withdrawal from the World Health Organization (WHO) in 2020 due to the organization’s mishandling of the COVID-19 pandemic that arose out of Wuhan, China, and other global health crises, its failure to adopt urgently needed reforms, and its inability to demonstrate independence from the inappropriate political influence of WHO member states.  In addition, the WHO continues to demand unfairly onerous payments from the United States, far out of proportion with other countries’ assessed payments.  China, with a population of 1.4 billion, has 300 percent of the population of the United States, yet contributes nearly 90 percent less to the WHO.”

ACTIONS: The United States intends to withdraw from the WHO. 
• The Presidential Letter to the Secretary-General of the United Nations signed on January 20, 2021, that retracted the United States’ July 6, 2020, notification of withdrawal is revoked.
• Executive Order 13987 (Organizing and Mobilizing the United States Government to Provide a Unified and Effective Response to Combat COVID–19 and To Provide United States Leadership on Global Health and Security), which, among other things, called for “engaging with and strengthening the World Health Organization” is revoked.
• Assistant to the President for National Security Affairs shall establish directorates and coordinating mechanisms within the National Security Council apparatus as necessary and appropriate to safeguard public health and fortify biosecurity.
• The Secretary of State and Director of the Office of Management and Budget shall take actions to pause future transfer of any U.S. funds, support, or resources to WHO; recall and reassign U.S. government personnel or contractors working in any capacity with WHO; and identify credible and transparent U.S. and international partners to assume necessary activities previously undertaken by WHO.
• The Director of the White House Office of Pandemic Preparedness and Response Policy shall review, rescind, and replace the 2024 U.S. Global Health Security Strategy.
• The Secretary of State shall immediately inform the Secretary-General of the United Nations, any other applicable depositary, and the leadership of the WHO of the withdrawal.
• While the withdrawal is in progress, Secretary of State will cease negotiations on the WHO Pandemic Agreement and the amendments to the International Health Regulations, and states that “actions taken to effectuate such agreement and amendments will have no binding force on the United States.”		What Happens Next/Implications: President Trump initiated a process to withdraw from the WHO during his first term in office, a process that takes a year to finalize, and halted funding. This time period was not met when President Biden took office and he reversed this decision and restored funding. Now, after issuance of a formal letter of withdrawal United Nations and WHO, the process will be initiated once again. Such a letter has been issued, indicating that membership will end as of January 22, 2026.

Per the Executive Order, U.S. government representatives may not work with WHO. While U.S. representatives attended the Executive Board meeting in February (the U.S. previously held a seat on the Executive Board), no representatives attended the World Health Assembly in May, where world leaders adopted the Pandemic Agreement. On May 30, the White House released details on the President’s Budget Request for FY 2026, requesting eliminated funding for WHO. Further, on June 3, the administration asked Congress to rescind funds previously appropriated for fiscal years 2024 and 2025, including contributions to WHO. However, for both the FY 2026 appropriations and FY2024-25 rescissions, Congress will determine the final funding levels.

As the largest donor to WHO providing approximately 16%-18% of the organization’s revenue, the absence of U.S. funding will have an impact WHO’s operations, as will the loss of U.S. technical expertise. See: KFF Fact Sheet and Quick Take
Reevaluating And Realigning United States Foreign Aid, January 20, 2025
PURPOSE: To pause funding and review all U.S. foreign assistance to assess alignment with American values.

The U.S. “foreign aid industry and bureaucracy are not aligned with American interests and in many cases antithetical to American values. They serve to destabilize world peace by promoting ideas in foreign countries that are directly inverse to harmonious and stable relations internal to and among countries.”

“It is the policy of United States that no further United States foreign assistance shall be disbursed in a manner that is not fully aligned with the foreign policy of the President of the United States.”

Calls for:

• 90-day pause in U.S. foreign development assistance (new obligations or disbursements) to assess programmatic efficiencies and consistency with U.S. foreign policy.
• Review of U.S. foreign assistance programs by the responsible department and agency heads under guidelines provided by the Secretary of State, in consultation with the Director of OMB.
• Responsible department and agency heads, in consultation with the Director of OMB, will make determinations within 90 days of this order on whether to continue, modify, or cease each foreign assistance program based upon the review recommendations, with the concurrence of the Secretary of State.
• New obligations and disbursements may resume for a program prior to the end of the 90-day period if a review is conducted, and the Secretary of State or his designee, in consultation with the Director of OMB, decide to continue the program in the same or modified form.  Additionally, any other new foreign assistance programs and obligations must be approved by the Secretary of State or his designee, in consultation with the Director of OMB.
• The Secretary of State may waive the pause for specific programs.		What Happens Next/Implications: Almost all global health programs are funded through foreign aid appropriations and are therefore subject to this order. The order temporarily freezes any new U.S. government spending (obligations or disbursements) through these programs, which could interrupt implementation of programs for which funds have not yet been obligated. It also calls for a 90-day review of all foreign aid programs. Key developments are as follows:
• On January 24, 2025, A Notice on Implementation of the Executive Order was issued by USAID which, among other things, calls for stop-work orders to be issued for all existing foreign assistance awards (not just new obligations and disbursements). It notes that waivers have been granted for: foreign military financing for Israel and Egypt and emergency food assistance (and related expenses) and, on a temporary basis, salaries and related administrative expenses, including travel, for U.S. direct hire employees, personal services contractors, and locally employed staff. The stop-work order on existing awards halted U.S. global health (and other foreign assistance) programs that were already underway, placing key programs at risk of not being able to provide critical services, and affecting access for individuals on the ground, unless a waiver was received.
• On January 28, the Secretary of State  issued a blanket waiver for life-saving humanitarian assistance programs, which also lays out a process for requesting additional waivers (more information is here). This guidance also states that the waiver does not apply to “activities that involve abortions, family planning, conferences, administrative costs [unless associated with waived activities], gender or DEI ideology programs, transgender surgeries, or other non-life saving assistance.”
• On February 1, PEPFAR, the global HIV/AIDS program, was granted a limited waiver enabling it to resume or continue “urgent life-saving HIV treatment  services”, defined as a set of care and treatment services and prevention of mother-to-child transmission services.
• On February 4, some additional services for other global health programs  – tuberculosis; malaria; acute risks of maternal and child mortality, including severe acute malnutrition; and other life-threatening diseases and health conditions – deemed to be “lifesaving” were also granted a limited waiver to allow them to resume or continue.
• On February 6, a lawsuit was filed by Democracy Forward and Public Citizen Litigation Group, on behalf of the American Foreign Service Association and American Federation of Government Employees, challenging the foreign aid funding freeze, the plan to put most staff on leave, and the fact that staff had already been placed on leave; on February 7, they filed a temporary restraining order (TRO). That same day, a temporary restraining order was issued by the U.S. District Court in the District of Columbia preventing the government from placing additional staff on leave or evacuating staff back to the U.S., and requiring reinstatement of all staff already placed on leave, until February 14. The court did not grant a TRO on the funding freeze, on the grounds that the plaintiffs in this case did not demonstrate that the freeze caused them irreparable harm. On February 13, the court extended the TRO through February 21 (further actions are described below, as this case was combined with another for purposes of the court’s consideration).
• On February 10, a lawsuit was filed in the U.S. District Court for the District of Columbia on behalf of two U.S. organizations seeking emergency relief from the freeze on funding for foreign assistance (AVAC v. United States Department of State).
• On February 11, a lawsuit was filed in the U.S. District Court for the District of Columbia on behalf of several U.S. organizations challenging the executive order and subsequent actions freezing foreign aid and dissolving USAID, and asking the court to temporarily restrain and preliminarily and permanently enjoin Defendants from implementing these actions (Global Health Council v. Trump).
• On February 13, the court, in a ruling pertaining to the February 10 and February 11 lawsuits brought by numerous U.S. organizations, issued a TRO preventing the Trump administration from “suspending, pausing, or otherwise preventing the obligation or disbursement of appropriated foreign-assistance funds in connection with any contracts, grants, cooperative agreements, loans, or other federal foreign assistance award that was in existence as of January 19, 2025; or issuing, implementing, enforcing”, or “otherwise giving effect to terminations, suspensions, or stop-work orders in connection with any contracts, grants, cooperative agreements, loans, or other federal foreign assistance award that was in existence as of January 19, 2025.”
• On February 14, the parties filed a joint status report proposing an expedited preliminary injunction briefing schedule.
• On February 18, the government filed a required status report stating that, despite the TRO, it had the authority to cancel contracts and suspend grant awards.
• This was followed by a February 19 request by the February 10 plaintiffs (AVAC v. Department of State) for an emergency motion to enforce the TRO and to hold the defendants in civil contempt.
• The defendants filed a required response on February 20, stating that they have not violated the TRO and should not be held in contempt, which was again opposed by the plaintiffs. Also on February 20, the February 11 plaintiffs (Global Health Council v. Trump) filed a response to the defendant’s status report with a motion to enforce the TRO.  The court reaffirmed the TRO on February 20 (but did not hold the defendants in contempt), stating it was prepared to hold a hearing on the preliminary injunction motions in both cases by March 4, 2025 and that the TRO would be in place through March 10, 2025, or the date the Court resolves the preliminary injunction motions, whichever is sooner.
• The plaintiffs filed an emergency order to enforce the TRO on February 24, due to continued lack of payment, and the court issued a motion to enforce on February 25. The government appealed, (asking for a stay pending appeal) but this was denied by the court. The government then appealed to the Supreme Court and was granted a stay until February 28 while the case was considered.
• On March 5, the Supreme Court denied the government’s request to vacate the federal district court’s TRO, sending the order back to the district court to clarify the government’s obligations for ensuring compliance with the TRO.
• On March 6, the federal district court judge ordered the government to release all payments that were due to plaintiffs as of February 13, by Monday, March 10 at 6pm, and on March 10, the federal district court judge preliminarily enjoined the government from taking certain actions related to the foreign aid freeze.
• On March 10, Secretary Rubio announced that a six-week review had been completed and that 83% of programs at USAID (5,200 contracts) had been cancelled. That same day, the court  preliminarily enjoined the government from enforcing actions taken to implement the foreign aid freeze (requiring it to reverse any terminations, suspensions, and stop-work orders and to pay for any work completed by February 13). The court stated that the government was “enjoined from unlawfully impounding congressionally appropriated foreign aid funds and shall make available for obligation the full amount of funds that Congress appropriated for foreign assistance programs in the Further Consolidated Appropriations Act of 2024.”
• On April 1, the government filed an appeal with the U.S. Court of Appeals for the District of Columbia challenging the preliminary injunction issued on March 10.
• On April 17, the administration extended the foreign aid review for another 30 days from the original deadline of April 20, 2025.
•On May 2 and May 30, the White House released information on its budget request for FY 2026, proposing significant decreases, and in some cases eliminations, of funding for global health activities. However, Congress will determine the final funding levels.
• On June 3, the administration asked Congress to rescind previously appropriated funds for fiscal years 2024 and 2025, including $8.3 billion in foreign assistance, of which at least $1.2 billion was designated for global health. However, Congress will need to approve any potential rescissions.
• On August 13, the U.S. District Court of Appeals for the District of Columbia Circuit partially vacated the March 10 preliminary injunction in the cases GHC v. Trump and AVAC v. State Department which required the government to make congressionally appropriated foreign assistance funds available for obligation. The appeals court ruled that the plaintiffs did not have the authority to challenge the President’s impoundment of funds. Instead, the court ruled that challenges of impoundment should be brought forward by the Comptroller General.
• On August 28, the U.S. District Court of Appeals for the District of Columbia Circuit amended its opinion, clarifying that while plaintiffs did not have the authority to challenge impoundment of foreign assistance funds through the Impoundment Control Act, they could seek relief through the Administrative Procedures Act. Following this amended opinion, plaintiffs in GHC v. Trump and AVAC v. State Department cases motioned for a preliminary injunction in the U.S. district court on September 1. On September 3, the U.S. district court granted the preliminary injunction, ordering defendants to obligate expiring foreign assistance funds before the end of the fiscal year on September 30. On September 4, defendants appealed this preliminary injunction and requested a stay on the preliminary injunction pending the resolution of the appeals case, from both the district court and appeals court. These requests were both denied on September 5. On September 8, defendants requested a stay of the preliminary injunction as it pertained to funds included in the President’s proposed rescissions package from the U.S Supreme Court. On September 9, the Chief Justice of the Supreme Court granted a partial administrative stay of the preliminary injunction, and on September 26, the court granted the partial stay.

The 90-day review of foreign assistance was initially supposed to go through April 19, 2025, however, has been granted a 30-day extension.
America First Policy Directive To The Secretary Of State, January 20, 2025
PURPOSE: To put core American interests first in foreign policy.

The foreign policy of the United States “shall champion core American interests and always put America and American citizens first.”

“As soon as practicable, the Secretary of State shall issue guidance bringing the Department of State’s policies, programs, personnel, and operations in line with an America First foreign policy, which puts America and its interests first.”		What Happens Next/Implications: The State Department is responsible for the supervision and overall strategic direction of foreign assistance programs administered by the State Department and USAID, which includes the vast majority of global health assistance. It also directly oversees PEPFAR, the global HIV/AIDS program, and many aspects of global health diplomacy for the U.S. Priorities and approaches for these and other global health programs are likely to be shaped by how the White House and State Department leadership define “America First” foreign policy and American interests, and how that definition is implemented in practice.

In the President’s Budget Request for FY 2026, the request proposes eliminated funding for several global health activities, including family planning and reproductive health (FPRH), neglected tropical diseases (NTDs), and nutrition, stating these are “programs that do not make Americans safer”. However, Congress will determine final funding levels and whether to include these eliminations in its appropriations bills.

Defending Women From Gender Ideology Extremism And Restoring Biological Truth To The Federal Government, January 20, 2025
PURPOSE: To define sex as an immutable binary biological classification and remove recognition of the concept of gender identity.

The order states that “It is the policy of the United States to recognize two sexes, male and female” and directs the Executive Branch to “enforce all sex-protective laws to promote this reality”. Elements of the order that may affect global health programs are as follows:

• Defines sex as “an individual’s immutable biological classification as either male or female”.  States that “sex” is not a synonym for and does not include the concept of “gender identity” and that gender identity “does not provide a meaningful basis for identification and cannot be recognized as a replacement for sex.”
• Directs the Secretary of Health and Human Services to provide the U.S. Government, external partners, and the public clear guidance expanding on the sex-based definitions set forth in the order within 30 days.
• Directs each agency and all Federal employees to “enforce laws governing sex-based rights, protections, opportunities, and accommodations to protect men and women as biologically distinct sexes, including when interpreting or applying statutes, regulations, or guidance and in all other official agency business, documents, and communications.
• Directs each agency and all Federal employees, when administering or enforcing sex-based distinctions, to use the term “sex” and not “gender” in all applicable Federal policies and documents.
• Directs agencies to remove all statements, policies, regulations, forms, communications, or other internal and external messages “that promote or otherwise inculcate gender ideology”, and shall cease issuing such statements, policies, regulations, forms, communications or other messages. Directs agencies to take all necessary steps, as permitted by law, to end the Federal funding of gender ideology.
• Requires that Federal funds shall not be used to promote gender ideology and directs agencies to ensure grant funds do not promote gender ideology.
• Rescinds multiple executive orders issued by President Biden, including: “Preventing and Combating Discrimination on the Basis of Gender Identity or Sexual Orientation” (13988) and “Advancing Equality for Lesbian, Gay, Bisexual, Transgender, Queer, and Intersex Individuals” (14075).		What Happens Next/Implications: This order is broad, directed to all federal agencies and programs. Because PEPFAR, and some other U.S. global health programs, serve people who are members of the LGBTQ community, guidance and implementation could affect the ability of these programs to reach individuals and organizations and provide them with services. In addition, the order will likely result in the removal of existing protections based on sexual orientation and gender identity, which had been provided in agency guidance for global health and development programs. Implementation guidance has been issued and all federal agencies must comply.
Memorandum For The Secretary Of State, The Secretary Of Defense, The Secretary Of Health And Human Services, The Administrator Of The United States Agency For International Development, January 24, 2025
PURPOSE: To reinstate Mexico City Policy and direct review of programs per the Kemp-Kasten Amendment.
• Revokes President Biden’s Presidential Memorandum of January 28, 2021 for the Secretary of State, the Secretary of Defense, the Secretary of Health and Human Services, and the Administrator of the United States Agency for International Development (Protecting Women’s Health at Home and Abroad)
• Reinstates President Trump’s Presidential Memorandum of January 23, 2017 for the Secretary of State, the Secretary of Health and Human Services, and the Administrator of the United States Agency for International Development (The Mexico City Policy).
• Directs the Secretary of State, in coordination with the Secretary of Health and Human Services, to the extent allowable by law, to implement a plan to extend the requirements of the reinstated Memorandum to global health assistance furnished by all departments or agencies.
• Directs the Secretary of State to take all necessary actions, to the extent permitted by law, to ensure that U.S. taxpayer dollars do not fund organizations or programs that support or participate in the management of a program of coercive abortion or involuntary sterilization.		What Happens Next/Implications: The Mexico City Policy is a U.S. government policy that – when in effect – has required foreign NGOs to certify that they will not “perform or actively promote abortion as a method of family planning” using funds from any source (including non-U.S. funds) as a condition of receiving U.S. global family planning assistance and, when in place under the Trump administration, most other U.S. global health assistance. First announced in 1984 by the Reagan administration, the policy has been rescinded and reinstated by subsequent administrations along party lines since; it was widely expected that the President Trump would reinstate it in his second term. The new memorandum calls for the implementation of a plan to extend the requirements to global health assistance furnished by all departments or agencies; until the plan is ready, the scope of the new memorandum is unknown.

The new memorandum also directs the Secretary of State to review programs under the Kemp-Kasten amendment, a provision of U.S. law that states that no U.S. funds may be made available to “any organization or program which, as determined by the [p]resident of the United States, supports or participates in the management of a program of coercive abortion or involuntary sterilization.” It has been used in the past to prevent funding from going to UNFPA.

See: KFF Mexico City Policy explainer and related resources and Kemp-Kasten explainer.
Renewed Membership in the Geneva Consensus Declaration on Promoting Women’s Health and Strengthening the Family, January 24, 2025
PURPOSE: To rejoin the Geneva Consensus Declaration.

The United States informed signatories of the Geneva Consensus Declaration of its intent to rejoin immediately. Established in 2020, the declaration, led by the United States, has the following objectives: “to secure meaningful health and development gains for women; to protect life at all stages; to defend the family as the fundamental unit of society; and to work together across the UN system to realize these values.”

What Happens Next/Implications: The Geneva Consensus Declaration, initially crafted and signed by the U.S. – along with 31 other countries at the time – was meant to enshrine certain values and principles related to women’s health and family, including a rejection of the “international right to abortion.”  The Biden administration withdrew from the Consensus in 2021.
Review of and Changes to USAID, January 27, 2025
Reorganization of the Department of State, April 22, 2025
PURPOSE: To review and potentially reorganize USAID “to maximize efficiency and align operations with the national interest,” which may include the suspension or elimination of programs, projects, or activities; closing or suspending missions or posts; closing, reorganizing, downsizing, or renaming establishments, organizations, bureaus, centers, or offices; reducing the size of the workforce at such entities; and contracting out or privatizing functions or activities performed by federal employees.What Happens Next/Implications: Related to but separate from the Executive Order on reevaluating and realigning foreign aid and on the America first policy directive to the Secretary of State, the administration has made changes to and begun a review of USAID, the U.S. government’s international development agency which oversees and/or implements most U.S. global health programs (see, The U.S. Government and Global Health). Key developments are as follows:
• On January 27, senior USAID career staff were placed on leave and hundreds of other staff were let go.
• On February 2, the USAID website was taken down.
• On February 3, the USAID building in DC was closed, which has prevented other staff from accessing it.
• The President appointed Secretary of State Rubio as Acting USAID Administrator on February 3. Secretary Rubio has said that the agency has “conflicting, overlapping, and duplicative functions that it shares with the Department of State” and that its systems and processes are not “well synthesized, integrated, or coordinated, and often result in discord in the foreign policy and foreign relations of the United States.” President Trump and other administration officials have called for dissolving the agency altogether. Formal notification of the intent to review the agency was sent by Secretary Rubio to Congress on February 3.
• On February 4, a notice was posted on the USAID website stating that on February 7, all USAID direct hire personnel would be placed on administrative leave globally, with the exception of “designated personnel responsible for mission­ critical functions, core leadership and specially designated programs.” The notice also said that staff posted outside the United States would need to return to the U.S. within 30 days.
• On February 6, a lawsuit was filed by Democracy Forward and Public Citizen Litigation Group, on behalf of the American Foreign Service Association and American Federation of Government Employees, challenging the foreign aid funding freeze, the plan to put most staff on leave, and the fact that staff had already been placed on leave; on February 7, they filed for a temporary restraining order (TRO). That same day, a temporary restraining order was issued by the U.S. District Court in the District of Columbia preventing the government from placing additional staff on leave or evacuating staff back to the U.S., and requiring reinstatement of all staff already placed on leave, until February 14. The court did not grant a TRO on the funding freeze, on the grounds that the plaintiffs in this case did not demonstrate that the freeze caused them irreparable harm. On February 13, the court extended the TRO through February 21, at which time, the court determined that further preliminary injunctive relief was not warranted and the TRO was ended, allowing the government to dismiss USAID staff.
• On February 11, a lawsuit was filed in the U.S. District Court for the District of Columbia on behalf of several U.S. organizations challenging the executive order pausing foreign aid, and subsequent actions freezing foreign aid and dissolving USAID, and asking the court to temporarily restrain and preliminarily and permanently enjoin Defendants from implementing these actions. In a February 13 ruling, a federal court issued a TRO preventing the Trump administration from freezing foreign aid assistance but stated that the proposed injunctions related to USAID were overbroad (in a separate case, the district court ended the TRO on dismissing USAID staff – see above).
• On February 13, a lawsuit was filed in the U.S. District Court for the District of Maryland by 26 former and current employees of USAID, suing Elon Musk and DOGE for taking actions to control and dissolve the agency. On February 18, the plaintiffs filed a motion for preliminary injunction. The defendants responded on February 24 and the plaintiffs replied on February 26. On March 18, the court granted a preliminary injunction, requiring the defendants to reverse many of the actions taken to dissolve USAID, and on March 21, the defendants filed an appeal on the preliminary injunction. On March 25, the U.S. 4th Circuit Court of Appeals granted the defendants’ motion for a temporary stay on the preliminary injunction, allowing DOGE to resume its efforts to dissolve USAID, until March 27. The following day on March 28, the court granted defendants’ motion for a stay, clearing the path for DOGE to continue its work dissolving USAID.
• On February 18, a lawsuit was filed in the U.S. District Court for the District of Columbia on behalf of the Personal Services Contractor Association (representing USAID personal service contractors) challenging the suspension of foreign assistance and the actions related to USAID, including “steps to dismantle USAID, cripple its operations, or transfer its functions to the State Department without Congressional authorization”. On February 19, the plaintiffs filed a motion for a temporary restraining order. On March 6, the court denied the TRO request.
• On March 28, Secretary Rubio announced that the Department of State and USAID have notified Congress on their intent to “undertake a reorganization that would involve realigning certain USAID functions to the Department by July 1, 2025, and discontinuing the remaining USAID functions that do not align with Administration priorities.” Additionally, nearly all the remaining USAID staff received notice that they would be subject to a final reduction-in-force.
• On April 22, Secretary Rubio announced the Department of State’s reorganization plan and new organization chart. The plan states that it would consolidate functions and remove non-statutory programs that are “misaligned with America’s core national interests.”
• On April 28, a lawsuit was filed by a group of labor unions, non-profits, and local governments challenging the administration’s moves to drastically reshape several federal agencies without congressional approval (American Federation of Government Employees v. Trump). The district court issued a TRO on May 9 and preliminary injunction on May 22 ordering the administration to pause large-scale reductions in force, program eliminations, and other actions related to federal agency restructuring. An emergency motion by the government for a stay pending appeal of the district court’s preliminary injunction was denied on May 30.
• On May 2 and May 30, the White House released information on its budget request for FY 2026, noting the reorganization of USAID into the Department of State.
• On May 29, the Department of State notified Congress of its reorganization plans, including absorbing USAID’s continued functions.
• On June 13, the district court in American Federation of Government Employees v. Trump ruled that the actions of the Department of State, including the reorganization announcement and notification to Congress, were in violation of the preliminary injunction.
• On July 8, the U.S. Supreme Court granted the government’s request for a stay of the preliminary injunction pending resolution of the appeals case in American Federation of Government Employees v. Trump, allowing the government to move forward with large-scale reductions to federal agency operations and workforces, including at the State Department.

While initially created through Executive Order in 1961 as part of the State Department, the Foreign Affairs Reform and Restructuring Act of 1998 established it as an independent agency within the executive branch. As such, the Executive branch does not have authority to dissolve it without Congress, and Congress also requires notification first as well as consultation on any proposed changes.
Withdrawing the United States From and Ending Funding to Certain United Nations Organizations and Reviewing United States Support to All International Organizations, February 4, 2025
PURPOSE: To review United States participation in all international intergovernmental organizations, conventions, and treaties and to withdraw from and end funding to certain United Nations (U.N.) organizations.

• The U.S. “helped found” the U.N. “after World War II to prevent future global conflicts and promote international peace and security.  But some of [its] agencies and bodies have drifted from this mission and instead act contrary to the interests of the United States while attacking our allies and propagating anti-Semitism.”
• States that the U.S. “will reevaluate our commitment to these institutions,” including three organizations that “deserve renewed scrutiny”:
• the U.N. Human Rights Council (UNHRC; the U.S. will not participate in and withhold its contribution to the budget of the body),
• the U.N. Educational, Scientific, and Cultural Organization (UNESCO; the U.S. will conduct a review of its membership in the body within 90 days), and
• the U.N. Relief and Works Agency for Palestine Refugees in the Near East (UNRWA; reiterates that the U.S. will not contribute to the body).

    Requires that within 180 days:
  • • the Secretary of State, with the U.S. Ambassador to the U.N., conduct a review of all international intergovernmental organizations of which the U.S. is a member and provides any type of funding or other support, and all conventions and treaties to which the United States is a party, to determine which organizations, conventions, and treaties are contrary to the interests of the United States and whether such organizations, conventions, or treaties can be reformed; and
• the Secretary of State to report the findings of the review to the President, through the National Security Advisor, and provide recommendations as to whether the U.S. should withdraw from any such organizations, conventions, or treaties.		What Happens Next/Implications: With a long history of multilateral global health engagement, the U.S. is often the largest or one of the largest donors to multilateral health efforts (i.e., multi-country, pooled support often directed through an international organization). It provided $2.4 billion in assessed or core contributions in FY 2024 – 19% of overall U.S. global health funding – as well as more funding in voluntary or non-core contributions.

The U.S. is also a signatory or party to numerous global health-related international conventions, treaties, and agreements; these include those that played a role in the global COVID-19 response (such as the International Health Regulations). It often has participated in negotiations for new international instruments, although the Trump administration indicated in a Jan. 20, 2025, Executive Order, listed above, that the U.S. would no longer engage in the Pandemic Agreement (sometimes called the “Pandemic Treaty”) negotiations.

This Executive Order will have immediate impacts via the ordered actions related to the three U.N. organizations specified, much as the impacts of the Jan. 20, 2025, Executive Order on the World Health Organization (WHO, which initiated U.S. withdrawal from membership and halted U.S. funding) are already being seen. Beyond these, additional impacts of this Executive Order will be determined by the findings and recommendations of the international organizations and conventions review, particularly if U.S. support for or membership in some international organizations is recommended to be reduced or eliminated and if it recommends the U.S. withdraw from any international agreements.

Congressional notification and oversight of any proposed changes will also be important to watch, including debates about whether advice or consent or congressional notification periods are or may be required prior to withdrawing the U.S. from international instruments such as treaties.

The administration has already signaled plans to discontinue support for several international organizations in its budget request for FY 2026 by proposing eliminated funding for Gavi, the Pan American Health Organization (PAHO), the United Nations Children’s Fund (UNICEF), the United Nations Population Fund (UNFPA), and the World Health Organization (WHO). However, Congress will determine final funding levels and whether to include these eliminations in its appropriations bills.

The 180 day review of all international intergovernmental organizations goes through August 3, 2025.
Memorandum For The Heads Of Executive Departments And Agencies, February 6, 2025
PURPOSE: The memorandum seeks to “stop funding Nongovernmental Organizations that undermine the national interest and administration priorities”.

The memorandum:

• States: it is Administration policy “to stop funding NGOs [Nongovernmental Organizations] that undermine the national interest.”
• Directs heads of executive departments and agencies to review all funding that agencies provide to NGOs and “to align future funding decisions with the interests of the United States and with the goals and priorities of my Administration, as expressed in executive action; as otherwise determined in the judgment of the heads of agencies; and on the basis of applicable authorizing statues, regulations, and terms.”		What Happens Next/Implications: This memo aligns with other Executive actions that target federal funding for global health and foreign assistance programs. Implementation of this memo could result in the Administration halting funding to global health NGOs they determine “do not align with administration priorities.” No criteria for how this determination will be made has been provided.

The majority of U.S. global health assistance is channeled through NGOs. In FY22, for example, 62% of U.S. global health funding was provided to NGOs as prime partners (45% to U.S.-based NGOs and 17% to foreign-based NGOs) and others are likely sub-recipients of U.S. assistance.* As such, this Order could have a significant impact on NGOs if it is determined that they do not align with administration policies.

*Source: KFF analysis of data from www.foreignassistance.gov.
Addressing Egregious Actions of The Republic of South Africa, February 7, 2025
PURPOSE: To stop U.S. support for South Africa due to its “commission of rights violations in its country or its ‘undermining United States foreign policy, which poses national security threats to our Nation, our allies, our African partners, and our interests.”

“It is the policy of the United States that, as long as South Africa continues these unjust and immoral practices that harm our Nation:
(a)  the United States shall not provide aid or assistance to South Africa; and
(b)  the United States shall promote the resettlement of Afrikaner refugees escaping government-sponsored race-based discrimination, including racially discriminatory property confiscation.”

ACTIONS:

• All executive departments and agencies, including USAID, shall, to the maximum extent allowed by law, halt foreign aid or assistance delivered or provided to South Africa, and shall promptly exercise all available authorities and discretion to halt such aid or assistance.
• The head of each agency may permit the provision of any such foreign aid or assistance that, in the discretion of the relevant agency head, is necessary or appropriate.
• The Secretary of State and the Secretary of Homeland Security shall take appropriate steps, consistent with law, to prioritize humanitarian relief, including admission and resettlement through the United States Refugee Admissions Program, for Afrikaners in South Africa. A plan shall be submitted to the President through the Assistant to the President and Homeland Security Advisor.		What Happens Next/Implications: South Africa receives a significant amount of global health assistance, particularly for HIV/AIDS, from the United States government. The executive order allows the heads of U.S. agencies to permit the provision of foreign aid or assistance under this order at their discretion. On February 10, the U.S. Embassy and Consulates in South Africa announced that PEPFAR would not be impacted by this Executive Order and could continue under the limited waiver already granted to the foreign aid funding freeze. No other exceptions have yet been announced.

The Government of South Africa has issued a statement in response to the Executive Order that, among other things, expresses concern “by what seems to be a campaign of misinformation and propaganda aimed at misrepresenting our great nation.”

Notes and Sources:

*There are several other Executive Actions issued by the President that instruct all government agencies on a variety of topics and as such broadly affect global health program operations but are not specific to global health. These include, for example, Executive Actions withdrawing from the Paris Agreement under the United Nations Framework Convention on Climate Change and ending DEI programs. These are not included in this resource.

Sources: White House, https://www.whitehouse.gov/presidential-actions/; State Department, www.state.gov.

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U.S. Foreign Aid Freeze & Dissolution of USAID: Timeline of Events

Published: Sep 30, 2025

Starting on his first day of his second term in office, President Trump and his administration have taken several executive actions that directly impact U.S. global health efforts. This timeline, which is a companion resource to components of KFF’s Overview of President Trump’s Executive Actions on Global Health, provides a detailed overview of actions, including counter-actions, related to the administration’s efforts to freeze all U.S. foreign aid, dissolve the U.S. Agency for International Development (USAID), which implements most U.S. global health programs, and reorganize the Department of State. It will be updated as needed to reflect additional developments. 

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ACA Marketplace Premium Payments Would More than Double on Average Next Year if Enhanced Premium Tax Credits Expire

Published: Sep 30, 2025

Affordable Care Act (ACA) enhanced premium tax credits are set to expire at the end of this year. Enhanced premium tax credits were introduced in 2021 and later extended through the end of 2025 by the Inflation Reduction Act. The enhanced tax credits both increased the amount of financial assistance already eligible ACA Marketplace enrollees received as well as made middle-income enrollees with income above 400% of federal poverty guidelines newly eligible for premium tax credits.

Since the introduction of the enhanced premium tax credits, enrollment in the Marketplace has more than doubled from about 11 to over 24 million people, the vast majority of whom receive an enhanced premium tax credit. If enhanced tax credits expire, many Marketplace enrollees will continue to qualify for a smaller tax credit, while others will lose eligibility altogether and be hit by a “double whammy” of losing their entire tax credit and being on the hook for rising premiums.

Since 2014, the ACA has capped how much subsidized enrollees pay for their health insurance premiums at a certain percent of their income, on a sliding scale, with the federal government covering the remainder in the form of a tax credit. Enhanced tax credits work by further lowering the share of income ACA Marketplace enrollees pay for a plan. For example, with the enhanced tax credits in place, an individual making $28,000 will pay no more than around 1% ($325) of their annual income towards a benchmark plan. If the enhanced tax credits expire, this same individual would pay nearly 6% of their income ($1,562 annually) towards a benchmark plan in 2026. In other words, if the enhanced tax credits expire, this individual would experience an increase of $1,238 in their annual premium payments net of the tax credit.

ACA Marketplace Enrollees Will Pay More for Benchmark Coverage if Enhanced Tax Credits Expire

A previous KFF analysis, based on data released by the federal government, showed the enhanced premium tax credits saved subsidized enrollees an average of $705 annually in 2024, bringing their annual premium payment down to $888. Without the enhanced premium tax credits, annual premium payments in 2024 would have averaged $1,593 (over 75% higher than the actual $888). More recent data have not been released.

Based on the earlier federal data and more recent other publicly available information, KFF now estimates that, if Congress extends enhanced premium tax credits, subsidized enrollees would save $1,016 in premium payments over the year in 2026 on average. In other words, expiration of the enhanced premium tax credits is estimated to more than double what subsidized enrollees currently pay annually for premiums—a 114% increase from an average of $888 in 2025 to $1,904 in 2026. (The average premium payment net of tax credits among subsidized enrollees held steady at $888 annually in 2024 and 2025 due to the enhanced premium tax credits).

Premium Payments in 2026 Will More than Double if ACA Enhanced Premium Tax Credits Expire

The increase in premium payments with expiration of the enhanced premium tax credits is even higher than previously estimated for two reasons:

  • Trump administration changes to tax credit calculations, and
  • Rising 2026 premiums.

The Trump administration made changes to the way tax credits are calculated, which were finalized in the ACA Marketplace Integrity and Affordability rule. The required contribution levels that will be in place for 2026 if the enhanced tax credits are not renewed will be higher relative to the required contribution levels calculated under the original methodology based on rules in effect at the time. This means that enrollees are expected to pay a higher share of their income towards a benchmark premium plan in 2026 than they otherwise would have. Additionally, inflation in private insurance premiums has led to higher premium contribution levels than previously expected.

Additionally, insurers in the ACA Marketplace are proposing to raise their rates by a median of 18%. Fueled by rising health care costs and the expiration of the enhanced premium tax credits, insurers are proposing the largest rate increases in 2026 since 2018, the last time uncertainty over federal policy changes contributed to sharp premium increases. As premiums increase, the enhanced tax credits provide additional savings to enrollees that receive them. This means that middle-income enrollees, whose payment for a benchmark plan is currently capped at 8.5% of their income and will lose financial assistance altogether, will have to cover the cost of premium increases in addition to the amount their tax credits would have previously covered to keep their same plan.

Enrollees across the income spectrum can expect big increases in premium payments  

Annual Premium Payments Would Increase for Subsidized Enrollees by an Average of $1,016 (114%) if Enhanced Premium Tax Credits Expire

Enrollees with incomes above 400% of poverty will be subject to large increases in premium payments if enhanced premium tax credits expire. On average, a 60-year-old couple making $85,000 (or 402% FPL) would see yearly premium payments rise by over $22,600 in 2026, after accounting for an annual premium increase of 18%. This would bring the cost of a benchmark plan to about a quarter of this couple’s annual income, up from 8.5%. Meanwhile, a 45-year-old earning $20,000 (or 128% FPL) in a non-Medicaid expansion state would see their premium payments for a benchmark plan rise from $0 to $420 per year, on average, from the loss of enhanced premium tax credits. About half (45%) of ACA Marketplace enrollees have incomes between 100-150% of poverty, about a fourth (28%) have incomes between 150-250% of poverty, and roughly 1 in 10 have incomes above 400% of poverty.

Methods

The average savings by income group for 2024 were taken from the 2024 Open Enrollment report. The average yearly premium savings from enhanced premium tax credits (ePTC) for enrollees under 400% FPL were defined as the sum of the differences between the required contribution amounts with and without ePTC, using the estimated percent of plan selections with ePTC by income category and assuming a uniform income distribution within each category. To extrapolate to 2026, income was inflated by the ratio of the 2025 federal poverty guidelines to the 2023 federal poverty guidelines for an individual in the continental US. For each income category, the savings were assumed to grow as the ratio of the savings between 2026 and 2024. Due to a provision in the reconciliation bill related to subsidized ACA Marketplace eligibility for immigrants, no enrollees under 100% FPL are assumed to receive premium tax credits in 2026 and are thus not included in the calculation of average savings. For enrollees at or above 400% FPL, savings were defined as difference between the average unsubsidized premium and 8.5% of the average individual income, the required contribution under the enhanced tax credits for enrollees in this income category. For 2026, the average unsubsidized premium was assumed to be 18% higher than the 2025 average unsubsidized premium, based on analysis of rate filings. Calculations assume that there are no changes in plan selection, family composition, income relative to FPL, and geography between 2024 and 2026. The annual premium payment for 2026 comprises the estimated savings from enhanced tax credits in 2026 and the average premium payment among subsidized enrollees in 2025 obtained from the 2025 Open Enrollment State-Level Public Use File. State-funded subsidies might offset some increases of premiums but are not accounted for in the estimation. Numbers from the Open Enrollment report for estimated consumer APTC savings due to the ARP and IRA by income category (Table 8) were reported as whole numbers; a Monte Carlo method was used to account for this rounding, keeping all observations that rounded to the grand mean listed in the report.

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Health Issues for Immigrants in Detention Centers

Published: Sep 30, 2025

President Trump has increased immigration enforcement activity to support mass deportation and detention. The administration has shifted enforcement actions from focusing on criminals and recent border crossers to prioritizing all of the estimated 14 million undocumented immigrants for deportation, even though many who have some form of temporary deportation protections. As a result, there has been a significant increase in the number of immigrants detained in Immigration and U.S. Customs Enforcement (ICE) detention facilities, which have a history of inadequate compliance with health and safety standards, insufficient health care, and limited oversight.

The extent to which President Trump will be able to implement interior enforcement policies in the face of potential court challenges remains uncertain. Meanwhile, Congressional Republicans and President Trump passed the tax and spending law in July 2025, which included $191 billion for the Department of Homeland Security (DHS) to support immigration enforcement and expand detention capacity. This brief provides an overview of recent trends in detention using ICE detention data and health care risks and challenges facing those held in detention facilities. These efforts also have broader ramifications for the nation’s workforce and economy given the role immigrants play.

Detention Policies under the Trump Administration

President Trump has identified deportation as a key priority and enhanced interior immigration enforcement efforts since taking office though some policies face legal challenges. President Trump has prioritized all undocumented immigrants for deportation and rescinded numerous Biden-era policies, including a policy that protected against enforcement in “sensitive areas,” such as schools and health care facilities; a ban on collateral arrests, which will allow ICE to pursue arrests without a warrant; and deportation protections for immigrants with humanitarian parole and Temporary Protected Status from numerous countries. The 2025 tax and spending law appropriated $191 billion to DHS to support these actions and increase detention capacity.

As of September 2025, the Trump administration has nearly 60,000 immigrants held in ICE detention facilities, a 50% increase from 39,000 immigrants held in ICE facilities at the end of the Biden administration in December 2024 (Figure 1). The number of immigrants held in detention increased slightly during the first few months of the year and then saw a sharp uptick in June 2025 due to heightened interior enforcement activity by ICE. ICE detention statistics likely undercount the number of immigrants held in detention due to reporting methodology issues and because they do not include immigrants held by local authorities on detainer requests, where local jails may detain immigrants upon request until they can be transferred to ICE. An analysis of ICE facilities in July 2025 found that many facilities were at or exceeded contractual capacity, which can lead to overcrowding conditions if deportations do not keep up with the pace of arrests. Due to facilities operating at capacity limits, ICE has expanded detaining immigrants in facilities such as hotels and military bases that may be excluded from public reporting. Reflecting the shift to prioritize all undocumented immigrants for deportation, seven in ten (72%) of immigrants in detention facilities have no criminal convictions as of September 2025. The number of immigrants held in detention varies by state, reflecting a combination of where immigrants live, logistics of ICE deportation operations, and the extent to which local laws support coordination with ICE.

Number of Immigrants Detained in ICE Facilities, December 2024 to September 2025

Health Care Risks and Challenges for Immigrants in Detention Facilities

ICE is responsible for oversight and management of detention facilities, but it has a history of inadequate compliance with detention standards and insufficient health care, and research shows that immigrants in detention experience widespread health risks. ICE has published health care and safety standards for detention centers, including those that are privately run. As part of its published standards, immigrants arriving at detention facilities must undergo an initial health screening and have access to 24-hour emergency care, daily sick calls, and comprehensive health services including prevention, health education, screening, diagnosis, and treatment. However, ICE provides little to no publicly available data on health care use, quality, and outcomes, and oversight reporting is inconsistent. According to a Congressional Research Service (CRS) report, there is a history of inadequate health care standard compliance in ICE facilities. The Government Accountability Office (GAO) reported on the lack of informed consent for immigrants when receiving offsite medical care, and a DHS report found instances where ICE did not establish medical necessity for surgical procedures, including when performing sterilization procedures on migrant women. Research shows that detainees, including pregnant people and children, can receive inadequate care in detention facilities, and that most detention center deaths were associated with ICE violating their own medical standards. A study on LGBT detainees found they experienced higher rates of harassment than non-LGBT detainees. Immigrants in detention are increasingly being placed in solitary confinement, which can worsen mental health and tends more frequently utilized for those with serious mental illness. The suicide rate also significantly increased from 2010-2020 among immigrants in ICE facilities. Further, a study of immigrants released from detention found significantly higher likelihood of poor or fair self-rated health, mental illness, and PTSD among those detained 6 months or longer compared to those detained less than 6 months. Research also shows that family separation policies while in detention worsened the mental health of both children and caregivers.

The Trump administration has reduced oversight of operations in immigration detention facilities, which may have negative implications for conditions and health risks in detention centers, including for children and families in detention. The Trump administration has shut down watchdog agencies in DHS, including the Immigration Detention Ombudsman office that conducted oversight on conditions at immigration detention centers. Fewer watchdog agencies may further limit transparency and oversight of ICE operations, including on issues such as overcrowding and inadequate medical care. The administration has also attempted to terminate the Flores Settlement Agreement, which set standards for the detention, treatment, and release of immigrant children in federal custody, but federal court recently upheld the settlement. The settlement requires the government to hold minors in the least restrictive settings, prioritize release to family members, and ensure access to basic necessities like food, medical care, and sanitation. Minors may be held with their families in ICE family detention centers, while unaccompanied minors are sent to other facilities when their parents are detained or deported. The tax and spending law approved funds for indefinite family detention, which may be in violation of the Flores Settlement Agreement.

Recent reports suggest immigrants in detention facilities are facing poor and sometimes dangerous conditions for extended periods of time. Some immigrants may be held in holding facilities while they are processed, such as local jails and field offices not designed for long-term detention, and they may not be included in ICE detention statistics. An analysis of ICE detention found that most facilities exceeded contractual capacity, which can lead to overcrowding conditions if deportations do not keep up with the pace of arrests. ICE inspectors found that immigrants held in an unfinished Texas facility still under construction violated many detention standards and failed to properly treat medical conditions. Recent reports have also detailed how immigrants in detention face poor living conditions, including inadequate meals and sanitation, lack of ventilation, and exposure to extreme temperatures. Immigrants held in a Florida detention facility experienced severe overcrowding and a lack of food, and those in Texas and Louisiana experienced extreme cold that the facilities were not equipped to handle. A judge ordered a facility in New York to improve conditions after reports of immigrants being in overcrowded conditions deprived of showers, meals, and bedding. Immigrants held in detention facilities across states reported not receiving adequate meals and foodborne illnesses spreading due to poor hygiene. Families and children in a Texas family detention center reported experiencing extreme temperatures and lacked access to showers or toilets. As of September 2025, 15 immigrants have died in detention, compared to 8 deaths in all of 2024 and the most seen under ICE custody since 2020.

Mass detention efforts may lead to increased fears among immigrant families, which can have negative mental and physical health impacts on immigrants across statuses and their children. As of 2023, 19 million, or one in four, children in the U.S. had an immigrant parent, including one in ten (12%) who are citizen children with a noncitizen parent. An estimated 4.6 million U.S.-born children live with an undocumented immigrant parent. Enforcement efforts have increased worries about detention and deportation among immigrants, including among naturalized citizens, and worsened the mental health and well-being of immigrant families with undocumented immigrants. KFF survey data from March 2025 find that about a third (32%) of immigrants overall say they have experienced negative health repercussions due to worries about their own or a family member’s immigration status. Immigrants also reported they avoided seeking health care due to concerns about costs and fears, were fearful of accessing public programs, and were confused whether these programs can negatively impact immigration status. Research has found that living near areas subject to immigration enforcement raids increased the risk of negative mental health among children of immigrants and worse birth outcomes among both Hispanic immigrant mothers as well as U.S.-born Hispanic mothers as compared to non-Hispanic White mothers. Education outcomes also worsened among Hispanic children in areas impacted by raids compared to White children. Studies have also found that children and caregivers impacted by family separations experience worse mental health, including anxiety, depression, and posttraumatic stress disorder. Family separations can also lead to financial challenges for mixed-status households due to loss of income. Mass detention efforts may also have negative impacts on the nation’s economy and workforce given the outsized role immigrants play in certain industries, including health care. Over 1 million immigrants are estimated to have left the workforce since January 2025.

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Status of State Medicaid Expansion Decisions

Published: Sep 29, 2025

The Affordable Care Act’s (ACA) Medicaid expansion expanded Medicaid coverage to nearly all adults with incomes up to 138% of the Federal Poverty Level ($21,597 for an individual in 2025) and provided states with an enhanced federal matching rate (FMAP) for their expansion populations.

To date, 41 states (including DC)   have adopted   the Medicaid expansion and 10 states   have not adopted   the expansion. Current status for each state is based on KFF tracking and analysis of state expansion activity.

These data are also available in a table format. The map may be downloaded as a Powerpoint.

Status of State Action on the Medicaid Expansion Decision
Key States with Expansion Activity

Medicaid Expansion Resources

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A Look at the Potential Impact of the High Unemployment Hardship Exception to Medicaid Work Requirements

Published: Sep 29, 2025

The Republican budget reconciliation package, signed into law on July 4th, will—for the first time—require some individuals enrolled in Medicaid to meet work requirements as a condition of eligibility. When implemented by January 2027 (or sooner at state option), adults enrolled through the Medicaid expansion and certain adults enrolled in Medicaid waiver programs in Wisconsin and Georgia, will be required to work or participate in work-related activity for 80 hours or more a month or attend school half time. The law exempts certain individuals from the requirements, including parents of children ages 13 and younger, people who are medically frail, and people who meet similar work requirements in the Supplemental Nutrition Assistance Program (SNAP). The law also permits states to allow for short-term hardship exceptions for individuals who live in areas of high unemployment, where it may be more difficult to find a job.

This issue brief describes the hardship exception for individuals living in counties with high unemployment, and using the most recent available county-level unemployment data from the Bureau of Labor Statistics (BLS) and county-level Medicaid expansion enrollment data, estimates the number of counties that could meet the criteria for this exception and the number of expansion enrollees living in those counties who could be exempt from the work requirements. Because county-level enrollment data for enrollees who would be subject to work requirements in Georgia and Wisconsin are not available, this analysis only includes expansion states.

Based on this analysis, the scope of this hardship exception may be limited; just 7% of counties meet the high unemployment criteria using a 12-month average unemployment rate and 7% of enrollees live in these counties and could be exempt if their state requests the hardship exception. However, how CMS operationalizes the criteria will affect the number of counties and enrollees that qualify. Allowing states to identify counties that meet the criteria using 6-month or 3-month average unemployment rates in addition to the 12-month average rate would increase the number of counties that qualify. Also, while the current national unemployment rate is low, changes in the economy and a tightening job market could cause unemployment rates to rise. If unemployment rates increase, the number of enrollees who would qualify for this hardship exception would also increase.

What is the High Unemployment Rate Hardship Exception?

The law allows states to request a hardship exception for individuals who live in counties with high unemployment rates. Specifically, the law permits states to request exemptions for individuals who reside in counties that have unemployment rates at or above 8% or below 8% but 1.5 or more times the national average unemployment rate. This exception is optional, but for states that request the exception and receive approval, all individuals who reside in counties that meet the criteria would be exempt from the work requirements for a specified period of time. The language in the reconciliation package is similar to the statutory language that defines a waiver exemption to the work requirements in SNAP, which permits states to request exemptions for areas that have unemployment rates over 10% or that lack a sufficient number of jobs.

The law grants the Secretary of Health and Human Services (HHS) discretion in how to implement this hardship exception, including what information states must submit. While the law lays out the broad criteria needed to meet the exception, the Secretary will have the discretion to set the parameters for how the criteria will be operationalized, including what information states must provide, the length of the exception period, and the process for applying for the exception. These decisions by the Secretary will affect how easy it is for states to apply for the exception and ultimately how many counties meet the criteria and how many enrollees will be exempt from the work requirements. The law requires the Secretary of HHS to issue an interim final rule implementing the Medicaid work requirements by June 1, 2026.

CMS may look to existing SNAP regulations to help guide the criteria for qualifying for an exception. CMS officials have indicated that they plan to follow sub-regulatory guidance that already exists in other programs with similar provisions, where possible. Existing SNAP regulations provide options for the data states can use to support a waiver request, including a readily approvable waiver using 12-month average unemployment rates. The regulation also specifies that the data states submit must rely on standard BLS data or methods. Waivers are generally approved for one year; however, waivers may be approved for a shorter or longer period, if deemed appropriate. CMS may choose to follow the SNAP regulations or allow for more or less flexibility in the data that states can use to identify counties with high unemployment. These decisions will affect the number of enrollees who could qualify for the exception. States can choose whether to apply for the exception, and some may decide not to for ideological reasons or because few counties and enrollees would meet the criteria. Notably, 18 states do not have SNAP work requirement waivers.

How Many Counties and Enrollees Could Meet the High Unemployment Exception?

KFF analysis uses 12-month average county unemployment rates from June 2024 through May 2025 to estimate the number of counties that meet the criteria for the high unemployment hardship exception. The 12-month average unemployment rate is the metric used in the readily-approvable SNAP exemption waivers. The analysis then uses enrollment data for the expansion population from the 2023 T-MSIS Research Identifiable Files to estimate the number of enrollees who live in qualifying counties and who could be exempt from the work requirements if all states applied for and were granted the exceptions.

Nationally, 158 counties in expansion states meet the high unemployment criteria, and 1.4 million enrollees in these states could qualify for the hardship exception, accounting for 7% of counties and enrollees. Alternative methods could have different effects. For example, using a method where counties could qualify for the exception by meeting the unemployment criteria in any month from June 2024 to May 2025, 386 counties in 34 expansion states had unemployment rates that met the criteria. These counties represented 17% of all counties in expansion states, and 4.6 million expansion enrollees, or 23% of all expansion enrollees, reside in these counties and could be exempt from the work requirements.

1.4 million Medicaid expansion enrollees live in counties with high unemployment rates and could qualify for a hardship exception from work requirements.

Overall, while 80% of counties that meet the criteria are rural, over 80% of expansion enrollees who could be exempt from work requirements live in urban counties (Figure 2). Of the 158 counties with unemployment rates that meet the statutory criteria, 126 are located in rural areas. Because of the higher unemployment rates in rural areas, a slightly larger share of all rural counties in expansion states meet the criteria (8.5% of rural counties vs. 7% of all counties). However, because the population in rural areas is smaller, over 80% of expansion enrollees who could qualify for the hardship exception live in urban counties. Of the 1.4 million expansion enrollees who could qualify for the exception, just 273,350 (19%) are in rural counties, accounting for 10% of all expansion enrollees who live in rural counties.

While 80% of counties that meet the high unemployment criteria are rural, 80% of enrollees who could be exempt from the work requirements live in urban counties.

Nine in ten expansion enrollees who are in counties that meet the high unemployment criteria and could be exempt from the work requirements live in five states (Figure 3). Expansion enrollees who live in counties with high unemployment rates are concentrated in just five states—California, New York, Michigan, Kentucky, and Ohio. Expansion enrollees in California account for over 50% of all enrollees living in counties that meet the criteria. In New York, over 260,000 expansion enrollees, representing 18% of all enrollees who could be exempt, live in Bronx County, the only county in the state to meet the high unemployment criteria. Overall, 93% of enrollees who could be exempt live in states with Democratic governors, who would be expected to request the exception. Across the majority of expansion states, however, the impact of the high unemployment hardship exception is small. In nine states, 2,000 or fewer expansion enrollees live in counties that meet the criteria, and in 17 states no counties meet the criteria.

Nine in ten expansion enrollees who are in counties that meet the high unemployment criteria and could be exempt from the work requirements live in five states.

Rural expansion enrollees who could qualify for the hardship exception are similarly concentrated in seven states. Half of the 273,350 expansion enrollees who live in rural counties with unemployment rates that meet the criteria and who could be exempt from the work requirements live in Kentucky and Michigan (Figure 3). Another 14% live in California, 6% live in Oregon, and 5% each live in Arizona, Louisiana, and Ohio. As with counties overall, the impact of this hardship exception in rural counties is limited. Just 10% of rural expansion enrollees live in qualifying counties, and in 20 expansion states, no rural counties meet the high unemployment criteria.

Appendix

1.4 Million People May Be Exempt from the Medicaid Work Requirements through the High Unemployment Exception
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Deja Vu: the Future of Abortion Coverage in ACA Marketplace Plans

Published: Sep 26, 2025

Abortion coverage was a key issue in the debate leading up to the passage of the Affordable Care Act.  Again, it could be an issue if Congress considers extending the enhanced premium tax credits that will expire by the end of the year absent Congressional action. Without the extension of these enhanced premium tax credits, out-of-pocket premiums would rise by over 75%  on average for the vast majority of individuals and families buying coverage through the ACA Marketplaces leading to an estimated  3.8 million more people becoming uninsured as they drop their coverage over the next 10 years. Anti-abortion advocates are currently urging Congress to prohibit any premium tax credits to be used towards any plans that include abortion coverage. This policy watch explains how abortion coverage works in ACA Marketplace plans, state actions to include or exclude abortion coverage in these plans, and the potential impact if Congress bans abortion coverage in all Marketplace plans.

The ACA Explicitly Says that Federal Funds May Not Be Used to Pay for Marketplace Abortion Coverage Beyond the Hyde Limitations

The ACA statute has specific language that applies Hyde Amendment restrictions to the use of premium tax credits, limiting them to using federal funds to pay for abortions only in cases that endanger the life of the woman or that are a result of rape or incest. The ACA also explicitly allows states to bar all plans participating in the state Marketplace from covering abortions, which 25 states have done since the ACA was signed into law in 2010. On the other hand, twelve states now have laws that require all fully-insured group plans and individual plans (including Marketplace plans) to include abortion coverage. Thirteen states and DC neither require nor prohibit abortion coverage in Marketplace plans (Figure 1). Federal law prohibits Marketplace plans from offering any riders, a supplemental benefit policy that covers certain services which are not included in a standard health insurance plan. So, if a plan does not include abortion coverage, an enrollee cannot buy a rider for abortion coverage.   

Twelve States Currently Require ACA Marketplace Plans to Cover Abortion Services

ACA Rules for Premiums for Abortion Coverage 

In states that do not bar coverage of abortions on plans available through the Marketplace, insurers may offer a plan that covers abortions beyond the permissible Hyde amendment situations when the pregnancy is a result of rape, or incest or the pregnant person’s life is endangered. , but this coverage cannot be paid with federal dollars. Plans must notify consumers of the abortion coverage as part of the summary of benefits and coverage explanation at the time of enrollment. The ACA outlines a methodology for states to follow to ensure that no federal funds are used towards coverage for abortions beyond the Hyde limitations. Any plan that covers abortions beyond Hyde limitations must estimate the actuarial value, the amount the plan expects to pay on behalf of its members on average, of such coverage by taking into account the cost of the abortion benefit (valued at least $1 per enrollee per month). The law says that this estimate cannot take into account any savings that might be achieved as a result of the abortions (such as prenatal care or delivery). 

The Anti-Abortion Advocates’ Claim That Federal Funds Are Subsidizing Abortion Coverage 

Abortion opponents are claiming that federal funds are being used to subsidize abortion because they believe these subsidies enable individuals to have coverage through the ACA Marketplace that includes abortion coverage, even though plans must charge each enrollee a $1 per month to pay for the costs of covered abortions and segregate these funds from other premium funds. While the anti-abortion advocates claim that the requirement for plans to segregate premiums for abortion coverage is an “accounting gimmick,” the required minimum of $1 per member per month that is specified in the ACA is higher than issuers estimate to be the actuarial value of the premium attributable to the cost of abortion coverage. In other words, the $1 month charge per enrollee (regardless of age or gender) exceeds the cost of abortions that plans are paying for with those funds.  For example, a recent review showed that Maryland plans were holding $25 million in unspent funds from policyholder payments for segregated premiums for abortion coverage and it is very likely that plans in other states have surplus funds that have been collected for abortion coverage.  

What Would Be the Impact if Congress Bans Premium Tax Credits for Plans that Include Abortion Coverage?  

Twelve states require plans that are not self-insured to cover abortion. If Congress were to ban the use of premium tax credits for Marketplace plans that include abortion coverage beyond the Hyde restrictions, individuals in these 12 states would not be able to use federal tax credits to obtain coverage in a Marketplace plan. In 2023, approximately 3.7 million people were enrolled in ACA marketplace plans in the 12 states that require abortion coverage.  In addition, it will also affect people in the 13 states and DC that allow abortion coverage but don’t mandate it. While Democrats  may not agree to a ban on the availability of ACA premium taxes for plans that cover abortion,  the lack of a ban could make it harder to attract Republican support for an extension of the enhanced tax credits.  

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Overview of President Trump’s Executive Actions Impacting LGBTQ+ Health

Published: Sep 25, 2025

Editorial Note: This resource was originally published on February 24, 2025, and will be updated as needed to reflect additional developments.

Starting on the first day of his second term, President Trump began to issue numerous executive actions, several of which directly address or affect health programs, efforts, or policies to meet the health needs of LGBTQ+ people. This guide provides an overview of these actions, in the order in which they were issued. The “date issued” is date the action was first taken; subsequent actions, such as litigation efforts, are listed under “What Happens/Implications.” It is not inclusive of administrative actions that impact LGBTQ+ people that are not directly related to health and health care access, such as efforts related to participation in sport even though those actions might have an impact on well-being. In addition, within the actions examined, only provisions directly related to health and health access are described in table.

Initial Rescissions of Harmful Executive Orders and Actions, January 20, 2025
Purpose: Initial rescissions of Executive Orders and Actions issued by President Biden.

Among these orders are several that addressed LGBTQ+ equity including “Preventing and Combating Discrimination on the Basis of Gender Identity or Sexual Orientation” (Executive Order 13988) and “Advancing Equality for Lesbian, Gay, Bisexual, Transgender, Queer, and Intersex Individuals” (Executive Order 14075). The order establishing the White House Gender Policy Council (Executive Order 14020) and several Orders related to diversity, equity, and inclusion were also rescinded, as were orders related to nondiscrimination and equity in schools.		Implications: This order could lead to less oversight, reduced health programing, and fewer policies protecting LGBTQ+ people, which could negatively impact access to care and well-being. Of particular note:

• Rescinds orders that had called for LGBTQ+ people’s health equity, the national public health needs of LGBTQ+ people, LGBTQ+ data collection, and nondiscrimination protections, including in health care.

• Rescinds orders that had called for nondiscrimination protections for LGBTQ+ young people in school, which could contribute to stigma and worsened mental health.
Defending Women From Gender Ideology Extremism and Restoring Biological Truth to The Federal Government, January 20, 2025
Purpose: To define sex as an immutable binary biological classification and remove recognition of the concept of gender identity, including in sex protections and in agency operations. 
 
The order states that “It is the policy of the United States to recognize two sexes, male and female” and directs the Executive Branch to “enforce all sex-protective laws to promote this reality”. Elements of the order that may affect LGBTQ people’s health are as follows:

• Defines sex as “an individual’s immutable biological classification as either male or female.” States that “’sex’ is not a synonym for and does not include the concept of ‘gender identity’” and that gender identity “does not provide a meaningful basis for identification and cannot be recognized as a replacement for sex.”

• Defines male and female based on reproductive cell production.Introduces the term “gender ideology” which is defined to include  “the idea that there is a vast spectrum of genders that are disconnected from one’s sex” and “maintains that it is possible for a person to be born in the wrong sexed body.”

• Directs the Secretary of Health and Human Services (HHS) to provide the U.S. government, external partners, and the public guidance expanding on the sex-based definitions set forth in the order within 30 days.

• Directs each agency and all federal employees to “enforce laws governing sex-based rights, protections, opportunities, and accommodations to protect men and women as biologically distinct sexes,” including “when interpreting or applying statutes, regulations, or guidance and in all other official agency business, documents, and communications.”

• Directs each agency and all Federal employees, “when administering or enforcing sex-based distinctions,” to “use the term ‘sex’ and not ‘gender’ in all applicable Federal policies and documents.”

• Directs agencies to “remove all statements, policies, regulations, forms, communications, or other internal and external messages that promote or otherwise inculcate gender ideology, and shall cease issuing such statements, policies, regulations, forms, communications or other messages.”

• Directs agency forms to exclude gender identity and directs agencies to “take all necessary steps, as permitted by law, to end the Federal funding of gender ideology.”

• Requires that federal funds “not be used to promote gender ideology” and directs agencies to ensure “grant funds do not promote gender ideology.”

• Directs the Attorney General to ensure the Bureau of Prisons revises policies to prohibit federal funds from being expended “for any medical procedure, treatment, or drug for the purpose of conforming an inmate’s appearance to that of the opposite sex.”

• Rescinds multiple executive orders issued by President Biden, including: “Preventing and Combating Discrimination on the Basis of Gender Identity or Sexual Orientation” (13988), “Establishment of the White House Gender Policy Council” (14020) (which is also dissolved), and “Advancing Equality for Lesbian, Gay, Bisexual, Transgender, Queer, and Intersex Individuals” (14075).

• Also directs agencies to rescind certain guidance documents, including, “The White House Toolkit on Transgender Equality”; “The Attorney General’s Memorandum of March 26, 2021 entitled “Application of Bostock v. Clayton County to Title IX of the Education Amendments of 1972,” and range of orders related to LGBTQ+ students in schools.



Implications: This order is broad, directed to all federal agencies and programs. Because federal health programs reach LGBTQ+ people, and some are specifically designed to be inclusive of the LGBTQ+ community, or account for gender identities in addition to biological sex, this Order could widely affect program funding, guidance, and access. It has several possible implications:

The terms used in the Order include several biological and social inaccuracies which could perpetuate misinformation about LGBTQ+ people and transgender people’s health needs. It also takes steps towards ban gender care in certain area, most explicitly in prisons.

Requiring that federal funds are not used to “promote gender ideology” has caused significant confusion. Since this order was issued, there have been multiple reports of HIV programs and community health centers that have lost funding as a result of supporting programs inclusive of transgender people. In addition, there have been reports that some health care facilities paused providing youth with gender affirming care, fearing that federal funding would be withheld according to this and another Order relating to youth access to gender affirming care (see separate entry). (See court decisions below.) Withholding care could lead to negative health outcomes for those that require it.

Data collection and data presentation/distribution have been impacted. At first some data was removed from federal websites, though due to court order this appears to have been restored. If public health messaging and services related to the health needs of transgender people, or other specific populations, are unavailable, this may result in adverse health outcomes such increased disease prevalence, greater difficulty with care engagement, and poor mental health outcomes. There have been reports that gender identity questions will be removed from federal surveys which makes tracking the experiences and well-being of LGBTQ+ people more difficult.

The order directs the HHS Secretary to take action to end gender affirming care through Section 1557 of the Affordable Care Act (ACA), the law’s major nondiscrimination provision, which includes protections on the basis of sex. While the Biden administration interpreted sex protections to include sexual orientation and gender identity, it is expected that the Trump administration will seek to remove these protections, as was the approach during his first term. Despite the Executive Orders and any future guidance, courts could continue to rule that such protections exist in statute.

On March 17th the VA announced that it would phase out providing gender affirming care to comply with this Executive Order. Exceptions include Veterans already receiving hormone therapy from the VA or Veterans “receiving such care from the military as part of and upon their separation from military service” who are eligible for VA health care. The VA will not provide other gender affirming medical services.

The statement writes that historically the VA had provided a range of gender affirming services and “letters of support encouraging non-VA providers to perform sex-change surgeries on Veterans.” These services had been authorized under the now rescinded Veterans Health Administration Directive 1341(4).

There have been multiple legal challenges to this Order with some judicial actions that have paused aspects of implementation:

• On February 4, 2025 a lawsuit was filed in federal court challenging the Order on the grounds that it usurps Congressional  power, violates Sec. 1557 of the ACA, and is unconstitutional and on February 11 a temporary restraining order  and memorandum opinion was issued requiring restoration of webpages, datasets, and any other  resources needed to provide medical care, identified by the Plaintiffs.

• On February 4, 2025, a separate federal lawsuit was filed challenging this Order and the Executive Order on “Protecting Children from Chemical and Surgical Mutilation” (see separate entry), asserting they are openly discriminatory, unlawful, and unconstitutional. On February 13, a federal judge issued a temporary restraining order preventing the federal government from withholding or conditioning funding on the basis of providing this care.

• An additional suit was filed on February 19, 2025 by the National Urban League, National Fair Housing Alliance, and AIDS Foundation of Chicago challenging three Executive Orders: “Ending Radical and Wasteful DEI Programs and Preferencing”, “Defending Women From Gender Ideology Extremism and Restoring Biological Truth to the Federal Government” and the “Ending Illegal Discrimination and Restoring Merit-Based Opportunity” as usurping the power of Congress, violating the Constitution and the Administrative Procedures Act, and, seeking declaratory and injunctive relief. In their complaint, plaintiffs highlight the potential harm this Order could bring to people with HIV and LGBTQ+ communities and the programs that serve them.

• On February 20, a separate case was filed in federal court by multiple LGBTQ+ health care and service organizations, challenging the “Ending Radical and Wasteful DEI Programs and Preferencing”, “Defending Women From Gender Ideology Extremism and Restoring Biological Truth to the Federal Government” and the “Ending Illegal Discrimination and Restoring Merit-Based Opportunity” Orders claiming they usurp the power of Congress and violate the Constitution. In their complaint, plaintiffs highlight the potential harm this Order could bring to people with HIV and LGBTQ communities and the programs that serve them. On June 9th, 2026, the court issued a preliminary injunction, blocking in part key provisions in this EO and in the DEI EO including those that instruct agencies to remove and cease to issue  materials and “communications…that promote or otherwise inculcate gender ideology” and instructing agencies to “end the Federal funding of gender ideology”; prohibit federal funds from being “used to promote gender ideology,”; and direct agencies and departments to terminate DEI offices and positions, materials, initiatives, performance requirements, and grants or contracts.

• On March 12, 2025 two physician and academic plaintiffs filed a lawsuit challenging the Order and related OPM memo when their articles were removed from HHS’ Agency for Healthcare Research and Quality (AHRQ)’s Patient Safety Network (PSNet), a federal online patient-safety resource. The reason for the removal articles was for their inclusion of passing references to transgender patients. On May 23, a MA district court found the plaintiffs would likely succeed on their constitutional 1st amendment claims and granted a preliminary injunction requiring HHS to republish the censored content.
Ending Radical and Wasteful Government DEI Programs and Preferencing, January 20, 2025
Purpose: To limit diversity, equity, inclusion, and accessibility (DEIA) activities in government and by government contractors and grantees.  
 
Directs each agency, department, or commission head to take the following actions (among others):  
• terminate, to the maximum extent allowed by law, all DEI, DEIA, and “environmental justice” offices and positions…; all “equity action plans,” “equity” actions, initiatives, or programs, “equity-related” grants or contracts… 
• provide the Director of the OMB with a list of all “federal grantees who received Federal funding to provide or advance DEI, DEIA, or “environmental justice” programs, services, or activities since January 20, 2021,” among other actions.  
Implications: As with the other DEIA related Order (see separate entry), these efforts could make reaching populations with unique health needs in culturally competent ways more challenging, including in programs related to LGBTQ+ health and HIV. It could also jeopardized programs and funding for agencies reaching these communities.
There have been multiple legal challenges to this Order:

• On February 3, a lawsuit was filed by four diverse plaintiffs challenging the constitutionality of this Order and the Order, “Ending Illegal Discrimination and Restoring Merit-Based Opportunity”.

• An additional suit was filed in federal court on February 19, 2025 by the National Urban League, National Fair Housing Alliance, and AIDS Foundation of Chicago challenging this order as well as the “Defending Women From Gender Ideology Extremism and Restoring Biological Truth to the Federal Government” and the “Ending Illegal Discrimination and Restoring Merit-Based Opportunity” ” as usurping the power of Congress, violating the Constitution and the Administrative Procedures Act, and, seeking declaratory and injunctive relief. In their complaint, plaintiffs highlight the potential harm this Order could bring to people with HIV and LGBTQ communities and the programs that serve them.

• On February 20, a separate case was filed in federal court by multiple LGBTQ+ health care and service organizations, challenging the “Ending Radical and Wasteful DEI Programs and Preferencing”, “Defending Women From Gender Ideology Extremism and Restoring Biological Truth to the Federal Government” and the “Ending Illegal Discrimination and Restoring Merit-Based Opportunity” orders claiming they usurp the power of Congress and violate the Constitution.  In their complaint, plaintiffs highlight the potential harm this Order could bring to people with HIV and LGBTQ communities and the programs that serve them. On June 9th, 2026, the court issued a preliminary injunction, blocking in part key provisions in this EO and in the “gender ideology” EO including those that instruct agencies to remove and cease to issue  materials and “communications…that promote or otherwise inculcate gender ideology” and instructing agencies to “end the Federal funding of gender ideology”; prohibit federal funds from being “used to promote gender ideology,”; and direct agencies and departments to terminate DEI offices and positions, materials, initiatives, performance requirements, and grants or contracts.
Ending Illegal Discrimination and Restoring Merit-Based Opportunity, January 21, 2025
Purpose: Order seeks to end federal “preferencing” through DEIA efforts within government and through contracting to the extent that they do not comply with the Administration’s view of civil rights law.

The order is broad and non-specific but includes the following directives:

• Orders all executive departments and agencies “to terminate all discriminatory and illegal preferences, mandates, policies, programs, activities, guidance, regulations, enforcement actions, consent orders, and requirements.  I further order all agencies to enforce our longstanding civil-rights laws and to combat illegal private-sector DEI preferences, mandates, policies, programs, and activities.”

• Orders agency heads to include in every contract or grant award “a term requiring the contractual counterparty or grant recipient to agree that its compliance in all respects with all applicable Federal anti-discrimination laws is material to the government’s payment decisions for purposes of section 3729(b)(4) of title 31, United States Code; and…A term requiring such counterparty or recipient to certify that it does not operate any programs promoting DEI that violate any applicable Federal anti-discrimination laws.”		Implications: As with the other DEIA related Order (see separate entry), these efforts could make reaching populations with unique health needs in culturally competent ways more challenging, including in programs related to LGBTQ+ health and HIV. It could also jeopardized programs and funding for agencies reaching these communities.

There have been multiple legal challenges to this Order:

• On February 3, a lawsuit was filed by four diverse plaintiffs challenging the constitutionality of this and the “Ending Radical and Wasteful Government DEI Programs and Preferencing” Order.

• An additional suit was filed in federal court on February 19, 2025 by the National Urban League, National Fair Housing Alliance, and AIDS Foundation of Chicago challenging this order as well as the “Defending Women From Gender Ideology Extremism and Restoring Biological Truth to the Federal Government” and the “Ending Radical and Wasteful Government DEI Programs and Preferencing” as usurping the power of Congress, violating the Constitution and the Administrative Procedures Act, and, seeking declaratory and injunctive relief. In their complaint, plaintiffs highlight the potential harm this Order could bring to people with HIV and LGBTQ communities and the programs that serve them.

• On February 20, a separate case was filed in federal court by multiple LGBTQ+ health care and service organizations, challenging the “Ending Radical and Wasteful DEI Programs and Preferencing”, “Defending Women From Gender Ideology Extremism and Restoring Biological Truth to the Federal Government” and the “Ending Illegal Discrimination and Restoring Merit-Based Opportunity” orders claiming they usurp the power of Congress and violate the Constitution.  In their complaint, plaintiffs highlight the potential harm this Order could bring to people with HIV and LGBTQ communities and the programs that serve them.
Protecting Children From Chemical and Surgical Mutilation, January 28, 2025
Purpose: Order directs agencies and programs to work towards significantly limiting access to gender affirming care for young people (defined as those under age 19) nationwide.

• Directs agencies to rescind and amend policies that rely on guidance from the World Professional Association for Transgender Health (WPATH).

• Directs the HHS Secretary to conduct and publish a review of existing literature and best practices related to gender affirming care and gender dysphoria and to “increase the quality of data to guide practices“ in this area.

• Directs executive department and agency heads “that provide research or education grants to medical institutions, including medical schools and hospitals”, “in coordination with the Director of the Office of Management and Budget” to “immediately take appropriate steps to ensure that institutions receiving Federal research or education grants end the chemical and surgical mutilation of children” (which is how the Order defines gender affirming care).

• Directs the HHS Secretary to take action to end gender affirming care for children “including [through] regulatory and sub-regulatory actions, which may involve the following laws, programs, issues, or documents:
– Medicare or Medicaid conditions of participation or conditions for coverage
– clinical-abuse or inappropriate-use assessments relevant to State Medicaid programs
– mandatory drug use reviews
– section 1557 of the Patient Protection and Affordable Care Actquality, safety, and oversight memoranda
– essential health benefits requirements; and
– the Eleventh Revision of the International Classification of Diseases and other federally funded manuals, including the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.”

• Withdraws Biden Administration “HHS Notice and Guidance on Gender Affirming Care, Civil Rights and Patient Privacy” and directs the Secretary of HHS “in consultation with the Attorney General [to] issue new guidance protecting whistleblowers who take action related to ensuring compliance with this order.”

• Directs the Secretary of the Department of Defense to “commence a rulemaking or sub-regulatory action” restrict access to gender affirming care for children in the TRICARE program.

• Directs the Director of the Office of Personnel Management to limit access to care in coverage for federal employees’ families by requiring “provisions in the Federal Employee Health Benefits (FEHB) and Postal Service Health Benefits (PSHB) programs call letter for the 2026 Plan Year” that would require eligible carriers to exclude “coverage for pediatric transgender surgeries or hormone treatments…”

• Directs the Attorney General to review Department of Justice laws on female genital mutilation and “prioritize enforcement of protections” and “to convene States’ Attorneys General and other law enforcement officers to coordinate the enforcement of laws against female genital mutilation.”

• Directs the Attorney General to “prioritize investigations and take appropriate action to end deception of consumers, fraud, and violations of the Food, Drug, and Cosmetic Act by any entity that may be misleading the public about long-term side effects of chemical and surgical mutilation.”

• Directs the Attorney General “in consultation with the Congress” “to draft, propose, and promote legislation to enact a private right of action for children and the parents” who have received gender affirming care “which should include a lengthy statute of limitations.

• Directs the Attorney General to “prioritize investigations and take appropriate action to end child-abusive practices by so-called sanctuary States that facilitate stripping custody from parents who support the healthy development of their own children, including by considering the application of the Parental Kidnapping Prevention Act and recognized constitutional rights.”

• Directs agency heads included in this executive order to “submit a single, combined report to the Assistant to the President for Domestic Policy, detailing progress in implementing this order and a timeline for future action” within 60 Days of its issuance.		Implications: If fully implemented, the Order would broadly and extensively limit access to gender affirming care for young people, across a range of payers and providers. Access to gender affirming care is associated with improved mental health outcomes for transgender people and limiting this care with negative ones, including poorer mental health outcomes. Additional impact includes:

• The executive order includes details about sex, gender identity, gender affirming care, and transgender people that conflict with science and evidence. These inaccuracies include suggesting that large shares of youth are seeking gender affirming medical care, that regret rates among those seeking care are high, and conflating “female genital mutilation” and gender-affirming care. This has the potential to promote hostility, stigma, and discrimination, and can lead to care denials.

• It seeks to remove Federal reference to one of the standards of evidence-based care for transgender people in the US. Directing the HHS Secretary to develop new guidance without this standard, and in accordance with this and other orders, could limit agency ability to identify standards that adequately meet the needs of transgender people.

• It also seeks to condition federal research and education grants on grantees not providing young people with gender affirming care.

• There has already been some confusion with certain states and providers looking to preemptively comply with the order and another Order relating to “gender ideology” (see separate entry).

• The order lays groundwork for the Administration remove explicit protects for LGBTQ+ people in health care, including with respect to accessing gender affirming care. Specifically, the Order suggests a reinterpretation of sex protections in Section. 1557 of the Affordable Care Act void of explicit protections on the basis of sexual orientation and gender identity.

• The order leans on laws and policies unrelated to gender affirming care in an effort to limit access to those services including by erroneously conflating gender affirming care and female genital mutilation, using the FDA regulatory process to limit access, and suggesting kidnapping protections be applied to parents in certain circumstance.

On February 19, 2025, additional guidance was released relating to this order, providing new and refined definition of terms “ which directs the Department of Health and Human Services (the Department) to promulgate clear guidance to the U.S. Government, external partners, and the public, expanding on the sex-based definitions set forth in the Executive Order.”

On February 20, 2025, pursuant to this Order, HHS issued a “Recession of ‘HHS Notice and Guidance on Gender Affirming Care, Civil Rights, and Patient Privacy’ issued by the Biden Administration” which had stated the Administration “stands with transgender and gender nonconforming youth” and that medically necessary for gender affirming care for minors improves physical and mental health. It also reiterated that administration’s view that Sec. 1557 of the ACA includes protections on the basis of sexual orientation and gender identity.

There have been multiple legal challenges to this Order with some judicial actions that have paused aspects of implementation:

• On February 4, 2025, a federal lawsuit was filed challenging this Order and the Executive Order on “Defending Women From Gender Ideology Extremism and Restoring Biological Truth to The Federal Government,” asserting they are openly discriminatory, unlawful, and unconstitutional. On February 13, a federal judge issued a temporary restraining order preventing the federal government from withholding or conditioning funding on the basis of providing this care. On March 4th, the court issued a preliminary temporary injunction.

• An additional federal lawsuit was filed on February 7th challenging this executive order with a separate temporary restraining order being issued on the 14th preventing the conditioning of federal funds and also applying to a condition linking gender affirming care to female genital mutilation. The restraining order was extended through March 5th on February 26th. 

On June 1, the FBI posted on social media urging the public to “report tips of any hospitals, clinics, or practitioners performing these surgical procedures on children,” despite pediatric gender affirming care being permitted in about half of states and not prohibited by the federal government.
Ending Radical Indoctrination in K-12 Schooling, January 29, 2025
Purpose: Order seeks to end federal “preferencing” through DEIA efforts within government and through contracting to the extent that they do not comply with the Administration’s view of civil rights law.

The order is broad and non-specific but includes the following directives:

• Orders all executive departments and agencies “to terminate all discriminatory and illegal preferences, mandates, policies, programs, activities, guidance, regulations, enforcement actions, consent orders, and requirements.  I further order all agencies to enforce our longstanding civil-rights laws and to combat illegal private-sector DEI preferences, mandates, policies, programs, and activities.”

• Orders agency heads to include in every contract or grant award “a term requiring the contractual counterparty or grant recipient to agree that its compliance in all respects with all applicable Federal anti-discrimination laws is material to the government’s payment decisions for purposes of section 3729(b)(4) of title 31, United States Code; and…A term requiring such counterparty or recipient to certify that it does not operate any programs promoting DEI that violate any applicable Federal anti-discrimination laws.”		Implications: Should the federal government proceed with conditioning federal funding for schools on whether or not they support transgender students, it could exacerbate existing mental health disparities, contribute to stigma and discrimination, and reduce school connectedness. For example, the policies detailed in the Order could prevent schools from recognizing transgender students’ identities (e.g. their names and pronouns), allow schools to withhold mental health services, to out students to (potentially unsupportive) families, and to restrict facility use and activity participation.
Memorandum For The Heads Of Executive Departments And Agencies, February 6, 2025
Purpose: The memorandum seeks to “stop funding Nongovernmental Organizations that undermine the national interest and administration priorities.”

The memorandum states:

• It is Administration policy “to stop funding [Nongovernmental Organizations] NGOs that undermine the national interest.”

• Direct heads of executive departments and agencies to review all funding that agencies provide to NGOs and “to align future funding decisions with the interests of the United States and with the goals and priorities of my Administration, as expressed in executive actions; as otherwise determined in the judgment of the heads of agencies; and on the basis of applicable authorizing statutes, regulations, and terms.”		Implications: This memo aligns with other administrative efforts to stop current and future funding from being provided to NGOs that do not align with administrative priorities and could impact funding to health organizations or programs aimed at serving transgender people or research funding inclusive of trans and gender diverse people. It could also potentially impact care for LGBTQ+ people more broadly if services aimed directly at this population are considered DEIA efforts.
DOJ Letter to the Supreme Court: United States v. Jonathan Skrmetti, Attorney, February 7, 2025
Purpose: “To notify the Court that the government’s previously stated views” on a case challenging a state’s ban on gender affirming care “no longer represents the United States’ position.”

• Notifies the Court that “following the change in Administration, the Department of Justice has reconsidered the United States’ position in” the case brought by the Biden Administration challenging Tennessee’s ban on gender affirming care for minors. The letter states, that their view is that the Tennessee law being challenged “does not deny equal protection on account of sex or any other characteristic,” which is the question before the Court.

• Despite this change in perspective, the Trump Administration encouraged the Court to resolve the questions presented without granting certiorari to the original plaintiffs.		Implications: There are 26 states with bans on gender affirming care for minors and litigation challenging these bans is ongoing. At the request of the Biden Administration, who brought the plaintiff’s case from the lower courts, the Supreme Court agreed to examine whether the Tennessee ban violates Equal Protection constitutional protections under the 14th Amendment. The case was briefed and argued prior to the administration change. Upon taking office, the Trump Administration wrote this letter to the Court stating that the Biden Administration position no longer represented that of the U.S. government but nevertheless asked the court to decide the case. The court will likely issue a decision in the case and technically, the Trump Administration letter should not have bearing on the court’s decision. The court is expected to issue a decision in the case this summer (2025).
Quality and Safety Special Alert Memo on Provision of Gender Affirming Care to Children, March 5, 2025
Purpose: To alert providers to the administration’s approach to children’s access to gender affirming care and serve as notice “that CMS may begin taking steps in the future to align policy, including CMS-regulated provider requirements and agreements…” to limit such care.

The memorandum states:

• That “CMS renews its commitment to promoting evidence-based standards through health quality and safety improvement activities, and reminds hospitals and other applicable facilities and providers of the obligation to prioritize the health and safety of their patients, especially children.” It questions evidence around gender affirming care for young people and states “CMS may begin taking steps in the future to adjust its policies to reflect this…”		Implications:

• The CMS memo aligns with policies put forward in the Executive Order, “Protecting Children From Chemical and Surgical Mutilation,” related to limiting young people’s access to gender affirming care, provisions of which are subject to a nationwide preliminary injunction (described in above entry). However, this is not explicitly stated in the memo.

• On March 6th the Health Resources & Services Administration (HRSA) and Substance Abuse and Mental Health Services Administration (SAMHSA) released additional guidance stating that they would review policies, grants, and programs for consistency with the CMS memo (SAMHSA letter unavailable but described in this filing). HRSA also specifically notes the agency will review its Children’s Hospitals Graduate Medical Education (CHGME) Payment Program for consistency with the memo.

• While the memo does not specifically refer to the Executive Order, on March 7th, plaintiffs in a case challenging the order sought enforcement of the preliminary injunction claiming that the CMS memo and HRSA/SAMHSA guidance violate its terms because by “threatening to withhold federal funding, the Executive Orders coerced hospitals into immediately shutting down gender affirming medical care for people under nineteen to avoid potential loss of funds.”

• Depending on how future policy is implemented, CMS could seek to significantly limit access to gender affirming care for young people.
National Child Abuse Prevention Month, 2025 April 3, 2025
Purpose: The memorandum seeks to “stop funding Nongovernmental Organizations that undermine the national interest and administration priorities.”

The memorandum states:

• It is Administration policy “to stop funding [Nongovernmental Organizations] NGOs that undermine the national interest.”

• Direct heads of executive departments and agencies to review all funding that agencies provide to NGOs and “to align future funding decisions with the interests of the United States and with the goals and priorities of my Administration, as expressed in executive actions; as otherwise determined in the judgment of the heads of agencies; and on the basis of applicable authorizing statutes, regulations, and terms.”		Implications: The proclamation includes details about gender affirming care and transgender people that conflict with science and evidence, including that children are being “indoctrinated” “with the devastating lie that they are trapped in the wrong body,” referring to gender affirming surgery (which is very rare among young people) as “sexual mutilation surgery,”  and suggesting that such care inhibits “happiness, health, and freedom,” for young people and creates “heartbreak” for parents and families.

• By erroneously conflating gender affirming care and abuse, potentially threatens those providing or facilitating access by stating, “we affirm that every perpetrator who inflicts violence on our children will be punished to the fullest extent of the law.”
Ryan White Letter to Awardees and Stakeholders Relating to Gender Affirming Care, April 7, 2025.
Purpose: Reverses a Biden Administration policy that had permitted the Ryan White HIV/AIDS Program to cover certain gender affirming care services as a part of whole person care to transgender people with HIV.

• Referring to a policy on gender affirming care from the Biden administration, the letter states that “under the previous administration, certain interpretations of RWHAP’s allowable uses…co-opted the program’s patient centered mission in favor of radical ideological agendas and policies.”

• The letter further states “that RWHAP funds shall be marshaled exclusively toward evidence-based interventions proven to combat HIV, sustain viral suppression, and improve the quality of life for those living with the disease” and reaffirms the prohibition on funding services outside the scope of outpatient care, including “surgeries and inpatient care, irrespective of setting or anesthesia”		Implications:

• Previously, Ryan White funds were permitted to be used to support gender affirming care within core medical and support service categories, including through the provision of hormones via ADAP programs. Additionally, funds could be used to “provide behavioral and mental health services to clients experiencing gender dysphoria and social and emotional stress related to transgender discrimination, stigma, and rejection.” The policy under the prior Administration prohibited surgery, as does the new one, so that does not represent a change.

• Prohibiting use of funds to support certain gender affirming care services may make care engagement more challenging for transgender Ryan White clients. In some cases, gender affirming care may have helped to connect clients with HIV services and thus improve HIV outcomes.
Nondiscrimination on the Basis of Disability in Programs or Activities Receiving Federal Financial Assistance; Clarification, April 11, 2025.
Purpose: HHS issued this notice “to clarify the non-enforceability of certain language that was included in the preamble to—but not the regulatory text of” the final rule on Section 504, “titled ‘Nondiscrimination on the Basis of Disability in Programs or Activities Receiving Federal Financial Assistance.’ The clarification states that language in the preamble concerning gender dysphoria, which is not in the regulatory text, does not have the force or effect of law and cannot be enforced.Implications:

• Section 504 prohibits recipients of federal funding, including publicly-subsidized health payers and health care providers who accept Medicare or Medicaid, from discriminating against people on the basis of disability. The Biden Administration’s final rule on Sec. 504 included in the preamble that HHS would “approach gender dysphoria as it would any other disorder or condition. If a disorder or condition affects one or more body systems, or is a mental or psychological disorder, it may be considered a physical or mental impairment.”

• This new interpretation could weaken certain protections for transgender and gender non-conforming people.
State Medicaid Director Letter “Re: Puberty blockers, cross-sex hormones, and surgery related to gender dysphoria,”  April 11, 2025.
Purpose: “The purpose of this letter is to ensure that state Medicaid agencies are aware of growing evidence regarding certain procedures offered to children, and to remind states of their responsibility to ensure that Medicaid payments are consistent with quality of care and that covered services are provided in a manner consistent with the best interest of recipients.”

States that “medical interventions for gender dysphoria in children have proliferated” and that “several developed countries have recently diverged from the U.S. in the way they treat gender dysphoria in children.”

CMS reminds states of the following federal Medicaid requirements:

• Program “responsibility to ensure that payments are consistent with ‘efficiency, economy, and quality of care.’”

• Requirement for states to “provide such safeguards as may be necessary to ensure covered care and services are provided in a manner consistent with the best interests of recipients.”

• Prohibition on “federal funding for coverage of services whose purpose is to permanently render an individual incapable of reproducing. Federal financial participation (FFP) is strictly limited for procedures, treatments, or operations for the purpose of rendering an individual permanently incapable of reproducing and…prohibited for such procedures performed on a person under age 21.”

• Drug utilization review (DUR) program requirements “to assure that prescribed drugs are appropriate, medically necessary, and are not likely to result in adverse results.”
– CMS encourages “states to review their DUR programs to ensure alignment with current medical evidence and federal requirements, including the evidence outlined above.
– Notes that “additional guidance on DUR approaches is forthcoming.”		Implications:

• Letter appears to encourage states to take steps to limit gender affirming care for youth within their state Medicaid programs and suggests that not doing so could put them out of compliance with federal law. It does not immediately change policy.

• Letter misrepresents certain information about gender affirming care including its frequency and the approach in international settings.

• Letter leverages a law aimed at addressing discrimination/unwanted sterilizations among people with disabilities to limit gender affirming care.

• The letter could lead to changes in state policy-making or make providers and/or employers less likely to cover services which could ultimately lead to more limited access to GAC. 

• CMS issued a press release along with the letter. The letter stated “Medicaid dollars are not to be used for gender reassignment surgeries or hormone treatments in minors.”
Department of Justice Memorandum “Preventing the Mutilation of American Children,” April 22, 2025.
Purpose: An internal Department of Justice (DOJ) memorandum seeks to implement, in part, an executive order aimed at limiting minor’s access to gender affirming care (GAC) (see above).

The memo is an internal document that was leaked. It is not law but provides guidance relating to an earlier executive order aimed at limiting minor access to gender affirming care (see above). The memo reportedly:

• The internal document was leaked and is not law but provides guidance relating to an earlier executive order aimed at limiting minor access to gender affirming care.

• Puts providers “on notice” that “it is a felony to perform, attempt to perform, or conspire to perform female genital mutilation (“FGM”*) on” minors and states that the FBI “alongside federal, state, and local partners, will pursue every legitimate lead on possible FGM cases.”

• States DOJ “will investigate and hold accountable medical providers and pharmaceutical companies that mislead the public about the long-term side effects of chemical and surgical mutilations.”

• Directs “investigations of any violations of the Food, Drug, and Cosmetic Act by manufacturers and distributors engaged in misbranding by making false claims about the…use of puberty blockers, sex hormones, or any other drug” in GAC.

• Directs “investigations under the False Claims Act of false claims submitted to federal health care programs for any non-covered services related to radical gender experimentation.” Gives example of prescribing puberty blockers to a minor for GAC but reporting the service as being for early onset puberty. States Department will work with whistleblowers “with knowledge of any such violations” under The False Claims Act.

• Following prior direction “that Department employees shall not rely on”… the World Professional Association for Transgender Health (WPATH)… “guidelines, and that they should withdraw all court filings” doing so, “expressly extend[s] that direction to all Department employees.” Directs department to “purge all…policies, memoranda, and publications and court filings based on WPATH guidelines.”

• Launches “the Attorney General’s Coalition Against Child Mutilation” to “partner with state attorneys general to identify leads, share intelligence, and build cases against…” providers “…violating federal or state laws banning female genital mutilation and other, related practices…[and] support the state-level prosecution of medical professionals who violate state laws “prohibiting gender affirming care.

• Instructs Office of Legislative Affairs to draft legislation “creating a private right of action for children and the parents of children” who have had gender affirming care with “a long statute of limitations and retroactive liability” and work with Congress “to bring this bill to President Trump.”
     
Implications:

• The memo directs action but is not law. It seeks to implement an executive order that is, in part, currently enjoined in court.

• The memo includes inaccuracies relating to gender identity, gender affirming care, and transgender people that conflict with science and evidence. These inaccuracies include suggesting that being transgender is a harmful medical condition, that large shares of youth are seeking gender affirming medical care, that regret rates among those seeking care are high, and conflating “female genital mutilation” and gender-affirming care. This has the potential to promote hostility, stigma, and discrimination, and can lead to care denials.

• Seeks to discredit WPATH’s widely relied on standard of care guidelines which providers look to deliver best practices gender affirming care and is regularly referenced by major medical associations including the American Psychological Association.

• While nothing in the memo prohibits provision of gender affirming care, its emphasis on litigation and enforcement of existing law that do not necessarily implicate this care, could have a chilling effect on providers.
     
HHS Report “Treatment for Pediatric Gender Dysphoria: Review of Evidence and Best Practices,” May 1, 2025.
Purpose: To develop an evidence review around pediatric gender affirming medical care as commissioned by the executive order on Protecting Children From Chemical and Surgical Mutilation (see above entry).

“This Review of evidence and best practices was commissioned pursuant to Executive Order 14187, signed on January 28, 2025. It is not a clinical practice guideline, and it does not issue legislative or policy recommendations. Rather, it seeks to provide the most accurate and current information available regarding the evidence base for the treatment of gender dysphoria in this population, the state of the relevant medical field in the United States, and the ethical considerations associated with the treatments offered. The Review is intended for policymakers, clinicians, therapists, medical organizations and, importantly, patients and their families.” Among the report’s findings:

• Report concludes that the quality of evidence on the effects of gender affirming intervention is low but also that evidence on harms is “sparse.”

• Cites “significant risks” of medical transition, departing from most medical associations and widely used guidelines in the U.S.

• In addition to a focus on medical intervention (e.g. surgery, puberty blockers, and hormones) report discusses role of psychotherapy in gender affirming care, supporting the use of psychotherapeutic approaches, including an approach termed “exploratory therapy”, which can include conversion therapy. Conversion therapy is a practice that seeks to change an individual’s sexual orientation or gender identity. These practices contrast with recommendations from major medical associations, which criticize conversion efforts for their lack evidence, ineffectiveness, and because they can cause harm. Additionally, many states ban these practices for the same reasons.		Implications:

• Review could be used as support for other actions the administration seeks to take (some described here) aimed at limiting minor access to gender affirming care. Outside experts, including from the American Academy of Pediatrics, have raised concerns that the “report misrepresents the current medical consensus and fails to reflect the realities of pediatric care.”

• With respect to therapeutic practices, it could shift how some practitioners approach gender affirming care or potentially provide support to those using conversion related approaches.

• The report could also fuel misinformation in other areas, particularly around regret rates (which the report states are high when they are actually very low) and the share of young people seeking a medical transition (which the report states is large, when the share is small).

On May 28, 2025, HHS sent a letter to an unspecified group of providers, state medical boards, and health risk managers urging providers to update treatment protocol to align with the review’s findings and avoid relying on the WPATH Standards of Care (which are seen by gender affirming care providers as valuable and trusted source of guidance.) The letter points to risk but not benefits of gender affirming medical care and highlights the report’s promotion of psychotherapy as an alternative to other medical care.
HHS Letter “Urgent Review of Quality Standards and Gender Transition Procedures” May 28, 2025
Purpose: The letter from the Center for Medicare and Medicaid Services (CMS) is directed at “select hospitals” providing minors with gender affirming care services including puberty blockers, hormones, and surgeries. The aim of the letter is to collect information on the delivery of these services and their associated costs and revenue. CMS states they are collecting this data to “ensure quality standards at institutions participating in the Medicare and Medicaid programs” and because “CMS has an obligation to be a good steward of taxpayer dollar.” 

In the letter CMS asks for information on the following within 30 days:
• consent protocols for children with gender dysphoria, including when parental consent is required
• changes to clinical practice guidelines and protocols in light of the HHS Review (see above entry)
• adverse events, particularly children who later look to detransition
billing codes utilized for gender affirming care
• facility and provider-level revenue and profit margins data related to these services
Implications: If facilities or providers believe HHS is excessively engaged in oversight of their practice of this area of medicine, it could have a chilling effect on willingness to provide these treatments. Depending on what the Administration does with data collected, this effort could represent a significant step in the administration’s aim to limit GAC for minors.

The effort to collect this level of information is likely burdensome for providers, particularly within a 30-day period.

The letter appears to stoke misinformation in its suggestion that there is a lack of parental involvement or consent in the practice of gender affirming care and that regret is a serious problem in this field.

It also appears to question the validity of using federal dollars to provide this care and possibly that delivering these services to minors is a significant cost-burden to the federal government. Because just a small share of the population is transgender, and not all trans people seek medical intervention, costs are likely very low.
CMS Informational Bulletin “Rescission of Guidance on Adding Sexual Orientation and Gender Identity Questions to State Medicaid and CHIP Applications for Health Coverage”  June 5, 2025
Purpose: To rescind a bulletin from the Biden administration that provided state Medicaid programs with guidance on implementing optional sexual orientation and gender identity (SOGI) questions on their applications for coverage.

The Trump administration bulletin states that “CMS no longer intends to collect this information from state Medicaid and Children’s Health Insurance Program (CHIP) agencies as part of Transformed Medicaid Statistical Information System (T-MSIS) data submissions.”		Implications: Collection of SOGI health data plays a role in documenting the health experiences and status of LGBTQ+ people. Data collection can reveal disparities and gaps in access, which can, in turn, inform policy making to address these challenges. Without this data, addressing these disparities is more challenging. SOGI Data collection expanded under the Biden administration and has retracted under the Trump administration.
Final Rule Changing ACA Coverage of Gender-Affirming Care, June 25, 2025.
Purpose: To rescind a bulletin from the Biden administration that provided state Medicaid programs with guidance on implementing optional sexual orientation and gender identity (SOGI) questions on their applications for coverage.

The Trump administration bulletin states that “CMS no longer intends to collect this information from state Medicaid and Children’s Health Insurance Program (CHIP) agencies as part of Transformed Medicaid Statistical Information System (T-MSIS) data submissions.”		Implications: The aim of the final rule aligns with policies expressed in Executive Orders on gender and limiting access to gender affirming care (discussed above), though the agency states the rule does not rely on these orders or their enjoined sections. The agency writes that the purpose of the rule is to ensure that health plans meet the ACA’s “typicality requirement,” that is that EHBs be “equal to the scope of benefits provided under a typical employer plan.” The preamble to the rule discusses debate among commenters about whether inclusion of these services is typical.

The rule does not mean that plans cannot cover gender affirming care services but excluding certain services from coverage as EHBs means that enrollees would not be assured the same cost-sharing and benefit design protections as for services included in the EHB package. Costs accrued for gender affirming care would not be required to count towards deductibles or out-of-pocket maximums and would not be protected from annual or lifetime limits, increasing out-of-pocket liability. Additionally, the portion of premiums attributable to specified gender affirming services would not be eligible for premium tax credits or cost-sharing reductions for low- and moderate-income enrollees.

While CMS does not believe the impact will be significant, some commenters expressed concern that the policy change, particularly its near implementation date for 2026 plan year, could create challenges for issuers, which have already been engaged in (and some completed) rate setting for 2026. They also stated that change would require plans that cover gender affirming care outside of the EHB to complete the necessary backend activities (e.g. changes to claims and utilization management programs and policies) to implement the change, activities that could be more burdensome for smaller issuers.

While HHS states that this rule does not violate various statues (e.g. ACA’s nondiscrimination provisions at Sec. 1557 or typicality requirements, ADA’s Section 505 protections, constitutional equal protections, etc.) and disagrees with those who commented on the proposed rule that HHS lacks legal authority to make these policy changes, the rule could ultimately face legal challenges on these or other grounds.
Federal Trade Commission Request for Information on Gender Affirming Care Practices, July 28, 2025. 
Purpose: The Federal Trade Commission (FTC) issued a request for public comment on “how consumers may have been exposed to false or unsupported claims about ‘gender-affirming care’(GAC), especially as it relates to minors, and to gauge the harms consumers may be experiencing.”

Arguing that GAC has been subject to “potential deceptive or unfair practices involved in this type of medical care,” the agency “seeks to evaluate whether consumers (in particular, minors) have been harmed by GAC and whether medical professionals or others may have violated Sections 5 and 12 of the FTC Act by failing to disclose material risks associated with GAC or making false or unsubstantiated claims about the benefits or effectiveness of GAC.”

As discussed in the RFI, this action comes on the heels of a recent workshop the agency held on the same topic and the agency now seeks comment related to:

• Experiences of individuals and families seeking GAC, including on recommendations made by providers, whether providers described risks/benefits/effectiveness, and whether providers discussed the current policy environment and debates related to GAC, among other issues.

• Whether GAC was obtained and whether individuals experienced benefits/side effects/adverse events, among other issues.

• Detail related to whether providers “made false representations regarding the benefits or effectiveness.”

• Information related to providers making “false representations regarding the benefits or effectiveness” related to GAC		Implications: This activity is likely to have a chilling effect on provider willingness to offer GAC. In addition to the workshop and RFI described above, more than 20 providers have received subpoenas from the DOJ for investigations related to GAC that “include healthcare fraud, false statements, and more.”

The RFI (and surrounding actions) also have the potential to promote misinformation around the risks and benefits of GAC and suggests that providers are using deceptive and unethical positions in delivering GAC on a significant scale, something that has not been demonstrated. Additionally, the RFI states that there is “widespread concern about the harms” related to GAC but does not acknowledge the broad clinical support GAC has as medically necessary treatment for gender dysphoria, including from major U.S. medical associations.
Improving Oversight of Federal Grantmaking, August 5, 2025
Purpose: The Executive Order seeks reform “the process of Federal grantmaking while ending offensive waste of tax dollars.”

The EO aims to overhaul the federal grantmaking and grant review process “to strengthen oversight and coordination of, and to streamline, agency grantmaking to address these problems, prevent them from recurring, and ensure greater accountability for use of public funds more broadly.”  One section of the EO requires agencies to “ensure that…[grants] are consistent with agency priorities and the national interest.” In addition to other actions, agencies are directed to ensure that awards are not “used to fund, promote, encourage, subsidize, or facilitate” certain themes including, “denial by the grant recipient of the sex binary in humans or the notion that sex is a chosen or mutable characteristic” and “racial preferences or other forms of racial discrimination by the grant recipient, including activities where race or intentional proxies for race will be used as a selection criterion for employment or program participation,” among others.		Implications: This approach to grantmaking could further chill research and grantmaking related to and aimed to supporting transgender and gender diverse people, including that related to health and healthcare. This could impact access to and availability of culturally competent services at the individual level and reduce research and data on transgender and gender diverse communities more broadly. Such research in turn could have been used to inform service delivery and policy making and to address health disparities.
CDC Priorities Statement, September 17, 2025.
Purpose: CDC updated its priorities statement on the agency’s “about” website to include discussion of gender affirming care, parental rights, and DEI (among a range of other topics) not previously included on the site.

With respect to gender affirming care, the agency refers to its “comprehensive review of the evidence and best practices for promoting the health of children and adolescents with gender dysphoria” (see above entry) and states it is  “a CDC priority to protect children from …” gender affirming care “and, to the extent allowable by applicable federal law and any relevant court orders, CDC programs will deprioritize programs that engage in these practices where permissible. CDC funds will also not support the costs of such practices where not required by the law or court order.” Further, CDC states it is an agency “priority to recognize that a person’s sex as either male or female is unchangeable and determined by objective biology, and to ensure CDC programs accurately reflect science, including the biological reality of sex.”

Another stated priority is that “CDC believes parents are the primary decision-makers in their children’s education and should have full authority over what their children are taught” and that school policies “and curricula should emphasize knowledge…without imposing ideas that may conflict with parents’ political, religious, or social beliefs.”
With respect to DEI the statement reads, “to the extent permitted by law, CDC will deprioritize diversity, equity, and inclusion (DEI) initiatives that prioritize group identity over individual merit” and that “CDC has previously invested substantially in ideologically-laden concepts like health equity—mainly on identifying and documenting worse health outcomes for minority populations.”		Implications: The new priorities statement represents are departure from the previous CDC “about” page which was much broader in its description and referenced the agency strategic plan stating that the plan “advances science and health equity and affirms the agency’s commitment to one unified vision— equitably protecting health, safety, and security.”

The new statement could potentially inform grant making and other agency activities such as reporting, recommendations/guidance, data collection, and data presentation. It may also impact CDC research ability to conduct research related to gender affirming care, transgender people, and health disparities. It also may limit the ability of grantees to use CDC resources to provide LGBTQ students with certain types of support or for the agency to provide resources to support LGBTQ youth. Targeting public health approaches to hard hit populations may be more difficult, including for conditions that disproportionately impact LGBTQ+ people, like HIV.

In its description of the HHS report findings on GAC, the CDC statement appears to go beyond what the review itself stated which was that the quality of evidence to support interventions was low and the evidence on harms was “sparse.” The CDC statement writes the review found that provision of gender affirming care to minors is “unsupported by the evidence and have an unfavorable risk/benefit profile.” Neither the report nor the CDC statement reference the well documented benefits associated with gender affirming care.
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LGBTQ Other Health Access to Care Courts Gender Identity Sexual Orientation

A Closer Look at the Growing Role of Special Needs Plans in Medicare Advantage

Published: Sep 25, 2025

Enrollment in Medicare Advantage, the private plan alternative to traditional Medicare, has increased steadily over the past two decades, and since 2023, more than half of eligible beneficiaries have enrolled in Medicare Advantage. Amidst this growth, an increasing number of beneficiaries are enrolling in special needs plans (SNPs), especially since 2018, when SNPs became a permanent part of the Medicare Advantage program. SNPs now account for 21% of all Medicare Advantage enrollees, compared with just 13% in 2018. The increase in the share of Medicare Advantage enrollees in SNPs also means that SNPs contribute disproportionately to the growth in Medicare Advantage enrollment. For example, between 2024 and 2025, growth in SNPs comprised nearly half (48%) of the total increase in Medicare Advantage enrollment.

There are three types of SNPs, and enrollment in each is restricted to specific groups of beneficiaries, all of which comprise some of the highest-need beneficiaries in the Medicare population. Over 4 in 5 (82%) SNP enrollees are enrolled in dual eligible SNPs (D-SNPs), which are limited to people with both Medicare and Medicaid (“dual-eligible individuals”). Dual-eligible individuals tend to have lower incomes, more chronic conditions, and more functional and cognitive impairments than Medicare beneficiaries without Medicaid coverage. The two other types of SNPs are chronic condition SNPs (C-SNPs, 16% of enrollees), which are limited to people with certain chronic conditions, and institutional SNPs (I-SNPs, 2% of enrollees), which are limited to people who require an institutional level of care. All SNPs are required to have a model of care, or framework detailing how the plan will identify the needs of each enrollee and address those needs through the plan’s care management practices. Other requirements vary across the three types of SNPs. D-SNPs may have additional requirements depending on the state in which they operate. (See Box 1 for additional information.)

In recent years, the Centers for Medicare and Medicaid Services (CMS) has made several changes to requirements for D-SNPs and other Medicare Advantage plans, which may affect insurer decisions about the types of plans they offer and promote. To better understand the growing role of SNPs in Medicare Advantage and the potential implications for beneficiaries of changes to SNP and Medicare Advantage plan requirements, this brief examines SNP enrollment patterns and trends using recent Medicare Advantage enrollment data published by CMS.

Key Takeaways

  • Since 2018 when SNPs became a permanent part of the Medicare program, SNP enrollment has tripled, rising from 2.6 million to 7.3 million, an increase of nearly 4.7 million enrollees.
  • Through 2024, growth in SNPs was driven by an increase in enrollment in D-SNPs, which grew from 2.2 million enrollees in 2018 to 5.8 million enrollees in 2024, comprising more than 90% of SNP enrollment growth over that time.
  • C-SNPs comprised 75% of total SNP enrollment growth between 2024 and 2025, in contrast to prior years, where enrollment growth was mainly in D-SNPs. In 2025, C-SNP enrollment increased by 476,300 new enrollees, triple the increase in D-SNP enrollment (159,400 new enrollees).
  • A small share of SNP enrollees, just 14%, are in plans administered by non-profit insurers. SNP enrollment is highly concentrated among a small number of large national carriers, with UnitedHealth Group and Humana plans comprising over half (54%) of total SNP enrollment. UnitedHealth Group accounts for half of all C-SNP enrollees.
  • The acceleration of C-SNP enrollment growth and slowing of D-SNP enrollment growth coincided with implementation of new rules for D-SNPs requiring greater integration between Medicare and Medicaid. C-SNPs are not required to have a similar level of integration.

From 2018-2024, growth in SNP enrollment was driven by increases in D-SNP enrollment, plans for dual-eligible individuals.

From 2018, when SNPs became a permanent part of the Medicare Advantage program, through 2024, growth in SNP enrollment was predominantly due to growth in enrollment in D-SNPs. In 2018, 2.2 million people were enrolled in a D-SNP, and in 2024, 5.8 million people were enrolled in a D-SNP. That increase comprises more than 90% of the total increase in SNP enrollment between 2018 and 2024.

C-SNP enrollment and I-SNP enrollment also increased during this period, though on a smaller scale relative to D-SNP enrollment growth. C-SNP enrollment grew from 346,000 enrollees in 2018 to 674,500 enrollees in 2024, and I-SNP enrollment grew from 71,500 enrollees in 2018 to 115,100 enrollees in 2024.

SNPs receive higher per capita payments under the Medicare Advantage payment system, on average, because enrollees have higher expected spending due to their higher health care needs. It is well-documented, however, that Medicare Advantage pays more for Medicare Advantage enrollees than spending would be for the same people if they were covered under traditional Medicare, and in 2025, MedPAC estimates that payments were 20% higher, on average. The higher payments are largely driven by the risk adjustment system, which pays more for people who are sicker, and less for those who are healthier, relying heavily on diagnosed heath conditions to determine adjustments to payment based on health status. SNPs are potentially better positioned to leverage this system to increase their payments relative to enrollee’s costs, contributing to higher margins for SNPs, on average, than other Medicare Advantage plans. MedPAC found that in 2022, the average margins for D-SNPs (7.5%) and C-SNPs (7.4%) were double the average margins of Medicare Advantage plans overall (3.6%). In turn, those higher payments leave more resources for plans to offer supplemental benefits that appeal to a population with complex health care needs.

Between 2018-2024, D-SNP Enrollment Grew from 2.2 Million to 5.8 Million Enrollees, Comprising Over 80% of the Total Increase in SNP Enrollment

Enrollment growth in SNPs from 2024-2025 was driven by an increase in enrollment in C-SNPs, plans for people with chronic conditions.

In recent years, CMS has made several changes to requirements for Medicare Advantage plans generally available to the public and D-SNPs, but not C-SNPs, which may affect insurer decisions about what types of plans to offer. Starting in 2022, CMS no longer contracts with conventional Medicare Advantage plans that enroll at least 80% dual-eligible individuals (“D-SNP look-alikes”). In 2025, this threshold was lowered to 70% and is scheduled to be lowered to 60% starting in 2026. Additionally, beginning in 2025, fully integrated dual eligible (FIDE) SNPs and highly integrated dual eligible (HIDE) SNPs have new enrollment, benefit, and coordination requirements (see Box 1 for additional details). The additional requirements are intended to promote better integration between Medicare and Medicaid for enrollees but could make D-SNPs less attractive to private insurers. These requirement changes could incentivize efforts to enroll more dual-eligible individuals in C-SNPs, which are not subject to the look-alike thresholds like conventional Medicare Advantage plans or Medicaid integration and coordination requirements like D-SNPs, particularly since many dual-eligible individuals have chronic conditions that may qualify them for C-SNP enrollment.

In contrast to previous years when enrollment growth in SNPs was driven by increased enrollment in D-SNPs, the largest increase in enrollment in SNPs from 2024 to 2025 was in C-SNPs, comprising more than three-quarters of the change in overall SNP enrollment. C-SNP enrollment increased sharply, rising by 476,300 enrollees from 2024 to 2025. That translates into a 71% jump over a one-year period. D-SNP enrollment and I-SNP enrollment remained relatively stable over the same period, with D-SNP enrollment growing by only 3% (159,400 enrollees) and I-SNP enrollment staying essentially unchanged.

While C-SNP enrollment has increased more quickly since the D-SNP look-alike rules first went into effect in 2022, the change accelerated over the last year, as the rules tightened further and other Medicaid integration and coordination requirements for FIDE and HIDE SNPs went into effect. This is the first time that the number of additional C-SNP enrollees has surpassed the number of additional D-SNP enrollees. A recent analysis of 2025 enrollment data (not yet available to KFF) shows that through January of 2025, just under 20% of the increase in C-SNP enrollment was comprised of dual-eligible individuals.

Dual-eligible individuals comprised a larger share of enrollment in SNPs than in non-SNP Medicare Advantage plans. For example, in 2023, 93% of SNP enrollees were dual-eligible individuals, which aligns with the dominance of D-SNPs in the SNP market. Over 90% of I-SNP enrollees were also dual-eligible individuals in 2023, reflecting the fact that Medicaid is the primary payer of long-term care, so people relying on an institutional level of care are more likely to be enrolled in both Medicare and Medicaid. In 2023, a quarter of enrollees in C-SNPs were dual-eligible individuals, while 9% of enrollees in individual Medicare Advantage plans were dual-eligible individuals.

In 2025, C-SNP Enrollment Grew by Nearly Half a Million Enrollees

For all SNP types, enrollment is highly concentrated among a small number of large national carriers.

Across all three SNP types, which enroll some of the most vulnerable beneficiaries in the Medicare population, a few large national carriers account for larger shares of enrollment in the SNP market as compared with the overall Medicare Advantage market. The distribution of D-SNP enrollment by insurer is more heavily concentrated in UnitedHealth Group Inc. (38% vs 29%) and Elevance Health Inc. (10% vs 7%) than for the overall Medicare Advantage market. UnitedHealth Group Inc. accounts for half (51%) of all C-SNP enrollment. Additional firms comprising larger shares of enrollment in C-SNPs than in the overall Medicare Advantage market include Humana Inc. (20% vs 17%) and Elevance Health Inc. (12% vs 7%). Although UnitedHealth Group Inc. accounts for a majority (51%) of I-SNP enrollment in 2025, smaller insurers play a larger role in the I-SNP market than in the overall Medicare Advantage market (42% vs 33%). Overall, 14% of SNP enrollees are in a plan offered by a non-profit organization (16% of D-SNP enrollees, 3% of C-SNP enrollees, and 5% of I-SNP enrollees).

UnitedHealth Group Inc. and Humana Inc. Account for Over Half (54%) of SNP Enrollment in 2025

For dual-eligible individuals, D-SNPs offer more integration with Medicaid than C-SNPs.

To facilitate integration of Medicare and Medicaid coverage, D-SNPs are required to contract with state Medicaid agencies, while C-SNPs are not subject to additional integration requirements. The minimum D-SNP requirements, which are set at the federal level, differ across the three categories of D-SNPs and can change year-to-year during annual rule making. D-SNPs with higher levels of integration, HIDE and FIDE SNPs, have additional requirements (see Box 1 for more details). Additionally, D-SNPs can be designated as applicable integrated plans if they meet federal requirements, including exclusively aligned enrollment, covering at least some Medicaid services through the D-SNP or an affiliated Medicaid managed care plan, and a unified grievance and appeals system. Given the lack of C-SNP integration requirements, to the extent the acceleration in C-SNP enrollment was driven by dual-eligible individuals, efforts to encourage greater integration between Medicare and Medicaid may face challenges.

States may establish additional requirements for D-SNPs through their contracts. Responses from KFF’s 24th annual budget survey of Medicaid officials in all 50 states and the District of Columbia in July 2024 show that these requirements vary across the different types of D-SNPs. For example, just over half (19) of the 35 states with coordination-only D-SNPs required these plans to include any of the additional optional requirements, the most common of which was offering certain supplemental benefits (7 states) and providing integrated member materials, such as one summary of benefits document that provides information on benefits covered by both Medicare and Medicaid (5 states). HIDE and FIDE SNPs operated in less than half of states in 2024, though most states had additional requirements for these types of plans beyond the federal requirements (14 of 15 for HIDE SNPs and all 12 states for FIDE SNPs) (Figure 4). New federal requirements for HIDE and FIDE SNPs went into effect in 2025. For FIDE SNPs, these include exclusively aligned enrollment, which limits enrollment to full-benefit dual-eligible individuals who were enrolled in the affiliated Medicaid managed care plan, and the requirement that the affiliated plan cover behavioral health, and certain other Medicaid benefits. To the extent these were not previously required by states, the new requirements may represent an additional burden for Medicare Advantage insurers and could influence their decisions on which plans to offer. In 2024, most states with FIDE SNPs did have these requirements. Specifically, of the 12 states with FIDE SNPs, 9 required exclusively aligned enrollment and 10 required the affiliated Medicaid managed care plan to cover behavioral health. (New requirements for HIDE SNPs were not among the items asked in the budget survey.) While these requirements are intended to facilitate integration and coordination between the programs, the relatively low availability of HIDE and FIDE SNPs may limit how effective they are at achieving that goal.

States Have Various Requirements in State Medicaid Agency Contracts to Improve Medicare and Medicaid Integration in D-SNPs

Box 1. Types of Special Needs Plans

Dual Eligible Special Needs Plans

Dual eligible special needs plans (D-SNPs) are limited to people who are enrolled in both Medicare and Medicaid. There are three types of D-SNPs:

Coordination-only Dual Eligible Special Needs Plans: This type of D-SNP provides Medicare-covered services and is required to coordinate the delivery of benefits with the Medicaid program, contract with state Medicaid programs, and notify states when enrollees are admitted to an inpatient hospital or skilled nursing facility.

Highly Integrated Dual Eligible Special Needs Plans: This type of D-SNP must meet the requirements of coordination-only D-SNPs (except the notification requirements) and must also include coverage of long-term care, behavioral health, or both.

New for 2025: HIDE SNPs must have aligned service areas, meaning they must also have a Medicaid plan operating in the same counties as the D-SNP.

Fully Integrated Dual Eligible Special Needs Plans: This type of D-SNP must meet the requirements of coordination-only D-SNPs (except the notification requirements) and provide Medicare and included Medicaid covered services through a single managed care organization. The same organization that offers the FIDE SNP must also offer a Medicaid managed care plan for any Medicaid benefits not included in the FIDE SNP. In some cases, certain Medicaid benefits may be provided by the state or by a different health plan. FIDE SNPs are paid by Medicare for Medicare-covered services and supplemental benefits included in the plan, and by Medicaid for Medicaid-covered services.

New for 2025: FIDE SNPs must have exclusively aligned enrollment, meaning they may only enroll full-benefit dual-eligible individuals who are enrolled in both the FIDE SNP and the Medicaid plan sponsored by the same organization, and either the D-SNP or Medicaid plan must cover long-term care and all Medicaid benefits via a separate capitated payment arrangement.

Chronic Condition Special Needs Plans

Chronic condition special needs plans enroll individuals who have specific severe or chronic disabling conditions. Nearly all (97%) C-SNPs plans are for people with diabetes or cardiovascular conditions.

Institutional Special Needs Plans

Institutional special needs plans enroll individuals who need services to be provided in a long-term care facility for at least 90 days.

Methods

Data: SNP enrollment data are from the Special Needs Plan (SNP) data published by Centers for Medicare & Medicaid Services (CMS) in the Medicare Advantage (MA)/Part D Contract and Enrollment Data section in March of the respective year. Enrollment data are only provided for plan-county combinations that have at least 11 beneficiaries; thus, we exclude any plans that do not meet this enrollment threshold.

This analysis uses data from the CMS Medicare Advantage Benefit and Landscape files for the respective year. Medicare Advantage enrollment and dual-eligible beneficiary enrollment are based on analysis of the Centers for Medicare & Medicaid Services (CMS) Chronic Conditions Data Warehouse (CCW) research-identifiable Master Beneficiary Summary File (MBSF) Base in 2023.

Identifying dual-eligible enrollees as a share of SNP enrollees: Beneficiaries with a valid contract ID and plan ID in March 2023 were identified as enrolled in Medicare Advantage. To determine the type of plan in which the beneficiary was enrolled, the contract ID and plan ID were matched to the March 2023 Monthly Enrollment by Plan, or the Special Needs Plan Report data published by CMS. This includes enrollment in all private plans which are predominately Medicare Advantage plans.

Counts of dual-eligible individuals include both full-benefit and partial-benefit dual-eligible individuals. Dual status in March (03) 2023 was identified using the Medicare monthly dual status code DUAL_STUS_CD_03 with values of 01,02,03,04,05,06, or 08. Enrollees also had to have both Part A and B in March 2023 to be included in this analysis. We excluded enrollees from Puerto Rico and the Virgin Islands from this analysis.

This work was supported in part by Arnold Ventures. KFF maintains full editorial control over all of its policy analysis, polling, and journalism activities.

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