The U.S. has been involved in efforts to improve the health of those living in low- and middle-income countries for decades and has been the largest donor to global health in the world. Starting on January 20, 2025, as part of a larger foreign aid review, the Trump administration began to take several steps to defund and dismantle most of the U.S. global health response, rendering its future uncertain. To better understand the U.S. global health response, as it was before this date, here are key facts to know (also see 10 Things to Know About U.S. Funding for Global Health):

1. What have been the goals of U.S. global health efforts?

U.S. global health efforts aim to help improve the health of people in developing countries while also contributing to broader U.S. global development goals (e.g., advancing a free, peaceful, and prosperous world), foreign policy priorities (e.g., promoting democratic institutions, upholding universal values, and promoting human dignity), and national security concerns (e.g., protecting Americans from external threats, sustaining a stable and open international system).¹ 

2. How long has the U.S. been involved in global health?

The U.S. government (U.S.) has been engaged in international health activities for more than a century beginning with efforts in the late 1800s to join with other nations to form the first international health organizations, standards, and treaties designed to promote growing international trade and travel while protecting borders from external disease threats. Since then, U.S. engagement in global health has grown considerably, particularly after the launch of USAID in 1961, the U.S. international development agency, but most markedly in the last two decades with the creation of PEPFAR and other signature U.S. global health efforts. Heightened engagement has been driven by factors such as globalization, the growing recognition that infectious disease threats – including the emergence of new infectious diseases such as HIV, SARS, avian influenza, and COVID-19 – are threats to national security in the U.S. as well as abroad, as well as demonstrated success in addressing global health challenges, such as polio.

3. How much global health funding does the U.S. provide?

In FY 2024, the U.S. provided $12.4 billion to global health. Most funding (81%) was provided bilaterally (provided to or on behalf of other countries or regions), reaching almost 80 low- and middle-income countries, primarily in sub-Saharan Africa. The remaining share was provided to multilateral institutions (where it is pooled with funding from other donors and, in turn, disbursed to countries and programs by the multilateral institution). U.S. funding for global health, however, represents a very small share of the federal budget (<1%). See Figure 1.

4. How does the U.S. rank as a global health donor?

The U.S. government has been the largest donor to health in low- and middle-income countries. The U.S. provided 42% of all international health assistance from major donor governments in 2023 (see Figure 2), the largest of any donor. In addition, the U.S. has historically devoted a larger share of its foreign assistance to health than other donor governments; global health accounted for almost 30% of U.S. foreign assistance in 2023 (all other donor governments devoted less than 20% of their foreign aid budget to global health).

5. What are the main U.S. bilateral global health programs and priorities?

The U.S. has focused its global health work on several main areas and programs, including establishing major initiatives such as PEPFAR, its signature global HIV/AIDS program. These programs include (see Figure 3 for funding amounts):

• President’s Emergency Plan for AIDS Relief (PEPFAR)
• President’s Malaria Initiative (PMI)
• Tuberculosis
• Maternal and Child Health
• Nutrition and Feed the Future
• Family Planning/Reproductive Health
• Neglected Tropical Diseases
• Global Health Security

6. What are the main multilateral health organizations supported by the U.S.?

The U.S. government has been a major donor to several multilateral organizations, including those that are United Nations (U.N.) entities as well as independent, public/private partnerships:

U.N. entities:

• U.N. Children’s Fund (UNICEF)
• World Health Organization (WHO)
• Pan American Health Organization (PAHO)
• Joint United Nations Programme on HIV/AIDS (UNAIDS)
• U.N. Population Fund (UNFPA)

Independent entities:

• Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund)
• Gavi, the Vaccine Alliance
• TB Global Drug Facility of the Stop TB Partnership
• Global Polio Eradication Initiative (GPEI)
• Pandemic Fund

7. How does the U.S. carry out its global health efforts?

The U.S. government’s engagement in global health is carried out and overseen by multiple executive branch departments and agencies and the legislative branch. The main federal agencies include:

• the National Security Council (NSC), within the White House, which is responsible for coordinating and reviewing the U.S. strategy and activities, particularly for GHS;
• the Department of State, including the Bureau of Global Health Security and Diplomacy (GHSD);
• USAID (although its future is uncertain);
• the Millennium Challenge Corporation (MCC);
• the Department of Health and Human Services (HHS), including the Office of Global Affairs (OGA), the Centers for Disease Control and Prevention (CDC), the National Institutes of Health (NIH), and the Food & Drug Administration (FDA); and
• the Department of Defense (DoD).

To implement health programs, the U.S. government partners with many organizations, ranging from non-profit and private sector organizations to foreign governments and international and multilateral organizations. In FY 2022, of the $10.6 billion in U.S. global health funding obligated to non-U.S. government recipients, the largest share (45%) went to U.S. NGOs, followed by multilateral organizations (34%), foreign NGOs (17%), and foreign governments (3%).

8. What do we know about the effectiveness of U.S. global health efforts?

U.S. global health programs have been shown to have significant impact. For example, PEPFAR is estimated to have saved 26 million lives (in addition to positive effects on health outcomes beyond HIV mortality, as well as impacts in the area of maternal and child health, along with significant, positive economic and educational spillover effects). Likewise, MCH efforts have supported a 55% decline in under-five mortality and a 42% drop in maternal deaths since 2000, while malaria efforts under PMI since 2006 have supported a 28.7% decline in malaria case rates and a 48.2% decline in malaria death rates.

9. What does the American public think about the U.S. involvement in global health?

Overall, there is broad support for the U.S. playing a role in improving the health for people in developing countries, although support is split along party lines, with the share of Republicans saying the U.S. should play a major role in this area declining since 2016. Half of the public says the U.S. should take a leading or major role in improving health for people in developing countries, while about one-third (36%) say the U.S. should take a “minor role.” Just over half the public says that before Trump took office this year, the U.S. was spending too little (19%) or about the right amount (37%) on these efforts. The public continues to recognize a benefit of spending money on global health. A large majority say that spending money on improving health in developing countries helps protect the health of Americans by preventing the spread of infectious diseases, although support is split along party lines, with most Democrats (86%) and many independents (67%) but fewer Republicans (49%) saying this spending helps Americans in this way.

10. What has the Trump administration done to affect the U.S. global health response?

Starting on January 20, 2025, the first day of his second term, President Trump began to announce numerous executive actions, several of which directly address or affect U.S. global health efforts. These have included a foreign aid freeze and “stop-work order”, cancelling the vast majority of foreign aid grants and contracts, and moving to dismantle USAID (the main implementing agency of U.S. global health efforts). As a result, many U.S. global health programs have been effectively shuttered. This situation presents considerable risks to the health of millions of people in low- and middle-income countries. Multiple lawsuits have been filed challenging these actions and litigation is ongoing.

KFF Resources

• Health Policy 101: The U.S. Government and Global Health
• KFF Global Health Fact Sheets on U.S. Global Health Policy and Programs
• KFF Global Health Budget Tracker
• KFF Breaking Down the Budget by Program Area
• KFF Overview of President Trump’s Executive Actions on Global Health Tracker

1. U.S. Code, Foreign Assistance Act of 1961, Title 22, Chapter 32; U.S. Code, U.S. Leadership Against HIV/AIDS Tuberculosis, and Malaria, Title 22, Chapter 83; U.S. Department of State and USAID, Joint Strategic Plan FY2022-FY2026, March 2022. White House, National Security Strategy, updated November 2022; USAID website, “Mission, Vision and Values,” webpage, https://www.usaid.gov/about-us/mission-vision-values [no longer accessible; accessed Oct. 2024]. ↩︎

Update: This rule was finalized on June 25, 2025 and was virtually the same as proposed rule, allowing the change to go into effect for the 2026 plan year. Differing from the proposed rule, which offered no definition, HHS defines “sex-trait modification” services to inlcude “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.”

On March 10^th, CMS issued a proposed rule that seeks to change how plans sold on and off the Affordable Care Act’s (ACA) Marketplaces (plans for individuals and small businesses), would cover gender affirming care services, which the rule calls “coverage for sex-trait modification¹ .” The rule proposes, beginning plan year 2026, to prohibit insurers from covering gender affirming care as an essential health benefit (EHB), which could lead insurers to drop coverage or shift costs to individuals and states.

While the policy aim of the proposed rule aligns with the administration’s Executive Orders on gender and limiting access to gender affirming care, certain provisions of these orders are currently subject to preliminary injunctions and the agency states that the proposal “does not rely on the enjoined sections of the executive orders in making this proposal.” Instead, CMS writes that they are proposing the prohibition “because coverage of sex-trait modification is not typically included in employer-sponsored plans, and EHB must be equal in scope to a typical employer plan…” CMS does not provide support for this assertion, instead stating that they find that “0.11 percent of enrollees in non-grandfathered individual and small group coverage market plans utilized sex-trait modification during PYs 2022 and 2023.” Utilization of gender affirming care services is expectedly low in the population overall because only a small share of the population is transgender and not all transgender people seek gender affirming medical care. Further, utilization of a service may be a poor proxy for how commonly it is covered. There are other cases where a small share of the population uses a service that is generally covered by insurance. For example, there were fewer than 5,000 heart transplants in the US in 2023 (equaling one ten thousandth of a percent of the population) but public and commercial insurance typically covers this service.

Coverage of gender affirming care services in employer plans is fairly common. KFF’s 2024 Employer Health Benefit Survey²  found that about one-quarter (24%) of large employers (200 or more workers) stated they covered gender-affirming hormone therapy, a plurality of respondents did not know if they covered these services (45%), and less than one-third (31%) did not offer coverage.  The largest firms in the country (5,000 or more workers) employ 43% of people with job-based coverage and were significantly more likely to report covering hormone therapy in their largest plan (50% offered coverage, 18% did not know). In 2023, KFF’s Employer Health Benefit Survey found a similar trend relating to gender-affirming surgery. Among large employers (200 or more workers) offering health benefits, 23% provide coverage for gender-affirming surgery in their largest health plan, with 40% indicating they did not know.  More than 60% of the largest firms provide coverage for gender-affirming surgery (and 12% did not know). While for both services, there was uncertainty among employers over the details of coverage, many large employers provided coverage. 2022 data from Mercer and 2025 data on fortune 500 company coverage from HRC found, as KFF did, that coverage rates are particularly high among the largest employers (where most US workers are covered).

If implemented, the proposal would likely have an impact on access and costs for individuals and states. Some plans might drop coverage and while plans could cover gender-affirming services outside of their EHB package, consumers 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 lifetime limits, increasing out-of-pocket liability. Given that transgender people are more likely to be living on lower-incomes than cisgender people, higher costs could pose a particular challenge. Increases in out-of-pocket costs would likely deter enrollees from accessing gender-affirming care services, which are medically necessary and recommended by practically every major US medical association.

States, including about half that prohibit transgender care related exclusions, could also be faced with defraying the cost of covering these services under certain scenarios. The proposal states “if any State separately mandates coverage for sex-trait modification outside of its EHB-benchmark plan, the State would be required to defray the cost of that State mandated benefit as it would be considered in addition to EHB….However, if any such State does not separately mandate coverage of sex-trait modification outside of its EHB-benchmark plan, there would be no defrayal obligation..”

The proposal also raises questions about whether the policy would violate the ACA’s major sex nondiscrimination protections (under Section 1557).  Sec. 1557 protects against sex (and other) discrimination in health care and while the Trump Administration has suggested that it will view these protections based on biological sex assigned at birth only, courts can and have said that those protections extend to sexual orientation and gender identity. This interpretation also differs from the opinion issued by the Supreme Court in the Bostock case which found employment sex-based nondiscrimination protections extend to sexual orientation and gender identity.

1. The proposed rule does not define “sex-trait modification” but references the definition of “chemical and surgical mutilation” used in the Trump administration’s Executive Order, “Protecting Children From Chemical And Surgical Mutilation”, which includes the use of puberty blockers, sex hormones, and surgical procedures to affirm an individual’s gender identity that differs from their sex assigned at birth. ↩︎
2. Since 1999, KFF’s Employer Health Benefit Survey has collected nationally representative information on the cost and coverage of employer sponsored plans. ↩︎

Medicaid is jointly financed by states and the federal government but administered by states within broad federal rules. Medicaid accounts for a large share of state budgets and can be central to state fiscal decisions. Following years of robust revenue growth, states are now contending with weakening tax revenues, budget shortfalls, and uncertainty in their long-term fiscal outlook, leaving some states with difficult budget decisions. At the same time, there are several options under consideration in Congress to significantly reduce federal Medicaid spending to help pay for tax cuts, with the recently passed House budget resolution targeting cuts to Medicaid of up to $880 billion or more over a decade. There are not yet detailed proposals under consideration by Congress to achieve federal Medicaid spending reductions. However, any reduction in federal Medicaid spending would leave states with tough choices about how to offset reductions through tax increases or cuts to other programs, like education. If states are not able to offset the loss of federal funds with new taxes or reductions in other state spending, states would have to make cuts to their Medicaid programs. This brief explores the magnitude of federal funding cuts under the House budget resolution and puts the $880 billion in context by comparing the size of the cuts to states’ tax revenues, spending on education, and the number of Medicaid enrollees covered for that cost. The analysis assumes $880 billion in federal Medicaid cuts over a decade, though the amount could end up being more or less depending on what Congress passes.

Key Take-Aways

• Federal cuts of $880 billion over 10 years (or $88 billion per year) would represent 29% of state-financed Medicaid spending per resident.
• States could opt to raise tax revenues to offset federal Medicaid reductions. Proposed federal cuts represent 6% of state taxes per resident.
• States could instead make cuts to other states programs such as education, the largest source of expenditures from state funds, to offset federal Medicaid reductions. Proposed federal cuts represent 19% of state education spending per pupil.
• To further put the proposed federal cuts in perspective, they are equivalent to all Medicaid spending on 3 million seniors and people with disabilities (18% of enrollees in that group), 14 million other adults (38% in that group), or 22 million children enrolled in Medicaid (76% of that group). These figures are meant to put the magnitude of the cuts in perspective, not to suggest that states would achieve savings by eliminating coverage by these amounts. The effects of federal cuts on Medicaid spending and coverage would depend on the specific policies enacted.

What is the size of federal Medicaid reductions under consideration?

Congress is currently targeting up to $880 billion or more in federal Medicaid spending reductions. The House passed a budget resolution instructing the House Energy & Commerce Committee (E&C) to reduce the federal deficit by at least $880 billion over 10 years. Although the budget resolution does not mention Medicaid, Medicaid comprises $8.2 trillion out of the $8.6 trillion in mandatory spending that E&C must use to come up with spending reductions (assuming Medicare cuts are off the table). As a result, major cuts to Medicaid are the only way to meet the House’s budget resolution required $880 billion (or more) in spending reductions.

This is an illustrative analysis designed to portray the potential impact of $880 billion in Medicaid cuts in the absence of specific policies that would yield federal savings. This analysis assumes that the $880 billion in cuts over a decade are spread uniformly across 10 years, or $88 billion a year, which represents 16% of federal Medicaid funding in federal fiscal year (FY) 2024. While this analysis applies cuts evenly across the 10-year period to get a one-year estimate, in practice, the cuts could grow over time. Policies are often implemented after a period of preparation and some may require multiple years before the effects are fully observed.

The analysis applies the federal cuts proportionally across states for illustrative purposes, though the distributional effects would vary depending on the specific policy changes proposed. This analysis applies the federal cuts proportionally to states based on their share of federal spending, resulting in a 16% cut to federal Medicaid funding across all states, though the total amount of the cuts varies by state, ranging from $78 million to $13 billion (Appendix Table 1). In practice, cuts would almost certainly not be allocated proportionately, and some states would be disproportionately impacted depending on the specific policy proposals pursued. Without specific policies yet under consideration by Congress, this illustrative analysis is a way of understanding the magnitude of the potential Medicaid cuts.

How does $880 billion in federal Medicaid reductions relate to states’ taxes and education spending?

Federal Medicaid cuts of $88 billion per year would represent 29% of state-financed Medicaid spending per resident (Figure 1). For states to maintain Medicaid spending and eligibility at current levels, they would have to increase state spending by $88 billion each year, shifting costs from the federal government to the states. This would result in a 29% increase in state-financed Medicaid spending per resident in FY 2024. Across states, the federal cuts per resident range from $100 to $700, representing anywhere from 17% to 59% in state Medicaid spending per resident (Appendix Table 1). These findings are based on the assumptions above; in practice, the increase in state Medicaid spending per resident would vary based on the specific policy proposals.

States could opt to raise taxes to offset the federal Medicaid cuts, with $88 billion per year in federal Medicaid cuts representing 6% of state taxes per resident nationwide. Total state taxes per resident ranged from $2,530 to $15,225 across states (Appendix Table 1). The federal cuts per resident range from $100 to $700 across states, representing anywhere from 2% to 11% in state tax dollars per resident.

Another option for states is to make cuts to another budget item like K-12 education, with proposed federal Medicaid cuts representing 19% of state spending on education per pupil. States could make cuts to any areas of state spending, but education is the largest source of expenditures from state funds, so it is used as an illustrative example in this analysis. Total education spending is primarily from state and local governments, with a small share financed by the federal government. Reductions in state government spending for K-12 education would have a direct impact on total spending per-pupil. State education spending per pupil ranges from $4,500 to $28,600 across states (Appendix Table 1). The federal cuts per pupil range from $700 to $3,400 across states, representing anywhere from 7% to 38% in state education spending per pupil.

How does $880 billion in federal Medicaid reductions relate to Medicaid coverage by eligibility group?

If states do not offset federal Medicaid cuts by picking up the new costs, they could reduce Medicaid spending by covering fewer people, offering fewer benefits, or paying providers less. To reduce eligibility, states would have to make tough choices about what enrollment groups to apply eligibility restrictions to given variation in enrollment and spending per enrollee across groups. It is unclear if more specific federal policy proposals will disproportionately affect certain eligibility groups (like the Affordable Care Act expansion group), or make changes to minimum eligibility standards or benefits set by the federal government. Also, depending on the specific policy proposals and assuming the matching structure of Medicaid financing is retained, states would have to reduce total Medicaid spending by more than one dollar to achieve a dollar in savings.

To provide context for the scope of proposed cuts to Medicaid, the following analysis shows how many people’s Medicaid benefits are covered with $88 billion. The numbers are presented across different enrollee groups to account for significant differences in Medicaid costs for different groups of enrollees (see Methods).

To put the proposed federal cuts into perspective, they are equivalent to all Medicaid spending on 3 million or 18% of Medicaid enrollees eligible because they are 65 and older or have a disability, 14 million or 38% of adult Medicaid enrollees, or 22 million or 76% of child enrollees (Figure 2). Spending per enrollee varies across eligibility groups and is over $18,000 per year for seniors and people with disabilities compared to $3,000 per year for children. As a result, a $88 billion a year cut would be equivalent to Medicaid spending on a smaller number of seniors and people with disabilities relative to other populations both nationally and across states (Appendix Table 2).

Appendix

As one of his first actions in office, President Trump signed executive orders revoking federal diversity, equity, inclusion, and accessibility (DEIA) related programs and actions in the federal government and among federal contractors and grantees. DEI initiatives are intended to create more diverse and inclusive work environments, to address discriminatory policies or practices, as well as to counter the impacts of historical actions that led to unequal opportunities for certain groups. In implementing President Trump’s executive orders, the administration has taken significantly broader actions beyond eliminating DEI programs to include eliminating priorities, actions, information, data, and funding related to concepts of diversity or disparities among federal agencies as well as federal contractors and grantees. Some of these actions have been paused due to ongoing litigation, and it remains to be seen what actions may proceed under final court rulings. Given the broad nature of these actions, they will not only likely lead to a less inclusive and diverse workforce, including in health care, but will also likely lead to widening disparities in health and health care, reversing prior efforts to address disparities and advance equity.

This brief explains the potential impacts of the elimination of diversity and disparities-related initiatives under the Trump administration on racial health disparities. While this brief focuses on racial and ethnic disparities, these actions have implications for health equity across other dimensions, including gender and sexual orientation. The terms DEI and DEIA are similar and often used interchangeably. The “A” in DEIA refers to accessibility for people with disabilities. The remainder of this brief uses DEI as it is more commonly known and used, but with the recognition that accessibility is also a key part of health equity

Federal Actions to Eliminate Disparities Initiatives

On the first day of his second term, President Trump signed Executive Order 14148 which revoked 78 executive orders and memoranda issued by the Biden administration, many related to DEI. This included President Biden’s Executive Order 13985, which required federal agencies to conduct equity assessments and collect data to track and address trends and barriers that underserved communities face in accessing federal positions and programs. The reversal also eliminated DEI frameworks that prioritized equity-driven decision-making and resource allocation in agencies such as the Department of Health and Human Services (HHS) and the Centers for Disease Control and Prevention (CDC).

President Trump also issued Executive Order 14151 and directives that mandate federal agencies to terminate all DEI related offices and positions; equity action plans, actions, initiatives or programs; equity-related grants or contracts; and DEI performance requirements for employees, contractors, or grantees. In addition, he issued Executive Order 14168 to “recognize two sexes, male and female;” specify that sex shall refer to a biological classification of male or female; direct federal agencies and employees to only use “sex” and not “gender;” remove all references to “gender ideology” or identity; and ensure that grant funds do not promote “gender ideology.” Further, he signed Executive Order 14173, which revoked the 1965 Equal Employment Opportunity rule that protected against discrimination in employment among federal contractors; the order also added new requirements for federal contractors and grantees to certify that they do not operate DEI programs that violate anti-discrimination laws and for federal agencies to identify entities, including publicly traded corporations, large nonprofit corporations or associations, and foundations, to target with civil investigations to deter DEI programs. Other actions include Executive Order 14224, which named English as the official language of the U.S. and rescinded an executive order and guidance that reaffirmed the federal government’s commitment to make services accessible to people with limited English proficiency, as well as guidance directing schools and other entities that receive federal funds from the Department of Education to stop using “racial preferences.” This guidance broadens the landmark 2023 U.S. Supreme Court ruling that effectively ended the use of race-conscious admissions policies in higher education, overturning decades of precedent supporting affirmative action.

To carry out the executive orders, the Office of Personnel Management (OPM) directed agencies and departments to take down all outward facing media that “inculcate or promote” “gender ideology,” as well as to remove all public facing DEI related websites and content. This resulted in the temporary shutdown of websites and removal of key health datasets. While some web pages and datasets began returning in several days, they included a warning message that they were being modified to comply with President Trump’s executive orders and some materials, such as codebooks and questionnaires, did not immediately return. The administration also directed departments and agencies to pause grants provided to federal contractors to identify and review programs and activities for consistency with the President’s policies. Reports also indicate that the administration has flagged over 100 words that federal agencies should limit or avoid to comply with the President’s policies, including disparities, diversity, equity, and race. The CDC reportedly ordered the withdrawal of papers pending publication to ensure language compliance. Similarly, reports suggest that the National Science Foundation froze payments to grantees and began screening grant proposals for terms related to gender, equity, and inclusion and that the National Institutes of Health began terminating research grants to comply with the new restrictions.

Multiple lawsuits have been filed challenging the executive orders and actions, which have halted some of these actions, but it remains to be seen what actions will be allowed under final court rulings. For example, a preliminary nationwide injunction blocked enforcement of significant provisions of the executive orders, including the termination of federal contracts and funding. Other litigation has ordered the return of public health web pages and datasets. Some of this information has been restored, such as the FDA’s draft guidance on diversity in clinical trials, but with an explanatory note that any information on the page promoting “gender ideology” is “extremely inaccurate” and that “Administration and this Department reject” the content:

Implications for Health and Health Equity

In the wake of the COVID-19 pandemic and racial reckoning following the murders of George Floyd and others, the federal government as well as many states and private entities increased efforts focused on addressing health disparities, including recognizing the role of historical and ongoing racism in driving disparities. This increased focus led to the development of programs and initiatives focused on mitigating disparities, including efforts to address disparities in maternal and infant health, cancer, and chronic disease, as well as other efforts, such as increasing diversity in clinical trials for development of new drugs and devices. Research efforts also increased to understand disparities, the factors driving them, and effective interventions to mitigate them. Implementation of President Trump’s executive orders eliminates much of this work, which will likely lead to widening disparities in health.

Elimination of focused efforts to address health disparities will potentially further exacerbate disparities, contributing to worsening overall health and unnecessary health care costs. To comply with the President’s executive orders, federal agencies have eliminated health equity plans, strategies, and guidance focused on mitigating disparities. For example, the administration ordered the Centers for Medicare and Medicaid Services to disband its Health Equity Advisory Committee, which was charged with addressing systemic barriers to access that included structural racism, and Federal Drug Administration draft guidance on diversity in clinical trials (although it was restored pursuant to a court order). Focused plans and initiatives to mitigate health disparities seek to address the underlying inequities that drive disparities and meet the needs and preferences of diverse populations. These efforts are important for equity and for improving the nation’s overall health and economic prosperity. Racial and ethnic health disparities result in higher rates of illness and death across a wide range of health conditions. Research also shows that disparities are costly, resulting in excess medical care costs and lost productivity, as well as economic losses due to premature deaths. In the absence of focused efforts, disparities will likely widen because the underlying inequities that contribute to them persist, leading to worse overall health and unnecessary health care costs.

Loss of information, data, and research will inhibit the ability to identify disparities and understand the factors driving them. In implementing the executive orders, agencies removed health information, such as HIV-related content, and reports on current disease threats, like bird flu, as well as federal data, including data from the Centers for Disease Control and Prevention and the U.S. Census. While some of the datasets were returned, they were marked with a warning message suggesting there could be future changes, leaving uncertainty about what data will be available over the long-term. Additionally, as noted, federal agencies are now screening and halting research related to disparities, equity, and inclusion, which will likely lead to reductions in funding to support research on disparities. Data are a cornerstone for efforts to address health disparities and advance health equity. Data are essential for identifying where disparities exist, directing efforts and resources to address disparities as they are identified, measuring progress toward achieving greater equity, and establishing accountability for achieving progress. Without adequate data and research disparities may remain unseen and unaddressed.

Elimination of DEI efforts among the federal workforce and contractors as well as in education will likely lead to a less diverse health care workforce, which would contribute to widening disparities in health care experiences and outcomes. People of color have historically been underrepresented in the health care workforce relative to their share of the population. Research shows that increasing the racial and ethnic diversity and cultural competency of health professionals is associated with improved access to care, greater patient choice and satisfaction, and other benefits. KFF 2023 survey data show Black, Hispanic, and Asian adults who have more health care visits with providers who share their racial and ethnic background report more frequent positive and respectful interactions. Other research suggests that patient and provider racial concordance contributes lower emergency department use, increased visits for preventative care, and greater treatment adherence. One study found that greater representation of Black primary care physicians led to increased life expectancy and lower mortality among Black people. The recent actions to eliminate diversity efforts among federal agencies and contractors as well as in education will likely reverse progress diversifying the health care workforce. For example, research suggests that the 2023 Supreme Court ruling banning affirmative action resulted in a decline in Black, Hispanic and American Indian and Alaska Native medical school students. Moreover, it remains unclear whether hospitals and providers are considered federal contractors subject to the executive orders to eliminate DEI-related activities, but there are concerns about the potential impact to hospital hiring, training, and programming.

Elimination of diversity efforts will lead to a less diverse and inclusive workforce among federal agencies and contractors with fewer protections against discrimination. The new executive orders undo longstanding policies that grew out of antidiscrimination laws focused on increasing employment opportunities for historically underrepresented groups in the federal government and among federal contractors. It reverses efforts by President Biden to strengthen the federal government’s ability to “recruit, hire, develop, promote our nation’s talent and remove barriers to equal opportunity.” Reports suggest that DEI initiatives can support talent acquisition and performance. Prior analysis from the Office of Personnel Management, which has since been removed from the web, found that the federal government achieved significant declines in the gender pay gap for women over time and has a much smaller gap compared to the national gap. Without diversity efforts, certain groups may face increased barriers to employment and advancement, which has impacts for health care access and health.

Federal actions to eliminate diversity and disparities-related efforts are having ripple effects in the private sector, schools, and states. As part of federal actions to eliminate DEI efforts, the federal government issued a statement that they will “investigate, eliminate, and penalize illegal DEI and DEIA preferences” at private companies and universities that receive federal funds. Reports show a wide range of private companies ending or reframing DEI related initiatives in the last several months as well as reversal of DEI efforts in universities and schools. Some states also are reversing or prohibiting DEI-related work, including efforts that began prior to President Trump taking office. In 2024, state legislatures introduced over 30 bills aimed at restricting DEI initiatives in public colleges and universities. Some states also have imposed limits on teaching concepts related to systemic racism, historical inequities, and unconscious bias.

The recently passed House budget resolution targets cuts to Medicaid of up to $880 billion or more over a decade to help pay for tax cuts. Major cuts to Medicaid may impact coverage for the almost 1 in 5 Medicare beneficiaries (12.2 million) who are also enrolled in Medicaid. For people covered under both programs (“dual-eligible individuals”), Medicare is the primary payer and covers medical acute and post-acute care, including skilled nursing facility services and home health care. Medicaid wraps around Medicare coverage by paying Medicare premiums and in most cases, cost sharing. Most dual-eligible individuals (8.9 million people in 2024) are “full-benefit” enrollees, which means they are eligible for Medicaid benefits that are not otherwise covered by Medicare, including long-term care, vision, and dental. The remaining 3.3 million dual-eligible individuals, “partial-benefit” enrollees, are eligible for Medicare premiums and often, cost sharing assistance, but not for full Medicaid benefits.

It is unclear what policies might be designed to achieve $880 billion in savings, but there are possible implications for Medicare beneficiaries, who account for nearly 30% of Medicaid spending. Effects would vary across states as coverage and benefits do.

1. Medicaid helps make Medicare more affordable for more than 12 million people with Medicare by covering the cost of premiums.

Nearly 1 in 5 (18%), or 12.2 million Medicare beneficiaries also have Medicaid coverage (Figure 1). Most Medicare beneficiaries with Medicaid have low incomes and modest savings, and Medicaid coverage makes the Medicare program more affordable by paying premiums, and in most cases, cost sharing. Medicare Part B premiums are $185 per month in 2025 and without Medicaid, these premiums alone would consume close to 15% of income for people in poverty. Most Medicare beneficiaries with Medicaid also get help from Medicaid to pay their Part A and B deductibles, coinsurance, and copayments through the Medicare Savings Programs, which provide coverage of Medicare premiums and often, cost sharing, to Medicare beneficiaries with limited financial resources. Many dual-eligible individuals receive additional Medicaid-covered wraparound services, such as long-term care, vision, and dental services. Just over half (55%) of Medicare beneficiaries who are under age 65 (who are eligible for Medicare on the basis of a permanent disability) are also covered by Medicaid. Most people with both Medicare and Medicaid receive benefits from separate Medicare and Medicaid coverage arrangements. In 2021, just 5% of people with Medicare and Medicaid were in a program that covered Medicare and Medicaid benefits under a single plan or program with integrated financing.

2. The share of Medicare beneficiaries who are also covered by Medicaid varies across states, ranging from 9% to 34%.

Across the 50 states and the District of Columbia, the share of Medicare beneficiaries who are also covered by Medicaid ranges from 9% in New Hampshire to 34% in D.C (Figure 2). The variation stems from differences in eligibility criteria for Medicaid, as well as the income and asset levels of Medicare beneficiaries living in different states. The primary Medicaid eligibility pathways for people with Medicare are through Supplemental Security Income and Medicare Savings Programs, both of which are mandatory. In addition, there are several optional pathways that states can choose to use to expand coverage, making eligibility complex and different across states. In general, in states where more people meet Medicaid eligibility criteria—which may reflect either lower incomes among Medicare beneficiaries or higher income eligibility criteria, a higher share of Medicare beneficiaries are also covered by Medicaid.

3. Medicare beneficiaries with coverage under Medicaid are in poorer health and have greater health needs than Medicare beneficiaries without Medicaid.

Four in ten (41%) people with both Medicare and Medicaid report their health as fair or poor, compared with 15% of Medicare beneficiaries without Medicaid coverage (Figure 3). More than a third (34%) of those with both Medicare and Medicaid have five or more chronic conditions, such as diabetes, hypertension, and heart disease, compared with 23% of Medicare beneficiaries without Medicaid coverage. Additionally, more than four in 10 (44%) have at least one mental health condition, such as depression and schizophrenia, compared with 24% of Medicare beneficiaries without Medicaid coverage.

A larger share of people with both Medicare and Medicaid experience functional or cognitive impairments than Medicare beneficiaries without Medicaid coverage. More than a third (34%) report difficulties performing two or more activities of daily living—such as eating, bathing, and toileting—compared to 11% of Medicare beneficiaries without Medicaid coverage. Additionally, a higher share of people with both Medicare and Medicaid coverage have cognitive impairments (36% versus 12%) and Alzheimer’s or other dementia (8% versus 3%) than beneficiaries without Medicaid coverage.

4. People with both Medicare and Medicaid account for a disproportionately high share of spending in both programs.

People with both Medicare and Medicaid comprise 16% of the traditional Medicare population and 31% of traditional Medicare spending in 2021 (Figure 4). Similarly, people with both Medicare and Medicaid comprise 14% of all Medicaid enrollment and 29% of federal and state Medicaid spending. The higher spending relative to enrollment is consistent with the greater health and functional needs of people with both Medicare and Medicaid. (People enrolled in private Medicare Advantage plans are not included in this analysis because Medicare comparable spending data are not available.)

5. Nearly 5 million Medicare beneficiaries receive Medicaid wraparound services, including long-term care.

Almost 5 million Medicare beneficiaries with Medicaid used at least one of four Medicaid wraparound services in 2021, including long-term care, vision services, dental services, and non-emergency medical transportation (Figure 5). Medicaid wraparound services are Medicaid benefits available to most Medicare beneficiaries with Medicaid that are not covered under Medicare Part A or Part B. (The services may be covered as a supplemental benefit for people enrolled in a Medicare Advantage plan.) All states are required to provide some wraparound benefits including nursing facility care (part of institutional long-term care), home health (part of home care), and non-emergency medical transportation. Other services are optional for states to provide including dental services, vision services, and all other home care, which includes personal care, support for family caregivers, and services for people in assisted living facilities.

Medicaid covered vision services for 1.9 million Medicare beneficiaries, dental services for 1.4 million beneficiaries, and non-emergency medical transportation for 1.0 million Medicare beneficiaries. In addition, Medicaid covered long-term care services for 2.8 million Medicare beneficiaries (some of whom used both home care and institutional long-term care). Most of the people using long term-care (2.2 million) receive services in home and community settings. The costs of long-term care often exceed the median income and would quickly exhaust the median savings of Medicare beneficiaries, making Medicaid the primary payer of long-term care in the U.S., covering 61% of total spending.

Since the Columbine school shooting in 1999, there have been over 420 school shootings across the United States. More than 160 of these shootings occurred after the onset of the COVID-19 pandemic, indicating a significant increase. While 2024 marked the beginning of a decline in the number of mass shootings per year since the onset of the pandemic, this trend did not apply to school shootings, the number of which remains consistently high to date. Although school shootings continue to account for a small portion of total firearm violence, they can have a widespread impact that goes beyond physical harm. According to the Washington Post, at least 390,000 students were exposed to a school shooting (exposure is defined as students attending a school at which a shooting occurred during the current school year) since the 1999 Columbine shooting.

This brief analyzes the rate of student exposure to school shootings over time. While these exposures often occur at the community level, this brief quantifies exposures at the state and national level in order to draw comparisons. Individual state policies may play a role in their exposure rates. A KFF analysis found that states with more restrictive firearm laws generally have lower youth firearm morality than states with fewer firearm laws. The rate of exposure to school shootings depends on factors including school enrollment size and state population size. Therefore, even a single school shooting incident in a state can impact many youths beyond those that are physically injured and may significantly increase exposure rates. Key findings include:

• The U.S. average yearly rate of student exposure to a school shooting has increased threefold over time (from 19 per 100,000 students in 1999-2004 to 51 in 2020-2024).
• From 2020 to 2024, the rate of school shooting exposure per 100,000 students was highest in Delaware (359), DC (356), Utah (166), Arkansas (130), and Nevada (127).
• Children exposed to gun violence may experience serious adverse effects, including anxiety, PTSD, suicide risk, and substance use issues. Some safety measures at schools, such as active shooter drills, may also negatively affect student mental health.

How has exposure to school shootings changed over time among U.S. students?

Since 1999, the rate of U.S. students exposed to a school shooting has nearly tripled, with most of the increase occurring during the pandemic years (2020-2024) (Figure 1). KFF analysis of the Washington Post’s school shooting database found that the average yearly rate of student exposure to school shootings grew from 19 per 100,000 in 1999-2004 to 51 in 2020-2024.

Delaware, the District of Columbia, Utah, Nevada, and Arkansas had the highest rates of students exposed to school shootings since the pandemic. These states have experienced student exposure rates that are at least double the U.S. average yearly rate of exposure (51 per 100,000 students) from 2020-2024. The rate per 100,000 students was highest in Delaware (359), DC (356), Utah (166), Arkansas (130), and Nevada (127) (Figure 2). Note that student exposure rates can vary greatly at the state level due to factors such as school student enrollment size and state population. For example, Delaware and DC had low student populations (under 200,000) from 2020 to 2024, making their exposure rates more volatile than in higher-population states, and a small number of shootings could produce a high rate. For more information, see Methods.

While student exposure to school shootings spiked during the pandemic, several states, including Washington state and Maryland, have had exposure rates higher than the U.S. average for the past several decades (Figure 3). Since 1999, Washington’s exposure rates have remained at or above national average exposure rates – including the state’s lowest average yearly rate in 2010-2014 (25 per 100,000 students) to the state’s highest average yearly rate in 2020-2024 (62). Similarly, Colorado, Maryland, North Carolina, and Nevada have often endured school shooting exposure rates that are higher than the national average rate. Some states have consistently experienced increases in exposure rates over time, including Florida (from a yearly average of 13 per 100,000 students in 1999-2004 to 52 in 2020-2024) and Georgia (from a yearly average rate of 12 in 1999-2004 to 76 in 2020-2024).

In contrast, Maine, Vermont, West Virginia, and Wyoming have had no student exposure to school shootings since 1999. However, there may have been incidences of gunfire on school grounds in these states that did not meet the Washington Post’s criteria for school shootings.

How do exposures to school shootings and efforts to mitigate them affect student mental health and well-being?

Although school shootings account for a small portion of gun violence, they are linked to negative mental health consequences for students and communities at large. Youth antidepressant use and suicide risk can increase in communities with exposures to school shootings. More broadly, exposure to gun violence is linked to post-traumatic stress disorder and anxiety, in addition to other mental health concerns among youth. Gun violence may also lead to challenges with school performance, including increased absenteeism and difficulty concentrating. Additionally, a survey prior to the pandemic found that the majority of teenagers and their parents felt at least somewhat worried that a school shooting may occur at their school. Although research is limited on how mass shootings affect individuals not directly exposed to them, current literature suggests that information and knowledge of mass shootings may be linked to increased levels of fear and anxiety.

Measures intended to combat school violence – such as the placement of school officers and the use of metal detectors – may also negatively affect the well-being of students and their sense of safety. Fifty-four percent of public schools reported having a sworn law enforcement officer (SLEO) such as a police officer or school resource officer on campus during the 2023-2024 school year. While many public schools report feeling that SLEOs have a positive impact on the school community, evidence that they reduce gun violence or school shootings is lacking. Further, among school shootings that involved a SLEO, several involved the officer shooting an unarmed student or staff member. Although nearly all (92%) public schools with SLEOs report that these officers carry a firearm, just over half of these schools have a written policy for firearm handling expectations among SLEOs. Further, the placement of these officers on school campuses may negatively impact students of color specifically, as they are more likely to face disciplinary action than their White counterparts. Separately, 8% of public schools report having metal detectors at school gates for all or most students and 14% of public schools perform random metal detector checks on students. While these detectors are used as a security measure, there are not enough data to demonstrate that they decrease the risk of violent behavior on school grounds. Additionally, the presence of metal detectors may damage students’ sense of safety at school.

Other safety measures include written action plans and drills in the event of an active shooter, with the latter being linked to psychological harm among participants. While 98% of public schools had a written procedure to handle an active shooter during the 2023-2024 school year, only 27% of these schools reported feeling “very prepared” for an active shooter situation. Additionally, many public schools drill students on emergency lockdown and evacuation procedures for school shootings with varying degrees of intensity, with some being psychologically harmful to participants. A longitudinal study on children exposed to school shootings in Texas demonstrated that even when school shootings do not result in deaths, the impacts of gun violence at schools – such as chronic absenteeism and economic consequences – can follow children into early adulthood. Similarly, when schools properly execute a plan prepared in advance, physical and mental harm is not completely preventable. For example, in the recent shooting at a Madison, Wisconsin school, officials praised the well-executed response by authorities, but injury and death occurred regardless.

Appendix

On March 15, 2025, the President signed a full-year “continuing resolution” (CR) that continues funding the federal government through the rest of the fiscal year. It maintains U.S. global health funding at the prior year (FY 2024) level ($10.8 billion).[i] The Full-Year Continuing Appropriations and Extensions Act, 2025, which was passed by the House on March 11, 2025 and the Senate on March 14, 2025, references relevant sections of the Further Consolidated Appropriations Act, 2024 – as well as the associated explanatory report, specifying funding levels for global health programs at the Department of State (State), U.S. Agency for International Development (USAID), Centers for Disease Control and Prevention (CDC), and National Institutes of Health (NIH). The CR also includes language (Section 1113) instructing departments and agencies to report back to Congress within 45 days on spending, expenditure, or operating plans at the program, project, or activity level for FY 2025, and specifically for foreign assistance programs funded under State and Foreign Operations (SFOPs), which includes State and USAID, at the country, regional, and central program level, and for any international organization. See other budget summaries for details on historical annual appropriations for global health programs.

[i] The $10.8 billion in global health funding is based on those amounts specified in appropriations bills. In past years, additional funding for global health has also been determined at the agency level.

Medicaid is the primary program providing comprehensive coverage of health and long-term care to 83 million low-income people in the United States and accounts for one-fifth of health care spending. Medicaid is jointly financed by states and the federal government but administered by states within federal rules. The recently passed House budget resolution targets cuts to Medicaid of up to $880 billion or more over a decade. While several options appear to be under consideration to significantly reduce Medicaid spending, President Trump publicly said recently about Medicaid, “We are not going to touch it. Now, we are going to look for fraud.” Speaker Johnson has said, “Medicaid is hugely problematic because it has a lot of fraud, waste, and abuse.” Although fraud, waste, and abuse can be related concepts (and all fall under a broader “program integrity” umbrella), they are also distinct in important ways (Box 1). These terms apply to other government health care programs, private health insurance, and other government programs more broadly.¹  On March 11, 2025, the White House released a statement saying most federal spending lost to fraud is from entitlement programs such as Medicaid and Medicare, citing “improper payment” estimates, without clarifying (as GAO does) that “improper payments” are not a measure of fraud or abuse and most improper payments are the result of missing documentation or missing administrative steps, and are not necessarily payments made for ineligible enrollees, providers, or services.

Speaker Johnson has referenced $50 billion in annual fraudulent payments (a figure that may reflect improper payments rather than fraud). In debates about broader Medicaid spending reductions, Republicans may try to recast policy changes such as adding work requirements to Medicaid and restricting the use of provider taxes as addressing fraud, waste, and abuse. Despite talk about eliminating fraud, the President’s recent order to remove Inspectors General (IGs), who are responsible for providing independent oversight of federal programs, from at least 17 government agencies—including HHS—appears to run counter to the stated focus on fraud, waste, and abuse. Recent KFF polling shows, while the public thinks that reducing fraud and waste in government health programs could lead to reductions in overall federal spending, many (60% of Republicans, 55% of Democrats, and 51% of independents) also think reducing fraud and waste in government programs could result in a reduction of benefits. Overall, most Americans (77%) hold favorable views of Medicaid, including six in ten Republicans (63%), and at least eight in ten independents (81%) and Democrats (87%).

This brief explains what is known about improper payments and fraud and abuse in Medicaid and describes ongoing state and federal actions to address program integrity.

1. Both the federal government and states are responsible for ensuring program integrity.

Program integrity refers to the proper management and functioning of the Medicaid program to ensure it is providing quality and efficient care while using funds–taxpayer dollars–appropriately with minimal waste. Medicaid is a very complex program that involves millions of beneficiaries, hundreds of thousands of providers, and significant federal and state expenditures. Program integrity efforts work to prevent and detect waste, fraud, and abuse, to increase program transparency and accountability, and to recover improperly used funds. Program integrity activities help ensure that eligibility decisions are made correctly; prospective and enrolled providers meet federal and state participation requirements; services provided to enrollees are medically necessary and appropriate; and provider payments are made in the correct amount and for appropriate services. Program integrity also includes routine oversight to ensure compliance with state and federal law.

State Medicaid agencies administer Medicaid on a day-to-day basis and have the primary responsibility for program integrity. Program integrity includes specific, dedicated activities, as well as activities that are built into program functions (e.g., beneficiary and provider enrollment, service delivery, payment). Federal laws and regulations include requirements for states to reduce fraud, waste, and abuse. Each state must have a Medicaid Fraud Control Unit (MFCU) to investigate fraud and prosecute or refer to prosecution individuals or entities defrauding Medicaid. Other state agencies and fiscal officers may be involved, including state auditors. Comprehensive managed care is the primary Medicaid delivery system (accounting for 75% of beneficiaries and over 50% of total Medicaid spending) which creates different risks, as the state is delegating provider contracting, utilization management, and claims processing to a managed care organization (MCO). States with managed care programs have additional program integrity responsibilities.

The federal government’s responsibility is to provide “effective support and assistance to states to combat provider fraud and abuse.” CMS supports states through funding, training, and defining in regulation how states must comply with Medicaid program integrity requirements. Three federal agencies – the HHS Office of Inspector General (OIG), U.S. Department of Justice (DOJ), and Government Accountability Office (GAO) – are also involved in this work, each with different roles and responsibilities. Federal agencies regularly report on Medicaid program integrity performance, including:

• The CMS Improper Payments Fact Sheet, which summarizes and explains annual statistics on HHS improper payment measurements
• The HHS Agency Financial Report, which includes Medicaid payment integrity statistics
• The Payment Error Rate (PERM) Findings and Reports, Supplemental Improper Payment Data Reports²  include state specific data
• The HHS-OIG Healthcare Fraud and Abuse Control (HCFAC) report and the Medicaid Fraud Control Units (MFCU) report, which summarize program integrity oversight and enforcement activities
• GAO’s High-Risk Series identifies government operations with vulnerabilities to fraud, waste, abuse

2. There is no comprehensive or reliable measure of fraud in Medicaid.

Fraud is not unique to Medicaid. Fraud occurs in Medicaid, Medicare, and private health insurance. Most monetary loss from fraud is by providers. Fraud includes obtaining a thing of value through willful misrepresentation. Measuring fraud is difficult, in part, because it can only be determined with certainty after the fact and if it is identified. There are no reliable measures of fraud against Medicaid. DOJ and HHS-OIG operate a Health Care Fraud and Abuse Control (HCFAC) program, designed to coordinate federal, state, and local health care fraud and abuse law enforcement activities. A HCFAC report is published annually, describing health care fraud enforcement actions. Recent analysis of the FY 2023 HCFAC report found no beneficiary fraud in the listing. Providers convicted (of different kinds of fraud against Medicaid and Medicare) included ambulance service providers, durable medical equipment suppliers, diagnostic labs, nursing homes, pain clinics, pharmacies, physical therapists, physicians, and substance use treatment providers. Examples of successful criminal and civil investigations highlighted in the report include:

• Sentencing of an EMT supervisor for an ambulance company who wrote and signed hundreds of false ambulance run sheets that were used to send fraudulent bills to the Texas Medicaid program;
• Sentencing of a pharmacy owner in a scheme to bill Kentucky Medicaid (and other health benefit programs) for drug prescriptions that were never filled; and
• Sentencing of a Michigan physician for his role in a health care fraud scheme that exploited patients suffering from addiction by administering unnecessary back injections and illegally distributing millions of medically unnecessary opioids.

In FY 2023, total HCFAC recoveries reached $3.4 billion (across Medicaid and Medicare). The reported return on investment for the HCFAC program (2021-2023) was $2.80 for every $1 spent. HHS-OIG also publishes an annual summary of the cases brought by state Medicaid Fraud Control Units (MFCUs). The report identifies criminal convictions and civil settlements and judgments by provider type. In FY 2024, MFCUs reported 1,151 convictions and $1.4 billion in recoveries (or $3.46 for every $1 spent).

3. Improper payments are not a measure of fraud.

The Improper Payments Information Act (IPIA) of 2002 (replaced by the Payment Integrity Information Act (PIIA) of 2019) requires the heads of federal agencies to annually review programs they administer and identify those that may be susceptible to significant improper payments, to estimate the amount of improper payments, to submit those estimates to Congress, and to submit a report on actions the agency is taking to reduce the improper payments. The Office of Management and Budget (OMB) has identified Medicaid and CHIP as programs at risk for significant improper payments. As a result, CMS developed the Payment Error Rate Measurement (PERM) program to comply with the IPIA / PIIA and related guidance issued by OMB.

The PERM program measures improper payments in Medicaid and produces a national improper payment rate, which is not a fraud rate. Improper payments, which are often cited when discussing program integrity, are payments that do not meet CMS program requirements. PERM is based on reviews of fee-for-service (FFS), managed care, and eligibility components of a state’s Medicaid program in the year under review. The error rate is not a “fraud rate” (or a waste or abuse rate) but a measurement of payments made that did not meet statutory, regulatory, or administrative requirements or are made in an incorrect amount (including overpayments and underpayments). While fraud and abuse may be one cause of improper payments, not all improper payments represent fraud or abuse. PERM is not designed to detect or measure fraud. States are audited on a rolling three-year basis, meaning each PERM cycle measurement includes one-third of states. Annually, the most recent three cycles are combined to produce a national improper payment rate (weighted by state size). (CMS also produces improper payment rates for CHIP, Medicare, and advanced premium tax credits (APTCs) for the federally facilitated exchange.) As with variation in all aspects of Medicaid operations, PERM rates vary across states ranging from under 1% in Alabama, South Dakota, and Washington to over 20% in South Carolina and Wyoming.

In 2024, Medicaid paid an estimated 94.9% of total outlays properly, representing $579.73 billion in proper federal payments (Figure 1). The overall Medicaid improper payment rate was 5.1% (or $31.10 billion in federal payments). However, 79.1% of the improper Medicaid payments were the result of insufficient documentation or missing administrative steps (Figure 1). These payments were not necessarily for ineligible enrollees, providers, or services (i.e., since they may have been payable if the missing information had been on the claim and/or the state had complied with requirements). Examples include state failure to document beneficiary eligibility or to appropriately screen enrolled providers, or medical records not submitted or missing required documentation to support the medical necessity of a claim. Other improper payments include payments for beneficiaries who were ineligible or were eligible but received a service that was not covered (15.6%), for providers not enrolled in the program (2.0%), and other monetary losses (3.3%) (Figure 1). States are often required to develop and implement corrective action plans for errors and deficiencies.

The 2024 improper payment rate was the lowest rate since the COVID-19 pandemic began due, in part, to flexibilities granted during the public health emergency (e.g., suspended eligibility renewal determinations and reduced requirements for provider enrollment and revalidations) and to improved state compliance with program rules. Prior to the pandemic, the improper payment rate increased following the reintegration of the PERM eligibility component in 2019, which was suspended from 2015 – 2018 to provide states with time to adjust to eligibility process changes in the Affordable Care Act.³  (In its place, CMS required states to implement pilots to assess the accuracy of their eligibility determinations.) While the national improper payment rate increased notably in 2019, 2020, and 2021 (to 21.7%), more than three quarters of improper payments (in each year) were due to insufficient documentation or missing administrative steps (data not shown). In 2024, CMS finalized rules related to eligibility and enrollment that included guidance for states on eligibility documentation procedures to reduce “paperwork” errors that lead to the majority of eligibility-related improper payments. Specifically, the rule requires records to be kept in electronic format for the entire period the case is active and for at least three years after and identifies the information that must be included in all case records; however, Congress may repeal these rules.

4. HHS and CMS identify key areas of program integrity focus, informed in part by recommendations made by other federal agencies.

HHS works with all states to develop strategies to address the root causes of improper payments. States are responsible for implementing, overseeing, and assessing the impact of these strategies and actions. Efforts include systems and process improvements (e.g., adding new claims processing checks, upgrading claims processing systems, and enhancing procedures for provider and beneficiary enrollment).

Every five years, HHS and CMS must issue a comprehensive Medicaid program integrity plan that outlines the agency’s strategy for working with states on program integrity. Historically, program integrity efforts focused on the recovery of misspent funds, but more recent initiatives move beyond “pay and chase” models to focus more heavily on prevention and early detection of fraud and abuse and other improper payments. The FY 2024-2028 CMS plan highlights key areas of focus including Medicaid managed care oversight, eligibility determination processes, systems improvements, data analytics and data sharing, and federal training and technical assistance. To help target oversight activities, CMS will continue to use a risk-based approach to focus efforts on high-risk states, providers, managed care plans, and program areas to maximize return on investment. CMS identified Medicaid managed care, non-emergency medical transport (NEMT), dental benefits, nursing facilities, and home- and community- based services as areas where there may be high-risk program integrity vulnerabilities.

Independent agencies like MACPAC and GAO regularly make recommendations to reduce fraud, waste, and abuse in Medicaid. In 2024, GAO indicated CMS had taken steps to address improper Medicaid payments (consistent with their recommendations) including improving managed care oversight (e.g., increasing audits), assessing fraud risks (including documenting vulnerabilities and identifying mitigation strategies), and improving state compliance with provider screening and enrollment requirements. GAO notes, however, actions on recommendations that remain unimplemented could further enhance program integrity—including additional CMS oversight/action to improve state compliance with provider enrollment and screening requirements, ensure timely state eligibility determinations, and improve collaboration with state auditors. Additionally, GAO made recommendations to CMS about other areas where program oversight and transparency could be improved including managed care, demonstration waivers, and other financing. MACPAC recommendations include simplifying and streamlining program integrity regulatory requirements, improving state-federal coordination, and identifying the most effective program integrity activities.

5. “Fraud, waste, and abuse” are at the forefront of current debates as a basis for making changes in Medicaid and more broadly.

Medicaid is a very complex program that involves millions of beneficiaries, hundreds of thousands of providers, 51 state agencies (including DC), different delivery systems, complicated eligibility rules, and significant federal and state expenditures—all of which together create vulnerabilities and opportunities for error. Since the enactment of Medicaid in 1965, the statute has evolved to promote program integrity. The focus of program integrity efforts has also evolved at CMS in response to changing legislation, policy developments, and priorities. Each administration may approach program integrity differently, with different goals and a willingness to accept different tradeoffs. Republicans in Congress and the Trump Administration state they are not aiming to cut Social Security, Medicare, or Medicaid benefits but aiming to root out fraud, waste and abuse—often citing improper payment estimates as evidence of extensive fraud in Medicaid and Medicare, despite GAO stating improper payments are not designed to identify fraud and are not a measure of fraud or abuse. While policy makers and the public support efforts to root out fraud and make government more efficient, there is little support for broad reductions in federal spending on Medicaid that could affect coverage, benefits, or access to care.

What is known about fraud in Medicaid is that it’s not unique to Medicaid (fraud also occurs in Medicare and private health insurance) and is mostly committed by providers. There are checks on fraud, waste, and abuse at both the federal and the state levels, as described in the sections above. GAO and MACPAC recommendations to reduce fraud and abuse may involve additional investments in oversight and transparency but not reductions in federal funding. As the budget debate continues, there may be efforts to recast certain Medicaid policy changes such as adding work requirements to Medicaid and restricting the use of provider taxes as addressing fraud, waste, and abuse. There are proponents and opponents of such policies, and these policies may come with tradeoffs (e.g., decreasing federal funding while shifting costs to the states and reducing coverage), but they are not about rooting out fraud in Medicaid.

1. GAO has issued separate overviews that apply government-wide of fraud and improper payments,  waste, and abuse. ↩︎
2. A subset of states are audited each year; CMS publishes an improper payment rate for the states measured in each cycle – most recently available in 2024 (p. 52), 2023 (p. 52), and 2022 (p. 53). ↩︎
3. CMS continued to report the 2014 improper payment rate for eligibility errors as part of its overall PERM improper payment rate calculation. ↩︎

Key Facts

• The World Health Organization (WHO), founded in 1948, is a specialized agency of the United Nations with a broad mandate to act as a coordinating authority on international health issues, including helping countries mount responses to public health emergencies.
• On January 20, 2025, President Trump issued an Executive Order announcing that the U.S. would withdraw as a member of WHO and halt funding to the organization, and on January 22, 2026, the administration announced the U.S. withdrawal was complete. In 2020 during the first Trump administration, the U.S. temporarily suspended U.S. funding to WHO and initiated a process to end U.S. membership in the organization, actions that were reversed by the Biden administration in 2021.
• Prior to these actions, the U.S. government (U.S.) had been actively engaged with WHO throughout its history, providing financial and technical support as well as participating in its governance structure and had historically been one of the largest funders of WHO. U.S. contributions had ranged between $163 million and $816 million annually over the last decade.
• Since 2021, WHO has overseen negotiation processes to update the International Health Regulations (IHR) and establish a new “pandemic agreement.” In May 2024, member states approved revisions to the IHR and, in May 2025, approved a new pandemic agreement. President Trump’s January 2025 Executive Order withdrawing from WHO also stated that the U.S. would not be bound by the revised IHR or the new pandemic agreement and would no longer participate in related discussions or other WHO-based negotiations.
• WHO now faces funding shortfalls and, in the absence of U.S. contributions, had to implement staffing cuts last year. Almost 3,000 positions – 22% of the organization’s staff – were eliminated between January and June 2025, and a number of WHO’s activities were cut or curtailed. The lack of U.S. support, a shrinking institutional footprint, and other challenges raise questions about WHO’s role going forward.

What is the World Health Organization?

WHO, founded in 1948, is a specialized agency of the United Nations. As outlined in its constitution, WHO has a broad mandate to “act as the directing and coordinating authority on international health work” within the United Nations system. It has 193 member states (the U.S. is no longer a member).

The agency has played a key role in a number of past global health achievements, such as the Alma-Ata Declaration on primary health care (1978), the eradication of smallpox (formally recognized in 1980), the Framework Convention on Tobacco Control (adopted in 2003), and the 2005 and 2024 revisions of the International Health Regulations (IHR), an international agreement that outlines roles and responsibilities in preparing for and responding to international health emergencies. WHO has regularly provided member states with technical guidance and support during responses to epidemics and pandemics, such as Ebola, Zika, mpox, and COVID-19.

Mission and Priorities

WHO’s overarching mission is “attainment by all peoples of the highest possible level of health.” It supports its mission through activities such as:

• providing technical assistance to countries;
• setting international health standards and providing guidance on health issues;
• coordinating and supporting international responses to health emergencies such as disease outbreaks; and
• promoting and advocating for better global health.

The organization also serves as a convener and host for international meetings and discussions on health issues. While WHO is generally not a direct funder of health services and programs in countries, it does provide supplies and other support during emergencies and carries out programs funded by donors.

WHO’s goal for its current work period (2025-2028) is to “get the world back on track to achieve the health-related Sustainable Development Goals (SDGs) while advancing health equity and building health systems resilience.” In pursuit of this, WHO focuses on three priorities: “to promote health by addressing the root causes of disease, including climate change; to provide health by strengthening health systems based on primary health care and expanding access to health services and financial protection; and to protect health by preventing, preparing for, mitigating, detecting and responding rapidly to health emergencies.”

As part of its work to help countries be better protected against health emergencies – and propelled by the issues and challenges faced during the COVID-19 pandemic – WHO has overseen two sets of international negotiations among member states since 2021. The first was a process to update and amend the IHRs, which was completed and approved by member states in May 2024 and came into force in September 2025. While the U.S. had, through Executive Agreement, become party to prior revisions of the IHR, the Trump administration has stated that the U.S. will not be bound by the IHRs any longer. The second is a new pandemic agreement designed to institute common principles and mechanisms contributing to global prevention, preparedness, and response capacities for health emergencies such as pandemics. In May 2025, 124 member states voted to approve the agreement and initiate the process by which it can be ratified by states and then formally adopted by WHO. Eleven countries (including Poland, Israel, Italy, Russia, Slovakia and Iran) abstained from voting on the agreement, while the U.S. and other countries such as Argentina did not participate in the vote and have criticized the agreement. WHO member states continue to negotiate an annex to the agreement that details a new pathogen access and benefits sharing (PABS) system.

Organization

WHO has a global reach, with a headquarters office located in Geneva, Switzerland, six semi-autonomous regional offices that oversee activities in each region,¹ and a network of country offices and representatives around the world. It is led by a Director-General (DG), currently Dr. Tedros Adhanom Ghebreyesus, who was first appointed in 2017 and was re-elected to a second five-year term in May 2022. Dr. Tedros has indicated that his priorities include continuing to strengthen WHO’s financing, staffing, and operations; building pandemic preparedness and response capacities at WHO and elsewhere; and helping countries re-orient health systems toward primary health care and universal health coverage.

World Health Assembly

The World Health Assembly (WHA), now, with the U.S. withdrawal, comprised of representatives from 193 member states, is the supreme decision-making body for WHO and is convened annually. It is responsible for selecting the Director-General, setting priorities, and approving WHO’s budget and activities. The annual WHA meeting in May also serves as a key forum for nations to debate and make decisions about health policy and WHO organizational issues. Every four years, the WHA negotiates and approves a work plan for WHO, known as the general programme of work (GPW). The current GPW (GPW 14) covers the period 2025-2028. Every two years the WHA also approves WHO’s programme budget in support of its work plan; the current programme budget covers the 2026-2027 biennium. More information about WHO’s budget provided below.

Executive Board

WHO’s Executive Board, comprised of 34 members technically qualified in the field of health, facilitates the implementation of the agency’s work plan and provides proposals and recommendations to the Director-General and the WHA. The 34 members are drawn from six regions as follows:

• 7 represent Africa,
• 6 represent the Americas,
• 5 represent the Eastern Mediterranean,
• 8 represent Europe,
• 3 represent South-East Asia, and
• 5 represent the Western Pacific.

Member states within each region designate members to serve on the Executive Board on a rotating basis.

Activities

WHO supports activities across a number of key areas, organized into several “budget segments,” including “base programmes,” emergency operations, polio eradication, and “special programmes” (see Table 1). “Base programmes” refer to WHO headquarters and regional operations activities in support of the organization’s strategic objectives, such as improving access to quality essential health services, essential medicines, vaccines, diagnostics, and devices for primary health care. “Emergency operations” includes WHO efforts to help countries prepare for and respond to epidemics and other health emergencies such as COVID-19, mpox, and natural disasters. “Special programmes” include a number of WHO-led initiatives such as the Research and Training in Tropical Diseases program and Pandemic Influenza Preparedness (PIP) Framework activities.

Funding

Programme Budget

WHO has a programme budget set in advance by member states, which is meant to outline planned activities to meet its work plan over a two-year period (biennium) and describe the “resource levels required to deliver that work.” The current programme budget of $6.2 billion covers the period 2026-2027, and was approved by member states in May 2025. This amount represents a 9% decrease from the previous 2024-2025 programme budget of $6.8 billion. See Table 1.

The programme budget represents a plan for the organization’s anticipated resources, but actual resources may deviate from the initial budgeted amounts over course of the biennium due to changing or unexpected circumstances, such as additional resources provided to WHO for emergency responses or lower levels of support than expected. For example, in the 2022-2023 biennium, WHO reported a final approved budget of $10.4 billion, compared to the initial planned budget of $6.1 billion, largely reflecting additional funding received for emergency operations, including for COVID-19 and polio eradication.

Revenue

WHO has two primary sources of revenue:

• assessed contributions (set amounts expected to be paid by member-state governments, scaled by income and population) and
• voluntary contributions (other funds provided by member states, plus contributions from private organizations and individuals).

Most assessed contributions are considered “core” funding, meaning they are flexible funds that are often used to cover general expenses and program activities. Voluntary contributions, on the other hand, are often “specified” funds, meaning they are earmarked by donors for certain activities. While decades ago the majority of WHO’s revenue came from assessed contributions, in recent years voluntary contributions have comprised the larger share of WHO’s budget. For example, in the 2024-2025 budget period, voluntary contributions accounted for $5.9 billion or 83% of total revenue.² See Figure 1.

Reliance on voluntary, relatively inflexible funding has, in WHO’s view, hampered its operations and effectiveness. In 2022, member states, including the U.S. at that time, agreed in principle to move toward more predictable, flexible funding for WHO and to reduce the role of specified voluntary contributions. Since then, member states have agreed to increases in assessed contributions, with a 20% increase already implemented for the 2024-2025 biennium and another 20% increase approved for the current 2026-2027 biennium, with the goal of having 50% of WHO’s programme budget financed through assessed contributions by 2030.

In 2024, member states also approved the launch of WHO’s first-ever “investment round,” which mobilized additional funding for WHO over the subsequent four years. In its investment case for 2025-2028, WHO estimated it needs $11 billion to implement its general programme of work (GPW) over this period, but member state assessments (core contributions) are likely to amount to $4 billion, leaving a $7 billion gap to fill with voluntary contributions and other donations. Thus far, the investment round has generated $3.8 billion in additional donor pledges through 2028, or 53% of its original goal of $7 billion. The Biden administration did not announce any additional U.S. pledges to WHO through the investment round, and now the Trump administration has ceased U.S. funding for the organization.

Challenges

WHO faces a number of institutional challenges, including:

• a scope of responsibility that has expanded over time with little growth in core, non-emergency funding;
• an inflexible budget dominated in recent years by less predictable voluntary contributions often earmarked for specific activities;
• a cumbersome, decentralized, and bureaucratic governance structure;
• a dual mandate of being both a technical agency with health expertise and a political body where states debate and negotiate on sometimes divisive health issues; and
• ongoing budget and staffing challenges due to the loss of U.S. contributions and changes in the global financial landscape.

These and other challenges were particularly evident during and after perceived failures of the agency in the response to the Ebola epidemic in West Africa (2014-2015), and in the criticisms directed at WHO as it tried to help coordinate a global response to the COVID-19 pandemic. Even as many member states continue to support WHO and recognize its importance for global health, many also call for reforms to the organization that would help address its weaknesses. WHO itself supports reforms in several areas and has taken some internal reform actions.

U.S. Engagement with WHO

Prior to 2025, the U.S. government had long been engaged with WHO in multiple ways including through financial support, participation in governance and diplomacy, and joint activities (see below).

Current Status

In 2020, after the onset of the COVID-19 pandemic, the first Trump administration suspended U.S. financial support for WHO and initiated a process to withdraw the U.S. from membership in the organization.³Under the Biden administration, U.S. relations with WHO were re-established in January 2021, and U.S. funding to the organization was restored.⁴ However, President Trump announced on the first day of his second term, January 20, 2025, that the U.S. would be withdrawing from WHO membership and signed an Executive Order to once again suspend U.S. contributions to the organization, withdraw the U.S. from membership, and recall all U.S. personnel working with the organization. On January 22, 2025, the Trump administration submitted a formal letter of withdrawal to WHO and  stated its withdrawal was completed on January 22, 2026. WHO, however, has responded by raising legal questions about whether the U.S. can complete any withdrawal without meeting its financial obligations such as assessed contributions it has not provided.

Since it began the process of withdrawing from WHO, the Trump administration has begun exploring alternative arrangements such as exploring the use of bilateral agreements to secure access to information about infectious disease outbreaks and has been considering building an alternative system for global outbreak detection and response, separate from WHO. Some U.S. states have expressed disagreement with the Trump administration’s withdrawal from WHO and are pursuing direct partnership with WHO themselves.

History

Financial Support

Prior to 2025, the U.S. government supported WHO through assessed and voluntary contributions (which have now been halted as directed by President Trump’s Executive Order). The U.S. had been the single largest contributor to WHO (though in the 2020-2021 period, when the first Trump administration withheld some U.S. funding during the COVID-19 pandemic, it was the third largest).

For many years, the assessed contribution for the U.S. has been set at 22% of all member state assessed contributions, the maximum allowed rate. Between FY 2017 and FY 2024, the U.S. assessed contribution was fairly stable, fluctuating between $109 million and $122 million (in FY 2019 and FY 2020 the U.S. actually paid less than its assessed amount, and in FY 2021 it paid more than that amount due to payments made toward outstanding arrears). See Figure 2.

Voluntary contributions for specific projects or activities, on the other hand, varied to reflect changing U.S. priorities and/or support during international crises. Over the past decade, U.S. voluntary contributions ranged from a low of $105 million in FY 2020 to a high of $694 million in FY 2022. Higher amounts of voluntary contributions were reflective of increased U.S. support for specific WHO activities such as emergency response. U.S. voluntary contributions also supported a range of other WHO activities such as polio eradication; maternal, newborn, and child health programs; mental health services for victims of torture and trauma; health coordination in COVID-19 response; and other infectious diseases.

For the 2022-2023 biennium period, WHO reported that U.S. assessed and voluntary contributions together represented 15.6% of WHO’s total revenue, making the U.S. the largest donor to WHO during that period.

Governance Activities

Prior to its withdrawal, the U.S. had been an active participant in WHO governance, including through the Executive Board and the World Health Assembly (WHA).  This had included  active engagement at the WHA, sending a large delegation each year that was typically led by a representative from the Department of Health and Human Services, with multiple other U.S. agencies and departments also participating and  active participation in pandemic agreement negotiations and in the process to update and amend the IHR agreement. All official U.S. participation in WHO governance has been terminated.

Technical Support

The U.S. had, in the past, provided technical support to WHO through a variety of activities and partnerships. This included U.S. government experts and resources supporting research and reference laboratory work via WHO collaborating centres, WHO-based international partnerships such as the global outbreak and response network (GOARN), and advisory groups convened or overseen by WHO. U.S. government representatives had often been seconded to or had served as liaisons at WHO headquarters and WHO regional offices, working day-to-day with staff on technical efforts,⁵ though those personnel were recalled following the initiation of the U.S. withdrawal.

Partnering Activities

The U.S. had also worked in partnership with WHO before and during responses to outbreaks and other international health emergencies, including participating in international teams that WHO organized to investigate and respond to outbreaks around the world. For example, the U.S. worked with WHO and the broader multilateral response to the Ebola epidemic in West Africa that began in 2014, and U.S. scientists were part of the WHO delegation that visited China in February 2020 to assess its response to COVID-19. However, U.S. withdrawal from WHO has brought such coordination to an end.

Endnotes

1. These include: AFRO (Africa), EMRO (Eastern Mediterranean), EURO (Europe), PAHO (The Americas), SEARO (Southeast Asia), and WPRO (Western Pacific). ↩︎
2. WHO. Contributors 2024-2025. http://open.who.int/2024-25/contributors/contributor. Data through December 2025. Accessed February 2, 2026. “Other revenue” includes contributions to the PIP (pandemic influenza preparedness) partnership and Contingency Fund for Emergencies. ↩︎
3. Trump Administration/White House. “President Donald J. Trump Is Demanding Accountability From the World Health Organization.” Fact Sheet. April 15, 2020; Trump Administration/White House. Letter to Dr. Tedros Adhanom Ghebreyesus, WHO Director-General from President Trump. May 18, 2020.; Trump Administration/White House. “Remarks by President Trump on Actions Against China.” Remarks by President Trump on May 29, 2020. May 30, 2020; Trump Administration/U.S. Department of State. “Update on U.S. Withdrawal from the World Health Organization.” Press Statement by Morgan Ortagus, Department Spokesperson. Sept. 3, 2020. https://2017-2021.state.gov/update-on-u-s-withdrawal-from-the-world-health-organization/index.html. ↩︎
4. White House, “Letter to His Excellency António Guterres,” correspondence from President Biden, Jan. 20, 2021, https://qa.usembassy.gov/letter-to-his-excellency-antonio-guterres/; Associated Press. ‘Biden’s US revives support for WHO, reversing Trump retreat’. January 2021. https://apnews.com/article/us-who-support-006ed181e016afa55d4cea30af236227. ↩︎
5. CDC. Global Health Partnerships webpage. https://web.archive.org/web/20241214013406/https://www.cdc.gov/global-health/partnerships/. ↩︎