Poll Finding

KFF/ESPN Survey of 1988 NFL Players

Published: Aug 15, 2025

Overview

The Survey of 1988 NFL players, conducted by KFF in partnership with ESPN, looks at the overall health and well-being of former professional football players who played in the 1988 NFL season. The results of this survey provide insight into the lives of these former players as they approach traditional retirement age. While many are grappling with the immense toll the sport has taken on their physical and neurological health, most say they would do it all over again.

Explore ESPN’s Reporting on This Survey

Summary of Key Findings

The Survey of 1988 NFL players, conducted by KFF in partnership with ESPN, explores the overall health and well-being of former professional football players who played in the 1988 NFL season. The aim of the project is to examine the physical, emotional, and financial well-being of a cohort of professional football players as they approach typical U.S. retirement age. Overall, the survey finds that these former players face a variety of health issues, including chronic pain and mobility problems, cognitive impairment, and mental health challenges – often at higher rates than their peers in the general population.

The survey also finds that former Black players are consistently more likely than White players to face physical, neurological, and mental health issues alongside poorer financial outcomes. This survey’s results document how racial disparities in health, health care, and income that occur in the U.S. persist among these former NFL players despite the potential financial and career benefits of playing in the NFL. At the same time, former Black players face unique challenges, as some of the racial disparities in health outcomes found in this survey – such as disability and cognition issues — are not always similarly observed among men the same age in the general population. Such data may inform and direct efforts to address such disparities among former NFL players and advance equity.

Despite these struggles, players’ views on their careers are overwhelmingly positive, and the vast majority, including both Black players and White players, say they would make the choice to play professional football again, extolling the benefits of the game on their life and relationships and citing the importance of brotherhood and the bonds they formed while playing.

5 Key Takeaways From the KFF/ESPN Survey of 1988 NFL Players

1. Overall, majorities of these players say professional football has had a positive impact on their life, including their finances, career opportunities, and relationships with family and friends. At the same time, most say the game has negatively impacted their physical health and one-third say it has had a negative impact on their mental health. For more information, see: Career Reflections / Views on Youth Football

Majorities of Former 1988 NFL Players Say Playing Professional Football Had a Positive Impact on Their Life Overall But a Negative Impact on Their Health

2. Compared to men in their age range in the population overall, former NFL players from the 1988 season are more likely to rate their physical health negatively and to report living with certain types of disability, chronic pain that interferes with their daily lives, cognitive challenges, and mental health issues. The gaps between players and men their age on these health outcomes hold when controlling for race. Incidence of these reported adverse health outcomes does not differ consistently between different position groupings (such as linemen v. skill positions, offensive v. defensive positions, and others), however, defensive players are more likely than offensive players to report some cognitive issues, such as worsening confusion and memory loss in the past year. For this survey, analysis by individual position types was not possible due to insufficient sample sizes. For more information, see: Health Issues

Former 1988 NFL Players are Consistently More Likely Than Men Their Age Overall to Report Experiencing a Wide Array of Physical and Cognitive Health Issues

3. The survey also finds stark racial disparities between players across a wide array of health measures. Black players are consistently more likely than White players to report adverse health outcomes, including physical limitations, cognitive problems, mental health challenges, pain, and disability. In many of these instances, similar disparities are not present among men in a similar age range in the population overall. These racial disparities may reflect a range of demographic and other differences between Black and White players, including racial differences by positions played (See Appendix Fig. 4), income, and access to health care and insurance. Nonetheless, some of these racial differences in reported physical disabilities and cognitive problems remain even when controlling for other factors such as higher risk position groups, income, age, and years played, suggesting that other socioeconomic factors may impact health. For more information, see: Health Issues and Mental Health

Black Players are Consistently More Likely Than White Players to Report Worse Physical and Mental Health and Physical and Cognitive Disabilities

4. Given the range of health issues reported by former players, health care access plays a key role in players’ overall well-being. While these former players have higher average incomes than men their age in the population at large, many report having gone without health insurance and necessary care since they stopped playing football, with about one in five saying they went without needed health care in the past year because of the cost. In addition, struggles affording medical bills, health insurance and other day-to-day expenses are particularly pronounced among Black players and those living with a disability. For many players, these financial difficulties may be tied to injuries they incurred during their professional football careers, as about three in ten say they were unable to work at some point since they stopped playing due to a football-related injury. For more information, see: Health Care and Finances

Among Former Players, Problems Paying for Health Care, Housing, and Food are More Common Among Those Living With a Disability and Black Players

5. Despite the physical toll playing football has had on many of these players, the vast majority say they would choose to play in the NFL again if they could go back, citing a love of the game, camaraderie with teammates, and a strong sense of purpose. Most players who are parents say they encouraged their children to play football if they expressed an interest, and a majority oppose banning youth tackle football below the high school level – although they are more divided on the whether the benefits of youth football outweigh the overall risks. For more information, see: Career Reflections

90% of Players Say if They Could Go Back, They Would Make the Decision to Play Football Again

“The experience built a foundation for my life. Discipline, how to work for and be a part of a team. How to handle success, how to handle failure. How to face adversity and work through it. I fall back on those lessons often.”

“Nothing will ever replace the camaraderie or the adrenaline to play against the best in the world.”

“Because of the brotherhood, all the brothers that I had from the game of football…I have the best relationships with my brothers. When you play football, you go through things and, when you go through things together, you develop a bond.”

“I would still have played because of the people, the culture that accepts you above your identity.”

“There is zero downside outside of the hardware in the body. Yes I ache a bit more but so does my wife who never played.”

Career Reflections, Life Satisfaction, and Views on Youth Football

Key Takeaways

  • The vast majority of former players from the 1988 NFL season say playing professional football has had a positive impact on their life but a negative impact on their physical health. Overall, nine in ten former players say playing professional football has had a positive impact on their life in general (91%), with majorities reporting positive impacts on their social life (73%), financial situation (72%), employment situation (65%), and relationships with family (65%). At the same time, about three in four (77%) players say the game has had a negative impact on their physical health, and one-third say it had a negative impact on their mental health.
  • Despite these negative health impacts, the overwhelming majority (90%) of 1988 players say they would choose to play professional football again if they could go back, while just 4% say they would not play again. These shares are consistent across Black and White players despite disparities in reported health and financial outcomes and among players who report negative impacts on their physical or mental health. In open-ended responses, players cite a love of the game, the importance of brotherhood, the instillation of a strong sense of purpose, and valuable life skills as reasons why they would do it all over again.
  • Nearly all former 1988 NFL players are parents, and two-thirds (73%) say at least one of their children played organized tackle football at some level. However, when it comes to children playing tackle football, players from the 1988 season are somewhat divided on the risks: about half (47%) of ’88 players say that when it comes to youth playing tackle football before high school, “the benefits outweigh the risks,” while about four in ten (37%) say the “risks outweigh the benefits.” Nonetheless, most players who are parents (57%) say they encouraged their children to play football if they expressed an interest, and seven in ten (71%) oppose banning youth tackle football below the high school level. This may be a reflection of how much the sport has changed since their time in the NFL; about eight in ten (78%) former players say that professional football is safer now compared to when they were playing.

Views on the Overall Impact of an NFL Career

An overwhelming majority of 1988 players (91%) say that playing professional football has had a positive impact on their life in general. This positive impact is echoed in other facets of their lives, with a majority saying professional football had a positive impact on their social life and relationship with friends (73%), their financial situation (72%), relationships with family (65%), and their employment situation or career opportunities (65%) since they stopped playing football. Just about one in ten say their football career has had a negative impact in each of these areas.

Players paint a far more negative picture when it comes to the game’s impact on their physical health. About three in four players (77%) say playing professional football had a negative impact on their physical health, while just 14% say it had a positive impact. Players are more divided on how their careers impacted their mental health. About four in ten (43%) say the game had a positive impact on their mental health, while one-third say it had a negative impact (33%). Among Black players, similar shares say playing football had a negative (41%) and a positive (39%) impact on their mental health (see Appendix for details on player race and ethnicity).

Three Quarters of 1988 NFL Players Say the Sport Negatively Impacted Their Physical Health, But the Vast Majority Say Playing Had a Positive Impact on Their Life in General

Most players report being generally satisfied with their lives, including majorities of Black and White players who say they are “very” or “somewhat satisfied” with their life as whole, their relationships with their spouses, children, and former teammates, the number of meaningful connections they have with other people, and their personal financial situation.

Large majorities of both Black and White players express satisfaction with these aspects of their lives, but fewer Black players than White players report being satisfied with their life as a whole (74% vs. 89%) or their financial situation (62% vs. 86%).

Large Majorities of Former NFL Players Report Satisfaction With Different Aspects of Their Lives, But Life Satisfaction is Somewhat Lower Among Black Players

Despite reporting negative impacts on their mental and physical health, an overwhelming majority of players from the 1988 season (90%) say they would still make the decision to play professional football if they could go back—a share that is consistent across Black and White players despite disparities in reported health and financial outcomes. Even among players who say football negatively impacted their physical health, nine in ten (88%) say they would make the decision to play again. A somewhat smaller share, but still a large majority, of players who say the game had a negative impact on their mental health say they would play again (78%).

The Overwhelming Majority of Players Say They Would Still Play Football Again if They Could Go Back, Including Majorities of Those Who Report Negative Health Impacts
In Their Own Words: Why NFL Players From the 1988 Season Would or Would Not Do It All Again

Quotes have been edited to protect player confidentiality and for clarity.

Among those who said they would play again (90% of players):

“The experience built a foundation for my life. Discipline, how to work for and be a part of a team. How to handle success, how to handle failure. How to face adversity and work through it. I fall back on those lessons often.”

“Greatest game in the world. High risks/High reward. Nothing will ever replace the camaraderie or the adrenaline to play against the best in the world.”

“There is zero downside outside of the hardware in the body. Yes I ache a bit more but so does my wife who never played.”

“Playing football especially pro’s I encountered people from different ethnicities, religious beliefs, achievements and family units that gave me great perspectives on living…I would still have played because of the people, the culture that accepts you above your identity.”

“… because of the brotherhood, all the brothers that I had from the game of football…I have the best relationships with my brothers. When you play football, you go through things and, when you go through things together, you develop a bond. I have a plethora of brothers, not just from pro football, but from every level from youth to high school to college. It is part of who I am.”

Among those who said they would not play again (4% of players):

“The injuries last much longer than expected. In fact every injury I had, that I thought I had rehabbed successfully, have all come back in my retirement from the game. They were just laying dormant waiting for muscle atrophy. Everything seems to hurt and the temporary money and fame just wasn’t a fair exchange.”

“My life is severely impacted. Having both hips replaced once…5 shoulder replacements. One knee replacement already and planning the other soon. All these issues have me not able to do any of the activities I grew up loving. I can’t play catch with my grandson. I can’t play the guitar or piano anymore. Can’t go hiking or walk my dogs. Can’t do a f****** thing physically. Then there is the brain s***…I went back to school and could not remember a thing which was my 1st indication something was/is wrong. Blew up two great relationships and have had issues with my kids as my temper and loss of memory hamper my ability to have a coherent conversation. My quality of life sucks, just sitting here waiting to die.”

When it comes to supportive relationships, most players from the 1988 seasons say they think their teammates (79%) and their coaches (64%) cared “a lot” or “some” about their overall well-being during their professional football career. Far fewer (36%) say they think the owners of the teams they played for cared about their overall well-being. The shares who say their teammates, coaches, or team owners cared about their well-being is similar among Black players and White players.

Most Former Players Felt Their Teammates and Coaches Cared About Their Well-Being During Their Career, Fewer Than Half Say the Same About Team Owners

Views on Safety, Youth Football, and Today’s NFL

When it comes to youth playing tackle football, players from the 1988 season are somewhat divided on whether the benefits outweigh the risks. Nonetheless, most players who are parents say they encouraged their children to play football if they expressed an interest, and a majority oppose banning youth tackle football below the high school level. This may be partially explained by the fact that the vast majority of 1988 players say they think professional football is safer now compared to when they played.

Nearly all players from the 1988 season are parents (96%) and a majority of players (67%) say they have coached a high school or youth football team. Among players who are parents, most say their children played football at some level (73%). This includes four in ten who say at least one of their children played at the college (33%) or professional level (8%).

Most NFL Players from the 1988 Season Say Their Children Played Tackle Football at Some Level, But Relatively Few Have Played Professionally

Most former players say they encouraged their children to play football, with many citing the important life lessons instilled by playing, including the importance of teamwork, camaraderie, discipline and work ethic. Overall, about six in ten (57%) players from the 1988 season say they encouraged their children to play tackle football if they expressed an interest compared to just 7% who say they discouraged their children. One in five (19%) say it depends on the child, while 16% report that none of their children ever expressed an interest in playing.

Most 1988 NFL Players Encouraged Their Children To Play Tackle Football if They Expressed an Interest

Players are somewhat divided on the relative risks of children playing tackle football below the high school level, with about half (47%) saying the “benefits outweigh the risks” and about four in ten (37%) saying the “risks outweigh the benefits,” while 16% say they have no opinion. Perhaps reflecting the sport’s impact on their health, Black players and players living with a disability are each less likely than White players and those without a disability, respectively, to say the benefits of youth playing tackle football outweigh the risks. Past studies among former NFL players have linked playing youth tackle football with cognitive issues later in life.

Former Players are Divided on the Risks of Youth Football, While Black Players and Those With a Disability Less Likely to Say the Benefits Outweigh the Risks

In recent years, there has been much debate over banning youth tackle football across the U.S., with legislators in several states introducing bills to ban tackle football below the high school level. Attempts to ban tackle football for youth, including a recent bill in California, have been unsuccessful thus far. The majority (71%) of players from the 1988 season say they oppose banning youth tackle football under the high school level and a quarter (26%) saying they would support such a ban. While few players across demographics support banning youth tackle football, the shares who support a ban are slightly higher among Black players compared to White players (29% v. 22%) and players living with a disability compared to those who are not (29% v. 21%).

Majorities of 1988 NFL Players Oppose Banning Youth Tackle Football

Since many of these players have retired from professional football, the game has changed markedly when it comes to safety, with changes to personal equipment and updated rules aimed at making the game safer. Most players (78%) from the 1988 season agree that professional football is safer now compared to when they were playing football, while 15% say it’s about the same and just 6% say it is more dangerous now.

Eight in Ten Former NFL Players from the 1988 Season Say Professional Football is Safer Now Compared to When They Played

Physical, Cognitive, and Neurological Health Issues

Key Takeaways

  • Across a range of measures, former NFL players from the 1988 season report being in worse health and experiencing more frequent pain and higher levels of disability compared to men their age in the general population, even when controlling for race. Former players are about three times as likely as other men their age to report living with a disability (60% v. 21%) and about twice as likely to report experiencing pain all or most days in the past three months (69% v. 33%). In open-ended responses players describe the isolating effects of pain and the toll it has taken on their daily life and mental health.
  • Just over half (55%) of players say they have experienced confusion or memory loss in the past year that is happening more often or getting worse – more than three times the share of men their age who say the same (16%). A notable share of former players report having been diagnosed with a neurological disorder, including about three in ten (28%) who say a health provider has told them they have post-concussion syndrome (28%) and 15% who report being diagnosed with dementia, including Alzheimer’s disease. Nearly one in five (18%) say a doctor or other health care provider has told them they have chronic traumatic encephalopathy (CTE), although CTE cannot definitively be diagnosed until after death. Defensive players are more likely than those in offensive positions to report worsening confusion and memory loss in the past year (63% v. 50%) and being diagnosed with a neurological condition (52% v. 37%), including post-concussion syndrome (36% v. 23%). Incidence of these neurological health issues does not differ consistently by other position groupings, such as linemen v. skill positions. Analysis by individual positions is not possible due to insufficient sample sizes.
  • Among former ’88 NFL players, there are consistent, stark racial disparities when it comes to physical and neurological health outcomes. Black players are more likely than White players to report living with some kind of disability (69% v. 48%), particularly those related to difficulty concentrating, remembering, or making decisions (60% v. 30%), and difficulty walking or climbing stairs (45% v. 27%). Notably, these wide racial disparities are not present among men in the same age range in the general population. Black players are twice as likely as White players to say they’ve been told by a doctor that they have CTE (25% v. 10%) or dementia (21% v. 9%), and significantly more likely to say they’ve been diagnosed with post-concussion syndrome (36% v. 19%). Though Black players are more likely than White players to have played in positions that previous research has linked to increased risk for cognitive problems, Black players’ higher incidence of disability and worsening confusion and memory problems remain significant compared to White players even when controlling for other factors, including higher risk position groups , income, age, and years played, suggesting other socioeconomic factors or experiences may be a contributing factor.
  • While Black players are more likely to report disability and pain that limits their life activities, White players report having a higher number of football-related surgeries compared to Black players, with half of White players compared to a third of Black players saying they’ve had five or more. Higher incidence of surgeries among White players may reflect disparities in health care access and financial situation. Black players are more likely than White players to say they did not have health insurance coverage for a year or more after their NFL career.
Racial Disparities Between Black and White Players

This survey finds stark differences between Black and White former NFL players across a wide array of physical, neurological, and cognitive health measures. These disparities are consistent with previous research and likely reflect several different and often interrelated factors, including racial differences in positions played (See Appendix Fig. 4), post-NFL income, access to health care, and social determinants of health.

Among 1988 NFL players, Black players are more likely than White players to have played in positions that previous research has linked to increased risk for cognitive problems, including running back, linebacker, and defensive line. Nearly half (47%) of Black 1988 players played in one of these positions compared to 31% of White players. Previous research from the Football Players Health Study at Harvard University shows that Black players have historically been more likely to play in these higher-risk positions – a phenomenon called “racial stacking,” which has been observed across different professional sports.

Differences in positions played, however, do not account for all of the differences in outcomes between Black and White players. Previous research among former NFL players has found that Black players are more likely than White players to experience physical and cognitive health issues even when controlling for a variety of factors, including positions and years played and concussion incidence. Similarly, among players from the 1988 season, Black players were more likely than their White counterparts to report having a disability and to report having worsening confusion and memory problems even when controlling for age, current income, higher-risk position groups, and years played in the NFL1 , suggesting that other factors, including injury incidence, access to health care, and socioeconomic factors play a role in these disparities.

Black players from the 1988 season are also more likely than White players to report lower average incomes, financial difficulties, and being uninsured at some point since they stopped playing. These differences mirror inequities seen in the U.S. population more generally, with studies documenting the racial wealth gap that continues in the U.S. today, and research highlighting employment discrimination experienced by Black adults. Moreover, studies indicate that some of these wealth and economic differences between Black and White players are present before they even reach the professional football stage of their careers. For example, Black NFL players are more likely than White players to have attended high schools with higher share of low-income students and are more likely to come from more economically disadvantaged areas.

See Appendix for more details on player race and ethnicity

Overall Health and Disability

About six in ten (62%) players from the 1988 season describe their physical health as either “excellent,” “very good,” or “good,” while about four in ten (38%) describe their physical health as “fair” or “poor.” Compared to men in their age cohort in the population overall, these former NFL players are more likely to describe their health negatively (38% v. 24%). These differences hold among Black players and White players when compared to their respective peers in the general population. (See Methodology for additional details on general population data.)

Four in Ten 1988 NFL Players Describe Their Physical Health Negatively Compared to a Quarter of Men Their Age Overall

Players from the 1988 season are much more likely than men their age to report living with a disability, especially those related to cognition and mobility. Overall, six in ten players from the 1988 season report currently living with a disability — three times the share of men in their age range overall (21%). Players living with a disability include those who say they have difficulty concentrating, remembering, or making decisions (47%), serious difficulty walking or climbing stairs (36%), difficulty dressing or bathing (18%), are deaf or have serious difficulty hearing (14%), or are blind or have serious difficulty seeing even when wearing glasses (8%). Players are about eight times as likely as men their age to report serious difficulty concentrating, remembering or making decisions, and at least three times as likely to report serious difficulty walking or climbing stairs or difficulty dressing or bathing. The higher incidence of disability among 1988 players compared to men their age holds when controlling for race, with both Black players and White players more likely than their peers in the general population to report living with a disability. Players who played in defensive positions are somewhat more likely than offensive players to report difficulty concentrating, remembering, or making decisions (55% v. 42%). The share who reports living with a disability overall, however, does not significantly differ by defensive v. offensive positions or linemen v. skill positions. Incidence of reported disability by specific positions is not possible due to insufficient sample sizes.

Six in Ten Players From the 1988 Season Report Living With Some Type of Disability, About Three Times the Share of Men Their Age Overall

Larger shares of Black players compared to White players report having some type of disability (69% v. 48%), with Black players twice as likely to report serious difficulties concentrating or remembering (60% v. 30%). Larger shares of Black players than White players also report serious difficulty walking or climbing stairs, difficulty dressing or bathing, or being blind or having serious difficulty seeing. These large racial disparities are not similarly observed among men in this age range in the general population.

Black players’ higher incidence of disability compared to White players remains significant when controlling for other factors, including higher risk position groups, income, age, and years played. The higher incidence of disabilities – and other adverse health outcomes – among Black players could be attributed to a number of factors, including racial differences in positions played (See Appendix Fig. 4), injury incidence, and access to health care and other services. Notably, Black players are more likely than White players to say they did not have health insurance coverage for a year or more after their NFL career.

Black Players are Much More Likely Than White Players to Report Living With a Disability, Particularly Those Related to Cognition and Mobility

Chronic Pain

Seven in ten (69%) players say they experienced pain either “every day” or “most days” in the past three months, twice the share of men their age in the general population (33%) – a difference that holds among both Black players and White players compared to their peers in the general population. This includes about a third (35%) of players who say they experienced pain that limited their life or work activities every or most days in the past three months, compared to about half that share among men their age overall (13%). While similar shares of Black players and White players report experiencing pain all or most days (71% and 67%, respectively), Black players are more likely than White players to report experiencing pain that limited their life or work activities all or most days in the past three months (41% v. 28%). Similar racial disparities are not present among men in a similar age range in the general population. The share who reports living with chronic pain does not notably differ by different position groupings, such as linemen v. skill positions or offensive v. defensive. Incidence of chronic pain by specific positions is unreportable due to insufficient sample sizes.

Seven in Ten 1988 NFL Players Say They Experience Near-Daily Pain and One-Third Have Pain That Limits Their Life and Work Activities

In open-ended responses, many players describe the enormous toll pain has had on their daily life, inhibiting their ability to spend time with family and friends, partake in hobbies, and work. Alongside these isolating effects of chronic pain, many describe negative impacts on their mental health and emotional well-being.

In Their Own Words: How Chronic Pain Has Limited Former Players’ Life and Work Activities

Quotes have been edited to protect player confidentiality and for clarity.

“I used to love going out with friends and now I’m always in pain. Over the past several years I’ve not associated with any of my friends and family because I don’t want them to see me like this. Mentally it’s killing me. So what do I do? I have become a loner and not even realizing it…I’ve always been so happy and friendly with everyone that I’ve ever had the pleasure of interacting with and I am not who I used to be. I would love to go back to work at some point but my memory often fails me and being around other people may not end well. This is when anxiety and mental pain enters my life. I do believe that if I had a job I would feel emotionally, psychologically and physically so much better.”

“I have serious back and knee and shoulder problems. I don’t like masking it with pills because a lot of my friends have become addicted to them. The sport pays well, but it doesn’t pay as well now.”

“My pain these days is enormous…Arthritis, back, hip, brain fog … If I was not able to get relief, I would most likely end my life… there is no way I could live with this pain & function.”

“After…years of playing in the NFL, with 2 surgically repaired knees…back and neck injuries… concussions that I can’t even count… it has been very difficult to do normal activities now that I have become older, by the grace of God. Football has been a blessing to me, but it has also been a curse in the long run. Sometimes I wish that I never played this dear sport that I loved. The sport of football gave me so much…but it took even more from me. In ways you can’t explain, unless you played yourself.”

“In general, walking is painful, standing and exercising is painful. I have stressful thought processing issues. I lose my concentration, I get panicky and it makes it worse. It’s hard for me to go anywhere because constantly the slightest thought can throw me into a panic and causes anxiety. I like playing golf but I shy away from it and don’t go anywhere because of this situation.”

“The pain also known as the stinger feels like a hot iron, pain and needles white hot pain that has been unbearable for years. I’ve used alcohol and opioids for the pain to cool off. I’ve bought opioids not prescription that I had to get off the street because I was declined and denied. My lower back interferes to this day to put on my socks and shoes and put on my underwear, it is embarrassing, debilitating and depressing…”

In addition to dealing with chronic pain in higher shares than men their age, players from the 1988 season are also more likely than men in their age cohort to say they’ve been diagnosed with arthritis and related disorders. Two-thirds (66%) of players say they have been told by a doctor or other health professional that they have arthritis, gout, lupus, or fibromyalgia compared to about four in ten (38%) men in a similar age range in the general population who report a diagnosis. This difference holds across racial groups, with both Black players and White players more likely than their peers to report a diagnosis. When it comes to other common chronic health conditions like hypertension, high cholesterol, and diabetes, somewhat similar shares of players and men their age overall report having been diagnosed.

One-third of players say they have been told by a doctor that they have obesity or are overweight, including similar shares of Black players and White players. Prior KFF polling found a similar share of men in this age range (38%) saying they were diagnosed as overweight or obese in the past five years.

Players From the 1988 NFL Season Are More Likely Than Men Their Age To Have Arthritis and Similar Chronic Pain Disorders

The overwhelming majority (87%) of NFL players from the 1988 season say they have had at least one orthopedic surgery related to playing football, including three in ten (39%) who have had five or more surgeries. While Black players are more likely than White players to report adverse physical health issues including disabilities and chronic pain that limits their life and work, a somewhat larger share of White players compared to Black players say they have had at least one football-related surgery (91% v. 84%), with White players being more likely to say they’ve had five or more surgeries (50% v. 33%). These racial disparities may reflect differences between Black and White players in post-football income and access to health care, which in turn may contribute to the long-term effects of increased pain and disability among Black players.

Nine in Ten Players From the '88 Season Have Had a Football-Related Surgery, With White Players More Likely Than Black Players to Report Five or More

Neurological Health, Confusion and Memory Loss

Many players from the 1988 season report cognitive issues, including worsening confusion or memory loss and being diagnosed with neurological conditions including chronic traumatic encephalopathy (CTE)2  and dementia. There are stark racial disparities when it comes to neurological health among these players, with much larger shares of Black players reporting dementia and CTE diagnoses. Black players are also more likely than White players to report worsening confusion and memory issues, a disparity that is not similarly observed among men their age in the general population. Players, including both Black and White players, are much more likely to report worsening confusion and memory loss issues compared to their peers in the general population.

Notably, nearly all players from the 1988 season (95%) report experiencing a head injury while playing football, which could include anything from “seeing stars,” a mild concussion, or fully losing consciousness. Past research has linked head injuries sustained while playing contact sports like football to the development of neurological issues, including CTE – a link that has been acknowledged by the National Football League (NFL).

About four in ten (43%) players from the 1988 season say they have been told by a doctor or other health professional that they have some type of neurological disease or condition, with the largest shares reporting diagnoses for post-concussion syndrome (28%), CTE (18%), and dementia, including Alzheimer’s disease (15%). Fewer players report being diagnosed with other neurological issues, including having a stroke (5%), Parkinson’s disease (5%), chronic fatigue syndrome (4%), or a seizure disorder (2%). Defensive players are more likely than those in offensive positions to have been diagnosed with a neurological condition (52% v. 37%), including post-concussion syndrome (36% v. 23%).

Black players are about twice as likely as White players to report neurological diagnoses, including for post-concussion syndrome (36% v. 19%), CTE (25% v. 10%), and dementia (21% v. 9%). Previous studies have shown that Black adults are more likely to develop dementia compared to White adults but less likely to receive a diagnosis.

Four in Ten 1988 Players, Including Larger Shares of Black Players, Report Being Diagnosed With a Neurological Condition Such as CTE, Dementia, or Others

About half (55%) of players from the 1988 season say they have experienced confusion or memory loss in the past year that is happening more often or getting worse, including larger shares of Black players compared to White players (65% v. 43%) – a disparity that is not present among men their age overall. Players are much more likely than men their age overall (55% v. 16%) to report worsening confusion or memory loss in the past year, a difference that holds among both Black players and White players when compared to their peers in the general population.

Beyond experiencing worsening confusion and memory issues, many players report that these issues have adversely affected their ability to carry out daily tasks, from household chores to working and socializing. About one-third of players say they have experienced worsening confusion or memory loss in the past year that has either caused them to give up day-to-day household activities at least “sometimes” (34%) or interfered with their ability to work, volunteer, or engage in social activities outside their home at least “sometimes” (37%). Black players are twice as likely as White players to report these adverse effects of worsening confusion and memory loss. Players who played in defensive positions are more likely than those who played offensive positions to report worsening confusion and memory loss in the past year (63% v. 50%). Incidence of reported worsening confusion or memory loss by specific positions is not possible due to insufficient sample sizes.

At Least One-Third of 1988 Players and Nearly Half of Black Players Report Worsening Confusion or Memory Loss That Inhibits Their Ability To Work or Socialize

Mental Health and Access to Mental Health Care

Key Takeaways

  • Many former NFL players from the 1988 season report struggling with mental health issues, and often in higher shares than men their age in the general U.S. population. About one-third (34%) of former players describe their mental health and emotional well-being as “fair” or “poor,” compared to just one in ten men their age overall. Additionally, players are more likely than men their age to report feeling lonely (40% v. 25%), depressed (45% v. 24%), or anxious (53% v. 34%) at least “sometimes” in the past year.
  • Black players are particularly likely to report negative mental health outcomes and are much more likely than White players to report regular feelings of anxiety (62% v. 42%), depression (52% v. 36%), and loneliness (51% v. 25%). These racial differences among former NFL players are not similarly observed among the general population of men ages 55 to 75, and Black players are more likely than Black men their age to report feelings of loneliness, anxiety, and depression in the past year.
  • One-quarter of former ’88 players say there was a time in the past three years when they needed mental health services or medication but didn’t get them, about three times the share among other men their age. The share of players who report skipping needed mental health services rises to over half (55%) among those who describe their mental health negatively, and Black players are twice as likely as White players to say they skipped needed mental health services in the past three years (31% v. 16%).
  • While self-reported addiction issues are not particularly common among players from the ’88 season, those with chronic pain, disabilities, and those in fair or poor mental health are more likely to say they’ve ever been addicted to alcohol or prescription painkillers compared to their peers. For example, players with fair or poor mental health are more likely than those who describe their mental health as at least “good” to say they’ve been addicted to alcohol (24% v. 15%) or prescription pain killers (14% v. 5%). Similarly, players who experience pain at least “most days” are more likely than those who do not to report ever being addicted to alcohol (21% v. 12%) or prescription painkillers (10% v. 2%).

Self-Reported Mental Health and Wellbeing

About one-third (34%) of players from the 1988 NFL season describe their current mental health and emotional well-being as “fair” or “poor,” including a larger share of Black players (46%) compared to White players (21%) (see Appendix for more details on player race and ethnicity). Notably, Black players are nearly twice as likely as White players to say that playing professional football had a negative impact on their mental health (41% v. 23%). Players who report having a disability, worsening confusion and memory loss, and fair or poor physical health are all more likely than those who do not to negatively rate their current mental health status. Past research has found that Black players are more likely to report negative physical and mental health outcomes, even when controlling for position and years played. Other factors may contribute to such disparities, such as social determinants of health, income, and access to health care. Among players from the 1988 season, Black players are more likely than their White counterparts to report negative physical health status, disability, and cognitive problems – all of which may contribute to and exacerbate mental health challenges.

Former ‘88 players are about three times as likely as men their age overall, per prior KFF polling, to describe their mental health as fair or poor. While both Black players and White players are each more likely than their peers in the general population to describe their mental health negatively, the gap between Black players and Black men their age is much wider (46% v. 12%). In fact, self-reported mental health status does not differ notably by race among men ages 55-75 overall.

A Third of '88 NFL Players, Including Just Under Half of Black Players, Describe Their Mental Health Negatively, Three Times the Rate of Men Their Age Overall

Poorer mental health outcomes among former players may be tied to physical health issues, including chronic pain and disabilities. Players who report having pain at least “most days” in the past three months are far more likely than those who experienced pain less frequently to describe their mental health negatively (43% v. 13%). Similarly, players who report living with a disability are far more likely than those who do not to describe their mental health negatively (52% v. 6%).

Former '88 Players Who Are Living With a Disability or Chronic Pain Are More Likely Than Those Who Are Not To Describe Their Mental Health Negatively

Players from the 1988 NFL season are more likely than men their age overall to report regular feelings of loneliness, anxiety and depression, with Black players much more likely than both White players and Black men their age to say they experienced these feelings. About half of former players from the ’88 season say they have felt anxious (53%) or depressed (45%) at least “sometimes” in the past 12 months, while four in ten say they’ve felt lonely at least “sometimes.” Larger shares of Black players compared to White players report experiencing these feelings at least “sometimes” in the past year, including anxiety (62% v. 42%), depression (52% v. 36%), and loneliness (51% v. 25%).

In each instance, players are more likely than men their age to report these feelings per past KFF polling, with large gaps between Black players and Black men their age overall. While White players are more likely than White men their age in general to report regular feelings of depression and anxiety by about a 10-point margin, they report feelings of loneliness in similar shares to White men their age.

Former NFL Players are More Likely Than Men Their Age to Report  Loneliness, Depression, and Anxiety - a Difference Largely Driven by Black Players

As with their mental health overall, players who report living with disabilities or chronic pain are much more likely than those who do not to report regular feelings of loneliness, anxiety, and depression. For example, players who report living with a disability are at least twice as likely as players without a disability to say they at least sometimes felt anxious (71% v. 27%), depressed (60% v. 21%), or lonely (54% v. 19%) in the past year.

Players Living With a Disability or Chronic Pain Are at Least Twice as Likely Than Those Who Are Not To Report Regular Feelings of Loneliness, Anxiety and Depression

Having a strong, local support network of friends or family is associated with a lower incidence of feelings of anxiety, depression, and loneliness among players. Players who say they have at least “a fair amount” of friends or family living nearby whom they can ask for support are far less likely than those who say they have “just a few” or “none” to say they felt anxious (40% v. 70%), depressed (30% v. 61%), or lonely (25% v. 58%) at least sometimes in the past year. Prior KFF polling has found a strong relationship between local support networks and mental health.

Even among players living with a disability, strong support networks are linked with a lower incidence of regular feelings of loneliness, anxiety, and depression. Among players with a disability, those who have at least a fair amount of friends of family living nearby who they can ask for help or support are far less likely than those who do not to report feeling lonely (35% v. 71%), depressed (45% v. 73%), or anxious (56% v. 85%) at least sometimes in the past 12 months.

Among Players Living With a Disability, Those With a Strong Local Support Network Are Less Likely To Report Regular Feelings of Loneliness, Depression, or Anxiety

Notable shares of 1988 NFL players report sleep, appetite, and anger problems, with these issues far more common among players who also report cognitive issues. Most players (68%) say they have had trouble falling or staying asleep or sleeping too much at least “sometimes” in the past 30 days, while around four in ten say they have experienced poor appetite or overeating (44%) or difficulty controlling their temper (39%). The share reporting these issues, however, rises drastically among players with worsening cognitive issues. Players who say they have experienced worsening confusion or memory loss in the past year are much more likely than those who have not to report experiencing issues related to sleep (82% v. 51%), eating (60% v. 23%) or controlling their temper (57% v. 17%) at least sometimes in the past 30 days.

88 NFL Players With Worsening Confusion and Memory Loss are More Likely to Report Sleep, Appetite, and Anger Issues

Access to Mental Health Care

With many 1988 players reporting mental health issues, notable shares say they have forgone needed mental health services in the past three years, including even larger shares of those who describe their mental health negatively. Overall, 16% of players say they have received mental health counseling or therapy in the past 12 months. However, a quarter of players say there was a time in the past three years when they thought they needed mental health services or medication but did not get them — three times the share of men their age overall who said the same (8%) in prior KFF polling. The share of former players who say they’ve gone without needed mental health services in the past three years is even higher among those who are likely most in need of such services; just over half (55%) of players who describe their mental health as “fair” or “poor” say they’ve gone without needed mental health care in the past three years.

Disparities in accessing mental health care also occur across race, with Black players about twice as likely as White players to report forgoing needed mental health care (31% v. 16%). This disparity is not similarly observed among the general population; among men ages 55 to 75, similar shares of Black and White men report forgoing needed mental health services in the past three years.

Among Former Players Who Describe Their Mental Health Negatively, Over Half Say They Have Gone Without Needed Mental Health Services in the Past Three Years
In Their Own Words: Why Former NFL Players Went Without Needed Mental Health Services

Quotes have been edited to protect player confidentiality and for clarity

“Maybe pride or I think I can just muscle through it.”

“Went a few times and it made me uncomfortable facing my own thoughts on my situation. It’s hard to hear yourself say these things out loud to someone else.”

“I just felt that I really didn’t need it and I wanted to see if it subsides. I decided I could handle whatever pain or depression I felt myself. Also, sometimes I questioned if it was just in my head. I am a little too hard on myself so sometimes what I am imagining is not as real and I may be a little paranoid about it.”

“I didn’t think it would work. Football players are taught to work it out.”

“I didn’t want the embarrassment or be labeled as someone who needs help with their mental health.”

“Just not reaching out sometimes because you feel it’s confidential. Football players they keep things to themselves and internalize.”

“No health insurance and I haven’t seen a doctor in over 20 years.”

Substance Use and addiction

While self-reported addiction issues are not particularly common among players from the ’88 season, the shares are higher among those who report experiencing chronic pain, disability, or describe their mental health negatively. Overall, about one in five (18%) players say they have ever been addicted to alcohol and fewer say they have ever been addicted to prescription painkillers (8%) or any illegal drug such as heroin, fentanyl, methamphetamine, or cocaine (3%).

Players who say they experience pain at least “most days” are nearly twice as likely as those who do not to say they’ve been addicted to alcohol (21% v. 12%) and much more likely to say they’ve ever been addicted to prescription painkillers (10% v. 2%). Similarly, players who describe their mental health as “fair” or “poor” and players who are living with a disability are each more likely than their peers to say they’ve ever been addicted to alcohol or prescription painkillers. Few players (1%) – including similar shares across mental health status and experiences with pain or disability – say they have ever had a drug overdose that required hospitalization.

Among players who say they were ever addicted to alcohol, prescription painkillers, or any illegal drug, three-quarters (75%) say they have never gotten treatment for addiction or substance use disorder.

1988 NFL Players With Chronic Pain, Disabilities, or Fair/Poor Mental Health Are More Likely To Report Addictions to Alcohol and Prescription Painkillers

Health Care Access and Coverage and Financial Wellbeing

Key Takeaways

  • With many former players from the 1988 NFL season reporting an array of health issues, access to health care and insurance likely plays a key role in players’ overall well-being. While most players (95%) say they are currently covered by some type of health insurance, four in ten (41%) report being uninsured at some point since they stopped playing professional football, including about a quarter (27%) who say they were uninsured for a year or more. Black players – who are much more likely than White players to report physical and cognitive health issues – are more likely than White players to say they have been uninsured at some point since leaving the NFL (48% v. 33%), including for a year or more (33% v. 20%).
  • Some former ‘88 NFL players report facing cost barriers when accessing health care in the past year. About one in five (21%) say they skipped or postponed getting health care they needed because of the cost in the past 12 months, while 16% say they’ve had problems paying their medical bills and 14% have had problems affording health insurance. These problems are even more common among players living with a disability, including skipping needed health care because of the cost (28%), problems paying medical bills (24%), and problems affording health insurance (21%).
  • While most 1988 NFL players say their football career had a positive impact on their finances and report higher average incomes than men their age in the general population, there are stark disparities in income and financial challenges by race and disability status. One-third of former players say it has been at least “somewhat difficult” to maintain steady employment or have a stable career since they stopped playing professionally, rising to 44% among Black players and 46% among players living with a disability. For some of these players, difficulties maintaining employment are tied to health issues they incurred from playing professional football. Three in ten (29%) former players say since they stopped playing professional football they have been unable to work at some point due to a football-related injury, including a larger share of Black players compared to White players (37% v. 19%) and defensive players compared to offensive players (36% v. 25%).
Racial Disparities Between Black and White Players

The KFF/ESPN Survey of 1988 NFL Players finds stark differences between Black and White former players across a wide array of health and economic measures. Black players from the 1988 season are more likely than their White counterparts to report lower average incomes, financial difficulties, and problems accessing health care. These differences mirror inequities seen in the U.S. population more generally, with studies documenting the racial wealth gap and research highlighting employment discrimination experienced by Black adults. Moreover, studies indicate that some of these wealth and economic differences between Black and White players are present before they even reach the professional football stage of their careers. For example, Black NFL players are more likely than White players to have attended high schools with higher shares of low-income students, and are more likely to come from more economically disadvantaged areas. Additionally, racial inequities in wealth and income are present even among college-educated adults, highlighting that the educational opportunities that football players may have do not resolve pre-existing economic inequities.

See Appendix for more details on player race and ethnicity.

Health Insurance and Access to Care

While nearly all former players (95%) say they are currently covered by health insurance, about four in ten (41%) report not being covered by health insurance at some point since they stopped playing football, including about one in four (27%) who say they were uninsured for a year or more. The share who reports being uninsured at some point post-NFL rises to about half of players living with a disability (49%) and Black players (48%). Notably, past KFF analysis has found that nationally, Black adults have a higher uninsured rate than White adults.

Four in Ten Players, Including Half of Those With a Disability, Say They Were Uninsured at Some Point Since They Stopped Playing

About one in five (21%) players from the 1988 season – including similar shares of Black players and White players – report postponing or skipping health care they needed in the past 12 months because of the cost, compared to 12% of men in a similar age range who reported the same in past KFF polling. This difference may reflect an increased need for care among these players, who are more likely than other men their age to be living with disabilities and cognitive issues. Overall, one in eight players (12%) – including similar shares across race – say their health got worse because they skipped or postponed needed care because of the cost (compared to 4% of men their age nationally who reported worsening health after skipping needed care for any reason).

Players living with disabilities are more likely than non-disabled players to report skipping or postponing needed health care because of the cost in the past 12 months (28% v. 11%) and to say their health got worse as a result (17% v. 3%). Forgoing needed health care is also much more common among players with lower household incomes. One-third (35%) of players with annual incomes below $90,000 say they’ve skipped or delayed needed care because of the cost in the past year, with one in four (23%) of this group overall reporting worse health for this reason. Far fewer players with annual incomes of $200,000 or more report skipping or postponing care because of the cost (9%) or worse health as a result (6%). Notably, players living with a disability report average lower incomes than players without a disability.

One in Five ‘88 Players Say They Recently Skipped Needed Health Care Because of the Cost, Including Larger Shares of Those With a Disability

Financial Situation

While most 1988 NFL players say their football career had a positive impact on their finances and report higher average incomes than men their age overall, there are stark disparities in income and financial challenges among players by race and disability status. Black players are more likely than White players to report lower incomes, difficulties maintaining employment, affording health care and housing, having debt, and declaring bankruptcy. These issues are also reported in higher shares among players living with a disability, who are themselves made up of larger shares of Black players.

Players from the 1988 season – including Black players and White players – have higher self-reported household incomes than men their age overall. However, similar to disparities seen in the U.S. population, Black players are much more likely than White players to have lower household incomes. Four in ten Black players report incomes of less than $90,000 compared to just 16% of White players. Conversely, White players are twice as likely as Black players to report annual incomes of $200,000 or greater (42% v. 19%).

While Former Players Have Higher Incomes Than Men Their Age Overall, Black Players are Much More Likely Than White Players to Have Lower Incomes

Most 1988 players (66%) say it was either “very” or “somewhat easy” for them to maintain steady employment or have a stable career after they stopped playing professional football, while one-third say it was either ”very” or “somewhat difficult.” The share who reports these difficulties, however, is much higher among Black players, lower-income players, and those living with a disability. For example, Black players are more than twice as likely as White players to say it was difficult to maintain steady employment or have a stable career after they stopped playing (44% vs. 20%).

One-Third of '88 NFL Players Say it Was Difficult To Maintain Employment Post-NFL Career, Including Larger Shares of Black Players and Those With a Disability

About three in ten players (29%) say that since they stopped playing football they were at some point unable to work due to a disability that was the result of a football-related injury, including a larger share of Black players (37%) compared to White players (19%) and a larger share of defensive players (36%) compared to offensive players (25%). Among players who report being unable to work due to a football-related disability since they retired from the NFL, most (73%) say they were unable to work for a year or more, and half (48%) were unable to work for five years or longer.

Three in Ten Former Players, Including Larger Shares of Lower-Income and Black Players, Say They Have Been Unable to Work Due to a Football-Related Disability
In Their Own Words: How Disabilities Have Impacted 1988 Players’ Financial Situation:

Quotes have been edited to protect player confidentiality and for clarity.

“For a few years the pain in my back and neck and knees prevented me from working. It’s hard to get around with the pain I’m in. I can’t walk far, sit too long, stand long. I’ve been on disability for over 10 years.”

“Knees bad. Memory and recall are my main problems. I’ve lost jobs because I didn’t remember something that I didn’t write down.”

“I don’t make the money that you should make based off of your education and knowledge. But because your memory is affected and you have disabilities and aches and pains, you can’t sustain work in jobs that require use of your memory.”

“I have [had] so many health challenges over the past 30 + years, both body & brain … I am so frustrated with the way we pre-93 former players do not get the proper health care & financial care to keep ourselves from being homeless. I have had to beg, borrow, pawn my rings, & other memorabilia – I am in the middle of having to sell things just to pay rent this month… Very frustrating.”

“My discs in my back are destroyed, where I can’t touch my toes if you paid me 1 trillion dollars. Both my knees are surgically repaired by 1980s standards and my cartilage and stability is nonexistent. My neck is stiff as an oak tree and my memory makes me forget 5 minutes ago. I feel ashamed about my mind and body falling apart. My condition keeps me to myself, and my wife takes care of me. If it wasn’t for my wife, I don’t know where I would be. Financially, I let the money go. I can’t chase it. I’m happy with my wife and family, for as long as I have left.”

“I have not had a full-time job for over 3 years. It is putting tremendous stress on my wife.  She is NOT happy at all. All the stress is on her & I am failing as the primary bread winner. I have my NFL pension but it is not a lot…I am not sure if I would qualify for disability. I could use a job but my body is not getting any better & my mental health is very negative.”

“…it’s extremely difficult to walk, sit, or stand for long periods of time. I can’t work, but if I even chose to work I could only make a certain amount of money or risk losing the little disability money I receive. The system really works against you overall. My Medicare is 80/20. Twenty-percent of high cost medical treatment is a great deal of money. I need knee replacements but I can’t afford 20% of the cost for the operation.”

Despite high rates of insurance coverage, some 1988 players report problems affording health care-related expenses, while one in ten or fewer report problems affording other needs like food and housing.

Overall, about one in six players from the ’88 season say that, in the past 12 months, they have had problems paying their medical bills (16%), and a similar share report problems affording health insurance (14%). Despite their relatively high incomes, one in ten say they’ve fallen behind in paying their rent or mortgage in the past year (10%), and about one in twenty report problems paying for food (6%). These affordability issues are far more common among players living with a disability compared to those who are not, including problems paying their medical bills (24% v. 5%), affording their health insurance (21% v. 5%), falling behind on their rent or mortgage (14% v. 2%) or problems affording food (10% v. 1%) in the past 12 months.

Black players are at least twice as likely as White players to report these affordability issues, including problems paying medical bills (22% v. 10%), affording health insurance (18% v. 10%), falling behind on housing costs (14% v. 23%), and problems paying for food (8% v. 3%).

1988 Players Living With a Disability are Far More Likely Than Those Who are Not to Report Problems Paying for Health Care, Housing, and Food

Reflecting income differences, Black players are more likely to report experiencing certain financial hardships than White players, including having outstanding debt, declaring bankruptcy, and losing a home due to eviction or foreclosure. Overall, a quarter (24%) of 1988 players say they have debt that is past due or that they are unable to pay, while just under one in five say that, since they have stopped playing football, they declared personal bankruptcy (17%) or lost a home due to eviction or foreclosure (16%).

Black players are more than twice as likely as White players to say they have outstanding debt (34% v. 13%), three times as likely to say they’ve declared bankruptcy (24% v. 8%), and six times as likely to say they lost a home due to eviction or foreclosure (25% v. 4%) since they stopped playing football.

Black Players From the '88 Season are More Likely to Report Financial Hardships, Including Outstanding Debt, Declaring Bankruptcy, or Losing  a Home

Appendix

Details on Race and Ethnicity of 1988 Player Sample

For this survey, Black players include all players who identify as Black, including those who may also identify as another race and/or Hispanic. White players are those who identify White as their only racial identity and are non-Hispanic. While players who identified with other racial groups are included in the total, there are insufficient sample sizes to report findings among players who identify as Hispanic (n=9), Asian (n=1), American Indian (n=9), Native Hawaiian (n=1), or Pacific Islander (n=3).

Comparison of 1988 Player Sample to Full 1988 Player Population

The project team took careful consideration to ensure the sample accurately reflected the population under study. One step in order to accomplish this was to track the sample demographics to the population demographics across key variables such as race and ethnicity, position, teams, and years in the league. While the majority of this information was publicly available for the population, race and ethnicity were coded by researchers at Davis Research and KFF. The following tables compare the survey sample to the full 1988 player population who were alive at the time of fieldwork.

1988 Player Sample Compared to All Living 1988 NFL Players: Key Demographics
1988 Player Sample Compared to All Living 1988 NFL Players: Position Type
1988 Player Sample Compared to All Living 1988 NFL Players: Teams

Positions Played by Race

Positions Played in KFF/ESPN Survey of 1988 NFL Players

Methodology

This KFF/ESPN Survey of 1988 NFL Players was designed and analyzed by public opinion researchers at KFF in collaboration with reporters at ESPN. The survey was designed to reach a representative sample of former NFL players who participated in at least one game during the 1988 season. 1,532 individuals were identified as meeting this criteria. The survey was conducted from October 17 through November 30, 2024 online and by telephone. All fieldwork was managed by Davis Research.

Sample and Contact MethodsAll players included in the population were researched and contact information was verified using multiple sources including Lexis-Nexis and Marketing Systems Group (MSG). Of the 1,532 former NFL players who participated in at least one game during the 1988 season, 128 were identified as deceased either prior to fielding or learned about during fielding.  For those cases, interviews with proxy respondents were attempted. Population members were originally contacted using USPS business letter explaining the project and providing both a website to complete the survey as well as an inbound telephone number for the individual to complete the survey with a live trained interviewer. Nonresponse follow-up included email contacts, a reminder letter, as well as telephone calls and text messages. Each player record contained up to six telephone numbers, and attempts were made to contact each record up to eight times. Calls and text messages were made at various times, including evenings and weekends, to maximize response rates.

The final sample includes interviews with 546 former players. An additional 18 interviews with family members of deceased players, and 1 interview with a family member of a living player who was identified as having cognition issues helped to contribute to the reporting.

Participants, including proxy respondents, were offered a $100 gift card or the option to donate the amount to Gridiron Greats, a charity supporting former NFL players.

Representation Considerations The project team took careful consideration to ensure the sample accurately reflected the population under study. One step in order to accomplish this was to track the sample demographics to the population demographics across key variables such as race and ethnicity, position, teams, and years in the league. While the majority of this information was publicly available for the population, race and ethnicity were coded by researchers at Davis Research and KFF. Intercoder reliability was achieved with 10% of the population, Cohen’s kappa (κ) of .898.

In order to increase the likelihood of interviewing Black players, Davis Research in collaboration with KFF maximized efforts to increase participation for that population, including additional telephone calls to targeted records, mailing approximately 500 USPS Priority Mail envelopes to non-responsive records flagged as likely Black/African American, and conducted additional research to refine contact information for records flagged as likely Black/African American.

Response rates were closely monitored throughout fielding to ensure both quality and balanced representation. The net effective response rate (AAPOR Response Rate 5) for living players was 40% and 16% respectively for family members of deceased players.

The final sample quality was assessed by researchers and no weighting adjustments were needed. The margin of sampling error for the full sample is plus or minus 3 percentage points. Numbers of respondents and margins of sampling error for key subgroups are shown in the table below. For results based on other subgroups, the margin of sampling error may be higher. Sampling error is only one of many potential sources of error and there may be other unmeasured error in this or any other public opinion poll.

KFF public opinion and survey research is a charter member of the Transparency Initiative of the American Association for Public Opinion Research.

National comparison data throughout the accompanying reports is based on KFF analysis of Centers for Disease Control and Prevention (CDC) 2023 Behavioral Risk Factor Surveillance System (BRFSS); National Center for Health Statistics 2023 National Health Interview Survey (NHIS); the U.S. Census Bureau’s 2023 American Community Survey (ACS); and KFF’s Racism, Discrimination, and Health Survey (June 6 – August 14, 2023.) Data from BRFSS is among men ages 55-74; all other data is among men ages 55-75. All estimates are based on self-reported survey results and may differ from other clinical estimates.

Endnotes

  1. A series of logistic regression models were conducted to test whether the relationship between race and different health outcomes held after controlling for higher risk position groups, income, age, and years played. ↩︎
  2. While CTE cannot definitively be diagnosed before death, these self-reports likely reflect instances where a health professional indicated to a player that they were showing signs or symptoms consistent with CTE. Other surveys of former professional football players have found that many players believe they have CTE. ↩︎

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

Published: Aug 15, 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: 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 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 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 inclcate 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: 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: 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: 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.

Health Provisions in the 2025 Federal Budget Reconciliation Bill

Updated: July 8, 2025


Note: KFF now has a clean summary of the health care provisions in the 2025 federal budget reconciliation law as well as a separate implementation timeline highlighting key dates in the law.

This side-by-side comparison tool compares the health care provisions in the House-passed and Senate-passed 2025 budget reconciliation law to each other and prior law. The Senate-passed bill ultimately passed the House on July 3 and was signed into law by President Trump on July 4. The comparison is divided into four categories: Medicaid, the Affordable Care Act, Medicare and Health Savings Accounts (HSAs). It also compares the provisions to a earlier draft of the bill passed by the House on May 22.

Summary of House Reconciliation Bill

VOLUME 28

Few Trust Most Health Content on Social Media, Autism Claims Follow Thimerosal Policy Shift, and Misleading Narratives About SSRIs in Pregnancy


Summary

This volume analyzes findings from the latest KFF Tracking Poll on Health Information and Trust, which show that just over half of adults say they use social media to find health information and advice, but less than half trust the health content they see across an array of social media sites and apps. It also examines false claims linking a mercury-based vaccine preservative to autism, following a federal decision to withdraw recommendations for flu vaccines containing the compound. In addition, it explores misleading narratives about antidepressant use during pregnancy and unproven claims about the health benefits of nicotine.


Featured: KFF’s Latest Poll Finds That Over Half of Adults Use Social Media For Health Information, But Few Trust Most of the Content They See

With public trust in government health agencies as reliable messengers declining, the latest KFF Tracking Poll on Health Information and Trust finds that over half (55%) of adults, including larger shares of young adults and Black and Hispanic adults, say they use social media to find health information and advice at least occasionally. Large shares of adults report seeing information on social media in the past month on about weight loss, diet, or nutrition (72%) and mental health (58%), and about four in ten (38%) report seeing vaccine-related content. Smaller shares say they saw information on social media about abortion (30%) and birth control (22%) in the past 30 days.

Weight Loss, Diet, Nutrition and Mental Health Top List of Health-Related Topics People See on Social Media

The poll also finds that most adults are skeptical of the health information and advice they see across social media platforms. Fewer than half of different social media platform users say they find “most” or “some” of the health information they see on the platforms they use trustworthy. Less than one in ten say they think “most” of this content is trustworthy. On some of the most widely used social media apps or sites including TikTok and YouTube, larger shares of younger adults compared to older adults trust the health information and advice they see.

On Some Platforms, Large Shares of Young Adults Say Most or Some of the Health Information and Advice Is Trustworthy

The latest poll also asked about social media influencers and found that so far, their influence on health is relatively small. As KFF President and CEO Drew Altman wrote in a recent column, just 14% of the public say they regularly get health information and advice from influencers online, and an even smaller share of social media users (5%) can name a particular health influencer they trust.


Recent Developments

Thimerosal Vaccine Claims Spread Online After Federal Policy Shift

SERGII IAREMENKO/SCIENCE PHOTO LIBRARY / Getty Images

False claims that a mercury-based vaccine preservative, thimerosal, is harmful to children gained traction in late July, coinciding with a federal decision to no longer recommend flu vaccines containing the compound. The narrative, which incorrectly links thimerosal to autism and other developmental issues, appeared in online conversation after Health and Human Services (HHS) Secretary Robert F. Kennedy Jr. rescinded the CDC’s recommendations of flu vaccines that contain the ingredient. Kennedy later accepted recommendations by the CDC’s Advisory Committee on Immunization (ACIP) to endorse routine influenza vaccination this year and to only recommend thimerosal-free formulations. The decision followed a June meeting and vote of the CDC’s Advisory Committee on Immunization Practices (ACIP), where a former leader of a group known for its opposition to vaccines presented unsupported claims that thimerosal is toxic to children. On July 23, the day the decision was announced, some X users with large followings cited the policy shift in posts that made false claims about thimerosal. One account, with more than 500,000 followers, repeated the claim that it causes autism and wrote, “You wouldn’t catch me dead taking a flu vaccine… never.. but this is good for those who religiously get it.”

Thimerosal, a mercury-based compound used to prevent contamination in multi-dose vaccine vials, was removed from routine childhood vaccinations in 2001, not because of any evidence of harm but in response to public concern about mercury exposure. Thimerosal contains a form of mercury called ethylmercury, which is excreted by the body much more quickly than methylmercury, the form of mercury found in fish which can accumulate in the body and have hazardous health effects. Confusion between the two compounds contributed to public unease, and the FDA and medical groups recommended removing the compound as a precautionary measure and to preserve confidence in vaccines. Some virologists have argued that the 2001 removal, while intended to increase confidence in vaccines, may have inadvertently reinforced false claims linking them to autism. Dozens of studies since have found no evidence of harm, and rates of autism diagnoses have steadily increased since the compound was largely removed from vaccinations.

In the United States, thimerosal is still used in a small portion of multi-dose influenza vaccine vials to prevent fungal or bacterial contamination. Because these vials are generally less expensive per dose and require less storage space, they are primarily used in high-volume or resource-limited settings, such as mass vaccination clinics. They also remain an important option in many low- and middle-income countries where single-dose vials are harder to distribute and store. The decision to rescind recommendations for thimerosal-containing vaccines may have global effects, leading to reduced access and increased cost, as international health authorities have historically closely watched recommendations by ACIP. In the U.S., insurance coverage for these vaccines may be affected, as coverage requirements are linked to CDC and ACIP recommendations in almost every case. Medical organizations, including the American Academy of Pediatrics (AAP), have further cautioned that the change could further the spread of false claims about vaccines and contribute to rising vaccine hesitancy.

Polling Insights: KFF’s April 2025 Tracking Poll on Health Information and Trust found that  three in four (74%) adults say they are either “very confident” or “somewhat confident” that vaccines for the flu are safe. Confidence in flu vaccines, however, differs across partisans. While majorities across groups are at least “somewhat” confident these vaccines are safe, Democrats (57%) are much more likely than independents (36%) or Republicans (24%) to say they are “very” confident. Confidence is also lower among parents of children under age 18 compared to non-parents (24% vs. 44% are “very” confident these vaccines are safe).

Most Adults are Confident That Flu Vaccines are Safe, But Confidence is Lower Among Republicans and Parents

Online Narratives Misrepresent Antidepressant Safety in Pregnancy

Cd3sign / Getty Images

About one in 10 people experience depression during pregnancy, and around 6% of pregnant people in the U.S. are treated with SSRIs (selective serotonin reuptake inhibitors). Online conversation about these antidepressants in July reflected public confusion about the safety of their use during pregnancy. In late July, social media users repeated exaggerated claims of risk following a July 21 meeting of an FDA advisory panel that presented unbalanced information by emphasizing potential harms of SSRIs during pregnancy beyond what current scientific evidence supports, while giving little attention to documented benefits. Some of the panelists claimed that perinatal usage of the medications can lead to autism, miscarriage, and other harms, or that they offer no therapeutic value, despite strong evidence demonstrating the importance of these medications in addressing maternal mental health. Some social media users shared and amplified these claims, inaccurately describing SSRIs as especially harmful for pregnant and breastfeeding people. One X user, with more than 500,000 followers, wrote, “Evil… so evil. Doctors are actively prescribing SSRI’s to Pregnant Women that Cause Birth Defects in Babies.”  

Some studies cited by panelists suggested potential risks, but psychiatrists and obstetricians criticized these studies for poor design and inadequate control for confounding factors, including the presence or severity of maternal depression. When accounting for these factors, research has largely supported the safety of SSRI use during pregnancy. A large cohort study controlling for confounding factors, for example, found no evidence of association with autism or other neurodevelopmental disorders. Other members of the panel also claimed, without evidence, that SSRIs are wholly ineffective, conflicting with numerous studies, including meta-analyses of randomized controlled trials that have shown SSRIs to be more effective than placebo in treating major depressive disorder.  

Misleading claims that overemphasize the risks of antidepressants in pregnancy may prompt patients to discontinue or delay treatment, putting them at risk for poor outcomes. Untreated perinatal depression carries well-documented and significant consequences for both maternal and fetal health, including preterm birth, low birth weight, and developmental delays. It may also lead to reduced prenatal care, higher rates of substance use, and increased risk of suicidality. According to the CDC, mental health conditions are a leading cause of pregnancy-related deaths, accounting for 22.5% of such deaths in 2020.  

While most evidence supports the safety of SSRIs in pregnancy, some studies have found small increased risks for adverse outcomes, including bleeding complications at delivery. Because the potential harms of medication must be weighed against the risks of leaving depression untreated, guidelines adopted by the American College of Obstetricians and Gynecologists (ACOG) emphasize that treatment for depression, including the use of SSRIs or selective norepinephrine reuptake inhibitors (SNRIs), should be highly individualized. The Substance Abuse and Mental Health Services Administration (SAMHSA) has called for more education on the use of medications during pregnancy, noting that people who had experienced mental health conditions during pregnancy reported that having clearer information would have improved their experiences. Medical organizations, including ACOG, the American Psychiatric Association (APA), and the Society for Maternal-Fetal Medicine (SMFM) stress that the harms of untreated depression in pregnancy may, for many patients, outweigh the risks of medication and therefore recommend a collaborative, shared clinical decision-making process. Research has shown that this practice, in which patients and healthcare providers work together to make informed healthcare decisions, can help improve trust in the physician-patient relationship. 

Influencers Promote Unproven Health Benefits of Nicotine

Anastassiya Bezhekeneva / Getty Images

Mentions of the supposed health benefits of nicotine have appeared widely on social media, with some health influencers and accounts with large followings sharing posts that claim that it is not addictive and that it improves focus, boosts brain function, and may prevent or cure neurodegenerative diseases. Some X accounts, including one with more than 100,000 followers, posted a video clip of a podcast interview in which a chiropractor and influencer claimed nicotine was not addictive and was a cure for Parkinson’s disease, Alzheimer’s disease, multiple sclerosis, COVID-19, and glioblastoma brain tumors. Another account, with more than 800,000 followers, posted a podcast clip of a prominent political commentator attributing his health to his use of nicotine. KFF’s latest Tracking Poll on Health Information and Trust found that 15% of adults who use social media, including 23% of those ages 18-29, say they regularly get health information and advice from influeners on social media.

Claims of nicotine’s health benefits are largely made without evidence. Researchers are investigating therapeutic applications of nicotine, specifically for Parkinson’s disease and Alzheimer’s-related cognitive decline, but results from observational and animal studies have not yet been replicated in large-scale clinical trials. Curative properties have not been demonstrated, and nicotine is not approved by the FDA for any of these therapeutic uses. A 2008 correlational review of nicotine and Parkinson’s disease, for example, suggested that nicotine could help reduce symptoms and drug-induced side effects, but a later clinical trial found that nicotine did not slow progression of the disease. For Alzheimer’s-related cognitive decline, a small trial investigating nicotine and mild cognitive impairment found some improvement in attention and memory, but the authors cautioned that further studies were needed, which are still underway.

As these speculative claims about nicotine’s health benefits continue to circulate, they may obscure established health risks, encourage use by non-users, and deter quitting among current users. Despite claims by some social media users, nicotine is known to be highly addictive, and a 2015 review found that it increases risk of cardiovascular, respiratory, and gastrointestinal disorders and has adverse effects on the immune system and reproductive health. It is particularly harmful in some populations, including pregnant people and adolescents, where nicotine exposure can be toxic to a developing fetus and interfere with brain maturation.


AI & Emerging Technology

AI-Generated Public Health Campaigns Most Effective With Human Oversight

KFF / Getty Images

Findings from a series of studies published in PNAS Nexus suggest that artificial intelligence (AI) could streamline public health media campaigns by selecting real-time, community-generated messages from social media to create persuasive health messaging. Researchers from the University of Pennsylvania, University of Illinois, Emory University, and government and community agencies developed an AI system to automatically generate an HIV prevention and testing campaign for counties in the U.S. The system collected messages from social media posts and evaluated whether they were actionable, relevant, and appropriate for the target population, men who have sex with men (MSM).

Researchers recruited 260 participants to review 36 selected messages and rate them on actionability, appropriateness, accuracy, relevance, and effectiveness. 12 messages were selected by the AI and reviewed by a human researcher, 12 were AI-selected without human review, and 12 were control messages taken from a simple keyword search. Participants rated messages selected by the AI higher than messages from the control group, with those vetted by a human scoring highest. In a separate test, researchers provided access to the tool to public health agencies and community-based organizations, finding that the AI selection process made them more likely to post HIV prevention messages on social media.

Researchers noted, though, that using machine learning tools in this way may introduce algorithmic bias, unintentional errors caused by existing prejudices in the data used to train AI systems, particularly when automated processes are used without a structured human review. They emphasized the continued importance of human oversight to mitigate this bias, as well as the risk of amplifying false information from community-generated messages. Among study participants, messages reviewed by human researchers were consistently rated more persuasive and accurate.

About The Health Information and Trust Initiative: the Health Information and Trust Initiative is a KFF program aimed at tracking health misinformation in the U.S., analyzing its impact on the American people, and mobilizing media to address the problem. Our goal is to be of service to everyone working on health misinformation, strengthen efforts to counter misinformation, and build trust. 


View all KFF Monitors

The Monitor is a report from KFF’s Health Information and Trust initiative that focuses on recent developments in health information. It’s free and published twice a month.

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Support for the Health Information and Trust initiative is provided by the Robert Wood Johnson Foundation (RWJF). The views expressed do not necessarily reflect the views of RWJF and KFF maintains full editorial control over all of its policy analysis, polling, and journalism activities. The data shared in the Monitor is sourced through media monitoring research conducted by KFF.

Policy Tracker: Youth Access to Gender Affirming Care and State Policy Restrictions

Last updated on August 12, 2025

states have enacted laws/ policies limiting youth access to GAC

of trans youth (ages 13-17) live in a state that has enacted a law/policy limiting access to GAC

states are facing lawsuits challenging their laws/policies limiting youth access to GAC

states impose professional or legal penalties on health care practitioners providing minors with GAC

State laws and policies prohibiting or restricting minor access to gender affirming care have proliferated in recent years. The first state to pass such a law was Arkansas in 2021. By January 2024, that number increased more than five-fold, with states having passed such laws/policies. Most are being challenged in court.

On June 18, 2025, the U.S. Supreme Court ruled in, United States v. Skrmetti, a case challenging Tennessee law (SB1) banning gender affirming care. The court found that the law did not constitute sex-based discrimination and did not violate the U.S Constitution’s 14th Amendment Equal Protection clause. As a result, 25 bans remain in place. However, bans in Montana and Arkansas are currently permanently enjoined by court order. The challenge in Montana relates to the state constitution and is therefore not directly impacted by the decision and the law remains blocked. The federal court in Arkansas found the law violated both the Equal Protection and Due Process clauses. The injunction remains in place given its basis on Due Process claims.

This tracker provides an overview of these laws/policies and any associated litigation by state, identifying which groups of people are impacted in addition to minors (e.g. providers, parents, etc.), the types of penalties providers face (i.e. professional or felony), the status of legal challenges, and other key information.

Learn more in this short analysis assessing the policy landscape as of January 24, 2024: The Proliferation of State Actions Limiting Youth Access to Gender Affirming Care

What is Gender Affirming Care (GAC)?

Gender-affirming care is a model of care which includes a spectrum of “medical, surgical, mental health, and non-medical services for transgender and nonbinary people” aimed at affirming and supporting an individual’s gender identity. Gender-affirming care is a model of care which includes a spectrum of “medical, surgical, mental health, and non-medical services for transgender and nonbinary people” aimed at affirming and supporting an individual’s gender identity. Gender affirmation is highly individualized. Not all trans people seek the same types of gender affirming care or services and some people choose not to use medical services as a part of their transition.

Nearly Half of States Have Enacted Laws/Policies Limiting Youth Access to Gender Affirming Care
Table 1: Overview - State Law/Policy Making Limiting Youth Access to Gender Affirming Care 
Table 2: Policy Details - State Law/Policy Making Limiting Youth Access to Gender Affirming Care  
Table 3: Litigation Landscape - State Law/Policy Making Limiting Youth Access to Gender Affirming Care 

How Recent Manufacturer Savings Programs May Impact Individual Out-of-Pocket Spending on Asthma and COPD Inhalers

Authors: Delaney Tevis, Justin Lo, Nisha Kurani, and Cynthia Cox
Published: Aug 11, 2025

A new analysis shows that individuals with employer insurance could save 41% on their out-of-pocket spending for asthma and COPD inhalers through manufacturer savings. In response to a U.S. Senate investigation into inhaler costs, 3 drug makers voluntarily capped out-of-pocket costs on their brand-name asthma and COPD inhalers.

Among the asthma and COPD inhalers covered under the voluntary out-of-pocket spending caps, over half may have patient savings of $19 or less per 30-day supply.

The full analysis and other data on health costs are available on the Peterson-KFF Health System Tracker, an online information hub dedicated to monitoring and assessing the performance of the U.S. health system.

Minors’ Ability to Consent to Contraception and Abortion Services

Authors: Mabel Felix, Laurie Sobel, and Alina Salganicoff
Published: Aug 7, 2025

Editorial Note

This brief was updated on August 11, 2025 to correct the number of states that allow and prohibit minors to consent to their own contraceptive care.

Across the country, minors’ ability to consent to their health care, particularly their reproductive health care, varies significantly. Expanding “parental rights’ in health and education has been a priority for politically conservative groups and was outlined as a “top-tier” right by the Heritage Foundation in Project 2025. While parental involvement in health care can facilitate access and improve outcomes, it is not always possible for teens to include parents in decisions about sensitive health care decisions. Some teens, particularly those who have unstable home lives, are in foster care, or fear abuse if their parents were to become aware they are seeking this type of care could be more likely to experience challenges in accessing services in states where parental notification or consent is required. Beyond parental involvement, minors face additional challenges accessing transportation, scheduling appointments outside school hours, and paying for the care. This brief examines state consent requirements for minors accessing contraceptive and abortion care, processes for minors to attempt to obtain abortion without parental involvement, and trends in state policy increasing requirements for parental involvement in minors’ health care decisions.

Contraception

In 24 states and D.C. all minors, regardless of age, can consent to their own contraceptive care, per explicit rights provided in state law (Figure 1). Nine states do not have any explicit laws allowing or prohibiting minors to consent to contraceptive services. Twelve states have laws that explicitly allow minors in certain circumstances, such as individuals who have been pregnant, reached a certain age, or have a referral to consent to contraceptive care. These state laws, however, do not specify whether minors outside these circumstances can consent to contraceptive care or if they need parental consent. State laws require minors to obtain parental consent to access contraceptive services in 5 states, with the exception of over-the-counter (OTC) contraceptive methods, such as condoms, Plan B, and Opill—though the latter two may be too costly for many minors to purchase on their own. In addition, in some retail outlets, Plan B and Opill are placed behind the pharmacy counter or in locked cabinets, requiring the pharmacy staff to hand the pills to the consumer despite the fact that no prescription is required. Most states allow minors who are emancipated (no longer under the custody of their parents), married, or living apart from their parents to consent to their own health care services, but these laws are not specific to contraceptive care.

In 24 States, Minors Cannot Consent to Contraceptive Care Unless They Are Receiving it at Title X Clinics

Historically, clinics that receive funds through the federal Title X family planning program have been required to offer confidential care which effectively bars participating providers from requiring parental consent for minors accessing care at their sites. This policy has applied to all Title X funded sites, regardless of whether parental consent is required in the state. This rule was challenged in a Texas case and in December 2022, a U.S. District Court in Texas ruled that this provision of the Title X regulations violates the constitutional rights of Texas parents to direct the upbringing of their children. Teens in Texas now must obtain parental consent to receive reproductive health care in Title X clinics in the state along with other sites. Minors in all other states are still entitled to confidential care and can still receive contraceptive care at Title X sites without parental consent, regardless of state law.

While many minors have coverage for contraceptive services under their parent’s health insurance plan, confidentiality is limited. The insurance company sends the Explanation of Benefits (EOB) summary of health care services used to the primary policyholder, typically the parent for a minor. While some states have implemented broad laws to ensure confidentiality when requested by minors seeking sensitive services, these laws are limited and do not apply to self-insured plans.

Abortion

Parental Involvement Laws

Among the states without abortion bans, 25 require some level of parental involvement in a minor’s ability to access abortion care while 13 states and D.C. have no parental involvement requirements (Figure 2). Nevada’s notification law, originally passed in 1985 and blocked for decades, is currently in effect. On July 21, 2025,  Planned Parenthood filed a lawsuit in state court contending the law violates the state constitution.

Parental Consent Requirements for Minors Seeking Abortion Care

State parental involvement laws generally require parental notification of a minor’s intent to receive abortion care or require parental consent for the abortion, or both notification and consent. Notification requirements vary, but they usually involve the provider informing the parent in person, by phone, or by mail with registered delivery that the minor is seeking abortion care 24-48 hours ahead of the minor actually receiving such care. When the law is limited to only parental notification, clinicians are not prohibited from providing minors with abortion care even if their parents disagree with their decision. Consent requirements generally involve the parent signing a document stating that they consent to the minor receiving an abortion. When both parental notification and consent are required, clinicians usually have to inform the parent of the minor’s intent to receive an abortion and, prior to actually providing that care, receive the signed parental consent.

Of the states without abortion bans, 13 require parental notification, 17 require parental consent, and 5 of these states require both notification of a minor’s intent to receive an abortion and parental consent to the abortion care. These requirements often impose barriers to access for minors seeking abortion services, especially for those who do not wish to involve their parents in their decision to seek abortion care, those who suffer from abuse, those whose parents or guardians disagree with their decision to receive an abortion and withhold their consent, or those whose parents are not present in their lives or are not easily accessible to them, as is the case for minors living in foster care. Additionally, the details of these requirements may be difficult to navigate for some minors and their parents, even if they are supportive of their decision to seek abortion care.

Some states, such as Kansas and Wisconsin, require that the parent be present in person at a counseling appointment prior to the appointment where the minor will be receiving abortion care. This raises further access difficulties for minors, since their parents may have difficulties taking time off from work or arranging childcare to be able to attend the counseling appointment.

Additionally, five states—Arizona, Florida, Kansas, Nebraska, and Virginia—require the parent’s written and signed consent be notarized. And two states—Florida and North Dakota—require parents to show a government-issued identification and/or proof of relationship to the minor, such as a birth certificate. These documentation requirements may be difficult for some minors and their parents to meet. The time and cost associated with getting the written consent notarized may delay care, as notary publics generally only work during business hours. Acquiring the correct documentation may be even more difficult for people living on low incomes who do not have access to a care or for people who no longer have access to an original birth certificate. In-person requests for a birth certificate generally can only be made in the county where the person was born and online requests may take weeks.

Three states—Kansas, Missouri, and North Dakota—require the involvement of both of the minor’s parents for abortion care. There are, however, some exceptions to this requirement. In four of these states, only the involvement of the custodial parent is required when the minor’s parents are divorced. The remaining state, Kentucky, makes an exception only for cases of domestic violence. However, these exceptions do not address situations where a minor’s parents are separated, but not divorced, or where one of the parents is not in the minor’s life, but there are no formal custodial agreements, or when one of the minor’s parents is incapacitated, incarcerated, or otherwise unreachable.

Eleven states allow other relatives or adults in the minor’s life to fulfill the parental consent requirement in some situations and with varying documentation requirements. For instance, in Wisconsin, a minor’s grandparent, aunt, uncle, or sibling who is over the age of 25 can consent to a minor’s abortion. In Virginia, any adult who is acting in loco parentis (i.e. an adult who has been taking care of a minor, even if they are not their legal guardian), may be notified and provide consent for the minor’s abortion. Other states, such as Nebraska, only allow other relatives to consent to the minor’s abortion if the minor attests in writing that they are abused by their parents and the physician reports this abuse to the relevant authorities.

In three of the states that have parental involvement requirements—Delaware, Maine, and Maryland—the requirement may be waived through counseling. In Delaware, mental health professionals are able to fulfill the notification requirement by providing the minor with options counseling. Maryland providers are able to waive the requirement themselves by determining that the minor is mature and capable of giving informed consent or if notification would not be in the best interest of the minor. And in Maine, the consent of a counselor can stand in place of the consent of a parent. Physician assistants, nurse practitioners, and other nurses qualify as counselors under this part of Maine law and every abortion clinic in the state has a counselor who can fulfill this requirement.

Every state with a parental involvement requirement has an exception for medical emergencies—except for Maryland, but the provider may waive the requirement for notification when it is not in the minor’s best interest. In many states, clinicians must notify the parents after the abortion is provided on an emergency basis. Some states have other exceptions to the parental involvement requirements, such as for cases where the pregnancy is the result of rape or incest and in cases of abuse. However, these exceptions generally require that the physician report the abuse or sexual assault to the authorities. This may dissuade some minors from disclosing abuse or assault to clinicians, as survivors of sexual assault are often reluctant to report sexual violence due to fear of retaliation.

Judicial Bypass and Waiver

In all but one state with a parental involvement requirement—Florida—minors may petition a court to allow them to receive abortion care without parental consent or notification, referred to as a “judicial bypass” or “waiver”. In all these states with parental involvement laws, the proceedings are confidential, minors filing a petition have a right to a court-assigned attorney, and most require that courts issue a final ruling in the petition within a specified timeline, usually in under a week after the filing of the petition. Yet, it is difficult for minors to navigate the process. In-person attendance is generally required of minors seeking a judicial bypass/waiver. Some states require minors to attend a counseling appointment as part of the process, which may conflict with school hours making it difficult for the minor to attend. In some states, parents can be notified if the minor’s request is denied.

Additionally, the process for judicial bypass or waiver can delay timely receipt of abortion care for some minors. In a study of minors accessing care in Massachusetts, a state that requires parental consent for abortions, those who obtained parental consent accessed abortion care an average of 8.6 days after they initially contacted an abortion provider, nearly 6 days faster than those using a judicial bypass (average of 14.2 days).

In the past few years, policy and judicial developments have limited minors’ ability to consent to their care and access abortion and contraception services in several states. In 2023, Idaho lawmakers passed a law that criminalizes aiding a minor in obtaining an abortion outside of the state without parental consent, even if the abortion was procured in a state where abortion is legal and there are no parental involvement requirements. Tennessee lawmakers passed a similar law in 2024. Advocates for abortion rights argue these laws effectively criminalize a broad range of actions, from driving a minor across state lines to receiving an abortion, providing funds for abortion care, or even providing minors with access to information about abortion in other states where it is legal.

Both laws were challenged in federal court, where judges granted preliminary injunctions blocking their enforcement while litigation proceeded. However, in December 2024, the Ninth Circuit Court of Appeals allowed most of the Idaho law to go back into effect, only blocking the provisions that would have prohibited providing minors with accurate information about abortion care. In the Tennessee case, an appeal to the preliminary injunction blocking enforcement of the law is pending with the Sixth Circuit Court of Appeals.

In 2024, lawmakers in Tennessee and Idaho also passed comprehensive legislation giving parents exclusive rights to consent to their children’s medical care and to access their medical records. Tennessee’s law contains an exception, allowing minors to retain the ability to consent to health care if it is already outlined in a separate statute. Under a separate already-existing state statute, minors had the ability to consent to birth control. Following enactment of the Tennessee law in July 2024, state public clinics stopped offering birth control to minors without parental consent, despite the law’s exception. However, after receiving clarification the exception was applicable as applied to minor’s ability to consent to birth control, clinics resumed providing these services in September 2024.

Additionally, in May 2025, a Florida state court of appeals held that the state’s judicial bypass process violates parents’ rights to raise their children under the U.S. Constitution. As discussed earlier, the judicial bypass process has been critical for teens seeking abortions in states with parental consent requirements. The case is now pending at the Florida Supreme Court. However, because the court of appeals ruling held that the process violates a U.S. constitutional right, not a state constitutional right, the case may ultimately make it to the U.S. Supreme Court with implications for minor access to abortion in Florida and beyond.

Prior Authorization Process Policies in Medicaid Managed Care: Findings from a Survey of State Medicaid Programs

Authors: Jada Raphael, Elizabeth Hinton, Aimee Lashbrook, and Kathleen Gifford
Published: Aug 7, 2025

Note: This brief was updated on Aug. 21, 2025, to include Kentucky in the count of states that require Medicaid managed care organizations (MCOs) to make standard prior authorization decisions within a timeframe shorter than 7 calendar days.

Medicaid managed care organizations (MCOs) deliver care to three-quarters of all Medicaid enrollees nationally. MCOs often require patients to obtain approval of certain health care services or medications before the care is provided—an insurance practice commonly referred to as “prior authorization”. This allows the MCO to evaluate whether care is covered, medically necessary, and being delivered in the most appropriate setting. If the MCO determines the requested service (or medication) is not appropriate or medically necessary, the MCO may deny the request (fully or partially). Providers and patients have raised concerns that MCO prior authorization processes have the potential to delay or limit access to care. A 2023 report from the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) found that Medicaid MCOs had an overall prior authorization denial rate (12.5%) that was more than double the Medicare Advantage rate (5.7%). OIG found most Medicaid enrollees (89%) do not appeal to the MCO for reconsideration. Of those who do appeal, only about one-third get the initial denial overturned—far less than for Medicare Advantage appeals (82% overturn rate). They also found limited state Medicaid agency oversight. The Medicaid and CHIP Payment and Access Commission (MACPAC) has highlighted similar concerns, making recommendations to improve state monitoring and oversight, transparency, and the enrollee experience.

To help reduce prior authorization-related burden, the Biden Administration issued the Interoperability and Prior Authorization final rule in 2024 aimed at streamlining and automating the prior authorization process and improving transparency for Medicare Advantage, Medicaid, CHIP, and Marketplace health plans. A growing number of states have also introduced limits on prior authorization requirements through state legislation. In June 2025, under the Trump Administration, HHS announced a voluntary initiative where dozens of health insurers pledged to reduce the burden of prior authorizations across insurance markets. The pledge included commitments to require prior authorization less often, speed up the timeframe to review prior authorization requests, and use clearer language when communicating with patients. A recent KFF poll found that about three-quarters (73%) of adults say that health insurance related delays and denials are “a major problem,” and few people think it is likely that health insurance companies will follow through on the new pledge in a meaningful way.

To improve understanding of state Medicaid managed care prior authorization processes and oversight, the 24th annual Medicaid budget survey, conducted by KFF and Health Management Associates (HMA) in the summer of 2024, asked about specific prior authorization process-related policies in place as of July 1, 2024. Key findings include:

  • Prior Authorization Decision Timeframes. Half of responding MCO states (18 of 36) required MCOs to make “standard” prior authorization decisions within 7 calendar days or a shorter timeframe. New federal rules that take effect in January 2026 require standard prior authorization decisions to be made within 7 calendar days.
  • Offering of Electronic Denial Notices. Only about one-third of responding MCO states (12 of 38) required MCOs to offer prior authorization denial notices electronically. Delayed receipt of denial notices can leave enrollees without enough time to request an appeal.
  • Access to External Medical Review. At least one-third of responding MCO states (15 of 39) provided enrollees with access to an independent external medical review process to review an MCO’s decision to uphold a denial.

Prior Authorization Process Overview

Prior authorization is a multi-step process where payers require medical providers to receive approval before providing a specific service, item, or medication. Federal regulations allow Medicaid MCOs to limit services based on medical necessity (must be no more restrictive than fee-for-service (FFS)) and for the purpose of utilization control if certain conditions are met.1  Federal rules also establish timeframes and processes MCOs must follow when making prior authorization and appeals decisions (Figure 1). State Medicaid agencies may impose stricter requirements on MCOs than set forth in federal regulations for prior authorization processes and timelines.

Figure 1 is titled "Process and Timeframes for Prior Authorization Decisions and Appeals in Federal Medicaid Managed Care Rules." It is a flow chart detailing MCO's review and appeal process.

Survey Findings

Prior Authorization Decision Timeframes

Federal rules currently require MCOs to make “standard” prior authorization decisions within 14 calendar days and “expedited” decisions within 72 hours of prior authorization requests; however, states may establish shorter timeframes. Starting January 2026, the Interoperability and Prior Authorization final rule shortens the timeframe for standard prior authorization decisions to 7 calendar days. (The timeframe for expedited prior authorization decisions in Medicaid managed care is unchanged by the final rule.) The 2024 KFF/HMA state survey asked states how their current MCO requirements compare to the final prior authorization rule’s timeframe standards.

Half of responding MCO states (18 of 36) reported requiring standard prior authorization decisions within 7 calendar days (8 states) or a shorter timeframe (10 states) (Table 1). Eighteen states reported requiring a timeframe longer than 7 calendar days for standard prior authorization decisions. For expedited prior authorization requests, about one-third of responding MCO states (13 states) reported having a standard shorter than 72 hours, while 23 states reported having a 72-hour standard.

State Timeframe Requirements for MCO Prior Authorization Decisions as of July 1, 2024

Denial Notices and Enrollee Support

About one-third of responding MCO states (12 of 38) require MCOs to offer electronic denial notices (Figure 2). MACPAC’s examination of denials and appeals in Medicaid managed care found that mailed denial notices often arrived late or not at all. Enrollees have 60 calendar days from the date on the denial notice to file a request for an appeal to the MCO. Delayed receipt of denial notices can leave enrollees without enough time to request an appeal. Offering an option to receive electronic notices may help enrollees receive denial notices faster and more reliably.

About One-Third of MCO States Required MCOs to Offer Electronic Denial Notices

More than half of responding MCO states (21 of 38 states) reported using standardized prior authorization denial notice templates or language. Both MACPAC and OIG found denial notices can be lengthy and challenging to understand, often using clinical and/or legal jargon. Denial notices may be missing key information such as why the original request failed to meet medical necessity standards/requirements and what documentation the MCO may need to approve the request, which can contribute to challenges with the appeals process and result in lower appeal rates. Standardized denial notice language may improve enrollees’ ability to understand the prior authorization process and next steps. However, in a review, OIG found even template language can lack key information in some instances (e.g., one state’s template failed to inform enrollees of their right to request a state fair hearing after appealing to the MCO).

While federal rules require MCOs to provide enrollees assistance with the appeals process upon request, MACPAC found some enrollees may not have confidence in information provided by MCOs or enrollees may hesitate to seek support (in navigating the appeals process) from the entity that denied their service request. External entities like ombudsperson offices can help enrollees navigate the appeals process. Although the survey asked whether states provide Medicaid funding to external entities (e.g., state ombudsperson offices, legal aid societies) that could assist enrollees through the MCO appeals process, it’s not clear how many states provide such external funding (as it appears the question was not interpreted consistently across states).

Independent External Medical Review

Enrollees who disagree with an MCO’s prior authorization decision have the right to appeal to the MCO for reconsideration. If the managed care plan upholds the original denial, states have the option to offer an external medical review but are not required to do so. An external medical review is a clinical review of an MCO’s decision to uphold a denial by an independent, third party (not affiliated with the state or MCO). If offered, it must be at no cost to the enrollee, cannot disrupt an enrollee’s “continuation of benefits,” or be used as a deterrent to a state fair hearing (the next step in the appeals process which involves an administrative law judge). In Medicare Advantage, if the managed care plan upholds the original denial, the case is automatically sent to an independent review entity. OIG suggests that this automatic independent review process might explain why Medicare Advantage’s appeal overturn rate is 82%–far higher than Medicaid MCOs 36% overturn rate. The 2024 KFF/HMA state survey asked states whether they provide access to an external medical review process to review an MCO’s decision to uphold a denial.

As of July 1, 2024, at least one-third of responding MCO states (15 of 39) provided enrollees access to an independent external medical review process to review an MCO’s decision to uphold a denial (Figure 3).2  These findings represent a slight increase in the number of states that report providing access to external medical reviews compared to OIG’s 2019 findings.

At Least One-Third of MCO States Provided Enrollees Access to an Independent External Medical Review Process to Review Denials Upheld by MCOs
  1. MCOs must ensure that the services they provide are sufficient in amount, duration, or scope to achieve the purpose for which they are furnished. Also, MCOs may not arbitrarily deny or reduce a required service based solely on an enrollee’s illness or condition. ↩︎
  2. States were counted as having an external review process if, in addition to their survey response, the state’s publicly available MCO contracts and/or Managed Care Program Annual Reports supported the availability or use of an external review process. ↩︎
Poll Finding

KFF Health Information and Trust Tracking Poll: Health Information and Advice on Social Media

Published: Aug 7, 2025

Findings

Key Takeaways

  • Just over half (55%) of adults, including larger shares of young adults and Black and Hispanic adults, say they use social media to find health information and advice at least occasionally and most adults report seeing health-related content in the past month on social media, with the largest shares saying they’ve seen content about weight loss, diet, or nutrition (72%) and mental health (58%). Overall, fewer adults report seeing content related to vaccines (38%), abortion (30%), and birth control (22%). Even people who say they never use social media for health information and advice report being exposed to health information in the past month – with weight loss, nutrition, and diet information being the most common.
  • Most adults are skeptical of the health information and advice they see across social media platforms. When asked to assess the health information and advice on various social media platforms, fewer than half say they find “most” or “some” of the information they see on each platform trustworthy, and less than one in ten say “most” of the information is trustworthy. There is some variance across platforms, with at least three in ten users of YouTube, TikTok, and Reddit saying they trust “some” of the health content they see, compared to about a quarter of Facebook, Instagram, and X users, and smaller shares of users of WhatsApp, Snapchat, and Bluesky who say this.
  • About one in six (15%) social media users (14% of the public overall) say they regularly get health information and advice from social media influencers. Among those who report regularly getting health information and advice from influencers on social media, six in ten (61%) say health influencers are mostly motivated by their own financial interests, while about four in ten (39%) say health influencers are mostly motivated by serving the public interest. Among those who use social media for health information and advice, more than one-third (36%) say there is a particular influencer whom they trust when it comes to health information and advice (5% of total social media users), with a variety of individuals named, including conservative influencers, as well as doctors and other health care providers mentioned by name.

The Public’s Use of Social Media for Health Information and Advice

Just over half (55%) of adults say they use social media to find health information and advice “at least occasionally,” with larger shares of younger adults, and Black and Hispanic adults reporting this. Overall, about one in ten adults say they use these sites or apps to find health information and advice “everyday” (11%) or “at least once a week” (11%), 4% say they use it “at least once a month,” and about three in ten (29%) say they use it “occasionally” for this purpose. About four in ten (45%) adults say they never use social media to look up health information and advice. Younger adults and Black and Hispanic adults are more likely to report using social media to find health information and advice, while similar shares of social media users by gender and partisanship say they do this.

About Three in Five Adults Say They Use Social Media To Find Health Information and Advice at Least Occasionally, Including Larger Shares of Younger Adults, and Black and Hispanic Adults

Majorities of the public report being exposed to health information and advice about weight loss, diet, and nutrition (72%) as well as mental health (58%) on social media in the past 30 days, with younger adults, women, and Democrats most likely to report seeing these topics. Overall, fewer adults report seeing other content related to vaccines (38%), abortion (30%), and birth control (22%) on social media in the past month. Democrats are more likely than their Republican counterparts to report seeing social media content in the past month related to mental health (61% vs. 49%), vaccines (43% vs. 31%), abortion (35% vs. 23%), and birth control (24% vs. 15%). Similar shares of adults by race and ethnicity report seeing most of these topics on social media, though White adults (41%) are more likely to report seeing content about vaccines compared with Black (34%) and Hispanic (29%) adults. Notably, sizeable shares of adults who say they “never” use social media to find health information and advice nonetheless report seeing these topics, including seven in ten who say they have seen weight loss, diet, and nutrition information on social media in the past month.

Weight Loss, Diet, Nutrition and Mental Health Top List of Health-Related Topics People See on Social Media

Less than one in ten social media users say they trust most of the health information and advice they see on social media platforms. At least three in ten users of YouTube, TikTok, and Reddit say “some” of the health content they see is trustworthy, as do about a quarter of those who use Facebook, Instagram, and X. Smaller shares of users of WhatsApp, Snapchat, and Bluesky say the same. Importantly, across all social media platforms, a majority of users say they trust the health information they see on the app either “a little” or say that none of the information is trustworthy.

Across Platforms, Less Than Half of Social Media Users Say They Trust Most or Some of the Health Information and Advice They See

On some of the most widely used social media apps or sites, large shares of younger adults trust the health information and advice they see. For example, just over half (54%) of TikTok users ages 18-29 say “most” or “some” of the health information and advice they see on the app is trustworthy, as do about half (47%) of young YouTube users, and about four in ten young Reddit (42%) and Instagram (38%) users. On lesser used sites by young adults like Facebook and X, younger adults are as trusting of the health information they see as older adults.

On Some Platforms, Large Shares of Young Adults Say Most or Some of the Health Information and Advice Is Trustworthy

The Role of Social Media Health Influencers

About one in six (15%) adults who use social media (14% of the public overall) say they regularly get health information and advice from influencers on social media. Notably, the share who say they get health information and advice from social media influencers is much smaller than the share who say they get news about politics from social media influencers (38% say so). Certain groups are more likely to report relying on social media influencers for health information and advice including about one in five 18–29-year-olds (23%) and Black adults who use social media (21%). Perhaps unsurprisingly, more frequent social media users are more likely to say they get health information and advice from influencers than less frequent social media users. Similar shares of social media users by gender and partisanship say they get health information and advice from influencers. About one in five users of each social media platform say they regularly get health information and advice, ranging from 15% of YouTube users to 21% of TikTok users.

Few Social Media Users Regularly Get Health Information and Advice From Influencers, but About Four in Ten Get Political News From Them

Among those who report regularly getting health information and advice from influencers on social media, six in ten (61%) say health influencers are mostly motivated by their own financial interests, while about four in ten (39%) say health influencers are mostly motivated by serving the public interest.

Most Adults Who Turn to Influencers for Health Information and Advice Say Health Influencers Are Motivated by Financial Interests

One-third (36%) of those who use social media for health information and advice say they trust a particular influencer for this (5% of total social media users). When asked to give the name or handle of the person whom they trust for health information and advice, a variety of individuals are mentioned, including Barbara O’Neill and Nurse Kate, conservative influencers like Ben Shapiro, Joe Rogan, as well as doctors and other health care providers who were mentioned by name.

Two-Thirds of Adults Who Turn to Health Influencers for Health Information and Advice Say They Do Not Trust Any Particular Influencer
Few Social Media Users Say They Trust a Particular Influencer for Health Information and Advice

Methodology

This KFF Health Tracking Poll/KFF Tracking Poll on Health Information and Trust was designed and analyzed by public opinion researchers at KFF. The survey was conducted July 8-14, 2025, online and by telephone among a nationally representative sample of 1,283 U.S. adults in English (n=1,212) and in Spanish (n=71). The sample includes 1,004 adults (n=58 in Spanish) reached through the SSRS Opinion Panel either online (n=979) or over the phone (n=25). The SSRS Opinion Panel is a nationally representative probability-based panel where panel members are recruited randomly in one of two ways: (a) Through invitations mailed to respondents randomly sampled from an Address-Based Sample (ABS) provided by Marketing Systems Groups (MSG) through the U.S. Postal Service’s Computerized Delivery Sequence (CDS); (b) from a dual-frame random digit dial (RDD) sample provided by MSG. For the online panel component, invitations were sent to panel members by email followed by up to three reminder emails.

Another 279 (n=13 in Spanish) adults were reached through random digit dial telephone sample of prepaid cell phone numbers obtained through MSG. Phone numbers used for the prepaid cell phone component were randomly generated from a cell phone sampling frame with disproportionate stratification aimed at reaching Hispanic and non-Hispanic Black respondents. Stratification was based on incidence of the race/ethnicity groups within each frame. Among this prepaid cell phone component, 135 were interviewed by phone and 144 were invited to the web survey via short message service (SMS).

Respondents in the prepaid cell phone sample who were interviewed by phone received a $15 incentive via a check received by mail. Respondents in the prepaid cell phone sample reached via SMS received a $10 electronic gift card incentive. SSRS Opinion Panel respondents received a $5 electronic gift card incentive (some harder-to-reach groups received a $10 electronic gift card). In order to ensure data quality, cases were removed if they failed two or more quality checks: (1) attention check questions in the online version of the questionnaire, (2) had over 30% item non-response, or (3) had a length less than one quarter of the mean length by mode. Based on this criterion, 1 case was removed.

The combined cell phone and panel samples were weighted to match the sample’s demographics to the national U.S. adult population using data from the Census Bureau’s 2024 Current Population Survey (CPS), September 2023 Volunteering and Civic Life Supplement data from the CPS, and the 2025 KFF Benchmarking Survey with ABS and prepaid cell phone samples. The demographic variables included in weighting for the general population sample are gender, age, education, race/ethnicity, region, civic engagement, frequency of internet use, political party identification by race/ethnicity, and education. The weights account for differences in the probability of selection for each sample type (prepaid cell phone and panel). This includes adjustment for the sample design and geographic stratification of the cell phone sample, within household probability of selection, and the design of the panel-recruitment procedure.

The margin of sampling error including the design effect for the full sample is plus or minus 3 percentage points. Numbers of respondents and margins of sampling error for key subgroups are shown in the table below. For results based on other subgroups, the margin of sampling error may be higher. Sample sizes and margins of sampling error for other subgroups are available on request. Sampling error is only one of many potential sources of error and there may be other unmeasured error in this or any other public opinion poll. KFF public opinion and survey research is a charter member of the Transparency Initiative of the American Association for Public Opinion Research.

GroupN (unweighted)M.O.S.E.
Total1,283± 3 percentage points
Party ID
Democrats439± 6 percentage points
Independents387± 6 percentage points
Republicans344± 6 percentage points
MAGA Republicans308± 7 percentage points

How Much and Why ACA Marketplace Premiums Are Going Up in 2026

Published: Aug 6, 2025

A new analysis of initial rate filings for Affordable Care Act (ACA) Marketplace plans submitted by 312 insurers in all 50 states and the District of Columbia finds the median proposed increase for 2026 is 18%, more than double last year’s 7% median proposed increase. The proposed rates are preliminary and could change before being finalized in late summer.

In addition to rising cost and utilization of services, insurers cited the expiration of enhanced premium tax credits as a significant factor in their rate hikes for next year. The analysis includes a data table showing proposed premium increases by state and by insurers.

The full analysis and other data on health costs are available on the Peterson-KFF Health System Tracker, an online information hub dedicated to monitoring and assessing the performance of the U.S. health system.