Federal law requires every state to operate a Medicaid Fraud Control Unit (MFCU) that investigates and prosecutes provider fraud and patient abuse and neglect. MFCUs are typically housed within the state Attorney General’s office and are required to operate independently from the state Medicaid agency that runs the Medicaid program. MFCUs are one component in the Medicaid program integrity system, which includes many different state and federal agencies with shared and distinct responsibilities defined by state and federal law. Ensuring Medicaid program integrity (i.e., the appropriate use of federal and state Medicaid funds) involves a range of activities from fraud prevention to enforcement activities—the primary responsibility of MFCUs. While MFCUs are a key part of the program integrity system, it can be difficult to compare MFCU data across states or to put fraud recovery dollars into the context of overall Medicaid spending because recovery data only capture a portion of Medicaid program integrity efforts (e.g., leaving out the value of fraud prevention or stopped payments) and don’t capture fraud that goes undetected.

As the Trump Administration continues to focus on addressing fraud, waste, and abuse in federal programs, including Medicaid, MFCUs are facing increased federal scrutiny. In May 2026, CMS announced the HHS Office of the Inspector General (HHS-OIG) would be initiating a review of every state’s MFCU before its next annual recertification. In June 2026, the HHS-OIG denied recertification and suspended federal funding for Hawaii’s and New York’s Medicaid Fraud Control Units. Within this context, this brief provides an overview of the role of MFCUs, examines caseload and case outcome data, and current issues facing MFCUs.

What are MFCUs and how do they work?

MFCUs are law enforcement entities that investigate and prosecute provider fraud and patient abuse and neglect. MFCUs investigate and prosecute, or refer to prosecution, provider fraud (in all settings) and complaints of patient abuse in certain health care settings, such as nursing homes and hospitals receiving Medicaid funds.¹ MFCUs do not investigate fraud or program abuse committed by beneficiaries (these cases are the responsibility of the state Medicaid agency), although evidence of beneficiary fraud is low.² MFCUs must operate independently from the state Medicaid agency and are often part of the State Attorney General’s office, employing teams of investigators, attorneys, and auditors. The HHS-OIG oversees MFCUs, annually recertifying each MFCU, assessing performance and compliance with federal requirements, and administering federal grant awards (which cover 75% of MFCU operating costs).

MFCUs open investigations after receiving referrals of suspected provider fraud or complaints involving patient abuse or neglect. A MFCU case typically begins with a referral from the state Medicaid agency (including program integrity or auditing offices), managed care organization (MCO), or from a complaint filed by a patient or former employee. The state Medicaid agency or MCO may initially detect fraud through monitoring Medicaid data and using data mining or analytics to identify billing pattern anomalies (e.g., billing spikes, upcoding, double billing, or unusual hours). All state Medicaid agencies have authority to conduct data mining, but some MFCUs have also specifically been granted permission by HHS-OIG to mine Medicaid data directly for evidence of fraud as part of their regular activities. More MFCUs may begin to conduct data mining or analytics as HHS-OIG in August 2026 waived the requirement that MFCUs obtain prior approval for these activities to identify suspected Medicaid fraud. While patient abuse or neglect may fall under the jurisdiction of several different law enforcement agencies, MFCUs may investigate patient abuse or neglect in health care facilities receiving Medicaid funds.³

MFCU cases vary in duration and scope, but investigations generally follow a standard process starting with an investigation and ending with potential financial recoveries (Figure 1).

Investigation. When a case is opened, the investigative team researches the alleged fraud or abuse by analyzing the evidence. Investigations may take months or years before charges are filed against providers.

Criminal Indictments & Civil Cases. Fraud and abuse can violate state and/or federal criminal law, civil law, or both. If a MFCU’s investigation team determines there is sufficient evidence of wrongdoing, the MFCU can bring criminal charges and/or civil lawsuits against the provider.

Criminal Convictions & Civil Judgments. Criminal convictions can result in a criminal record, financial penalties, and/or incarceration. Civil judgments can establish liability and/or impose financial penalties and other court-ordered remedies. Providers who are convicted or liable for criminal fraud or patient abuse/neglect (along with other crimes) legally must be excluded from participating in federally funded health care programs. HHS-OIG or state Medicaid agencies may also decide to exclude providers beyond these minimum standards.

Recoveries. HHS-OIG defines recoveries as the amount of money that defendants are required to pay as a result of a settlement, judgment, or prefiling settlement in criminal and civil cases. Recoveries may not reflect the amounts actually collected from defendants (e.g., if the defendant is a company that dissolved before collections could be obtained). MFCUs work with state Medicaid agencies to return the state and federal share of any recovered Medicaid payments.

Note: Throughout the lifecycle of a case, MFCUs may collaborate with other state and federal program integrity and law enforcement partners. State entities include state inspectors general and state health departments and federal entities include the U.S. Department of Justice (DOJ) (including Federal Bureau of Investigation (FBI)) and the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG). Some investigations or cases may be transferred to (or handled by) federal law enforcement agencies.     

What data do MFCUs report?

Annually, MFCUs report investigation, enforcement, and financial recoveries data to HHS-OIG. Each year, HHS-OIG releases a summary report of MFCU activities that provides an annual snapshot of aggregated case outcomes from all MFCUs and certain case outcome trends. In addition to the summary report, HHS-OIG releases individual (state) MFCU case activity and outcomes data.

At the end of FY 2025, there were 15,810 open investigations across all state MFCUs. While MFCUs investigate both provider fraud and patient abuse and neglect, data show most MFCU investigations are related to provider fraud (Figure 2). A subset of investigations leads to criminal indictments or civil cases / complaints. MFCU investigations can take months to years, depending on various factors, including the types of allegations involved, volume of records, and agencies involved.

In FY 2025, MFCUs obtained 1,180 criminal convictions and reached 661 civil settlements and judgements (Figure 3). Most criminal convictions were for provider fraud. HHS-OIG uses information it receives from MFCUs to exclude individuals and entities from participating in federal health programs. In FY 2025, 900 individuals or entities were excluded because of criminal convictions obtained by MFCUs—accounting for nearly one-third (32%) of all OIG exclusions that year (data not shown).

On average, MFCUs recover more than $1 billion each year from fraud investigations. Nationally, MFCUs recovered $1.97 billion in FY 2025. While recoveries include other financial penalties in addition to Medicaid funds recouped from providers due to MFCU investigations (and may not reflect amounts actually collected⁴), the total amount of recoveries is small compared to total Medicaid spending. Recoveries vary each year and can be skewed by factors, including timing of settlements and large multi-year cases. Recoveries typically vary substantially from year to year and have averaged $1.48 billion per year over the period 2016 to 2025. A 5-year rolling average accounts for periodic variation and shows that recoveries decreased during the COVID-19 Public Health Emergency and are returning to pre-COVID levels. Recoveries, after accounting for year-to-year variation, have remained generally steady over time while total Medicaid spending has increased. Recoveries are not a comprehensive measure of enforcement (because they may not include Medicaid-related enforcement actions that occurred outside of MFCU actions) and do not include the possible financial impacts of other program integrity efforts, such as preventing fraud before it occurs. Of the $1.97 billion in recoveries, two-thirds (64%) were due to criminal convictions and one-third (36%) were due to civil judgments or settlements (data not shown). This is proportionate to the share of criminal and civil case resolutions in FY 2025 (Figure 3).

Comparing data across states or considering recovery dollars in the context of overall Medicaid spending can be challenging. Comparing MFCU data across states or years can be difficult due to differences in state law (that impact the handling of cases) and varying duration, scope, or complexity of cases, among other factors. Comparing MFCU recoveries to overall Medicaid spending can also be challenging to interpret as a hypothetical indicator of MFCU performance because these data only capture a portion of Medicaid program integrity efforts and include amounts other than recouped Medicaid payments. States can also make policy decisions that might impact state spending and MFCU recoveries differently. For example, states that spend more on prevention or early detection may see fewer recoveries (if these activities are successful), while states that invest less in fraud prevention may see higher levels of enforcement action and recoveries. There are no estimates of fraud that may have been successfully prevented or fraud that went undetected/unrecovered; however, over time there has been a shift in focus from efforts to recover misspent funds (“pay and chase”) to prevention and early detection. A higher level of MFCU recoveries could indicate more fraud, more aggressive enforcement, or less effective prevention.

What are current issues involving MFCUs?

MFCUs continue to work with state and federal agencies to stop fraud and abuse but also face increased federal scrutiny. On May 13, 2026, HHS Investigator General Bell sent a letter to every state Attorney General communicating a stance of “insistence on rigid MFCU compliance” with requirements and performance standards that will be enforced through “robust review” by the HHS-OIG. MFCUs are recertified annually on a rolling schedule, based on each specific state or territory’s original certification date.⁵ As of September 17, 2026, HHS-OIG has followed release of the May 2026 letter by issuing standard recertifications to 3 states and “conditionally recertifying” 11 state MFCUs, a designation which accompanies a set of corrective actions recommended by HHS-OIG. It does not appear that HHS-OIG regularly issued conditional recertifications prior to 2026.

In June 2026, Hawaii’s and New York’s MFCUs were notified that HHS-OIG was denying their annual recertification in letters citing insufficient case outcomes in both states. HHS announced that it was denying Hawaii’s and New York’s annual MFCU recertifications, discontinuing federal funding for the fraud control units. In each state’s recertification denial letter, HHS cites insufficient case outcomes (particularly low production of criminal indictments and convictions) and recoveries that are disproportionately low relative to the staffing and budget of the state MFCU (New York) or relative to the growth in the state’s Medicaid spending (Hawaii). States that have their MFCU recertification denied can appeal the decision and request that HHS-OIG reconsider; Hawaii indicated they intended to seek reconsideration. Hawaii and New York have responded to their denied MFCU certifications by reiterating their states’ commitment to Medicaid program integrity and highlighting ongoing actions to prevent and detect suspected Medicaid fraud. It is unclear if HHS-OIG may deny the recertification of other state MFCUs, but the discontinuation of federal funding could hamper states' ability to continue ongoing operations or initiate new investigations.

1. MFCUs can also elect to investigate and prosecute patient abuse and neglect in non-institutional settings (e.g., home and community-based settings). ↩︎
2. While states may have their own laws defining responsibilities around investigating beneficiary fraud or program abuse, MFCUs cannot use federal funding to investigate alleged beneficiary fraud unless it is in relation to suspected provider fraud. ↩︎
3. Ibid. ↩︎
4. Recoveries may not reflect the amounts actually collected from defendants (e.g., if the defendant is a company that dissolved before collections could be obtained). MFCUs work with state Medicaid agencies to return the state and federal share of any recovered Medicaid payments. ↩︎
5. Federal requirements and performance standards serve as the basis for MFCU annual recertification by HHS-OIG. When a MFCU applies for annual recertification, the MFCU submits performance and budget data, including staffing, costs, case numbers and outcomes, and other information requested by HHS-OIG. HHS-OIG may conduct an onsite review of the MFCU. ↩︎

Introduction

On September 10, 2026, the Census Bureau published a proposed rule adding two new parts to the regulations that govern the decennial census of population and housing. The proposed changes would prohibit the inclusion of questions on race and ethnicity (in addition to sexual orientation) and would narrow the definition of “usual residence” to exclude millions of noncitizen immigrants, including undocumented immigrants as well as lawfully present immigrants without lawful permanent resident status (i.e., LPR status or a green card) from the census’ apportionment count. This count is the official measurement used to proportionately divide the 435 seats in the U.S. House of Representatives across all 50 states. Further, under the proposed rule, the Census Bureau would consider tax records to determine “usual residence,” which could result in the exclusion of people who don’t file taxes from the census count. As outlined in the U.S. Constitution, the purpose of the decennial census is to count every person living in the U.S., with that information being used to determine “the number of seats each state has in the U.S. House of Representatives” as well as to distribute federal funds.

Since its inception in 1790, the census has always collected data on race and ethnicity and counted all persons living in the U.S., regardless of citizenship or immigration status. While President Trump attempted to exclude undocumented immigrants from the 2020 decennial census during his first term via executive action, legal challenges prevented the policy from being implemented. If finalized and implemented, the changes in the September 2026 proposed rule would mark the first time that race and ethnicity data are not collected in the decennial census and would also be the first time that millions of noncitizen immigrants, including those who are lawfully present but who lack LPR status, are excluded from U.S. population counts.

Public comments on the proposed rule are due by October 13, 2026, after which the Census Bureau is required to review and respond to comments before publishing a final rule. If finalized, the rule is likely to face legal challenges. A change in presidential administration prior to the 2030 decennial census could also impact implementation.

This issue brief provides an overview of the decennial census and discusses potential implications of the changes outlined in the proposed rule. Key takeaways include:

• If finalized, the proposed changes to census data collection would signal the first time since its inception in 1790 that the U.S. decennial census does not collect data on race and/or ethnicity and excludes millions of noncitizen immigrants from apportionment counts.
• The exclusion of millions of noncitizen immigrants from apportionment counts could lead to decreased federal funding and resources for states and localities with higher shares of immigrants. This includes funding for health programs such as Medicaid and the Children’s Health Insurance Program (CHIP).
• Lack of race and ethnicity data could negatively impact research on health and health care disparities as well as data quality and representation since the decennial census is the only source of complete, block-level data on race and ethnicity as well as other key sociodemographic characteristics. Further, the exclusion of many noncitizens will also mean that the census will not accurately reflect who is residing in the U.S.
• The proposed changes could impact the redistricting process and lead to shifts in political representation, including potentially reallocating congressional seats in ways that would reduce political representation for states with large immigrant populations.

The Decennial U.S. Census

The decennial census is constitutionally mandated to obtain a count of every person living in the U.S. to determine political representation and the allocation of federal funds. Beginning in 1790, the U.S. Census Bureau has conducted a census once every decade on April 1 in years ending in zero “to determine the number of people living in the United States.” The data collected by the decennial census are used to proportionately divide the 435 seats in the U.S. House of Representatives across all 50 states as well as to determine the allocation of hundreds of billions of dollars in federal funding annually.

The decennial census is the only source of complete, block-level (smallest geographic unit defined by the Census Bureau) data on race and ethnicity as well as other demographic characteristics. Researchers and organizations rely on census data to understand population distribution by key demographic characteristics, for drawing nationally representative survey samples and weighting surveys, and to do in-depth research in areas like the U.S. workforce, the economy, and housing stock, among others. The race and ethnicity data collected by the census are also used to evaluate the effectiveness of government programs and policies as well as to measure and ensure fairness, equity, and compliance with anti-discrimination laws and policies.

Since its inception in 1790, the U.S. census has collected information on race and ethnicity that has informed policy, the allocation of resources, and research on different groups within the country. How the census has collected and categorized information on race and ethnicity and the racial and ethnic groups for which data have been collected have evolved significantly over time, reflecting social and political shifts and the growing diversity of the U.S. population (Figure 1). In 1977, the Office of Management and Budget (OMB) established federal standards for collecting and reporting race and ethnicity data. The OMB standards guide not only the census but also other federal surveys, ensuring consistency across government data collection efforts. In March 2024, the OMB revised the racial and ethnic data collection and reporting standards to add Middle Eastern or North African as a category, clarify instructions for individuals to select multiple racial and ethnic categories, and require collection of more detailed data. The OMB indicated that these revisions were intended to result in more accurate and useful race and ethnicity data across the federal government. However, the Trump administration has extended the deadline for implementation of these changes twice and canceled plans to use the new standards in the 2027 American Community Survey.

Since its inception in 1790, the decennial census has included all people residing in the U.S. regardless of citizenship or immigration status, consistent with the Constitution's directive to enumerate "persons" rather than citizens. Article I, Section 2 of the U.S. Constitution requires an "actual Enumeration" of the population every ten years for purposes of proportionately dividing, or apportioning, seats in the U.S. House of Representatives, and Section 2 of the Fourteenth Amendment, which eliminated the Three-Fifths Compromise, specifies that representatives be apportioned "according to their respective numbers, counting the whole number of persons in each State…". Consistent with this description, the Census Bureau's longstanding practice has been to count every single “person,” regardless of citizenship or immigration status, who usually lives and sleeps in the U.S. in the decennial census. It has never excluded noncitizens from the apportionment base. During his first term, President Trump sought to exclude undocumented immigrants from the 2020 apportionment count through executive action, but legal challenges prevented the policy from taking effect.

Implications of Proposed Changes

The exclusion of millions of noncitizen immigrants from apportionment counts could lead to decreased federal funding and resources for states and localities with higher shares of immigrants. The proposed rule's exclusion of immigrants without LPR status from the U.S. resident population (in addition to the apportionment base) by redefining the term “usual residence” will impact the allocation of federal funds and resources across areas. The change will lead to areas with higher shares of noncitizen immigrants receiving less funding since the census will show them having fewer residents and the income and demographic profile of state residents may change without those noncitizens being counted. Prior research has found that, beyond total population counts, each state’s poverty rate and share of people living in rural areas are key factors that drive allocation of federal funds since they often are directed to low-income households and rural areas. According to analysis by the Project on Government Oversight, over 370 public programs relied on census data to allocate at least some portion of over $2.2 trillion in federal funds to states, counties, local communities, organizations, and households in fiscal year 2023. The largest share of this funding is for health programs, including Medicaid and CHIP. For example, the federal government’s share of most Medicaid and CHIP expenditures (or Federal Medical Assistance Percentage (FMAP)) is based on a state’s per capita income derived from decennial census data. Excluding many noncitizens--who are disproportionately likely to have lower incomes--from the resident count could result in a reduction in the FMAP for states with large immigrant populations, such as Florida and Texas. Other states that also have large immigrant populations, like California, would likely be affected less since their FMAP is already at the lowest level of 50%. The change could also affect the location of federally funded resources. For example, the Health Center Program uses census-derived data to determine medically underserved areas, which helps determine the location of Federally Qualified Health Centers (FQHCs). Decennial census data also indirectly shape where hospitals are located. For example, 36 states, including D.C., have certificate of need (CON) laws that help determine whether a new hospital or additional beds may be built using "bed need" methodologies that are benchmarked to census data.

Lack of race and ethnicity data and the exclusion of many noncitizen immigrants could negatively impact research on health and health care disparities as well as data quality and representation. Elimination of racial and ethnic data collection from the decennial census will have important implications for the measurement of disparities since the decennial census is the only source of complete, block-level data on race and ethnicity as well as other key sociodemographic characteristics. The exclusion of many noncitizens will also mean that the census will not accurately reflect who is residing in the U.S. Changes to the data beginning with the 2030 decennial census will eliminate a key source of data researchers use to understand population demographics and to ensure surveys are nationally representative and also limit the ability to examine trends over time, since the data will not be comparable to earlier versions. In the proposed rule, the Census Bureau indicates that they are not proposing restrictions on asking demographic questions on the American Community Survey or other surveys that are not used for enumeration of the population. While the administration is not currently proposing changes to such surveys, if similar changes are made to these surveys in the future, that would further limit the ability to understand the demographics of the U.S. population and the ability to measure and address health and health care disparities.

The proposed changes to stop collecting data on race and ethnicity are also likely to affect the redistricting process and lead to shifts in political representation. Decennial race and ethnicity data obtained from the census underpin the redistricting process and consequently, the voting power of communities of color. Under public law 94-171, enacted in 1975, the Census Bureau is required to provide states with block-level demographic data from the decennial census to redraw congressional and state legislative districts based on updated population counts. Section 2 of the Voting Rights Act (VRA) of 1965 prohibits voting practices that discriminate on the basis of race, among other factors. Block-level data on race and ethnicity cross-tabulated by voting age have long been used to establish the threshold required to bring a vote dilution claim under the law. In April 2026, the Supreme Court's decision in Louisiana v. Callais narrowed Section 2, holding that plaintiffs must show a strong inference that a state intentionally drew districts to afford minority voters less opportunity because of race as well as offer alternative maps meeting the state's legitimate goals. Eliminating block-level racial and ethnic data would compound these heightened evidentiary requirements by removing the underlying data to identify vote dilution, draw districts that provide communities of color an opportunity to elect candidates of their choice, and litigate VRA claims in the future.

The exclusion of millions of noncitizen immigrants from the decennial census could lead to the reallocation of congressional seats in ways that would reduce political representation for states with large immigrant populations. According to Pew Research Center, as of 2023, there were roughly 14 million undocumented immigrants and over 2 million lawfully present immigrants without LPR status in the U.S. Although these numbers have likely fallen since 2023, omitting these people from the count could impact representation for states with large numbers of immigrants. For example, a Pew Research Center analysis of President Trump’s earlier proposal to exclude undocumented immigrants from the 2020 decennial census found that, at that time, California, Florida, and Texas would each lose one congressional seat due to the change in population counts, while three other states would gain seats (Alabama, Minnesota, and Ohio).

Paid family and medical leave and sick leave can help workers meet their personal and family health care needs, while also fulfilling work responsibilities. Access to paid leave is a particularly salient concern for women, who comprise nearly half of the nation’s workforce and often take on the bulk of caregiving responsibilities. The federal Family and Medical Leave Act (FMLA) requires eligible employers to provide certain workers unpaid family leave; however, unlike nearly all other industrialized nations, the U.S. does not have a national requirement for paid family or sick leave, resulting in a patchwork of policies determined by state and local laws, employers, and/or labor contracts. While many have been advocating a national standard for paid leave for decades, there has been relatively little federal action.       

Though many states and localities have passed laws to expand access to paid leave within their jurisdictions, many workers still do not have access to these benefits. Employees not covered by these state and local laws must rely on voluntary employer policies, which can vary considerably in scope and compensation. This fact sheet summarizes federal, state, and local policies on paid family and medical leave and paid sick leave.

Federal, State, and Local Policies on Sick, Family, and Medical Leave

Sick Leave

Paid sick leave allows workers to take short durations of time off if they are sick or need to care for a family member who is sick without losing pay. There is no federal requirement that employers offer paid leave benefits, but many states have requirements, and some employers do so voluntarily. According to the Bureau of Labor Statistics (BLS), eight in ten workers (82%) had access to paid sick leave through their employer in 2025. 

Proponents of a national paid sick leave mandate stress that workers should not be forced to choose between going to work while sick and losing pay or their job, pointing to numerous studies on the benefits of paid sick leave, such as preventing the spread of illnesses, increased use of preventive health care services, reduced on-the-job injuries, and fewer inappropriate emergency room visits. Opponents of a national paid sick leave mandate generally contend that it is not necessary because many employers already provide these benefits, or that it should be a voluntary benefit. They cite concerns about the financial implications for employers who would be required to provide this benefit, particularly for smaller businesses, and potential reductions in wages designed to offset those costs. 

At the federal level, the Healthy Families Act has been reintroduced annually and would require employers nationwide with 15 or more employees to provide at least 7 days annually, based on a 40-hour work week if it were to pass. Employees would be able to use sick leave for their own illness, to care for a sick family member, obtain medical care, or address needs resulting from domestic violence, sexual assault, or stalking, known as “safe time,” “safe days,” or “safe leave.” Federal government employees have generally had access to paid sick leave through employee benefits packages. 

There has been more traction on paid sick leave policies at the state and local level. Since the first law was passed by voter initiative in 2006 in San Francisco, 18 states plus D.C., and 18 other localities have passed laws requiring covered employers to provide eligible employees paid sick leave (Figure 1). Most of these policies permit the use of accrued sick leave for “safe time.” Three additional states and three localities have general paid time off laws that allow employees to use accrued leave for any reason, including illness. Ten states and 12 localities permit use of accrued paid sick leave for workplace closure or closure of the worker’s child’s school or childcare associated with a public health emergency.

The scope and generosity of paid sick leave laws vary. Most state and local laws have exemptions based on the size and type of employer and/or permit employers to impose certain worker eligibility requirements. Most laws also permit employers to impose a waiting period before new employees can use accrued leave, most often 90 days from the start of employment. Laws generally provide for accrual of 30-40 hours per year, though there is wide variation by policy, with lower accrual rates for smaller employers in many cases.

Family and Medical Leave 

FMLA and Unpaid Family and Medical Leave

It has been more than 30 years since the federal government passed the Family and Medical Leave Act (FMLA), giving eligible employees up to 12 weeks of unpaid, job-protected leave per year for their own serious health condition, to care for a seriously ill family member, for the arrival of a new child, and to address needs related to a family member’s military deployment. Eligible employees also receive up to 26 weeks of unpaid, job-protected leave per year to care for a seriously ill or injured family servicemember or veteran. The law applies to public agencies and local educational agencies of all sizes, as well as private employers with 50 or more employees. The FMLA has provided job security to millions of workers who need to take time off work for a qualifying reason; however, just over half (56%) of the workforce is eligible for FMLA protections because small employers are exempt, and even in covered worksites, not all employees meet FMLA eligibility requirements. Most states have opted to expand job-protected leave benefits beyond FMLA’s minimum standards by expanding eligibility, the duration of leave, the definition of family members, or qualified reasons for taking leave in the private and/or public sector in the private and/or public sector. 

Paid Family and Medical Leave

BLS data found that just over one in four (27%) workers had access to paid family leave in 2023, the most recent year for which there is data (Figure 2). Data on the share of workers with explicit access to paid medical leave for a longer, serious illness are limited, but BLS also estimates that 42% of workers had access to short-term disability insurance in 2025, which can be used to take paid time off for parental leave or medical leave.​ 

Proponents of a national paid family and medical leave program urge that it would provide employees with greater financial security when they must take extended leave for medical reasons or to care for an ailing family member or new child. Research indicates that access to paid family and medical leave is associated with improved physical and mental health for new parents, improved birth outcomes, financial security for caregivers in the short- and long-term, and improved connections to the workforce, particularly for women, who are more likely than men to be caregivers for children and older adults. Opponents often cite concerns about the impact of new federal requirements on businesses, government overreach into the free market, increased taxes for businesses (should that be the funding mechanism), as well as the financial implications a new benefit would have on wages and employment.  

Like sick leave, there have been many attempts to enact a national paid family and medical leave policy, but no permanent, broad-scale federal legislation has ever been passed. The Family and Medical Insurance Leave (FAMILY) Act, re-introduced in 119th Congress, if passed, would create a national insurance program to provide workers up to 12 weeks of their partial income for their own serious health condition or that of an immediate family member, and for the birth or placement of a child. The program would be funded by employee and employer payroll contributions. The program would be funded by employee and employer payroll contributions.

At the state level, 14 states and D.C. have enacted paid family and medical leave (Figure 3). In November 2020, Colorado became the first state to enact paid family and medical leave through a ballot measure. In 2026, Virginia became the first southern state to pass a statewide requirement for paid family and medical leave. Six states (Colorado, Maine, Minnesota, New Jersey, Oregon, and Virginia) also explicitly include safe leave as part of their paid family and medical leave laws. Oregon permits use of paid leave for reasons associated with a public health emergency. Paid leave durations for an employee’s own serious medical condition range from 6 to 52 weeks per year and 8-12 weeks for family leave. Four states (Colorado, Connecticut, Oregon, and Washington) plus D.C. provide a 2–4-week extension for a worker’s own pregnancy-related health issues. Wage replacement ranges from 50% to 100% of regular pay, up to certain caps, and requirements vary by state. Some states provide benefits on a sliding scale, with a higher percentage of wage replacement for lower-income workers. All states offering paid family and medical leave have minimum earnings or employment length requirements to qualify, and some have 7-day unpaid waiting periods. Paid leave benefits are administered by the state or by employers with qualifying programs and are funded through employer and/or employee contributions. 

Employer Provision of Paid Leave Benefits

The BLS’s National Compensation Survey (NCS) releases annual data related to employer benefit plans, including leave benefits. The share of employees with access to paid leave benefits varies by establishment characteristics, such as size, worker status, and wages. Nonetheless, access to paid leave benefits has increased overall in the last few years. The share of workers with access to paid family leave increased from 17% in 2018 to 27% in 2023; similarly, the share of workers with access to paid sick leave slightly increased from 78% in 2020 to 82% in 2025.  

There are differences between different groups of workers in access to paid sick leave (Figure 4). Just over half (56%) of part-time workers had access, compared to nine in ten (90%) full-time workers. The lower likelihood of paid sick leave for part-time workers has a disproportionate impact on women, who are more likely than men to hold part-time jobs and more likely than men to care for sick children when they stay home from school. Among establishments with 500 workers or more, the share of workers with access to this benefit was 91%, compared to 73% of workers in establishments with less than 50 workers.

Similarly, in 2023, 31% of full-time workers had access to paid family leave benefits compared to 14% of part-time workers (Figure 5). Among establishments with less than 50 workers, the share of workers with access to this benefit was about one in five (19%). The share of workers with access nearly doubles (37%) in establishments with over 500 workers.  

Short of federal action, the movement for paid leave will likely continue to be centered on state and local policies or those voluntarily adopted by employers or negotiated through union contracts. Given that most people will need time off during their working lives to care for a personal or family illness, or for a new child, this issue will continue to be a salient concern for working families across the country in the years to come. 

Since the Supreme Court’s 2022 Dobbs ruling, state ballot initiatives have become a powerful tool used by advocates on both sides hoping to either protect or limit abortion access in their state. Successful ballot initiatives that enact state constitutional amendments provide stronger legal authority to either protect or restrict abortion than laws enacted by the legislature or state Supreme Court rulings. Since 2022, twelve states have passed ballot initiatives, usually, but not exclusively, to protect abortion rights in their state. Once again, this November, four states (Table 1) will have abortion-related measures for their voters to consider. Abortion rights advocates in Nevada and Virginia have placed a constitutional amendment protecting the right to abortion on the November ballot. The Missouri legislature has placed an initiative on the ballot to repeal a state constitutional amendment protecting the right to abortion approved by voters in 2024. In addition, voters in Idaho will decide on a state statute that would guarantee a right to abortion until fetal viability or after fetal viability when the patient experiences a medical emergency. This issue brief reviews the abortion-related initiatives on the ballot in November 2026 and examines how these measures may impact abortion access in the state. 

Ballot Initiatives Seeking to Protect Abortion Rights

Virginia

Virginia is currently the only state in the South that does not ban the provision of abortion or impose an early gestational limit, currently allowing abortion until the third trimester. Unless the litigation, described below, challenging the placement of the ballot measure succeeds, voters in Virginia will decide whether to enshrine these abortion protections into the state constitution in November. On February 6, 2026, Governor Spanberger signed a bill, placing the Right to Reproductive Freedom Amendment on the ballot, after the legislature passed it in two successive sessions, as is required by state law. However, on March 3, 2026, Charla Bansley, the District 3 Supervisor for the Bedford County Board of Supervisors, filed a lawsuit seeking to block the placement of the measure on the November ballot. Ms. Bansley alleges state election officials failed to distribute the constitutional amendment to circuit clerks in all counties, as required by state law, before certifying the abortion measure for the ballot.

On July 24, 2026, a district court judge issued an order dismissing Bansley’s lawsuit with prejudice because she failed to establish that she had standing to bring the lawsuit, and the operative law that Bansley attempted to rely on to challenge the ballot language had been repealed. On September 12, 2026, the Virginia Court of Appeals heard an appeal to Bansley’s lawsuit, challenging the ballot initiative placement on the November 2026 ballot. The Virginia Court of Appeals denied Bansley’s petition to bypass appellate review and go directly to the Virginia Supreme Court. Bansley’s opening brief is due October 19, 2026.

A separate lawsuit challenging the Right to Reproductive Freedom Amendment was filed on April 30, 2026, by two medical advocacy groups and by Meagan Kade, a member of the Bluefield town council. The Plaintiffs argue that the language of the ballot initiative does not accurately convey the legal impact of the new constitutional amendment to voters. Additionally, they make the same argument as Bansley that the amendment was not properly circulated. A hearing was held in June 2026. The case is still unresolved, and early voting for Virginia began on September 18, 2026.

The Right to Reproductive Freedom Amendment would amend the state constitution to guarantee a fundamental right to abortion until the third trimester, as well as contraception and fertility care. The Amendment would allow the Commonwealth of Virginia to regulate abortion in the third trimester; however, abortion cannot be prohibited if the pregnant person’s life or physical or mental health is at risk, or if the fetus is not viable. If passed, the Amendment will provide durable protection for abortion rights in the state’s constitution by ensuring that changes in the composition of the legislature or the courts in the Commonwealth do not impede access to abortion care.

Nevada

Nevada law requires citizen-initiated ballot initiatives amending the state’s constitution to pass in two successive general elections. Therefore, Nevadans will vote for the second time on the Reproductive Rights Amendment initially approved by voters in 2024. If passed, the Reproductive Rights Amendment will, “guarantee a right to all individuals to abortion performed or administered by a qualified health care practitioner until fetal viability or when needed to protect the life or health of the pregnant patient, without interference from the state or its political subdivisions.” 

Abortion is currently legal in Nevada until 24 weeks gestation. In 1990, voters passed as a “statute affirmation” which upheld the existing law, NRS 442.250, which legalized abortion until 24 weeks, and prohibited the state legislature from amending or repealing the law unless it was placed on the ballot. In 2019, Nevada enacted the Trust Nevada Women Act, which decriminalized medication abortion and removed informed consent laws. The Reproductive Rights Amendment would protect the individuals’ right to abortion beyond the existing law by limiting state interference. While passage of the Reproductive Rights Amendment would provide the strongest protection against efforts to limit reproductive rights by the legislature or courts, any effort to change the gestational limit for abortion in Nevada would have to be approved by a direct vote of state residents, not by the legislature. 

If the Reproductive Rights Amendment passes, abortion rights advocates are likely to bring a new challenge to Nevada’s parental notification for minors law, contending it is not permissible under the new constitutional amendment. If successful, this challenge would allow minors to consent for their own abortions. Last year, a lower court lifted a 1985 injunction blocking the notification law and reinstated the parental notification requirement. Planned Parenthood Mar Monte, the affiliate that operates the Nevada Planned Parenthood clinics, challenged the lower court's order, and the Nevada Supreme Court preliminarily enjoined the law.

Idaho

Idaho has among the most restrictive abortion laws in the nation. Abortion rights advocates are seeking to reverse these restrictions by trying to get a new law approved, the Reproductive Freedom and Privacy Act, which will change the legality of abortion in the state. Idaho is currently enforcing a total ban on the provision of abortion, with exceptions only to prevent the death of the pregnant person or in the first trimester for reported cases of rape or incest. The Reproductive Freedom and Privacy Act would create a state law giving people the right to make decisions about their own reproductive health care, including abortion up to fetal viability, and after fetal viability if the patient is experiencing a medical emergency, miscarriage care, prenatal, pregnancy, and postpartum care, contraception, and fertility treatment. However, the initiative faced considerable barriers to getting on the ballot. In Idaho, a citizen-initiated ballot initiative can only be placed on the ballot if the petitioner gathers signatures from 6% of the registered voters in the last election in 18 of the state’s 35 legislative districts and submits these signatures by May 1 of the election year. The signatures must then be verified by the county clerks and submitted to the secretary of state for certification. Idahoans United for Women and Families, a nonprofit group that advocates for comprehensive reproductive health care in the state, is organizing the 2026 ballot initiative. On July 13, 2026, the Idaho Secretary of State announced that Idahoans United for Women and Families had collected enough valid signatures for the initiative to qualify for the November 2026 ballot.

In addition to facing barriers to collecting signatures, Idahoans United has also filed multiple lawsuits against the attorney general’s office regarding the ballot language. In January 2025, the group sued the attorney general’s office, arguing that the financial impact statement and the short title of the ballot initiative contained biased language. On June 16, 2025, the Idaho Supreme Court agreed and ordered the attorney general to draft a new financial statement and short title. 

On August 27, 2026, Idahoans United for Women and Families filed another lawsuit against the Secretary of State and the Attorney General of Idaho, alleging that the drafted ballot language did not contain a clear and concise statement on the effect of a “YES” or “NO” vote. The original “NO” statement, as written by the Secretary of State and Attorney General, provided: "A NO vote would make no change to Idaho’s current law, which protects the life of the unborn while allowing abortion in reported cases of rape or incest, or when necessary to protect the life of the mother. Idahoans United alleged that the “NO” statement, as written, mischaracterized Idaho’s current abortion law, leading voters to believe that Idaho law “allow[s] abortion . . . when necessary to protect the life of the mother,” when the current law only allows abortions to prevent the death of a pregnant person, and used inaccurate and argumentative language such as “protects the life of the unborn.”

Additionally, Idahoans United argued that the “YES” statement similarly violated Idaho law because it was not a clear and concise statement that describes the legal effect of a “YES” vote. The original “YES” statement provided: “A YES vote would establish reproductive rights, including a right to abortion before a fetus's ability to survive and after a fetus's ability to survive in cases of a medical emergency, and provide liability protections for healthcare providers.” Idahoans United argued that the “YES” statement description of fetal viability could confuse voters because if the statement continued on the ballot as written, it would describe the same point in pregnancy (viability) four different ways: in the initiative text, in the short title, in the long title, and in the “YES” statement.

On September 4, 2026, the Idaho Supreme Court ordered the Secretary of State and the Attorney General to rewrite the ballot language after finding the original version failed to comply with state law by not clearly and concisely stating the effects of “YES” and “NO” votes.

If passed, the Reproductive Freedom and Privacy Act could expand access to abortion in Idaho. However, the Act would still face challenges after the election because Idaho allows its legislature to amend or repeal a citizen-initiated statute without restrictions. There are numerous examples where the legislature has reversed or amended the will of the electorate. In 2002, the Idaho legislature repealed citizen-initiated statutes that sought to place term-limits on elected officials. In 2019, the Idaho legislature amended a citizen-initiated statute that expanded Medicaid eligibility.

Ballot Initiatives Seeking to Curtail Abortion Rights 

Missouri 

In 2026, voters in Missouri will again be asked to decide the legal status of abortion in their state, but this time to reverse a recently approved constitutional amendment. In 2024, Missouri voters approved Amendment 3, the Right to Reproductive Freedom Amendment, which amended the state’s constitution to guarantee a right to abortion until fetal viability. Before Amendment 3 was passed, Missouri banned the provision of abortion with exceptions only to avert the death of the pregnant person or to avert a serious risk of substantial and irreversible physical impairment of a major bodily function of the pregnant person. After Amendment 3 passed, Planned Parenthood, one of the abortion providers in the state, filed a lawsuit challenging not only the state’s total abortion restriction, but also a series of regulations on facilities and clinicians providing abortions. These restrictions included a 72-hour waiting period between an initial appointment and when an abortion could be performed, and abortion specific informed consent requirements. The court struck down the abortion restriction, allowing abortion to be legal in the state, but did not block regulations on facilities and clinicians providing abortions while the litigation continues. 

State legislators who oppose abortion rights have drafted a new ballot initiative that seeks to repeal Amendment 3. The 2026 ballot initiative, also known as Amendment 3, would ban the provision of abortion except in cases of medical emergencies, fatal fetal anomalies, or pregnancies 12 weeks or less gestation that are a result of rape or incest. The initiative includes a parental or guardian consent requirement for minors except in medical emergencies and prohibits state funding of abortions in most circumstances. The ballot initiative explicitly allows the legislature to regulate abortion provision, facilities, and providers including, “requiring physicians providing abortion care to have admitting privileges at a nearby hospital; laws requiring facilities where abortions are performed or induced to be licensed and inspected for clean and safe conditions and adequate instruments to treat any emergencies arising from an abortion procedure; laws requiring physicians to perform a sufficient examination of the woman to determine the unborn child's gestational age and any preexisting medical conditions that may influence the procedure; and laws requiring ultrasounds to be performed only by physicians or licensed medical technicians.” In addition, the initiative includes a ban on gender affirming care for minors. 

The 2026 ballot initiative has faced legal scrutiny. On July 2, 2025, the ACLU of Missouri filed a lawsuit against the secretary of state, alleging that the language for the 2026 ballot initiative was intentionally misleading, contained an inaccurate summary, and is unconstitutional because it included more than one subject. The ACLU argued that the language of the ballot initiative failed to properly inform voters that a “yes” vote would lead to a repeal of reproductive rights protections that passed in 2024. The ACLU also contended that the subject of the ballot initiative is related to “reproductive health care,” but includes topics unrelated to reproductive health, including a ban on gender-affirming care for minors. On July 4, 2025, the Missouri Western District Court of Appeals ruled that the language of the 2026 ballot initiative failed to inform voters that the initiative would repeal and replace the 2024 Right to Reproductive Freedom Amendment, and certified new ballot language for the 2026 ballot initiative. The language certified by the court will appear on the November 3, 2026, ballot. This is the first time voters could decide to repeal a state constitutional amendment protecting abortion. Passage of the 2026 ballot initiative would ban the provision of abortion in Missouri and prevent minors from accessing gender affirming care. 

Some Abortion Restrictions Remain in Place After Voters Pass Constitutional Amendments

Voters in Arizona, Ohio, and Missouri passed state constitutional amendments establishing the right to abortion in recent elections. After abortion advocates challenged existing state restrictions on the provision of abortion under the new constitutional amendments, courts have blocked the pre-existing state abortion restrictions. However, legal challenges to existing abortion restrictions such as waiting periods and telemedicine restrictions, have taken longer as courts have not uniformly blocked these provisions. 

On November 5, 2024, Arizona voters passed Proposition 139, a ballot initiative that amended the state constitution to guarantee a right to abortion until fetal viability. The amendment also allows abortions after fetal viability if the physician providing the abortion determines that the abortion is necessary to protect the life or physical or mental health of the pregnant person. After this constitutional amendment became effective in December 2024, advocates filed legal challenges to block Arizona’s 15-week ban on the provision of abortion and other abortion restrictions. In March 2025, a court ruled Arizona’s 15-week ban was unconstitutional under the new amendment. In February 2026, an Arizona state court ruling blocked several abortion restrictions, including: (1) a ban on abortion based on fetal diagnoses; (2) a 24-hour waiting period and (3) a prohibition on telemedicine for abortion care due to new protections granted in the state’s constitutional amendment. However, Republican state legislators who have intervened in the lawsuit may appeal this decision. The Democratic Arizona Attorney General declined to defend the laws on behalf of the state, and therefore it is unlikely the state will appeal. 

There are, however, still abortion restrictions in effect in Arizona, including a ban on state funds for abortion (which affects Medicaid), a parental consent requirement for minors seeking abortions, and a law that bars medical professionals other than doctors from providing abortions. In February 2026, the ACLU of Arizona filed a lawsuit on behalf of advanced practice clinicians, contending the physician-only law violates the constitutional amendment protecting abortion. 

On November 7, 2023, Ohio voters passed Issue 1, a ballot initiative that amended the state constitution to guarantee every individual has the right to make their own reproductive decisions, including contraception, fertility treatment, continuing a pregnancy, miscarriage care, and abortion care. The amendment also allows the state to prohibit abortion after fetal viability; however, an abortion cannot be prohibited after viability if it is necessary to protect the life or health of the pregnant person. After the passage of Issue 1, advocates cited the new amendment in legal challenges to the state’s 6-week ban on the provision of abortion as well as the many other abortion restrictions. In October 2024, the Hamilton County Court of Common Pleas issued a permanent injunction blocking Ohio’s 6-week abortion ban from taking effect, marking the first permanent injunction based on Ohio’s Reproductive Freedom Amendment. Courts have blocked many of the other abortion restrictions as well. One provision that was challenged, but is still in effect, is a requirement for providers to document the reason for an abortion, but this provision does not impact patients’ access to abortion care. Ohio law still requires parental consent for minors seeking abortions and blocks public funding for abortions. 

As was discussed earlier, Missouri voters approved Amendment 3, the Right to Reproductive Freedom Amendment, in 2024, which guarantees a right to make and carry out decisions about all matters relating to reproductive health care, including: prenatal care, childbirth, postpartum care, birth control, abortion care, miscarriage care, and respectful birthing conditions. The amendment also allows the government to regulate abortion after fetal viability; however, it prevents the government from restricting abortion after fetal viability if the abortion is necessary to protect the life, physical or mental health of the pregnant person. After the passage of Amendment 3, a court blocked the state’s ban on the provision of abortion, but many restrictions on abortion (72-hour waiting period and abortion specific informed consent requirements) remain in place and are the subject of ongoing litigation.

Options for Future Citizen-Referred Ballot Measures Are Limited

Citizens are allowed to propose a constitutional amendment for the ballot in 17 states. There are only two states, Arkansas and Oklahoma, with current bans on the provision of abortion which allow for citizen-initiated constitutional amendments and have yet to vote on an abortion measure (Figure 1). There were efforts in Arkansas (where there is a near-total ban on the provision of abortion) to get an initiative on the ballot, but the Arkansas Secretary of State rejected the petition for the initiative because the signatures were not properly gathered, and thus the initiative did not make it to the ballot. The Arkansas Supreme Court upheld this decision. 

Oklahoma has a total ban on the provision of abortion, with an exception only to save the life of the pregnant person, and classifies performing an abortion as a felony. A citizen-led effort to put a state constitutional amendment that would have added an “individual right to reproductive freedom” on the ballot was withdrawn in December 2022, before signature gathering began.

In 2024, in Florida, Nebraska, and South Dakota, abortion rights amendments failed to garner sufficient votes for passage. In Nebraska, voters approved a competing measure to ban the provision of abortion after the first trimester. In South Dakota, the measure failed to pass, only garnering 41% of the votes. In Florida, the initiative received 57% approval. However, state law requires 60% approval for a constitutional amendment. As the popular vote fell just 3 percentage points short of approval, abortion rights supporters in Florida may try again in a future election to reverse the 6-week ban on the provision of abortion. 

Conversely, in states with current abortion protections without a constitutional amendment protecting abortion, only three states (Illinois, Massachusetts, Oregon) have a process for citizen-initiated constitutional amendments. However, in today’s political climate, it is unlikely that new citizen initiatives will be brought to the electorate to weaken existing abortion protections.

TrumpRx prices for brand-name drugs are about as likely to be higher as lower compared to average prices in other wealthy countries, according to an analysis that compares 32 brand-name drugs (without generics or biosimilars) on the TrumpRx website with publicly available prices in one or more of 11 OECD member countries: Australia, Austria, Belgium, Canada, France, Germany, Japan, the Netherlands, Sweden, Switzerland, and the United Kingdom.

For 17 of the 32 drugs, the TrumpRx price is lower than the average price in comparable countries. This includes five drugs for which the TrumpRx price is lower than the prices available in any of the other countries. Eight drugs have a price that is $100 less than the average in other countries. For the other 15 drugs, the TrumpRx price is higher than the average price in comparable countries. This includes 13 drugs for which the TrumpRx price is higher than prices available in any of the other countries.

The full analysis and other data on health costs are available on the Peterson-KFF Health System Tracker, an online information hub dedicated to monitoring and assessing the performance of the U.S. health system.

Section:

0 / 0

Findings

Copy link to Findings

Affordability has dominated national conversations. High inflation rates, increased gas and grocery prices, and the constant rise in health care costs and insurance premiums have emerged as major political issues. Historically, national surveys find that many Americans report difficulties affording health care and have problems paying for health care services, particularly women, who have lower incomes, fewer financial resources, and use the health care system more than men. In recent years, people with health coverage have increasingly experienced difficulties affording care. The 2026 KFF Women’s Health Survey was fielded between March 11, 2026 to April 14, 2026 to better understand women’s experiences accessing and using health care services including barriers to care. The survey is a nationally representative survey of 4,688 women, ages 18 to 64, and 1,148 men, ages 18 to 64. This brief provides new information about the affordability challenges women report experiencing in the past 12 months and their impact on access and utilization of health care services.¹

Key Findings

• Many women, even those with insurance coverage, have delayed or postponed care they thought they needed in the past 12 months because of cost. Four in ten (42%) women, ages 18-64, and 35% of men, ages 18-64, report they have delayed or postponed care they thought they needed in the past year. While about two-thirds (68%) of uninsured women report putting off needed care due to costs, those with insurance are not immune from this problem. Half of women with individually purchased plans and a third of women with Medicaid (34%) and employer sponsored coverage (38%) report delaying or postponing needed care because of cost. 
• The cost of care is a barrier to a sizable minority of women in getting specific recommended tests and treatments. Three in ten (31%) women ages 18 to 64 report they have skipped or postponed recommended medical tests or treatments in the past year because of costs. Higher shares of uninsured women, women with low or modest incomes, and those with self-reported fair or poor health report skipping or postponing tests or treatments due to the costs of care.
• The cost of prescription drugs leads some women to alter their prescription drug use by not filling prescriptions, skipping doses, or cutting pills in half. A quarter (27%) of women ages 18 to 64 report they didn’t fill a prescription in the last year because of cost and almost a fifth (17%) report they cut pills in half or skipped doses of medicine because of cost. Four in ten women in fair or poor health didn’t fill prescriptions and one quarter cut pills or skipped doses because of costs.
• Health care costs can force some women to make tradeoffs in paying for other basic needs. One in four (25%) women ages 18 to 64 report that in the past 12 months they have spent less money on their basic needs, such as food, clothes and electricity so they could have enough money for health care. Among uninsured women, the share was 42%. Approximately three in ten women on Medicaid or with individually purchased insurance, who were Black or Hispanic, low-income or in fair or poor health report making health-related financial tradeoffs.

Affordability Challenges

Four in ten (42%) women report that they delayed or postponed care they thought they needed because of the cost in the last 12 months. While women and men both can feel the impact of health costs, such as insurance premiums, co-payments, and deductibles, they can be particularly burdensome for women who on average earn lower wages, have fewer financial assets, accumulate less wealth, and have higher rates of poverty than men. Four in ten (42%) women and 35% of men ages 18 to 64 report they have delayed or postponed care they thought they needed. One in three women (31%) report they have skipped recommended tests or treatments, over a quarter (27%) report they haven’t filled a prescription for a medicine, and 17% report they have cut pills in half or skipped recommended doses of medicine, all because of cost. Half of women and four in ten (42%) men report one of these cost delays or gaps in the past 12 months.

Many women, even those with insurance coverage, report having delayed or postponed care because of cost. Nearly seven in 10 (68%) uninsured women say theydelayed or postponed care in the past 12 months because of the cost. While younger adults, those with lower incomes, poor health and people of color have higher uninsured rates, even after controlling for these characteristics in a regression model, the association between being uninsured and delaying or postponing care remains. Even women with insurance are susceptible to cost barriers (Figure 1). Half of women ages 18 to 64 with individually purchased plans, which often have higher deductibles and premiums as well as narrower networks, report cost was a reason for delaying or postponing care in the past 12 months, as do 38% of women with employer sponsored plans. Medicaid, the national health coverage program for people with low incomes, is supposed to have only nominal out of pocket costs, but a third (34%) of women with Medicaid coverage also say they had to delay or postpone care due to costs. While Medicaid copayments are modest, they could still be a financial burden for low-income people. Women could also face challenges paying for uncovered services or services during a period when they were uninsured. Women with lower incomes, Hispanic women, and women with fair/poor and good health are also more likely to report having delayed or postponed care in the past year.

Affordability Challenges Lead Many Women to Delay Needed Care

Bar chart showing the share of women ages 18–64 who delayed or postponed needed care in the past 12 months because of cost, overall and by insurance, race/ethnicity, income, and health status. Forty-two percent of women delayed care, compared with 32% of men. Delayed care was highest among uninsured women (68%), women with fair or poor health (56%), and women with incomes below 200% of the federal poverty level (48%).

Subgroup analysis is among women 18 to 64. Income is based on 2023 ASPE income levels. Two hundred percent (200%) of the federal poverty level (FPL) in 2023 for an individual was $29,160. Persons of Hispanic origin may be of any race; other racial groups are non-Hispanic. The sample primarily includes English-speaking Asian adults and, therefore, may not be representative of the overall Asian population. *Estimate is statistically different than reference (ref) estimate within group (p < 0.05).

KFF Women's Health Survey 2026

High costs can cause many women to skip specific recommended tests and treatments, even women with health coverage. Half (52%) of uninsured women ages 18 to 64 report skipping recommended tests or treatments due to cost, as do four in ten (41%) of women with individually purchased health plans, three in 10 (28%) women with employer sponsored plans, and one in five (22%) of women with Medicaid coverage (Figure 2). Higher shares of women with self-reported fair/poor health (40%) or good health (32%) report skipping recommended tests or treatments in the past year compared to a quarter of women (23%) who rate their health as excellent/ very good. Hispanic women and women with low or modest incomes (up to 399% FPL) are also more likely to report skipping recommended services compared to their White and higher income counterparts.

Three in Ten Women Have Skipped Recommended Medical Tests or Treatments in the Past Year

Bar chart showing the share of women who skipped recommended medical tests or treatments because of cost. Overall, 31% skipped care, with higher rates among uninsured women (52%), women with individually purchased coverage (41%), Hispanic women (35%), women with incomes below 400% of the FPL (35%), and women in fair or poor health (41%).

Subgroup analysis is among women 18 to 64. Income is based on 2023 ASPE income levels. Two hundred percent (200%) of the federal poverty level (FPL) in 2023 for an individual was $29,160. Persons of Hispanic origin may be of any race; other racial groups are non-Hispanic. The sample primarily includes English-speaking Asian adults and, therefore, may not be representative of the overall Asian population. *Estimate is statistically different than reference (ref) estimate within group (p < 0.05).

KFF Women's Health Survey 2026

Cost limits women’s ability to fill their prescriptions or take their medications as prescribed. The majority of women ages 18 to 64 (62%) report they take at least one prescription medication on a regular basis, yet many women report issues affording prescription drugs. A quarter (27%) of all women ages 18-64, report they didn’t fill a prescription in the last year and almost a fifth (17%) report they cut pills in half or skipped doses of medicine because of cost. Among the share who report currently taking a prescription medication, the share who say they have not filled a prescription increases to 32% and one in five say they have cut pills in half or skipped doses in the past year because of cost.

Women with self-reported fair/poor and good health and women with lower incomes are more likely to report they have either not filled a prescription or taken medications as prescribed. A higher share of uninsured women report not filling a prescription (42%) or taking medication as prescribed (17%), but substantial shares of insured women also report having trouble with their prescriptions because of cost in the past 12 months (Figure 3).

Cost Limits Many Women’s Ability to Fill Prescriptions or Take Medications as Prescribed

Bar chart showing the share of women ages 18 to 64 who skipped filling a prescription or cut pills/skipped doses in the past 12 months because of cost, broken down by insurance, race/ethnicity, income, and health status. Cost-related barriers are highest among uninsured women, those with lower incomes, and those in fair or poor health, while women with employer-sponsored insurance, higher incomes, and better health report the lowest rates.

Subgroup analysis is among women 18 to 64. Income is based on 2023 ASPE income levels. Two hundred percent (200%) of the federal poverty level (FPL) in 2023 for an individual was $29,160. Persons of Hispanic origin may be of any race; other racial groups are non-Hispanic. The sample primarily includes English-speaking Asian adults and, therefore, may not be representative of the overall Asian population. Estimate for not filled a prescription for a medicine (*) or cut pills in half or skipped doses of medicine (^) is statistically different than reference (ref) estimate within group (p < 0.05).

KFF Women's Health Survey 2026

Health care costs can force women to make tradeoffs in paying for other basic needs. One in four (25%) women ages 18 to 64 report that in the past 12 months they have spent less money on their basic needs, such as food, clothes and electricity so they could have enough money for health care (Figure 4). Four in ten (39%) women without insurance and three in ten women with Medicaid (31%) coverage and individually purchased coverage (30%) report spending less in their basic needs to have enough money for health care compared to one in five (18%) women with employer-sponsored plans. This is more common amongwomen with lower incomes, Black and Hispanic women, as well as women with poorer self-reported health status.

One in Four Women Have Spent Less Money on Their Basic Needs To Have Enough Money to Cover their Health Care Needs

Bar chart showing the share of women ages 18 to 64 who spent less on basic needs like food, clothes, or electricity in the past 12 months so they'd have enough money for health care, broken down by insurance, race/ethnicity, income, and health status. About one in four women overall report doing this, with the share notably higher among uninsured women, Black and Hispanic women, those with lower incomes, and those in fair or poor health.

Subgroup analysis is among women 18 to 64. Income is based on 2023 ASPE income levels. Two hundred percent (200%) of the federal poverty level (FPL) in 2023 for an individual was $29,160. Persons of Hispanic origin may be of any race; other racial groups are non-Hispanic. The sample primarily includes English-speaking Asian adults and, therefore, may not be representative of the overall Asian population. *Estimate is statistically different than reference (ref) estimate within group (p < 0.05).

KFF Women's Health Survey 2026

The majority of women 18 to 64 report they are insured, but almost one in five women 18 to 64 (18%) report they are either currently uninsured or were uninsured at some point in the past 12 months. Health insurance coverage is an important factor in making health care affordable and accessible to women.Seven percent of women say they are currently insured but were uninsured at some point during the past 12 months. Women can be uninsured for periods of time because of job loss or change, premium prices becoming unaffordable, or in the case of dependent coverage, a spouse’s job loss, divorce, or widowhood. Younger women, women with lower incomes and women with poor/fair health are uninsured at higher rates and larger shares report being currently insured but having been uninsured at some point during the year (Appendix Table 1).

Women with Medicaid coverage (11%) and those with individually purchased private plans (14%) are more likely to report having been uninsured at some point in the past 12 months compared to women covered by an employer-sponsored plan (5%) (Figure 5). In the coming years, the number of uninsured is expected to increase significantly due to recent federal policy changes in Medicaid and the expiration of the ACA enhanced tax credits. Many women with Medicaid coverage and ACA marketplace plans will be directly impacted by these policy changes and will likely see more periods without insurance coverage.

Higher Shares of Women with Medicaid Coverage and Those With Individually Purchased Plans Report They Were Uninsured at Some Point During the Year

Three pie charts showing the share of women ages 18 to 64 who are currently insured but were uninsured at some point in the past 12 months, broken out by current insurance type. Women with Medicaid or individually purchased plans are notably more likely to have had a coverage gap during the year than those with employer-sponsored insurance.

Among women 18 to 64. ^Estimate for currently Insured, but uninsured at some point in the last 12 months is statistically different than reference (ref) estimate (p < 0.05).

KFF Women's Health Survey 2026

Appendix

Copy link to Appendix

Share of Women Who Are Currently Insured but Were Without Coverage at Some Point in Past 12 Months, by Selected Characteristics

Bar chart showing the share of currently insured women ages 18 to 64 who were without coverage at some point in the past 12 months, broken down by age, insurance type, income, race/ethnicity, and health status. Younger women and those with Medicaid, individually purchased plans, or lower incomes report the highest rates of a coverage gap during the year.

Among women ages 18 to 64. Income is based on 2023 ASPE income levels. Two hundred percent (200%) of the federal poverty level (FPL) in 2023 for an individual was $29,160. Persons of Hispanic origin may be of any race; other racial groups are non-Hispanic. The sample primarily includes English-speaking Asian adults and, therefore, may not be representative of the overall Asian population. *Estimate is statistically different from estimate for reference (ref) estimate (p < 0.05)

KFF Women's Health Survey 2026

Methodology

Copy link to Methodology

The 2026 KFF Women’s Health Survey was designed and analyzed by women’s health researchers at KFF. The survey was conducted from March 11 – April 14, 2026, online and by telephone among a nationally representative sample of 5,854 adults ages 18 to 64, including 3,538 women ages 18 to 49. Women include anyone who selected woman as their gender. Sampling, data collection, weighting, tabulation, and IRB approval by the University of Southern Maine’s Collaborative Institutional Review Board were managed by SSRS of Glenn Mills, Pennsylvania in collaboration with women’s health researchers at KFF.

Throughout the reports of findings, we refer to “women.” This includes respondents who said their gender is “woman,” and includes those who selected “woman” in addition to another gender, such as “transgender,” or “non-binary,” or another gender. We followed this approach to try to include as many people as possible but recognize that some people who need and seek abortion and other reproductive health care services may not be represented in the findings or identify as women. Some questions about sexual and reproductive health were only asked among those with a specific sex assigned at birth (i.e. male or female).

The national sample was drawn from two nationally representative probability-based panels: the SSRS Opinion Panel and the Ipsos Knowledge-Panel. The SSRS Opinion Panel is a nationally representative probability-based panel where panel members are recruited randomly in one of two ways: (a) Through invitations mailed to respondents randomly sampled from an Address-Based Sample (ABS) provided by Marketing Systems Groups (MSG) through the U.S. Postal Service’s Computerized Delivery Sequence (CDS); (b) from a dual-frame random digit dial (RDD) sample provided by MSG. For the online panel component, invitations were sent to panel members by email followed by up to five reminder emails. 5,660 panel members completed the survey online and panel members who do not use the internet were reached by phone (n=194). Another 514 respondents were reached online through the Ipsos Knowledge Panel to help reach adequate sample sizes among subgroups of interest, specifically women ages 18 to 49. This panel is recruited using ABS, based on a stratified sample from the CDS. The questionnaire was translated into Spanish, so respondents were able to complete the survey in English or Spanish. 

The national sample was weighted by splitting the sample into three groups: [1] Women 18-49, [2] Women 50-64, and [3] Men 18-64 and each group was separately weighted to match known population parameters (see table below for weighting variables and sources). Weights within the three groups were then trimmed at the 4^th and 96^th percentiles, to ensure that individual respondents do not have too much influence on survey-derived estimates. After the weights were trimmed, the samples were combined, and the weights adjusted, so that the groups were represented in their proper proportions for a final combined, gender by age-adjusted weight.

Dimensions	Source
CPS 2024 Voting and Registration Supplement	Current Population Survey 2025
Education
Age by Education
Age by Gender
Census Region
Race/Ethnicity by Nativity
Home Tenure
Civic Engagement	2023 CPS Volunteering and Civic Life Supplement
Internet Frequency	Pew Research Center’s National Public Opinion Reference Survey (NPORS 2025)
Population Density	Claritas Pop-Facts Premier 2026
Voter Registration	CPS 2024 Voting and Registration Supplement

The margins of sampling error for the national sample of women ages 18 to 64 and reproductive age women ages 18 to 49 are plus or minus 2 percentage points. Numbers of respondents and margins of sampling error for key subgroups are shown in the table below. For results based on other subgroups, the margin of sampling error may be higher. Sampling error is only one of many potential sources of error and there may be other unmeasured error in this survey.

Group	N (unweighted)	M.O.S.E.
National Women Ages 18-64	4,688	± 2 percentage points
White, non-Hispanic	2,262	± 2 percentage points
Black, non-Hispanic	767	± 4 percentage points
Hispanic	1,135	± 4 percentage points
Asian or Pacific Islander	347	± 6 percentage points
18-25	508	± 5 percentage points
26-35	1,313	± 3 percentage points
36-49	1,715	± 3 percentage points
50-64	1,152	± 3 percentage points
<200% FPL	1,641	± 3 percentage points
200%-399% FPL	1,232	± 3 percentage points
400%+ FPL	1,475	± 3 percentage points
Employer-Sponsored	2,490	± 2 percentage points
Individually Purchased	386	±6 percentage points
Medicaid	977	± 4 percentage points
Uninsured	537	± 5 percentage points

General Notes:

The sample primarily includes English-speaking Asian adults and, therefore, may not be representative of the overall Asian adult population. Despite this limitation, it is important to report the views of Asian adults on the topics in this study. As always, Asian adults’ responses are incorporated into the general population figures throughout this report.

Income is based on 2023 ASPE income levels. Two hundred percent (200%) of the federal poverty level (FPL) in 2023 for an individual was $29,160.

Endnote

1. The data in this brief report affordability challenges for adults ages 18 to 64. Other KFF polling data includes estimates for all adult women and men, including those 65 and older. ↩︎