Sterilization or permanent contraception is the most commonly used form of family planning in the United States. There are two main methods of sterilization: tubal ligations and vasectomies. Both are safe and nearly 100% effective in preventing pregnancy. The Affordable Care Act’s (ACA) contraceptive coverage requirement applies to sterilization procedures for women, but not for men. Some states, however, have passed laws that require male procedures to be covered by state-regulated insurance plans. Permanent contraception services, however, are not available in all health care settings due to policies followed by faith-based health providers that have religious objections to the procedures. This fact sheet explains the types of permanent contraception or sterilization procedures available, reviews private insurance and Medicaid coverage policy, and discusses issues that affect availability in the U.S.

Types of Sterilization

Tubal Ligation

Tubal ligation is an outpatient surgical procedure conducted on people with female reproductive organs in which the fallopian tubes are either removed or blocked to prevent eggs from travelling to the uterus and sperm from fertilizing eggs. Data from the 2024 KFF Women’s Health Survey show that one in four women between the ages of 18 and 64 report they have had a sterilization procedure. Larger shares of women 50 years old and older, women with lower incomes, and women with Medicaid have had a sterilization procedure (Figure 1).

There are two main methods of surgical tubal ligation: mini-laparotomy (or a minilap) and laparoscopic sterilization (Table 1). The minilap can be performed immediately postpartum, right after childbirth, while the laparoscopic procedure cannot. Tubal ligation procedures are effective immediately and have a failure rate of less than 1% within the first year of having the surgery. After 10 years, the failure rate can increase to 18 to 37 pregnancies out of 1,000 women depending on how the fallopian tubes are closed. Complications are rare, but they can include bleeding, infection, and ectopic pregnancy. While the procedure sometimes can be reversed, the process is costly, invasive, typically not covered by insurance, and not guaranteed to work. Sterilization does not protect against sexually transmitted infections (STIs).

Vasectomies

A vasectomy is an outpatient procedure done on people with male reproductive organs and is typically done under local anesthesia. In the traditional procedure, a doctor will clip, cut and tie, or cauterize the vas deferens. There is also a newer “no-scalpel” technique which is less invasive, reducing complications and recovery time (Table 1). Despite lower frequency of use compared to tubal ligations, vasectomies are safer, cheaper, and even more effective. Only one out of every 10,000 women will become pregnant using this contraceptive method; however, vasectomies are not effective immediately. It can take two to four months for sperm to be reabsorbed or ejaculated, so an alternate form of contraception should be used to prevent pregnancy. Vasectomies also do not protect against STIs.

The 2024 KFF Women’s Health Survey, found that one in ten (11%) men ages 18 to 64 say they have undergone a sterilization procedure. The share who have been sterilized is higher among white men, men with higher incomes, and men with private insurance (Figure 1).

Insurance Coverage

Sterilization is a highly cost-effective method of contraception. Although it can have high upfront costs, it typically requires no long-term follow-up care and therefore can be cheaper in the long run than other methods. Depending on location, insurance, and procedure type, the out-of-pocket cost of tubal ligation procedures may range from $0 to $6,000, whereas a vasectomy may cost between $0 and $1,000.

Private Insurance and Affordable Care Act

The ACA requires private health insurance plans to cover at least one form of all 18 FDA-approved contraceptive methods for women without cost sharing, meaning tubal ligation procedures must be fully covered by most private health insurance plans. This federal policy does not include vasectomies; however, nine states—California, Illinois, Maryland, New Jersey, New Mexico, New York, Oregon, Vermont, and Washington—require state-regulated private health insurance plans to cover vasectomies at no additional cost to the patient (Figure 2). State-regulated benefit requirements do not apply to self-insured employer plans, though, which covered 63% of covered workers in 2024.

Medicaid

Medicaid, the national health coverage program for low-income individuals, is financed and operated jointly by the federal and state governments. Under Medicaid, it is mandatory for states to cover family planning, including sterilization procedures for women. Vasectomies are not federally required to be covered under any of the Medicaid pathways, but a KFF state survey found that most states report they cover the procedure.

Regulations prohibit federal funds from being used for sterilization procedures on women younger than 21 years old. They also require patients to sign an informed consent form at least 30 days prior to the procedure, with some exceptions. In the event of a premature delivery, consent must have been obtained at least 30 days prior to the due date. However, if a premature delivery or emergency abdominal surgery occurs within the 30-day waiting period, the physician must certify that consent was obtained at least 72 hours after the date on the patient’s signed consent form. This provision was implemented to guard against coercive practices and abuses that were historically directed towards women with low incomes, women with disabilities, women of color, and incarcerated women. However, some advocates suggest that this requirement places a burden on publicly insured women seeking sterilization services that women with private insurance do not face.

Uninsured

Some states have extended access to family planning services to uninsured populations through the Medicaid family planning expansion program that provides Medicaid coverage solely for family planning services to women and men who do not qualify for full Medicaid benefits. These programs are available in 32 states as of January 2025, and most report that they cover tubal ligations and vasectomies.

Although most public funding for sterilization comes from Medicaid, a share is provided by the federal Title X National Family Planning Program and the Maternal and Child Health and Social Services block grants. Changes to federal funding for clinics providing family planning programs may impede access to sterilization services for those who rely on these programs for reproductive health coverage.

Religious Providers

Currently, federal and state laws allow providers with religious objections to refuse sterilization services to patients. The Church Amendments prohibit the federal government from requiring a provider to assist in abortion or sterilization services if they violate the provider’s religious beliefs. As of 2023, 19 states have laws that allow some health care providers to refuse to provide sterilization services for religious reasons (Figure 3). In areas with a limited choice of health care providers, refusal policies could limit the availability of sterilization services.

Another challenge to the availability of sterilization services is the growing number of acute care hospitals that are affiliated with the Catholic Church. These hospitals usually adhere to the religious restrictions required by the U.S. Conference of Catholic Bishops, which prohibit the use of sterilization. These directives also prohibit referrals for contraception, abortion, and sterilization services. As of 2020, 7 of the 25 largest health systems nationwide are Catholic-affiliated. There is concern that the growing dominance of Catholic hospitals in some areas may limit access to tubal ligations and post-delivery sterilization procedures. The lack of a postpartum sterilization option could pose a particular challenge for women in communities where the only hospital available to them is part of a Catholic health system (Figure 4). Catholic-affiliated hospitals receive a share of their revenue from public sources, such as Medicaid and Medicare, and serve diverse populations who may not be aware of the limits placed on their care, nor follow the hospital’s religious tenets.

Impact of the Dobbs Ruling

The reproductive health landscape in the United States has drastically changed since the Supreme Court’s decision to overturn Roe v. Wade in Dobbs v. Jackson Women’s Health Organization in 2022 and contraceptive choices have also changed in response to the ruling. A KFF survey found that in 2023, four in ten (43%) OBGYNs reported an increase in the number of patients who sought sterilization since Dobbs. A little over half (51%) of OBGYNs in states with abortion bans or restrictions reported the same, compared to 36% of OBGYNs in states where abortion is legal. Research suggests that the demographics of individuals seeking sterilization may have changed since the Dobbs decision, though it is important to note that the research is limited, and long-term trends continue to be studied. Although sterilization is most common in individuals over 35 years old, a limited number of studies found that the number of sterilization procedures performed on adults under 35 years old increased post-Dobbs. In addition to being younger, similar research has found that a higher share of men who underwent vasectomies or sought consultations since Dobbs are childless and single.

This updated chart collection explores how health spending is expected to grow in coming years, based on National Health Expenditure (NHE) projections from federal actuaries.

Health spending is projected to reach $5.6 trillion in 2025, with hospitals making up the largest share of spending ($1.8 trillion). By 2033, health spending is expected to hit $8.6 trillion.

These projections do not account for recent regulatory changes under the Trump Administration, nor do they account for recent legislative changes in the tax and budget law (formerly “the One Big, Beautiful Bill Act”), which the Congressional Budget Office (CBO) expects to decrease spending on Medicaid and the Affordable Care Act (ACA) Marketplaces by over a trillion dollars through 2034.

The analysis can be found on the Peterson-KFF Health System Tracker, an information hub dedicated to monitoring and assessing the performance of the U.S. health system.

On July 4, 2025, President Trump signed a budget reconciliation bill into law that includes significant reductions in federal health care spending, large tax cuts, and other changes. The new law will reduce federal Medicaid spending alone by $911 billion over ten years and lead to 10 million more people becoming uninsured by 2034 based on Congressional Budget Office (CBO) estimates. While this legislation was being debated, Members of Congress from both parties raised concerns about the potential impact on rural hospitals, particularly given the ongoing trend of rural hospital closures. In response, and just prior to passage, the Senate added $50 billion in funding for a new “rural health transformation program,” referred to here as the “rural health fund.”

This brief describes the rural health fund, explains what the law says about the allocation of funds, and highlights outstanding questions about how the funds will be distributed across and within states to pay rural hospitals and for other purposes. Based on the statutory language, it is not yet clear what specific criteria the Centers for Medicare and Medicaid Services (CMS) will ultimately use to approve or deny state applications and distribute funds across states; what share of the $50 billion fund will go to rural areas; what share will go to the nearly 1,800 hospitals in rural areas or be used for other providers or purposes; whether funds will be targeted to certain types of rural hospitals, such as the 44% of rural hospitals with negative margins; and to what extent the CMS Administrator will be able to influence how states use their funds prior to approving an application. Further, the law does not require CMS to publish information about the distribution of funds so that the allocation decisions are transparent. Similar questions were raised during the COVID-19 pandemic about how well provider relief funds were targeted to hospitals with the greatest need.

The rural health fund includes $50 billion, which is a little over one third (37%) of the estimated loss of federal Medicaid funding in rural areas

The fund provides $50 billion for state grants (DC and the U.S. territories cannot apply). Half ($25 billion) will be distributed by CMS “equally among all states with an approved application,” which appears to suggest that each state with an approved application would receive the same amount from this pool regardless of the size of its rural population, the number of rural hospitals or other providers in the state, the financial standing of its rural hospitals, or other factors. For example, Connecticut (which has 3 rural hospitals based on one definition) could receive the same amount as Kansas (which has 90 rural hospitals) if both are approved for funding. CMS will have some discretion in determining how to allocate the remaining half ($25 billion) (see Figure 1 and more details below).

States can apply to use the funds in a variety of ways, such as for promoting care interventions, paying for health care services, expanding the rural health workforce, and providing technical assistance with system transformation.

The $50 billion in new funding could offset a little over a third (37%) of the estimated cuts to federal Medicaid spending in rural areas ($137 billion over ten years) based on KFF analysis of CBO’s estimates, or about 5% of the total estimated cuts to federal Medicaid spending ($911 billion over ten years). This does not account for other revenue losses related to the bill, including cuts to federal spending for the ACA Marketplaces, or the revenue losses stemming from the increased number of people who will be uninsured because of the expiration of the enhanced ACA premium tax credits and the implementation of final Marketplace integrity rules. The impact of these changes on rural areas, and the extent to which the rural health fund offsets losses, will vary across the country.

The rural health fund will be temporary, while many of the cuts in health spending are not time limited

While many of the major cuts related to Medicaid and the ACA Marketplaces under the law are not time limited, the rural health fund is temporary. The law provides $10 billion per year through the rural health fund for fiscal years 2026 through 2030, a five-year period. According to statements made by the CMS Administrator, CMS will distribute applications to states in early September 2025, states will submit applications to CMS in that month, and CMS will process their applications in November and send out the first batch of funds at the end of the year. States will be allowed to spend funds that they receive at a given point through the end of the following fiscal year, and CMS may be able to redistribute some unused funds over time, but all funds must be spent before October 1, 2032. New legislation would be required to provide additional support to rural areas after the funds dry up.

The distribution of dollars from the rural health fund will occur before many of the health care spending cuts under the law are fully realized. The rural health fund was put in place, and doubled in size, to address concerns of lawmakers from rural states, and front loading these dollars could allow systems to absorb forthcoming cuts. As described above, the law specifies that rural health fund dollars will first be available for fiscal year 2026, with $10 billion dollars available per year over five years through fiscal year 2030, and all funds must be spent before October 1, 2032. Yet most of the health care spending reductions are backloaded and occur after fiscal year 2030. For example, based on KFF’s analysis of CBO estimates, nearly two thirds (64%) of the ten-year reductions in federal Medicaid spending would occur after fiscal year 2030.

CMS will have broad leeway in how it distributes funds across states

The law grants CMS broad discretion over the distribution of funds and confirms that these decisions are not subject to administrative or judicial review. The law gives CMS authority to determine which state applications to approve or deny, without specifying the criteria CMS should use to make these decisions, though it does specify certain items that states must include in their applications.

As noted above, half of the funds ($25 billion) will be distributed equally among states with approved applications. For the second half of the funds ($25 billion), CMS has more flexibility. The law requires that CMS considers certain factors when distributing these funds (the share of the state population that lives in a rural part of a metropolitan area, the share of rural health facilities in the state as a share of all rural health facilities nationwide, and the situation of hospitals that serve a disproportionate number of low-income patients with special needs). It also allows the CMS Administrator to consider “any other factors that [it] determines appropriate.”  CMS could choose to restrict this $25 billion pool of funds to a subset of states, though the law specifies that it must distribute these funds to at least a quarter of states with approved applications.

States will have discretion in how they distribute funds among hospitals, and other providers, and may be able to steer some dollars to nonrural areas, subject to CMS approval

Just as the law grants CMS broad discretion over the distribution of funds across states, it also permits states to use the funds for a wide variety of purposes, subject to CMS approval. States must use the funds for at least three of the following purposes:

• Promoting evidence-based, measurable interventions to improve prevention and chronic disease management.
• Providing payments to health care providers for the provision of health care items or services, as specified by the CMS Administrator.
• Promoting consumer-facing, technology-driven solutions for the prevention and management of chronic diseases.
• Providing training and technical assistance for the development and adoption of technology-enabled solutions that improve care delivery in rural hospitals, including remote monitoring, robotics, artificial intelligence, and other advanced technologies.
• Recruiting and retaining clinical workforce talent to rural areas, with commitments to serve rural communities for a minimum of 5 years.
• Providing technical assistance, software, and hardware for significant information technology advances designed to improve efficiency, enhance cybersecurity capability development, and improve patient health outcomes.
• Assisting rural communities to right size their health care delivery systems by identifying needed preventative, ambulatory, pre-hospital, emergency, acute inpatient care, outpatient care, and post-acute care service lines.
• Supporting access to opioid use disorder treatment services, other substance use disorder treatment services, and mental health services.
• Developing projects that support innovative models of care that include value-based care arrangements and  alternative payment models, as appropriate.
• Additional uses designed to promote sustainable access to high quality rural health care services, as determined by the CMS Administrator.

Within the contours of this list, states could restrict the funds to rural hospitals or specific types of rural hospitals (such as those that are isolated and in financial distress) or they could use them for additional or different purposes, such as paying nursing facilities or recruiting clinical workers to rural areas.

While the fund is described as a “rural” program, the law appears to give states some ability to direct some of the dollars to urban and suburban areas, pending CMS approval. For example, most of the permitted uses in the list above do not specify that the funds would need to go to rural areas, such as the description of payments to hospitals and other providers and of support for opioid use treatment services, other substance use disorder treatment services, and mental health services. The current CMS Administrator indicated that nonrural areas could potentially receive money from the fund. The law also does not define “rural” when describing the scope of the program, meaning that states or the administration could do so broadly.

The law does not direct CMS or states to be transparent about the allocation and use of funds

CMS is not required to publish information about how the funds are distributed—such as by posting the amount sent to each state or why certain state applications were approved or denied—though it could choose to do so. States are required to submit annual reports to CMS on the use of the allotments. CMS could require states to disclose information about the amount they receive or the use of funds to the public.

As of 2023, there were over 47 million immigrants residing in the country, accounting for 14% of the total population, including roughly 1.8 million living in rural America. The Trump administration has undertaken a range of actions aimed at restricting immigration; increasing interior immigration enforcement efforts, including among lawfully present immigrants; and eliminating access to health coverage and care for lawfully present and undocumented immigrants. Research shows that immigrants make significant contributions to the U.S. workforce. Efforts to limit immigration may have negative ramifications for the country’s labor supply and economy, particularly in key occupations such as health care that are already experiencing worker shortages. Research further shows that health care workforce shortages are particularly stark in rural areas, which are also home to larger shares of older residents as well as residents who have worse health conditions as compared to their urban counterparts.

This data note examines the role that immigrants play in the rural workforce, particularly in industries disproportionately filled by immigrants, including health care, agriculture, construction, and service. It is based on KFF analysis of the 2023 American Community Survey 1-year Public Use Microdata Sample (see Methods for more details). It also highlights the socioeconomic and health coverage barriers that immigrant workers in rural areas face. For the purposes of this analysis, rural areas (non-metropolitan) are defined as counties or a group of counties that have a population of at least 10,000 but less than 50,000.

This analysis shows that although immigrants account for a small share of the rural adult population (5%) and rural adult workforce (5%), they play an outsized role in certain occupations in rural areas, including as physicians and surgeons (14%), agriculture workers (28%), and construction workers (10%). Despite having similar rates of employment as their citizen counterparts, noncitizen immigrant workers in rural areas are somewhat more likely to have lower incomes (annual incomes below $20,000) (22% vs. 18% among U.S.-born workers) and to be uninsured (40% vs. 8% among U.S.-born workers).

Immigrant adults make up 5% of the rural workforce nationwide, with the share varying from 1% to 17% across states.

Overall, immigrants account for 5% of rural adults and the rural adult workforce. However, their share of the rural workforce ranges from 1% to 17% across the 40 states with sufficient data to examine immigrant workers in rural areas. In nine states (HI, FL, CT, DE, NM, AK, WA, TX, and CA), immigrants account for at least one in ten or more of rural adult workers, including 17% in Hawaii, 15% in Florida, and 14% in Connecticut, reflecting these states generally having higher shares of immigrant adults residing in rural areas and immigrants overall.

Immigrant adults make up nearly three times the share of physicians and surgeons in rural America than their share of the overall rural workforce (14% vs. 5%).

Immigrant adults account for similar shares of the total rural workforce (5%) and the total rural health care workforce (3%) but make up nearly three times (14%) the share of physicians and surgeons in rural America (Figure 2). These physicians and surgeons include one in ten naturalized citizens and 4% noncitizen immigrants. In addition, immigrant adults account for 6% of nursing assistants, 3% of nurses, 2% of therapists, 1% of physician assistants, and 4% of other clinical workers in rural America.

Immigrant adults also play an outsized role in the agriculture, construction, and service workforces in rural America.

In addition to their role as physicians and surgeons, immigrant adults make up significantly higher shares of the agriculture, construction, and service (including restaurant and cleaning) workforces in rural America compared to their share of the total rural workforce (Figure 3). These patterns are similar to the outsized role immigrant adults play in these workforces nationwide. In rural areas, immigrant adults account for nearly three in ten (28%) agricultural workers, including nearly a quarter (24%) who are noncitizen immigrants. Immigrant adults also make up about one in ten construction (10%) and service (9%) workers in rural America, again driven by larger shares of noncitizen immigrants who account for these workers.

More than one in five noncitizen immigrant workers in rural America earn less than $20,000 a year.

Despite their workforce contributions, noncitizen immigrant workers in rural America are somewhat more likely than their citizen counterparts to earn less than $20,000 a year (Figure 4). More than one in five (22%) of noncitizen immigrant workers earn less than $20,000 a year compared to 18% of U.S.-born citizen and 16% of naturalized citizen workers in rural America. In contrast, about one in six (17%) U.S.-born and one in five (21%) naturalized citizen workers in rural America report earning $80,000 or more per year compared to one in ten noncitizen immigrant workers. This pattern likely reflects noncitizen immigrants’ disproportionate employment in lower-wage jobs such as agriculture, construction, food services, and cleaning services.

Four in ten noncitizen immigrant workers in rural America are uninsured.

Roughly six in ten of naturalized citizen (60%) and U.S.-born citizen (57%) adults, as well as two in three noncitizen immigrant adults (66%) 18 years and older in rural America are employed. However, noncitizen immigrant workers in rural America are roughly four times more likely to lack health insurance coverage (40%) than their naturalized citizen (11%) and U.S.-born citizen (8%) counterparts (Figure 5). Roughly three in four U.S.-born (74%) and naturalized citizen (72%) workers have private coverage compared to half (51%) of noncitizen immigrant workers. U.S.-born and naturalized citizen (18%) workers also are twice as likely to be covered by Medicaid compared to noncitizen immigrant workers (9%). These patterns reflect noncitizen immigrants’ disproportionate employment in jobs that are less likely to offer employer-sponsored health coverage as well as their limited access to federally funded health coverage. Provisions in the recently passed tax and spending law will further limit access to health coverage for noncitizen immigrants, which could further increase their uninsured rates and result in workforce productivity losses as well as an exacerbation of worker shortages in rural areas.

The Senate Committee on Appropriations approved its FY 2026 Labor, Health and Human Services, Education, and Related Agencies (Labor HHS) appropriations bill, accompanying report, and amendments on July 31, 2025.

While most U.S. global health funding is provided to the State Department through a separate appropriations bill, the Labor HHS appropriations bill includes funding for global health programs at the Centers for Disease Control and Prevention (CDC) as well as funding for global health research activities at the National Institutes of Health (NIH). Total global health funding at CDC and NIH through the Labor HHS bill is not yet known, as funding for some programs (i.e. global HIV/AIDS and malaria research) at NIH is determined at the agency level rather than specified by Congress in annual appropriations bills. Funding for global health programs at CDC totals $693 million in the bill and funding for global health research activities at the Fogarty International Center (FIC) at NIH totals $95 million; these are the same levels as the FY 2025 enacted amounts.^[i],[ii]

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 FY26 Request eliminates CDC’s Global Health Center and most of its bilateral programs, except funding for “Global Disease Detection & Emergency Response”, which is transferred to “Crosscutting Activities and Program Support”, and “Parasitic Diseases and Malaria”, which is transferred to “Emerging and Zoonotic Infectious Diseases”.

Read the news release about these poll findings.

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Findings

Key Findings

• Amid ongoing news from federal agencies about changing COVID-19 vaccine recommendations, the replacement of the Centers for Disease Control and Prevention’s vaccine advisory committee members (ACIP), and re-examination of the federal childhood vaccine schedule, there is confusion among the public about U.S. vaccine policy. While half of the public thinks Department of Health and Human Services (HHS) Secretary Robert F. Kennedy Jr. has made “major” (26%) or “minor” (26%) changes to vaccine policy in the U.S., the other half either say they “don’t know enough to say” (40%) or say no changes have been made (7%). At least three in ten adults across demographic groups and party identification say they don’t know enough about the recent changes from Kennedy to vaccine policy to describe them. In addition, half (48%) of parents are not sure if federal health agencies are currently recommending that healthy children receive a COVID-19 vaccine this fall or not.
• Once told about the changes to U.S. vaccine policy, the public is divided by partisanship in whether they think these changes will make people safer or less safe. About two in ten adults, including 41% of Republicans, think these changes will make people safer while about one-third of adults, including most Democrats (62%) and four in ten independents (41%) say they will make people less safe. Another third of adults (31%) say they “don’t know enough to say” as to whether the recent changes to U.S. vaccine policy will make people safer or not, and about one in ten say the changes won’t make a difference.
• Most of the public (59%) say they will either “definitely not” or “probably not” get the COVID-19 vaccine this fall – including about six in ten Republicans who say they will “definitely not” get the vaccine. Older adults and Democrats are much more likely to report that they will get the COVID-19 vaccine. About four in ten Black adults and Hispanic adults say they plan to get the COVID-19 vaccine as do 37% of White adults.
• With most of the public reporting that they will not get a COVID-19 vaccine this fall, few are worried about the availability of the vaccine or whether it will be covered by insurance. One-third (33%) of adults are concerned that COVID-19 vaccines won’t be available to them this fall, while a third (34%) of insured adults are also worried that their insurance won’t cover a shot. Concern about availability and coverage are tied to vaccine intention, with those who plan to get the vaccine much more likely to be concerned that it might not be available to them (66%), including specific demographic groups who are more likely to get vaccinated such as older adults and Democrats.
• Personal doctors or health care providers remain the most trusted source for information about vaccines among asked sources, with eight in ten (83%) adults who say they trust their own doctor at least “a fair amount.” Smaller shares of the public, but still majorities trust their local public health department and the U.S. Centers for Disease Control and Prevention, or CDC, to provide information on vaccines, though the share who say so has been steadily in decline since September 2023. Fewer continue to say they trust HHS Secretary Robert F. Kennedy Jr. to provide information on vaccines, with about four in ten (37%) saying they trust him at least a fair amount, unchanged since his appointment in April of this year.
• About half of the public have confidence in agencies like the CDC and Food and Drug Administration (FDA) to ensure the safety and effectiveness of vaccines approved for use in the U.S. (49%), while less than half say they have at least some confidence in the agencies to make decisions based on science rather than the personal views of agency officials (42%), or act independently, without interference from outside interests (37%). Democrats continue to be more confident in federal health agencies than Republicans to ensure the safety and effectiveness of vaccines.

Awareness of Changes to Vaccine Policy

Since his appointment as Secretary of Health and Human Services, Robert F. Kennedy Jr. has made several headlines about changing vaccine recommendations, leaving many confused about the scope of changes to U.S. vaccine policy and unsure of how these changes might affect people.

About half (52%) of the public are aware that RFK Jr. has made changes to U.S. vaccine policy, with about a quarter describing them as “major changes” (26%) or “minor changes” (26%). Four in ten adults say they don’t know enough about the changes to say whether they are “major” or “minor.” In addition, another 7% are unaware that changes have been made.

Whether the public views the changes as “major” or “minor” is largely partisan, with Democrats more likely to say they are “major” changes while Republicans describe them as “minor” changes. About four in ten (39%) Democrats say the changes that have been made to U.S. vaccine policy are “major,” compared to a quarter (25%) of independents and one in six (16%) Republicans. Nearly four in ten Republicans describe the changes as “minor,” compared to a quarter of independents and 18% of Democrats.

Young adults and those without a college degree are more likely to report that they don’t know enough about the issue to say whether or not the Secretary of HHS has made changes to vaccine policy. About half of those ages 18-29 (47%) and those without a college degree (45%) report that don’t know enough to say about changes to vaccine policy, compared to smaller shares of older adults and those with a college degree or higher.

With RFK, Jr. focusing attention on the childhood vaccine schedule, about half of parents are aware that changes have been made but the other half of parents are either unaware that changes have been made (9%) or report they don’t know enough to say (39%). Similar to all adults, how parents described the scope of the changes is largely partisan with Democratic-leaning parents describing them as major changes, and Republican-leaning parents describing them as minor changes.

In light of the recent changes to policy, a third (36%) of the public say the changes that HHS Secretary Robert F. Kennedy Jr. has made to vaccine policy will make people less safe while a smaller share (20%) say the changes to vaccine policy will make people safer. Similar to overall awareness of the changes, a substantial share (31%) say they don’t know enough about the recent changes to say whether they will make people safer or less safe. An additional one in ten (13%) say the changes will not make any difference.

Once again, views are largely partisan, including among parents. Pluralities of Democrats and independents say the changes RFK Jr. has made to vaccine policy will make people less safe, including six in ten (62%) Democrats and four in ten (41%) independents. However, Republicans are split, with similar shares who say the policy makes people safer (41%) and that they don’t know enough to say (34%).

Parents are also split, with a third (32%) who don’t know enough to say and three in ten (29%) who say these changes will make people less safe. Another quarter (22%) of parents say it’ll make people safer, while one in six (17%) say it won’t make a difference. Parents who are Democrats or Democratic-leaning independents are more likely to say the changes will make people less safe, while Republican-leaning parents are more likely to say the changes will make people safer.

The Fall 2025 COVID-19 Vaccines

Overall, most of the public (59%) say they will either “definitely not” or “probably not” get the COVID-19 vaccine this fall. KFF has been tracking uptake of the COVID-19 vaccine since early 2021. Older adults and Democrats are much more likely to report that they will get the COVID-19 vaccine, while six in ten Republicans (59%) say they will “definitely not” get the COVID-19 vaccine. Similar shares across race and ethnicity say they plan to get the vaccine this fall, but notably White adults are the most likely to be against getting the vaccine, with four in ten (42%) saying they will “definitely not” get the vaccine.

Views of the changes to U.S. vaccine policy also vary by vaccine intention. Those who say they will “definitely” or “probably” get the shot are more likely to say they think the changes to U.S. vaccine policy are “major changes” and these changes will make people less safe.

Few Are Worried About Availability of Vaccines

With the Trump administration instituting possible changes to vaccine recommendations, including the COVID-19 vaccine, and coverage of vaccines largely tied to recommendations from the Advisory Committee on Immunization Practice (ACIP) or the Centers for Disease Control and Prevention (CDC), those who want a COVID-19 vaccine are worried about being able to access the vaccine.

With less than half of adults saying they plan to get a COVID-19 vaccine this fall, just one-third (33%) of all adults are “very” or “somewhat” concerned that COVID-19 vaccines won’t be available to them this fall. Most adults (67%) say they’re “not too” or “not at all” concerned about the availability of the vaccine. Similarly, among those who have insurance, a third (34%) are “very” or “somewhat” concerned that their insurance won’t cover a COVID-19 vaccine this fall, while two-thirds (65%) are “not too” or “not at all” concerned.

Those who plan to get the vaccine are much more likely to be concerned that it might not be available to them. Among those who say they’ll “definitely” or “probably” get a COVID-19 vaccine this fall, two-thirds (66%) are concerned that the vaccine won’t be available to them, while six in ten (62%) of insured adults who will likely get a vaccine this fall are concerned their insurance won’t cover it. Predictably, just about one in ten of those who likely won’t get the vaccine are concerned about availability (11%) or insurance coverage (14%).

Groups that are more likely to say they plan on getting the COVID-19 vaccine are predictably more concerned about both the availability of the vaccine and whether their insurance would pay for it. Over half (56%) of Democrats are concerned about the availability of the COVID-19 vaccine or insurance coverage (53%), compared to under four in ten independents and one in ten Republicans worried about availability or coverage.

In addition, people who are ages 50 and older are more concerned than younger adults that the vaccine won’t be available to them, though majorities still report they are not concerned, with about four in ten of older adults who are concerned about both availability and insurance coverage, compared to about a quarter of those under the age of 50.

Black adults and Hispanic adults are among the most concerned about the availability and insurance coverage of the COVID-19 vaccine, with half of Black adults concerned about availability (48%) and insurance coverage (46%), and half (47%) of Hispanic adults concerned about insurance coverage, compared to smaller shares of White adults concerned about either item.

Half (48%) of parents say they are not sure if federal health agencies are currently recommending that healthy children receive a COVID-19 vaccine this fall. Currently, the CDC is recommending that decisions around the COVID-19 vaccine for healthy children ages 6 months to 17 years should be between the health care provider and the patient or their parents, with no formal recommendation from the CDC. This comes after RFK, Jr. announced that the COVID-19 vaccine is not being recommended for this group.

Two in ten (21%) parents believe the COVID-19 vaccines are being recommended, while three in ten (31%) say COVID-19 vaccines are not being recommended for healthy children this fall. This is similar across partisans, with half of parents regardless of party identification saying they don’t know enough to say, and about three in ten Republican and Republican-leaning independent parents (31%) and Democratic and Democratic-leaning independent parents (35%) aware that the CDC is not recommending the COVID-19 vaccine for healthy children this fall.

Trust in Sources to Provide Vaccine Information

Personal doctors or health care providers remain the most trusted source for information about vaccines, with eight in ten (83%) adults saying they trust their doctor “a great deal” or “a fair amount” to provide reliable information about vaccines. Smaller shares of the public, but still majorities, trust their local public health department (62%) and the U.S. Centers for Disease Control and Prevention, or CDC (57%), to provide information on vaccines. Four in ten trust their state government officials (43%). HHS Secretary Robert F. Kennedy Jr. continues to be the least trusted source of information on vaccines with just over one-third of adults (37%) saying they trust him at least a fair amount.

Individuals’ doctors or health care providers also garner the highest shares of trust across partisans, with at least eight in ten Democrats (92%), independents (85%), and Republicans (80%) who trust them “a great deal” or “a fair amount” to provide vaccine information. Notably, Republicans’ next trusted source behind their own personal doctor is RFK Jr., with seven in ten Republicans saying they trust him to provide reliable information on vaccines, compared to three in ten independents and one in ten (11%) Democrats.

Democrats are more trusting of vaccine information from health agencies than independents or Republicans, with three-quarters (77%) of Democrats saying they trust their local public health department to provide reliable information on vaccines, compared to two-thirds (63%) of independents, and half (53%) of Republicans. Similarly, another seven in ten (72%) Democrats trust the CDC compared to six in ten (61%) independents and just under half (44%) of Republicans. These partisan divides in trust are consistent with findings from previous KFF polling.

Republicans or Republican-leaning independents who support the MAGA movement are consistently less trusting of sources of information about vaccines than non-MAGA Republicans and leaners, with significantly fewer who say they trust their local public health department, the CDC, and their state government officials. Similar shares say they trust their personal doctors “a great deal” or “a fair amount,” but larger shares of MAGA Republicans trust RFK Jr. to provide information on vaccines (77% vs. 48% of non-MAGA Republicans).

The latest polling shows that overall trust in government agencies, like the CDC or people’s local public health departments, to provide reliable information on vaccines is continuing a downward trend since first asked in September 2023. The share of adults who say they trust either the CDC or their local public health department has dropped six percentage points, while the share who trust their own provider has stayed relatively stable.

Even as majorities of the public express trust in government health agencies, like the CDC, to provide information on vaccines, few have confidence in agencies like the CDC and FDA to carry out many of their responsibilities, including ensuring the safety and effectiveness of vaccines approved for use in the U.S. (49%), making decisions based on science rather than the personal views of agency officials (42%), or acting independently, without interference from outside interests (37%). Fewer than one in five adults say they have “a lot” of confidence in these agencies to fulfill each of these tasks.

Despite the fact that Trump administration appointees lead these federal health agencies, larger shares of Democrats than Republicans have at least “some” confidence in government health agencies to ensure the safety and effectiveness of vaccines approved for use in the U.S. About six in ten (58%) Democrats say they are confident in these agencies to ensure the safety and effectiveness of vaccines, compared to less than half (45%) of Republicans who agree.

Similar shares of Democrats (41%), independents (42%), and Republicans (46%) have confidence in the government to make decisions based on science rather than personal views of agency officials, and similar shares of Democrats (41%) and Republicans (41%) are confident in the federal health agencies to act independently, without interference from outside interests. A smaller share of independents – about a third (32%) – say the same about agencies’ ability to act independently.

Methodology

This KFF Health Tracking Poll/KFF Tracking Poll on Health Information and Trust was designed and analyzed by public opinion researchers at KFF. The survey was conducted July 8-14, 2025, online and by telephone among a nationally representative sample of 1,283 U.S. adults in English (n=1,212) and in Spanish (n=71). The sample includes 1,004 adults (n=58 in Spanish) reached through the SSRS Opinion Panel either online (n=979) or over the phone (n=25). 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 three reminder emails.

Another 279 (n=13 in Spanish) adults were reached through random digit dial telephone sample of prepaid cell phone numbers obtained through MSG. Phone numbers used for the prepaid cell phone component were randomly generated from a cell phone sampling frame with disproportionate stratification aimed at reaching Hispanic and non-Hispanic Black respondents. Stratification was based on incidence of the race/ethnicity groups within each frame. Among this prepaid cell phone component, 135 were interviewed by phone and 144 were invited to the web survey via short message service (SMS).

Respondents in the prepaid cell phone sample who were interviewed by phone received a $15 incentive via a check received by mail. Respondents in the prepaid cell phone sample reached via SMS received a $10 electronic gift card incentive. SSRS Opinion Panel respondents received a $5 electronic gift card incentive (some harder-to-reach groups received a $10 electronic gift card). In order to ensure data quality, cases were removed if they failed two or more quality checks: (1) attention check questions in the online version of the questionnaire, (2) had over 30% item non-response, or (3) had a length less than one quarter of the mean length by mode. Based on this criterion, 1 case was removed.

The combined cell phone and panel samples were weighted to match the sample’s demographics to the national U.S. adult population using data from the Census Bureau’s 2024 Current Population Survey (CPS), September 2023 Volunteering and Civic Life Supplement data from the CPS, and the 2025 KFF Benchmarking Survey with ABS and prepaid cell phone samples. The demographic variables included in weighting for the general population sample are gender, age, education, race/ethnicity, region, civic engagement, frequency of internet use, political party identification by race/ethnicity, and education. The weights account for differences in the probability of selection for each sample type (prepaid cell phone and panel). This includes adjustment for the sample design and geographic stratification of the cell phone sample, within household probability of selection, and the design of the panel-recruitment procedure.

The margin of sampling error including the design effect for the full sample is plus or minus 3 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. Sample sizes and margins of sampling error for other subgroups are available on request. Sampling error is only one of many potential sources of error and there may be other unmeasured error in this or any other public opinion poll. KFF public opinion and survey research is a charter member of the Transparency Initiative of the American Association for Public Opinion Research.

Group	N (unweighted)	M.O.S.E.
Total	1,283	± 3 percentage points
Party ID
Democrats	439	± 6 percentage points
Independents	387	± 6 percentage points
Republicans	344	± 6 percentage points
MAGA Republicans	308	± 7 percentage points

 

As federal vaccine policy changes, most (59%) adults do not expect to get a COVID-19 vaccine this fall, while four in 10 (40%) say that they will “definitely” or “probably” get the shot, a new KFF Tracking Poll on Health Information and Trust finds.

The groups most likely to say they will “probably” or “definitely” get the vaccine this fall include older adults (55%) and Democrats (70%). In contrast, most Republicans say they won’t get the shot, including 59% who say they will “definitely not” get the vaccine.

Among those who plan to get the shot, two-thirds (66%) say they are concerned the vaccine won’t be available to them, and a similar share of those with insurance (62%) are concerned their insurance won’t cover the cost. 

The poll comes after Health and Human Services Secretary Robert F. Kennedy Jr.’s announcement this spring that the Centers for Disease Control and Prevention (CDC) would no longer recommend the vaccine for healthy children or pregnant women, and the CDC subsequently recommended shared decision-making between parents and doctors.

The poll finds that many parents of children under age 18 are confused and uncertain about whether COVID-19 vaccines are recommended for healthy children this year. 

About half (48%) of parents say they don’t know whether or not federal agencies recommend healthy children get the vaccine this fall. More say the vaccine is not recommended (31%) than recommended (21%) for healthy children.

When asked about the impact of the changes that Secretary Kennedy is making to vaccine policy, one in five (20%) adults nationally say they are making people safer, while more than a third (36%) say they are making people less safe. Others say that they don’t know enough to say (31%) or that the changes won’t make a difference (13%).

Views on the impact of the changes split along partisan lines, with Republicans much more likely to say the changes are making people safer (41%) than less safe (9%), and Democrats much more likely to say less safe (62%) than safer (4%). Among independents, more than twice as many say the changes are making people less safe (41%) than safer (16%). At least a quarter of adults across partisans say they don’t know enough to say how the changes will impact people.

The poll also assesses the public’s trust and confidence in federal authorities around vaccine issues. Findings include:

• More than half of people (57%) say they have at least “a fair amount” of trust in the CDC to provide reliable information on vaccines.
• Fewer than four in 10 (37%) say they trust Secretary Kennedy to provide reliable information on vaccines. Republicans (70%) are far more likely than independents (30%) or Democrats (11%) to say they trust Secretary Kennedy to provide reliable vaccine information.
• About half (49%) of the public says they have at least some confidence in federal agencies like the CDC and the Food and Drug Administration (FDA) to ensure the safety and effectiveness of vaccines, consistent with recent findings.

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.

Note: This analysis was updated to include the Congressional Budget Office’s (CBO) latest cost estimates for the reconciliation package that was enacted on July 4, 2025, as well as new provisions in the law.

On July 4, President Trump signed into law a budget reconciliation package once called the “One Big, Beautiful Bill” that includes significant changes to the Medicaid program. The Congressional Budget Office (CBO) estimates the Medicaid work requirement provisions in the passed budget reconciliation law will be the largest source of Medicaid savings, reducing federal spending by $326 billion over ten years and cause millions to become uninsured.

Implementing work requirements on a national scale, requiring states to verify individuals’ monthly work status (at least every 6 months) and implement a long list of exemptions are policies that proved challenging for Arkansas and Georgia to operationalize and led to 18,000 people losing coverage in Arkansas. KFF analysis shows most Medicaid adults under age 65 are working already (without a requirement) or face barriers to work. Many Medicaid adults who are working low-wage jobs are employed by small firms and in industries that have low employer-sponsored insurance offer rates. In previous analysis, CBO found that a Medicaid work requirement would not have any meaningful impact on the number of Medicaid enrollees working, and cited research from Arkansas indicating that “many participants were unaware of the work requirement or found it too onerous to demonstrate compliance,” resulting in coverage loss.

The law will require states to condition Medicaid eligibility for adults in the Affordable Care Act (ACA) Medicaid expansion group at application and following enrollment on meeting work requirements starting January 1, 2027, with the option for states to implement requirements earlier. Currently, 41 states (including DC) have expanded their Medicaid programs under the ACA to nearly all adults up to 138% FPL ($21,597 for an individual in 2025). As of June 2024, over 20 million people were enrolled through Medicaid expansion, representing nearly a quarter of total Medicaid enrollment across all states and 31% of total enrollment in expansion states. The Medicaid expansion population includes adults without dependents as well as many parents and people with disabilities or chronic conditions who do not receive SSI.

Key takeaways include:

• CBO estimates. Of the Medicaid provisions included in the law, CBO estimates implementing work requirements will account for the largest share of federal Medicaid savings. Earlier CBO estimates found work requirements will cause the largest increase in the number of people without health insurance.
• Verification requirements. The law requires states to verify at application and at renewal that individuals in the ACA expansion group meet work requirements (80 hours of work activities per month) or exemption criteria. States can also require verification more frequently.
• Implementation timeline. The law requires HHS to release an interim final rule by June 2026 leaving states with limited time to develop or change implementation plans, protocols, and systems (and to test systems changes) before the January 2027 work requirement implementation deadline.
• State implementation choices. State choices to impose more stringent requirements than the minimum federal requirements outlined in the law (e.g., requiring more frequent verification or imposing longer “look-back” periods when verifying coverage) as well as state effectiveness in using existing data to automate verification processes, will affect the number of individuals at risk of losing coverage.
• Comparison to other waivers and proposals. The Medicaid work requirement policies included in the law are more stringent than previous policies considered by Congress and work requirements implemented under state Medicaid demonstration waivers; for example, the law makes it harder to gain coverage and to re-enroll and does not exempt older adults from requirements

What does CBO say?

Of the Medicaid provisions included in the enacted reconciliation package, CBO estimates implementing work requirements will account for the largest share of federal Medicaid savings; earlier CBO estimates also found work requirements will cause the largest increase in the number of people without health insurance. Over ten years, work requirements are estimated to reduce federal Medicaid spending by $326 billion, representing the largest share of the estimated $911 billion in total Medicaid cuts included in the law (Figure 1). (CBO also projects indirect effects from the work requirement provision will decrease federal revenues by $8.65 billion over a decade.) The savings will largely stem from coverage losses. CBO has not published updated estimates of the number of people who will lose Medicaid under the reconciliation package previously referred to as the “One Big, Beautiful Bill.” Earlier CBO analysis of the House-passed version of the reconciliation bill estimated 18.5 million people will be subject to the requirements each year and by 2034 federal Medicaid coverage will decrease by an estimated 5.2 million adults, with work requirements ultimately increasing the number of people without health insurance by 4.8 million in 2034. CBO expects few of those disenrolled to have access to employment-based coverage and that no one will be eligible for Marketplace premium tax credits (as the law makes those losing or denied Medicaid coverage due to work requirements ineligible for premium tax credits to purchase coverage through the ACA Marketplaces).

What does the law require?

Expansion adults will be required to complete 80 hours of work or community service activities per month or meet exemption criteria to enroll in and maintain coverage (Figure 1). (Work requirements will also likely apply to states like Wisconsin and Georgia that have partial adult coverage expansions under 1115 waivers.) Individuals applying for coverage and those enrolled in coverage will need to work or engage in specified “qualifying activities” for at least 80 hours per month. States will be required to verify qualifying activities or exemptions in (at least) the month before application and (at least) one month between eligibility redeterminations (see Figure 2 and additional discussion below). The law specifies mandatory exemptions including parents and caretakers with children ages 13 and under, individuals who are “medically frail,” and individuals who are pregnant or postpartum, among others (Figure 1). The “medically frail” designation includes individuals who are blind or disabled, individuals with physical, intellectual, or developmental disabilities, individuals with substance use disorder or a “disabling” mental disorder, and those with “serious or complex” medical conditions. States may allow short-term hardship exceptions from work requirements, for enrollees (or applicants) experiencing certain extenuating circumstances (Figure 2).

At a minimum, states will be required to verify individuals’ work or exemption status when individuals apply for coverage and at eligibility renewal (Figure 3). At application, states will be required to “look back” one or more consecutive months (immediately preceding the application month, up to three total months) to confirm compliance with the requirements. Every six months when eligibility is redetermined (or more frequently as determined by states), states will be required to “look back” one or more months (consecutive or non-consecutive) to verify compliance. In effect, states could require individuals to comply with work requirements for multiple months before they can enroll in coverage or for multiple months within any six-month eligibility period (or more frequently than every six months). The law directs states to use available information (e.g., payroll data) “where possible” to verify compliance with work activities or exemption status, without requiring additional documentation from individuals.

When a state is unable to verify compliance with the requirements or that an individual meets exemption criteria, it must issue a “notice of noncompliance” and deny the application or disenroll the individual from coverage if the individual is unable to show compliance (Figure 3). Individuals will have 30 days to show compliance (coverage will be maintained during this period if already enrolled). After 30 days, if an individual is unable to demonstrate compliance with the requirements or show they are exempt, the state will be required to deny the application or disenroll the individual from coverage (no later than the end of the month following the 30-day period). States will be required to follow standard Medicaid termination processes, including determining whether an individual qualifies for Medicaid coverage on another basis and provide written notice and opportunity for a fair hearing. To regain Medicaid coverage, individuals will need to reapply (triggering another compliance check at application). Individuals will also be barred from receiving subsidized Marketplace coverage, as the law makes those losing (or denied) Medicaid coverage due to work requirements ineligible for premium tax credits to purchase coverage through the ACA Marketplaces.

What is the timeline for implementation?

The law specifies key work requirement implementation and compliance dates (Figure 4). The law directs the Secretary of HHS to issue an interim final rule on implementing work requirements by June 1, 2026 (the law specifies the interim rule will not be subject to public notice or public comment). States will be required to condition Medicaid expansion eligibility and coverage on meeting work requirements by January 1, 2027, with an option to implement requirements sooner. States must begin outreach to notify individuals of the new requirements at least three months before the start of the first compliance “look-back” period and notify individuals “periodically thereafter.” The law allows the Secretary to exempt states from compliance with the new requirements until no later than December 31, 2028, if the state is demonstrating a “good faith” effort to comply.

Figure 4

A forthcoming HHS interim rule may identify implementation parameters and additional state requirements; however, if the rule is slated to be released by June 2026, states will have limited time to develop or change implementation plans, protocols, and systems (and to test systems changes). The work requirement provisions outlined in the law raise many operational and implementation questions (Appendix Table 1). The law includes references to areas where additional HHS guidance may further define standards and processes for states (Table 1). Implementing work requirements will involve complex systems changes (e.g., developing or adapting eligibility and enrollment systems), enrollee outreach and education, staff training, and coordination with managed care plans, providers, and other stakeholders. The law allows states flexibility to impose more stringent requirements than the minimum requirements specified (e.g., requiring more frequent verification or imposing longer “look-back” periods when verifying coverage) and allows states to implement requirements sooner than January 2027.

How could implementation vary across states?

States will have flexibility to impose more stringent requirements than the minimum federal requirements outlined in the law. For example, states will have flexibility to determine how many months to “look back” at application (up to three months) and redetermination to verify compliance (and whether to verify compliance more frequently than at redetermination). In effect, states could choose to require compliance with work requirements for multiple months prior to the application month and for every month following enrollment (Box 1).

State data matching process decisions and how effective states are with data matching will affect how many individuals will need to submit proof of work hours or exemption status, and ultimately the number of individuals at risk of losing coverage. States with older or weaker systems or less integration (e.g., with SNAP or TANF) may be less effective. But even with effective systems, not all work can be verified through existing data sources, including, for example, community service and self-employment. As noted earlier, the law directs states (“where possible”) to data match work activities and automate the verification of exempted individuals/groups. Some exemptions may be easier to identify with existing data including parent/caretaker status, recent incarceration, and compliance with SNAP/TANF work requirements. Others may be more difficult such as participation in SUD program or meeting the “medically frail” definition (e.g., individuals with SUD, individuals with physical, intellectual, or developmental disabilities, those with “serious or complex” medical conditions).

How does this law compare to state waivers and previous proposals?

The Medicaid work requirement policies included in the law are more stringent than previous policies considered by Congress and work requirements implemented under state Medicaid demonstration waivers (Table 2). The law shares some similarities in structure to other federal legislative proposals and waivers, including requiring 80 hours per month of qualifying activities such as employment, community service, or work programs, and allowing exemptions for parents and individuals with certain health conditions (although Georgia’s waiver currently offers no exemptions). However, the law will condition eligibility at initial application and after enrollment on meeting work requirements, making it harder to gain coverage and to re-enroll (than in Arkansas or under the Limit, Save, Grow Act considered by Congress in 2023). Individuals lost coverage after three months of noncompliance in Arkansas and under the Limit, Save, Grow proposal, while under the law individuals could lose coverage more quickly (if the state chooses to verify monthly). The policy in the law will also extend to older age, through age 64 (unlike Arkansas’s waiver and the Limit, Save, Grow Act). In Georgia where the work requirement extends through age 64, the state’s interim evaluation found that work requirements have had a significant impact on lowering program enrollment, particularly for adults ages 50-64. For more on lessons learned from Arkansas’ and Georgia’s experience implementing work requirements (under demonstration waivers), see KFF’s previous explainers.

Appendix