Approximately 1 in 5 teens in the United States experience symptoms of anxiety or depression and many youth experience bullying and violence, which can have adverse effects on their mental health. Schools can play a role in promoting mental health and connecting youth to treatment. One approach that many schools have implemented is social and emotional learning, which teaches skills such as emotional management, resilience, and relationship building. Social and emotional learning in schools has received more attention in recent years. For instance, the Surgeon General’s 2021 Youth Mental Health Advisory recommended the expansion of social and emotional programs. Meanwhile, critics argue that these programs should be banned from schools, suggesting that they take away from academic instruction time and incorporate critical race theory.

Social and emotional learning programs focus on developing intrapersonal and interpersonal skills; however, specific program content and integration strategies can vary widely across schools. Goals, benchmarks, and guidelines for social and emotional learning programs in schools are typically developed at the state level. Individual schools may then implement social and emotional learning in a number of ways, including through academic instruction (e.g. group projects to encourage collaboration, or complex problem-solving to encourage persistence); through separate, dedicated time for social and emotional learning instruction; or through schoolwide measures (e.g. disciplinary methods that incorporate social and emotional learning competencies). Regardless of how social and emotional learning is integrated, the content typically focuses on intrapersonal and interpersonal skill building, including self-awareness, self-management, responsible decision making, social awareness, and relationship skills.

Sixty-three percent of public schools in the U.S. had a formal curriculum to support their students’ social and emotional skill development in the 2023-2024 school year (Figure 1). These curricula are more common in elementary schools (74%) compared to middle (58%) and high schools (43%). Additionally, among schools with a formal curriculum, 81% of teachers and 51% of non-teaching staff received training or professional development to implement their school’s curriculum.

Among schools with a social and emotional learning curriculum in the 2023-2024 school year, 72% found that the curriculum was moderately, very, or extremely effective in improving student outcomes. Social and emotional learning has been linked to positive outcomes for students, including fostering emotional intelligence, reducing emotional distress, fostering empathy, developing and maintaining peer relationships, and academic improvement. However, measuring outcomes of social and emotional learning programs can be difficult as implementation strategies and content may vary between programs.

Common barriers to implementing social and emotional learning curricula in schools include lack of funding and materials. Thirty-seven percent of public schools reported not having a formal curriculum for social and emotional skill development in the 2023-24 school year. Among these schools, a lack of time (46%), funding (37%), and materials and resources (34%) were the main reasons for not having a formal curriculum (Figure 2). Several funding opportunities to support social and emotional learning have opened in the last decade, including the Every Student Succeeds Act in 2015, and more recently, the American Rescue Plan Act (ARPA) in 2021, which required school districts to use a portion of funds to support students’ mental health needs. Analyses of how school districts planned to spend ARPA funds found that student social-emotional development was a priority, with many districts allocating some funds to social and emotional instruction materials and training. However, schools often have many competing budget priorities, such as providing funds to address staffing shortages and academic recovery in light of the pandemic, which may limit the amount of funds they have available for social and emotional learning.

As support for social and emotional learning in schools has grown in recent years, so has opposition. Opponents argue that social and emotional learning in schools can take away from academic instruction time; and, more recently, that it incorporates critical race theory and gender identity lessons. This has led to the introduction of several state bills – including Indiana, Iowa, Montana, North Dakota, Oklahoma, Maine, and New Hampshire – banning or limiting social and emotional learning in schools. Supporters, however, argue that social and emotional learning is an evidence-based approach that allows schools to focus on the “whole child”, leading to a wide array of positive outcomes, such as academic achievements, emotional intelligence, and growth opportunities for all students regardless of their backgrounds. This support was recently reflected in a bipartisan resolution designating a “National Social and Emotional Learning Week” which also received recognition from President Biden.

On July 16, 2022, the federally mandated crisis number, 988, became available to all landline and cell phone users at no charge. This three-digit number connects users–via phone, text, or chat–to a network of over 200 local and state-funded crisis call centers, providing access to the 988 Suicide & Crisis Lifeline for crisis counseling, resources, and referrals. Federal investments supported the launch and implementation of 988, but ongoing funding of local call centers, as well as the development of other core components of the behavioral health crisis continuum, largely falls to state and local governments.

Over half a million lives (500,399) were lost to suicide between 2012 to 2022, with suicide rates rising nationally and in most states over this period (Appendix Table 1). Reflecting rising suicide rates, 9 in 10 adults believe the United States is amid a mental health crisis. Firearms are the predominant suicide method, involved in over half of all suicides, and increases in firearm suicides drove the total suicides to a record high in 2022.

This brief examines 988 two years after implementation using the most recent data available through May 2024 from Lifeline, including: 988 performance metrics nationally and by state, state efforts to fund local 988 call centers, emerging policies and initiatives that may indicate future trends, and a look at data that may be helpful in ongoing monitoring and development of 988.

Key takeaways from this KFF analysis of Lifeline data include the following:

• Since launch in July 2022, 988 has received 10.8 million calls, texts, and chats. In May 2024, monthly contacts exceeded half a million, up about one-third from a year ago and 80% since May 2022. Despite increased demand for 988 services, national answer rates improved and wait times decreased, though some gains slipped in the second year.
• State-level call volume and in-state answer rates vary widely across states. Monthly call volume increased in all states—ranging from 25% to 185% since launch — and the most recent in-state answer rates range from 64% to 97% in May 2024.
• Ten states have added telecom fees to provide more sustainable funding for local 988 crisis call centers, which may help centers keep up with the rising call volumes.
• Developments in 988 policy and crisis service policy include potential changes in 988 routing (georouting), continued expansion of mobile crisis and short-term crisis stabilization facilities, enhanced technology and infrastructure to connect 988 with other crisis and emergency services, and growth of specialized services for certain populations.
• 988 metrics are available online through Lifeline, though these data tend to be somewhat limited. Some states are using dashboards to provide additional data that may help to inform efforts to address suicide rates in their state.

What do we know about 988 utilization and awareness?

Since launch in July 2022, 988 received nearly 10.8 million contacts, including 1.4 million to the Veteran’s Crisis Line (VCL), with the remaining contacts consisting of 6.4 million calls, 1.4 million chats, and 1.6 million texts. SAMHSA reports that over 10 million calls, texts and chats have been answered by crisis counselors since launch, including those to the VCL. Detailed data for the VCL is not publicly available, so the remainder of the brief will not include that data. Calls are the most common mode of 988 contact, accounting for about two-thirds (68%) of total contacts to 988. Text messages and chats make up the remaining one-third of total contacts, accounting for 17% and 15%, respectively. Lifeline metrics provide only a partial picture of total crisis hotline contacts, as fewer than half of all crisis call centers (about 200 of 544) participate in the Lifeline network.

988 contacts (calls, texts, and chats) exceeded half a million in May 2024, up about one-third from a year ago and 80% since May 2022. Text message volume saw the highest relative increase, growing more than 11-fold since launch, compared to nearly 2-fold for calls. In contrast, chat volume decreased, possibly because text communication via cell phone is preferred over browser-based chat (Figure 1).

Since launch, national answer rates improved and wait times fell, even with substantial rises in contact volume—though some gains slipped in year 2. Overall answer rates rose from 70% in May 2022 (before launch) to 89% two years later, and wait times fell from 2 minutes and 20 seconds to 1 minute and 31 seconds. While these do represent improvements since launch, they are somewhat lower than they stood at one year after 988’s launch—where answer rates were higher, at 93% and wait times were lower, at 35 seconds. The decline in some performance metrics in year 2 may be due to continued rise in 988 contacts (Table 1).

KFF polling indicates that public awareness of 988 is generally low, with 18% of adults reporting they have heard a lot or some about it. As of mid-2023, fewer than 2 in 10 adults reported familiarity with 988 and its services, though awareness may have increased since then. Despite generally low awareness, those with high psychological distress, adults who speak English very well, and White adults are more likely to report familiarity with 988. In contrast, awareness is lower among Black, Hispanic, and Asian adults and among those who do not speak English very well (Figure 2). Federal awareness campaigns set to launch in mid to late 2024, along with proposed legislation introduced to Congress late last year, aim to boost public awareness of 988 and its services. As knowledge of 988 rises, so could the demand for its services.

How does implementation vary by state?

Call volume increased in all states, with increases up to 185%. State-level data is available through Lifeline for calls to 988, but not for text or chat. Nationally, call volume rose by 95% from pre-launch to two years later, but this varied widely across states, from a low of 24% in Idaho to a high of 185% in Oklahoma. The variation in growth rates across states may be influenced by the development of 988 infrastructure and public awareness campaigns

Although nearly all states have maintained or improved their in-state answer rate since 988’s launch, answer rates continue to vary across states and range from 64 to 97% as of May 2024. 988 routes calls based on the caller’s area code to the nearest crisis center. An “in-state answer rate” measures the percentage of calls answered in the state that aligns with the caller’s area code. In May 2024, in-state answer rates ranged from a low of 64% in Nevada up to 97% in Mississippi, Montana, and Rhode Island. Calls not answered in-state are either transferred to one of Lifeline’s national backup centers or abandoned by their caller. Long wait times or local crisis center unavailability can lead to a call being redirected to national backup centers, where counselors will answer the crisis call, but may be less familiar with local resources. These calls count toward the national answer rate but not toward the answer rate of the state where the Lifeline backup center is located. Nationally, about 6% of state calls are transferred to a federal overflow facility and 10% are abandoned in-state, though these rates also vary by state. Per SAMHSA, calls may be abandoned by their user due to a technical reason (e.g. internet or mobile connection strength or service interruptions, etc.) or because the person seeking assistance ends the contact before a counselor answers, which could also happen for a range of reasons, such as they had to wait too long or decided they were not comfortable discussing their experience.

Ten states have added telecom fees to provide more sustainable funding for local 988 crisis call centers, which may help local crisis centers keep up with rising demand for the service. Although federal investments support 988 nationally and help to support state implementation, states are largely responsible for long-term funding of the local 988 crisis call centers, which have historically received minimal funding from the federal government. Under the National Suicide Hotline Designation Act of 2020, states can collect cell phone fees to help sustainably fund their local 988 call centers (similar to how 911 is funded). So far, ten states have enacted legislation to fund crisis services through telecom fees, including Virginia, Colorado, Washington, Nevada, Minnesota, California, Oregon, Delaware, Maryland, and most recently Vermont. Additionally, four other states have pending telecommunications fee legislation. Early adopters of telecom fees, such as Virginia and Washington, collected between $10.9 to $30.4 million in 988 telecom fees during FY 2022, according to an FCC report. Other sources of 988 funding include trust funds and general fund appropriations, and 5% crisis services set aside from mental health block grant funds. Insurer payments can help financially sustain 988 and other crisis services, with some states billing Medicaid or other payers and several states also passing laws requiring insurers to cover crisis care services.

What are new developments related to 988 and the crisis continuum, more broadly?

Proposals to improve 988 routing aim to mirror certain 911 standards, including georouting and requirements for cell phone carriers to route 988 calls during service interruptions. Currently, 988 routes calls based on the caller’s area code, which can be problematic for people with area codes not reflective of their current location, resulting in connections to distant crisis centers with counselors unfamiliar with the local resources near the caller. Unlike 911, which uses precise geolocation data, the proposed 988 georouting would direct calls to the nearest crisis center without disclosing the caller’s exact location, helping to address technical, privacy, and legal concerns. In April of this year, the Federal Communications Commission (FCC) issued a notice proposing rulemaking for wireless carriers to adopt 988 georouting and requested comments on extending this to text messages and specialized services like LGBTQ+ and Spanish services, which are not available at all local crisis center locations. Separate legislation proposed late last year aims to improve 988 access by requiring carriers to allow 988 calls during service disruptions and ensuring multi-line systems, such as those in hotels, recognize 988 calls directly without additional steps like dialing 9 first.

Similar to 988, mobile crisis units and short-term crisis stabilization facilities are core components of the behavioral health crisis continuum, though their development and availability varies across states. Mental health professionals staff these services and provide alternatives to emergency departments and law enforcement during mental health emergencies. States are at different stages of establishing mobile crisis and short-term crisis stabilization services, and some states have leveraged Medicaid and Medicaid-focused provisions in the American Rescue Plan Act to support mobile crisis development. Most states have some form of mobile crisis, but short-term crisis stabilization facilities are less common. Even among states that have mobile crisis units, these units are often not available 24/7 or statewide. Compared to 988, other components of the crisis response system have little federal coordination, which may result in more variation in their development and structure across states.

States are investing in technology to improve infrastructure and coordination across crisis services and other emergency and health services. For example, some states are developing infrastructure to enable coordination and call diversion for mental health calls from 911 to 988. However, technical and logistics challenges, such as the presence of multiple local 911 call centers per area code and the need to develop operational rules and agreements for each, have slowed progress. Other technological developments include service registries to track bed availability, facility capacity, and appointment scheduling. GPS-enabled mobile crisis dispatch systems and tools for crisis staff to view and schedule mental health appointments are also being developed. Recent CMS guidance clarifies how Medicaid may help support some of these efforts. Additionally, the federal government’s action plan, part of the HHS’s 2024 National Strategy for Suicide Prevention, proposes funding a mobile crisis locator for use by 988 crisis centers.

Specialized services to meet the unique needs of various populations, including LGBTQ people, Spanish speakers, American Indian and Alaska Native (AIAN) people, older adults, and others, are being developed at both federal and state levels. In March 2023, Lifeline expanded its LGBTQ+ services, providing 24/7 text and phone access to affirming counseling for those under age 25. This line accounted for nearly 10% of all 988 contacts over a four-month period, but had higher abandonment rates and longer wait times than the general 988 line. Additionally, 988 offers options to route Veterans, people who speak Spanish, and people who have difficulty hearing to specialized services. Certain states are building targeted services for older adults (staffed with older adult peer supports) and launching youth-specific initiatives, including mobile crisis services for youth. Efforts are being made to provide culturally competent services for AIAN populations and other racial and ethnic groups, to address the unique needs of rural and remote areas, and to support individuals with co-occurring mental health and substance use needs.

What data beyond Lifeline could help inform implementation and improvement efforts?

Additional state and national crisis center metrics may help inform the 988 implementation and future program improvements. Call volume, wait times, and other metrics from Lifeline provide some insights into accessibility and demand for 988, but they don’t tell the whole story. For example, without additional data, it’s not possible to answer questions about the conditions or circumstances that prompted the 988 calls, the resolution of these calls and whether they connected to additional crisis or outpatient services, and user experience across different demographics and geographies. Comprehensive metrics can help policymakers and researchers evaluate 988’s effectiveness, identify gaps, and develop targeted interventions. Table 2 lists metrics that could be helpful for understanding 988’s implementation.

Some states or crisis call centers already track and display detailed crisis metrics through regularly updated dashboards. These online dashboards display key metrics of crisis call data, refreshed at regular intervals. In Arizona, the Solari Crisis Response Network displays aggregate data for crisis call centers in two regions. Similarly, the University of Utah summarizes Utah’s crisis data in a dashboard and in crisis services annual reports (2021 and 2020). South Dakota’s only crisis line displays detailed aggregate data on a publicly accessible dashboard, including historical data and breakouts by age, race, and gender. Data presented on these dashboards are more detailed than Lifeline data, containing metrics on accessibility, referral source, reason for the call, and some outcomes, but many do not contain historical summaries. Wisconsin’s dashboard is an exception, as it provides monthly snapshots and downloadable historical summary data.

If you or someone you know is considering suicide, call or text the 988 Suicide & Crisis Lifeline at 988

Health care debt is a widespread problem in the United States, garnering the attention of some policymakers and emerging as a potential campaign issue. A 2022 KFF survey found that 2 in 5 US adults (41%) of all ages report some form of debt due to medical or dental bills for their own or someone else’s care. Nearly three-quarters of adults say they are worried about affording unexpected medical bills or the cost of health care services, higher than the shares who report worrying about affording other household expenses. The Medicare program, which provides health insurance coverage to 66 million people, most of whom are older adults ages 65 or older, helps to cover the cost of medical care for those who qualify, yet health care cost-related problems among Medicare-age adults are not uncommon and leave many exposed to debt, with potentially serious and long-lasting health and financial consequences.

Medicare offers coverage for a range of health care services, including hospitalizations, physician visits, prescription drugs, and post-acute care, but Medicare beneficiaries generally pay out-of-pocket for their monthly premiums and deductibles, cost-sharing for Medicare-covered services, and the cost of services not covered by Medicare, such as dental, vision, and hearing care and long-term services and supports. Medicare households also spend more on health care than other households and devote a larger share of their household budgets to medical costs and premiums. Health costs are a particular challenge for the millions of Medicare beneficiaries with limited income and savings to absorb unexpected health or other expenses. Finally, older adults are more likely than younger populations to have cognitive impairments such as Alzheimer’s Disease, which have been shown to contribute to a decline in credit scores and financial instability years before the condition is diagnosed.

This data note examines findings from the KFF Health Care Debt Survey to assess the prevalence, sources and consequences of health care debt among Medicare-age adults.

Key Takeaways

• More than one in five US adults ages 65 and older (22%) reported having some form of debt in 2022 as a result of medical or dental bills for their own or someone else’s care, which is half the share reported among adults ages 50-64 (44%).
• Among Medicare-age adults with health care debt, large shares say that some of the bills that caused their debt were due to routine health care services such as lab fees and diagnostic tests (49%), dental care (48%), and visits to the doctor (41%).
• Nearly three in ten Medicare-age adults with health care debt (29%) say their household has been contacted by a collection agency in the past five years as a result of medical or dental bills, while one in four (23%) say that health care debt has negatively affected their credit score.
• Three in five Medicare-age adults with health care debt (62%) say that they, or another member of their household, have delayed, skipped, or sought alternatives to needed health care or prescription medications due to costs in the past year.

In 2022, more than one in five US adults ages 65 and older (22%) had some form of debt as a result of medical or dental bills (Figure 1). This is roughly half the share found among adults ages 50 to 64 (44%), who are not yet eligible for Medicare based on age. Lower rates of health care debt among older adults are likely due, in part, to nearly universal Medicare coverage among people ages 65 and older. Additionally, most Medicare beneficiaries have some form of coverage that limits their cost-sharing expenses, such as Medicare Advantage, or supplemental coverage, such as Medicaid, retiree health benefits, or Medigap.

The rate of health care debt among people ages 65 and older is higher than reported by some others,  principally because of methodological differences in the way health care debt is defined. Surveys of health care debt in the US have commonly focused on unpaid medical bills, or bills which have been sent to collections, which may overlook the share of adults who pay off their health care bills by accumulating credit card debt, taking out loans, or borrowing from family and friends. For this reason, the KFF Health Care Debt Survey provides a broad measure of health care debt, which includes other types of debt incurred as a result of medical or dental bills, as well as debts owed for the care of someone else, such as a child, spouse, or parent.

Many older adults pay off their health care bills by accumulating credit card debt or debt from other sources (Figure 2). Roughly one in ten Medicare-age adults report having medical or dental bills that they are paying off over time directly to a provider (12%), put on a credit card and are paying off over time (11%), are past due or unable to be paid (8%), or have debts owed to a bank, collection agency or other lender as a result of loans used to pay off medical or dental bills (7%). A smaller share report debts owed to family and friends for money borrowed to pay off medical or dental bills (3%).

Roughly two in five Medicare-age adults with health care debt (39%) owe less than $1,000, including one in five (19%) who owe less than $500, but one in ten Medicare-age adults with health care debt (11%) owe $10,000 or more (data not shown). Even relatively small amounts of debt can contribute to a drop in credit ratings.

Sources of health care debt among older adults are varied, and include many routine health care needs (Figure 3). Nearly half of Medicare-age adults with health care debt say that some of the bills that caused their debt were due to lab fees and diagnostic tests (49%), dental care (48%), and visits to the doctor (41%). One in three (31%) attribute a portion of their debt to emergency care, and one in four (24%) to prescription drugs. Dental care is one of the leading causes of health care debt among Medicare-age adults, likely due to the fact that traditional Medicare does not offer coverage for dental care services. (Most Medicare Advantage plans include some dental care coverage, but the scope of coverage varies widely, and enrollees may still incur substantial out-of-pocket costs for these services.)

Just 6% of Medicare-age adults attribute a portion of their debt to bills for long-term care services and supports, such as the cost of nursing home care, assisted living or full or near full-time home health aides. These services are used extensively by a relatively small segment of the Medicare population but can be quite costly. For example, in 2023, the median annual cost of a private room in a nursing home was $116,800 and $288,288 for round-the-clock home health aide services. These costs far exceed the median income ($36,000 per person) and savings ($103,800 per person) of the average Medicare beneficiary in 2023. Medicare does not generally cover these services, placing them out of reach for many older adults and leaving some with substantial debt. (Survey findings may underrepresent the costs and associated debt incurred by people living in nursing homes, assisted living facilities and other institutional settings, though the survey does include debt associated with long-term services and supports if incurred by other family members.)

The financial consequences of health care debt may be lasting. Nearly three in ten Medicare-age adults with health care debt (29%) say their household has been contacted by a collection agency as a result of medical or dental bills, while one in four (23%) say that health care debt has negatively affected their credit score (Figure 4). For retirees with health care debt, these consequences may be difficult to reverse, and can make it more challenging to secure affordable credit in the future. The Consumer Financial Protection Bureau recently proposed a rule that would remove health care bills from most credit reports and prohibit lenders from making loan decisions based on medical information, with the goal of reducing the burden of health care debt for US adults and safeguarding against coercive credit reporting practices.

Two in five Medicare-age adults with health care debt report that they, or another member of their household, have cut back spending on household necessities (42%) or used up a large portion of their savings (39%) in the past five years as a result of their health care debt (Figure 5). One in three have taken money out of long-term savings accounts, such as a retirement account (34%) or increased their credit card debt for non-medical purchases (31%), and one in five have taken out a loan (21%) or skipped or delayed payment of other bills (18%). Sacrifices such as these can have serious consequences for financial stability and general wellbeing and may perpetuate the cycle of health care debt by leaving older adults with fewer resources for other needed health expenses.

Three in five Medicare-age adults with health care debt (62%) say that they, or another member of their household, have delayed, skipped, or sought alternatives to needed health care or prescription medications due to costs (Figure 6). Nearly half (48%) of Medicare-age adults with health care debt postponed getting health care they needed in the past year, while two in five (43%) relied on home remedies or over the counter drugs instead of going to the doctor, and one in three did not get a medical test or treatment recommended by a doctor (31%) or took less than the prescribed dose of a medication by skipping doses, cutting pills in half, or leaving the prescription unfilled (28%).

This fact sheet summarizes the major statutory requirements and policies pertaining to U.S. global family planning/reproductive health (FP/RH) efforts over time and identifies those currently in effect.  These laws and policies collectively serve to direct how U.S. funds are spent, to where and which organizations funds are provided, and generally shape the implementation and define the scope of U.S. global FP/RH activities. It includes U.S. laws and annual requirements enacted by Congress through appropriations bills (statutory provisions) as well as executive branch policies and guidance specific to FP/RH (policy provisions). Each category lists provisions in chronological order.

1. As noted in CRS, Abortion and Family Planning-Related Provisions in U.S. Foreign Assistance Legislation and Policy, July 2022: “No restrictions exist on funding for the medical evacuation of Peace Corps volunteers who decide to have an abortion. Under existing policy, the Peace Corps covers the cost of evacuation to a location where ‘medically adequate facilities’ for obtaining an abortion are available and where abortions are legally permissible.” ↩︎
2. In most recent years, a provision is included requiring that any Kemp-Kasten determination that is made must be accompanied by the evidence and criteria used to make the determination. ↩︎
3. USAID defines a target/quota as “a predetermined figure that a service provider or referral agent is assigned or required to affect or achieve” for the purposes of the Tiahrt Amendment. It states that “the key to interpreting ‘incentives’ is to see whether they are provided in exchange for accepting a method (in the case of a client) or linked to achievement of a predetermined target or quota (in the case of program personnel).” USAID Global Health eLearning Center, “FP Legislative & Policy Requirements (Updated),” online course, February 2009, authored by Debbie Gueye, MSI. ↩︎
4. USAID Global Health eLearning Center, “FP Legislative & Policy Requirements (Updated),” online course, Feb. 2009, authored by Debbie Gueye, MSI. ↩︎
5. Although such reallocation began in practice in FY 2002, it was first authorized by Congress in legislation beginning in FY 2004 with reference to FY 2002 and FY 2003 funds. ↩︎
6. Informed Choice: Effective access to information on family planning choices and to the counseling, services, and supplies needed to help individuals choose to obtain or decline services; to seek, obtain, and follow up on a referral; or simply to consider the matter further. Voluntarism: Decision to use a specific method of family planning or to use any method of family planning is based upon the exercise of free choice and is not obtained by any special inducements or any element of force, fraud, deceit, duress or other forms of coercion or misrepresentation. USAID Global Health eLearning Center, “FP Legislative & Policy Requirements (Updated),” online course, Feb. 2009, authored by Debbie Gueye, MSI. ↩︎
7. This policy was first instituted via presidential memorandum in 1984 by President Reagan. In 1993, it was rescinded by President Clinton, although it was briefly applied legislatively in 1999 (see “Status” column). In 2001, it was reinstated by President Bush, who expanded its applicability in 2003 to include family planning funds at the State Department (see “Applies to” column) with some exemptions. In 2009, it was rescinded by President Obama. In 2017, it was reinstated by President Trump, who expanded its applicability to include the vast majority of global health assistance furnished by all departments and agencies. In 2021, it was rescinded by President Biden.. ↩︎
8. Note that, with one exception, has been applied via Executive action. The exception was in FY 2000, when President Clinton agreed to a one-year legislative codification with a partial waiver of restrictions as part of a broader arrangement to pay the U.S. debt to the United Nations. See P.L. 106-113, Sec. 599D, and PAI, Global Gag Rule Timeline, July 12, 2011. ↩︎
9. For example, one provision related to abortion included in the Standard Provisions is: “M16. VOLUNTARY POPULATION PLANNING ACTIVITIES – MANDATORY REQUIREMENTS (MAY 2006) … b. Prohibition on Abortion-Related Activities: (1)           No funds made available under this award will be used to finance, support, or be attributed to the following activities: (i) procurement or distribution of equipment intended to be used for the purpose of inducing abortions as a method of family planning; (ii) special fees or incentives to any person to coerce or motivate them to have abortions; (iii) payments to persons to perform abortions or to solicit persons to undergo abortions; (iv) information, education, training, or communication programs that seek to promote abortion as a method of family planning; and (v) lobbying for or against abortion. The term “motivate,” as it relates to family planning assistance, must not be construed to prohibit the provision, consistent with local law, of information or counseling about all pregnancy options. (2)           No funds made available under this award will be used to pay for any biomedical research which relates, in whole or in part, to methods of, or the performance of, abortions or involuntary sterilizations as a means of family planning. Epidemiologic or descriptive research to assess the incidence, extent, or consequences of abortions is not precluded.”   ↩︎

As a candidate in 2020, President Biden campaigned on building upon the Affordable Care Act (ACA) by increasing the amount of financial assistance available to people buying their own health insurance coverage through the ACA Marketplaces. Temporary subsidies were originally passed as part of the American Rescue Plan Act (ARPA) in 2021, which included two years of enhanced subsidies (2021 and 2022). The Inflation Reduction Act (IRA), which passed in 2022, extended these enhanced subsidies for an additional three years, ending after 2025.

The IRA and ARPA’s enhanced health insurance subsidies both increase the amount of financial help available to those already eligible for assistance under the ACA and also newly expand subsidies to middle-income people (with incomes over four times the poverty level, $103,280 for a family of three in 2024), many of whom were previously priced out of coverage. These subsidies, combined with increased funding for outreach and marketing, have led to record-high enrollment in the ACA Marketplaces.

By the time these enhanced subsidies are currently set to expire at the end of next year, they will have been an integral part of the ACA Marketplaces for 5 years, or nearly half as long as the ACA Marketplaces have existed. Millions of enrollees have come to rely on the enhanced subsidies, with more people gaining Marketplace coverage since President Biden took office than had signed up for ACA Marketplace when the markets first launched in 2014. If the enhanced subsidies expire, almost all ACA Marketplace enrollees will experience steep increases in premium payments in 2026. However, the subsidies come at a steep cost to taxpayers, with the CBO projecting that a permanent extension of the subsidies would cost $335 billion over the next ten years.

The charts below show the impact these subsidies have had on enrollment and premium payments, and the potential implications if the enhanced subsidies expire. This analysis finds that:

• The recent growth in ACA Marketplace plan enrollment has been driven primarily by low-income people, with signups by people with incomes up to 2.5 times poverty growing 115% since 2020.
• Enhanced subsidies have cut premium payments by an estimated 44% ($705 annually) for enrollees receiving premium tax credits. If the subsidies expire, most Marketplace enrollees will see premium payment increase substantially.
• Without these enhanced subsidies, premiums would double or more, on average, for subsidized enrollees in 12 states using Healthcare.gov.

While enhanced subsidies expire at the end of 2025, insurers and regulators will want to know well in advance whether the subsidies will be renewed or discontinued so they can set accurate premiums for 2026.

Since 2020, the year before the enhanced subsidies went into effect, the number of people with ACA Marketplace coverage has grown by 88% from 11.4 million to 21.4 million.

All the growth in Marketplace enrollment in the last four years is among people receiving an advanced payment of the premium tax credit. Subsidized enrollment is up 106%, from 9.6 million (84% of Marketplace enrollees) in 2020 to 19.7 million people (92% of the total number of Marketplace enrollees). If the Inflation Reduction Act’s enhanced subsidies expire, the Congressional Budget Office (CBO) expects ACA Marketplace enrollment to drop sharply from an estimated 22.8 million in 2025 to 18.9 million the following year. CBO projects that enrollment would continue to fall in the subsequent years reaching as low as 15.4 million in 2030.

Spurred by the availability of plans with no or very low premium payment – often with very low deductibles – made possible by enhanced subsidies, low-income enrollees (those with incomes up to 2.5 times the federal poverty level) have driven most (83%) of the enrollment growth in the ACA Marketplaces from 2020 to 2024. While these plans with little or no premium payment are available nationwide, they are available to a larger share of ACA Marketplace enrollees in the ten states that have not expanded Medicaid.

While most of the recent growth in enrollment is from low-income enrollees, all income groups have seen substantial growth. From 2020 to 2024, the number of Marketplace enrollees with incomes up to 2.5 times poverty grew by 115%, whereas enrollment for those with incomes between 2.5 and 4 times poverty grew by 36%, and enrollment for those with incomes above 4 times poverty grew by 57%.

ACA Marketplace enrollees with incomes just above the federal poverty level (up to 2.5 times poverty) are eligible for cost sharing reductions (CSR) that reduce deductibles and other cost sharing. From 2020 to 2024, the number of enrollees receiving cost sharing reductions increased by 91% from 5.6 million to 10.6 million enrollees.

The Inflation Reduction Act’s enhanced subsidies make the reduced cost sharing plans more affordable. For example, $0 premium silver plans with very low deductibles are available to the lowest income enrollees (those with incomes up to 1.5 times poverty), whereas before the enhanced subsidies became available, these enrollees would have had to pay about 2%-4% of their household income for a plan with a reduced deductible.

The enhanced subsidies in the Inflation Reduction Act reduce net premium costs by 44%, on average, for enrollees receiving premium tax credits, though the amount of savings varies by person. In 2024, the average annual premium payment would have been $1,593, but instead was $888 because of the Inflation Reduction Act subsidies, which average $705 per enrollee.

On average, the total annual premium is similar in 2024 ($7,320) to what it was in 2020 ($7,132), but the federal government is paying a larger share of the total premium (a subsidy of $6,432 or 88% of the average annual premium in 2024, compared to a subsidy of $5,942 dollars or 83% of the average annual premium in 2020).

Enhanced subsidies work by reducing the amount an enrollee has to pay for a benchmark silver plan. Under the Inflation Reduction Act, the amount of money enrollees are required to contribute toward their monthly silver premium varies by income, on a sliding scale with lower income enrollees paying as little as $0 and higher income enrollees paying as much as 8.5% of their household income.

Without enhanced subsidies, an enrollee making just above poverty would be required to pay around 2% of their income for a benchmark silver plan. With enhanced subsidies, however, most enrollees with incomes around the poverty level are eligible for zero-dollar benchmark silver plans. Similarly, without enhanced subsidies, an enrollee with an income just above 400% of the poverty level would have to pay full price for their monthly premium (because they would be ineligible for financial assistance), but with the enhanced subsidies, they pay no more than 8.5% of their household income.

The chart above depicts the percent increase in premium payments for a 45-year-old buying a silver plan, if enhanced subsidies were to expire. (Because 2025 premiums and federal poverty guidelines are not yet available, the chart is based on 2024 premiums and poverty guidelines.)

Low-income enrollees would experience the steepest percent increase in their annual premium payments if enhanced subsidies were unavailable. A 45-year old enrollee making $25,000 (166% of poverty) would see their annual premium payments grow by an average of 573%, or $917, for a benchmark silver plan (an increase from $160 for the annual premium payment with enhanced subsidies to $1,077 without enhanced subsidies). Prior to the enhanced subsidies, enrollees making above 400% of poverty were ineligible for premium assistance. Without enhanced subsidies, a 45-year old individual making $65,000 (432% of poverty) would experience a premium increase of $941 annually from $5,525 to $6,466 (the full cost of the benchmark silver premium).

Prior to the ARPA and Inflation Reduction Act, individuals making above 400% of poverty were ineligible for ACA Marketplace premium subsidies and had to pay the full cost of monthly health insurance premiums. In 2024, CMS estimates that individuals making above four times poverty in HealthCare.gov states save an average of $4,248 annually due to the Inflation Reduction Act’s enhanced subsidies. Without the Inflation Reduction Act subsidies, middle income ACA Marketplace enrollees with incomes just above four times poverty would, in many cases, be priced out of health insurance coverage. The number of ACA Marketplace enrollees making above four times of poverty quadrupled from approximately 400 thousand in 2021 to 1.5 million in 2024.

Inflation Reduction Act subsidies are available nationwide, but current data on the amount of the enhanced subsidies are only available in the 32 states that use Healthcare.gov. In these states, 15.5 million people are receiving an average of $624 per year in enhanced subsidies because of the Inflation Reduction Act. On an annual basis, this translates to nearly $10 billion in enhanced Inflation Reduction Act subsidies going to enrollees in these 32 states in 2024. Among states using Healthcare.gov, the majority (52%) of this federal funding is going to enrollees in Florida ($2.2 billion, or 22%), Texas ($1.5 billion, or 16%), Georgia and North Carolina ($660 million, or 7%, each). These are all high-population states, but also stand out because most have not expanded Medicaid, and therefore have more low-income residents who qualify for substantial ACA subsidies.

The Congressional Budget Office estimates that making enhanced subsidies permanent would result in an increase of $275 billion in direct outlays and a reduction in revenues of $60 billion, for a net impact of $335 billion on the federal budget over the 10-year period from 2025 to 2034. This amount reflects higher enrollment induced by the enhanced subsidies and projections of premium growth over time.

If the Inflation Reduction Act’s enhanced subsidies expire, the vast majority of ACA Marketplace enrollees will see their premium payments increase significantly in 2026.

The results of the 2024 elections will likely play a major role in whether enhanced subsidies are extended beyond 2025. The map above shows 2024 ACA Marketplace enrollment by congressional district in the 118^th Congress. (Though some states have redrawn their congressional district lines ahead of the 2024 election for the 119^th Congress, they remain the same for the majority of states as in the 2022 elections for the 118^th Congress).

Generally, enrollment in Marketplace coverage by congressional district is largest in the South. At least 10% of the population is enrolled in ACA Marketplace plans throughout all congressional districts in Florida and South Carolina, along with most in Texas, Georgia, and Utah. In Florida, there are nine congressional districts where at least 20% of the population is enrolled in in a Marketplace plan.

If the Inflation Reduction Act’s enhanced subsidies were to expire at the end of next year, the vast majority of ACA Marketplace enrollees would see significant increases in their premium payments. However, these increases would vary by state because of differences in the incomes and ages of people living in each state, as well as differences in the premiums charged by insurers in each state.

For subsidized enrollees in states using Healthcare.gov, premium payments average about $672 per year in 2024 ($56 per month). Without enhanced subsidies, the average annual premium payment would rise by 93% ($624) to $1,296.

Based on 2024 premiums, if these enhanced premium subsidies were to expire, subsidized Marketplace enrollees in at least 12 states would see their annual premium payments double or more, on average. As these data are only available in states using Healthcare.gov, there could be additional states that would see average premium payments double. Among states using Healthcare.gov, average annual premium payments for subsidized enrollees would grow the most in Wyoming (195%, or $1,872), Alaska (125%, or $1,836), and West Virginia (133%, or $1,404). In Texas, annual premium payments would increase by an average of 115%, or $456, for the 3.4 million people receiving premium tax credits, if these subsidies were to expire.

If enhanced subsidies expire, gains in Marketplace enrollment are projected to reverse and the health status of remaining enrollees may be sicker, on average, than it is with enhanced subsidies. If insurers expect to lose their healthier enrollees, they may raise premiums heading into 2026.

Every year, in early spring, insurers compile and then submit detailed rate filings proposing premium changes for the following year, for review by state regulators. Regulators evaluate insurer justifications for premium increases, provide feedback to the insurers, and request revisions or additional justifications as deemed necessary. This process stretches into the summer each year.

For the 2026 plan year, when the Inflation Reduction Act subsidies are set to expire, insurers will have to submit their proposed premiums and justifications in early 2025 and finalize their premiums by August 2025, in advance of the 2026 open enrollment period beginning November 1, 2025.

Because of this lengthy process, insurers and state and federal regulators will want to know whether enhanced subsidies will expire or be renewed well in advance of their expiration or renewal. In the leadup to the passage of the Inflation Reduction Act, uncertainty over whether the enhanced subsidies would be extended led some insurers to increase premiums. An April 2022 letter to Congress from the National Association of Insurance Commissioners and signed by regulators from Idaho, Missouri, Connecticut, and North Dakota urged Congress to “to act by July of this year to extend the enhanced premium tax credits beyond their current end date,” which, at the time, was the end of 2022.

Without the enhanced subsidies in the Inflation Reduction Act (IRA), Affordable Care Act (ACA) Marketplace enrollees in 12 of the states that use HealthCare.gov would see their annual premium payments at least double on average, according to a new KFF analysis. Enrollees in three states would see the steepest annual increases: Wyoming (195% or $1,872), Alaska (125% or $1,836), and West Virginia (133% or $1,404), and premiums would rise by an average of 93% or $624 overall in HealthCare.gov states.

The results of the 2024 elections will likely play a major role in whether the enhanced subsidies are extended beyond 2025. Nationally, enhanced subsidies have cut premium payments by an estimated 44% ($705 annually) on average for people receiving a subsidy. If they expire, almost all subsidized ACA Marketplace enrollees, including those in state-run marketplaces, would experience steep increases in premium payments in 2026. Because enhanced subsidies have made Marketplace coverage more affordable for low- and middle-income people, they would be the most impacted by a potential subsidy expiration.

Enrollees with low incomes would see the greatest jump in their premium payments. For example, a 45-year-old enrollee earning $25,000 on average would pay 573% ($917) more annually for a benchmark silver plan (from $160 with enhanced subsidies to $1,077 without them).

The number of people with Marketplace coverage nearly doubled since the enhanced subsidies began in 2021, from 11.4 million in 2020 to 21.4 million in 2024. This enrollment growth has been concentrated among low-income individuals, spurred by the availability of low-cost (and in some cases, zero-premium) plans made available by the enhanced subsidies. Zero-premium plans are available to a larger share of ACA Marketplace enrollees in the 10 states that have not expanded Medicaid. Among states that use HealthCare.gov, enrollees in Florida and Texas received the most ($2.2 and $1.5 billion respectively) in enhanced IRA subsidies in 2024.

This fact sheet does not reflect recent changes that have been implemented by the Trump administration, including a foreign aid review and restructuring. For more information, see KFF’s Overview of President Trump’s Executive Actions on Global Health.

Key Facts

• HIV, the virus that causes AIDS (acquired immunodeficiency syndrome), is one of the world’s most serious health and development challenges. Approximately 40 million people are currently living with HIV, and tens of millions of people have died of AIDS-related causes since the beginning of the epidemic.
• Many people living with HIV or at risk for HIV infection do not have access to prevention, treatment, and care, and there is still no cure.
• In recent decades, major global efforts have been mounted to address the epidemic, and despite challenges, significant progress has been made in addressing HIV. Current global health goals are to end AIDS as a public health threat by 2030.
• The U.S. government (U.S.), through PEPFAR (the President’s Emergency Plan for AIDS Relief), is the single largest donor to international HIV efforts in the world, including the largest donor to the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund). PEPFAR, which now spans over 50 countries, has directed approximately $120 billion toward HIV prevention, care, and treatment efforts since it launched in 2003.

Global Response

HIV, the virus that causes AIDS (see box), has become one of the world’s most serious health and development challenges since the first cases were reported in 1981. Approximately 88 million people have become infected with HIV since the start of the epidemic.¹  Today, there are approximately 40 million people currently living with HIV, and tens of millions of people have died of AIDS-related causes since the beginning of the epidemic.²  

Over the past two decades in particular, major global efforts have been mounted to address the epidemic, and significant progress has been made. The number of people newly infected with HIV, especially children, and the number of AIDS-related deaths have declined over the years, and the number of people with HIV receiving treatment increased to 30.7 million in 2023.⁵ 

Still, remaining challenges continue to complicate HIV control efforts. Many people living with HIV or at risk for HIV infection do not have access to prevention, treatment, and care, and there is still no cure. HIV primarily affects those in their most productive years, and it not only affects the health of individuals, but also impacts households, communities, and the development and economic growth of nations. Many of the countries hardest hit by HIV also face serious challenges due to other infectious diseases, food insecurity, and additional global health and development problems.

Latest Estimates⁶ 

• Global prevalence among adults (the percent of people ages 15-49 who are infected) has leveled since 2001 and was 0.8% in 2023, though prevalence was higher for certain groups of people, including women and girls and key populations (i.e., men who have sex with men, sex workers, people who inject drugs, transgender people, and people in prisons).
• There were 40 million people living with HIV in 2023, up from 32 million in 2010, the result of continuing new infections and people living longer with HIV. Of the people living with HIV in 2023, 38.6 million were adults and 1.4 million were children under age 15.
• Although HIV testing capacity has increased over time, enabling more people to learn their HIV status, about one in seven people with HIV (14%) are still unaware they are infected.
• While there have been significant declines in new infections since the mid-1990s, there were still about 1.3 million new infections in 2023, or about 3,500 new infections per day. The pace of decline varies by age group, sex, race, and region, and progress is unequal within and between countries. ⁷ 
• HIV remains a leading cause of death worldwide and the leading cause of death globally among women of reproductive age.⁸  However, AIDS-related deaths have declined, due in part to antiretroviral treatment (ART) scale-up. 630,000 people died of AIDS in 2023, a 51% decrease from 1.3 million in 2010 and a 69% decrease from the peak of 2.0 million in 2004.
• Sub-Saharan Africa,⁹  home to approximately two-thirds of all people living with HIV globally, is the hardest hit region in the world, followed by Asia and the Pacific. Latin America, Western and Central Europe and North America, as well as Eastern Europe and Central Asia are also heavily affected. In 2023, however – for the first time in the history of the epidemic – there were more new HIV infections outside of sub-Saharan Africa than within the region.¹⁰ 

Affected/Vulnerable Populations

• Most HIV infections are transmitted heterosexually, although risk factors vary. In some countries, men who have sex with men, people who inject drugs, sex workers, transgender people, and prisoners are disproportionally affected by HIV.
• Women and girls represent over half (53%) of all people living with HIV worldwide, and HIV (along with complications related to pregnancy) is the leading cause of death among women of reproductive age.¹¹  Gender inequalities, differential access to service, and sexual violence increase women’s vulnerability to HIV, and women, especially younger women, are biologically more susceptible to HIV. In many countries in sub-Saharan Africa, HIV incidence among adolescent girls and young women ages 15-24 is more than three times that among adolescent boys and young men.
• Young people in particular face barriers to accessing HIV and sexual and reproductive health services, including age-appropriate comprehensive sexuality education. Over a third (36%) of older adolescents, ages 15-19 years, living with HIV were not on treatment in 2023.
• Globally, in 2023, children accounted for 1.4 million people living with HIV; among children, there were 76,000 AIDS-related deaths and 120,000 new infections, the lowest number of new infections in children since the 1980s. Since 2010, new HIV infections among children have declined by 62%.

HIV & TB

HIV has led to a resurgence of tuberculosis (TB), particularly in Africa, and TB is a leading cause of death for people with HIV worldwide.¹²  In 2022, approximately 6% of new TB cases occurred in people living with HIV.¹³  However, between 2010 and 2022, TB deaths in people living with HIV declined substantially, largely due to the scale-up of joint HIV/TB services. ¹⁴   (See the KFF fact sheet on TB.)

Prevention and Treatment¹⁵ 

Numerous prevention interventions exist to combat HIV, and new tools such as vaccines, are currently being researched.¹⁶ 

• Effective prevention strategies include behavior change programs, condoms, HIV testing, blood supply safety, harm reduction efforts for injecting drug users, and male circumcision.
• Additionally, recent research has shown that engagement in HIV treatment not only improves individual health outcomes but also significantly reduces the risk of transmission (referred to as “treatment as prevention” or TasP). Those with undetectable viral loads (known as being virally suppressed) have effectively no risk of transmitting HIV sexually.¹⁷ 
• Pre-exposure prophylaxis (PrEP) has also been shown to be an effective HIV prevention strategy in individuals at high risk for HIV infection. In 2015, the World Health Organization (WHO) recommended PrEP as a form of prevention for high-risk individuals in combination with other prevention methods.¹⁸  Further, in 2016, the U.N. Political Declaration on HIV/AIDS stated PrEP research and development should be accelerated, and in 2022, WHO released new guidelines for the use of long-acting PrEP.¹⁹ 
• Experts recommend that prevention be based on “knowing your epidemic” (tailoring prevention to the local context and epidemiology), using a combination of prevention strategies, bringing programs to scale, and sustaining efforts over time. Access to prevention, however, remains unequal, and there have been renewed calls for the strengthening of prevention efforts.²⁰ 

HIV treatment includes the use of combination antiretroviral therapy (ART) to attack the virus itself, and medications to prevent and treat the many opportunistic infections that can occur when the immune system is compromised by HIV. In light of research findings, WHO released a guideline in 2015 recommending starting HIV treatment earlier in the course of illness.²¹  Further, research on long-acting ART is currently underway.²² 

• Combination ART, first introduced in 1996, has led to dramatic reductions in morbidity and mortality, and access has increased in recent years, rising to 30.7 million people (77% of people living with HIV) in 2023.
• The percentage of pregnant and breastfeeding women receiving ART for the prevention of mother-to-child transmission of HIV increased to 84% in 2023, up from 49% in 2010.
• While access to ART among children has increased, treatment gaps still remain, and children are less likely than adults to receive ART; treatment coverage in children was 57% compared to 77% among adults in 2023.
• Approximately 72% of all people living with HIV are virally suppressed, which means they are likely healthier and less likely to transmit the virus. Viral suppression varies greatly by region, key population, age, and sex.

Global Goals

International efforts to combat HIV began in the first decade of the epidemic with the creation of the WHO’s Global Programme on AIDS in 1987. Over time, new initiatives and financing mechanisms have helped increase attention to HIV and contributed to efforts to achieve global goals; these include:

• the Joint United Nations Programme on HIV/AIDS (UNAIDS), which was formed in 1996 to serve as the U.N. system’s coordinating body and to help galvanize worldwide attention to HIV/AIDS; and
• the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), which was established in 2001 by a U.N. General Assembly Special Session (UNGASS) on HIV/AIDS as an independent, international financing institution that provides grants to countries to address HIV, TB, and malaria (see the KFF fact sheet on the Global Fund).

The contributions of affected country governments and civil society have also been critical to the response. These and other efforts work toward achieving major global HIV/AIDS goals that have been set through:

• the Sustainable Development Goals (SDGs). Adopted in 2015, the SDGs aim to “end the AIDS epidemic,” or end AIDS as a public health threat, ²³  by 2030 under SDG Goal 3, which is to “ensure healthy lives and promote well-being for all at all ages.” ²⁴ 
• UNAIDS targets to end the epidemic by 2030. On World AIDS Day 2014, UNAIDS set targets aimed at ending the AIDS epidemic by 2030. To achieve this, countries are working toward reaching the interim “95-95-95” targets—95% of people living with HIV knowing their HIV status; 95% of people who know their HIV positive status on treatment; and 95% of people on treatment with suppressed viral loads—by 2025.²⁵  These targets are successors to the earlier 90-90-90 targets for 2020, which were missed.²⁶  Based on the 2023 data and trends (the latest data available),²⁷  86% of people living with HIV knew their status; among those who knew their status, 89% were accessing treatment; and among those accessing treatment, 93% were virally suppressed.²⁸  Additional interim “95-95-95” targets have also been set for 2025, which place a greater emphasis on social services and reducing stigma and discrimination to address inequalities that hinder the HIV response.²⁹ 

Over the past decade, world leaders reaffirmed commitments to end AIDS by 2030³⁰  and adopted a Political Declaration with global commitments and targets for 2025 to address inequalities that impede the AIDS response.³¹ 

Global Resources

UNAIDS estimates that $22.1 billion was available from all sources (domestic, donor governments, multilaterals, and foundations) to address HIV in low- and middle-income countries in 2023.³²  Of this, donor governments provided $7.9 billion (see Figure 1).³³  Other governments and organizations that contribute substantially to funding the global response include:

•  hard-hit countries, which have also provided resources to address their epidemics;
• the Global Fund, which has approved over $27 billion for HIV efforts in more than 100 countries to date;³⁴  and
• the private sector, including foundations and corporations, which also plays a major role (the Gates Foundation, for one, has committed more than $3 billion in HIV grants to organizations addressing the epidemic, as well as provided additional funding to the Global Fund).³⁵ 

Looking ahead, UNAIDS estimates at least $29.3 billion annually will be needed by 2025 to meet global targets to end AIDS as a global public health threat by 2030.³⁶ 

U.S. Government Efforts

The U.S. government (U.S.) has been involved in HIV efforts since the 1980s and, today, is the single largest donor to international HIV efforts in the world, including the largest donor to the Global Fund.³⁷  The U.S. first provided funding to address the global HIV epidemic in 1986. U.S. efforts and funding increased slowly over time through targeted initiatives to address HIV in certain countries in Africa, South Asia, and the Caribbean, but they intensified with the 2003 launch of the President’s Emergency Plan for AIDS Relief (PEPFAR), which brought significant new attention and funding to address the global HIV epidemic, as well as TB and malaria.³⁸ 

PEPFAR

Created in 2003, PEPFAR is the U.S. government’s global effort to combat HIV. As an interagency initiative, PEPFAR involves multiple U.S. departments, agencies, and programs that address the global epidemic, and it is carried out in close coordination with host country governments and other organizations, including multilateral organizations such as the Global Fund and UNAIDS.³⁹  Collectively, U.S. bilateral activities span more than 50 countries, including countries reached through regional programs in Asia, West Africa, and the Western Hemisphere, with U.S. support for multilateral efforts reaching additional countries.⁴⁰  (For more information, see the KFF fact sheet on PEPFAR.)

Since its creation, PEPFAR funding, which includes all bilateral funding for HIV as well as U.S. contributions to the Global Fund and UNAIDS, has totaled approximately $120 billion.⁴¹  For FY 2024, Congress appropriated $4.8 billion for bilateral HIV, as well as $50 million for UNAIDS and $1.65 billion for the Global Fund, totaling $6.5 billion.⁴²  (For more details on historical appropriations for U.S. global HIV/AIDS efforts, see the KFF fact sheets on the U.S. Global Health Budget: Global HIV, Including PEPFAR and the U.S. Global Health Budget: The Global Fund, as well as the KFF budget tracker.)

1. UNAIDS, Global HIV statistics 2024 fact sheet; July 2024. ↩︎
2. UNAIDS, 2024 Global AIDS Update: The urgency of now – AIDS at the crossroads; July 2024. UNAIDS, AIDSinfo website; accessed July 2024, available at: http://aidsinfo.unaids.org/. UNAIDS, 2024 Core epidemiology slides; July 2024. ↩︎
3. AIDS is the last and most severe stage of HIV infection, during which the immune system is so weak that people with AIDS acquire an increasing amount of severe illnesses. CDC HIV Website, https://www.cdc.gov/hiv/about/. ↩︎
4. UNAIDS, 2024 Global AIDS Update: The urgency of now – AIDS at the crossroads; July 2024. ↩︎
5. UNAIDS, Global HIV statistics 2024 fact sheet; July 2024. ↩︎
6. UNAIDS, 2024 Global AIDS Update: The urgency of now – AIDS at the crossroads; July 2024. UNAIDS, AIDSinfo website; accessed July 2024, http://aidsinfo.unaids.org/. UNAIDS, 2024 Core epidemiology slides; July 2024. UNAIDS, Global HIV statistics 2024 fact sheet; July 2024; UNAIDS, UNAIDS data 2024; July 2024. ↩︎
7. UNAIDS, 2024 Global AIDS Update: The urgency of now – AIDS at the crossroads; July 2024. ↩︎
8. UNAIDS, Women and HIV – A spotlight on adolescent girls and young women; March 2019. ↩︎
9. Sub-Saharan Africa constitutes as East and Southern Africa and West and Central Africa. ↩︎
10. UNAIDS, 2024 Global AIDS Update: The urgency of now – AIDS at the crossroads; July 2024. UNAIDS, AIDSinfo website; accessed July 2024, http://aidsinfo.unaids.org/. UNAIDS, Global HIV statistics 2024 fact sheet; July 2024. ↩︎
11. UNAIDS, 2024 Global AIDS Update: The urgency of now – AIDS at the crossroads; July 2024. UNAIDS, Global HIV statistics 2024 fact sheet; July 2024. UNAIDS, UNAIDS 2016-2021 Strategy; Aug. 2015. ↩︎
12. WHO, Tuberculosis, fact sheet, https://www.who.int/news-room/fact-sheets/detail/tuberculosis. ↩︎
13. WHO, Global Tuberculosis Report 2023; 2023. ↩︎
14. WHO, Global Tuberculosis Report 2023; 2023. ↩︎
15. UNAIDS, 2024 Global AIDS Update: The urgency of now – AIDS at the crossroads; July 2024. UNAIDS, AIDSinfo website; accessed July 2024, http://aidsinfo.unaids.org/. UNAIDS, 2024 Core epidemiology slides; July 2024. UNAIDS, Global HIV statistics 2024 fact sheet; July 2024; UNAIDS, UNAIDS data 2024; July 2024. ↩︎
16. UNAIDS, Get on the Fast Track; 2016. Global HIV Prevention Working Group, Behavior Change for HIV Prevention: (Re) Considerations for the 21st Century; Aug. 2008. WHO, WHO recommends long-acting cabotegravir for HIV prevention, July 2022. ↩︎
17. UNAIDS, UNAIDS Explainer: Undetectable = untransmittable; July 2018. ↩︎
18. WHO, Guideline on When to Start antiretroviral Therapy and on Pre-Exposure Prophylaxis for HIV; Sept. 2015. WHO, WHO expands recommendation on oral pre-exposure prophylaxis of HIV infection (PrEP); Nov. 2015. ↩︎
19. United Nations, Political Declaration on HIV and AIDS: On the Fast-Track to Accelerate the Fight Against HIV and to End the AIDS Epidemic by 2030; June 8, 2016. WHO, WHO recommends long-acting cabotegravir for HIV prevention, July 2022. ↩︎
20. UNAIDS, 2024 Global AIDS Update: The urgency of now – AIDS at the crossroads; July 2024. United Nations, Reinvigorating the AIDS response to catalyse sustainable development and United Nations reform: Report of the Secretary-General; June 2017. ↩︎
21. UNAIDS, Get on the Fast Track; 2016. WHO, Guideline on When to Start antiretroviral Therapy and on Pre-Exposure Prophylaxis for HIV; September 2015. WHO, Press Release: NIAID START Trial confirms that immediate treatment of HIV with antiretroviral drugs (ARVs) protects the health of people living with HIV; May 28, 2015. NIAID, Starting Antiretroviral Treatment Early Improves Outcomes for HIV-Infected Individuals; May 27, 2015. ↩︎
22. NIH, News release: Long-acting HIV treatment demonstrates efficacy in people with challenges taking daily medicine as prescribed, February 21, 2024. ↩︎
23. UNAIDS states that endings AIDS as a public health threat requires a 90% reduction in HIV incidence and mortality by 2030, compared to 2010. UNAIDS, Fast-Track: ending the AIDS epidemic by 2030; 2014. ↩︎
24. United Nations, Transforming our world: the 2030 Agenda for Sustainable Development; 2015. ↩︎
25. UNAIDS, Fast-Track: ending the AIDS epidemic by 2030; 2014. ↩︎
26. These goals and targets were reiterated in the UNAIDS 2016-2021 Strategy, which also aligns with the SDGs. UNAIDS, Fast-Track: ending the AIDS epidemic by 2030; 2014. UNAIDS, UNAIDS 2016-2021 Strategy; Aug. 2015. ↩︎
27. UNAIDS, 2024 Global AIDS Update: The urgency of now – AIDS at the crossroads; July 2024. See also KFF Dashboard: Progress Toward Global HIV Targets in PEPFAR Countries, September 2023. ↩︎
28. UNAIDS, Global HIV statistics 2024 fact sheet; July 2024. ↩︎
29. UNAIDS, Press Release: UNAIDS calls on countries to step up global action and proposes bold new HIV targets for 2025; November 26, 2020. UNAIDS, “2025 AIDS Targets,” webpage, https://aidstargets2025.unaids.org/#. UNAIDS, World AIDS Day Report 2020: Prevailing Against Pandemics by Putting People at the Centre; November 2020. ↩︎
30. The 2016 U.N. General Assembly High-Level Meeting on Ending AIDS reaffirmed commitments made in the 2001 Declaration of Commitment on HIV/AIDS and the 2006 and 2011 political declarations on HIV/AIDS. UNAIDS, Declaration of Commitment on HIV/AIDS; 2001, https://www.unaids.org/sites/default/files/sub_landing/files/aidsdeclaration_en_0.pdf. UNAIDS, 2006 Political Declaration on HIV/AIDS; 2006, https://www.unaids.org/sites/default/files/sub_landing/files/20060615_hlm_politicaldeclaration_ares60262_en_0.pdf. UNAIDS, 2011 Political Declaration on HIV/AIDS; 2011, http://www.unaids.org/en/aboutunaids/unitednationsdeclarationsandgoals/2011highlevelmeetingonaids/. United Nations, 2016 Political Declaration on HIV and AIDS; 2016, https://www.unaids.org/sites/default/files/media_asset/2016-political-declaration-HIV-AIDS_en.pdf. UNAIDS, Press Release: Bold Commitments to Action Made at the United Nations General Assembly High-Level Meeting on Ending AIDS; June 10, 2016. UNAIDS, Reinvigorating the AIDS response to catalyse sustainable development and United Nations reform; 2017. ↩︎
31. These commitments and targets align with the more recent UNAIDS 2021-2026 Global AIDS Strategy, which is focused on reducing inequalities. UNAIDS, Global AIDS Strategy 2021-2026 – Ending Inequalities. End AIDS.; March 2021. United Nations, Political Declaration on HIV and AIDS: Ending Inequalities and Getting on Track to End AIDS by 2030; June 2021. UNAIDS, Press release: United Nations High-Level Meeting on AIDS draws to a close with a strong political declaration and bold new targets to be met by 2025; June 2021. ↩︎
32. UNAIDS estimates that US$19.8 billion was available for HIV from all sources (domestic resources, donor governments, multilaterals, and philanthropic organizations) in 2023, expressed in 2019 USD. For purposes of this fact sheet, this estimate was converted to 2022 USD, or $22.1 billion. KFF/UNAIDS, Donor Government Funding for HIV in Low- and Middle-Income Countries in 2023; July 2024. ↩︎
33. KFF/UNAIDS, Donor Government Funding for HIV in Low- and Middle-Income Countries in 2023; July 2024. ↩︎
34. Global Fund, The Global Fund Data Explorer, accessed September 2023, https://data.theglobalfund.org. ↩︎
35. Bill & Melinda Gates Foundation, HIV Strategy Overview, accessed July 2024, http://www.gatesfoundation.org/What-We-Do/Global-Health/HIV#OurStrategy. ↩︎
36. KFF/UNAIDS, Donor Government Funding for HIV in Low- and Middle-Income Countries in 2023; July 2024. UNAIDS, 2024 Global AIDS Update: The urgency of now – AIDS at the crossroads; July 2024. ↩︎
37. KFF analysis of data from the Office of Management and Budget, Agency Congressional Budget Justifications, and Congressional Appropriations Bills. KFF/UNAIDS, Donor Government Funding for HIV in Low- and Middle-Income Countries in 2023; July 2024. ↩︎
38. U.S. Congress, P.L. 108-25, May 27, 2003. KFF analysis of data from the Office of Management and Budget, Agency Congressional Budget Justifications, and Congressional Appropriations Bills. ↩︎
39. KFF, The U.S. Government and Global Health, Sep. 2022. CRS, PEPFAR Reauthorization: Key Policy Debates and Changes to U.S. International HIV/AIDS, Tuberculosis, Malaria and Programs and Funding; Jan. 2009. ↩︎
40. KFF analysis of data from congressional budget justification documents; PEPFAR, “Where We Work” webpage, https://www.state.gov/where-we-work-pepfar/; PEPFAR 2024 Country Operational Plan Guidance for all PEPFAR Countries; and CDC’s “Where We Work” webpage, https://www.cdc.gov/global-hiv-tb/php/where-we-work/. ↩︎
41. KFF analysis of data from the Office of Management and Budget, Agency Congressional Budget Justifications, and Congressional Appropriations Bills. Totals include funding for bilateral HIV and contributions to multilateral organizations (specifically, the Global Fund and UNAIDS). ↩︎
42. Totals represent funding specified by Congress in annual appropriations bills and/or identified by agencies for the Department of State, USAID, CDC, and DoD. In addition, international HIV research activities are supported by the NIH Office of AIDS Research (OAR) through its annual appropriated budget, but these amounts are not considered part of PEPFAR. See KFF’s “Breaking Down the U.S. Global Health Budget by Program Area” for additional information. ↩︎

Introduction

In April 2024, the Federal Trade Commission (FTC) approved a final rule barring employers’ use of non-compete clauses in certain employment contracts. Non-compete clauses are used in many industries to prevent employees from taking a job with a competitor or starting a related business within a certain amount of time or distance. The FTC estimates that one in five workers (about 30 million) are subject to a non-compete clause. The regulation, which is set to take effect in September 2024, already faces multiple legal challenges, and possibly more to come, with plaintiffs claiming that the FTC exceeded its regulatory authority. Plaintiffs in of those cases were granted a preliminary injunction in July 2024, enjoining the FTC from enforcing the rule against them while the case makes its way through the courts.

This policy watch use 2022 data from the American Hospital Association (AHA) Annual Survey Database to present the number and share of hospital workers by occupation who may not be covered by the federal protections against non-compete agreements because they work for a non-profit hospital (see Methods section for details).

Overview of Rule

The American Medical Association estimates that non-compete clauses are common in health care and affect 37%-45% of physicians. The extent to which these non-competes are enforced or enforceable is unclear, though they may alter market dynamics. Less is known about the share of other health care professionals subject to non-compete clauses.

The FTC only has authority over companies organized to make a profit, so the new regulation will not apply to many non-profit hospitals, which comprise most U.S. hospitals and the majority of hospital workers. Not all tax-exempt hospitals fall outside the FTC’s jurisdiction. The FTC is authorized to regulate these entities if they are, in a fact-specific determination, a “profit-making enterprise,” and tax-exempt status is just one factor it considers. While the regulation might still apply to a non-profit hospital claiming tax-exempt status if it is “organized for profit,” the FTC can only make this determination on a case-by-case basis. (Also not generally covered are hospitals run by state and federal governments, which are typically regulated by specific public-sector employment laws whose employment practices differ substantially from private sector employers.)

A broad swath of employment relationships will be covered, including independent contractors, interns, and apprentices. Affiliations and employment arrangements between physician practices and hospitals are often complex, and some non-profit hospitals are affiliated with for-profit hospitals and medical groups. The new rule leaves open the question of whether it would apply to clinicians in these types of hospital relationships.

Hospital Worker Data

According to KFF’s analysis of 2022 AHA survey data, about 7.2 million people worked at a hospital. Two-thirds (67%) of them (about 4.8 million) worked at non-profit hospitals and may not be covered by protections under the FTC’s new non-compete agreement regulation.

In 2022, hospitals employed about 2.2 million nurses, 68% (nearly 1.5 million) of whom worked at a non-profit hospital (Figure 1). (Nurses include registered nurses and licensed practical (vocational) nurses.)

Nursing assistive personnel provide basic nursing procedures under the supervision of a registered nurse, licensed practical nurse, or other health care professionals. Nursing assistive personnel can include certified nursing assistants, birthing assistants, and medication aides. In 2022, 64% (417,078) of hospital-based nursing assistive personnel worked for non-profit hospitals and therefore also might not be covered by the FTC non-compete protections (Figure 1).

Among hospital-based health care workers, 71% of technicians, 66% of physicians and dentists, 66% of respiratory therapists, and 62% licensed pharmacists were also employed by non-profit hospitals (Figure 1). (Technicians include those working in radiology, laboratory, and pharmacy.)

Other Considerations

Millions of health care workers could be impacted by the new federal regulations barring the use of non-compete clauses, and there are particular implications for lower-wage workers. That said, although the new rule applies nationally, several states have already taken action to restrict the use of non-competes for certain workers.

Lower-Wage Health Care Workers

Based on the comments the FTC received as well as economic evidence, the agency stated that non-compete clauses can suppress worker wages in part because they can prevent a worker from obtaining a higher-paying job in the same field elsewhere.

Many higher-paid health care workers may be excluded from the new regulation based on their annual earnings and duties. While the final rule would prevent new non-compete clauses for workers in “senior executive” roles—defined as those earning more than $151,164 annually who are in a “policy-making position”—it does not extend to existing non-competes for these workers. Nonetheless, data from the Bureau of Labor Statistics (BLS), which the rule references, suggest that most non-federal hospital health care workers earned well below this “senior executive” salary threshold in 2023. The FTC also presented evidence that many lower-wage workers, including hair stylists and fast-food workers, are subject to non-compete clauses.

Some of the lowest-paid non-federal hospital health care workers are nursing assistants and pharmacy technicians, who, on average, earned less than the national average annual salary of $65,470 in 2023. Nursing assistants at non-federal hospitals had an average annual salary of $40,820, pharmacy technicians made $49,950, and licensed practical and vocational nurses earned $56,450 (Figure 2). Non-compete clauses may make it more difficult for lower-paid workers to obtain a higher-paying job in their field with a different employer.

State Non-Compete Restrictions

Many states have limited the use of non-compete agreements in at least some health care employment contracts (Figure 3). Four states have laws prohibiting non-competes for nearly all workers in those states (CA, MN, ND, and OK). The District of Columbia prohibits non-compete agreements for most workers earning less than $150,000 per year, or less than $250,000 for most physicians. Eleven other states prohibit non-competes for certain health care professionals (AL, CO, DE, IN, MA, MD, MT, NM, NH, RI, and SD). The new federal regulations establish a federal “floor” of protections, and these state laws will continue to apply. Applying a uniform standard across the country, the rule explains, could help alleviate confusion resulting from the patchwork of state laws, especially considering recent increases in interstate remote work.

Implications For Consumers

The implications of the rule for access to health care providers, especially those already in short supply, such as behavioral health care providers, are not yet clear. While some health care industry groups commented that a prohibition on non-competes could exacerbate workforce shortages, particularly in underserved areas, several comments from providers and patients indicated that non-compete contracts can create access barriers for patients when providers have to move long distances to continue practicing in their field. On the other hand, some health care industry commenters expressed concern that if non-compete agreements are prohibited, physicians may be inclined to leave markets with lower reimbursement in favor of markets with higher reimbursement rates, potentially, they say, increasing health care costs. Whether, and to what extent, the new rule may influence these access issues is an open question.