Status of State Medicaid Expansion Decisions

Name: Status of State Action on the Medicaid Expansion Decision
Creator: KFF

Published: May 21, 2026

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

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

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

Status of State Action on the Medicaid Expansion Decision (Choropleth map)

Key States with Expansion Activity (Table)

Medicaid Expansion Resources

Texas Emerges as Focus of New Trump Administration Actions to Limit Gender-Affirming Care

Author: Lindsey Dawson

Published: May 21, 2026

Since early 2025, the Trump Administration has sought to limit youth access to gender-affirming care, taking a comprehensive approach to impose and enforce limitations. The administration has implemented or initiated dozens of actions with this aim, some of which have been challenged in court. In response to these actions, at least 40 health care institutions have walked back the provision of gender-affirming care over the last year and a half. This attrition has occurred in waves and in direct response to policy making – first following an executive order laying out the administration’s approach to limiting this care in January 2025, and then several times since in response to subpoenas (see below), proposed rulemaking, and a (now vacated) “declaration” from the Secretary of Health and Human Services, among other efforts. Over this period, when providers shut down services, they have generally said they were doing for reasons such “external pressures beyond our control,” “new federal orders targeting such procedures,” and “mounting pressure from the federal government”, not because they had concerns about safety, medical indication, or effectiveness. At times state Attorneys General have pushed providers to reopen or maintain services, stating that failing to do so would put them in potential violation of state non-discrimination laws and some have expressed frustration that pulling back on this care has at times preempted formal policy making. Pressure from the federal government to end care, oppositional pressure from states to provide care, and institutional barriers to providing best practice care, have left clinics and clinicians in a challenging position.

Notably, the most recent actions out of the administration have been concentrated in Texas, even though the state has banned youth access to gender-affirming medical care since 2023. The administration may have selected Texas as a site to enforce and pursue investigations against providers in an effort to forum shop and force changes within a hospital in a state where the Attorney General has aligned policy priorities. This includes three main actions in just the last couple of weeks, widely seen as intensifying federal efforts to limit this care. The three actions are as follows:

On April 30, 2026, the DOJ sought assistance from a federal district court in Texas in enforcing a subpoena of Rhode Island Hospital (RIH). This request for enforcement stemmed from a July 2025 action where the department issued over 20 civil subpoenas (at least 7 of which have been quashed in court) to providers delivering gender-affirming care to young people, including to RIH. While the hospital does not operate in Texas, DOJ states its investigation of Federal Food, Drug, and Cosmetic Act (FDCA) claims is taking place in the Northern District of Texas in front of Judge Reed O’Connor without providing a more detailed explanation for the relevance of the venue. The DOJ appears to be especially focused on off-label prescribing of hormonal/puberty blocking prescription medication, a common practice in medicine across medication classes and diagnoses. The FDA regulates drug approval, labeling and manufacturer promotion. However, the FDA does not regulate physicians’ prescribing decisions. This marked the first time the department asked a court to compel compliance with these administrative subpoenas. Within hours of the request for enforcement, and before hearing from RIH, the Texas court ordered RIH to comply within 14 days. RIH appealed to the 5^th Circuit Court of Appeals (covering Texas, Louisiana, and Mississippi) and sought a stay which was denied, though the appeal continues.

In parallel, on May 4, 2026, the Rhode Island Child Advocate, the state official charged with protecting the legal rights of children in state care, asked a federal district court in Rhode Island to quash the same subpoena and on May 9^th the hospital asked to join as an intervenor (specifically noting it had not had an opportunity to respond to DOJ’s petition in Texas and that the clock to comply with the order was running), which the court granted. RIH filed its own motion to quash on May 11^th. On May 13, 2026, the court quashed the subpoena and enjoined DOJ from “seeking, receiving, using, retaining, or disseminating any patient-identifying information or protected health information produced by RIH in response to Administrative Subpoena.” The court also questioned the case’s nexus to Texas. DOJ stated it would comply and appeal to the 1st Circuit Court of Appeals (covering Maine, Massachusetts, Rhode Island, and Puerto Rico), which it filed on May 15th.

On May 18^th the federal district court in Texas demanded that RIH produce the requested documents in just over 24 hours in camera (to be held by the court and not available to DOJ). In response, though they were not a party in the Texas matter, Rhode Island Child Advocate sought an emergency injunction with the 1^st Circuit on May 19^th , requesting the court order the hospital not to produce documentation (to the Texas district court). The 1^st Circuit denied the emergency request that night. At the same time, RIH told the Texas court it planned to comply with the document request and would anonymize and de-identify patient information (though on an extend timeline than that requested by the court). Watching what happens next will require monitoring both district (Texas and Rhode Island) and both appellate (5^th and 1^st) courts moving forward and teasing out parallel litigation.
On May 6, 2026, the U.S. Attorney’s office in the Northern District of Texas issued grand jury subpoenas to NYU Langone Hospital, and per NYU, other health care institutions. A grand jury summons suggests a criminal investigation, as does the direction to turn requested documents over to the FDA’s Office of Criminal Investigation. This is widely viewed as an escalation over the previous subpoena efforts that were administrative in nature. These subpoenas were issued by the Federal District Court in the Northern District of Texas less than a week after DOJ efforts to enforce the out of state RIH administrative subpoena in Texas, in the same federal district court (discussed above).

What is known is based on information released by NYU Langone, first by way of a public statement, and then in making the full subpoena public (and eventually adding it to an updated version of their statement. New York’s Shield Law requires any entity in the state that receives a request for legally protected health information to attempt to notify the individuals to whom that request pertains at least 30 days before complying with it, which may have influenced the hospital’s decision to go public. The subpoena to NYU included a sweeping demand for document production for the 2020-2026 time period. The documents requested included, for example, personnel files of those associated with provision of or billing for gender-affirming care, billing records and documentation policies, communications and materials with pharmaceutical companies regarding gender-affirming care, the identities of and detailed medical information on patients seen for gender-affirming care, communications related to off-label use of hormones, communications with World Professional Association for Transgender Health (WPATH), among other types of information. The subpoena requests that the produced materials be sent to the FDA Office of Criminal Investigations in the Kansas field office which might suggest an investigation related to the FDCA.
On May 15, 2026, the DOJ announced a “resolution to end pediatric ‘gender-affirming care’ and create [a] detransition clinic” with Texas Children’s Hospital [TCH]. DOJ stated the settlement is part of its “ongoing national investigation into violations of federal law in connection with the provision of sex-rejecting procedures on minors” (their term for gender-affirming care). The release stated TCH “entered into agreements with the Department and the Texas Attorney General that include commitments” not to provide young people with gender-affirming medical care (which is already banned in Texas) and “pay over $10 million in damages and civil penalties” related to “false billing” allegations under the FDCA, the False Claims Act, and federal fraud and conspiracy laws. Additionally, TCH agreed to establish a clinic dedicated to providing detransition-related services, an unusual move that the state and DOJ say are “first-of-its-kind”.In relatively rare cases when someone seeks medical care in detransitioning, they would not need a specialized clinic to do so.Separately, the Texas AG, Ken Paxton, issued his own press release with similar content to the one issued by DOJ except that it additionally notes that as part of the settlement, multiple providers were terminated and had their privileges revoked.

The DOJ wrote that “the claims resolved by the United States in the settlements are allegations only and there has been no determination of liability. Both entities have denied all allegations.” In a press statement that has since been removed from their website, TCH, wrote that throughout the process with the DOJ and Texas AG they have been “navigating an unconscionable campaign of mistruths and mischaracterizations related to gender affirming care.” The institution writes they have been compliant with all laws and is “settling to protect our resources from endless and costly litigation.”

The administrative and grand jury subpoenas as well as the settlement DOJ entered into with TCH, especially relating to provider terminations and revocation of privileges, will likely add to the chilling effect already characterizing the provision of gender-affirming care. Additionally, the language used throughout the DOJ documents discussed here could foster misinformation related to gender-affirming medical care (such as referring to it as a “destructive and discredited practice”), which remains recommended for young people who need it.

While Texas has banned core gender-affirming medical services for young people since 2023, the Trump administration DOJ has chosen a federal district court in Texas to file its enforcement efforts, and with the help of the Texas Attorney General negotiated a settlement with a Texas hospital, potentially seeing it as a warning to other hospital systems. The Rhode Island federal district court judge who quashed the administrative subpoena offers one theory as to why the lone star state has been in the spotlight, in a generally sternly worded order, accusing DOJ of selecting Texas “in favor of a distant forum that DOJ deems friendly to its political positions.”

Understanding Medicaid Cost Sharing and Policy Changes from the 2025 Reconciliation Law

Authors: Anna Mudumala and Jennifer Tolbert

Published: May 21, 2026

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Introduction

The 2025 reconciliation law makes significant changes to the Medicaid program, including requiring states to impose cost sharing on adults enrolled through the Affordable Care Act (ACA) Medicaid expansion, marking the first time the federal government has required states to impose cost sharing on Medicaid enrollees. Current federal rules allow, but do not require, states to impose cost sharing on certain Medicaid enrollees. In addition, the law creates new eligibility requirements that will affect expansion enrollees, including work requirements and the requirement for states to redetermine eligibility every six months. Together these provisions could create barriers to expansion enrollees maintaining coverage and increase their health care costs.

This brief explains current Medicaid cost sharing rules and changes made to cost sharing rules by the 2025 reconciliation law, reports on cost sharing amounts states currently impose on ACA expansion adults, and highlights literature on the impact of cost sharing. Key takeaways include:

As of January 2026, 19 states of the 41 that have adopted the ACA Medicaid expansion charge cost sharing on some services for adults enrolled in the expansion.
While current rules generally limit cost sharing to nominal amounts, states can charge higher cost sharing to individuals with income above 100% of the federal poverty level (FPL), which is $27,320 for a family of three. The Medicaid expansion covers people with incomes up to 138% of the poverty level.
The 2025 reconciliation law requires states to impose cost sharing of up to $35 per service on adults enrolled in the Medicaid expansion with income between 100% and 138% FPL. CMS guidance may address how much flexibility states have in determining which non-exempt services require cost-sharing and how much states may charge.
Evidence shows that cost sharing is associated with reduced use of care, worse health outcomes and increased financial burden for low-income populations.
Nearly half of expansion adults have at least one chronic condition. Medicaid expansion enrollees utilize some services more than traditional Medicaid enrollees, and expansion enrollees who are older or who have multiple chronic conditions are likely to face greater cost sharing burden than younger, healthy enrollees.

Current Cost Sharing Rules

Current rules permit, but do not require, states to impose cost sharing on certain populations, within limits designed to protect Medicaid enrollees who have low incomes from high out-of-pocket costs. States have flexibility to impose cost sharing on certain populations. Cost-sharing is generally limited to nominal amounts but may be higher for those with incomes above 100% FPL. Certain populations and services are exempt from cost sharing requirements (Table 1). Total out-of-pocket costs for premiums and cost sharing for all individuals in a Medicaid household are capped at 5% of monthly or quarterly household income. States are required to establish a process for tracking incurred cost sharing that does not rely on enrollee documentation and stops cost sharing once a family meets the cap. States must allow providers to reduce or waive cost sharing for enrollees on a case-by-case basis. A state may allow providers to deny services to enrollees for nonpayment of cost sharing, if the enrollees have a household income above 100% FPL and are not a part of a population exempt from cost sharing except for certain services.

While cost sharing is generally limited to nominal amounts, states can charge higher cost sharing to individuals with income above 100% FPL. The nominal cost sharing amounts for individuals with income up to 100% FPL are specified in regulation and are set at $4 for most outpatient services and preferred drugs, $8 for non-preferred drugs and non-emergency use of the emergency department (ED), and $75 per inpatient stay. These maximum allowable amounts are increased annually by the percentage increase in the medical care component of the Consumer Price Index. For services other than prescription drugs and non-emergency ED use, cost sharing cannot exceed 10% of the cost of the service for individuals in families with incomes from 101-150% FPL and cannot exceed 20% of the cost of the service for individuals in families with incomes above 150% FPL.

States have additional flexibility for imposing cost sharing on non-preferred drugs and non-emergency ED (emergency department) use, including imposing cost sharing for populations otherwise exempt from cost sharing. For prescription drugs, states may impose different cost sharing amounts for preferred and non-preferred drugs and may impose nominal cost sharing for non-preferred drugs on populations otherwise exempt from cost sharing. Preferred drug cost sharing must be applied to non-preferred drugs if the prescribing doctor determines that the preferred drug would not be as effective or would have adverse effects for the individual.

For non-emergency ED use, states may require cost sharing if enrollees are screened by a medical professional to confirm that the care is non-emergency. Enrollees must be notified about the cost sharing charges and provided with the name and location of an available and accessible alternative non-emergency services provider. States may impose cost sharing for non-emergency ED use for individuals otherwise exempt from cost sharing but must limit cost sharing to the maximum amount allowed for individuals with income below 150% FPL. For individuals with income above 150%, there is not a maximum cost sharing amount states may impose. (See Table 1 for full cost sharing rules on prescription drugs and non-emergency ED use.)

Under current rules, states may not charge premiums for Medicaid enrollees with incomes less than 150% FPL. States may charge certain pregnant individuals with premiums of up to 10% of the amount by which their income exceeds 150% FPL. States may also obtain waivers to impose premiums in Medicaid that federal rules do not otherwise allow.

New Cost Sharing Requirements

The 2025 reconciliation law requires states to impose cost sharing on adults enrolled in the Medicaid expansion with income between 100% and 138% FPL. Starting October 1, 2028, states will be required to impose cost sharing of up to $35 per service on expansion adults with incomes between 100-138% FPL (Table 1). The law maintains existing exemptions of certain services from cost sharing and exempts additional services from cost sharing for this group. It also limits cost sharing for prescription drugs to nominal amounts. States may continue imposing existing cost sharing on other populations, including expansion adults with incomes below 100% FPL under existing rules. CMS guidance may clarify any flexibility states may have in determining whether some or all non-exempt services must require cost-sharing, and what cost sharing amounts are allowable. The reconciliation law does not specify a minimum level of cost-sharing that must be imposed, except that the cost sharing must be greater than $0.

Current Medicaid Cost Sharing Rules and New Cost Sharing Rules for ACA Expansion Enrollees (Table)

Current Cost Sharing Imposed by States

As of January 2026, 19 states that have adopted the ACA Medicaid expansion charge cost sharing on some services for adults enrolled in the expansion. Fourteen of the 19 states impose cost sharing regardless of income while three states impose cost sharing only on expansion adults with income 100%-138% FPL and two states charge cost sharing starting at incomes less than 100% FPL. States most commonly charge cost sharing for prescription drugs (Figure 1). Sixteen states charge cost sharing for preferred brand-name drugs. Fifteen states charge cost sharing for generic drugs and non-preferred brand-name drugs. Most of these states charge the same cost sharing amount for both preferred and non-preferred drugs. Twelve states require a copayment for non-emergency ED and outpatient hospital visits, while ten states charge cost sharing for inpatient hospital visits.

Number of ACA Expansion States Imposing Cost Sharing by Service Type (Bar Chart)

Four states (Delaware, Louisiana, Maryland, and New Hampshire) only impose cost sharing for prescription drugs. One state (Colorado) only imposes cost sharing for non-emergency ED visits. (Full details on cost sharing amounts by service can be found in Appendix Table 1. Data was collected through KFF’s 2026 Medicaid Eligibility, Enrollment, and Renewal Policies Annual Survey.)

While most states limit cost sharing amounts to under $10 per service, four states charge more than $35 for hospital stays. Each of these four states charges more than $35 for inpatient hospital stays. Alaska charges $50 per day up to $200 per discharge; Michigan charges $50 per inpatient stay; Utah charges $75 per stay; and West Virginia charges $75 per stay for enrollees with income above 100% FPL. These states will likely need to reduce these cost sharing amounts to meet the new requirements.

North Carolina has recently enacted legislation that sets all Medicaid copayments at the maximum amount allowable under federal law starting July 1, 2027. This will require North Carolina to increase current cost sharing amounts for certain services (e.g., non-preferred drugs, non-emergency use of ED, and inpatient stays) to the maximum allowable amounts for populations currently subject to cost sharing. When new cost sharing rules for expansion adults go into effect on October 1, 2028, the state will increase cost sharing amounts for most services to $35 for these adults.

Impact of Cost Sharing on Enrollees

Evidence shows that cost sharing is associated with reduced use of care, worse health outcomes and increased financial burden for low-income populations. Cost-sharing results in higher costs and greater financial burden for low-income adults. Studies show that cost-sharing reduces utilization of both medically necessary care, including medications, behavioral health services for Medicaid enrollees with substance use disorders (SUDs) and clinically appropriate cancer screenings, as well as care that may be less necessary. Studies suggest that cost-sharing in older and low-income populations causes higher mortality.

Medicaid expansion enrollees utilize some services more than traditional Medicaid enrollees, and expansion enrollees who are older or who have multiple chronic conditions are likely to face greater cost sharing burden than younger, healthy enrollees. KFF analysis of 2021 Medicaid claims data found that one-third of expansion adults have a chronic physical health condition and a quarter have a chronic behavioral health condition. Likely because of these health conditions, expansion adults were more likely to use prescription drugs and behavioral health treatment compared to other adult Medicaid enrollees. Another KFF analysis of Medicaid utilization patterns estimates that among Medicaid expansion enrollees who used non-exempt services, the average enrollee could pay $542 if states charge $35 on all non-exempt services. Copayments that are required at the point of service have a greater impact on enrollees with higher health care needs who use more services. The analysis further suggests that expansion adults who are older could face cost sharing that is twice as high as younger enrollees and those with multiple chronic conditions could pay up to five times more cost sharing compared to enrollees with no chronic conditions.

Appendix

Cost Sharing Requirements for Selected Services for ACA Expansion Adults, January 2026 (Table)

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

Authors: Lindsey Dawson and Jennifer Kates

Published: May 20, 2026

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.

Executive Order: Defending Women From Gender Ideology Extremism and Restoring Biological Truth to The Federal Government, January 20, 2025

Purpose: To define sex as an immutable binary biological classification and remove recognition of the concept of gender identity, including in sex protections and in agency operations.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

On March 17^th 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 9^th, 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 1^st amendment claims and granted a preliminary injunction requiring HHS to republish the censored content.

Executive Order: Ending Radical and Wasteful Government DEI Programs and Preferencing, January 20, 2025

Purpose: To limit diversity, equity, inclusion, and accessibility (DEIA) activities in government and by government contractors and grantees.

Directs each agency, department, or commission head to take the following actions (among others):
• terminate, to the maximum extent allowed by law, all DEI, DEIA, and “environmental justice” offices and positions…; all “equity action plans,” “equity” actions, initiatives, or programs, “equity-related” grants or contracts…
• provide the Director of the OMB with a list of all “federal grantees who received Federal funding to provide or advance DEI, DEIA, or “environmental justice” programs, services, or activities since January 20, 2021,” among other actions.

Implications: As with the other DEIA related Order (see separate entry), these efforts could make reaching populations with unique health needs in culturally competent ways more challenging, including in programs related to LGBTQ+ health and HIV. It could also jeopardized programs and funding for agencies reaching these communities.
There have been multiple legal challenges to this Order:

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

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

• On February 20, a separate case was filed in federal court by multiple LGBTQ+ health care and service organizations, challenging the “Ending Radical and Wasteful DEI Programs and Preferencing”, “Defending Women From Gender Ideology Extremism and Restoring Biological Truth to the Federal Government” and the “Ending Illegal Discrimination and Restoring Merit-Based Opportunity” orders claiming they usurp the power of Congress and violate the Constitution. In their complaint, plaintiffs highlight the potential harm this Order could bring to people with HIV and LGBTQ communities and the programs that serve them. On June 9^th, 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.

Executive Order: 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.”

There have been multiple legal challenges to this Order:

• 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 9^th, 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.

Executive Order: 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 January 31, 2025. FEHB issued a letter to carriers stating that begining plan year 2026, carriers should not covre surgical or hormonal gender affirming care.

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 7^th challenging this executive order with a separate temporary restraining order being issued on the 14^th 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.

• In March a class action lawsuit was filed in federal district court challenging the Bureau of Prisons (“BOP”) implemention of the order. In June a preliminary injunction blocking BOP officials from providing hormone therapy and accommodating transgender people was granted.

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

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

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 14^th 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 6^th 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 7^th, 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: Issued to proclaim April as National Child Abuse Prevention Month. Describes “the sinister threat of gender ideology” as “one of the most prevalent forms of child abuse facing our country today.”

Erroneously conflates youth access to gender affirming care with child abuse.
References other efforts (see above) aimed at “prohibiting public schools from indoctrinating our children with transgender ideology” and “taking action to cut off all taxpayer funding to any institution that engages in the sexual mutilation of our youth.”
Promises legal action against those perpetrating child abuse.

Implications: The proclamation includes details about gender affirming care and transgender people that conflict with science and evidence, including that children are being “indoctrinated” “with the devastating lie that they are trapped in the wrong body,” referring to gender affirming surgery (which is very rare among young people) as “sexual mutilation surgery,” and suggesting that such care inhibits “happiness, health, and freedom,” for young people and creates “heartbreak” for parents and families.

• By erroneously conflating gender affirming care and abuse, potentially threatens those providing or facilitating access by stating, “we affirm that every perpetrator who inflicts violence on our children will be punished to the fullest extent of the law.”

Ryan White Letter to Awardees and Stakeholders Relating to Gender Affirming Care, April 7, 2025.

Purpose: Reverses a Biden Administration policy that had permitted the Ryan White HIV/AIDS Program to cover certain gender affirming care services as a part of whole person care to transgender people with HIV.

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

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

Implications:

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

• Prohibiting use of funds to support certain gender affirming care services may make care engagement more challenging for transgender Ryan White clients. In some cases, gender affirming care may have helped to connect clients with HIV services and thus improve HIV outcomes.

Nondiscrimination on the Basis of Disability in Programs or Activities Receiving Federal Financial Assistance; Clarification, April 11, 2025.

Purpose: HHS issued this notice “to clarify the non-enforceability of certain language that was included in the preamble to—but not the regulatory text of” the final rule on Section 504, “titled ‘Nondiscrimination on the Basis of Disability in Programs or Activities Receiving Federal Financial Assistance.’ The clarification states that language in the preamble concerning gender dysphoria, which is not in the regulatory text, does not have the force or effect of law and cannot be enforced.

Implications:

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

• This new interpretation could weaken certain protections for transgender and gender non-conforming people.

State Medicaid Director Letter “Re: Puberty blockers, cross-sex hormones, and surgery related to gender dysphoria,” April 11, 2025.

Purpose: “The purpose of this letter is to ensure that state Medicaid agencies are aware of growing evidence regarding certain procedures offered to children, and to remind states of their responsibility to ensure that Medicaid payments are consistent with quality of care and that covered services are provided in a manner consistent with the best interest of recipients.”

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

CMS reminds states of the following federal Medicaid requirements:

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

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

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

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

Implications:

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

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

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

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

• CMS issued a press release along with the letter. The letter stated “Medicaid dollars are not to be used for gender reassignment surgeries or hormone treatments in minors.”

Department of Justice Memorandum “Preventing the Mutilation of American Children,” April 22, 2025.

Purpose: An internal Department of Justice (DOJ) memorandum seeks to implement, in part, an executive order aimed at limiting minor’s access to gender affirming care (GAC) (see above).

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

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

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

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

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

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

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

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

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

Implications:

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

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

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

• While nothing in the memo prohibits provision of gender affirming care, its emphasis on litigation and enforcement of existing law that do not necessarily implicate this care, could have a chilling effect on providers.

HHS Report “Treatment for Pediatric Gender Dysphoria: Review of Evidence and Best Practices,” May 1, 2025.

Purpose: To develop an evidence review around pediatric gender affirming medical care as commissioned by the executive order on Protecting Children From Chemical and Surgical Mutilation (see above entry).

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

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

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

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

Implications:

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

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

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

On May 28, 2025, HHS sent a letter to an unspecified group of providers, state medical boards, and health risk managers urging providers to update treatment protocol to align with the review’s findings and avoid relying on the WPATH Standards of Care (which are seen by gender affirming care providers as valuable and trusted source of guidance.) The letter points to risk but not benefits of gender affirming medical care and highlights the report’s promotion of psychotherapy as an alternative to other medical care.

HHS Letter “Urgent Review of Quality Standards and Gender Transition Procedures” May 28, 2025

Purpose: The letter from the Center for Medicare and Medicaid Services (CMS) is directed at “select hospitals” providing minors with gender affirming care services including puberty blockers, hormones, and surgeries. The aim of the letter is to collect information on the delivery of these services and their associated costs and revenue. CMS states they are collecting this data to “ensure quality standards at institutions participating in the Medicare and Medicaid programs” and because “CMS has an obligation to be a good steward of taxpayer dollar.”

In the letter CMS asks for information on the following within 30 days:
• consent protocols for children with gender dysphoria, including when parental consent is required
• changes to clinical practice guidelines and protocols in light of the HHS Review (see above entry)
• adverse events, particularly children who later look to detransition
billing codes utilized for gender affirming care
• facility and provider-level revenue and profit margins data related to these services

Implications: If facilities or providers believe HHS is excessively engaged in oversight of their practice of this area of medicine, it could have a chilling effect on willingness to provide these treatments. Depending on what the Administration does with data collected, this effort could represent a significant step in the administration’s aim to limit GAC for minors.

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

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

It also appears to question the validity of using federal dollars to provide this care and possibly that delivering these services to minors is a significant cost-burden to the federal government. Because just a small share of the population is transgender, and not all trans people seek medical intervention, costs are likely very low.

CMS Informational Bulletin “Rescission of Guidance on Adding Sexual Orientation and Gender Identity Questions to State Medicaid and CHIP Applications for Health Coverage” June 5, 2025

Purpose: To rescind a bulletin from the Biden administration that provided state Medicaid programs with guidance on implementing optional sexual orientation and gender identity (SOGI) questions on their applications for coverage.

The Trump administration bulletin states that “CMS no longer intends to collect this information from state Medicaid and Children’s Health Insurance Program (CHIP) agencies as part of Transformed Medicaid Statistical Information System (T-MSIS) data submissions.”

Implications: Collection of SOGI health data plays a role in documenting the health experiences and status of LGBTQ+ people. Data collection can reveal disparities and gaps in access, which can, in turn, inform policy making to address these challenges. Without this data, addressing these disparities is more challenging. SOGI Data collection expanded under the Biden administration and has retracted under the Trump administration.

Final Rule Changing ACA Coverage of Gender-Affirming Care, June 25, 2025.

Purpose: The rule prohibits gender affirming care services from being covered as an Essential Health Benefit (EHB) in ACA plans.
CMS changes how ACA complaint individual and small group plans cover gender affirming care services, which the rule calls “coverage for sex-trait modification.” Beginning plan year 2026, insurers are prohibited from covering gender affirming care as an essential health benefit (EHB).

Differing from the proposed rule, which offered no definition, HHS defines “sex-trait modification” services to mean “any pharmaceutical or surgical intervention that is provided for the purpose of attempting to align an individual’s physical appearance or body with an asserted identity that differs from the individual’s sex.”
If a state mandates coverage for gender affirming care, the state would be required to defray the cost.

The preamble to the rule clarifies that CMS finds that as non-EHB services, EHB non-discrimination in the ACA do not apply.

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.

Department of Justice (DOJ) Issued Civil Subpoenas to Providers Delivering Gender Affirming Care to Young People, July 9, 2025.

Purpose: The Department announced it issued more than 20 subpoenas to doctors and clinics providing young people with medical gender affirming care, to investigate “healthcare fraud, false statements, and more.”

Implications: Multiple providers (at least 7) have sought to quash the subpoenas in court, most successfully. In April 2026, the DOJ sought assistance from a Texas court in enforcing a subpoena of Rhode Island Hospital. This marked the first time the department asked a court to compel compliance with their administrative subpoenas relating to gender affirming care. The court sided with DOJ ordering compliance. Rhode Island Hospital appealed to the 5^th Circuit and requested a stay but was denied. A Rhode Island district court was separately hearing a motion to quash by the Rhode Island Child Advocate. The hospital then asked to join that effort as an intervener which the court granted. On May 13, 2026, a Rhode Island district court quashed the subpoena and enjoined DOJ from “seeking, receiving, using, retaining, or disseminating any patient-identifying information or protected health information produced by RIH in response to Administrative Subpoena .” (The court offered multiple explanations as to why it permitted the hospital to join and why it was issuing an order counter to that of the Texas court, including that Rhode Island Hospital was not given an opportunity to present its own position to the Texas court before it issued an order.) DOJ stated it would comply but appeal to the 1st Circuit. Meanwhile the Texas court ordered RIH to produce the requested documents to the court for preservation to be held in camera (with DOJ having no access). Rhode Island Child Advocate asked the 1st Circuit for injuction but before that court denied the request, RIH told the Texas Court it would comply.

Separately, in May 2026, 11 families moved for a proposed class action in federal court in Maryland seeking to enjoin DOJ from enforcing subpoenas when it comes to their personal information.

The investigation further amplified the chilling effect other administrative actions (see above) have had on providers, leading some to close down their gender affirming care clinics or curtail practices.

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.

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.

FEHBP Carrier Letter Addendum on “Chemical and Surgical Sex-Trait Modification Services for Plan Year 2026 Proposals,” August 15, 2025.

Purpose: Building on an earlier carrier letter laying out criteria for coverage (see Jan. 28, 2025 entry), states that for Plan Year 2026, hormonal and surgical gender affirming care will not be covered under the Federal Employees Health Benefits (FEHB) and Postal Service Health Benefits (PSHB) Programs for enrollees, regardless of age. Requires carriers to “establish an exceptions process…for enrollees who are mid-treatment.” Policy permits the same interventions for other medical indications.

Implications: Restricts adult coverage (building on previously restricted minors’ coverage) for gender affirming hormonal and surgical care under the FEHB and PSHB programs. Requires implementation of a case-by-case exceptions process for those receiving gender affirming care. This is a reversal of a 2015 policy that had prohibited carriers, as of plan year 2016, from having a “a general exclusion of services, drugs or supplies related to gender transition or sex transformations.”

CDC Priorities Statement, September 17, 2025.

Purpose: CDC updated its priorities statement on the agency’s “about” website to include discussion of gender affirming care, parental rights, and DEI (among a range of other topics) not previously included on the site.

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

Another stated priority is that “CDC believes parents are the primary decision-makers in their children’s education and should have full authority over what their children are taught” and that school policies “and curricula should emphasize knowledge…without imposing ideas that may conflict with parents’ political, religious, or social beliefs.”
With respect to DEI the statement reads, “to the extent permitted by law, CDC will deprioritize diversity, equity, and inclusion (DEI) initiatives that prioritize group identity over individual merit” and that “CDC has previously invested substantially in ideologically-laden concepts like health equity—mainly on identifying and documenting worse health outcomes for minority populations.”

Implications: The new priorities statement represents are departure from the previous CDC “about” page which was much broader in its description and referenced the agency strategic plan stating that the plan “advances science and health equity and affirms the agency’s commitment to one unified vision— equitably protecting health, safety, and security.”

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

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

Proposed Rule Seeking to Amend CMS Hospital Condition of Participation to Prohibit Provision of Certain Gender Affirming Care Services for Young People, December 18, 2025.

Purpose: The proposed rule wouldchange the hospital Conditions of Participation (CoPs) to prohibit most Medicare and Medicaid enrolled hospitals from providing specified gender affirming medical care for youth.

The proposal would prohibit most hospitals (i.e. those covered by section 42 CFR part 482) that accept payments from the Medicare or Medicaid programs (the majority of hospitals in the U.S.) from providing pharmaceutical and surgical services related to gender affirming care to young people under age 18. Prohibited services would include puberty blockers (which delay the onset of puberty), hormone therapy, and surgery (which is very rare among young people). While these services would be prohibited for the purposes of providing gender affirming care, the rule would permit hospitals to provide them to youth when the service is not intended to affirm a person’s gender.

The proposal does not take immediate effect. There is a 60-day comment period from the date of publication in the federal register.

The rule applies to facility type (not payer) and therefore, if adopted, would prohibit hospitals from offering gender affirming services to all patients under 18 years old regardless of payer, including youth with private insurance or other coverage and those paying cash, not just those covered by Medicare and Medicaid.

If finalized, the proposed rule would further limit access to gender affirming care nationwide. To the extent that academic research hospitals discontinue provision of care, this could also have implications for research being conducted in these institutions.

See KFF’s overview of this proposed rule: https://www.kff.org/lgbtq/new-trump-administration-proposals-would-further-limit-gender-affirming-care-for-young-people-by-restricting-providers-and-reducing-coverage/

Proposed Rule Seeking to Prohibit Federal Medicaid/CHIP Funds from Covering Gender Affirming Care Services for Young People, December 18, 2025.

Purpose: The proposed rule would prohibit the use of federal Medicaid of CHIP funds from covering pharmaceutical and surgical gender affirming services for young people (under age 18 for those covered by Medicaid and under age 19 for those covered by CHIP). Prohibited services would include puberty blockers (which delay the onset of puberty), hormone therapy, and surgery (which is very rare among young people). Federal funds would be permitted to cover the same services when the service is not intended to affirm a person’s gender. Under the proposal, states would be permitted to use state-only funds to cover the prohibited services.

The proposal does not take immediate effect. There is a 60-day comment period from the date of publication in the federal register.

Implications: The aim of the proposed rule aligns with earlier actions (e.g. the Executive Order aimed at limiting access to gender affirming care, letters from HHS to providers/states, etc. (discussed above)).
The rule applies to federal Medicaid as a payer and therefore restrict reimbursement for care regardless of provider type (e.g. hospitals, primary care providers, endocrinologists, etc.). However, it does not prohibit providers from offering these services
If finalized, the proposed rule would further limit access to gender affirming care nationwide and impact families with lower incomes the hardest. While young people with Medicaid and CHIP coverage could theoretically seek care outside of hospitals without using their insurance, the cost of doing so would likely be prohibitive.
See KFF’s overview of this proposed rule: https://www.kff.org/lgbtq/new-trump-administration-proposals-would-further-limit-gender-affirming-care-for-young-people-by-restricting-providers-and-reducing-coverage/

Proposal to Amend Regulations Implementing Section 504 of the Rehabilitation Act of 1973, to exclude protections related to gender dysphoria, December 18, 2025.

Purpose: The proposed rule seeks to amend federal regulations implementing Section 504 of the Rehabilitation Act of 1973, which prohibits discrimination on the basis of disability in federal and federally funded programs, as it applies to recipients of funding from the Department of Health and Human Services (HHS). It would revise a Biden Administration final rule which, in the preamble, stated that HHS would be willing to view gender dysphoria as covered by Sec. 504 “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.” The proposed rule would do the opposite, and clarified that the current administration interprets statutory exclusions related to ‘‘gender identity disorders not resulting from physical impairments’’ to encompass ‘‘gender dysphoria not resulting from a physical impairment.’’

The proposal does not take immediate effect. There is a 30-day comment period from the date of publication in the federal register.

Implications: This new interpretation could weaken certain protections for transgender and gender non-conforming people.
(See related April 11, 2025 Notice above.)

Declaration of the Secretary of the Department of Health and Human Services, December 18, 2025.

Purpose: HHS Sec. Kennedy issued a declaration stating certain gender affirming care procedures are “neither safe nor effective as a treatment modality for gender dysphoria, gender incongruence, or other related disorders in minors, and therefore, fail to meet professional recognized standards of health care.” It further stated that “the Secretary ‘may’ exclude individuals or entities from participation in any Federal health care program if the Secretary determines the individual or entity has” delivered services that fail “to meet professionally recognized standards of health care.” However, HHS notes the “declaration does not constitute a determination that any individual or entity should be excluded from participation in any Federal health care program.”

Implications: The declaration was issued on the same day that proposed rules aiming to restrict youth access to gender affirming care in the Medicaid program and by hospitals participating in Medicare and Medicaid were released. (See more on the proposed rules in a separate entry below).

The declaration seeks to discredit widely used U.S. standards of care for gender affirming care (i.e. WPATH and Endocrine Society guidelines) and recommendations by major medical associations, instead relying on HHS’s evidence review relating to gender affirming care for minors (see above entry). It seeks to develop a Secretary-defined standard that would instead find that certain gender affirming services fail to meet professional recognized standards of care and therefore provide a basis for HHS to restrict federal funding to providers offering this care. This diverges from current recommendations which support access to this care and deem it a medical necessity.

While the declaration states that it does not determine that specific individuals or entities “should be excluded from participation in any Federal health care program” and that “any such determination…[would be]…subject to further administrative and judicial review,” it represents an additional effort aimed at restricting federal funding from reimbursing for gender affirming care for minors. As with other efforts, the declaration excepts the same services used in gender affirming care for other medical purposes.

Should the declaration be further implemented, it could increase the limitations on youth access to gender affirming care. The declaration is not limited to payer (as the Medicaid proposed rule is) or to a specific facility type (as the Conditions of Participation rule is). It could apply to any provider receiving federal funds. Even if the declaration is not implemented, it could stoke additional fear among providers who may choose to continue to or newly stop offering these services out of retaliatory fear.

On December 24, 2025, a lawsuit was filed in which 20 states challenged the administration’s authority to issue the declaration, claiming it violates the Administrative Procedures Act and the Medicare and Medicaid statutes and that “the Secretary has no legal authority to substantively alter the standards of care and effectively ban, by fiat, an entire category of healthcare.” In March 2026, a federal judge issued a ruling from the bench finding that HHS had overstepped its authority, offering relief for the (now 21) plaintiff states. In April, the written order from the court was published. The court granted summary judgment in favor of the plaintiffs and vacated HHS’ declaration. The court found that “defendants lack the authority to unilaterally establish standards of care that supersede professionally recognized standards of care for provision of gender-affirming care…[and] lack the authority to exclude providers from federal healthcare programs based on their provision of gender-affirming care.” The court further enjoined HHS from enforcing or implementing the declaration against providers in the Plaintiff States.

HHS has since referred mulitple providers to the Office of Inspector General based on the declaration.

Assistant Sec. for HHS Public Health Message on “Evidence-Based Care for Children and Adolescents with Gender Dysphoria”, December 18, 2025.

Purpose: To “inform healthcare providers, families, and policymakers about evidence-based approaches to caring for children and adolescents experiencing gender dysphoria.”

It reviews findings from the HHS review of gender affirming care for youth (see above entry) and summarizes elements of other reviews before recommending that providers refuse to provide pharmaceutical and surgical gender affirming care for young patients, prioritizing instead psychosocial assessment and care. It also recommends providers share with families the administration’s view that there is “weak evidence for medical interventions” and “substantial documented harms” in medically treating gender dysphoria in young people.

Implications: The recommendations made are not binding but add to administrative efforts to reduce access to gender affirming care for young people. They ignore widely recognized benefits associated with gender affirming care access and recommendations of dominant US medical associations and guidelines.

FDA Warning Letters Related to the Sale and Manufacturing of Chest Binders, December 16-18, 2025.

Purpose: To issue warning letters to retailers and manufacturers of chest binders which include marketing language about their use to help alleviate gender dysphoria. The FDA letters, issued to 12 retailers and manufacturers, state the binders are “misbranded” and that they are medical devices that must be registered with the FDA. In a press release HHS wrote “Breast binders are Class 1 medical devices used for purposes such as assistance in recovery from cancer-related mastectomy.”

FDA states that these companies “should take prompt action to address any violations identified in this letter. Failure to adequately address this matter may result in regulatory action being initiated by the FDA without further notice. These actions include, but are not limited to, seizure and injunction.” FDA states “if you believe that your products are not in violation of the FD&C Act, include your reasoning and any supporting information for our consideration as part of your response.”

Implications: The FDA efforts could create financial and logistical challenges for retailers and manufactures of chest binders used by transgender and nonbinary people. These challenges could result in access challenges for consumers, such as those relating to supply and cost.

Federal Bureau of Prisons Guidance on evaluation and treatment of inmates with Gender Dysphoria, February 19, 2026.

Purpose: “To establish professional guidelines for the mental health evaluation and treatment of inmates meeting the diagnostic criteria’ for Gender Dysphoria (GD) to assist their progress toward recovery, while reducing or eliminating the frequency and severity of symptoms and associated negative outcomes.” Restricts the Bureau of Prisons (BOP) from providing surgical and hormonal medical services related to gender affirming care and offering accommodations. Specifically, the guidance:

Prioritizes mental health care in the treatment of gender dysphoria, emphasizing assessment of comorbid psychiatric conditions, and collection of past medical records.
Connects guidance to the gender ideology Executive Order (described in above entry) which “prohibits the Bureau from expending federal funds for ‘any medical procedure, treatment, or drug for the purpose of conforming an inmate’s appearance to that of the opposite sex’” unless prohibited by court order. While referencing the Executive Order, it also states that the policy is being adopted independent of the Order.
States that treatment plans should be individualized and address all identified medical and psychiatric concerns but prohibits BOP from providing gender affirming surgeries and hormone therapy for those not currently receiving hormones.
Requires a “rapid discontinuation” tapering plan for those already but recently receiving hormones as a part of gender affirming care and an “appropriately paced” discontinuation plan for those who have received hormones for “extended periods.” States that for those who have had gender affirming surgeries and have been on hormones for an extended period, “it may not be appropriate…for the initial tapering plan to include cessation of hormones. But tapering plans should be reevaluated regularly.”
Prohibits BOP from providing (and says BOP may confiscate items related to) “social accommodation,” defined to include clothing, cosmetics, and other items like binders to help an inmate’s appearance align with their gender identity.

Implications:

Marks an area where federal restrictions around gender affirming care extend to adults.
Suggests that GD may be the result of, and addressed by, treatment of comorbid psychiatric conditions and prioritizes mental health interventions to the exclusion of other medical interventions that are widely considered best practice and not seen as interchangeable. As such, the policy could stand to negatively impact the well-being of transgender and nonbinary inmates in federal prisons seeking medically necessary gender affirming care. In addition, unwanted physical and emotional symptoms can occur because of hormone discontinuation.
By restricting and/or confiscating “social accommodation” this policy puts up barriers to social transition and goes beyond medical restrictions.
Uses the definitions section to reject the existence of transgender people’s identities stating that gender identity “does not provide a meaningful basis for identification.”
The Gender Ideology Executive Order is being challenged in court, parts of which are subject to preliminary injunctions. This includes a case in which a federal judge temporarily enjoined federal prisons from withholding gender affirming care from inmates as a result of the order. It is yet to be seen how the new policy will intersect with the existing injunction but the judge has ordered the administrative record for the BOP policy be filed with the court.

The Federal Trade Comission (FTC) issued multiple Civil Investigative Demands (CIDs) to Provider Groups, January 15, 2026.

Purpose: FTC issued three CIDs to the American Academy of Pediatrics (see Exhibit 1), Endocrine Society (see Exhibit 1), and WPATH (see Exhibit 1) to investigate whether these organizations “has made, or assisted others in making, false or unsubstantiated representations or engaged in unfair practices in connection with the marketing and advertising of Pediatric Gender Dysphoria Treatment (PGDT)—medical interventions for minors with gender dysphoria, including but not limited to pubertal suppression, hormone therapy, and surgery.”

Implications: These actions could lead to the false impression that these medical organizations are engaged in marketing practices, delivery of goods/services (and specifically “unfair” ones) related to gender affirming care. These actions could further intensify the chilling effect other administrative actions have already had on provider willingness to offer gender affirming care to minors.

2027 Plan Year FEHB Program Carrier Letter, March 31, 2026.

Purpose: U.S. Office of Personnel Management’s (OPM) carrier letter further laying out criteria for coverage for the Federal Employees Health Benefits (FEHB) and Postal Service Health Benefits (PSHB) Programs. Builds on two earlier policies (see details on Jan. 2025 and Aug. 2025 policies above) stating that “Beginning in the 2027 Plan Year, Carriers must remove any exceptions process…for coverage of excluded services for members who are mid-treatment within a surgical and/or hormonal regimen for diagnosed gender dysphoria.” Counseling services for possible or diagnosed gender dysphoria must still be covered. Covered counseling services must be provided by a licensed mental health provider.

Implications: In 2025, the administration restricted coverage for gender affirming care for those enrolled in insurance through the FEHBP and PSHB programs but required carriers to have an exceptions process in place for those already receiving services. The new policy further restricts access by removing the exceptions process, further limiting coverage.

Department of Justice (DOJ) Issued Grand Jury Subpoenas, May 6, 2026.

Purpose: On May 11, 2026, NYU Langone Hospital publicly announced that it and other health care institutions had received a grand jury subpoena from the U.S. Attorney’s office in the Northern District of Texas. Accompanying the subpoena was a demand for document production for the 2020-2026 time period.

NYU made the subpoena public on May 13, 2026. The documents requested are sweeping in nature ranging from personnel files of those associated with provision of or billing for gender affirming care, billing records and documentation policies, communications and materials with pharmaceutical companies regarding gender affirming care, the identities of and detailed medical information on patients seen for gender affirming care, communications related to off-label use of hormones, communications with WPATH, among other types of information. The subpoena requests that the produced materials be sent to the FDA Office of Criminal Investigations in the Kansas field office. Documents are requested from the hospital and a range of associated entities.

It is not known what other institutions received subpoenas and whether they received the same document request. It is also not known why the subpoena came out of the Northern District of Texas but notably, this is where the DOJ had earlier sought Rhode Island Hospital compliance with an administrative subpoena (see below and separate entry.)

Implications: A grand jury summons suggests a criminal investigation as does the direction to turn requested documents over to the FDA’s Office of Criminal Investigation. It could indicate that the government is pursuing claims under the Food Drug and Cosmetic Act, which the administration previously sought to use in efforts to enforce a subpoena in court against Rhode Island Hospital and also in the Northern District of Texas case (discussed above in separate entry). This is widely seen as an escalation in oversight compared to the previous DOJ subpoenas which were administrative in nature.

Grand jury subpoenas are likely to add to the escalating chilling effect administrative actions have had on providers of gender affirming care.

DOJ Announces “Resolution to End Pediatric ‘Gender-Affirming Care’ and Create Detransition Clinic” with Texas Children’s Hospital, May 15, 2026.

Purpose: The DOJ announced a resolution with Texas Children’s Hospital (TCH) as part of its “ongoing national investigation into violations of federal law in connection with the provision of” gender affirming care. TCH “entered into agreements with the Department and the Texas Attorney General that include commitments” not to provide young people with gender affirming medical care (which is already banned in Texas) and “pay over $10 million in damages and civil penalties” related to “false billing” allegations under the “Federal Food, Drug, and Cosmetic Act, the False Claims Act, and federal fraud and conspiracy laws.” TCH also agreed to establish a clinic dedicated to providing detransition-related services.The DOJ notes “The claims resolved by the United States in the settlements are allegations only and there has been no determination of liability. Both entities have denied all allegations.”

Implications: Because Texas already prohibits the provision medical gender affirming care for young people, the settlement does not change access to services in the state. The action, however, promotes misinformation related to gender affirming care, calling it a “destructive and discredited practice.” In fact, it is recommended for the treatment of gender dysphoria by major medical groups. Additionally, the creation of a “detransition clinic” could imply that detransitioning is widespread, which it is not, and that it warrants a specialized clinical environment.

Separately, the Texas AG, Ken Paxton, issued his own press release with similar content to the one issued by DOJ. However, it additionally notes that multiple providers were terminated and had their privileges removed. The AG’s release also noted that the settlement had been reached in coordination with the DOJ.

The terminations and revocation of privileges will likely add to the chilling effect already characterizing the treatment of hospitals and providers when it comes to these services. Notably, these actions appear to penalize providers for provision of care occurring several years ago, before it was prohibited in the state.

While the DOJ release states that TCH had not been determined to be liable and had denied all allegations, reputational damage may still occur for the health care institution and some may perceive any provision of gender affirming care as in violation of federal law. The state AG’s release made no such disclaimer.

In a press statement that has since been removed from their website, TCH, wrote that throughout the process with the DOJ and Texas AG they have been “navigating an unconscionable campaign of mistruths and mischaracterizations related to gender affirming care.” The institution writes they have been compliant with all laws and is “settling to protect our resources from endless and costly litigation”

Assessing PEPFAR’s Health Spillover Effects Beyond HIV: An Update

Authors: Jennifer Kates, William Crown, Collins Gaba, Monica Jordan, and Allyala Nandakumar

Published: May 20, 2026

This represents an update of earlier analyses:
Assessing PEPFAR’s Impact: Analysis of Mortality in PEPFAR Countries
Assessing PEPFAR’s Impact: Analysis of Maternal and Child Health Spillover Effects in PEPFAR Countries

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Summary

This analysis updates earlier work that assessed whether PEPFAR, the U.S. global HIV/AIDS program credited with saving 26 million lives, had health impacts beyond HIV (a companion update looks at economic and educational spillover effects). Specifically, the earlier analysis found that PEPFAR investments were associated with significant improvements in all-cause mortality and maternal and child health measures between 2004 and 2018, positive spillover effects that suggest the program has had a greater impact than for HIV alone; this was the case even though PEPFAR funding has been relatively flat for more than a decade. The current analysis updates these estimates through 2022 to capture additional years of data as well as the potential impact of the COVID-19 pandemic, which more broadly affected health and development. It similarly finds that PEPFAR was associated with continued health gains, especially for mortality outcomes. Moreover, where COVID-19 seems to have had a temporary impact, it did so across all countries, not just those receiving PEPFAR support. These findings suggest that more recent changes to the PEPFAR program by the Trump administration, including significantly scaling back funding and services with plans to further do so in the coming years, could not only have negative impacts on the HIV response, but dampen improvements in other health areas.

Introduction

The current analysis, done by researchers at KFF and Boston University, updates earlier work to assess whether the spillover effects found between 2004 and 2018 persisted through 2022, to capture additional years of data as well as the potential impact of the COVID-19 pandemic, which more broadly affected health and development. Specifically, the analysis uses a difference-in-difference, quasi-experimental design to analyze the change in the all-cause mortality rate, maternal and child mortality rates, and childhood immunizations in PEPFAR countries and a comparison group of low- and middle-income countries between 2004 and 2022. Several model specifications were tested. The final model specification controls for numerous baseline variables that could also be expected to influence these health outcomes, which helps to make the non-PEPFAR group more comparable to the PEPFAR group. Still, despite the strengths of the difference-in-difference model design, it is possible that there may be other, unobservable ways in which comparison countries differed from PEPFAR countries, which could account for the results (see Methodology for more detail).

Findings

PEPFAR was associated with significantly lower mortality during the 2004 to 2022 period.

Prior to the initiation of PEPFAR, all-cause mortality rates were higher in PEPFAR than in comparison countries. Once PEPFAR began, there was a much more rapid decline in mortality in PEPFAR countries, with the average all-cause mortality rate converging with that of comparison countries over time. While there was a substantial uptick during COVID-19, this occurred in both sets of countries (see Figure 1).
Moreover, the difference-in-difference analysis finds that PEPFAR investments were associated with an all-cause mortality rate that was 2.5 deaths per 1,000 lower, on average, than would have been expected in the absence of PEPFAR — a 23.4% reduction relative to the 2004 baseline (see Figure 2 and Tables 5-6).
The estimated effects were larger in PEPFAR’s “COP” countries, those that engaged in more intensive planning and programming, and also generally had greater PEPFAR investments.³[i] In COP countries, the reduction was 28.0% relative to the 2004 baseline (see Tables 5-6).

Line chart comparing all-cause mortality rates per 1,000 people from 1990 to 2022 between PEPFAR countries and comparison countries. Mortality rates in PEPFAR countries start higher at about 12 deaths per 1,000 in 1990 and steadily decline after 2004, when PEPFAR funding began, reaching near 8 deaths per 1,000 by 2022. Comparison countries show a relatively stable mortality rate around 8 deaths per 1,000 throughout the period. The chart highlights a notable decline in mortality rates in PEPFAR countries after the program's start, converging with comparison countries by 2022.

PEPFAR was associated with even larger reductions in both maternal and child mortality over the period.

Maternal and child mortality rates were significantly higher in PEPFAR countries than comparison countries before the start of the program. While their decline accelerated after PEPFAR began, they remained higher over the period. There was some uptick in maternal mortality rates during COVID-19 in both sets of countries (see Figures 3-4).
As with all-cause mortality rates, PEPFAR investments were associated with significant reductions in both maternal and child mortality, reducing them further than what would have been expected without PEPFAR. Specifically, PEPFAR was associated with a maternal mortality ratio that was 119.1 deaths per 100,000 live births lower than would have been expected without PEPFAR — a 29.1% reduction relative to the 2004 baseline — and a child mortality rate that was 30 deaths per 1,000 live births lower, a 38.0% reduction (see Figure 1 and Tables 5-6).
These effects were stronger in COP countries. In these countries, maternal mortality was 31.3% lower and child mortality 40.3% lower, relative to the baseline. (see Tables 5-6).

Bar chart showing estimated percent change in mortality associated with PEPFAR investments from 2004 to 2022 relative to 2004 baseline. All-cause mortality decreased by 23.4%, maternal mortality decreased by 29.1%, and child mortality decreased by 38.0%. The data indicate significant reductions in mortality rates linked to PEPFAR investments.

Line chart comparing maternal mortality rates per 100,000 live births from 2000 to 2022 between PEPFAR countries and comparison countries. The PEPFAR group starts with a higher mortality rate around 460 in 2000, which steadily declines to about 210 by 2022. The comparison countries start near 110 in 2000 and show a slight decline to around 60 by 2022. The start of PEPFAR funding in 2004 is marked, after which the PEPFAR countries show a consistent downward trend in maternal mortality.

Line chart comparing child mortality rates per 1,000 live births from 1990 to 2022 between PEPFAR-supported countries and comparison countries. Both groups show a decline in child mortality rates over time. PEPFAR countries start with a higher rate around 115 in 1990, decreasing to about 40 by 2022. Comparison countries start near 45 in 1990, declining to about 18 by 2022. The start of PEPFAR funding in 2004 is marked, after which the child mortality rate in PEPFAR countries continues to decline but remains higher than in comparison countries.

In addition, PEPFAR was associated with significant increases in childhood immunization rates.

Immunization coverage increased in PEPFAR countries over time approaching coverage levels in comparison countries for measles, DPT, and hepatitis B and converging for the share of newborns protected from tetanus because their mothers were immunized. Coverage rates for measles, DPT, and hepatitis B fell slightly during COVID-19 in both PEPFAR and comparison countries (see Figures 5-8).

PEPFAR investments were associated with improvements in immunization coverage rates for all measures compared to what would have been expected without PEPFAR, including measles coverage that was 7 percentage points higher (or a 9% increase relative to the baseline), DPT coverage 8.9 percentage points higher (11.4% increase), and Hepatitis B vaccine coverage of 6.4 percentage points higher (8.1% increase). In addition, the share of newborns protected against tetanus was 5 percentage points higher (6.6%). As with the above measures, these effects were stronger in COP countries (See Figure 9 and Tables 5-6).

Finally, for most outcomes, PEPFAR investments were associated with incremental improvements in each successive phase of the program.

In each successive phase of the program, corresponding to its different authorization periods, PEPFAR investments continued to be associated with improvements in most outcomes (with the exception of newborn tetanus protection; in addition, other immunization measures did not see incremental improvement in the most recent phase). The greatest incremental improvements were in the first five years of the program, which also marked a significant influx of new funding; PEPFAR funding plateaued after that which may explain the smaller gains in later years. Incremental improvements were largest for the three mortality measures (see Table 7).

Taken together, these findings provide continued evidence of PEPFAR’s knock-on effects for health beyond HIV alone, suggesting that such investments have yielded bigger dividends and served as a wider platform. These findings also suggest that more recent changes made to the PEPFAR program by the Trump administration, including significantly scaling back funding and services with plans to further do so in the coming years, could not only have negative impacts on the HIV response, they could also dampen improvements in these other health areas.

Line chart comparing measles immunization rates from 1990 to 2022 between PEPFAR-supported countries and comparison countries. The vertical axis shows measles immunization percentage from 0% to 100%. The horizontal axis shows years from 1990 to 2022. The chart highlights the start of PEPFAR funding in 2004. Before 2004, PEPFAR countries had immunization rates around 65% to 75%, while comparison countries were higher, around 82% to 88%. After 2004, immunization rates in PEPFAR countries steadily increased, reaching about 85% by 2014 and then slightly declining to around 78% by 2022. Comparison countries maintained higher rates, fluctuating near 85% to 90%, with a slight decline after 2018. Overall, PEPFAR countries showed notable improvement in measles immunization after 2004 but remained below comparison countries throughout the period.

Line chart comparing DPT immunization rates from 1990 to 2022 between PEPFAR-supported countries and comparison countries. The vertical axis shows DPT immunization percentage from 0% to 100%, and the horizontal axis shows years. PEPFAR countries start around 68% in 1990, gradually increasing to about 82% by 2022. Comparison countries start higher at about 85%, rising slightly to around 90% by 2004, then remaining stable near 88-90%. The start of PEPFAR funding in 2004 is marked, after which PEPFAR countries show a steady increase in immunization rates, narrowing the gap with comparison countries.

Line chart comparing hepatitis B immunization rates from 1990 to 2022 between PEPFAR-supported countries and comparison countries. The vertical axis shows immunization percentage from 0 to 100%. The horizontal axis shows years from 1990 to 2022. Immunization rates in PEPFAR countries start around 20% in 1990, dip in the early 1990s, then steadily increase to about 80% by 2022. Comparison countries start higher near 65% in 1990 and rise to around 85% by 2004, remaining relatively stable through 2022. A vertical line marks the start of PEPFAR funding in 2004. After 2004, immunization rates in PEPFAR countries continue to rise and narrow the gap with comparison countries. The chart highlights progress in hepatitis B immunization in PEPFAR countries following the start of funding.

Line chart comparing the percentage of newborns protected against tetanus through HepB immunization in PEPFAR and comparison countries from 1990 to 2022. Both groups show an upward trend in immunization rates, starting around 50% for PEPFAR and 60% for comparison countries in 1990. PEPFAR rates steadily increase, surpassing comparison countries around 2006, shortly after PEPFAR funding began in 2004. By 2022, both groups reach about 88% immunization. The chart highlights the convergence and improvement in newborn tetanus protection over time.

Bar chart showing estimated percent changes in childhood immunizations associated with PEPFAR investments from 2004 to 2022, relative to the 2004 baseline. The chart compares four immunizations: measles increased by 9.0%, DPT by 11.4%, HepB by 8.1%, and newborn tetanus protection by 6.6%. The data indicate positive effects of PEPFAR on vaccination rates, with DPT showing the highest increase.

Jen Kates is with KFF. William Crown, Collins Gaba, Monica Jordan and Allyala Nandakumar are with Boston University.

Methods & Tables

A difference-in-difference, quasi-experimental design was used to estimate a “treatment effect” (PEPFAR), based on comparison to a control group (the counterfactual). The difference-in-difference design compares the before and after change in outcomes for the treatment group to the before and after change in outcomes for the comparison group. The outcomes of interest, their definitions and sources are listed in Table 1. Baseline variables are listed in Table 2. The panel data set of 157 low- and middle- income countries used in the prior analysis, covering 1990 to 2018, was updated to include data through 2022 (due to data limitations, the time trend for maternal mortality began in 2000). COVID-related funding was not included. All values were adjusted to constant 2022 dollars.

The PEPFAR group included 90 countries that had received PEPFAR support over the period. The comparison group included 67 low- and middle- income countries that had not received any PEPFAR support or had received minimal PEPFAR support (<$1M over the period or <$.05 per capita) between 2004 and 2022. Data on PEPFAR spending by country were obtained from the U.S. government’s https://foreignassistance.gov/ database and represent U.S. fiscal year disbursements. Data on mortality rates were obtained from the World Bank’s World Development Indicators (WDI) (https://datatopics.worldbank.org/world-development-indicators/. Several different model specifications were explored. Each specification controlled for numerous baseline variables, compared to an unadjusted model, variables which may be expected to influence the outcomes of interest and which help make the comparison group more comparable to the PEPFAR group.

Table 3 provides the model specifications tested in the updated analysis. Each model specification produced similar, statistically significant results. All models were also run with and without China and India, the two most populous countries in the world, to assess whether they were influencing the results. In both cases, PEPFAR’s impact was still significant and results were similar. The final reported results are from model specification 3. The pre-intervention period for this model started in 2002. Almost all results were significant at the p<0.001 level; one result was significant at the p<0.01 level and one at the p<0.05 level. Table 4 provides the mean values for baseline outcomes and Tables 5-6 provide model results. The Table 5 difference-in-difference estimates should be interpreted as the unit change (e.g., in number of deaths per 1,000) in the outcome associated with PEPFAR. The Table 6 estimates should be interpreted as the percent change in the outcome, relative to the baseline, associated with PEPFAR.

Despite the strengths of the difference-in-difference design, there are limitations to this approach. While the models adjusted for numerous baseline factors that could be correlated with the outcomes of interest, there may be other, unobservable factors not captured. Similarly, while baseline factors are also intended to adjust for selection bias, and make the PEPFAR and comparison groups more similar, there may be other ways in which comparison countries differed from PEPFAR countries (and factors which influenced which countries received PEPFAR support), which could bias the estimates. Recent, published research, based on the earlier 2004-2018 period, examined several other model specifications as well as double log transformations for each model. The results were similar across all models, adding to the confidence of the analytic approach used here.⁴ Another analysis, under review for publication, conducted additional robustness tests and found consistent results.⁵

Table 1: Outcome Variables
Variable	Data Source
1. Crude death rate	All causes per 1,000 population
2. Child mortality rate	Probability of a child dying between birth and 5 years of age per 1,000 live births
3. Maternal mortality ratio	Number of women who die from pregnancy-related causes while pregnant or within 42 days of pregnancy termination per 100,000 live births
4. Measles immunization	Percent of children ages 12-23 months who received the measles vaccination
5. DPT immunizations	Percent of children ages 12-23 months who received DPT vaccinations (3 doses)
6. Hepatitis B immunizations	Percent of children ages 12-23 months who received hepatitis B vaccinations (3 doses)
7. Newborns protected against tetanus	Percentage of births by women of child-bearing age who are immunized against tetanus
Source: World Bank, WDI, https://datatopics.worldbank.org/world-development-indicators/

Table 2: Baseline Variables
Variable	Data Source
1. Gross Domestic Product (GDP) per capita (current USD)	World Bank Development Indicators
2. Recipient of U.S. HIV funding prior to 2004 (dummy variable)	https://foreignassistance.gov/
3. Total population	United Nations, Department of Economic and Social Affairs, Population Division
4. Life expectancy at birth (years)	World Bank Development Indicators
5. Total fertility rate (births per woman)	World Bank Development Indicators
6. Percent urban population (of total population)	World Bank Development Indicators
7. School enrollment, secondary (% gross)	World Bank Development Indicators
8. World Bank country income classification	World Bank
9. HIV prevalence (% of population ages 15-49)	World Bank Development Indicators. To address missing values in some cases, additional data were obtained from the Global Burden of Disease Collaborative Network
10. Per capita donor spending on health (non-PEPFAR) (constant $)	OECD Creditor Reporting System database
11. Per capita domestic health spending, government and private, PPP (current $)	World Bank Development Indicators
12. Measles prevalence in under 5 population (measles immunization models only)	IHME, http://ghdx.healthdata.org/gbd-results-tool
13. Diphtheria prevalence in under 5 population (DPT immunization models only)	IHME, http://ghdx.healthdata.org/gbd-results-tool
14. Whooping cough prevalence 15. in under 5 population (DPT immunization models only)	IHME, http://ghdx.healthdata.org/gbd-results-tool
15. Tetanus prevalence in under 5 population (DPT immunization models only)	IHME, http://ghdx.healthdata.org/gbd-results-tool
16. Hepatitis B prevalence in under 5 population (Hepatitis B immunization models only)	IHME, http://ghdx.healthdata.org/gbd-results-tool

Table 3: Model Specifications

1. Unadjusted model

2. Includes baseline variables 1-9 (and an additional baseline variable for disease incidence, 12-16, depending on outcome measure)

3. Includes baseline variables 1-11 (and an additional baseline variable for disease incidence, 12-16, depending on outcome measure)

Table 4: Baseline Mean Outcome Values, 2004
Outcome	All PEPFAR Countries	PEPFAR COP Countries
All-cause mortality rate	10.5	12.6
Maternal mortality ratio	409.8	497.5
Child mortality rate	78.9	97.9
Measles immunization percent	77.5	74.5
DPT immunization percent	78.0	74.2
Hepatitis B immunization percent	79.1	74.4
Prevalence of newborns protected against tetanus	75.7	75.6

Table 5: Difference-in-Difference Estimates Associated with PEPFAR, 2004-2022 (standard errors in parentheses)
Outcome	All PEPFAR Countries	PEPFAR COP Countries
All-cause mortality rate	-2.452***	-3.523***
	(0.171)	(0.235)
Maternal mortality ratio	-119.1***	-155.9***
	(14.618)	(19.101)
Child mortality rate	-30.02***	-39.48***
	(1.329)	(1.979)
Measles immunization percent	7.004***	7.795***
	(0.678)	(0.956)
DPT immunization percent	8.871***	9.022***
	(0.626)	(0.880)
Hepatitis B immunization percent	6.435**	13.67***
	(2.133)	(2.915)
Prevalence of newborns protected against tetanus	4.962***	3.303*
	(1.299)	(1.495)
*p < 0.001 p < 0.01 *p < 0.05

Table 6: Estimated Percent Change Associated with PEPFAR, 2004-2022 (Relative to 2004 Baseline)
Outcome	All PEPFAR Countries	PEPFAR COP Countries
All-cause mortality rate	-23.4%***	-28.0%***
Maternal mortality ratio	-29.1%***	-31.3%***
Child mortality rate	-38.0%***	-40.3%***
Measles immunization percent	9.0%***	10.5%***
DPT immunization percent	11.4%***	12.2%***
Hepatitis B immunization percent	8.1%**	18.4%***
Prevalence of newborns protected against tetanus	6.6%***	4.4%*
*p < 0.001 p < 0.01 *p < 0.05

Table 7: Estimated Incremental Percent Change Associated with PEPFAR by Time Period (Relative to 2004 Baseline)
Outcome	2004 – 2008	2009 – 2013	2014 – 2018	2019 – 2022
All-cause mortality rate	-9.8%	-5.7%	-5.0%	-2.8%
Maternal mortality ratio	-14.2%	-6.3%	-4.1%	-4.5%
Child mortality rate	-22.0%	-7.0%	-5.7%	-3.3%
Measles immunization percent	5.3%	2.4%	1.2%	0.1%
DPT immunization percent	7.9%	2.3%	1.1%	0.1%
Hepatitis B immunization percent	6.8%	0.6%	1.0%	-0.3%
Prevalence of newborns protected against tetanus	9.0%	-1.3%	-0.8%	-0.4%

Endnotes

Eran Bendavid E, Bhattacharya J. The President’s Emergency Plan for AIDS Relief in Africa: An Evaluation of Outcomes. Ann Intern Med. 2009;150:688-695. Available at: https://www.acpjournals.org/doi/10.7326/0003-4819-150-10-200905190-00117?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed&; Bendavid E, Holmes CB, Bhattacharya J, Miller G. HIV Development Assistance and Adult Mortality in Africa. JAMA. 2012;307(19):2060–2067. Available at: https://jamanetwork.com/journals/jama/fullarticle/1157487; IOM (Institute of Medicine). 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. Available at: https://www.ncbi.nlm.nih.gov/books/NBK207013/; Wagner Z, Barofsky J, Sood N. PEPFAR Funding Associated With An Increase In Employment Among Males in Ten Sub-Saharan African Countries. Health Aff (Millwood). 2015;34(6):946-953. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4782769/; and Daschle T, Frist B. Building Prosperity, Stability, and Security Through Strategic Health Diplomacy: A Study of 15 Years of PEPFAR. Bipartisan Policy Center, Washington DC, 2018. Available at: https://bipartisanpolicy.org/download/?file=/wp-content/uploads/2019/03/Building-Prosperity-Stability-and-Security-Through-Strategic-Health-Diplomacy-A-Study-of-15-Years-of-PEPFAR.pdf; Chun HM, Dirlikov E, Cox MH, et al. Vital Signs: Progress Toward Eliminating HIV as a Global Public Health Threat Through Scale-Up of Antiretroviral Therapy and Health System Strengthening Supported by the U.S. President’s Emergency Plan for AIDS Relief — Worldwide, 2004–2022. MMWR Morb Mortal Wkly Rep 2023;72:317–324. Available at: https://www.cdc.gov/mmwr/volumes/72/wr/mm7212e1.htm?s_cid=mm7212e1_w#suggestedcitation; Gaumer G, Luan Y, Hariharan D, Crown W, Kates J, Jordan M, et al. “Assessing the impact of the president’s emergency plan for AIDS relief on all-cause mortality”. PLOS Glob Public Health 2024; 4(1): e0002467. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC10796053/. ↩︎
“The Future of Investment In PEPFAR: Understanding PEPFAR’s Multiple Economic, Health, And Diplomatic Impacts”, Health Affairs Blog, April 17, 2017. Available at: https://www.healthaffairs.org/content/forefront/future-investment-pepfar-understanding-pepfar-s-multiple-economic-health-and-diplomatic; Crown W, Hariharan D, Kates J, Gaumer G, Jordan M, Hurley C, et al. “Analysis of economic and educational spillover effects in PEPFAR countries.” PLoS ONE 2023; 18(12): e0289909. Available at: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0289909; ; Gaumer G, Crown WH, Kates J, et al. “Analysis of maternal and child health spillover effects in PEPFAR countries.” BMJ Open 2023;13: e070221. Available at: https://bmjopen.bmj.com/content/13/12/e070221.long. ↩︎
Historically, a subset of countries receiving PEPFAR support had been required to prepare annual Country Operational Plans (COPs) which documented annual funding levels linked to results and served as budget and tracking tools. These were prepared by country teams who worked intensively to develop these plans in concert with headquarters at the State Department. ↩︎
Gaumer G, Luan Y, Hariharan D, Crown W, Kates J, Jordan M, Hurley CL, Nandakumar A. “Assessing the impact of the president’s emergency plan for AIDS relief on all-cause mortality”. PLOS Glob Public Health. 2024 Jan 18;4(1):e0002467. doi: 10.1371/journal.pgph.0002467; Gaumer G, Crown WH, Kates J, Luan Y, Hariharan D, Jordan M, Hurley CL, Nandakumar A. “Analysis of maternal and child health spillover effects in PEPFAR countries”. BMJ Open. 2023 Dec 21;13(12):e070221. doi: 10.1136/bmjopen-2022-070221. ↩︎
Crown W, Stenoien D, Reid MJA, Kumar S, Kates J, Jordan M, Nandakumar A. “The Economic Impact of Lives Saved in PEPFAR Countries”, under review BMJ Global Health. https://doi.org/10.12688/verixiv.2057.1 ↩︎

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Assessing PEPFAR’s Economic and Educational Spillover Effects: An Update

Authors: William Crown, Jennifer Kates, Deborah Stenoien, and Allyala Nandakumar

Published: May 20, 2026

This represents an update of an earlier analysis:
Assessing PEPFAR’s Impact: Analysis of Economic and Educational Spillover Effects in PEPFAR Countries

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Summary

This analysis updates earlier work that assessed whether PEPFAR, the U.S. global HIV/AIDS program credited with saving 26 million lives, had impacts beyond health (a companion update looks at broader health spillover effects). Specifically, the earlier analysis found that PEPFAR investments were associated with a significant increase in the GDP per capita growth rate and reductions in the shares of girls and boys who were out of school between 2004 and 2018, positive spillover effects that suggest the program has had a greater impact beyond health alone; this was the case even though PEPFAR funding has been relatively flat for more than a decade. The current analysis updates these estimates through 2022 both to capture additional years of data as well as the potential impact of the COVID-19 pandemic, which severely affected the global economy and resulted in widespread school closures. It similarly finds that PEPFAR was associated with continued improvement in these non-health indicators. These findings suggest that more recent changes to the PEPFAR program by the Trump administration, including significantly scaling back funding and services with plans to further do so in the coming years, could not only have negative impacts on the HIV response, but dampen improvements beyond health.

Introduction

PEPFAR, the U.S. global HIV/AIDS program credited with saving 26 million lives, is the largest commitment by any nation to address a single disease. In many countries, PEPFAR funding had accounted for the biggest share of external health investment, often surpassing domestic HIV spending. Numerous studies have documented PEPFAR’s impact on improving HIV outcomes, including reductions in new HIV infections and HIV-related deaths, reversing the epidemic’s impact in sub-Saharan Africa.¹ In addition, a growing body of research has also found that PEPFAR investments are associated with improvements in other health areas, such as maternal and child health and outbreak response.² Research has also examined the relationship between PEPFAR and non-health benefits, such as to the economy and educational sectors. For example, the prior analysis found that PEPFAR was associated with a significant increase in the GDP per capita growth rate and reductions in the shares of girls and boys who were out of school between 2004 and 2018. The reasons for this impact are multifaceted and although PEPFAR is a health program, its investments have led to significant reductions in mortality and greater life expectancy, which are generally associated with economic growth and other benefits. External aid also acts as an economic stimulus in countries.³

The current analysis, done by researchers at KFF and Boston University, updates earlier work to assess whether the spillover effects found between 2004 and 2018 persisted through 2022, to capture additional years of data as well as the potential impact of the COVID-19 pandemic, which severely disrupted the global economy and resulted in widespread school closures. Specifically, the analysis uses a difference-in-difference, quasi-experimental design to analyze the change in the GDP per capita growth rate and the shares of girls and boys of primary school age who were out of school in PEPFAR countries and a comparison group of low- and middle-income countries between 2004 and 2022. Several model specifications were tested. The final model specification controls for numerous baseline variables that could also be expected to influence these outcomes, which helps to make the non-PEPFAR group more comparable to the PEPFAR group. Still, despite the strengths of the difference-in-difference model design, it is possible that there may be other, unobservable ways in which comparison countries differed from PEPFAR countries, which could account for the results (see Methodology for more details).

Findings

PEPFAR was associated with a significantly higher GDP per capita growth rate during the 2004 to 2022 period.

Prior to PEPFAR’s initiation, the GDP per capita growth rate was generally higher in comparison countries than PEPFAR countries, although there was some volatility in both.⁴ The rate in PEPFAR countries accelerated particularly after program’s initiation and until the 2008 global financial crisis, when it dropped in both sets of countries; however, this drop was more pronounced in comparison countries, where it was briefly negative. Similarly, during COVID-19, the GDP per capita growth rate was negative in both PEPFAR and comparison countries, but more so in comparison countries. (see Figure 1).
The difference-in-difference analysis finds that PEPFAR investments were associated with an annual GDP per capita growth rate 1.98 percentage points higher than what would have been expected without the program. While it is possible that the broad economic shocks of 2008 and 2020 affected PEPFAR and comparison countries differently, the model is designed to control for this possibility, supporting the finding that PEPFAR itself was associated with the outcome of interest (see Figure 2 and Tables 5-6).
These estimated effects were even larger in PEPFAR “COP” countries, those that engaged in more intensive planning and programming.⁵ In COP countries, PEPFAR was associated with an annual GDP per capita growth rate 2.41 percentage points higher (see Tables 5-6).

PEPFAR was also associated with significant declines in the shares of girls and boys of primary school age who were out-of-school over the period.

Before PEPFAR, the shares of girls and boys who were out-of-school were higher in PEPFAR than in comparison countries. While they had begun to drop in PEPFAR countries, the drop accelerated after the introduction of the program, moving closer to comparison countries. There was a slight uptick in both sets of countries during COVID-19, a period marked by widespread school closures. (see Figures 3-4).
The analysis finds that the share of primary school-age girls who were out of school was 9.37 percentage points lower than would have been expected without PEPFAR (a 43.3% decline relative to the 2004 baseline). The percentage point decline for boys was 8.14 (a 44.1% decline (see Figures 5-6 and Tables 5-6).
The estimated effects were larger in COP countries (57.9% for girls and 63.7% for boys relative to the baseline) (see Tables 5-6).

Finally, PEPFAR investments were associated with incremental improvements in most outcomes in each successive phase of the program.

In each successive phase of the program, corresponding to its different authorization periods, PEPFAR investments continued to be associated with improvements in most outcomes; the only exception was the GDP per capita growth rate in the most recent period. The greatest incremental improvements were in the first five years of the program, which also marked a significant influx of new funding; PEPFAR funding plateaued after that which may explain the smaller incremental gains in later years (see Table 7).

Taken together, these findings provide continued evidence of PEPFAR’s knock-on effects beyond health alone. This is supported by numerous other studies that have found that health investments generally are correlated with educational attainment and economic growth, including, for example, by enabling children to stay in school longer and by supporting adults to join and/or remain in the labor force.These findings also suggestthat more recent changes made to the PEPFAR program by the Trump administration, including significantly scaling back funding and services with plans to further do so in the coming years, could not only have negative impacts on the HIV response, they could also dampen economic and educational gains beyond health.

Jen Kates is with KFF. William Crown, Deborah Stenoien, and Allyala Nandakumar are with Boston University.

Methods & Tables

A difference-in-difference, quasi-experimental design was used to estimate a “treatment effect” (PEPFAR), based on comparison to a control group (the counterfactual). The difference-in-difference design compares the before and after change in outcomes for the treatment group to the before and after change in outcomes for the comparison group. The outcomes of interest, their definitions and sources are listed in Table 1. Baseline variables are listed in Table 2. The panel data set of 157 low- and middle- income countries used in the prior analysis, covering 1990 to 2018, was updated to include data through 2022. COVID-related funding was not included. All values were adjusted to constant 2022 dollars.

The PEPFAR group included 90 countries that had received PEPFAR support over the period. The comparison group included 67 low- and middle- income countries that had not received any PEPFAR support or had received minimal PEPFAR support (<$1M over the period or <$.05 per capita) between 2004 and 2022. Data on PEPFAR spending by country were obtained from the U.S. government’s https://foreignassistance.gov/ database and represent U.S. fiscal year disbursements. Data for other indicators were obtained from the World Bank’s World Development Indicator database (WDI) (https://datatopics.worldbank.org/world-development-indicators/, unless otherwise noted. Several different model specifications were explored. Each specification controlled for numerous baseline variables, compared to an unadjusted model, variables which may be expected to influence the outcomes of interest and which help make the comparison group more comparable to the PEPFAR group.

Table 3 provides the model specifications used in the updated analysis. Each model specification produced similar, statistically significant results. All models were also run with and without China and India, the two most populous countries in the world, to assess whether they were influencing the results. In both cases, PEPFAR’s impact was still significant and results were similar. The final reported results are from model specification 3. The pre-intervention period for this model started in 2002. All results were significant at the p<0.001 level. Table 4 provides the mean values for baseline outcomes and Tables 5-6 provide model results. The Table 5 difference-in-difference estimates should be interpreted as the unit change (e.g., percentage point change in the GDP per capita growth rate) in the outcome associated with PEPFAR. The Table 6 estimates should be interpreted as the percent change in the outcome, relative to the baseline, associated with PEPFAR.

Despite the strengths of the difference-in-difference design, there are limitations to this approach. While the models adjusted for numerous baseline factors that could be correlated with the outcomes of interest, there may be other, unobservable factors not captured. Similarly, while baseline factors are also intended to adjust for selection bias, and make the PEPFAR and comparison groups more similar, there may be other ways in which comparison countries differed from PEPFAR countries (and factors which influenced which countries received PEPFAR support), which could bias the estimates. A recent published research article, based on the earlier 2004-2018 period, tested multiple model specifications and conducted sensitivity analyses. The results were similar across all models, adding to the confidence of the analytic approach used here. At the same time, there were some tests that indicated that the parallel trends assumption was not supported in all cases, warranting further analysis.⁶ Another recent analysis, under review for publication, conducted additional robustness tests and found consistent results.⁷

Table 1: Outcome Variables
Variable	Data Source
1. GDP per capita growth (annual %)	Annual percentage growth rate of GDP per capita based on constant local currency. GDP per capita is gross domestic product divided by midyear population.
2. Children out of school, female (% of female primary school age)	Percentage of female primary-school-age children who are not enrolled in primary or secondary school.
3. Children out of school, male (% of male primary school age)	Percentage of male primary-school-age children who are not enrolled in primary or secondary school.
Source: World Bank, WDI, https://datatopics.worldbank.org/world-development-indicators/

Table 2: Baseline Variables
Variable	Data Source
1. Gross Domestic Product (GDP) per capita (current USD)	World Bank Development Indicators
2. Recipient of U.S. HIV funding prior to 2004 (dummy variable)	https://foreignassistance.gov/
3. Total population	United Nations, Department of Economic and Social Affairs, Population Division
4. Life expectancy at birth (years)	World Bank Development Indicators
5. Total fertility rate (births per woman)	World Bank Development Indicators
6. Percent urban population (of total population)	World Bank Development Indicators
7. School enrollment, secondary (% gross)	World Bank Development Indicators
8. World Bank country income classification	World Bank
9. HIV prevalence (% of population ages 15-49)	World Bank Development Indicators To address missing values in some cases, additional data were obtained from the Global Burden of Disease Collaborative Network
10. Per capita donor spending on health (non-PEPFAR) (constant $)	OECD Creditor Reporting System database
11. Per capita domestic health spending, government and private, PPP (current $)	World Bank Development Indicators

Table 3: Model Specifications

1. Unadjusted model

2. Includes baseline variables 1-9

3. Includes baseline variables 1-11

Table 4: Baseline Mean Outcome Values, 2004
Outcome	All PEPFAR Countries	PEPFAR COP Countries
GDP per capita growth rate (% change)	4.5	4.1
Primary School-Age Girls Out of School (%)	21.7	21.3
Primary School-Age Boys Out of School (%)	18.5	19.2

Table 5: Difference-in-Difference Estimates Associated with PEPFAR, 2004-2022 (standard errors in parentheses)
Outcome	All PEPFAR Countries	P Countries
GDP per capita growth rate (% change)	1.977	2.410
	(0.449)	(0.653)
Primary School-Age Girls Out of School (%)	-9.374	-12.31
	(1.077)	(1.223)
Primary School-Age Boys Out of School (%)	-8.140	-12.19
	(0.961)	(1.089)
All results significant at p < 0.001

Table 6: Estimated Percent Change Associated with PEPFAR, 2004-2022 (Relative to 2004 Baseline)
Outcome	All PEPFAR Countries	PEPFAR COP Countries
GDP per capita growth rate (% change)	43.5%	59.2%
Primary School-Age Girls Out of School (%)	-43.3%	-57.9%
Primary School-Age Boys Out of School (%)	-44.1%	-63.7%
All results significant at p < 0.001

Table 7: Estimated Incremental Percent Change Associated with PEPFAR by Time Period (Relative to 2004 Baseline)
Outcome	2004-2008	2009-2013	2014-2018	2019-2022
GDP per capita growth rate (% change)	19.3%	21.6%	4.7%	-2.1%
Primary School-Age Girls Out of School (%)	-30.9%	-7.0%	-4.5%	-0.9%
Primary School-Age Boys Out of School (%)	-30.7%	-8.2%	-4.3%	-1.0%

Endnotes

Eran Bendavid E, Bhattacharya J. The President’s Emergency Plan for AIDS Relief in Africa: An Evaluation of Outcomes. Ann Intern Med. 2009;150:688-695. Available at: https://www.acpjournals.org/doi/10.7326/0003-4819-150-10-200905190-00117?url_ver=Z39.88-2003&rfr_id=ori%3Arid%3Acrossref.org&rfr_dat=cr_pub%3Dpubmed&; Bendavid E, Holmes CB, Bhattacharya J, Miller G. HIV Development Assistance and Adult Mortality in Africa. JAMA. 2012;307(19):2060–2067. Available at: https://jamanetwork.com/journals/jama/fullarticle/1157487; IOM (Institute of Medicine). 2013. Evaluation of PEPFAR. Washington, DC: The National Academies Press. Available at: https://www.ncbi.nlm.nih.gov/books/NBK207013/; Wagner Z, Barofsky J, Sood N. PEPFAR Funding Associated With An Increase In Employment Among Males in Ten Sub-Saharan African Countries. Health Aff (Millwood). 2015;34(6):946-953. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4782769/; and Daschle T, Frist B. Building Prosperity, Stability, and Security Through Strategic Health Diplomacy: A Study of 15 Years of PEPFAR. Bipartisan Policy Center, Washington DC, 2018. Available at: https://bipartisanpolicy.org/download/?file=/wp-content/uploads/2019/03/Building-Prosperity-Stability-and-Security-Through-Strategic-Health-Diplomacy-A-Study-of-15-Years-of-PEPFAR.pdf; Chun HM, Dirlikov E, Cox MH, et al. Vital Signs: Progress Toward Eliminating HIV as a Global Public Health Threat Through Scale-Up of Antiretroviral Therapy and Health System Strengthening Supported by the U.S. President’s Emergency Plan for AIDS Relief — Worldwide, 2004–2022. MMWR Morb Mortal Wkly Rep 2023;72:317–324. Available at: https://www.cdc.gov/mmwr/volumes/72/wr/mm7212e1.htm?s_cid=mm7212e1_w#suggestedcitation; Gaumer G, Luan Y, Hariharan D, Crown W, Kates J, Jordan M, et al. “Assessing the impact of the president’s emergency plan for AIDS relief on all-cause mortality”. PLOS Glob Public Health 2024; 4(1): e0002467. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC10796053/. ↩︎
“The Future of Investment In PEPFAR: Understanding PEPFAR’s Multiple Economic, Health, And Diplomatic Impacts”, Health Affairs Blog, April 17, 2017. Available at: https://www.healthaffairs.org/content/forefront/future-investment-pepfar-understanding-pepfar-s-multiple-economic-health-and-diplomatic; Crown W, Hariharan D, Kates J, Gaumer G, Jordan M, Hurley C, et al. “Analysis of economic and educational spillover effects in PEPFAR countries.” PLoS ONE 2023; 18(12): e0289909. Available at: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0289909; ; Gaumer G, Crown WH, Kates J, et al. “Analysis of maternal and child health spillover effects in PEPFAR countries.” BMJ Open 2023;13: e070221. Available at: https://bmjopen.bmj.com/content/13/12/e070221.long. ↩︎
“The Future of Investment In PEPFAR: Understanding PEPFAR’s Multiple Economic, Health, And Diplomatic Impacts”, Health Affairs Blog, April 17, 2017. Available at: https://www.healthaffairs.org/content/forefront/future-investment-pepfar-understanding-pepfar-s-multiple-economic-health-and-diplomatic; Crown W, Hariharan D, Kates J, Gaumer G, Jordan M, Hurley C, et al. “Analysis of economic and educational spillover effects in PEPFAR countries.” PLoS ONE 2023; 18(12): e0289909. Available at: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0289909; ; Gaumer G, Crown WH, Kates J, et al. “Analysis of maternal and child health spillover effects in PEPFAR countries.” BMJ Open 2023;13: e070221. Available at: https://bmjopen.bmj.com/content/13/12/e070221.long.
[iii] Vogl T, Education and health in developing economies, Working Papers 1453, Princeton University, Woodrow Wilson School of Public and International Affairs, 2012; Wagner Z, Barofsky J, Sood N, “PEPFAR funding associated with an increase in employment among males in ten sub-Saharan African countries,” Health Affairs, 2015 Jun, 34(6): 946-953. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC4782769/; Piabuo S, Tieguhong J, “Health expenditure and economic growth – a review of the literature and an analysis between the economic community for central African states (CEMAC) and selected African countries,” Health Econ Rev, 2017 Dec, 7(23); Bloom D, Kuhn M, Prettner K, Health and economic growth, 2018, IZA DP No. 11939, available at: https://www.iza.org/publications/dp/11939/health-and-economic-growth; Collin M, Weil D, The effect of increasing human capital investment on economic growth and poverty: a simulation exercise, World Bank, WPS8590, 2018, available at: https://openknowledge.worldbank.org/handle/10986/30463. Remes J, Wilson M, Ramdorai A, How investing in health has a significant economic payoff for developing economies, Brookings, July 2020, available at: https://www.brookings.edu/blog/future-development/2020/07/21/how-investing-in-health-has-a-significant-economic-payoff-for-developing-economies/; Bloom D, Khoury A, Kufenko V, Prettner K, “Spurring economic growth through human development: research results and guidance for policymakers,” Population and Development Review, 2021 Jun, 47(2): 377-409; World Bank, Human Capital Project, available at: https://www.worldbank.org/en/publication/human-capital. ↩︎
This volatility appears to have been influenced by a subset of outlier countries; after removing these countries from the analysis, the results remain significant. ↩︎
Historically, a subset of countries receiving PEPFAR support had been required to prepare annual Country Operational Plans (COPs) which documented annual funding levels linked to results and served as budget and tracking tools. These were prepared by country teams who worked intensively to develop these plans in concert with headquarters at the State Department. ↩︎
Crown W, Hariharan D, Kates J, Gaumer G, Jordan M, Hurley C, Luan Y, Nandakumar A. (2023) “Analysis of economic and educational spillover effects in PEPFAR countries”. PLOS ONE 18(12): e0289909. https://doi.org/10.1371/journal.pone.0289909. ↩︎
Crown W, Stenoien D, Reid MJA, Kumar S, Kates J, Jordan M, Nandakumar A. “The Economic Impact of Lives Saved in PEPFAR Countries”, under review, BMJ Global Health. https://doi.org/10.12688/verixiv.2057.1 ↩︎

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State Health Coverage for Immigrants and Implications for Health Coverage and Care

Authors: Akash Pillai, Drishti Pillai, and Samantha Artiga

Published: May 19, 2026

As of 2024, there were 24 million noncitizen immigrants, including lawfully present and undocumented immigrants, living in the U.S. Noncitizen immigrants, particularly those who are undocumented, face significant barriers to accessing health coverage and care and are significantly more likely than citizens to be uninsured. These higher uninsured rates reflect more limited access to private coverage and eligibility restrictions for federally funded coverage options. Undocumented immigrants are not eligible for federally funded coverage options and lawfully present immigrants face eligibility restrictions for coverage. Under the 2025 reconciliation law there will be increased eligibility restrictions for many lawfully present immigrants for Medicaid and the Children’s Health Insurance Program (CHIP), subsidized Affordable Care Act (ACA) Marketplace coverage, and Medicare coverage.

Some states have taken up options in Medicaid and CHIP to expand coverage for lawfully present immigrants and/or established fully state-funded programs to fill gaps in coverage for immigrants. However, some states have recently made reductions to these programs due to budget pressures. On the other hand, a few states are considering how they can use state funded coverage to fill the gaps in coverage that will result from the reconciliation law eligibility restrictions. This brief provides an overview of state take-up of these options and fully state-funded health coverage programs for immigrants.

As of April 2026, 15 states, including DC, provide fully state-funded coverage for income-eligible children regardless of immigration status; seven states, including DC, provide fully state-funded coverage to some income-eligible adults regardless of status; and most states have taken up options in Medicaid and CHIP to expand coverage to lawfully present immigrant children and pregnant people. Six states, including DC, have recently scaled back their state funded coverage for adults. Two states have plans to expand state-funded coverage to fill gaps in coverage that will be created by the 2025 reconciliation law eligibility restrictions, and several other states have pending legislation to fill gaps.

Looking ahead, states may face increased challenges maintaining state-funded coverage programs, while at the same time there may be growing need for coverage due to new restrictions in federally funded coverage for lawfully present immigrants under the reconciliation law. More limited access to federally funded coverage as well as reductions in state-funded coverage programs will likely lead to increases in uninsured rates for immigrant families contributing to greater challenges accessing care and potentially worse health outcomes over the long-term. These changes could also have negative implications for the U.S. economy and workforce, where immigrant families make significant contributions.

Health Coverage for Immigrants

Lawfully present immigrants may qualify for federally funded coverage but face eligibility restrictions. For example, many must meet a five-year waiting period before qualifying for Medicaid or CHIP even if they meet other eligibility criteria. Lawfully present immigrants can purchase coverage through the ACA Marketplaces and may receive tax credits for this coverage without a waiting period. Lawfully present immigrants have been eligible for Medicare if they have the required work quarters and meet the disability or age requirements. Under the 2025 reconciliation law, eligibility for Medicaid and CHIP, subsidized Marketplace, and Medicare coverage will be limited to immigrants who are lawful permanent residents (LPRs) or green card holders, certain Cuban and Haitian entrants, and people residing in the U.S. as citizens of the Freely Associated (COFA) nations of the Marshall Islands, Micronesia, and Palau. The law also eliminates ACA Marketplace coverage for lawfully present immigrants with incomes less than 100% FPL effective January 1, 2026. States may also continue to cover lawfully residing children and pregnant immigrants under a Medicaid or CHIP option. These changes will result in some groups of lawfully present immigrants losing access to federally funded coverage, including refugees and asylees.

Undocumented immigrants are ineligible to enroll in federally funded coverage, including Medicaid or CHIP, the ACA Marketplaces, or Medicare. Medicaid payments for emergency services reimburse hospitals for emergency care they are obligated to provide to individuals who meet other Medicaid eligibility requirements (such as income), but who do not have an eligible immigration status, including undocumented immigrants as well as some lawfully present immigrants. These payments help cover costs to hospitals for providing emergency care to immigrants who remain ineligible for Medicaid but are not coverage for individuals. Emergency spending accounted for less than one percent of total Medicaid spending between fiscal years 2017 and 2023. The 2025 reconciliation law reduces the federal Medicaid matching rate provided to states for Emergency Medicaid services provided to expansion adults who would otherwise be eligible for Medicaid except for their immigration status to the regular matching rate starting October 1, 2026.

State Take-up of Optional Coverage for Lawfully Present Immigrants

Most states have taken up options in Medicaid and CHIP to expand coverage for lawfully residing children and/or pregnant people. In general, lawfully present immigrants must have a “qualified” immigration status to be eligible for Medicaid or CHIP, and many, including most lawful permanent residents or “green card” holders, must wait five years after obtaining qualified status before they may enroll even if they meet other eligibility requirements. Some immigrants, such as those with Temporary Protected Status, are lawfully present but do not have a qualified status and are not eligible to enroll in Medicaid or CHIP regardless of their length of time in the country. As noted, under the 2025 reconciliation law, eligibility will be further restricted to lawfully present immigrants who are LPRs or green card holders, certain Cuban and Haitan entrants, and people residing in the U.S. under COFA starting October 1, 2026. States can provide coverage to lawfully residing children and pregnant people without a five-year wait under the Immigrant Children’s Health Improvement Act (ICHIA) option. As of April 2026, 38 states, including DC, have taken up this option for children and 32 states, including DC, have elected the option for pregnant people (Figure 1). States may continue to provide this coverage under the 2025 reconciliation law. North Carolina enacted a Medicaid funding bill in April 2026 that codified the 2025 reconciliation law’s immigrant eligibility changes by limiting eligibility to coverage that the state is federally required to provide, starting October 1, 2026. This would eliminate ICHIA coverage as it is optional for states to provide. However, the Governor has called for the state legislature to reinstate this coverage and some state legislators have indicated that the cut was unintentional.

Federally-Funded Coverage of Lawfully Residing Immigrant Children and Pregnant People Without a 5-Year Waiting Period as of April 2026 (Choropleth map)

A total of 25 states, including DC, have extended coverage through the CHIP From-Conception-to-End-of-Pregnancy (FCEP) option, which provides prenatal care and pregnancy related benefits to eligible low-income children beginning from conception to end of pregnancy regardless of their parent’s citizenship or immigration status (Figure 2). While other pregnancy-related coverage in Medicaid and CHIP requires 60 days of postpartum coverage, the CHIP FCEP option does not include this coverage. However, some states that took up this option provide postpartum coverage through a CHIP health services initiative or using state-only funding. Eleven of the states that have implemented the FCEP option (California, Colorado, Connecticut, Illinois, Maine, Massachusetts, Minnesota, New York, Oregon, Rhode Island, and Washington) have used state funding or CHIP health services initiatives to extend postpartum coverage to 12 months to align with the Medicaid extension established by the American Rescue Plan Act. Maryland extends coverage for four months postpartum, and Alabama, Texas, Virginia, and DC extend coverage for 60 days postpartum using CHIP health services initiatives.

State Take-Up of CHIP From-Conception-to-End-of-Pregnancy (FCEP) Option to Cover Pregnant People Regardless of Immigration Status as of April 2026 (Choropleth map)

Fully State-Funded Coverage

Beyond state take-up of options in Medicaid and CHIP for lawfully present immigrants, some states provide fully state-funded coverage to fill gaps in coverage for immigrants. States vary in the eligibility and scope of benefits offered through these coverage programs. These programs extend coverage to lawfully present immigrants who are in the five-year waiting period for Medicaid or CHIP or do not have “qualified status” and are ineligible for federally funded coverage as well as undocumented immigrants. These programs also extend coverage to Deferred Action for Childhood Arrivals (DACA) recipients who are not considered lawfully present for purposes of eligibility for federally funded health coverage programs. While the Biden administration had published regulations to extend Marketplace coverage to DACA recipients, new regulations by the Trump administration and the 2025 reconciliation law excluded them from coverage.

As of April 2026, 15 states, including DC, provide comprehensive state-funded coverage for children regardless of immigration status, with one state (Colorado) planning to scale back coverage due to budget pressures (Figure 3). These states include California, Colorado, Connecticut, Illinois, Maine, Massachusetts, Minnesota, New Jersey, New York, Oregon, Rhode Island, Utah, Vermont, Washington, and DC. Three of these states (Colorado, New Jersey, and Vermont) also provide state-funded coverage to income-eligible pregnant people regardless of immigration status, with Vermont extending this coverage for 12 months postpartum. Colorado plans to implement rollbacks to their state-funded coverage program for children and pregnant people, including capping enrollment and limiting certain benefits, starting January 2027 due to funding constraints.

State-Funded Coverage for Children and Pregnant People Regardless of Immigration Status as of April 2026 (Choropleth map)

As of April 2026, seven states, including DC, have also expanded fully state-funded coverage to at least some income-eligible adults regardless of immigration status (Figure 4). These states include California, Colorado, DC, Illinois, New York, Oregon, and Washington. In some cases, coverage is limited to certain age groups, and several states have closed new enrollment. Some additional states cover some income-eligible adults who are not otherwise eligible due to immigration status using state-only funds but limit coverage to specific groups, such as lawfully present immigrants who are in the five-year waiting period for Medicaid coverage, or provide more limited benefits.

Six states, including DC, have recently eliminated or reduced or plan to scale back state-funded coverage due to budget pressures.

California previously extended state-funded coverage to all income-eligible adults regardless of immigration status but implemented coverage reductions for adults 19 and older who are not pregnant or former foster youth under age 26 due to funding constraints, including: closing enrollment starting January 2026, ending dental benefits starting July 2026, and charging $30 monthly premiums for adults ages 19-59 starting July 2027. The California governor’s 2026-27 budget also proposes applying Medicaid policy changes included in the 2025 reconciliation law (work requirements and more frequent six-month renewals) to adults enrolled in the state-funded coverage program.
Colorado allows adults regardless of immigration status to obtain Marketplace coverage through OmniSalud using a section 1332 waiver. Colorado uses state funds to provide plans with $0 premiums through SilverEnhanced Savings. The state reduced the enrollment cap for the program from 12,000 in 2025 to 6,700 people due to funding constraints. As noted above, the state also plans to cap enrollment and limit benefits for children and pregnant people beginning in January 2027 due to funding constraints.
DC provides health coverage to low-income adults 21 and older regardless of immigration status through its longstanding locally funded Healthcare Alliance program. However, DC closed enrollment to adults ages 26 and older and reduced income limits for adults 21 and older starting October 2025. DC plans to end coverage for all adults ages 21 and older by October 2027.
Illinois extended state-funded coverage to low-income individuals ages 65 and older regardless of immigration status through its Health Benefits for Immigrant Seniors (HBIS) program in December 2020 but new enrollment has been paused since 2023. Illinois previously extended coverage to low-income immigrants ages 42 to 64 regardless of immigration status through the Health Benefits for Immigrant Adults (HBIA) program in 2022, but ended HBIA coverage on July 2025 due to funding constraints.
Minnesota extended state-funded health coverage to income-eligible adults 18 and older regardless of immigration status in January 2025 but ended this coverage starting January 2026 due to funding constraints.
Washington uses state funds to provide Marketplace coverage with premium subsidies to individuals with incomes up to 250% FPL regardless of immigration status through Cascade Care using a section 1332 waiver, but funding is limited. In July 2024, Washington extended state-funded health coverage to individuals with incomes up to 138% FPL regardless of immigration status, but the state closed enrollment due to funding constraints and proposes to move current and future enrollees to a limited benefit health care program.

In addition to these states, Maryland also delayed plans to allow income-eligible individuals to purchase Marketplace coverage without subsidies regardless of immigration status to 2028 due to changes in the 2025 reconciliation law that will require additional administrative resources to implement.

State-Funded Coverage for Adults Regardless of Immigration Status as of April 2026 (Choropleth map)

Two states (New Mexico and New York) are planning to provide fully state-funded coverage to lawfully present immigrants that will lose Medicaid and ACA Marketplace coverage due to eligibility restrictions in the 2025 reconciliation law. New Mexico plans to use state funds to cover lawfully present immigrants losing Medicaid and ACA Marketplace Coverage in addition to DACA recipients. The New York governor’s 2026-27 budget proposes using state funds to cover lawfully present immigrants losing Medicaid coverage. The state will also use state funds to cover income-eligible lawfully present immigrants losing federally-subsidized health coverage through the Essential Plan. Under a longstanding court ruling, New York is required to provide state-funded coverage to lawfully present immigrants who would be eligible for Medicaid if not for their immigration status. Legislation introduced in New York and several other states, including California, Illinois, and Washington, would expand state-funded health coverage for immigrants to help fill gaps created by the reconciliation law; however, it is uncertain these bills will be enacted.

Impact of State Coverage Expansions on Health Care Access and Use

While coverage expansions for immigrants increase spending, research suggests that they reduce uninsured rates, increase health care use, and improve health outcomes. Data from the KFF/New York Times 2025 Survey of Immigrants show that immigrant adults who live in states that provide more expansive coverage, including the ACA Medicaid expansion for low-income adults overall and immigrant coverage expansions, are about half as likely to be uninsured compared with those living in states with less expansive policies (11% vs. 23%). Other research shows that coverage expansions for immigrant children increase access to health care and are associated with improved health outcomes. A study found that eliminating the five-year wait for Medicaid or CHIP was associated with a decline in uninsured rates among lawfully present foreign-born children in states without state-funded health care programs. California’s 2016 expansion to low-income children regardless of immigration status was associated with a 34% decline in uninsurance rates, and the state’s expansion to all adults was associated with an increase in health coverage among immigrant adults ages 50 and older. Similarly, a study found that children who reside in states that have expanded coverage to all children regardless of immigration status were less likely to be uninsured, to forgo medical or dental care, and to go without a preventive health visit than children residing in states that have not expanded coverage. Another study found that immigrant children residing in states with more expansive health coverage policies were more likely to have uninterrupted health coverage and a usual source of primary care than those residing in states with less expansive health coverage policies. Research has also found that expanding Medicaid coverage to pregnant people regardless of immigration status is associated with higher rates of prenatal care and improved birth outcomes, while more restrictive state coverage policies were associated with reduced postpartum care utilization.

Children in Immigrant Families: Key Facts on Health Coverage and Care

Authors: Drishti Pillai, Akash Pillai, and Samantha Artiga

Published: May 19, 2026

Introduction

One in four children aged 18 and under living in the U.S. has at least one immigrant parent. Policies undertaken by the Trump administration and Congress aimed at restricting access to health coverage and care for immigrants as well as the significant increase in immigration enforcement activities could have significant implications for the health and well-being of these children, the vast majority of whom are citizens.

This brief provides key data on socioeconomic characteristics and health coverage among children (aged 18 and under) of immigrants based on KFF analysis of 2024 American Community Survey data. It also examines potential implications of recent policies and actions on the health and well-being of children in immigrant families drawing on KFF survey data from Fall 2025.

Children in Immigrant Families

One in four children aged 18 and under in the U.S. has an immigrant parent, and the vast majority of these children are U.S. citizens. As of 2024, close to 20 million, or one in four (26%), children in the U.S. had an immigrant parent (Figure 1). This includes about one in ten (12%) who are citizen children with a noncitizen parent, a similar share (11%) who are citizen children with a naturalized citizen parent, and 3% who are noncitizen children. The share of children with an immigrant parent varies significantly by state, ranging from about 3% in West Virginia to about 45% in California.

About One in Four Children in the U.S. Has an Immigrant Parent (Pie Chart)

Most children of immigrants live in households with a full-time worker regardless of parental citizenship status; however, children with a noncitizen parent are more likely than children with citizen parents to live in lower income households. More than eight in ten citizen children live in a household with a full-time worker across parental citizenship statuses, and over three in four (77%) noncitizen children live in a household with a full-time worker (Figure 2). However, noncitizen children (34%) and citizen children with a noncitizen parent (26%) are more likely than those with U.S.-born parents (19%) and naturalized citizen parents (13%) to live in lower income households with annual incomes of less than $40,000. Lower household income among children of noncitizen immigrants reflects noncitizen immigrants’ disproportionate employment in lower-wage jobs in industries such as construction, agriculture, and service, which are less likely to provide employer-sponsored insurance.

Most Children Live With At Least One Full-Time Worker But Children of Noncitizen Immigrants Have Lower Incomes (Split Bars)

Uninsured rates among children remain relatively low, but those with a noncitizen parent or who are noncitizens are more likely to be uninsured than those with citizen parents. As of 2024, the uninsured rate was 9% among citizen children with noncitizen parent(s) and 26% among the small share of children who are noncitizens compared to 5% of citizen children with citizen parents (Figure 3). Medicaid and the Children’s Health Insurance Program (CHIP) offer broad coverage to lower-income children. However, lawfully present immigrant children may face eligibility restrictions on coverage, including a five-year waiting period, and the small number of children who are undocumented are ineligible for Medicaid, CHIP, and other federally funded coverage options. Moreover, parents may be reluctant to enroll citizen or lawfully present children in coverage even if they are eligible due to immigration-related fears or have difficulty enrolling their children due to confusion about eligibility rules or language barriers. States have an option to expand Medicaid or CHIP coverage for lawfully residing children without a five-year waiting period, which was taken up by 38 states, including DC, as of April 2026. Additionally, as of April 2026, 15 states, including DC, provide comprehensive fully state-funded coverage for lower income children regardless of immigration status with one state (Colorado) planning to scale back coverage due to budget pressures (Figure 4).

Uninsured Rates Among Most Children Are Low, but Noncitizen Children are More Likely to be Uninsured (Column Chart)

State-Funded Coverage for Children Regardless of Immigration Status as of April 2026 (Choropleth map)

Potential Implications of Recent Policies

Since taking office, the Trump administration has taken a range of actions focused on increasing immigration enforcement, restricting immigration, and limiting immigrants’ access to health care and other services. These actions include an Executive Order (EO) issued in January 2025 to end birthright citizenship, a right guaranteed under the 14^th amendment of the U.S. Constitution, for the children of some noncitizen parents, including those who may be undocumented as well as lawfully present individuals on non-immigrant visas (for example, certain work visas). Implementation of the EO is blocked as of April 2026 under court order, with the Supreme Court expected to rule on it in June or July 2026. Ending birthright citizenship for the children of some immigrants would have broad implications, including limiting their access to health coverage. Moreover, the 2025 reconciliation law will further restrict lawfully present immigrants’ access to health coverage, which is expected to increase the number of uninsured. The combination of growing immigration-related fears among immigrant families, increased restrictions on coverage for lawfully present immigrants, and growing financial pressures will likely negatively impact health and health care for children in immigrant families, including U.S. citizens, and could have longer-term impacts on the U.S. workforce.

Increased immigration-related worries will likely have long-term negative impacts on children’s physical and mental health. The American Academy of Pediatrics has identified fear of parental deportation and separation as a toxic stress, which can adversely affect a child’s development, leading to lifelong negative effects on physical, mental, and behavioral health. KFF survey data from Fall 2025 show that over one in four (27%) immigrant parents say their children have expressed worries about something bad happening to someone in their family due to immigration status, with this share rising to six in ten of likely undocumented parents. These worries have negative impacts on children’s health and well-being. About one in five (18%) immigrant parents say a child has experienced problems sleeping or eating (14%), changes in school performance or attendance (12%), or behavior problems (12%) due to worries about a family member’s immigration status (Figure 5). This share rises to nearly half among parents who are likely undocumented.

About One in Five Immigrant Parents Report Negative Impacts on the Well-Being of Their Child Due to Immigration-Related Worries Since January 2025 (Split Bars)

Children in immigrant families may face greater barriers to accessing health care due to increased restrictions on health coverage and immigration-related fears. The Trump administration and Congress have enacted a number of policy changes aimed at reducing access to health coverage and care for immigrants including but not limited to new restrictions on eligibility for health coverage for lawfully present immigrants under 2025 reconciliation law, proposed changes to public charge rules, sharing of noncitizen Medicaid enrollee data with immigration enforcement officials, as well as restrictions on access to community health centers and other social services. These changes are likely to result in coverage losses for immigrants, including among citizen children in immigrant families. Coverage losses among immigrant parents may lead to losses among their children as research shows that parental coverage impacts children’s access to health coverage and care. Moreover, growing immigration-related fears have made families more reluctant to access programs and services even if they are eligible. KFF survey data from Fall 2025 show that about one in ten (11%) immigrants say they stopped participating in government programs that help pay for food, housing, or health care since January 2025 due to immigration-related fears. Further, one in seven (14%) immigrant parents, rising to over four in ten (43%) of likely undocumented immigrant parents, say that their child missed, skipped, or delayed health care in the past 12 months due to immigration-related concerns (Figure 6).

Three in Ten Immigrant Parents Say That Their Child Skipped or Delayed Health Care in the Past 12 Months (Split Bars)

Beyond impacts on the health and well-being of immigrant families, the current environment may negatively impact the U.S. workforce given the significant role immigrants and their adult children play, especially in health care. Adult children of immigrants have higher educational attainment and incomes than their parents as well as the adult children of U.S.-born parent(s) and play an outsized role in the U.S. health care workforce. Based on KFF analysis of 2024 federal survey data, adult children of immigrants ages 18 and older make up about 7%, or over 1.4 million, of the total health care workforce, including 11% of physicians, surgeons, and other practitioners. Moreover, immigrants and their adult children contribute billions of dollars in federal, state, and local taxes each year and help to create jobs for U.S.-born people. Research further shows that adult children of immigrants contribute more in taxes on average than their parents or the rest of the U.S.-born population and that their fiscal contributions exceed their costs associated with health care, education, and other social services. As such, restrictions in immigration could have long-term implications for the U.S. workforce and economy.

Key Facts on Health Coverage of Immigrants

Published: May 19, 2026

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Summary

As of 2024, there were about 50 million immigrants residing in the U.S., including 24 million noncitizen immigrants and 26 million naturalized citizens, who each accounted for about 7% and 8% of the total population, respectively. Noncitizens include lawfully present and undocumented immigrants. Many individuals live in mixed immigration status families that may include lawfully present immigrants, undocumented immigrants, and/or citizens. One in four (26%) children has an immigrant parent, including over one in ten (12%) who are citizen children with at least one noncitizen parent.

This fact sheet provides an overview of health coverage for immigrants based on data from the KFF/New York Times 2025 Survey of Immigrants and discusses implications of the current policy and immigration enforcement environment for their health and health care. It shows:

Although the majority of uninsured people are citizens, noncitizen immigrant adults, particularly likely undocumented immigrants, are significantly more likely to report being uninsured than citizens. As of 2025, almost half (46%) of likely undocumented immigrant adults and one in five (21%) lawfully present immigrant adults reported being uninsured compared to less than one in ten naturalized citizen (7%) and U.S.-born citizen (6%) adults. These higher uninsured rates reflect a combination of more limited access to private coverage due to working in jobs less likely to offer health coverage and exclusions and limitations on eligibility for federally funded coverage options, including Medicaid, Affordable Care Act (ACA) Marketplace, and Medicare coverage.
Reflecting their higher uninsured rate, noncitizen immigrants are more likely than citizens to report barriers to accessing health care and skipping or postponing care. Immigrants have lower health care expenditures than their U.S.-born counterparts reflecting lower use of care due to a combination of them being younger and healthier and facing more barriers to accessing care.
Some states have expanded access to health coverage for immigrants through Medicaid options for lawfully residing immigrant children and pregnant people and fully state-funded programs, but some states have rolled back this coverage since 2025.
Recent policy changes will further restrict lawfully present immigrants’ access to health coverage, and immigrants across all statuses have become more fearful about accessing health coverage and care due to increased immigration enforcement actions under the Trump Administration.

Overview of Immigrants

Based on federal survey data, as of 2024, there were about 50 million immigrants residing in the U.S., including 24 million noncitizen immigrants and 26 million naturalized citizens, who each accounted for about 7% and 8% of the total population, respectively (Figure 1). More recent estimates show that the number of immigrants in the U.S. has since been declining, with the population declining by about 1.4 million immigrants between January 2025 and June 2025. KFF estimates for this analysis are based on the American Community Survey, the latest year of data for which is 2024, and thereby don’t reflect population changes since 2025. Estimates suggest that about half of noncitizens were lawfully present immigrants, such as lawful permanent residents (“green card” holders) and those with a valid work or student visa, while the remaining half were undocumented immigrants, who may include individuals who entered the country without authorization, individuals who entered the country lawfully and stayed after their visa or status expired, or individuals who lost their lawful status due to recent policy changes like immigrants with temporary protected status (TPS) from certain countries.¹ The underlying estimates used in this analysis also include some immigrants with temporary deportation protections in the undocumented immigrant population. Many individuals live in mixed immigration status families that may include lawfully present immigrants, undocumented immigrants, and/or citizens. Close to 20 million, or one in four (26%), children living in the U.S. had an immigrant parent as of 2024, and the majority of these children were citizens (Figure 2). About 9 million, or 12%, were citizen children with at least one noncitizen parent.

About 50 Million Immigrants Resided in the U.S. as of 2024 (Pie Chart)

Uninsured Rates by Immigration Status

The KFF/New York Times 2025 Survey of Immigrants, a nationally representative survey of immigrants, provides data on health coverage of immigrant adults and experiences accessing health care, including by immigration status.

Although the majority of uninsured people are citizens, noncitizen immigrant adults, particularly likely undocumented immigrants, are significantly more likely to report being uninsured than citizens. As of 2025, almost half (46%) of likely undocumented immigrant adults and one in five (21%) lawfully present immigrant adults reported being uninsured compared to less than one in ten naturalized citizen (7%) and U.S.-born citizen (6%) adults (Figure 3).

About One in Five Lawfully Present Immigrant Adults and Nearly Half of Likely Undocumented Immigrant Adults Report Being Uninsured (Bar Chart)

Reflecting their higher uninsured rates, noncitizen immigrants, especially those who are likely undocumented, are more likely than citizens to report barriers to accessing health care and skipping or postponing care. Research shows that having insurance makes a difference in whether and when people access needed care. Those who are uninsured often delay or go without needed care, which can lead to worse health outcomes over the long-term that may ultimately be more complex and expensive to treat. Overall, likely undocumented immigrant adults are more likely than lawfully present immigrant adults and naturalized citizen adults to report not having a usual source of care other than an emergency room and skipping or postponing care in the past 12 months (Figure 4).

Likely Undocumented Immigrant Adults are More Likely Than Lawfully Present Immigrant Adults and Naturalized Citizen Adults to Report Barriers to Health Care (Grouped column chart)

Research also shows that immigrants have lower health care use and expenditures than their U.S.-born counterparts and help to subsidize health care for U.S.-born citizens. Overall, research shows that immigrants, including lawfully present and undocumented immigrants, use less health care than U.S.-born citizens. Lower use of health care among immigrants likely reflects a combination of them being younger and healthier than their U.S.-born counterparts as well as them facing increased barriers to care including a higher uninsured rate, language access challenges, confusion, and immigration-related fears. Reflecting their lower use of health care, immigrants have lower health care expenditures than their U.S.-born counterparts. 2023 Medical Expenditure Panel Survey data show that, on average, annual per capita health care expenditures for immigrants are about 30% lower than those for U.S.-born citizens ($5,453 vs. $7,838).² Research further finds that, because immigrants, especially undocumented immigrants, have lower health care use despite contributing billions of dollars in insurance premiums and taxes, they help subsidize the U.S. health care system and offset the costs of care incurred by U.S.-born citizens.

Access to Health Coverage Among Immigrants

Private Coverage

Despite high rates of employment, noncitizen immigrants have limited access to employer-sponsored coverage. Although most noncitizen immigrant adults report being employed, they are significantly more likely than citizens to report being lower income (household income less than $40,000) (Figure 5). This pattern reflects disproportionate employment of noncitizen immigrants in low-wage jobs and industries that are less likely to offer employer-sponsored coverage. Given their lower incomes, noncitizen immigrants also face challenges affording employer-sponsored coverage when it is available or through the individual market.

Most Immigrant Adults are Employed but Noncitizen Immigrant Adults Have Lower Household Incomes (Grouped column chart)

Federally Funded Coverage

Some lawfully present immigrants may qualify for Medicaid and the Children’s Health Insurance Program (CHIP) subject to eligibility restrictions. Prior to the 2025 reconciliation law, lawfully present immigrants who have a “qualified” immigration status have been eligible for Medicaid or CHIP if they meet other eligibility requirements such as income. Qualified immigrants are a subset of lawfully present immigrants and generally include lawful permanent residents, refugees, asylees, survivors of trafficking, Compact of Free Association (COFA) migrants, Cuban/Haitian entrants, members of federally recognized tribes, and some parolees (Appendix A). Many immigrants with qualified status, including most lawful permanent residents or “green card” holders, must wait five years after obtaining qualified status before they may enroll. Some immigrants with qualified status, such as refugees and asylees, as well as citizens of COFA nations, do not have to wait five years before enrolling. Some immigrants, such as those with temporary protected status, are lawfully present but do not have a qualified status and are not eligible to enroll in Medicaid or CHIP regardless of their length of time in the country (Appendix A). Once changes in the 2025 reconciliation law go into effect, fewer qualified immigrants will be eligible for Medicaid and CHIP (see below).

For children and pregnant people, states can eliminate the five-year wait and extend coverage to some lawfully present immigrants without a qualified status. As of April 2026, 38 states, including DC, have taken up this option for children and 32 states, including DC, have elected the option for pregnant individuals. A total of 25 states, including DC, have also extended coverage to pregnant people regardless of immigration status through the CHIP From-Conception-to-End-of-Pregnancy (FCEP) option. States have the option in CHIP to provide prenatal care and pregnancy related benefits to eligible low-income children beginning from conception to end of pregnancy regardless of their parent’s citizenship or immigration status. While other pregnancy-related coverage in Medicaid and CHIP requires 60 days of postpartum coverage, the CHIP FCEP option does not include this coverage. However, some states that took up this option provide postpartum coverage through a CHIP health services initiative or using state-only funding. Eleven of the states that have implemented the FCEP option (California, Colorado, Connecticut, Illinois, Maine, Massachusetts, Minnesota, New York, Oregon, Rhode Island, and Washington) have used state funding or CHIP health services initiatives to extend postpartum coverage to 12 months to align with the Medicaid extension established by the American Rescue Plan Act. Maryland extends coverage for four months postpartum, and Alabama, Texas, Virginia, and DC extend coverage for 60 days postpartum using CHIP health services initiatives.

Lawfully present immigrants can purchase coverage through the ACA Marketplace and, like citizens, may receive tax credits to help pay for premiums and cost sharing that vary on a sliding scale based on income. Generally, these tax credits are available to people with incomes starting from 100% of the federal poverty level (FPL) who are not eligible for other affordable coverage. In addition, lawfully present immigrants with incomes below 100% FPL had been eligible to receive tax credits if they were ineligible for Medicaid based on immigration status, for example due to being in the five-year waiting period for Medicaid or CHIP or because they did not have a “qualified” status. However, this coverage was eliminated effective January 1, 2026, under the 2025 reconciliation law (see below).

Individuals with Deferred Action for Childhood Arrivals (DACA) status are not considered lawfully present for purposes of health coverage eligibility and remain ineligible despite having a deferred action status, which is otherwise considered a lawfully present status. The Biden administration published regulations in 2024 that changed the definition of lawfully present to include DACA recipients for purposes of eligibility to purchase coverage through the ACA Marketplace and to receive tax credits to help pay for premiums and cost sharing, but this change faced legal challenges. The Trump administration published regulations in June 2025 that once again made DACA recipients in all states and DC ineligible for ACA Marketplace coverage. Most states terminated coverage for enrolled DACA recipients on September 30, 2025.

Lawfully present immigrants also can qualify for Medicare subject to certain restrictions. Specifically, lawfully present immigrants must have sufficient work history to qualify for premium-free Medicare Part A. If they do not have sufficient work history, they may qualify if they are lawful permanent residents and have resided in the U.S. for five years immediately prior to enrolling in Medicare, although they must pay premiums to enroll in Part A. Once changes in the 2025 reconciliation law go into effect, fewer lawfully present immigrants will be eligible for Medicare (see below).

Undocumented immigrants are not eligible to enroll in federally funded coverage including Medicaid, CHIP, or Medicare or to purchase coverage through the ACA Marketplaces. Medicaid payments for emergency services may be made to hospitals on behalf of individuals who are otherwise eligible for Medicaid but for their immigration status. These include lawfully present immigrants who are subject to a five-year waiting period for Medicaid, lawfully present immigrants who are not eligible for Medicaid, and undocumented immigrants. These payments may help cover the costs for emergency care provided to immigrants who remain ineligible for Medicaid but are not coverage for individuals. Much of Emergency Medicaid spending goes towards labor and delivery costs and Emergency Medicaid spending represented less than 1% of total Medicaid spending in fiscal year 2023.

Eligibility Restrictions for Immigrants Under the 2025 Reconciliation Law

The 2025 reconciliation law will further limit the groups of lawfully present immigrants who may qualify for federally funded coverage, including Medicaid and CHIP, the ACA Marketplace, and Medicare. Specifically, effective October 1, 2026, Medicaid and CHIP eligibility will be limited to lawful permanent residents (LPRs or “green card” holders), Cuban and Haitian entrants, people residing in the U.S. under COFA, and lawfully residing children and pregnant immigrants in states that cover them under the Medicaid and/or CHIP option (Table 1). This will result in some groups of lawfully present immigrants losing eligibility, including refugees and asylees without green cards. The law also eliminates ACA Marketplace coverage for lawfully present immigrants with incomes less than 100% FPL effective January 1, 2026, and limits subsidized ACA Marketplace coverage to lawfully present immigrants who are LPRs, Cuban and Haitian entrants, and people residing in the U.S. under COFA beginning January 1, 2027. As a result, a broader group of lawfully present immigrants will lose access to subsidized Marketplace coverage, including refugees and asylees without green cards, people with TPS, and individuals on work visas, among others. Medicare eligibility also will be limited to lawfully present immigrants who are LPRs, Cuban and Haitian entrants, and people residing in the U.S. under COFA, eliminating eligibility for similar groups. Current beneficiaries subject to the new restrictions will lose coverage no later than 18 months from the enactment of the legislation (January 4, 2027).

The Congressional Budget Office (CBO) estimates that the health coverage eligibility restrictions for lawfully present immigrants in the 2025 reconciliation law will result in 1.4 million lawfully present immigrants becoming uninsured by 2034. This includes 100,000 who will lose coverage due to eligibility restrictions for Medicaid and CHIP, 1.2 million who will lose coverage due to eligibility restrictions for ACA Marketplace coverage, and another 100,000 who will lose coverage due to eligibility restrictions in Medicare by 2034. The CBO also estimates that these coverage restrictions will result in $131 billion in reduced federal spending and $4.8 billion in increased federal revenues by 2034.

State-Funded Coverage

Some states have established fully state-funded programs to provide health coverage to some groups of low-income immigrants who remain ineligible for federally funded coverage options. This coverage is sometimes limited to certain groups, such as children, and varies in scope. While some programs offer benefits similar to Medicaid coverage, these programs are separate state programs that are not part of the Medicaid program. Several states have recently scaled back their state-funded coverage due to budget pressures.

As of April 2026, 15 states, including DC, provide comprehensive state-funded coverage to children regardless of immigration status, with one state (Colorado) planning to scale back coverage due to budget pressures (Figure 6). These states include California, Colorado, Connecticut, Illinois, Maine, Massachusetts, Minnesota, New Jersey, New York, Oregon, Rhode Island, Utah, Vermont, Washington, and DC. Three of these states (Colorado, New Jersey, and Vermont) also provide state-funded coverage to income-eligible pregnant people regardless of immigration status, with Vermont extending this coverage for 12 months postpartum. Colorado plans to implement rollbacks to their state-funded coverage program for children and pregnant people, including capping enrollment and limiting certain benefits, starting January 2027 due to funding constraints.

As of April 2026, seven states, including DC, have also expanded fully state-funded coverage to some income-eligible adults regardless of immigration status (Figure 7). These states include California, Colorado, DC, Illinois, New York, Oregon, and Washington. In some cases, coverage is limited to certain age groups, and several states have closed new enrollment. Some additional states cover some income-eligible adults who are not otherwise eligible due to immigration status using state-only funds but limit coverage to specific groups, such as lawfully present immigrants who are in the five-year waiting period for Medicaid coverage, or provide more limited benefits.

Six states, including DC, have recently eliminated or reduced or plan to scale back state-funded coverage due to budget pressures.

California previously extended state-funded coverage to all income-eligible adults regardless of immigration status but implemented coverage reductions for adults 19 and older who are not pregnant or former foster youth under age 26 due to funding constraints, including: closing enrollment starting January 2026, ending dental benefits starting July 2026, and charging $30 monthly premiums for adults ages 19-59 starting July 2027. The California governor’s 2026-27 budget also proposes applying Medicaid policy changes included in the 2025 reconciliation law (work requirements and more frequent six-month renewals) to adults enrolled in the state-funded coverage program.
Colorado allows adults regardless of immigration status to obtain Marketplace coverage through OmniSalud using a section 1332 waiver. Colorado uses state funds to provide plans with $0 premiums through SilverEnhanced Savings. The state reduced the enrollment cap for the program from 12,000 in 2025 to 6,700 people due to funding constraints. As noted above, the state also plans to cap enrollment and limit benefits for children and pregnant people beginning in January 2027 due to funding constraints.
DC provides health coverage to low-income adults 21 and older regardless of immigration status through its longstanding locally funded Healthcare Alliance program. However, DC closed enrollment to adults ages 26 and older and reduced income limits for adults 21 and older starting October 2025. DC plans to end coverage for all adults ages 21 and older by October 2027.
Illinois extended state-funded coverage to low-income individuals ages 65 and older regardless of immigration status through its Health Benefits for Immigrant Seniors (HBIS) program in December 2020 but new enrollment has been paused since 2023. Illinois previously extended coverage to low-income immigrants ages 42 to 64 regardless of immigration status through the Health Benefits for Immigrant Adults (HBIA) program in 2022, but ended HBIA coverage on July 2025 due to funding constraints.
Minnesota extended state-funded health coverage to income-eligible adults 18 and older regardless of immigration status in January 2025 but ended this coverage starting January 2026 due to funding constraints.
Washington uses state funds to provide Marketplace coverage with premium subsidies to individuals with incomes up to 250% FPL regardless of immigration status through Cascade Care using a section 1332 waiver. In July 2024, Washington extended state-funded health coverage to individuals with incomes up to 138% FPL regardless of immigration status, but the state closed enrollment due to funding constraints and proposes to move current and future enrollees to a limited benefit health care program.

Data suggest that state coverage expansions for immigrants make a difference in their health coverage and health care access and use. The KFF/New York Times 2025 Survey of Immigrants shows that immigrant adults residing in states with more expansive coverage policies for immigrants are less likely to be uninsured compared to their counterparts living in states with less expansive coverage policies. Other research shows that coverage expansions for immigrant children increase access to health care and are associated with improved health outcomes. A study found that eliminating the five-year wait for Medicaid or CHIP was associated with a decline in uninsured rates among lawfully present foreign-born children in states without state-funded health care programs. California’s 2016 expansion to low-income children regardless of immigration status was associated with a 34% decline in uninsurance rates, and the state’s expansion to all adults was associated with an increase in health coverage among immigrant adults ages 50 and older. Similarly, a study found that children who reside in states that have expanded coverage to all children regardless of immigration status were less likely to be uninsured, to forgo medical or dental care, and to go without a preventive health visit than children residing in states that have not expanded coverage. Another study found that immigrant children residing in states with more expansive health coverage policies were more likely to have uninterrupted health coverage and a usual source of primary care than those residing in states with less expansive health coverage policies. Research has also found that expanding Medicaid coverage to pregnant people regardless of immigration status is associated with higher rates of prenatal care and improved birth outcomes, while more restrictive state coverage policies were associated with reduced postpartum care utilization.

Enrollment Barriers

Among immigrants who are eligible for coverage, many remain uninsured because of a range of enrollment barriers, including fears around immigration-status and data privacy. Trump administration immigration policy changes and increased enforcement efforts are contributing to growing fears among immigrant families and increased reluctance to access health coverage and care for themselves and/or their children. The share of immigrant adults who say they personally worry that they or a family member could be detained or deported has increased significantly in 2025 (41%) as compared to 2023 (26%). As of 2025, over one in ten (12%) immigrant adults also report avoiding applying for government assistance as compared to 8% in 2023 and 29% report skipping or postponing health care as compared to 22% in 2023. Further, about half (51%) of immigrant adults overall and about eight in ten (78%) of those who are likely undocumented say they are “somewhat” or “very” concerned about health care providers sharing information about immigration status with immigration enforcement officials, a fear that could be further exacerbated following the public notice of CMS’s new Medicaid data sharing policy with ICE.

Appendix

Appendix Table A

Lawfully Present Immigrants by Qualified Status as of April 2026
Qualified Immigrant Category	Other Lawfully Present Immigrants
Lawful permanent resident (LPR or green card holder)	Granted Withholding of Deportation or Withholding of Removal, under the immigration laws or under the Convention against Torture (CAT)
Refugee	Individual with Non-Immigrant Status, includes worker visas, student visas, U-visa, and other visas, and citizens of Micronesia, the Marshall Islands, and Palau
Asylee	Temporary Protected Status (TPS)
Cuban/Haitian entrant	Deferred Enforced Departure (DED)
Paroled into the U.S. for at least one year	Deferred Action Status
Conditional entrant granted before 1980	Lawful Temporary Resident
Granted withholding of deportation	Administrative order staying removal issued by the Department of Homeland Security
Battered noncitizen, spouse, child, or parent	Resident of American Samoa
Victims of trafficking and their spouse, child, sibling, or parent or individuals with pending application for a victim of trafficking visa	Applicants for certain statuses
Member of a federally recognized Indian tribe or American Indian born in Canada	People with certain statuses who have employment authorization
Citizens of the Marshall Islands, Micronesia, and Palau who are living in one of the U.S. states or territories (referred to as Compact of Free Association or COFA migrants)	People with certain statuses who have employment authorization

Endnotes

The estimate of the total number of noncitizens in the U.S. is based on the 2024 American Community Survey (ACS) 1-year Public Use Microdata Sample (PUMS). The ACS data do not directly indicate whether an immigrant is lawfully present or not. KFF draws on the methods underlying the 2013 analysis by the State Health Access Data Assistance Center (SHADAC) and the recommendations made by Van Hook et. al. This approach uses the Survey of Income and Program Participation (SIPP) to develop a model that predicts immigration status; it then applies the model to ACS, controlling to state-level estimates of total undocumented population from Pew Research Center. For more detail on the immigration imputation used in this analysis, see Technical Appendix B. ↩︎
KFF analysis of 2023 Medical Expenditure Panel Survey full-year consolidated data file. ↩︎

What We Know So Far About 2026 ACA Marketplace Enrollment, Premiums, and Deductibles

Authors: Matt McGough, Jared Ortaliza, Justin Lo, and Cynthia Cox

Published: May 19, 2026

News Release: The Average Marketplace Deductible Grew by About $1,000 Per Person in 2026, With More Enrollees Shifting to Higher-Deductible Plans as Enhanced Tax Credits Expired

The enhanced premium tax credits established by the American Rescue Plan in 2021 and extended through 2025 by the Inflation Reduction Act significantly expanded Affordable Care Act (ACA) Marketplace affordability, driving enrollment to record highs. When those enhancements expired at the end of 2025, premium payments rose sharply for many enrollees, particularly those with incomes above 400% FPL who had been newly eligible for subsidies under the enhanced credits.

This analysis draws on data from the Centers for Medicare & Medicaid Services (CMS) and state-based Marketplace (SBM) Open Enrollment reports, as well as KFF survey data and individual market enrollment estimates from Wakely Consulting Group, to examine early indicators of how the expiration of enhanced premium tax credits has affected effectuated enrollment levels (i.e., enrollment among people who have paid their premiums), plan selections, and out-of-pocket costs in 2026.

Key Findings

Based on reports to date of sign-ups and premium payments, average monthly effectuated ACA Marketplace enrollment could fall to about 17.5 million people in 2026 and could be as low as 16.5 million people, down from 22.3 million people in 2025.
A disproportionately large share of the drop in sign-ups (27%) is among people with incomes just above the “subsidy cliff” (between 400%-500% FPL), despite this group making up just 3% of plan selections in 2025.
Premium payments from enrollees increased by an average of 58% from $113 to $178 per month. This is lower than the 114% increase KFF projected if everyone had stayed in the same plan because many people bought down to higher-deductible plans and because those just past the subsidy cliff with the steepest increases dropped ACA coverage at higher rates. Additionally, the 114% increase was among people receiving a tax credit whereas the 58% increase is among all consumers, including the most number who did not receive a tax credit in 2025.
Average ACA Marketplace deductibles increased by 37% (or $1,027 per person) to a record high of $3,786 in 2026. This is the steepest increase in deductibles ever seen in this market and largely reflects the shift from silver plans with reduced deductibles for lower-income enrollees to bronze plans with very high deductibles.

How Many People Are Leaving the ACA Marketplace?

Plan sign-ups fell by over a million to 23.1 million people during the 2026 Open Enrollment Period, the sharpest single-year drop since the ACA Marketplaces launched. However, Open Enrollment plan selection data alone do not capture the full scope of coverage loss — they measure how many people chose a plan or were automatically renewed, not how many ultimately paid their premiums for their coverage. Effectuated enrollment (the number of people who pay premiums and maintain effective coverage) is expected to fall even further than previous years as 2026 unfolds and many enrollees are unable to afford higher premium payments without enhanced tax credits, signaling significant mid-year attrition on top of already declining sign-ups.

According to an analysis of proprietary data on January premium payments by Wakely Consulting Group, approximately 86% of January 2026 enrollees in the individual market (of which over 90% was through ACA Marketplaces in 2025) paid their first month’s premium, with considerable variation across states. State-based exchanges, many of which have their own premium subsidy programs and more robust outreach efforts, tended to retain higher shares of enrollees than federally-facilitated exchanges.

Figure 1

Accounting for unpaid premiums, mid-year attrition, and other factors, Wakely estimates that average effectuated enrollment in the individual market could decline by between 17% and 26% in 2026 compared to the number of people who had effectuated coverage in 2025.

If applied to the ACA Marketplaces (which represent the vast majority of the individual insurance market in 2025), Wakely’s estimated enrollment decline could translate to an average of about 17.5 million enrollees over the course of 2025, which would represent a potential drop of 4.8 million people from the Marketplaces relative to 2025. To arrive at this estimate, the midpoint value of the range Wakely projects for individual market enrollment to decline by (21.5%) was applied to the average effectuated enrollment in the ACA Marketplace for the first 7 months of 2025. The low and high ends of the grey region in Figure 1 represent estimated effectuated enrollment if the endpoints of the range estimate (17% and 26%, respectively) were applied, ranging from a drop of 3.8 to 5.8 million.

Several other sources of information also point to a sharp decline in ACA effectuated enrollment associated with the expiration of enhanced premium tax credits. A decline of effectuated enrollment to 17.5 million aligns closely with the Congressional Budget Office’s previous projection of a roughly 25% ACA Marketplace contraction in enrollment following the expiration of the enhanced premium tax credits. CBO had projected average monthly ACA Marketplace enrollment of 16.9 million for 2026. Federal data reported on by NOTUS indicated a similarly steep increase in cancellations and terminations due to nonpayment, with about 19 million enrollees in the weeks following Open Enrollment.

Moreover, a KFF survey fielded in late February and early March of 2026 showed that 9% of 2025 Marketplace enrollees had become uninsured, 4% of returning ACA Marketplace enrollees had not yet paid their first month’s premiums, and that one in six (17%) returning enrollees were not confident they could afford their premiums for the entire year.

Recently published data from California, the nation’s largest state-based Marketplace, indicate that the cancellation rate among consumers who renewed coverage increased roughly six percentage points from 2025 such that nearly one in five renewing consumers actively terminated their plans before the end of March or had their coverage cancelled due to nonpayment.

Some states, like Maryland, expect that in the coming months, high premium payments will prompt even more people to either actively cancel their plans or be terminated due to nonpayment of premiums. These cancellations, whether active or passive, will drive a gap between the number of plan sign-ups and effectuated coverage.

Who Dropped ACA Marketplace Coverage?

While there is no publicly available effectuated enrollment data broken out by income, the plan selection data indicate that a large share of the drop in ACA Marketplace coverage is among consumers above 400% of the federal poverty level (FPL), where eligibility for premium tax credits ends (“subsidy cliff”). Under the enhanced premium subsidies, people with incomes above 400% of the poverty level had their premium payments for a benchmark silver plan capped at 8.5% of income. People with incomes above 400% up to 500% FPL, who represented just 3% of 2025 sign-ups, accounted for 27% of the drop in sign-ups from 2025 to 2026. Plan sign-ups for this group fell by 44% (over 321,000 people). Those with incomes above 500% FPL accounted for an additional 21% of the difference.

Overall, consumers with incomes known to be above the subsidy cliff made up just 7% of 2025 enrollment but nearly half (48%) of the decline in plan selections from 2025 to 2026. (There are about 1 million consumers for whom household income is unknown, so the actual share of consumers who are above the subsidy cliff may be higher.)

Lower-income consumers, who continue to receive financial assistance but still saw increases in their premium payments with the expiration of the enhanced tax credits, dropped ACA Marketplace coverage at lower rates. Still, they account for a large share of the decline in sign-ups. Sign-ups for those with incomes below 150% FPL — the largest income group in the Marketplace — fell by roughly 441,000 people (a 4% drop from 2025), accounting for 37% of the decline. Those with incomes greater than 150% and up to 250% FPL accounted for 30% of the drop in ACA Marketplace coverage. Plan selections among consumers with incomes above 250% up to 400% FPL was roughly flat, as losses among the 250 to 300% FPL group were largely offset by gains among the 300 to 400% FPL group.

Declines in plan sign-ups for young adults ages 18 to 34 account for more of the decrease in ACA Marketplace plan selections than any other age group. This is in line with expectations detailed in insurer rate filings from last year, which reported that the expiration of the enhanced premium tax credits would cause younger adults, who are typically healthier, to leave the Marketplace. Sign-ups in this age group declined by 542,000, or 8%, from 6.7 million people in 2025 to 6.2 million people in 2026, comprising 46% of the total decline in ACA Marketplace sign-ups.

Marketplace plan selections declined in 41 states in 2026. In percentage terms, plan selections fell the most in North Carolina (22%), Ohio (20%), West Virginia (17%) and Indiana, Delaware, and Arizona (all 16%).

A smaller number of states saw stable or modestly increasing sign-ups, in some cases reflecting state-specific policy decisions that helped offset the loss of enhanced federal premium tax credits. Notably, New Mexico experienced an 18% increase in plan selections, likely due in part to the state’s supplemental financial assistance program, which temporarily backfills the entirety of the lost federal premium assistance.

Increases in Premium Payments

Figure 4

In 2026, the average monthly premium payment among consumers net of tax credits (including those who did not receive premium tax credits) rose 58% from $113 to $178 in 2025. With the expiration of enhanced premiums tax credits, KFF previously estimated that premium payments would increase by 114% on average for subsidized ACA Marketplace enrollees to keep their same plan in 2026. However, as discussed more below, many Marketplace enrollees bought down to bronze plans (with lower premiums and higher deductibles). Additionally, people with the steepest increases in premiums — those who lost eligibility for tax credits entirely — appear to have left the market at a disproportionately high rate.

At the same time, the share of people receiving premium tax credits fell from 92% in 2025 to 87% in 2026, the first decline in subsidy uptake since 2020. This is due, in part, to the loss of financial assistance eligibility for people making greater than 400% of poverty and the relatively large exodus from the market among people with incomes over this amount, who would have faced some of the largest premium increases if they had remained in the market.

Increase in Deductibles

The Share of Consumers Signing Up for Bronze and Gold Plans Reached Record Highs in 2026 (Stacked column chart)

To offset these increases in premium payments with the expiration of enhanced premium tax credits, a number of consumers switched to bronze plans, which have lower premiums but higher deductibles. The share of people selecting bronze plans increased from 30% (7.3 million people) in 2025 to 40% (9.2 million people) in 2026, while the share selecting gold plans rose from 13% (3.2 million people) to 17% (4.0 million people). Meanwhile, the share of ACA marketplace consumers selecting a silver plan fell from 57% (13.7 million people) to 43% (9.8 million people), marking a record low and the first time fewer than half of ACA consumers have selected a silver plan.

Average Deductibles Have Surged to Record-Highs in 2026 (Line chart)

With more people signing up for bronze plans than ever before, average deductibles in the ACA Marketplaces are rising. From 2025 to 2026, the average deductible in the ACA Marketplaces has grown by over a thousand dollars per person, a 37% increase, from $2,759 to $3,786. This marks the steepest increase ever in the average Marketplace deductible since the markets launched in 2014. For context, if the distribution of plan selections across metal levels had stayed the same as in 2025, the average Marketplace deductible would have gone up just 6% (to $2,912).

A Record-Low Share of Consumers Selected Cost-Sharing Reduction Plans in 2026 (Line chart)

The lowest income Marketplace enrollees (100-250% FPL) also qualify for cost-sharing reductions (CSRs), which lower their out-of-pocket costs (deductibles, copayments, and coinsurance) when paying for health care services if they enroll in silver plans. These CSR plans are offered on a sliding scale, such that those with lower incomes receive more assistance. The average silver deductible available to a person making up to 150% of poverty is $80, compared to $5,304 for the standard silver plan. Previously, with enhanced premium tax credits, silver plans enrollees in this low-income group could get a silver plan with a $0 monthly premium payment. After the expiration of enhanced tax credits, an enrollee would now pay 4.19% of their income, or about $82 a month for a single person at 150% of poverty to keep that low-deductible silver plan.

The share of all Marketplace consumers selecting a cost-sharing reduction (CSR) plan fell to its lowest level on record in 2026 (37%). Available data suggests that people are choosing non-CSR plans despite having the income to be eligible for this financial assistance. In 2025, 66% of people in states using the federal platform who were eligible for CSRs signed up for a silver CSR plan. But in 2026, the share of eligible consumers in Healthcare.gov states who selected a CSR plan fell to 45%.

A More Complete Picture is Still to Come

All the information available so far on the demographics of people who left the ACA Marketplace and the increase in premium payments and deductibles is based on plan selections, not effectuated enrollment. Even among those who do effectuate coverage, some could lose it during the year if they cannot afford to continue their premium payments. When CMS publishes effectuated enrollment data later this year, it will include only aggregate counts — without the demographic and plan-level breakdowns available in the plan selection files. Additionally, a grace period was available for returning enrollees to have until late March to make their premium payments, and CMS effectuated enrollment data fully reflecting that grace period may not be available for another year. As a result, a complete picture of how the expiration of enhanced premium tax credits reshaped who has coverage and what kind of plan they hold may not be available for some time.

Methods

This analysis used plan selection and effectuated enrollment data from the Centers for Medicare & Medicaid Services (CMS) and state-based Marketplace (SBM) Open Enrollment reports for plan selections (sign-ups). The estimate of the potential loss in ACA effectuated enrollment (Figure 1) references the report “Who Paid, and Who Stayed? Early 2026 Enrollment Trends in the Individual Market” produced by the Wakely Consulting Group. ACA effectuated enrollment values reflect average monthly effectuated enrollment estimates over the full year for 2017-2024 and over the first seven months for 2025. Potential 2026 enrollment was estimated by applying the midpoint of Wakely Consulting Group's estimates of reduction in individual market enrollment to average 2025 Marketplace effectuated enrollment. Blue dots represent high and low estimates of effectuated enrollment. Wakely's estimate may understate enrollment decline in the Marketplaces if a higher share of off-Exchange enrollees pay their January premiums.

Changes in sign-ups by income (Figure 2) and state (Figure 3) were extracted from Open Enrollment Public Use Files. The "Other/Unknown" income category refers to the count of unique consumers with household incomes not otherwise described. This includes consumers who did not provide household income because they were not requesting financial assistance. Trends in average premium (net of tax credits) and share of consumers with advanced premium tax credits (APTC) were taken from the CMS Health Insurance Exchanges 2026 Open Enrollment Report. Average premium payment includes those who signed up both with and without APTC. Distribution of metal level (Figure 5), sourced from the Open Enrollment Period Public Use Files and data from the Office of the Assistant Secretary for Planning and Evaluation (ASPE), does not include platinum and catastrophic plans, which each had <1% of plan selections in 2026. Shares may not sum to 100% due to rounding.

Average deductible over time by plan type (Figure 6) trends the individual medical deductible in plans with combined medical and prescription drug deductibles for only plans offered in the federally facilitated Marketplace, with plan design information from the Medical Individual Market file of the QHP Landscape Files. Plans included were not adjusted for states transitioning to state-based exchanges. First, simple averages over distinct plans were calculated within each metal level (or CSR variant) and were not weighted by plan enrollment. A distinct plan was defined by having a unique state, issuer, metal level, and cost-sharing design combination. In 2014 and 2015, a distinct plan took into consideration the plan marketing name. “Expanded bronze” and “bronze” plans were combined; catastrophic and platinum plans were excluded from analysis. Second, the weighted average was calculated using plan selection data at the metal and CSR (or FPL) level from Marketplace Open Enrollment Period Public Use Files and ASPE data. Share of CSR and non-CSR variants among those selecting silver plans for 2017 and earlier were from the 2017 Open Enrollment income distribution among silver plan selections; consumers selecting a silver plan with income ≥100% to ≤150% of FPL , >150% to ≤200% of FPL , and >200% to ≤250% of FPL were assumed to have selected CSR94, CSR87, and CSR73 variants, respectively. All other years, including 2026, used plan selection, metal level, and CSR distributions from that year.

The share of CSR-eligible consumers with a CSR plan (Figure 7) was calculated from Open Enrollment Public Use Files. While the overall share of consumers with a silver CSR plan includes all states, the share of eligible consumers that signed up for a CSR plan pertains to states using the federally facilitated exchange that year, without adjustment for states transitioning to state-based exchanges.

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