In the aftermath of the Supreme Court ruling overturning Roe v. Wade, there has been an increased focus on the use of telehealth as a way to both expand and restrict access to medication abortion at both the federal and state level. Several states that support abortion rights have enacted “shield” laws which aim to reduce the legal risks for clinicians who provide abortion medication via telehealth to patients who live in states where abortion is banned or restricted. An estimated one in four abortions are obtained via telehealth, and about half those are from abortion providers practicing in states with shield laws who mailed abortion pills to people living in states with bans or early stage gestational abortion restrictions. Recently, Louisiana and Texas, two states with abortion bans, filed lawsuits against a New York doctor for mailing medication abortion into their states. At the federal level, the possible enforcement of the Comstock Act, an 1873 anti-vice law, a recently initiated federal Food and Drug Administration (FDA) review of mifepristone safety, along with the potential reinstatement of FDA restrictions for mifepristone could result in the limitation or prohibition of the use of telehealth for medication abortion and restrict the availability of mifepristone nationwide.

The tension between the state right to ban or restrict abortion and federal jurisdiction to regulate medication abortion is a central issue in ongoing legal challenges. In addition, there is a conflict also playing out in the courts between states that ban abortion and those seeking to protect abortion providers in their states. Organizations on both sides of the abortion issue are advocating for the Trump administration’s FDA to take action to address access to mifepristone. This brief reviews current state and federal policies, ongoing litigation, and potential federal actions that may impact access to telehealth for medication abortion.

FDA Regulation of Medication Abortion

Mifepristone, often referred to as medication abortion, RU-486, or the abortion pill, was approved by the FDA as a medication to end pregnancy 25 years ago. A regimen of mifepristone, followed by misoprostol, is the FDA approved protocol for abortion during the first 70 days or up to 10 weeks after the first day of a missed period. Mifepristone works by blocking progesterone, a hormone essential to the development of a pregnancy, and thereby preventing an existing pregnancy from progressing. Misoprostol, taken 24–48 hours after mifepristone, works to empty the uterus by causing cramping and bleeding, similar to an early miscarriage. The national median self-pay price for medication abortion at a bricks and mortar provider in 2023 was $563, although the cost was significantly lower when obtained through a virtual clinic ($150). Medication abortions account for two-thirds (63%) of all abortions in the US and it is a safe and highly effective method of pregnancy termination. The pregnancy is terminated successfully 99.6% of the time, with a 0.4% risk of major complications, and an associated mortality rate of less than 0.001 percent (0.00064%).

A robust body of research has confirmed that the use of telehealth for medication abortion is safe and effective. Studies have found similar pregnancy termination rates without the need of interventions between telehealth and in-person abortion patients. Adverse events (such as infections, blood transfusions or hospital admissions) are very rare (<1%) among both in-person and telehealth patients. Telehealth patients also report high satisfaction rates with their use of telehealth. Despite the high share of states with abortion bans and early-stage gestational restrictions, the total number of abortions in the US has increased in the three years since the Dobbs decision. While this increase is due to a number of factors, telehealth has played a role in that increase. By the end of 2024, one in four abortions in the U.S. were provided via telehealth.

Since 2011, how mifepristone is dispensed has been subject to the FDA’s Risk Evaluation and Mitigation Strategy (REMS) restrictions. Currently, the REMS for mifepristone do not require in-person dispensing and allow certified non-physicians and pharmacies to prescribe and dispense the drug (Table 1). The original 2011 REMS only permitted certified physicians to prescribe and dispense mifepristone and required three in-person visits, thereby restricting the use of telehealth for medication abortion across the country. Over the years as new research has emerged, the FDA has modified the REMS, and in 2021 it removed the in-person dispensing requirements, which were formalized in 2023. In addition, in 2016, the FDA updated and approved a new evidence-based regimen and drug label for medication abortion. This protocol approved the use of medical abortions for up to 70 days (10 weeks) of pregnancy. Until 2019, mifepristone was only sold under the brand name Mifeprex, manufactured by Danco Laboratories. In 2019, the FDA approved GenBioPro, Inc.’s application for generic mifepristone.

State Policies Affecting Telehealth for Medication Abortion

Access to medication abortion hinges on whether state laws ban or restrict abortion, abortion-specific regulations that are on the books in many states, and the FDA prescribing and dispensing protocol (Appendix 1). As of July 2025, 12 states have laws banning abortion and four states have a 6-week LMP gestational limit, often before many women know that they are pregnant. State laws that ban or restrict abortion apply to both medication and procedural abortions.

Currently nine states (AZ, AR, FL, IN, KY, OK, SC, TX and WV) have laws in place explicitly prohibiting the use of telehealth for medication abortion and/or the mailing of medication abortion drugs. Six of these states also have total abortion bans in place, and two have 6-week abortion bans, limiting access to all abortion services in the state. In Arizona, the only state with these laws in place that does not have a law banning or restricting abortion, doctors have filed a lawsuit contending that the state’s telehealth ban and the ban on mailing medication abortion drugs violate the state’s constitutional amendment protecting the right to abortion up to viability that was approved by voters in the November 2024 election.

In addition to the laws banning abortion or directly banning the use of telehealth for abortion, other state regulations—including ultrasound and counseling requirements, waiting periods, and specific in-person dispensing mandates—also play a role in limiting the feasibility of using telehealth for medication abortion (Figure 1). In states without these restrictions, people do not need to make any in-person visits to a clinic to safely have a medication abortion under the supervision of a health care provider.

In the aftermath of the Dobbs decision, some states started passing “shield” laws. These laws aim to protect physicians from prosecution brought by states where abortion is banned as long as the physician is located within the state with the shield law and the care they provided is legal in that same state, regardless of patient location. As of July 2025, eight states have shield laws in place that explicitly protect providers regardless of where the patient lives. By the end of 2024, over one in seven (15%) abortions in the U.S. were medication abortions for which the pills were mailed by providers practicing in states with shield laws to states where abortion is banned, with 6-week gestational limits, or the state has telehealth restrictions in place (Figure 2).

Potential Federal Actions that Could Restrict Medication Abortion

Questions remain about what actions the federal government can and/or will take to restrict the use of telehealth for medication abortion. The Comstock Act – an 1873 anti-vice law banning the mailing of obscene matter and articles used to produce abortion could be used to sharply restrict abortion nationwide. In the aftermath of the Supreme Court’s Dobbs decision, anti-abortion activists have argued in federal court that the Comstock Act prohibits the mailing of mifepristone directly to patients, as well as the general distribution of the medication to physicians, hospitals, and pharmacies.

A literal interpretation of the Act could potentially apply to materials used to produce all abortions, not just medication abortions; would not have exceptions; and could affect other medical care, such as miscarriage management. The Biden administration’s Department of Justice determined that the Act only applies when the sender intends for material or drug to be used for an illegal abortion, and because there are legal uses of abortion drugs in every state including to save the life of the pregnant person, there is no way to determine the intent of the sender. While he was running for a second term, President Trump made inconsistent statements about whether he would enforce the Act. If the Trump administration follows the Project 2025 blueprint and enforces the Comstock Act people across the country would be impacted, even those that have a guaranteed right to abortion in their state constitutions.

The Secretary of Health and Human Services (HHS), Robert F. Kennedy Jr., has directed the FDA commissioner, Dr. Martin Makary, to launch a safety review of mifepristone following the release of a report which has been criticized as having methodological flaws and lack of data transparency aiming to cast doubt on the long-standing research on the safety of mifepristone. Project 2025 and other anti-abortion advocates have long been calling for the FDA to retract the approval of mifepristone or for the FDA to revert to the older FDA mifepristone REMS that would reduce the gestational period for the use of mifepristone, prohibit telehealth appointments, and access through pharmacies.

Four citizen petitions have recently been filed with the FDA about mifepristone, calling for the agency to either restrict or expand access to the drug (Table 2). FDA citizen petitions allow individuals and organizations to petition the agency to issue, change, or cancel regulations. The FDA is required to respond to citizen petitions within 180 days by granting or denying the request, or saying it needs more time. The FDA must document its position in its response.

Current Litigation on Mifepristone Access

There are multiple ongoing cases seeking either to restrict or expand the availability of medication abortion (Table 3). In June 2024, the Supreme Court dismissed the case filed by the Alliance for Hippocratic Medicine, finding that the anti-abortion doctors and organization did not have standing to sue the FDA. Before this case was reviewed by the Supreme Court, three states (Missouri, Idaho, and Kansas) intervened as parties in this case at the district court level. This case is now proceeding as State of Missouri v. FDA, and the states are seeking the reinstatement of the in-person dispensing requirement for mifepristone and the requirement for three in-person visits which would prohibit the use of telehealth for medication abortion. In May 2025, the Trump administration filed a motion asking for the dismissal or transfer the states’ lawsuit to an appropriate venue instead of allowing the case to be considered by the federal district court in the northern district of Texas. GenBioPro, a manufacturer of generic mifepristone, filed a lawsuit in April 2023 in a federal district court in Maryland to prevent other federal court rulings from suspending FDA approval of mifepristone without following the required statutory and regulatory procedures. This case is currently paused pending the Texas district court decision in the case, Missouri v. FDA.

In February 2023, the Oregon and Washington Attorneys General joined by 16 other states filed a case in federal district court in the eastern district of Washington challenging the FDA’s decision-making about mifepristone, calling into question the FDA’s decision to impose restrictions on prescribing and dispensing mifepristone through the Risk Evaluation and Mitigation System (REMS). In April 2023, the judge in this case issued a preliminary injunction blocking the FDA from changing any rules that would impact the availability of mifepristone in states bringing the lawsuit (WA, OR, CO, CT, IL, NV, AZ, RI, OR, DE, MI, NM, VT, HA, MD, ME, MN, PA, and DC). The states alleged that the REMS imposes “hurdles” to drug access “without any corresponding medical benefit” in violation of the Federal Food, Drug and Cosmetic Act (FDCA). In July 2025, the federal district court vacated the preliminary injunction and dismissed the case finding that the “FDA did assess whether mifepristone qualifies for REMS…based on the criteria” set forth in the law, and came to a “reasonable conclusion.”

In addition, in May 2023, Whole Woman’s Health and other independent abortion providers in Virginia, Montana and Kansas filed a lawsuit challenging the imposition of REMS on mifepristone. The federal district court for the western district of Virginia heard the case on May 19, 2025, and is expected to rule on the case soon. A similar case originally filed in October 2017, now called Hawaii, Purcell v. Kennedy, is pending in the Hawaii District Court, where a hearing is scheduled for August 22, 2025.

There are two cases challenging state restrictions that go beyond what the FDA requires, contending the FDA rules preempt state laws regulating mifepristone. One of these cases was brought by GenBioPro, a manufacturer of generic mifepristone, challenging West Virginia’s law banning telehealth for medication abortion and the other case was brought by a North Carolina physician contending that North Carolina cannot require in-person dispensing only by a physician in a hospital or clinic certified by the state. On July 15, 2025, the 4^th Circuit Court of Appeals ruled on the West Virginia case, affirming the District Court’s decision in favor of West Virginia. The North Carolina case is currently pending in the 4^th Circuit Court of Appeals.

There is one active case in Louisiana state court that could impact the availability of mifepristone. After Louisiana reclassified misoprostol and mifepristone as controlled substances, subjecting these drugs to stricter regulation in the state, a doula collective, two patients, a physician and a pharmacist brought a legal challenge contending that the law violates the state constitution.

Challenges to State Shield Laws

States with abortion bans are testing the use of shield laws in the courts. In December 2024, in the first action testing a shield law, the Texas Attorney General filed a lawsuit against a New York doctor for mailing medication abortion pills into the state. The lawsuit alleges the physician violated Texas law by practicing medicine in the state of Texas without a Texas license and for violating the state’s abortion ban and prohibitions on telehealth for abortion care. On February 13, 2025, after the physician did not respond to the lawsuit or appear at court proceedings, a trial court issued a default judgment for the state, blocking the physician from prescribing medication abortions to Texas residents and ordering her to pay $100,000 in civil fines. Additionally, in January 2025, a Louisiana grand jury indicted the same New York physician for violating Louisiana’s abortion ban and restrictions. The New York shield law has blocked enforcement of the Texas and Louisiana judgments. A county clerk has refused the Texas Attorney General’s request to file the Texas judgment twice, once in March 2025 and again in July 2025. The New York’s Governor cited the shield law when she blocked an extradition request from Louisiana’s Governor. Louisiana and Texas might seek help from a federal court to enforce their orders in New York, and this would serve as test case for shield laws and their ability to protect clinicians providing abortion care via telehealth to patients located in states that ban or restrict abortion. In another case filed in Texas on July 20, 2025, citing Texas state law and the Comstock Act, a man is seeking civil damages from a California doctor for mailing medication abortion drugs to his girlfriend.

 Appendix 1: State Policies Affecting Access to Medication Abortion via Telehealth

Approximately 66 million people – about 20% of the U.S. population – live in rural areas, where Medicaid covers 1 in 4 adults (a higher share than in urban areas) and plays a large part in financing health care services. In rural communities, Medicaid covers nearly half of all births and one fifth of inpatient discharges. The Congressional Budget Office (CBO) estimates that the enacted reconciliation package  would reduce federal Medicaid spending by an estimated $911 billion over ten years, and result in 10 million more uninsured people nationwide. Senators from both parties have raised concerns about potential impacts on rural hospitals and other providers, particularly given the ongoing trend of rural hospital closures.

To address those concerns, the reconciliation package includes $50 billion in funding over five years (starting in fiscal year 2026) for state grants through a Rural Health Transformation Program (referred to here as the “rural health fund”). This policy watch estimates how the reconciliation package would affect federal Medicaid spending in rural areas and how that compares to the newly proposed funding for rural areas through the rural health fund. This analysis estimates the likely effects in rural areas by building on KFF’s estimated reductions  in Medicaid spending across the states.

Under the reconciliation package, federal Medicaid spending in rural areas is estimated to decline by $137 billion, more than the $50 billion appropriated for the rural health fund (Figure 1). Building on separate KFF estimates of state-by-state Medicaid cuts, this analysis estimates that federal Medicaid spending in rural areas could decrease by $137 billion over 10 years—about $87 billion more than is appropriated for the rural health fund.

The analysis allocates each state’s estimated spending reductions from the KFF analysis of the reconciliation package to urban and rural areas using the percentage of Medicaid spending that paid for services used by rural enrollees within each state. The estimates may understate the effects on rural areas because they do not account for the full change in total Medicaid spending, which would include the federal spending reductions and the associated reduction in state Medicaid spending stemming from lower enrollment. The estimates also do not account for spending cuts related to Affordable Care Act (ACA) Marketplace coverage from the reconciliation bill, the expiration of enhanced ACA premium tax credits that were enacted during the COVID-19 pandemic, and the impact of proposed Marketplace integrity rules. Combined, the changes represent the “biggest rollback in federal support for health coverage ever.” Federal spending cuts and coverage losses could also have implications for rural hospitals and other providers, including increases in uncompensated care. While providers could potentially offset at least some of the cuts—including through the new rural health funding—any financial pressure on hospitals and other providers could lead to layoffs of staff, more limited investments in quality improvements, fewer services, or additional rural hospital closures.

Although this analysis provides state-by-state estimated reductions in Medicaid funding, it does not show estimated rural health funds by state because it is unclear how the rural health funds will be allocated across the states and how the Secretary may interpret the law. Fifty percent of the funding would be equally distributed among states with approved applications, while the remainder would be allocated by the Centers for Medicare and Medicaid Services (CMS) using a method that takes into account such factors as states’ rural populations within metropolitan areas, the share of rural health facilities nationwide that are in a state, and the situation of hospitals which serve a disproportionate number of low-income patients with special needs. The bill specifies that the funds could be used in a variety of ways, including promoting care interventions, paying for health care services, expanding the rural health workforce, and providing technical or operational assistance aimed at system transformation. It is unclear how the funds will be distributed across states and how states will allocate funding between hospitals, other providers, and various state initiatives.

Over half of the spending reductions in rural areas are among 12 states that have large rural populations and have expanded Medicaid under the ACA, 10 of which could see rural federal Medicaid spending decline by $5 billion or more over 10 years. Those 10 states include Kentucky, North Carolina, Illinois, Virginia, New York, Michigan, Ohio, Pennsylvania, Oklahoma, and Louisiana. Kentucky would experience the largest rural Medicaid spending reduction, with an estimated drop of nearly $11 billion over 10 years (Figure 2). Over half of the estimated federal spending cuts stem from provisions that only apply to states that have adopted the ACA expansions, including work requirements, more frequent eligibility determinations, and new cost sharing requirements. As a result, the effects of the reconciliation bill in rural areas will be larger for expansion than non-expansion states.

The House Committee on Appropriations approved the FY 2026 National Security, Department of State, and Related Programs (NSRP) appropriations bill and accompanying report on July 23, 2025. The NSRP bill includes funding for U.S. global health programs at the State Department through the Global Health Programs (GHP) account, which represents the bulk of global health assistance. Global health funding in the bill totaled $9.5 billion, a decrease of $512 million (-5%) below the FY 2025 enacted level and $5.7 billion (151%) above President Trump’s FY 2026 request.[i] As compared to FY 2025 enacted levels, funding through the GHP account for the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) and family planning and reproductive health (FP/RH) declined, while all other areas either remained flat or increased slightly; funding for global health security was not specified.[ii]  The bill does not specify funding for the Health Reserve Fund, Global Health Workforce Initiative, or the Pan American Health Organization (PAHO), and explicitly prohibits funding for the United Nations Population Fund (UNFPA) and World Health Organization (WHO).[iii] The bill also eliminates funding for the International Organizations & Programs (IO&P) account, which has historically been the source of U.S. contributions to the United Nations Children’s Fund (UNICEF).[iv]

Policy provisions in the bill include:

• the Helms amendment, a standard provision that is regularly included in appropriations bills (see the KFF fact sheet here),
• an expanded Mexico City Policy (Protecting Life in Global Health Assistance) that was put in place by President Trump and rescinded by President Biden (see the KFF explainer here),
• a provision stating that support for multilateral organizations through the Contributions to International Organizations (CIO) account must comply with statutory prohibitions and requirements related to abortion, and
• a requirement that the Secretary of State submit a strategy detailing transition plans in PEPFAR-supported programs towards country-led efforts.

See the table below for additional details on global health funding (downloadable table here). See other budget summaries and the KFF budget tracker for details on historical annual appropriations for global health programs.

[i] Funding for FY25 was provided in a full-year Continuing Resolution (CR), which maintained FY24 levels. All FY25 amounts and associated notes are based on those specified in relevant FY24 appropriations bills.

[ii] The report accompanying the House FY26 NSRP appropriations bill does not provide specific funding amounts for family planning and reproductive health (FP/RH) or global health security (GHS) under the GHP account. After the funding amounts specified for all other areas (e.g., HIV, TB, MCH, etc.) are removed, $864.71 million remains under the GHP account, which is funding that could be used for FP/RH and GHS (or other areas as determined by the Administration). Since the House FY26 bill text states that “of the funds appropriated by this Act, not more than $461,000,000 may be made available for family planning/reproductive health” without specifying an account, it is possible the Administration could fund all or a portion of this amount through the GHP account with the remainder directed to GHS (or other areas as determined by the Administration). If the Administration funds the full $461 million through the GHP account, this could represent a significant decrease to GHS funding; if the Administration funds the full $461 million through non-GHP accounts, this could represent an increase to GHS funding.

[iii] The report accompanying the House FY26 NSRP bill states that U.S. funding for PAHO is dependent on meeting specific requirements detailed in the report.

[iv] The report accompanying the House FY26 NSRP bill states that a contribution to UNICEF may be made using funding provided to the newly established National Security Investment Programs account.

Nearly half (46%) of the public says that they expect the new tax and budget law signed by President Trump earlier this month to generally hurt them and their families, nearly twice the share (26%) who say it will generally help, a new KFF Health Tracking Poll finds. Among people who rely on Medicaid for their health coverage, two-thirds (65%) say it will hurt their families compared to one in five (18%) who say it will help.

The law combines tax cuts with spending reductions, including cuts and changes to Medicaid and the Affordable Care Act that are expected to leave millions more people without health insurance. Among people with household incomes under $40,000 annually, most (56%) say that the law will hurt them.

Perceptions of how the law will impact people’s families varies among partisans. Most Democrats (72%) and just over half of independents (53%) say it will mostly hurt them and their families, while just over half of Republicans (54%) say it will help. Those who identify as supporters of President Trump’s “Make America Great Again” movement are more than five times more likely to say the law will help their families (61%) than hurt (9%).

The law itself remains largely unpopular, with many more people holding unfavorable views (63%) than favorable ones (36%).

The split is unchanged from June before the legislation dubbed the “big beautiful bill” by President Trump became law, though the new poll shows a sharper partisan divide, with Republicans more likely to view the law favorably and Democrats more likely to view it unfavorably.

Two-thirds (68%) of the public now say that they’ve heard “a lot” or “some” about the legislation, up from half who said the same in June.

The poll also examines what people are seeing about the legislation on social media. Most (73%), including similar shares of partisans, say they saw information about the bill on social media in the past month.

Among those who saw information about the legislation on social media, about half (47%) say most of the content they saw was in opposition to the legislation, while about one in ten (11%) say it was mostly in support. The others (41%) say they saw a mix of both.

Designed and analyzed by public opinion researchers at KFF, this survey was conducted July 8-14, 2025, online and by telephone among a nationally representative sample of 1,283 U.S. adults in English and in Spanish. The margin of sampling error is plus or minus 3 percentage points for the full sample. For results based on other subgroups, the margin of sampling error may be higher.

Since the Supreme Court overturned Roe v. Wade in June 2022, states have been able to set policy that defines abortion access across this nation. In the past three years, voters in 10 states have passed constitutional amendments to protect abortion rights. These amendments, however, do not automatically invalidate the states’ laws restricting abortion such as waiting periods, coverage bans, and ultrasound requirements. The restrictions need to be challenged in court before they can be invalidated. This process can take years, and in states with new constitutional protections, people seeking abortion care may still face access restrictions while the litigation proceeds. Additionally, in some instances, after courts have blocked restrictions, conservative state legislatures have passed laws enacting very similar restrictions, lengthening the process to block these laws, since advocates have to challenge multiple state laws or amend already-existing challenges to block the newly passed laws. This policy watch provides an update on the status of abortion restrictions in states that passed a constitutional amendment protecting abortion, or where a state court previously interpreted the state constitution as protecting abortion access.

Status of Litigation Based on Recent Constitutional Amendments

In four states with recently passed constitutional amendments protecting the right to abortion or a broader right to reproductive freedom — Arizona, Michigan, Missouri, and Ohio – advocates have filed lawsuits seeking to block abortion restrictions, alleging that these restrictions violate the newly passed constitutional amendments. These lawsuits test the reach of these constitutional amendments beyond pre-viability gestational limits. In Montana, another state that recently passed a constitutional amendment, abortion providers are also challenging prior abortion restrictions, but because this challenge was filed before the state’s constitutional amendment passed, they are relying on previous state supreme court precedent to make their arguments. Advocates in Alaska and Kansas, where there is no specific constitutional amendment protecting abortion, have challenged restrictions based on state supreme court cases finding abortion is protected in the state constitution.

Whether or not the restrictions that are being challenged will be permanently blocked depends on how each respective state’s supreme court interprets the state constitution’s right to abortion. The language of the constitutional amendments varies and some might provide greater protections than others (Table 9). States that rely on state supreme court precedent protecting a right to abortion—as opposed to a constitutional amendment explicitly protecting this right—may provide protections today, but future courts may overturn that precedent, much like the U.S. Supreme Court did with Roe v. Wade.

The following section provides an overview of the status of legal challenges to abortion restrictions in states with recently passed constitutional amendments or litigation that has found that the state constitution protects abortion rights.

Arizona

The Arizona constitutional amendment – passed in November 2024 – protects a fundamental right to abortion and forbids the state from enacting, adopting, or enforcing any law that “denies, restricts or interferes with that right before fetal viability unless justified by a compelling state interest that is achieved by the least restrictive means.” Currently, the gestational limit in the state is fetal viability. However, there are other restrictions that are still in effect.

Abortion rights advocates in Arizona filed a lawsuit in May 2025 challenging the in-person counseling requirement, 24-hour waiting period, ultrasound requirement, and ban on the use of telehealth for abortion care. The state court where this challenge was filed is yet to issue a ruling.

Michigan

In November 2022, voters passed a constitutional amendment in Michigan that protects a fundamental right to reproductive freedom, the right to make decisions regarding pregnancy, including the right to abortion, among others. It states that “[a]n individual’s right to reproductive freedom shall not be denied, burdened, nor infringed upon unless justified by a compelling state interest achieved by the least restrictive means.”

The state has no gestational limit on abortion, however, a state funding ban on abortion funding for Medicaid enrollees and a parental consent requirement are still in effect.

In two separate lawsuits, advocates in Michigan are challenging the exclusion of abortion coverage from the state’s Medicaid program and laws requiring a 24-hour waiting period and limiting abortion provision to physicians. A trial court recently ruled that the latter two requirements are unconstitutional and blocked them permanently. However, the state’s supreme court is yet to rule on these restrictions.

Missouri

In November 2024, voters in Missouri passed a constitutional amendment protecting a fundamental right to reproductive freedom, including the right to make decisions about abortion care. The amendment states that this right “shall not be denied, interfered with, delayed, or otherwise restricted unless the Government demonstrates that such action is justified by a compelling governmental interest achieved by the least restrictive means. Any denial, interference, delay, or restriction of the right to reproductive freedom shall be presumed invalid.” Currently, the gestational limit in the state is fetal viability, but other restrictions are still in effect.

Several clinics in Missouri filed a lawsuit alleging that the state’s pre-viability bans as well as many restrictions violate the state’s newly granted constitutional right to reproductive freedom. In December 2024, a Missouri state trial court sided with the clinics, and blocked the state’s pre-viability abortion bans, as well as many of the restrictions, while the litigation continues. However, in late May 2025, the Missouri Supreme Court lifted the preliminary injunction for the restrictions, and ordered the trial court to use a more strenuous test to determine if the plaintiffs meet the bar for a preliminary injunction. When restrictions went back into effect, clinics stopped providing abortion care, even though the total ban was not in effect. The case went back before the trial court, where the judge reviewed the request for a preliminary injunction using the standard set forth by the state supreme court and in response issued an order on July 3, 2025 blocking once again the state’s pre-viability ban and some restrictions, including the 72-hour waiting period. The state has appealed this order to the Missouri Supreme Court.

Ohio

The Ohio constitution was amended by voter initiative in November 2023 protecting the right to make and carry out reproductive decisions, including decisions about abortion care. Per the amendment, “[t]he State shall not, directly or indirectly, burden, penalize, prohibit, interfere with, or discriminate against… the exercise of this right, unless the State demonstrates that it is using the least restrictive means to advance the individual’s health in accordance with widely accepted and evidence-based standards of care.”

Currently, the gestational limit in the state is 22 weeks LMP (last menstrual period), however, are other restrictions are still in effect or temporarily blocked.

In two different lawsuits, abortion providers in Ohio challenged the 24-hour waiting period, the in-person counseling appointment, the telehealth abortion ban, and a law that limits the provision of abortion care to physicians. Abortion providers used the state’s constitutional amendment as the basis for these challenges. In both of these lawsuits, the trial courts have temporarily blocked the challenged restrictions while litigation proceeds. After the constitutional amendment was passed by voters, some Ohio legislators sought to curtail judges’ ability to block these laws and interpret the constitutional amendment, but these efforts did not progress.

Status of Litigation in States with State Supreme Court Precedent Protecting the Right to Abortion

Alaska

In 1997, the Alaska Supreme Court found that the state constitutional right to privacy protects the right to abortion. The state has no gestational limit on abortion, however, other restrictions are still in effect.

Advocates in Alaska are challenging a law that limits abortion provision to physicians, using previous state supreme court precedent as the basis for their challenge. This requirement was originally blocked by a preliminary injunction in 2021 and in September 2024, a state trial court ruled that the requirement violates the constitutional protection for the right to abortion.

Kansas

In 2019, the Kansas Supreme Court found that the Kansas Bill of Rights includes the right to abortion. The gestational limit in the state is 22 weeks LMP (last menstrual period), other restrictions are still in effect.

In Kansas, advocates are challenging a 24-hour waiting period law that is temporarily blocked due to a court order while litigation proceeds and a law banning advanced practice registered nurses from providing medication abortion care. Advocates in Kansas have also used Kansas Supreme Court precedent to successfully challenge laws that limit the provision of abortion care to physicians and require ultrasounds before an abortion, as well as in-person dispensing of medication abortion.

Montana

In 1999, the Montana Supreme Court found that the state constitution protects the right to abortion. In 2024, the Montana Supreme Court reaffirmed this protection.

In addition, voters approved an amendment in November 2024 recognizing an individual’s right to make decisions about pregnancy, including the right to abortion. It states that “[t]his right shall not be burdened unless justified by a compelling government interest achieved by the least restrictive means.”

The gestational limit in the state is fetal viability, however, a state parental consent law is still in effect.

Abortion providers in Montana are challenging a law that excluded abortion coverage from the state’s Medicaid program, relying on previous Montana Supreme Court precedent that held that the state constitutional protection for privacy includes a protection for the right to abortion, instead of relying on the state’s newly passed constitutional amendment, since the challenge was underway before the constitutional amendment passed. In March 2025, a trial court ruled that this restriction is unconstitutional and permanently blocked it. Additionally, the Montana Supreme Court recently concluded in a different case that was also brought by abortion providers, that restrictions including an in-person dispensing requirement, a 24-hour waiting period, and a ban on telemedicine for abortion were unconstitutional. These restrictions are no longer in effect.

On July 4, President Trump signed into law a budget reconciliation package once called the “One Big, Beautiful Bill” that made major reductions in federal health care spending to offset part of the costs of extending expiring tax cuts. The Congressional Budget Office’s (CBO) latest cost estimate shows that the reconciliation package would reduce federal Medicaid spending over a decade by an estimated $911 billion (after accounting for interactions that produce overlapping reductions across different provisions of the law) and increase the number of uninsured people by 10 million. Building on prior KFF analysis of the House-passed reconciliation bill, this analysis allocates CBO’s federal spending reductions in the enacted reconciliation package across the states. The Medicaid reconciliation provisions are numerous and complicated, but the majority of federal savings stem from work requirements for the Affordable Care Act (ACA) expansion group, limiting states’ ability to raise the state share of Medicaid revenues through provider taxes, restricting state-directed payments to hospitals, nursing facilities, and other providers, and increasing barriers to enrolling in and renewing Medicaid coverage.

This analysis allocates the CBO’s estimated reduction in federal spending across states based on KFF’s state-level data and where possible, prior modeling work; and shows the federal spending reductions relative to KFF’s projections of federal spending by state under current law. KFF allocates the spending reductions provision-by-provision, pulling in a variety of data sources on which states are estimated to be most affected by each provision (see Methods). The total Medicaid spending cuts, nationally and by state, equal the sum of spending changes for each Medicaid provision ($990 billion over 10 years) less KFF’s estimate of the CBO interaction effects that are tied to Medicaid interactions ($79 billion over 10 years, see Methods). KFF did not apply the interaction effects to the estimated effects for each provision because it is unknown which provisions are driving CBO’s estimated interactions. The estimates exclude the $50 billion in funding for state grants through a Rural Health Transformation Program because it is highly uncertain how those funds will be allocated across the states.

CBO has not published updated estimates of the number of people who would lose Medicaid under the reconciliation package once called the “One Big, Beautiful Bill,” so this analysis does not include updated enrollment estimates like those included in KFF’s analysis of the House-passed reconciliation bill. CBO’s most recent estimate of Medicaid enrollment loss from an earlier version of the House reconciliation bill was 10.3 million people in 2034, which was associated with a $625 billion decrease in Medicaid spending (reflecting preliminary estimates prepared for the House Committee on Energy and Commerce). Given the Medicaid spending reductions are considerably larger in the enacted reconciliation package, more than 10.3 million people are likely to lose Medicaid.

This analysis does not predict how states will respond to federal policy changes, and anticipating how states will respond to Medicaid changes is a major source of uncertainty in CBO’s cost estimates. Instead of making state-by-state predictions, CBO generates a national figure by estimating the percent of the affected population that lives in states with different anticipated types of policy responses. For example, different states might choose to implement a work requirement with reporting requirements that are easier or harder to comply with. In estimating the costs of the legislation, CBO assumes that in aggregate, states would replace half of reduced federal funds with their own resources in response to provisions that reduce the resources available to states, such as limits on provider taxes. For provisions that reduce enrollment but don’t affect the division of costs between the federal and state governments, such as work requirements, CBO estimates that the federal and state Medicaid spending would go down. However, those assumptions reflect states’ responses as a whole and are likely to vary and may not apply in all states.

To the extent that states’ responses are far different from the overall average response, changes in federal Medicaid spending will be larger or smaller than what is shown here. States could make further Medicaid cuts, which would result in spending reductions greater than is estimated here and further reduce states’ Medicaid spending. Alternatively, states could increase their spending on Medicaid to mitigate the effects of federal cuts, which could result in spending reductions that are smaller than is estimated here. This analysis illustrates the potential variation by showing a range of spending effects in each state, varying by plus or minus 25% from the CBO estimated midpoint.

Key Take-Aways

• After accounting for CBO’s estimated interactions, KFF estimates that the enacted reconciliation package would reduce federal Medicaid spending by $911 billion. (Without accounting for interactions, the total is $990 billion, see Methods).
• The five biggest sources of Medicaid savings in the reconciliation package sum to $851 billion in savings, which is 86% of the gross savings (before accounting for interactions) and include:
  • Mandating that adults who are eligible for Medicaid through the ACA expansion meet work and reporting requirements ($326 billion),
  • Establishing a moratorium on new or increased provider taxes and reducing existing provider taxes in expansion states ($191 billion),
  • Revising the payment limit for state directed payments ($149 billion),
  • Increasing the frequency of eligibility redeterminations for the ACA expansion group ($63 billion).  
• Provisions that would only apply to states that have adopted the ACA expansion account for $526 billion, over half of the total gross federal spending reductions.
• Over three-quarters (76%) of the ten-year reductions in federal Medicaid spending in the reconciliation package would occur in the final five years of the period. While policy effects do typically compound overtime, many of the health care spending reductions are also backloaded and occur from 2030 through 2034.
• Federal cuts to states of $911 billion over 10 years would represent 14% of federal spending on Medicaid over the period. The spending cuts vary by state; Louisiana, Illinois, Nevada, and Oregon are the most heavily affected with spending cuts of 19% or more over the period.

Background on the U.S. and CEPI

• The Coalition for Epidemic Preparedness Innovations (CEPI) aims to accelerate the development of vaccines and other technologies to prepare for and respond to epidemic and pandemic threats. Pooling and leveraging contributions from more than 30 governments, philanthropic foundations, and private sector partners, CEPI invests to drive research and development into vaccine and therapeutic candidates against high-threat pathogens. It also works to strengthen global laboratory and vaccine manufacturer networks and regulatory environments and to research and support vaccine safety. A core focus is its “100 Days Mission”, an effort to reduce the time it takes to develop vaccines and other countermeasures during outbreaks with pandemic potential.
• Since its founding in 2017, CEPI contributed to the first licensed vaccine for Chikungunya; is supporting the development of vaccines for Lassa fever, MERS, Nipah virus and Rift Valley fever, all of them currently in clinical trials; and aided in the development of seven COVID-19 vaccines that were licensed for use.
• The U.S. government made its first financial contribution to CEPI in 2020 and has thus far invested $217 million in the organization. In January of this year, CEPI and the U.S. International Development Finance Corporation (DFC) announced an MOU to collaborate on aligning vaccine investments, among other activities. In May, CEPI and the U.S. Department of Defense signed a new agreement to enable collaboration on projects to expand protection against disease outbreaks, including a project to advance a therapeutic product against Nipah virus that. CEPI has also collaborated with the U.S. Biomedical Advanced Research and Development Agency (BARDA) on emergency response and vaccine development for filoviruses, particularly Ebola Zaire, Ebola Sudan, and Marburg. The FDA is a member of CEPI’s Joint Coordination Group and the overall relationship between CEPI and the U.S. government had been managed by USAID, which has held the U.S. government seat on the CEPI Investors Council.
• CEPI reports that it has contributed significantly to the U.S. economy through its funding of U.S.-based vaccine developers and that this funding far exceeds the amount of funding it has received from the U.S. government.
• CEPI replenishes funding every five years. For the last replenishment round, held in 2022, the U.S. pledged $150 million over five years, which has been exceeded. The U.S. accounts for approximately 6% of total contributions received by CEPI to date.

Current Status of U.S. Support for CEPI

• Funding: In FY 2024, Congress approved up to $100 million in funding to be allocated to CEPI. The FY 2025 Continuing Resolution that passed in March carried forward language from the prior year again stating that up to $100 million could be provided to the organization. CEPI has not yet received its FY24 funds, and it is not yet known if or how much funding will be provided for FY25.
• Foreign aid review/freeze: The foreign aid review’s stop-work order initially froze all U.S. bilateral programming but was not applied to CEPI or other multilateral institutions. The administration subsequently announced that it canceled 86% of all USAID awards. KFF analysis finds that of 770 global health awards identified, 80% are listed as terminated, including the CEPI contract. CEPI reports that it has not received a termination notice.
• International organizations review. A second executive order, calling for a 180-day review of U.S. participation in all international intergovernmental organizations, is currently underway. Per the order, the purpose of the review is to determine which are “contrary to the interests of the United States and whether such organizations, conventions, or treaties can be reformed.”
• Reorganization: The administration notified Congress on March 28, 2025 of its intent to permanently dissolve USAID and that any remaining USAID operations would be absorbed by the State Department, including remaining global health activities which would be integrated into its Bureau of Global Health Security and Diplomacy (GHSD). On May 29, 2025, the State Department further notified Congress of its proposed reorganization plan.

What to Watch

• Results of foreign aid and international organization reviews: The administration could soon release results of its 90-day foreign aid review (which has already been extended by 30 days), and the outcome of the review of international organizations is expected later this year. It is unknown whether there will be any recommendations related to U.S. support for or engagement with CEPI, and how or if Congress will respond to any such recommendations.
• Reorganization. While the administration has notified Congress that it intends to retain and integrate certain USAID activities into the State Department’s GHSD, no additional information is available on what this would mean for the relationship with CEPI.
• Funding/Budget Request: The administration’s FY 2026 budget request includes significant reductions in funding for global health, and does not include funding for CEPI. Final appropriation amounts for FY 2026 will be determined by Congress. The administration also submitted its first rescission package to Congress, including proposed rescissions of more than $1 billion in FY 2025 funding for global health. Congress voted to amend the package, reducing that amount to $500 million and exempting some program areas from the rescission though it is not yet known if CEPI will be exempted.

Background on the U.S. and Gavi

• Gavi, the Vaccine Alliance (Gavi), is an independent public-private, multilateral financing entity created in 2000. It raises and pools resources from multiple donors and in turn, disburses approximately $1.7 billion per year to support procurement and distribution of vaccines in low- and middle-income countries (LMICs).
• Gavi supports vaccines against 20 infectious diseases, and hosts the global emergency vaccine stockpiles against Ebola, yellow fever, meningitis, and cholera. By playing a market shaping role through pooled procurement, demand forecasting, support for regional manufacturing capacity, and other strategies, Gavi helps to drive down prices for vaccines in LMICs.
• Gavi reports that it has helped to immunize more than 1.1 billion children in 78 LMICs, preventing more than 18.8 million deaths, and generating economic benefits estimated at more than $250 billion, between 2000-2023.
• The U.S. government was one of the original donors to Gavi, and currently accounts for 13% of its funding, making it Gavi’s third largest contributor. Gavi also has a donor liquidity partnership with the U.S. International Development Finance Corporation (DFC) allowing Gavi to quickly access up to $1 billion from a “Rapid Financing Facility” to support routine immunization and pandemic response, backed by forthcoming donor pledges.  Additionally, the U.S. was the largest donor to COVAX, the international effort housed at Gavi that supported the development, procurement, and delivery of COVID-19 vaccines to LMICs (COVAX ended in 2023).
• Only LMICs whose most recent Gross National Income (GNI) per capita is below a certain threshold are eligible for Gavi assistance (54 countries in 2024). Countries are required to co-finance a portion of their vaccines on a sliding scale. To date, 19 countries have graduated from Gavi assistance.
• Gavi has been the primary mechanism by which the U.S. government supports the procurement of vaccines for LMICs (in addition to U.S. support for polio vaccination through the Global Polio Eradication Initiative). USAID’s bilateral maternal and child health program has complemented Gavi by supporting in-country capacity building and immunization campaigns.
• Every five years, Gavi replenishes funding through “pledging conferences”. The previous replenishment, for 2021-2025, generated $10.5 billion. For the 2026-2030 period, Gavi is seeking to raise $9 billion in new funding (towards a budget of $11.9 billion) which it estimates would save an additional 8-9 million lives by immunizing an additional 500 million children by 2030

Current Status of U.S. Support for Gavi:

• Funding: The U.S. provides funding to Gavi as part of its maternal and child health program. In FY 2024, U.S. funding for Gavi was $300 million. The FY 2025 Continuing Resolution that passed in March included level funding of $300 million, which marks (and would fulfill) the first year of Gavi’s new pledge period. The administration’s FY 2026 budget request does not include funding for Gavi and, while final funding levels are determined by Congress, Secretary of Health and Human Services Robert F. Kennedy Jr. has said that the U.S. will not provide additional funding to Gavi (see “Replenishment” below).
• U.S. Representation on the Gavi Board: The U.S. also plays a role in Gavi’s governance and oversight, sharing one of the donor government board seats on Gavi’s 28-member Board, and currently serving as the Board member for the seat.
• Foreign aid review/freeze: The foreign aid review’s stop-work order initially froze all U.S. bilateral programming but was not applied to Gavi or other multilateral institutions. The administration subsequently announced that it canceled 86% of all USAID awards. KFF analysis finds that of 770 global health awards identified, 80% are listed as terminated, including the main Gavi contract as well as the COVAX contract. Gavi reports that it has not received a termination notice for its main contract, although it did receive one for COVAX (all U.S. funding was already disbursed to COVAX in 2021).
• International organizations review: A second executive order, calling for a 180-day review of U.S. participation in all international intergovernmental organizations, is currently underway. Per the order, the purpose of the review is to determine which are “contrary to the interests of the United States and whether such organizations, conventions, or treaties can be reformed”.
• Reorganization: The administration notified Congress on March 28, 2025 of its intent to permanently dissolve USAID and that any remaining USAID operations would be absorbed by the State Department, including remaining global health activities which would be integrated into its Bureau of Global Health Security and Diplomacy (GHSD). Delivery of lifesaving vaccines is listed among the USAID activities to be continued. On May 29, 2025, the State Department further notified Congress of its proposed reorganization plan.
• Potential impact on health outcomes: The loss of U.S. support for Gavi would affect procurement of vaccines for LMICs, with particular impact on children. Gavi estimates that loss of funding could result in 75 million children not receiving routine vaccinations over the next five years, leading to more than 1.2 million children dying as a result. Reductions in vaccine stockpiles could also impact outbreak control.

What to Watch

• Results of foreign aid and international organization reviews: The administration could soon release results of its 90-day foreign aid review (which has already been extended by 30 days), and the outcome of the review of international organizations is expected later this year. It is unknown whether there will be any recommendations related to U.S. support for or engagement with Gavi, and how or if Congress will respond to any such recommendations.
• Reorganization: While the administration has notified Congress that it intends to retain and integrate USAID’s delivery of lifesaving vaccines activities into the State Department’s GHSD, no additional information is available on what this would mean for the relationship with Gavi.
• Funding/Budget Request: The administration’s FY 2026 budget request includes significant reductions in funding for global health, and does not include funding for Gavi. Final appropriation amounts for FY 2026 will be determined by Congress. The administration also submitted its first rescission package to Congress, including proposed rescissions of more than $1 billion in FY 2025 funding for global health. Congress voted to amend the package, reducing that amount to $500 million and exempting some program areas, including Gavi as part of maternal and child health funding, from the rescission.
• Replenishment: Gavi’s June 2025 pledging conference raised $9 billion in funding towards its $11.9 billion target. Last year, the Biden administration pledged at least $1.58 billion over five years to Gavi’s replenishment. However, Secretary Kennedy announced that the U.S. will not provide additional funding to Gavi unless it changes its evaluation of vaccine science and safety, among other issues. In response, Gavi has stated that it relies on WHO’s independent, science-based, global vaccine evaluation and recommendation process. In addition, individual country requests for vaccine support from Gavi are made in line with their own national immunization policies. While final U.S. funding amounts are determined by Congress, it remains to be seen how this will unfold over the next year.