A new KFF analysis finds that a congressional proposal to significantly cut federal spending on the Affordable Care Act’s Medicaid expansion could reduce total Medicaid spending by up to nearly one-fifth, or $1.9 trillion, over a 10-year period, and end Medicaid coverage for as many as 20 million people.The impacts would be felt in both blue and red states and could effectively reverse and end the Medicaid expansion in most or all states that have adopted it.

The analysis shows state-by-state estimates for two scenarios if Congress eliminates the ACA provision under which the federal government picks up 90% of the cost of covering the Medicaid expansion population and instead reimburses states at their traditional match rate, which ranges from 50% to 77%. 

• The first scenario assumes that all states would maintain their Medicaid expansion by replacing lost federal dollars with increased state spending, meaning no enrollees would lose coverage.  That would result in a decrease in federal Medicaid spending of 10%, or $626 billion, across all states over a 10-year period, and a corresponding increase in collective state Medicaid spending of 17% (also $626 billion) over that time, according to the analysis.
• The second assumes that states would not make up the funding shortfall resulting from federal spending reductions and drop the ACA Medicaid expansion. This would result in a 25% decrease in federal Medicaid spending, or $1.7 trillion, and a 5% decrease in state Medicaid spending, or $186 billion, across all states over a 10-year period. All told, total Medicaid spending would decline by nearly one-fifth, or $1.9 trillion, and 20 million people would lose coverage.

Only the 40 states and Washington D.C. that have adopted the Medicaid expansion would see any spending or enrollment impacts under the current proposal being considered by congressional Republicans. But as the analysis shows, the impacts in those states – which include 21 states that voted for President Donald Trump and 19 states plus D.C. that voted for former Vice President Kamala Harris – would vary considerably by state.

For instance, if states drop the Medicaid expansion, enrollment declines will range from 49% in Oregon to 19% in Massachusetts, Minnesota, North Carolina and South Dakota. In raw numbers, at the extremes, 5 million people in California could lose Medicaid coverage, compared to 24,000 in North Dakota and South Dakota.

Twelve states currently have “trigger” laws in place that would automatically end expansion or require changes if the federal match rate were to drop below 90%, but other states would also likely drop the expansion in response to the loss of federal funding. 

If states seek to preserve their Medicaid expansion, the lost federal funding that they would have to replace (over the 10-year period) would range from $129.4 billion in California to $953.4 million in South Dakota.  Other states that would see notable federal funding declines/increases in state spending include New York ($71.7 billion), Illinois ($40.9 billion), Pennsylvania ($27 billion), and Ohio ($20.1 billion) to name a few. (See the full list in Appendix Table 1.)

Eliminating the Medicaid expansion match is one of several options under consideration by Republicans in Congress to reduce Medicaid spending to help pay for an extension of the 2017 tax cuts. Medicaid provides health coverage to low-income Americans and accounts for nearly $1 out of every $5 spent on health care in the U.S. 

There are several options under consideration in Congress to significantly reduce Medicaid spending to help pay for an extension of expiring tax cuts. Medicaid is the primary program providing comprehensive health and long-term care to one in five people living in the U.S. and accounts for nearly $1 out of every $5 spent on health care. Medicaid is administered by states within broad federal rules and jointly funded by states and the federal government, meaning restrictions in federal Medicaid spending could leave states with tough choices about how to offset reductions. This analysis examines the potential impacts on states and Medicaid enrollees of one prominent proposal, which would eliminate the 90% federal match rate for the Affordable Care Act (ACA) expansion, which currently covers over 20 million people. Key takeaways include:

• This analysis explores the impact of eliminating the ACA expansion match rate under two scenarios. The first assumes that states maintain Medicaid expansion coverage and pick up new expansion costs, resulting in a decrease of 10% (or $626 billion) in federal Medicaid spending and an increase of 17% (or $626 billion) in state Medicaid spending across all states over a 10-year period.
• The second scenario assumes that states drop the ACA Medicaid expansion in response to the elimination of the 90% federal match rate. This would result in a 25% (or $1.7 trillion) decrease in federal Medicaid spending and a 5% (or $186 billion) decrease in state Medicaid spending across all states over a 10-year period. This would also cut total Medicaid spending by nearly one-fifth (or $1.9 trillion), and nearly a quarter of all Medicaid enrollees (20 million people) would lose coverage.
• Only states that have adopted the Medicaid expansion would see any spending or enrollment impacts under this policy proposal, though changes vary by state.

What is the proposed policy change?

States that have implemented the ACA Medicaid expansion currently receive a 90% federal match rate or “FMAP” for adults covered through the expansion, meaning the federal government pays 90% of the costs for expansion enrollees. The ACA expanded Medicaid coverage to nearly all adults with incomes up to 138% of the Federal Poverty Level ($21,597 for an individual in 2025). However, a Supreme Court ruling effectively made the decision to implement the Medicaid expansion an option for states. Forty-one states (including DC) have since adopted Medicaid expansion, and Medicaid expansion enrollees represent nearly a quarter of Medicaid enrollment (as of March 2024) and one-fifth of total Medicaid spending (as of FY 2023). The FMAP for services used by people eligible through traditional Medicaid is determined by a formula set in statute. The formula is designed so that the federal government provides a match rate of at least 50% and provides a higher match rate for states with lower average per capita income. For FY 2026, the traditional FMAP will range from 50% to 77%.

This analysis estimates the impact of eliminating the enhanced FMAP for adults in the Medicaid expansion. The analysis assumes that, starting in FY 2026, expenditures for people eligible in the Medicaid expansion would be matched at each state’s traditional 2026 FMAP rate. Details regarding the design of this policy change have yet to be released, and the details of proposed legislation may differ from the assumptions made to complete this analysis. This is also only one of the various Medicaid policy changes that have been suggested and estimates would change if multiple policies were considered together.

What are the potential impacts on Medicaid spending and enrollment?

This analysis does not make assumptions about specific state behavioral responses and instead examines the impact of eliminating the ACA expansion match rate under two scenarios. These scenarios are designed to illustrate the range of potential policy change effects; in practice, each state may respond to the policy change differently. While some states may choose to continue ACA Medicaid expansion coverage with substantially reduced federal funding, many likely would not given the extra spending that would be required. The analysis also excludes secondary effects such as people who lose coverage through the Medicaid expansion enrolling in Medicaid under other eligibility pathways or enrolling in private health coverage. The estimates presented here are not directly comparable to the estimates of federal savings from the Congressional Budget Office (CBO) because CBO’s estimates account for assumptions about state behavioral responses and other secondary effects.

• Scenario 1: All expansion states pick up new expansion costs. Expansion enrollment and total spending would remain constant while costs shift from the federal government to the states.
• Scenario 2: All states drop the ACA Medicaid expansion, resulting in changes to enrollment as well as total, federal, and state spending.

Eliminating the enhanced FMAP for adults in the Medicaid expansion could reduce Medicaid spending by nearly one-fifth ($1.9 trillion) over a 10-year period and up to nearly a quarter of all Medicaid enrollees (20 million people) could lose coverage. Under scenario 1, federal Medicaid spending would decrease by $626 billion or 10% across all states over the 10-year period, with the federal government providing matching funds at the standard rate rather than 90%. If all states picked up those costs and retained the Medicaid expansion, that would mean an additional $626 billion in state spending or a 17% increase in state spending across all states over the 10-year period. Under scenario 2, all state and federal financial support for Medicaid expansion is withdrawn, resulting in a $1.7 trillion dollar or 25% cut to federal Medicaid spending and a $186 billion dollar or 5% cut to state Medicaid spending across all states, including non-expansion. Combined, Medicaid spending would decrease by 18% or $1.9 trillion over the 10-year period. The cuts are even larger when looking among expansion states alone, resulting in a 31% decline in federal spending, a 6% decline in state spending, and a 22% decline in total spending. Under this scenario, an estimated 20 million Medicaid enrollees eligible through expansion would lose coverage, decreasing total Medicaid enrollment by 24% (by year 10).

Only states that have adopted the Medicaid expansion would see any spending or enrollment impacts under this policy proposal, though changes vary by state (Figure 2 and Appendix Table 1). The 10 states, primarily in the South, that have not expanded Medicaid under the ACA would see no change. Enrollment under scenario 1 would not change from baseline projections with states picking up the extra cost, but enrollment declines under scenario 2 vary by state, ranging from a decrease in estimated total Medicaid enrollment by year 10 of 19% in Massachusetts, Minnesota, North Carolina, and South Dakota to 49% in Oregon. The number of enrollees that could lose coverage ranges from 5 million in California to 24 thousand in North Dakota and South Dakota. (This analysis includes all states that had expanded Medicaid as of February 2025. In practice, there could also be effects in states that expand Medicaid in the years after 2025. In its baseline projections of Medicaid enrollment and spending, CBO assumes some states will continue to expand Medicaid but does not specify which states those are.)

What are other implications to consider?

Twelve states currently have “trigger” laws in place that would automatically end expansion or require changes if the federal match rate were to drop, but coverage would be at risk in other states given the substantial loss of federal funding. Not all trigger laws would immediately end the Medicaid expansion, but enrollees in states with trigger laws are at greater risk of losing coverage. States are actively debating their Medicaid expansion trigger laws, with some states working to remove and others working to establish the automatic termination of Medicaid expansion coverage if federal support declines.

If states maintained their Medicaid expansion coverage in the wake of this policy change, they would need to find ways to offset the loss of federal funding. This could include increasing state tax revenues or decreasing spending on non-Medicaid services such as education, which is the largest source of expenditures from state funds. States could alternatively decrease Medicaid coverage for other groups, eliminate coverage of optional benefits such as prescription drugs and home care, or reduce provider payment rates. Given the size of the federal funding cut, states would face significant challenges in efforts to replace the loss of federal funds, which would be exacerbated if paired with other reductions in federal funding for Medicaid or in other areas such as education.

If states are unable to maintain Medicaid expansion coverage (or terminate expansion due to a trigger law), the number of uninsured would increase and could reverse gains in financial security, access to care, and health outcomes associated with Medicaid expansion. In all states, some of the people who lose expansion eligibility may qualify for Medicaid under a different eligibility pathway, for example based on a disability, but some of those people may only qualify for partial Medicaid benefits such as coverage of family planning services or breast and cervical cancer screening and prevention. Other enrollees with incomes between 100% and 138% of poverty could be eligible for coverage through the ACA marketplaces, but ACA coverage will soon become more costly for enrollees if the enhanced subsidies expire at the end of 2025.  Enrollees with incomes below poverty could fall into the coverage gap. Research shows that after losing Medicaid, many people become uninsured. Increasing numbers of uninsured people could lead to loss of revenues and increased uncompensated care costs for providers. A large body of prior research shows that Medicaid expansion has helped to reduce the uninsured rate and improve health care access, affordability, and financial security among the low-income population. More recent research shows improvements in health outcomes and continues to show positive effects for providers (particularly rural hospitals) and for sexual and reproductive health. Because of the widespread adoption of the Medicaid expansion across states, the financial and coverage impacts will fall on states that voted for President Trump and those that voted for former Vice President Harris.

Appendix

Methods

Data: To project Medicaid enrollment, spending, and spending per enrollee by state and eligibility group, this analysis uses the Medicaid CMS-64 new adult group expenditure data collected through MBES for FY 2023 (downloaded in December 2024), Medicaid new adult group enrollment data collected through MBES for June 2024 (downloaded in December 2024), the 2019-2021 T-MSIS Research Identifiable Demographic-Eligibility and Claims Files, and the June 2024 Congressional Budget Office (CBO) baseline.

Overview of Approach:

• Develop baseline projections of Medicaid enrollment, spending, and spending per enrollee by state and eligibility group from FY 2025 through FY 2034 (a 10-year period). This model estimates Medicaid enrollment and spending under the status quo with no policy changes.
• Estimate Medicaid enrollment, spending, and spending per enrollee by state and eligibility group over the same 10-year period after accounting for the effects of proposed policy changes.
• Calculate differences in Medicaid enrollment, spending (including federal, state, and total spending), and spending per enrollee in the policy change scenario relative to the baseline projections.
• The estimates do not predict states’ responses to federal policy changes, but we examine differences in Medicaid enrollment, spending, and spending per enrollee under different scenarios to reflect the range of outcomes depending on state responses.

Definitions and Limitations:

• At the time of publishing, CBO had released their January 2025 baseline. However, this analysis uses CBO’s June 2024 baseline because it was the most recent baseline with spending projections by Medicaid eligibility group.
• The estimates assume that all states experience the same growth rates for Medicaid enrollment and spending; and that total spending grows at the same rate as federal spending.
• FMAP calculations do not account for the other services that are matched at a higher rate, which include family planning, services received through an Indian Health Services facility, expenditures for Medicare beneficiaries enrolled in the “Qualifying Individuals” program, and health home services that are matched at a 90% rate. For this reason, the model may underestimate the federal share of spending in some states.
• Estimates of total spending include all spending that is matched as medical assistance but exclude states’ administrative costs which are matched at a separate rate. Federal payments for administrative costs are less than 4% of total federal spending, according to the CBO June 2024 baseline.
• The analysis does not account for secondary effects or people’s behavioral responses.
• The analysis does not include policy effects for states that had not expanded Medicaid under the ACA as of February 2025 but would have done so in the absence of the policy change.
• We implement the policy change scenarios in FY 2026 and assume they take effect immediately.

We provide more details about the baseline model below.

1. Estimate initial Medicaid spending and enrollment by eligibility group using the most recent years’ data available (FY 2023 for spending data and FY 2024 for enrollment data).

•  First, we pull the quarterly Medicaid CMS-64 new adult group expenditure data collected through MBES for FY 2023 and aggregate total spending by state for enrollees in the ACA expansion group and for all other Medicaid enrollees. Spending reflects an accrual basis of accounting.
• We exclude spending on DSH by calculating the share of spending on DSH from the FY 2023 CMS-64 Financial Management Report and reducing medical assistance among non-expansion enrollees by that share.
• Separately, we pull the Medicaid new adult group enrollment data collected through MBES for June 2024. This data includes enrollment by state and is broken into ACA expansion group enrollees and all other Medicaid enrollees. MBES enrollment includes individuals enrolled in limited benefit plans and only includes individuals whose coverage is funded through Medicaid (not CHIP).
• To obtain spending and enrollment estimates across the remaining eligibility groups (seniors, individuals with disabilities, children, and other adults), we apply the distribution of spending and enrollment across the groups and by state from T-MSIS to the FY 2023 spending data and June 2024 enrollment data. We use the average distribution from 2019 to 2021 to mitigate the impact of the continuous enrollment provision (data in states denoted as “unusable” for a given year by the DQ atlas were excluded from the averages).

2. Calculate initial spending per enrollee in FY 2024.

• We grow Medicaid spending in FY 2023 by CBO’s growth rates for federal benefit payments by eligibility group to get Medicaid spending in FY 2024. The June 2024 enrollment data is used as our FY 2024 enrollment.
• We divide Medicaid spending in FY 2024 by Medicaid enrollment in FY 2024 (for each state and eligibility group) to get Medicaid spending per enrollee in FY 2024.

3. Project total spending and spending per enrollee for fiscal years 2025 through 2034 using CBO growth rates and use those estimates to calculate future years’ enrollment.

• Starting with spending data for FY 2024, we apply the CBO growth rates to estimate Medicaid spending in FY 2025 through FY 2034.
• Starting with per enrollee spending in FY 2024, we apply the CBO growth rates for average federal spending on benefit payments per enrollee to estimate Medicaid spending in FY 2025 through FY 2034.
• We calculate enrollment growth in FY 2025 through FY 2034 by dividing estimated Medicaid spending by estimated spending per enrollee.

4. Split total Medicaid spending over the 10-year period into federal and state spending.

• We calculate federal and state spending by using a 90% match rate for the ACA expansion group and the traditional state FMAPs for the remaining eligibility groups. We use the FY 2025 FMAPs for FY 2025 and FY 2026 FMAPs for FY 2026 and beyond.

We provide more details about the policy change scenarios below.

1. Calculate spending and enrollment under scenario 1 (ACA expansion states pick up new expansion costs) by state.

• Assume expansion enrollment and total spending remain the same as the baseline model over the 10-year period.
• Split total Medicaid spending (from baseline) into federal and state spending.  We assume the policy change takes effect in FY 2026, so FY 2025 federal and state spending is the same as baseline.
• Starting in FY 2026, we apply the 2026 traditional state FMAPs to the expansion group spending instead of the 90% rate to split total spending into the federal and state share. For the expansion group, spending shifts from the federal to state governments. Spending for all other eligibility groups remains unchanged.

2. Calculate spending and enrollment under scenario 2 (all states drop the ACA Medicaid expansion) by state.

• Expansion enrollment is reduced to zero for FY 2026 – FY 2034, leading to zero total spending for expansion enrollees for FY 2026 – FY 2034.
• Spending and enrollment for all other eligibility groups remains unchanged.

3. Calculate differences in Medicaid enrollment and spending (including federal, state, and total spending) relative to the baseline projections.

Note: This content was updated on July 1, 2025 to reflect new regulations eliminating ACA Marketplace eligibility for DACA recipients.

The Deferred Action for Childhood Arrivals (DACA) program was created to protect eligible young adults who were brought to the U.S. as children from deportation and to provide them with work authorization for temporary, renewable periods. As of September 30, 2024, there were roughly 538,000 active DACA recipients from close to 200 different countries of birth residing all over the U.S. While individuals with DACA status can be authorized to work, they had previously been ineligible for federal health coverage through Medicaid, the Children’s Health Insurance Program (CHIP), and the Affordable Care Act (ACA) health insurance Marketplaces. These restrictions result in higher uninsured rates among DACA recipients, contributing to barriers to accessing health care.

The Biden Administration published regulations to expand eligibility for ACA Marketplaces, including tax credits to help pay for premiums and cost-sharing, to DACA recipients as of November 1, 2024. However, as of January 2025, DACA recipients in 19 states are ineligible to enroll in ACA Marketplace coverage due to pending court challenges. On June 25, 2025, the Centers for Medicare and Medicaid Services (CMS) finalized a rule that will once again exclude DACA recipients from the definition of “lawfully present” immigrants for the purposes of health coverage, making them ineligible to purchase coverage through the ACA Marketplaces across the U.S. beginning 60 days after the final rule’s publication. The future of the DACA program as a whole also remains uncertain with a case challenging the legality of the program making its way to the Supreme Court in 2025.

This brief provides an overview of DACA and who DACA recipients are and provides data on health coverage, work status, and income among individuals who meet eligibility criteria for DACA since there are no administrative data on these measures available for DACA recipients. It also discusses potential impacts of ending the DACA program. It is based on analysis of data on DACA recipients from the United States Citizen and Immigration Services and analysis of individuals who are likely eligible for DACA using 2022 Current Population Survey Annual Social and Economic Supplement (CPS-ASEC) data (see methods for more details).

Overview of DACA

DACA was originally established via executive action in June 2012 to protect certain undocumented immigrants who were brought to the U.S. as children from removal proceedings and to receive authorization to work for renewable two-year periods. To be eligible, individuals must have arrived in the U.S. prior to turning 16 and before June 15, 2007; be under the age of 31 as of June 15, 2012 (i.e., under age 44 as of 2025); be currently enrolled in school, have completed high school or its equivalent or be a veteran; and have no lawful status as of June 15, 2012. The program has enabled over 900,000 immigrants to stay in the U.S., go to school, and contribute to the economy through employment.

The Biden Administration published a final rule in 2022 to codify DACA largely consistent with its existing eligibility requirements and scope, but its implementation remains limited subject to court rulings. Promulgation of this rule followed a rescission of the program by the Trump Administration in 2017, which was ruled unlawful by the Supreme Court in 2020. Subject to ongoing litigation and current court rulings, current DACA approvals and work authorizations remain in effect, and the Department of Homeland Security (DHS) will continue to process DACA renewal requests and related requests for employment authorization. It is also accepting initial DACA and employment authorization requests, however, it cannot process initial requests under the current court orders, so these requests remain on hold.

While DACA protects an individual from removal action for a certain period of time, it does not provide a pathway to U.S. citizenship, and people with DACA status previously were ineligible for any federally funded health coverage. Individuals with DACA status can be authorized to work, and studies have found that DACA eligibility helps improve physical and mental health, particularly among individuals with low incomes, and can improve the well-being of children of DACA recipients. However, individuals with DACA have limited options for health insurance coverage if they do not have access to employer-sponsored insurance since they previously were ineligible for federal health coverage programs, including Medicaid, the Children’s Health Insurance Program (CHIP), and the ACA health insurance Marketplaces.

The Biden administration expanded Marketplace coverage with subsidies to DACA recipients, but implementation of the expansion is blocked in 19 states due to pending litigation. On May 3, 2024, the Biden administration published regulations that updated the definition of lawfully present to include DACA recipients for purposes of eligibility to purchase coverage through the ACA Marketplaces and to receive tax credits to help pay for premiums and cost sharing effective November 1, 2024. The Biden administration estimated that this eligibility expansion could extend coverage to nearly 100,000 uninsured DACA recipients. However, as of January 2025, DACA recipients in 19 states are ineligible to enroll in ACA Marketplace coverage due to court decisions. Additionally, on June 25, 2025, the Centers for Medicare and Medicaid Services (CMS) finalized a rule that will once again exclude DACA recipients from the definition of “lawfully present” immigrants for the purposes of health coverage, making them ineligible to purchase coverage through the ACA Marketplaces beginning 60 days after the final rule’s publication in all states. Elimination of the coverage expansion could leave thousands of DACA recipients without an affordable coverage option.

Characteristics of DACA Recipients

As of September 30, 2024, there were roughly 538,000 active DACA recipients in the U.S. Over one in four (28%) active DACA recipients reside in California, with another 17% living in Texas, 5% in Illinois, 4% in New York, 4% in Florida, and the remaining 42% distributed in other states across the country (Figure 1). DACA recipients are young, with the majority under age 36 (Figure 2), and over half are female. Seven in ten DACA recipients are single, while nearly three in ten are married. The top countries of birth for active DACA recipients include Mexico (81%), El Salvador (4%), and Guatemala (3%).

Health, Work Status and Income among Individuals Likely Eligible for DACA

No administrative data are available on health, health coverage, work status, and income among DACA recipients. As such, using 2022 CPS-ASEC data we present data for undocumented immigrants likely eligible for DACA based on them meeting age, education, and length of residence requirements. (See methods for more details.)

Most individuals likely eligible for DACA are healthy and the large majority live in a family with at least one full-time worker (Figure 3). Among individuals who are likely eligible for DACA, nearly two-thirds (64%) report their health as excellent or very good, while an additional 28% report their health as good. In comparison, 71% of U.S.-born individuals ages 15-41 report being in excellent or very good health, with an additional 22% reporting being in good health. These findings reflect that younger individuals tend to be healthy. The large majority (84%) of individuals likely eligible for DACA live in a family with at least one full-time worker and over half (54%) of adults are working full-time themselves. Despite high rates of employment, 43% of individuals likely eligible for DACA have incomes below 200% of the federal poverty level (FPL) compared with 26% of U.S.-born individuals in the same age group (Figure 3). This income disparity likely reflects disproportionate employment in lower wage jobs among individuals likely eligible for DACA.

Uninsured Rates for Individuals Likely Eligible for DACA

Individuals likely eligible for DACA are much more likely than U.S.-born individuals in their age group to be uninsured (Figure 4). Overall, based on 2022 data, 47% of individuals likely eligible for DACA were uninsured, compared to 10% of U.S.-born individuals in their age group. These estimates are higher than other estimates of uninsured rates among DACA recipients based on survey data, likely reflecting differences in the group being analyzed and data source. Although most individuals who are likely eligible for DACA are in a family with a full-time worker, as noted above, they are more likely to be low-income, which likely reflects disproportionate employment in low-wage jobs that are less likely to offer employer-sponsored health insurance. Those without access to affordable coverage through an employer or who cannot afford coverage on the individual market are left with limited options since they previously were prohibited from enrolling in Medicaid, CHIP, and Marketplace coverage. With the Biden administration coverage expansion, DACA recipients are now eligible for Marketplace coverage in some states. Those who are uninsured are largely reliant on care through community health centers and public health services and can receive treatment for emergency conditions. California, which is home to the largest share of DACA recipients (28%), provides fully state-funded coverage to individuals regardless of immigration status for which DACA recipients can qualify.

Key Issues Looking Ahead

The number of young adults who may benefit from DACA is dwindling over time, and the future of the program remains uncertain. Given the requirements to have entered the U.S. prior to June 15, 2007, and to be under the age of 31 as of June 15, 2012, the number of people who could be eligible for DACA is decreasing over time. The American Dream and Promise (DREAM) Act of 2023 would provide a pathway to lawful permanent resident status and eventually citizenship for undocumented immigrants who were brought to the U.S. as children and who meet certain requirements. Different versions of this Act have been proposed in the U.S. Congress since 2001, but have never been passed, and there does not appear to be a current pathway to passage for such legislation. The future of the DACA program remains uncertain due to ongoing litigation. Since 2021, the DHS has been unable to process first-time DACA applications due to court challenges but has continued to process DACA renewal requests and related requests for employment authorization. In January 2025, a federal appeals court ruled against the legality of the DACA program in Texas, the state that filed the lawsuit. However, there is currently a stay on the ruling until there are further orders by the appeals court or the Supreme Court. As a result, there is no change to the status of the DACA program as of January 2025, with active DACA recipients nationwide continuing to be eligible to renew their status while the processing of first-time DACA applications by the DHS continues to be on hold.

President Trump attempted to end DACA during his first term but was blocked by the Supreme Court in 2020; how he will treat the program during his second term remains unclear. After the attempt to end DACA had failed in 2020, the Trump administration said that it would try again to eliminate DACA protections, suggesting it would be unlikely to appeal the decision if a court decides to eliminate the DACA program. While the second Trump administration has implemented a number of restrictive immigration policies, in an interview prior to his inauguration, President Trump indicated that he would work on addressing the status of “Dreamers” and indicated a willingness to work with Democrats on the issue, although the details of this proposed plan remain unclear.

Elimination of the DACA program would have implications for the health and well-being of DACA recipient families. There are over half a million DACA recipients, a majority of whom are working and many of whom have U.S.-born children, who could be at risk of deportation if the program is eliminated. Eliminating the DACA program could increase negative physical and mental health outcomes among recipients and their families due to increased likelihood of deportation, family separation, loss of employment, and increased barriers to health care. Research shows that DACA increases access to employer-sponsored health insurance, and expanded coverage is associated with reduced barriers to health care and increased access to culturally competent care. Research also finds that children of mothers that are eligible for DACA were more likely to participate in the Special Supplemental Nutrition Program for Women, Infant, and Children, compared to children of mothers who were ineligible. Uncertainty about DACA has been shown to increase negative mental health outcomes and worse self-reported health among DACA recipients, while program protections lead to improved mental health. A study found that children of mothers eligible for DACA experienced a significant decrease in anxiety disorder diagnoses compared to children whose mothers were ineligible.

Elimination of the DACA program could also have negative economic and workforce impacts. DACA has reduced unemployment rates and allowed DACA recipients to contribute to the workforce and their communities. Research also shows that DACA is associated with increased wages among U.S.-born workers with little to no decrease in their employment in labor markets with higher shares of DACA recipients, suggesting that DACA recipients act as complements instead of substitutes for U.S.-born workers in the labor market. Elimination of the DACA program would lead to loss of employment among DACA recipients since they would lose work authorization.

KFF’s January 2025 Prescription Drug Advertisements Poll looks at the public’s experiences with prescription drug advertisements. The poll measures the share of adults who report seeing such advertisements, as well as how these drug advertisements influence the care the public reports receiving from their doctor or health care provider.

On January 28, 2025, President Trump issued an Executive Order titled, “Protecting Children From Chemical And Surgical Mutilation.” Among other actions, the Order directs agencies and programs to work towards significantly limiting youth access to gender affirming care nationwide. It also includes misinformation about gender affirming care and young people who are transgender.

While the order does not immediately change policies or regulations that guide access to gender affirming care, it has already created significant confusion and some disruption of services, and there is now a legal challenge, as well as responses by several states. This Policy Watch reviews the key provisions of the Executive Order that aim to restrict youth access to gender affirming care and examines state and legal responses.

The Executive Order

Key provisions related to care restrictions include:

• Directs agency/department heads to take steps to prohibits those receiving certain federal research grants, including hospitals and medical schools, from proving gender affirming care to children: “The head of each executive department or agency (agency) that provides research or education grants to medical institutions…shall…take appropriate steps to ensure that institutions receiving Federal research or education grants end” end gender affirming care for children.
• Directs the Secretary of the Department of Health and Human Services (HHS) to take action to end gender affirming care for children “including [through] regulatory and sub-regulatory actions, which may involve the following laws, programs, issues, or documents:
  • Medicare or Medicaid conditions of participation or conditions for coverage;
  • clinical-abuse or inappropriate-use assessments relevant to State Medicaid programs;
  • mandatory drug use reviews
  • section 1557 of the Patient Protection and Affordable Care Act
  • quality, safety, and oversight memoranda
  • essential health benefits requirements; and
  • the Eleventh Revision of the International Classification of Diseases and other federally funded manuals, including the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.”

Taken together, and if implemented broadly, restrictions across these programs and policies could significantly limit access to gender affirming care for most young people nationwide, including for those with both private and public insurance, and even for some who are able to pay out-of-pocket. It would also likely lead to a reinterpretation of the major sex nondiscrimination protections in the Affordable Care Act (Section 1557) to remove explicit named protections on the basis of sexual orientation and gender identity in health programs receiving federal funding.

• Directs the Secretary of the Department of Defense “commence a rulemaking or sub-regulatory action” restrict access to gender affirming care for children in the TRICARE program. This restriction goes beyond those already enacted by Congress.
• Directs the Director of the Office of Personnel Management to limit access to care in coverage for federal employees’ families by requiring the inclusion of “provisions in the Federal Employee Health Benefits (FEHB) and Postal Service Health Benefits (PSHB) programs call letter for the 2026 Plan Year” that would require eligible carriers to exclude “coverage for pediatric transgender surgeries or hormone treatments…”

Additionally, the Executive Order promotes misinformation, including that large shares of youth are seeking gender affirming medical care, which is not the case, that regret rates among those who do seek care are high, when regret rates are very low, and erroneously conflating “female genital mutilation” and gender-affirming care.

Notably, the Executive Order defines children to include 18 year olds, which goes beyond how most states define minors.

State Responses

As of February 6, 2025, Attorneys General in seventeen (17) states have publicly responded to the Executive Order. Fifteen (15) have stated that they oppose the Executive Order in a coalition led by the Massachusetts Attorney General. The coalition press release states that the State Attorneys General “reaffirm their commitment to protecting access to gender-affirming care” and that the Executive Order “is wrong on the science and the law.” Additionally, the Oregon Attorney General issued a statement in support of youth access to gender affirming care and stated that they “are vigorously exploring all legal options to challenge any policies or actions that hinder access to the care Oregonians need and their rights to make their own medical decisions,”  but stopped short of directly opposing the Executive Order.

In addition to being part of the coalition letter, some Attorneys General have directed providers to continue proving gender affirming care, noting that failing to do so could be in violation of state nondiscrimination protections.

In contrast, the Attorney General in at least one state, Virginia, instructed at least two university Hospital systems to stop providing care in order to comply with the order and minimize “significant legal risk and substantial financial exposure.”

None of the 26 states with laws prohibiting or limiting youth access to gender affirming care have yet to officially respond to the Executive Order.

Legal Response

On February 4, 2025 the ACLU, Lambda Legal, and others, filed a lawsuit in federal court challenging the Executive Order. The complaint states that the Executive Order aimed at restricting gender affirming care (and another related to “gender ideology”) “were issued for the openly discriminatory purpose of preventing transgender people from expressing a gender identity different from their sex designated at birth” and are unlawful and unconstitutional. Specific counts named in the filing are that the orders:

• “unconstitutionally usurp congressional authority by withholding lawfully appropriated federal funds from medical institutions, providers, and researchers…”;
• conflict with protections imbedded in Section 1557 of the ACA (sex nondiscrimination protections in health programs in receipt of federal funds);
• violate federal disability protections;
• violate equal and due process (infringe upon parents’ fundamental rights) protections under the Fifth Amendment; and
• violate First Amendment freedom of speech protections.

In addition to asking the court to find the orders unconstitutional and unlawful, the plaintiffs seek injunctive relief, enjoining their implementation and enforcement.

On February 7, 2025 a second lawsuit was filed in federal court by three states (Washington, Minnesota and Oregon) and three physicians from the state of Washington, challenging the gender affirming care Executive Order, calling it “blatantly unconstitutional.”  Specific counts named in the filing are that the Order:

• violates protections under the Fifth Amendment
• “is an unconstitutional usurpation of the spending power of Congress, an unconstitutional effort to amend Congressional appropriations…, and a violation of the separation of powers”
• is a violation of the Tenth Amendment in its seizure of “the States’ historic police powers to regulate the practice of medicine

As with the plaintiffs in the first suit, the plaintiffs here ask the court to find certain sections of the Executive Order unconstitutional and seek injunctive relief, enjoining their implementation and enforcement. They also ask the court for an expedited hearing to determine whether the court should enter a preliminary injunction or the Temporary Restraining Order (in a separate case that stopped a pause on federal funding) should be extended.

On January 20, President Trump issued an Executive Order calling for a re-evaluation and realignment of U.S. foreign aid that put a 90-day pause on new obligations and disbursements and initiated a full review of all foreign aid programs. This was followed by a stop-work order for existing efforts (with limited exception) already funded and underway, freezing most service delivery in countries around the world. With reports of the effective dissolution of USAID, the international development agency created more than six decades ago, there is uncertainty about the future of the aid it provides if it is incorporated into the State Department as President Trump calls to “CLOSE IT DOWN!”.

To shed light on the role of USAID in global health, this brief provides an analysis of the share of global health assistance obligated or implemented by USAID and other agencies on behalf of countries (or, “bilateral”) in FY 2023, using data from foreignassistance.gov. This includes funding that agencies either: 1) obligated for global health activities (e.g., USAID manages and provides funding to an implementing partner, such as a non-governmental organization, to directly carryout health programs); or 2) received from other agencies to directly implement specific programs (e.g., State Department directs funding to USAID to implement HIV/AIDS programs in countries). This does not include funding appropriated by Congress to the Centers for Disease Control and Prevention (CDC) for global health efforts, as these totals are not part of the foreignassistance.gov database (in FY 2023 Congress appropriated approximately $693 million to CDC global health). As this analysis shows, the majority of U.S. bilateral global health assistance is obligated or implemented by USAID, including for PEPFAR. (For more information on federal funding flows for global health, see 10 Things to Know About U.S. Funding for Global Health).

In FY 2023, USAID obligated/implemented 73% of all U.S. global health bilateral assistance. Of the $8.5 billion for bilateral global health efforts, across all program areas, USAID obligated/implemented $6.2 billion (73%) (see Figure 1). The next largest share was at the Department of Health and Human Services (HHS) ($1.9 billion or 22%), primarily the Centers for Disease Control and Prevention (CDC). Two percent ($141 million) was at State and 3% ($280 million) at all other agencies combined.

For PEPFAR, the U.S. global HIV/AIDS program, USAID obligated/implemented 60% of bilateral assistance. Of the $4.2 billion for bilateral HIV programs in FY 2023, $2.5 billion (60%) was obligated/implemented by USAID, followed by $1.6 billion (37%) at HHS, and 2% ($79 million) at State (see Figure 2). Just 1% ($25 million) was at other agencies.

USAID’s role is even greater in some sectors, including 100% in some cases. For maternal and child health, TB efforts, and global health security, USAID obligated 100% of all bilateral support in FY 2023 (see Figure 3). It obligated 99% of family planning and reproductive health and 96% for malaria efforts. PEPFAR, as noted above, is 60%, and nutrition programs are 59%. As noted above, these totals do not include funding appropriated by Congress to the CDC for global health efforts, as these totals are not part of the foreignassistance.gov database.

There remains significant uncertainty surrounding the administration’s review of USAID and of U.S. foreign aid more generally, including which programs will be maintained, and how they will be carried out going forward. Given the current role of USAID in managing U.S. global health programs, through its thousands of staff around the world and its work with implementers on the ground, changing USAID, including by reducing or eliminating its capacity, would leave a gap that could affect service delivery and health outcomes, should it not be filled.

Options under consideration in Congress to reduce Medicaid spending by up to $2.3 trillion, nearly one-third over ten years, could have major implications for people with disabilities. Medicaid is the primary program providing comprehensive health and long-term care coverage to one in three with disabilities, including 2.3 million children, 8.8 million working-age adults, and 4.4 million adults ages 65 and older. Although some people with disabilities qualify for Medicaid because they receive Supplemental Security Income, most are eligible for Medicaid through other pathways, including the Affordable Care Act (ACA) expansion group.

Policy changes under consideration include imposing a per capita cap on federal Medicaid spending, reducing the federal government’s share of costs for the ACA expansion group, and imposing Medicaid work requirements, among other changes. Such policy changes would fundamentally alter how Medicaid financing works and federal spending reductions of this magnitude would put states at significant financial risk, forcing them to make tough choices about reducing the number of people covered, covering fewer benefits, or reducing payment rates for physicians, hospitals, nursing homes, and other providers. It is unknown how much Medicaid pays for people with disabilities because health care claims data do not include information about disabilities unless they are also a diagnosis code associated with the medical care being provided. However, Medicaid enrollees who are eligible because of disability or being over age 64 account for over half of Medicaid spending but less than a quarter of enrollees on account of their higher costs. That group includes most non-elderly adults with disabilities who qualify for Medicaid through regular eligibility pathways, such as the ACA expansion.

Because they have high levels of health care spending, people with disabilities may be particularly vulnerable if federal spending is capped. Loss of Medicaid coverage or benefits poses unique challenges for seniors and people with disabilities, many of whom live on fixed incomes, face barriers to employment and accessing private health coverage, have high health care needs and spending, and rely on Medicaid for coverage of long-term care and other services not available in other health coverage.

1. Medicaid is a major source of health coverage for people with disabilities.

More than 1 in 3 people with disabilities (15 million) have Medicaid (35%). In comparison, only 19% of people without disabilities have Medicaid (Figure 1). Disability is defined as having any of the following difficulties: hearing, vision, cognitive, ambulatory, self-care, or independent living. The difference in coverage rates stems from lower rates of employment and employer-based coverage among working age adults with disabilities. Among working age adults with disabilities, almost half of people with disabilities do not work at all and only one third work full time (defined as 35 or more hours per week). In comparison, over 64% of adults without a disability work full time and only 16% do not work at all. Lower rates of employment result in lower rates of employment-based coverage among working age adults with disabilities: Only 33% have insurance through an employer compared with 64% among working age adults without disabilities.

2. More than one in five Medicaid enrollees have a disability, many of whom are non-elderly adults.

Over 1 in 5 Medicaid enrollees have a disability, with the rate of disability among Medicaid enrollees rising steeply with age (Figure 2, Tab 1). Only 8% of children have a disability compared with 22% of adults ages 19 to 49 and 43% of adults ages 50 to 64. Over half of Medicaid enrollees ages 65 and older have a disability. Because disability incidence rises with age, Medicaid enrollees with disabilities tend to be older than those without (Figure 2, Tab 2). Among Medicaid enrollees with a disability, over 50% are ages 50 and older compared with less than 20% of Medicaid enrollees without disabilities.

3. Among Medicaid enrollees with disabilities, more than half have multiple difficulties.

Nearly 60% of Medicaid enrollees with disabilities have two or more difficulties and 16% have four or more difficulties (Figure 3, Tab 1). Among the over 15 million Medicaid enrollees with disabilities, 53% report difficulties with cognition, which is defined as difficulty concentrating, remembering, or making decisions; 48% report difficulties with ambulation (defined as difficulty with walking or climbing stairs); 44% report difficulties living independently (defined as difficulty doing errands alone such as visiting a doctor’s office or shopping); and 24% report difficulties with self-care (defined as difficult dressing or bathing). Fewer than 1 in 5 enrollees report difficulties with hearing or vision (Figure 3, Tab 2).

4. Two thirds of Medicaid enrollees with disabilities do not receive Supplemental Security Income (SSI).

Although federal statutes generally require states to enroll people who receive SSI in Medicaid, only one third of Medicaid enrollees with disabilities receive SSI income (Figure 5). That rate varies from a low of 18% in North Dakota to a high of 44% in Texas (Appendix Table 1). SSI is a disability program that provides monthly income to people who are unable to work on account of a disability and who have income and financial resources below federal limits. Receipt of SSI increases with age: Only 15% of children ages 15-19 receive SSI but close to 40% of adults ages 50 and older do. Medicaid enrollees ages 19-64 who do not receive SSI are eligible for Medicaid through other eligibility pathways, and many adults could be subject to Medicaid work and reporting requirement policies (Appendix Table 2). A smaller number of Medicaid enrollees with disabilities are eligible for Medicaid through pathways that relate to their disability or need for long-term care. Those pathways have more complex eligibility requirements than coverage for children and non-elderly adults. Most Medicaid enrollees with disabilities qualify for Medicaid under regular adult pathways, including the ACA expansion group.

5. Medicaid enrollees with disabilities are likely to comprise most of the people who use Medicaid long-term care.

Nearly half of Medicaid enrollees with a disability (47%) report having a difficult with self-care or independent living, disabilities that frequently require long-term care. Medicaid is the primary payer of long-term care because it is generally not covered by Medicare or private health insurance. KFF estimates that nearly 6 million people use Medicaid long-term care and spending for those people is much higher than spending for other enrollees, with the costs of enrollees who use institutional care nearing $50,000 each year. In comparison, average Medicaid spending for enrollees who do not use long-term care is under $5,000. Because of the higher spending, enrollees who use long-term care comprise 6% of Medicaid enrollment but 34% of Medicaid spending (Figure 5).

Appendix

Options under consideration in Congress to reduce Medicaid spending by nearly one-third in future years could have major implications for seniors and people with disabilities. Nearly 1 in 4 Medicaid enrollees are eligible for the program because they are ages 65 and older or have a disability, and they have higher per-enrollee costs than other enrollees. Within this group, there are multiple eligibility pathways, most of which are optional for states to cover, and all of which have more complex eligibility requirements than coverage for children and non-elderly adults. Proposals to limit federal spending on Medicaid may create incentives for states to drop or reduce their eligibility or coverage for seniors and people with disabilities in response to fewer federal revenues. Loss of Medicaid coverage poses unique challenges for seniors and people with disabilities, people who are likely to live on fixed incomes, have high health care spending, and rely on Medicaid for coverage of long-term care.

Considering the proposed reductions in Medicaid spending, this issue brief describes Medicaid eligibility pathways, enrollment, and spending among people eligible through the age and disability-related pathways (known as “non-MAGI” pathways because they do not determine eligibility based on Modified Adjusted Gross Income, as is the case for people covered under the Affordable Care Act Medicaid expansion and other groups). This analysis uses the most recent data available to KFF at the time of the analysis (Medicaid T-MSIS data, 2021, see Methods).

1.  Over half of Medicaid spending is on people eligible for Medicaid because of old age or disability.

Over half of Medicaid spending ($339 billion in 2021) pays for care for people eligible through the non-MAGI pathways (Figure 1). Seniors and people with disabilities often have higher health care costs than other enrollees due to more complex health care needs, higher rates of chronic conditions and being more likely to utilize long-term care. There is significant state variation in the percentage of Medicaid spending that pays for non-MAGI enrollees (Appendix Table 1). In some states (Alaska, Nevada, Montana, Illinois and Indiana), only a third of spending went to these populations, and in five states (Alabama, Florida, Kansas, Mississippi, and North Dakota), care for seniors and people with disabilities accounted for at least two-thirds of spending (Figure 1). Differences in the percentage of spending across the states stem from differences in eligibility criteria for both MAGI and non-MAGI eligibility pathways, which also affects relative levels of enrollment in these pathways, as well as demographic variation across states.

2.  Most non-MAGI Medicaid enrollees are eligible through mandatory eligibility pathways that are tied to Medicare and Supplemental Security Income.

Federal statutes require states to enroll people who receive Supplemental Security Income (SSI) in Medicaid and to enroll eligible Medicare beneficiaries in the Medicare Savings Programs. SSI is a disability program that provides monthly income to people who are unable to work on account of a disability and who have income and financial resources below federal limits. The Medicare Savings Programs provide Medicaid coverage of Medicare premiums and in most cases, cost sharing to Medicare beneficiaries with limited financial resources. People who are eligible for the Medicare Savings Programs, but not full Medicaid, only receive Medicaid coverage for the costs of Medicare premiums and usually, cost sharing. Beyond these two “mandatory” eligibility pathways, there are optional Medicaid eligibility pathways that states may choose to offer for people who have disabilities or are ages 65 and older, including options to expand coverage beyond what is required under federal law to low-income seniors and people with disabilities and coverage for people who need long-term care.

Roughly two-thirds of Medicaid enrollees who qualify based on old age or disability are eligible for Medicaid through a mandatory pathway and those enrollees account for about two-thirds of Medicaid spending on non-MAGI enrollees (Figure 2). The remaining third of enrollees includes people coming in through optional income-related pathways (28% of all non-MAGI enrollees and 19% of spending) and those coming in on account of their need for long-term care (6% of enrollees, 16% of spending).

Most seniors and people with disabilities who are eligible for non-MAGI Medicaid must demonstrate limited financial resources and go through an application process that requires documentation of their income and savings (Table 1). States that offer eligibility based on long-term care have higher income eligibility criteria for those eligibility pathways, but nearly all still require applicants to demonstrate having limited savings ($2,000 for an individual, $3,000 for a couple). Some assets, including the home, are excluded from the calculation of financial resources, but states are required to recoup the certain Medicaid costs after enrollees die through a process known as estate recovery. States that offer eligibility for seniors and people with disabilities based on income, have income limits generally little more than the federal poverty level with similarly low thresholds for applicants’ savings; and most states have more complicated eligibility processes for non-MAGI pathways than they do for MAGI pathways.

3.  Enrollees eligible because they need long-term care have much higher spending per enrollee.

Among the four eligibility pathways specifically for people who use long-term care, per-enrollee spending is over $40,000 per year for three of the pathways (Figure 3). Per-enrollee spending for children with disabilities enrolled through Katie Beckett programs (which include Family Opportunity Act options too) is more similar to that of other eligibility pathways for seniors and people with disabilities (close to $20,000 per year) because many of those children also have private health insurance. In such cases, Katie Beckett coverage helps lower- and middle-income families cover the costs of long-term care for children, which are very difficult to save for. Although per-enrollee costs for people eligible through the long-term care pathways are high, they still represent a small share of total Medicaid spending because the number of people enrolled is so low.

4.  Per-enrollee spending varies across states, especially for enrollees who use long-term care.

For mandatory and income-related optional eligibility pathways, per-enrollee spending (including all services) varies from under $2,000 per enrollee to over $33,000 per enrollee for the Medicare Savings Programs and nearly $60,000 per enrollee for the SSI eligibility pathway (Figure 4). As large as that variation is, variation for the long-term care-related pathways is far greater: Variation in per-enrollee spending for people who use institutional care ranges from $24,000 to nearly $200,000 per year in Alaska. For people eligible through one of the two home care programs, per-enrollee spending ranges from about $3,000 to well over $100,000. in Washington, D.C. (Appendix Table 2).

The large variation in spending among the long-term care related pathways reflects states having considerable flexibility in determining who is eligible to receive optional benefits, what services to provide, and how much to pay providers. Long-term care is extremely expensive, with average nursing facility rates for all payers exceeding $100,000 per year, full-time home health aide costs nearing $70,000, and round-the-clock home health costs nearing $300,000 per year. Not all people use services for the full year, and Medicaid does not always cover 100% of the costs of people’s care or pay the same rate as private payers, contributing to the variation in spending. There is little information about how much states pay providers, but a KFF survey about payment rates for home care showed significant variation among states able to report. The Biden Administration finalized regulations that would require states to report payment rates for Medicaid, but Congress or the Trump administration may seek to undo that rule.

5.  Across all non-MAGI eligibility pathways, per-enrollee spending is higher in ACA expansion states.

Although some researchers have criticized the ACA eligibility pathway as diverting resources away from Medicaid enrollees with disabilities, the data show per-enrollee spending for seniors and people with disabilities is two times larger in expansion states ($20,345 versus $9,950, Figure 5). The largest difference in per-enrollee spending stems from people eligible through optional income-related pathways, where spending is $17,000 per enrollee per year in expansion states but less than $5,000 per year in non-expansion states. Even in mandatory pathways, expansion states spent more per enrollee: Expansion states spent $6,386 more per enrollee eligible through the Medicare Savings Program pathway, and $7,219 more per enrollee through the SSI pathway.

Appendix Tables

Methods

Data: Data are from the 2021 and 2020 T-MSIS Research Identifiable Demographic-Eligibility and Claims Files (T-MSIS data). This analysis includes all Medicaid-eligible enrollees, with either full or partial benefits.

State Inclusion Criteria: National estimates include enrollees living in 48 states and DC and exclude residents in the U.S. territories. West Virginia and Mississippi enrollees were not included in the national estimates due to unusable data in 2021, according to the DQ Atlas. However, their reported state-level data in figures 1 and 4, and in the appendix tables, was calculated using 2020 T-MSIS data.

Medicaid non-MAGI eligibility pathways:  Eligibility pathways for older adults and individuals with disabilities were identified using ELGBLTY_GRP_CD_LTST in the T-MSIS demographic-eligibility file.

Eligibility pathways for older adults and individuals with disabilities:

Supplemental Security Income (SSI) with values of 11-22, 37, 38, 40, 41

Medicare Savings Program (MSP) with values of 23-26.

Buy In Programs with values of 47, 48, 49.

Poverty Level with values of 46.

Medically Needy with values of 53-56, 59, 60.

Other Home Care with values of 39, 43, 51.

Special Income, Institutional with a value of 42.

Special Income, Home Care with a value of 52.

Katie Beckett with values of 45, 50.

Missingness: Approximately 0.36% (N=334,091) of Medicaid enrollees were missing a value for ELGBLTY_GRP_CD_LTST, representing 0.29% ($1.9 billion) of Medicaid spending, and were thus not included in this analysis.

Spending: Spending was calculated by summing the total Medicaid paid amount on all claims for each Medicaid-eligible enrollee with the desired ELGBLTY_GRP_CD_LTST code in the T-MSIS claims files.

President Trump has made a slew of immigration policy changes focused on restricting entry at the border and increasing interior enforcement efforts to support mass deportation. These include rescinding protections against enforcement action in previously protected areas such as health care facilities and schools. While many of these actions focus on the estimated 11 million undocumented immigrants in the U.S., they will have ripple effects among the much larger number of people in immigrant families, including millions of U.S.-born citizen children. During the first Trump administration, restrictive immigration policies and increased enforcement activity led to increased fears among immigrant families across immigration statuses that had negative effects on health and well-being, employment, and daily life. They also could lead to family separations as well as mass detentions, which can have negative mental and physical health impacts on immigrants across statuses and their children. Mass deportations also could negatively impact the U.S. economy and workforce, given the role immigrants play, particularly in certain industries, including health care.

The extent to which President Trump will be able to carry out his plans without additional legislative action and in the face of potential court challenges remains uncertain. However, these plans are already affecting immigrants’ daily lives and increasing fears, with Immigrations and Customs Enforcement (ICE) agents carrying out raids across communities, and reports of nearly 1,000 people arrested in one recent day. This brief discusses the potential implications of increased enforcement actions under the Trump administration for the health and well-being of families and potential broader impacts for communities, the workforce, and the economy, including health care.

What actions is President Trump taking to increase interior enforcement and who may be affected?

Upon taking office, President Trump issued a series of executive orders focused on restricting immigration and increasing interior enforcement activity. These include orders limiting birthright citizenship, declaring a national emergency at the Southern border and restricting access at the border, expanding enforcement policies, suspending the refugee admissions program, and rescinding numerous Biden-era policies, including a policy that protected against enforcement in “sensitive areas,” including schools and health care facilities. Many of the changes outlined in the orders may require legislative or regulatory action to implement, and many are likely to be challenged in court. For example, a federal judge has already blocked the order to end birthright citizenship through a temporary restraining order. However, these changes are already increasing fears and uncertainty among families and communities. Other changes may put other groups with lawful status at risk of losing protections, including Deferred Action for Childhood Arrivals (DACA) recipients and people with Temporary Protected Status (TPS) designations from some countries. The administration recently revoked TPS for Venezuelans living in the U.S., which will make them at risk for deportation in coming months and eliminate their work authorizations.

While enforcement actions are focused on undocumented immigrants, they will have ripple effects across millions more people living in immigrant families, including U.S.-born citizen children. As of 2023, there were 47.1 million immigrants residing in the U.S., including 22.4 million noncitizen immigrants, of whom an estimated 11 million are undocumented. Additional immigrants that currently have lawful statuses may be at risk for enforcement actions under new policies if they lose protections, including nearly 1.2 million immigrants who either have or are eligible for TPS, the over 530,000 active DACA recipients, and individuals in the U.S. with pending asylum cases. Millions of additional individuals living in immigrant families also are likely to be impacted. Many undocumented immigrants live in families with mixed immigration statuses that may include people with lawful status and U.S. citizens. As of 2023, 19 million, or one in four, children in the U.S. had an immigrant parent, including one in ten (12%) who are citizen children with a noncitizen parent. An estimated 4.4 million U.S.-born children live with an undocumented immigrant parent.

What are the likely impacts of enhanced enforcement activity on the health and well-being of immigrant families?

Prior KFF focus groups with immigrant families during the first Trump administration found that restrictive immigration policies, including increases in detention and deportation, led to increased fears among immigrant families across immigration statuses that had negative effects on health and well-being. Immigrant families, including those with lawful status, reported experiencing resounding levels of fear and uncertainty. Some also reported changes in daily life such as increased difficulty finding employment, leading to increased financial strains on families. Some parents, particularly those who are undocumented or who have an undocumented family member, said they would only leave the house when necessary, such as for work; limit driving; or no longer participate in recreational activities, leading to children spending many hours inside. Parents and pediatricians reported a broad array of impacts of increased fears among children, including behavioral changes, such as problems sleeping and eating; psychosomatic symptoms, such as headaches and stomachaches; and mental health issues, such as depression and anxiety. Parents and pediatricians also felt that fears negatively affected children’s behavior and performance in school. Pediatricians expressed significant concerns about the long-term health consequences of these fears for children, including the damaging effects of toxic stress on physical and mental health over the lifespan, negative effects on children’s growth and development, and compounding social and environmental challenges that negatively impact health.

Increased fears under the first Trump Administration also led to growing reluctance among some families, including lawfully present immigrants and citizen children, about participating in programs and seeking services for which they are eligible, including health coverage and care. In KFF focus groups with immigrant families during the first Trump administration, parents noted that they highly prioritize their children’s health and generally viewed hospitals and doctors’ offices as safe spaces. However, there were some reports of changes in health care use, including decreased use of some care, and decreased participation in Medicaid and CHIP and other programs due to increased immigration-related fears. Despite efforts by the Biden administration to reduce these fears, data from the KFF/LA Times Survey of Immigrants showed that, as of 2023, nearly seven in ten (69%) likely undocumented immigrants, a third (33%) of lawfully present immigrants, and over one in ten (12%) naturalized citizen immigrants said they ever worried that they or a family member could be detained or deported. Moreover, about a quarter (27%) of likely undocumented immigrants and nearly one in ten (8%) lawfully present immigrants say they avoided applying for food, housing, or health care assistance in the past year due to immigration-related fears (Figure 1). Fears about accessing health care services may be enhanced under the second Trump administration, given the recission of a policy dating back to 2011, that protected against enforcement activity in sensitive areas, including health care facilities. Health care providers will face new challenges helping families feel safe accessing health care, protecting patient information, and establishing protocols to respond to potential encounters with ICE agents. Additionally, Florida and Texas have implemented policies that require hospitals to request immigration status from patients, which may further enhance fears about accessing care.

KFF interviews with individuals who had a family member detained or deported during the first Trump administration reported broad negative impacts on health and well-being. Respondents reported that detention and deportation of family members often occurred suddenly and unexpectedly, leaving families in shock and unprepared. One of the most immediate and significant effects on families was the loss of income, which left them struggling to pay their bills, including rent, food, and utilities. They further reported disruptions to children’s daily lives, and, in some cases, older children assuming new responsibilities and changing plans, such as no longer attending college, to support the family. Families also reported direct health impacts, including symptoms of depression and worsening chronic conditions. Some families reported losing health coverage and increased barriers to accessing coverage or care due to fears and increased financial challenges.

Other research shows that immigration enforcement raids and family separations can lead to worsened physical and mental health of both parents and children of deported parents. Exposing children to traumatic events and prolonged or toxic stress such as raids and separation from a parent disrupts a child’s healthy development and can result in short- and long-term negative effects on physical, mental, and behavioral health. Research has found that living near areas subject to immigration enforcement raids increased the risk of negative mental health among children of immigrants and worse birth outcomes among both Hispanic immigrant mothers as well as U.S.-born Hispanic mothers as compared to non-Hispanic White mothers. Education outcomes also worsened among Hispanic children in areas impacted by raids compared to White children. One potential consequence of raids and detentions and deportations is the separation of parents from their children. Studies have found that children and caregivers impacted by family separations experience worse mental health, including anxiety, depression, and posttraumatic stress disorder. Family separations can also lead to financial challenges for mixed-status households due to loss of income.

Prior experience suggests that immigrants held in detention facilities may not receive sufficient health care and face unsafe conditions. As the Trump administration escalates enforcement actions, the number of people held in detention facilities will grow likely beyond current capacity. Research showed that detainees, including children, experience poor conditions and inadequate care in detention facilities. An analysis found that most of the deaths of immigrants in detention occurred among “relatively young and healthy men” and were associated with ICE violating their own medical standards. Detention and solitary confinement can also worsen the mental health of immigrants. Studies show high levels of psychiatric distress, including depression and post-traumatic stress, among detained immigrants and their children, even after short detention periods. Research on immigrant detention centers have also found gaps in care for pregnant Hispanic migrants and that LGBT detainees experience higher rates of harassment than non-LGBT detainees.

What are the potential impacts of enhanced enforcement activity on the nation’s economy and workforce?

Mass deportations could also negatively impact the U.S. workforce, given the role immigrants play, particularly in certain industries, including health care. Most immigrants say they came to the U.S. for better work and educational opportunities. Immigrants and their U.S.-born children fill unmet labor market needs and have been the primary drivers of workforce growth, accounting for 83% of the growth in the U.S. labor force between 2010 and 2018. Research shows that immigration does not displace nor lead to more unemployment among U.S. born workers as they often do not compete for the same jobs. Immigrants and their adult children play outsized roles in certain occupations, including agriculture, construction, and health care (Figure 1). As the U.S. 65 and older population grows, deportation of immigrants may exacerbate the health care workforce shortage. Immigrants and their adult children make up a larger share of physicians, surgeons, and other health care practitioners than they do of the population and play a particularly large role as direct care workers in home and community-based settings.

Mass deportations may also reduce the billions of dollars immigrants, including undocumented immigrants, pay in federal, state, and local taxes, which help subsidize health care for U.S.-born citizens. It is estimated that more than a third of their tax dollars are payroll taxes that fund programs they cannot access, including Social Security, Medicare, and the federal share of unemployment insurance. Children of immigrants also contribute more in taxes on average than their parents or the rest of the U.S.-born population. The Congressional Budget Office (CBO) estimates that the recent immigration surge will reduce the federal deficit over the next decade. Research further finds that immigrants pay more into the health care system through taxes and health insurance premiums than they utilize, helping to subsidize health care for U.S.-born citizens. Earlier research found that without the contributions undocumented immigrants make to the Medicare Trust Fund, it would reach insolvency earlier, and that undocumented immigrants result in a net positive effect on the financial status of Social Security.

Expanding capacity to carry out mass deportations would likely be a significant cost to taxpayers and may require additional allocations by Congress. New estimates suggest that Trump’s plan to deport millions of undocumented immigrants could cost hundreds of billions of dollars. Trump’s selected border czar reported an estimated cost of $86 billion. Increases in enforcement activity would likely strain limited resources at ICE and the current system of detention centers, which is already at capacity. Expanding detention capacity to support large-scale deportations would require large investments in infrastructure, including setting up new detention facilities, expanding immigration court capacity, increasing the use of private contractors, and paying for more flights used for deportations.