On Monday, April 7, Judge Matthew Kacsmaryk in the US District Court for Northern Texas ruled to overturn key elements of a Biden administration rule that established the first-ever minimum staffing ratios for nursing facilities. The court’s opinion stated that the regulations ultimately overstepped CMS’ authority, noting “the agency lacks authority to eliminate consideration of a facility’s nursing ‘needs’ when prescribing minimum staffing standards”, and “any regulatory response must be consistent with Congress’s legislation governing nursing homes.”

The rule, finalized to address long-standing concerns about the effect of staffing shortages on the quality of care in nursing homes, has been mired in controversy since it was issued. The nursing home industry opposed the rule, suggesting it was too burdensome and costly, and could lead to nursing facility closures. Resident and family advocates and others supported the new staffing standards to address well-documented concerns about substandard facility conditions, unattended residents, and poor patient care. According to one estimate, the rule was projected to save 13,000 lives each year. In April 2022, the National Academies of Science, Engineering, and Medicine also recommended minimum staffing levels as part of its comprehensive report to improve nursing home quality.

The ruling overturned two requirements that were slated to phase in over time, but take effect no later than 2029 for all facilities:

1. Facilities must have a registered nurse (RN) on duty 24 hours a day, 7 days a week (24/7 requirement);
2. Facilities must have a minimum of 3.48 hours per resident day of total nursing care, including at least 0.55 hours of RN care and 2.45 hours of nurse aide care.

Before the rule had passed, the only federal requirements for nursing facility staffing were that, irrespective of facility size, there had to be one RN on staff for 8 consecutive hours a day and at least one RN or licensed practical nurse working for the remaining 16 hours. There were no requirements for nurse aides or minimum staffing ratios that would account for facility size. Updated data maintain that about 1 in 5 nursing facilities meet the now-overturned minimum staffing hour requirements, and the percentage of for-profit facilities (12%) that meet the requirements is lower than that of non-profit (47%) and government-owned facilities (41%).

The court left several other requirements from the staffing rule intact, including the requirement for state Medicaid agencies to report the percentage of Medicaid payments for institutional long-term care that are spent on compensation for direct care workers and support staff.

The future of nursing home regulation is unclear, though President Trump’s first term may provide some insight. During President Trump’s first term, CMS proposed regulations that rolled back or relaxed many of the 2016 Obama-era regulations, categorizing them as “unnecessary, obsolete, or excessively burdensome.” Those rollbacks were not finalized under his first term, though the Administration may reissue them or issue similar ones. Another open question is the fate of regulations issued under the Biden Administration aimed at promoting transparency around nursing facility ownership.

Congress has been considering legislative proposals as part of a tax and spending package to overturn the nursing home staffing rule which could have included up to $22 billion in savings over the next 10 years. It is unclear how the CBO will score these proposals in light of the recent court ruling, and it could depend on future court decisions and actions by the administration. The House budget resolution includes up to $880 billion or more in federal Medicaid reductions. Such reductions in Medicaid spending could have implications for nursing facility residents, since Medicaid covers 63% of all nursing home costs nationwide, and could lead to reductions in Medicaid payment rates for nursing homes, making it harder for nursing facilities to bolster staffing to improve the quality of patient care.

Note: This brief was updated on April 14, 2025 to clarify the sources of data, which include data on both self-reported and diagnosed chronic conditions.

Chronic conditions (also referred to as chronic disease or illness) have drawn increased attention in recent months, partly due to the focus on chronic conditions under HHS secretary Robert F. Kennedy’s “Make America Healthy Again,” (MAHA) initiative. Among working age adults enrolled in Medicaid, approximately three quarters have one or more chronic conditions, and nearly one-third have three or more. Medicaid coverage facilitates access to care for this population.

To achieve the federal savings required by the House budget resolution, Congress would need to cut federal Medicaid spending by hundreds of billions of dollars, leaving states with significant budget shortfalls. Federal funding cuts of that magnitude would force states to make difficult choices—such as reducing Medicaid eligibility, scaling back benefits, lowering provider reimbursement rates, raising taxes, or cutting spending on other programs such as education. Because state Medicaid programs differ considerably, their policy responses would likely vary. Amid this evolving landscape, this issue brief examines Medicaid’s coverage of adults with chronic conditions using data from the National Health Interview Survey (NHIS) and Medicaid administrative data (see Methods).

1. Three in four adults enrolled in Medicaid report one or more chronic conditions.

Chronic conditions are conditions that last at least one year and require ongoing medical care or limit daily activities (e.g. heart disease, diabetes, cancer, mental illness, etc.). Medicaid-enrolled adults (ages 19-64) report higher chronic condition rates than privately insured adults (75% vs. 66%), and nearly one-third report three or more chronic conditions (Figure 1). Higher rates among Medicaid enrollees partly reflect program eligibility criteria because states are generally required to cover people with disabilities who receive Supplemental Security Income, and all states choose to provide additional optional coverage for other adults with disabilities or high medical spending. Uninsured adults report lower chronic condition rates, which may reflect less incentive to obtain coverage because they don’t feel it’s needed or a lack of awareness of their health conditions because of limited health care access. Other KFF work shows that less than half of those without insurance had a doctor’s visit in the past year versus about 85% of insured adults.

2. Medicaid facilitates access to care for people with chronic conditions.

Nine in ten (91%) of Medicaid-enrolled adults with chronic conditions reported having a healthcare visit in the last year, which is just higher than privately insured adults (86%), and significantly higher than uninsured adults (63%) (data not shown). In addition to health care visits, many chronic conditions require routine access to prescription medications and when that access is limited, the risk of health complications, including those that are life-threatening, rises. Over three-quarters of Medicaid-enrolled adults with one or more chronic conditions filled a prescription medication in the past year, rising to 95% among those with three or more conditions (data not shown). Low or no out-of-pocket costs for prescription medications in the Medicaid program help adults with chronic conditions avoid cost-related rationing or delays in prescription access. Uninsured adults were 2.5 times more likely than Medicaid-enrolled or privately insured adults to report skipping or delaying prescription medications due to cost (28%, 11%, and 8%, respectively, Figure 2).

3. The most common chronic conditions diagnosed among adult Medicaid enrollees are physical conditions, followed by behavioral health.

The most common chronic conditions are physical, with 13.9 million adult Medicaid enrollees having a diagnosed physical health condition in 2021. High blood pressure, high cholesterol, and obesity were the most frequently diagnosed physical health conditions and can act as risk factors for other chronic conditions, such as heart disease. More than 10.1 million nonelderly Medicaid-enrolled adults have a diagnosed behavioral health condition, including mental health and substance use conditions. A separate KFF analysis shows that among those with any mental illness, approximately 2.3 million have a diagnosed serious mental illness. Cognitive impairment conditions, including dementia and intellectual and developmental disabilities (IDD), affect over 700,000 nonelderly Medicaid adults and often cause functional limitations that require long-term care (Figure 3). The number of enrollees diagnosed with behavioral, physical, or cognitive impairment conditions varies by state, but in all states, at least 1,000 Medicaid enrollees have each type of chronic condition (Appendix Table 1).

Unlike earlier exhibits, this analysis uses Medicaid claims data from 2021, the latest available to KFF. Claims data reflect only diagnoses recorded during medical visits in 2021 and do not measure overall prevalence. Prevalence rates from surveys are generally higher than claims-based estimates because not everyone is screened, treated, or has a recorded diagnosis for their chronic conditions in claims data in any given year. Additionally, during the pandemic, certain types of health care utilization declined even as Medicaid enrollment increased. While the direction of change for utilization rates is more clear (a decline), it is uncertain how these changes impacted the total number of people with recorded diagnoses in 2021 claims data. The numbers exclude Medicaid enrollees who also have Medicare (since Medicare is the primary payer for outpatient and acute care services), as well as enrollees ages 65 and older, nearly all of whom also have Medicare coverage (see Methods).

4. Rates of diagnosed physical conditions among adult Medicaid enrollees increase with age.

Unlike behavioral health and cognitive impairment conditions, rates of diagnosed physical health conditions among adult Medicaid enrollees increase with age. Seventeen percent of Medicaid enrollees ages 19 to 26 have one or more diagnosed physical health conditions in a year, rising to 32% of enrollees ages 27 to 49 and 61% of enrollees ages 50 to 64. In contrast, rates of diagnosed behavioral health conditions remain relatively stable across age groups, ranging from 20% among those ages 19 to 26 to 27% among the older age groups. Cognitive impairments are less prevalent among adults under age 65, affecting only 3% of Medicaid enrollees ages 19-26 and 1% of enrollees ages 27-64 (Figure 4).

5. Medicaid spending doubles for adult enrollees diagnosed with one or two chronic conditions and increases fourfold for those with three or more conditions.

Medicaid spends an average of $5,000 for adult enrollees without chronic conditions compared with $10,000 for those with one or two diagnosed conditions in a year, and nearly $20,000 for those with three or more conditions (Figure 5). The higher spending reflects increased health care needs, which result in in more health care visits, greater use of acute care, and an increased likelihood of using long-term care. Adult enrollees with chronic conditions account for 69% of all spending for adult enrollees (data not shown).

Enrollment in Medicare Advantage, the private plan alternative to traditional Medicare, has grown steadily over the past decade, and since 2023, more than half of all eligible Medicare beneficiaries have been enrolled in Medicare Advantage. The rapid transformation of the Medicare program to a system that is largely administered by private companies has been less pronounced in places where Medicare Advantage has a smaller presence, such as in rural counties, especially those that are far from metropolitan areas.

This data note examines the share of eligible Medicare beneficiaries (those with both Part A and Part B) with coverage under traditional Medicare and Medicare Advantage across counties that are part of either urban or rural areas, defined using Urban Influence Codes published by the U.S. Department of Agriculture. To focus on rural areas that have less access to the goods and services of urban areas, including for the delivery of health care services, rural counties are further classified as adjacent or not adjacent (most rural) to an urban area.

In the most rural areas, nearly six in ten (58%) Medicare beneficiaries are covered by traditional Medicare.

The share of Medicare beneficiaries who receive their coverage through traditional Medicare is higher in the most rural counties (58%) than in rural counties that border an urban area (48%) or counties that are within an urban area (44%) (Figure 1). Among the just over 61 million Medicare beneficiaries with both Part A and Part B in 2024, 3.4 million lived in a rural county that is outside an urban area, 7.3 million lived in a county that borders an urban area, and 50.4 million lived in a county that is in an urban area.

In 44% of the most rural counties, at least 70% of Medicare beneficiaries are in traditional Medicare.

In 44% of the most rural counties, at least 70% of Medicare beneficiaries are in traditional Medicare, which is substantially larger than the 13% of counties in rural counties adjacent to urban areas, and 6% of counties in urban areas where at least 70% of Medicare beneficiaries are in traditional Medicare (Figure 2). Across all 3,144 counties in the United States (excluding territories), 912 are in a rural area not adjacent to an urban area, 1,046 are in a rural area adjacent to an urban area, and 1,186 are in an urban area.

Half as many Medicare Advantage plans are available to people living in the most rural areas compared with those living in urban areas

Medicare Advantage plans are offered at the county level and the number of plans available varies considerably across counties. Counties with larger populations tend to have more plans available. In 2024, the average Medicare beneficiary living in one of the most rural counties had 22 plans to choose from, compared with 30 for those living in rural counties adjacent to urban areas, and 46 for those in urban areas (Figure 3) (note, plan counts include those with and without Part D prescription drug coverage).

The share of Medicare beneficiaries in traditional Medicare varies substantially in both rural and urban counties.

Among the most rural counties, the share of beneficiaries in traditional Medicare ranges from 26% in Clay County, Kentucky to 100% in Lake and Peninsula Borough, Alaska (Figure 4, Tab 1). Among rural counties adjacent to urban areas, the share of beneficiaries in traditional Medicare ranges from 16% in Starr County, Texas to 99% in Yukon-Koyukuk Census Area, outside of Fairbanks, Alaska (Figure 4 Tab 2). Similarly, among counties in urban counties, the share of eligible beneficiaries in traditional Medicare ranges from 17% in Monroe County, New York to 98% in Fairbanks, AK (Figure 4, Tab 3).

The cost of health care in the United States has continued to grow in recent years. Between 2022 and 2023, overall health spending rose 7.5%, and it is projected to rise another 4.2% in 2025.

A new issue brief authored by KFF and the Peterson Center on Healthcare examines market trends contributing to rising health costs and identifies several potential federal and state policy issues to watch throughout 2025, including high-cost drugs, federal funding cuts, and workforce shortages.

This brief is available through the Peterson-KFF Health System Tracker, an online information hub dedicated to monitoring and assessing the performance of the U.S. health system.

The “Ending the HIV Epidemic Initiative” (EHE), is a federal effort to reduce new HIV infections in the United States, launched by the first Trump administration in 2019, with the goal of a 75% reduction in five years and 90% reduction in ten years. The EHE built on earlier efforts made by the Obama administration and was continued throughout the Biden administration.

The initiative has focused on a subset of “Priority Jurisdictions”, comprised of the 48 counties in the U.S. that had the largest number of HIV diagnoses (in 2018), as well as San Juan, Puerto Rico, Washington D.C., and 7 states with a substantial share of rural HIV cases (see Figure 1). It also has been accompanied by additional federal funding, including reprogrammed funding in FY 2019 and new Congressional appropriations in FY 2020 through FY 2025. Still, this additional funding accounts for a relatively small share of overall federal HIV funding provided to state and local jurisdictions.

While the second Trump administration has continued the EHE. However, there were some questions as to whether it would when a leaked document suggested the administration may not support EHE early on. The administration has proposed cutting HIV prevention funding at the Centers for Disease Control and Prevention (CDC) and moving that EHE funding to the proposed Adminstration for Healthy America (AHA). More recently, the CDC’s HIV Prevention branch and the Office at Health and Human Services (HHS) tasked with coordinating the EHE were eliminated as were key HIV officials at NIH as was the Office of Infectious Disease Policy at HHS, which coordinated EHE.

This tracker provides up-to-date data on federal EHE funding, including an overview of funding mechanisms by year, agency, grant mechanism, and jurisdiction. It will be updated over time.

Funding by Year, Agency, and Grant Mechanism

While FY 2020 is considered the first year of EHE funding, in FY 2019, some funds were reprogrammed from existing accounts to help start the initiative. From FY 2019-2024, funding totaled $2.33 billion. Funding for the EHE increased each year from FY 2020-2023 but has since been flat funded. (See Table 1.)

Prior to the Congressional appropriations process, the administration makes a presidential budget request for Congress to consider. A budget request lays out presidential priorities both in terms of the policy issues identified and the level of funding requested. Table 2 provides the history of EHE presidential budget requests showing that EHE funding requests increased each year from FY 2020 to FY 2023. In FY 2024 the request was flat compared to the prior year. The FY 2025 budget request represents a $256.75 million decrease compared to the FY 2024 request. Since then, funding has been similar except for the Indian Health Services (IHS), which has seen declining request levels. (seen in Table 1).

Table 3 provides detail on each federal EHE grant mechanism by agency. Most EHE funding is allocated directly to EHE jurisdictions to assist with local efforts. A subset of EHE funding is provided to other grantees to carry out related efforts, such as to support capacity building and technical assistance and for science implementation hubs through NIH-funded Centers for AIDS Research (CFAR) and the NIMH AIDS Research Centers (ARC) programs.

Funding by Year and Jurisdictions

Tables 4 and 5 detail funding from FY 2019 to FY 2024 directed to EHE priority jurisdictions (data for FY 2025 are not yet available). Table 4 includes funding directed to EHE Counties and other local jurisdictions. Table 5 includes funding directed to the seven EHE states. See notes in these tables for details on how funding was allocated in this analysis.

On March 27^th, the Trump administration announced that the U.S. Department of Health and Human Services (HHS) would implement “a dramatic restructuring” in accordance with President Trump’s Executive Order, “Implementing the President’s ‘Department of Government Efficiency’ Workforce Optimization Initiative.” This included plans to reduce the Department’s workforce by 10,000 employees. As a result, thousands of federal HHS employees were given “reduction in force” announcements (or RIFs) or otherwise learned that their roles had been eliminated when they were denied access to their offices. Others were offered reassignments. In addition, several HHS offices and functions have reportedly been reduced or ended. These actions seem to be particularly focused on the federal government’s work on HIV and have the potential to negatively affect the nation’s HIV response. While there continues to be some uncertainty about the full extent of these actions, and there are some reports that certain personnel may be reinstated, here is what is known thus far about the implications of these actions on HIV efforts:

• Centers for Disease Control and Prevention (CDC): A near 20% cut to CDC staff and elimination of divisions and offices:
  • This includes cuts within the National Center for HIV, Viral Hepatitis, STD, and Tuberculosis Prevention (NCHHSTP), the division that handles most federal HIV prevention efforts, with several branches being effectively eliminated, and it’s director, Jonothan Mermin, reassigned. For HIV, these include the elimination of the following divisions:
    • Prevention Communication Branch
    • Division of Behavioral & Clinical Surveillance Branch
    • Capacity Development Branch
    • Quantitative Sciences Branch
    • HIV Research Branch
  • These divisions within the CDC have provided leadership, subject matter expertise, tools and campaigns for communication with the public (important for a providing evidence-based information on a communicable and often stigmatizing disease), generated and analyzed data, helped develop capacity among grantees, supported outbreak investigation, and conducted research across a range of areas to improve HIV prevention, care engagement, and response efforts.
  • Beyond these HIV specific divisions, cuts also occurred within branches or divisions related to public health concerns that have a disproportionate impact on people with HIV or relate to conditions that increase vulnerability to HIV, including those focused on addressing tuberculosis, viral hepatitis, and sexually transmitted diseases (STD). For example, the disease intervention and response branch within the STD division faced eliminations, an office whose role it is to identify STD case and outbreaks and mitigate spread through linkage to care and provision of technical assistance.
• HHS: Elimination of the Office of Infectious Disease Policy (OIDP) within the Office of the Secretary at HHS:
  • The OIDP office was eliminated and most staff were terminated or reassigned. This includes staff who supported coordination of the Ending the HIV Epidemic Initiative (EHE) which spans multiple HHS agencies and the Executive Director of the President’s Advisory Council on HIV/AIDS (PACHA), who was an employee within the office.
  • OIDP provides infectious disease leadership, expertise, and coordination across the federal government, with HIV being a special focus of the office. This includes coordinating multiple national strategies aimed at addressing infectious diseases including, the National HIV/AIDS Strategy (NHAS), Vaccines National Strategic Plan (Vaccine Plan), Viral Hepatitis National Strategic Plan (Viral Hepatitis Plan), and the STI National Strategic Plan (STI Plan), in addition to providing EHE leadership.
• National Institutes of Health (NIH): Key officials in NIH leadership were placed on administrative leave and some offices were eliminated:
  • Specific to HIV, Jeanne Marrazzo, the director of the National Institute of Allergy and Infectious Diseases (NIAID) was reportedly placed on administrative leave. The role was previously held by Anthony Fauci.
  • Additionally, there have been reports that the Workforce Operations, Communications, and Reporting Branch (WOCRB) at the Division of AIDS (DAIDS) within NAID has been eliminated. WOCRB’s role is to coordinate division-wide operational activities.
  • NIAID conducts and supports research related to infectious, immunologic, and allergic diseases, including HIV. Specifically related to HIV, NIAID has worked to “better understand HIV and how it causes disease, find new tools to prevent HIV infection, develop new and more effective treatments for HIV-infected people, and find a cure.” NAID’s HIV research has focused on HIV treatment, prevention, cure and vaccine.
• Beyond those offices dedicated to HIV, several others that have reportedly faced staff or complete elimination conduct activities relevant to addressing the needs of people with and at risk for HIV. These offices address communities disproportionately represented among people with HIV, including those focused on the needs of people of color, LGBTQ people, those with lower incomes, those with comorbidities, including mental health substance use problems, and those that address aging issues.
  • Examples of where such cuts/elimination have reportedly occurred include following offices/agencies: the Centers for Medicare & Medicaid Services (CMS)’s Office of Minority Health, the Substance Abuse and Mental Health Services Administration (SAMHSA) (including multiple offices such as the National Mental Health and Substance Use Policy Laboratory and the Office of Minority Health), and the Administration for Community Living (including the Center for Policy and Evaluation). In addition to NIAID at NIH described above, the National Institute on Drug Abuse with NIH was also reportedly The Office of Minority Health at HHS has also reportedly been told to prepare for elimination.

There are also plans for a new agency, the Administration for a Healthy America (AHA) to be created, consolidating activities from the Office of the Assistant Secretary for Health (OASH), the Health Resources Services Administration (HRSA) (home to the health center and Ryan White HIV/AIDS programs), SAMHSA, and others. AHA will consist of multiple divisions, including one on HIV/AIDS. It is not known whether AHA will seek to reinstitute some of the terminated positions or eliminate additional roles from within the agencies it consolidates.

Regardless of what happens with AHA, the elimination of directors, staff, and departments across HHS to date, represents a significant loss to HIV research, prevention efforts, leadership, expertise, and coordination of the HIV response across the federal government. In addition to cuts described above, it has also been reported that there may be cuts to CDC’s HIV prevention budget, that funding for NIAID’s HIV Prevention Trials Network and HIV Vaccine Trials Network (HVTN) has been suspended, and that some NIH grants focused on HIV have been rescinded. Taken together these actions could all hamper the nation’s ability to address HIV in the immediate term, jeopardize innovation, and lead to increased HIV incidence. In addition, expertise built by these officials and offices has been utilized in public health arenas outside of HIV, as was the case with the development of the COVID-19 vaccine which was built on HIV vaccine research. Given this, erosion of HIV expertise, research, and infrastructure could have ramifications for public health more broadly.

Summary

Federal funding has long been a major source of support for public health efforts across the United States, estimated to account for more than half of state and local health department budgets. The Centers for Disease Control and Prevention (CDC), the primary public health agency of the federal government, provides much of this funding, helping to support public health systems and activities across the country. However, CDC and other federal health agencies are being targeted by the Trump administration for downsizing and budget cuts, reductions that could impact the amount of funding available for public health. To better understand how much CDC funding is provided to state and local jurisdictions, we analyzed FY 2023 funding obligation data (see Methods and Appendix 1). Among the key findings:

• In FY 2023, CDC obligated almost $15 billion to state and local jurisdictions. While most (62% or $9.2 billion) was from CDC’s regular budget, a significant share (38% or $5.7 billion) was from time-limited, supplemental funding for COVID-19 and public health infrastructure rebuilding.
• Of the $9.2 billion in regular budget obligations, half ($4.7 billion or 51%) was for the Vaccines for Children program, a mandatory program that provides vaccines at no cost for children who are uninsured or underinsured and other eligible children (4% was for additional mandatory programs). The remaining $4.1 billion (45%) was discretionary funding supporting a range of programs including HIV/AIDS, Viral Hepatitis, STI and TB Prevention, Chronic Disease Prevention and Health Promotion, Public Health Preparedness and Response, and Injury Prevention and Control.
• Both red and blue states benefit from CDC funding, with states that voted for President Trump in 2024 receiving the majority of funding (56%), compared to states that voted for Kamala Harris (44%); on a per capita basis, states voting for Harris received slightly more compared to those that voted for Trump ($46 vs $43 per capita).
• The top five state recipients also represent a mix of red and blue states (California, Texas, New York, Florida, and Georgia), as do the top five states by funding per capita (District of Columbia, Alaska, Maryland, Vermont, and Wyoming).
• By region, Southern states received the largest share of funding (43%) followed by the West (22%), Midwest (19%), and Northeast (17%); the South also ranked first in funding per capita.

Funding cuts, therefore, could have a significant impact on the amount of funding available to states and local jurisdictions for public health activities. Such cuts, coupled with the expected end in supplemental funding for COVID-19 and public health infrastructure support, could also represent a double whammy, affecting both red and blue states, and especially states in the South. While state and local governments could potentially fill some of the gap left by federal dollars, they may also be facing their own budget constraints and other cuts in federal funding, leaving the future of the nation’s public health infrastructure capacity uncertain.

Findings

• In FY 2023, CDC obligated $14.9 billion to state and local jurisdictions. This included $9.2 billion (62%) as part of its regular budget and $5.7 billion (38%) in supplemental funding (see Figure 1). These amounts were distributed to jurisdiction across a number of categories (see Figure 2).

• Of the $9.2 billion in regular budget obligations, $5.1 billion (56%) was mandatory funding, required by law, and $4.1 billion (44%) was discretionary and dependent on annual appropriations from Congress. The share of mandatory vs discretionary funding provided varied by state (see Appendix Table 2).
  • Most mandatory funding (92%) was for the Vaccines for Children program. The remainder was for Chronic Disease Prevention and Health Promotion, Cross-Cutting Activities and Program Support, and several other smaller mandatory programs.
  • Discretionary funding was spread across a wide range of public health areas, with the largest share (22%) directed to HIV/AIDS, Viral Hepatitis, STI and TB Prevention efforts. Chronic Disease Prevention and Health Promotion received the next largest share (17%), followed by Public Health Preparedness and Response (16%), and Injury Prevention and Control (15%). A variety of other programs comprised the remainder (see Figure 3).
• Of the $5.7 billion in supplemental funding, most ($4.9 billion or 87%) was from the Public Health and Social Services Emergency Fund (PHSSEF), transferred to CDC by HHS to support COVID-19 response activities as well as public health infrastructure and workforce. The remainder was for Cross-Cutting Activities and Program Support, which included COVID response activities and hurricane supplemental funding.

• There was significant variation in the amount of CDC funding provided to the 50 states and Washington D.C., ranging from $45.9 million to $1.4 billion; when standardized by population size, funding ranged from $35 to $314 per capita (see Figure 4 and Appendix Table 3).
  • Funding was concentrated in a subset of states, with the top 10 state recipients accounting for 51% of all funding, and the top five states accounting for a third (34%). The top five state recipients were California, Texas, New York, Florida, and Georgia. Per capita, the top five state recipients were the District of Columbia, Alaska, Maryland, Vermont, and Wyoming (see Figure 5).
  • If supplemental funding is removed, CDC’s funding by state ranged from $25.7 million to $906 million, or $21 to $235 per capita; the top five state recipients, representing over a third (36%) of non-supplemental funding, remain the same (California, Texas, New York, Florida, and Georgia), with some variation in the rank by per capita funding (District of Columbia, Alaska, Vermont, Rhode Island, and Wyoming).

• By region, the South received the largest share of funding overall (43%) followed by the West (22%), Midwest (19%), and Northeast (17%). In per capita terms, the South remained the top funded region followed by the Northeast, West, and Midwest. With supplemental funding removed, the funding distribution is largely the same as is the per capita rank by region (see Figure 6).
• States that voted for President Trump in the 2024 election received the majority of CDC funding, although there was a more even distribution when standardized by population size. The 31 states that voted for President Trump received 56% of overall CDC funding, compared to 44% for the 20 states that voted for Kamala Harris. On a per capita basis, states voting for Harris received slightly more ($46 per capita) compared to those voting for Trump ($43 per capita). With supplemental funding removed, the distribution of funding remains almost the same (57% for Trump states and 43% for Harris states) while funding per capita was almost even ($27 per capita for Trump states vs $28 per capita for Harris states) (see Figure 7).

Appendix 1: What Does the CDC Budget Include?

CDC’s budget is comprised of three major categories:

• A discretionary budget determined and appropriated annually by Congress;
• A mandatory budget determined by a specific set of congressionally-mandated program authorizations, such as the Vaccines for Children program;
• In some years, supplemental funding is also provided to CDC outside of the regular annual appropriations process, typically to help with response to disease outbreaks or other health emergencies. Starting in 2020, CDC funding has included supplemental funds supporting COVID-19 response.

In FY 2023, the CDC discretionary budget was $8.28 billion, while mandatory budget totaled $6.97 billion. The exact amount of supplemental funding in CDC’s FY2023 budget is not clear. Since 2020, Congress provided CDC with additional funding via five different COVID-19 relief laws, with much of these supplemental appropriations made available to be spent over several years. In addition, other supplemental funds have been provided to CDC via transfers from other agencies. Further, in later legislation Congress rescinded some of the previously appropriated COVID-19 relief funding for CDC. CDC does not publicly report how much supplemental funding it has available in its budget, so developing a full picture of CDC’s available funding is a challenge.

However, CDC does report the amount of funds that it directs to state and local entities, which amounted to $14.9 billion in FY2023. CDC reports this funding by category and sub-category (program areas and activities) In addition, KFF designated these by funding type (discretionary, mandatory, and supplemental), as determined by appropriation bill language; Appendix Table 1 shows these categories and corresponding funding types.

Appendix 2: Additional Charts